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Improving Mental Health through Empowerment: A Group Counseling Goal for Women

By johnnyrr Oct 31, 2014 5323 Words

Improving Mental Health through Empowerment:
A Group Counseling Goal for Women
Capella University
Table of Contents
TOC \o "1-5" \u Background and Justification for the Group PAGEREF _Toc182735939 \h 1 Objectives PAGEREF _Toc182735940 \h 2
Desired Outcome Goals PAGEREF _Toc182735941 \h 2
Review of Literature PAGEREF _Toc182735942 \h 3
Introduction PAGEREF _Toc182735943 \h 3
Using the Group Approach to Improve Mental Health PAGEREF _Toc182735944 \h 3 Research on Empowerment Using a Group Approach PAGEREF _Toc182735945 \h 6 Theoretical Approach PAGEREF _Toc182735946 \h 9

Ethical Practice PAGEREF _Toc182735947 \h 11
Group Organization PAGEREF _Toc182735948 \h 12
Member Screening PAGEREF _Toc182735949 \h 12
Consent Form PAGEREF _Toc182735950 \h 13
Location and Other Considerations PAGEREF _Toc182735951 \h 13 Group Sessions and Activities PAGEREF _Toc182735952 \h 14
Evaluating the Group PAGEREF _Toc182735953 \h 16
Leadership Development PAGEREF _Toc182735954 \h 17
References PAGEREF _Toc182735955 \h 19

Background and Justification for the Group
The group to be considered in this project is that of a counseling group because the writer is a mental health-counseling learner. The focus of this proposal is improving the mental health of women by reducing depression and increasing empowerment. Group treatment sheds light on many problems that do not surface under individual therapy, especially attitudes toward social customs, ideals, ideologies, and body concepts. Each group participant will be asked to answer a questionnaire at the start of the program and to write a short autobiography. These procedures will provide material to be used in stimulating discussion and in guiding the therapist’s interpretation. According to Laitinen and Ettorre (2004), major depression is the most serious mental health problem for women throughout the world. Lara and her coworkers (2004) confirm this problem among women. They note that women suffer from depression twice as much as men and that it is a leading cause of disability on a worldwide basis. Thus, women will be selected for the group therapy because stress, depression and empowerment problems appear to be more prevalent within this group (Hammen, 2003). The project involves a guided self-help group using the non-directive approach and employing a behavioral and cognitive orientation as the therapeutic intervention. The effect of group participation on reducing depressed feelings and gaining feelings of empowerment will be evaluated at the end of the nine sessions that will comprise the program. A survey questionnaire will be administered before and after the group program to evaluate changes. The question to be answered will be whether or not there will be significant changes in individual and social feelings after program participation. Objectives

The objectives for the group - operationalized so that they can be measured and evaluated to build accountability into the group process - may be stated as follows: To reduce depression and feelings of powerlessness by 50% among group members through group-based therapy using therapeutic enactment which engages clients in interpersonal and action-oriented processes, as measured by survey questionnaire administration pre and post-testing. To determine the effects of a nine session group therapy program on ten depressed women’s’ ability to overcome hopelessness and powerlessness through group intervention, showing a 50% improvement from the start to the finish of the program, as measured by survey questionnaire administration pre and post-testing. To determine if four self-help exercises enabled group members to learn how to manage their depression and improve their self-esteem and negative thinking by 50%, as determined through survey administration pre and post-testing. Desired Outcome Goals

Process outcome goals refer to the choice of approaches and strategies used in the program to meet the group’s needs. Desired content outcome goals relate to the specific purposes of the group program itself. Two strategies will be used self-help exercises and therapeutic enactment. Thus, the long-range process outcome goal that is desired for the group members will be to work on self-awareness, self-acceptance and self-confidence in order to reduce depression, stress, and feelings of powerlessness. The short-range process goal will center on a socialization goal – behavioral and attitude changes in the depressed women within nine program sessions through the use of four self-help exercises and therapeutic enactment which engages clients in interpersonal and action-oriented processes. The long-range content goal will be to improve the self-help exercises until the most appropriate ones are verified and to validate the use of the therapeutic enactment approach. The short-range content goal will be to prove the efficacy of the four self-help exercises used in the initial program. Review of Literature

IntroductionThe purpose of this section of the proposal is to review the literature pertinent to the major variables of the study. The following two sections review studies on using the group approach to improve mental health and research on empowerment using a group approach. Studies containing this information were difficult to find. Few centered on both depression among females and the group approach for intervention. Data were obtained from a university library, Goggle Scholar, and Using the Group Approach to Improve Mental HealthAccording to the literature, there are a number of group approaches used in mental health therapy for a wide variety of reasons. These include didactic, family, nondirective, activity group, and inspirational group therapy, among others (Corey & Corey, 2001; Ellis, 2007; Yalom, 2005). While these techniques greatly differ, all of them are based upon the premise that the intimate sharing of feelings and experiences among others who offer understanding and mutual respect greatly improves self-understanding. As further explained by Westwood, Keats, and Wilensky (2003) in their study of integrating individual and group counseling models for change, “Self-knowledge and understanding evolve out of an individual’s full engagement in experiential and interpersonal opportunities in life” (p. 122). Of the greatest importance, counseling therapy groups function in two essential ways: to help individuals develop a sense of belonging; and

as a support system (Corey & Corey, 2001).
This researcher will employ the nondirective group therapy approach to the group therapy because of a belief in the underlying theory of Carl Rogers which views each individual from the standpoint of self-discovery and self-realization (Glauser & Bozarth, 2001). Thus, this writer will employ a client-centered approach to group counseling therapy. This process is viewed as a form of self-healing through the application of self-help techniques (Yalom, 2005). My theoretical model to helping with the understanding of human nature is based in the client-centered approach, using a caring frame of reference. It is the belief of this writer that client-centered counseling with a behavioral and cognitive orientation is the better approach to group counseling, especially for women with empowerment issues. It is important to explain that in using this approach, the therapist is not directly the leader, but rather a leader catalyst who will help the female group members of the program reach self-understanding by confronting them with their own attitudes and reactions (Glauser & Bozarth, 2001). Members in group therapy can become empowered to understand themselves and believe in their potential as social individuals through their participation in the group because the group setting provides an opportunity for members to examine their fears and assertive behavior difficulties in the presence of others (Yalom, 2005). It is believed that at the end of the therapeutic group program, the female members will find that they have increased their feelings of empowerment and self-esteem, as well as their relationships to themselves and their environment. As the leader catalyst of the group, members will be encouraged to elaborate on their feelings. The object is to stimulate the group to explore and clarify their own feelings rather than to determine the dynamics that produced their feelings (Glauser & Bozarth, 2001). Using this strategy, the emphasis will be placed on the value of communication between the group members and the importance of group members to be able to perceive themselves as others see them. As noted by Himle, Van Etten, and Janeck (2006), insight is a predictor of treatment outcome in any group treatment program, regardless of the interest area or topic. Also, group treatment brings many problems to light that cannot be illuminated by individual therapy, especially attitudes toward family ideals, ideologies, and body concepts. My client-centered group counseling approach will employs a number of methods which are closely tied to behavioral and cognitive techniques. In this way the program can help the group function optimally, as well as mediate dysfunction. The program will incorporate such subjects as how to cope with strong emotions, communication with others, managing depression, and improved self-esteem. Within these sessions, the following self-help techniques have been suggested in the literature and will be included (Corey & Corey, 2000; Ellis, 2007; Westwood et al, 2003). Group members will learn assertiveness techniques, journal logging, and consciousness raising (Tantillo, 2006). Also, according to Reiss (2002), the group approach of using the peer group technique should also be employed within the program sessions because this provides new opportunities for self-exploration and self-correction. Group discussions and group therapy experiences help to socialize group members. In addition, group therapy provides motivations often lacking when the therapist uses the individual approach. Grievances can be aired and insight can be gained through listening to the experiences of others. Group members can gradually learn how self-defeating negative attitudes and depression are (Corey & Corey, 2001; Hammen, 2003). Self-help exercises will enable group members to learn how to manage their depression, improve their self-esteem and negative thinking, and perhaps help themselves out of their depression altogether, thereby empowering them. According to the literature, very low self-esteem does appear to be linked to negative outcomes such as depression, especially for women. In women, low self-esteem and negative thinking have been found to be predictors of the development of depression (Peden, 2000; Peden et al., 2001). As noted by Peden et al. (2001), negative thinking is a common, incapacitating symptom of depression) that significantly influences the person’s perceptions and sustains depressed moods. Research on Empowerment Using a Group Approach

Empowerment improvement as related to various mental health problems using the group therapy approach has been the subject of much research investigation and study, some of which pertained strictly to women. Chan, Chan, and Lou, (2002), for example, evaluated an empowerment group that consisted of 67 divorced Chinese Women in Hong Kong. The group intervention program consisted of five sessions. Perceived level of stress and sense of empowerment were the variables that were evaluated to determine the effectiveness of the group intervention. Pre and post-test comparison results clearly indicated the effectiveness of the group intervention in increasing the sense of empowerment within the group. Tantillo (2006) studied empowerment within a multifamily therapy group consisting of both women and men as related to eating disorders. In her view, the major mental health healing power within a multifamily therapy group “comes from the sense of mutual empathy and empowerment experienced within its diverse therapeutic social network” (p. 82). Disconnectedness was believed to be a major variable causing the problem and group therapy was viewed as an avenue to increase empowerment. In her study, eating disorders were defined as diseases of disconnection. The disorder disconnected patients from real internal experiences and helped displace needs and unacceptable feelings onto their bodies. Many disconnections lead to advancement of negative relational images. Inability to accept differences in relationships (feelings, needs, etc.) wears down a sense of empowerment that is required to foster positive connections with others. Several major goals of the study were to: Build mutually empathic and empowering relationships among group members. Increase understanding regarding the impact of disconnections on the eating disorder and recovery. Develop and practice new coping strategies and relational skills that promote recovery. The therapy group schedule included an introduction, strategies to promote mutual connections, empowering the “we” in the family connection, and explanations of biopsychosocial risk factors for eating disorders. The group intervention consisted of eight sessions. Tantillo (2006) concluded from her study “the sense of mutual empathy and empowerment within the diverse therapeutic social network of the program fuels patients and families to persevere together on the path to recovery” (p. 99). Others have also studied a multi-family framework for mental health interventions, indirectly focusing on empowerment (Bishop, Clilverd, Cooklin & Hunt, 2002; Colahan & Robinson, 2002). Reiss (2002), however, did focus directly on empowerment as also related to eating disorders in a multimodal group therapeutic approach. She created and described an integrative time-limited group therapy program for the treatment of bulimia nervosa. The program she suggested consisted of 12 sessions using such therapy approaches as cognitive-behavioral, interpersonal, relationship, and psychoeducation. Pilot data supporting her intervention was provided. The integrative approach was judged by her data to be more successful than group therapy using only one approach for two reasons. It incorporates the peer group approach and it provides a dual benefit of achieving symptom reduction: “…by two different mediating mechanisms: those that directly affect eating behaviors and those that address the interpersonal and relational context in which the disordered eating has developed” (p. 1). Laitinen, Ettorre, and Sutton (2006) investigated changes in individual and social feelings in guided self-help groups in Finland. Their study directly centered on empowerment as well as depression. A total of 101 women participated in the study. Ages ranged from 20 to 65, with an average mean of 40. Participants were self-selected, adult women who had defined themselves as being depressed and had been treated for clinical depression in a group setting. The project that was developed consisted of professionally guided self-help groups that were conducted at three different times. Changes were measured via a questionnaire that was culturally sensitive. From a review of empowerment literature, the researchers divided feelings into two groups: social (those having an external impact) and individual (those directed internally towards the self). Laitinen et al. (2006) concluded from their data analysis that women accepted, managed, or healed their depression during the group sessions. For feelings directed internally, the researchers found significant positive increases in hopefulness and happiness with significant negative decreases in feelings of depression, sleeplessness, guilt, and misery. For the social category, statistically significant positive increases were found with respect to self-satisfaction; feelings of attractiveness, and feelings of value while significant negative decreases were recorded for feelings of self-destruction, powerlessness, and uselessness. Through participation in the group, the members also achieved an increased sense of empowerment once they began to understand and believe in themselves as viable social individuals. At the end of the program changes in self-esteem and an increased sense of empowerment were evident. Feelings were altered with regard to the environment and the self. Theoretical ApproachAs previously noted, the project involves a guided self-help group using a non-directive strategy and employing a behavioral and cognitive orientation as the therapeutic intervention. This theoretical approach derives from Carl Roger’s non-directive client-centered strategy as orientated to groups. The non-directive approach is based on the view that people have an inner growth potential in addition to a need to actualize the self. This approach is effective in-group counseling with the client group that will be served by this project. The group setting allows members to reach the self-actualization stage by giving each one an opportunity to examine her behavior difficulties and conflicts in the presence of others. This allows her to discover that she can gain what she needs by developing better and more stable relationships with other people. The entire process is viewed as a form of self-healing (Laitinen et al., 2006; Himle, et al., 2006; Westwood et al., 2003). According to the literature, this type of group approach will help depressed women who experience feelings of powerlessness and stress in the following ways: to realize that others are in the same situation which will reduce anxiety and give them courage to express their deeper feelings; to be stimulated to recall and relive their affective experiences by listening to experiences of others and exchanging ideas; to see new ways of approaching and solving problems as a result of listening to the comments and experiences of others; to dissipate some of the feelings of guilt and hostility that may be standing in the way of improvement when they express themselves in the presence of a sympathetic group; to learn interpersonal skills and anxiety management strategies in a safe environment; to put new solutions into practice and learn to set goals as a result of receiving emotional support from group acceptance; and to test and reinforce new attitudes, ways of behaving, and new relationships with others in practical and realistic ways as a result of new opportunities provided for them in the group setting (Colahan & Robinson, 2002; Corey & Corey, 2001; Dowrick, Dunn, Ayuso-Mateos, Dalgard, Page et al, 2000; Reiss, 2001). Ethical PracticeClearly, the ethical aspects of confidentially within the group situation have a different meaning as compared to individual therapy. In a legal context, it is really not possible to guarantee complete confidentiality within the group setting because client self-disclosure is encouraged. However, the leader counselor should raise the issue within his group right at the start and this writer, as the counselor would do this during the start of every session. As explained by Corey and Corey (2001), it is the leader who predetermines that the issue of trust and confidentiality is the first topic addressed during each session of the program. It is only in this way that confidentiality and trust problems can be adequately addressed during various group development stages. Before group members can express their innermost thoughts and feelings, they need to have a certain level of trust in the other group members as well as the leader. Although my leadership style would be democratic and non-directive, it is my responsibility as the group leader to be sensitive to issues such as age, disability, race, culture, and sexual orientation differences. There are reasons why group members may break confidentiality and I cannot prevent all of these, but by setting confidentially as the norm for a cohesive group, there is a better chance that the secrets of group members will stay within the group. By reaffirming the importance of not discussing with outside people what members say during each group session, this norm is established. Group Organization

The group will be organized at first into one round circle setting. During working sessions (3, 4, and 5, mostly), the group will be divided into smaller groups in order to better learn and practice the self-help exercises and engage in therapeutic enactment. As the sessions progress, however, the group will be brought back together again into a cohesive whole. The organization of the group will coincide with the stages through which the group will go. In the first stage, members will acknowledge their stress, feelings of powerlessness, and depression. Next, they will learn to process their emotions related to these feelings and use the self-help exercises to achieve this. In the third stage, they will identify the effects of these feelings on their present day functioning. Finally, they will learn new strategies for effectively managing their lives, thereby becoming empowered. The counselor - as leader of the group - needs to consider each of these stages as being a different point in their lives and plan his strategy accordingly. For example, during the second stage the counselor will introduce the self-help exercises and therapeutic enactment techniques, which will engage the clients in interpersonal and action-oriented processes. These are the techniques they will need to practice to process their emotions and then be able to identify the effects on their every day life. Member ScreeningMembers will be screened through administration of a published test instrument that identifies significant depression and feelings of powerlessness in women. Those who receive scores verifying significant depression and powerlessness feelings will be considered for the group. This tool has not yet been identified, however. The optimal number of members for the group would be about ten (ranging in age from 21 through 70) to have a manageable and controllable group of clients. The group could be one specific ethnic/income group or mixed ethnicity and income level. Two Caucasians, two Asians, two African Americans. One Mexican American and one Native American would be the ideal for a mixed group. However, one specific ethnic and/or income group may be better because more inferences can derive because the population is very small and comprised of only one segment of the female population. Also, all group members who are selected for the group therapy program will need to speak fluent English – both in speaking and understanding - and to agree to participate in the therapeutic program for no compensation. Then each participant will be entitled to learn the results of the data analysis after pre and post-testing, however. Consent FormA consent form in the present case would be simple. It would inform the potential group candidate about the group program, and its purpose, require attendance at each of the nine sessions, and ask them to agree to participate for no compensation. It would also ensure each member of anonymity as regards test instrument data publication. Each group participant will be asked not to sign her name on the before and after test forms – only on the consent form. The only consideration that was taken into account by this writer was the need to assure anonymity as regards test data publication. A parent or guardian’s permission is not needed because all in the group will be 21 years of age and older. Location and Other ConsiderationsThe location of the program will be a clinic that is within twenty miles of the office of the counselor. Group members will be selected from that particular area also to eliminate transportation problems. A portfolio will be needed for each group member. Each will include an explanation of the program, a consent form that needs to be signed and returned to the counselor; a brief information sheet describing the facility and counselor, and details of the self-help exercises themselves. Group Sessions and ActivitiesThe program will consist of nine group sessions. The first three will begin with a professionally led discussion on one of three topics: how to cope with strong emotions; communication with others; managing depression. In the initial session the group leader will describe the nature and goals of the group, distribute group orientation folders, and have group members introduce themselves. The rest of the session will be devoted to discussing empowerment change by learning to cope with strong emotions- stages and processes. Communication and managing depression strategies to help members develop and be motivated for readiness to change will be included. In the second session the group leader will continue the use of validation and promote mutual exchange and the tolerance of group differences. Self-disclosure will be used to demystify the counselor’s role and the therapy process, validate group member dilemmas, and promote increased mutual connection. The leader will be established as a guide and mediator of the group work. As Lara and her coworkers (2004) suggest, this role should be emphasized and maintained throughout the duration of the entire program. The group’s purpose will be emphasized again: to raise the awareness level of the women, to provide them with an appropriate forum to discuss and challenge negative cultural messages, to help them make more adaptive choices about themselves and their relationships, and to provide an experience of community that both encourages and challenges them. Ultimately, the group process is intended to positively impact the self-esteem of the participants. The next three will concentrate on self-help techniques. These will include how to be more assertive, journal logging, and consciousness raising. Self-help exercises will be included to help group members to learn how to manage their depression and perhaps help themselves out of their depression altogether. Emphasis during the third session will thus be on using four self-help exercises to assist in feeling energized and find ways to connect with one another without a focus on their depressed mental health state. As previously noted, self-help exercises will enable group members to learn how to manage depression, improve self-esteem and negative thinking, and reduce depression, thereby empowering them. Therapeutic enactment will also be used during work group sessions. “Group-based therapy using therapeutic enactment engages clients in interpersonal and action-oriented processes…. [It] offers clients and therapists a holistic solution to the complex concerns that single system therapies cannot address (Westwood, Keats, & Wilensky, 2003, p. 123). This type of intervention will used to assist group members in receiving validation and support, learn empowerment skills, and identifying the effects of stress and powerlessness on their present functioning. It is through this expressive therapeutic approach that counselors can fully utilize the dynamics of the group processes. This process will lead to restorative progression for the group members. Personal spontaneity is the result of a successful process, which leads to catharsis then on to healing. Discussions will include the existence of the self, the other, and the relationship as the three main parts of any relationship. According to Yalom (2005), interventions are made more effective by incorporating a focus on the interpersonal process. It is for this reason that this session will include the sharing of ideas and experiences that have made the group members feel depressed, stressed, full of anxiety, and ultimately powerless. By making mutual connections, however, an energy will be created among group members – one that will bring about healing power. Sessions 4, 5 and 6 will consist of working stage sessions. The focus for members will be on developing new perceptions, learning how the self grows developmentally over time, and how changes in attitude should ideally occur to promote this growth. When change does not occur, members need to express their tensions. These interventions will not stress therapy, but rather instruction with concrete strategies and the promotion of activities geared to improve mood as Dowrick, Dunn, Avuso-Mateos, Page, Casey et al. (2000) recommend. Sessions 7, 8 and 9 will continue to emphasize the connectivity of the group – that is, the “we” of the group. It is a known fact that almost everything can be discussed and resolved under joint problem solving circumstances if clients feel connected to each other. Also, themes related to termination will be interwoven into the sessions, particularly Session 8. Group members will discuss their accomplishments and new feelings of empowerment during the final session. All will be encouraged to attend monthly community-based support groups. Evaluating the GroupA pre and post-test comparison will be employed for evaluating the group to determine the effectiveness of the intervention and if the program met its objectives. Effectiveness will be determined by comparing perceived level of stress and sense of empowerment before and after the program. A survey questionnaire will be developed to obtain data. It will consist of items identifying feelings of depression, sense of stress and sense of empowerment. Program objectives will thus be evaluated. It is expected that feelings of stress, depression, and powerlessness will be much greater before the program as compared to after program completion. Leadership DevelopmentOf the greatest importance to my leadership development will be the way in which I have learned how to handle confidentiality and trust within my group. Quite frankly, I had not thought about this in the past. It is important during group sessions that I give examples of who the group members can and should not talk to as well as what they may talk about. I will also solicit information from the members as to whom they wish to discuss group meetings and what their purpose would be. With regard to group processes and dynamics, I must consider the sociometry of the group in order to better assist all members in reaching their goals of reducing depression and anxiety while at the same time increase feelings of empowerment. Discovering the interpersonal relationships (i.e., indifferences, attractions, etc.) that exist among the members of the group will be important in a number of ways. It will allow me to determine whether or not the group is integrated or fragmented; whether the group revolves around one woman or several; whether a minority group member is perceived to be “out” of the circle; and who is/is not popular. After I construct an observer’s sociogram consisting of my impressions, I will apply my observed information in attempting to improve the cohesiveness of the group. It is important to explain that a sociogram is a way of depicting the relationships between and among group members by drawing circles, then showing member preferences by drawing arrows that point from one circle to another. This technique is used with groups of people after they become acquainted with one another - such as a team, club, therapy group, or class (Westwood et al., 2003; Yalom, 2005). ReferencesBishop, P., Clilverd, A., Cooklin, A., & Hunt, U. (2002). Mental health matters: A multi-family framework for mental health interventions. The Association for Family Therapy and Systemic Practice, 24, 31–45. Colahan, M., & Robinson, P. H. (2002). Multifamily groups in the treatment of young adults with eating disorders. The Association for Family Therapy and Systemic Practice, 24, 17–30. Chan, C.L., Chan, Y., & Lou, V.W. (2002). Evaluating an empowerment group of divorced Chinese Women in Hong Kong. Research on Social Work Practice, 22(4), 558-569. Dowrick, C., Dunn, G., Ayuso-Mateos, J., Dalgard, O. S., Page, H. et al. (2000). Problem solving treatment and group psychoeducation for depression. BMJ, 321, 1450. Accessed online Nov 10, 2007 at http://bmj.bmjjournals. com/cgi/content/ abstract/321/7274/1450 (retrieved 23 August 2001). Corey, M. S., & Corey, G. (2001). Groups: Process and practice (6th ed.). Pacific Grove, CA: Brooks/Cole Ellis, A. (2007). Overcoming resistance: A rational emotive behavior therapy integrated approach. Englewood Cliffs, NJ: Springer Publishing co. Glauser, A. S. & Bozarth, J. D. (2001). Person-Centered counseling: The culture within. Journal of Counseling & Development, 79(2), 142-147. Hammen, C. (2003). Interpersonal stress and depression in women. Journal of Affective Disorders, 74, 49–57. Himle, J.A., Van Etten, M.L., & Janeck, A.S. (2006). Insight as a predictor of treatment outcome in behavioral group treatment. Cognitive Therapy and Research, 30(5), 661-666. Laitinen, I., Ettorre, E., & Sutton, C. (2006). Empowering depressed women: Changes in individual and social feelings in guided self-help groups. European Journal of Psychotherapy and Counselling., 8(3), 305-320. Laitinen, I., & Ettorre, E (2004). The Women and Depression Project: Feminist action research and guided self-help groups emerging from the Finnish women’s movement. Women’s Studies International Forum, 27, 203–21. Lara, M.A., Navarro, C., Acevedo, M., Berenzon, S., Mondrago, L., & Rubi, N.A. (2004). A psycho-educational intervention for depressed women: A qualitative analysis of the process. Psychology and Psychotherapy: Theory, Research and Practice, 77, 429–447 Peden, A.R. (2000). Negative thoughts of depressed women. Journal of the American Psychiatric Nurses Association, 6, 41-48. Peden, A.R., Rayens, M.K., Hall, L.A. & Beebe, L.H. (2001). Preventing depression in high-risk women: A Report of an 18-month follow-up. Journal of American College Health, 49 (6), 299-307. Reiss, H. (2002). Integrative time-limited group therapy for bulimia nervosa. International Journal of Group Psychotherapy, 52(1), 1-26. Tantillo, M. (2006). A relational approach to eating disorders multifamily therapy group: Moving from difference and disconnection to mutual connections. Families, Systems & Health, 24(1), 82-102. Westwood, M.J., Keats, P.A., & Wilensky, P. (2003). Therapeutic enactment: Integrating individual and group counseling models for change. Journal for Specialists in Group Work, 28(2), 122-138. Yalom, I.D. (2005). Theory and practice of group psychotherapy. (5th ed.). New York: Basic Books

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