Difference between revisions of "Adventure therapy"

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==History==
 
==History==
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The use of adventure as a part of healing process can be traced back in history to many cultures including [[Indigenous peoples of the Americas|Native American]], [[Jewish]] and [[Christian]] traditions.<ref name="Parker 1992" /> Tent therapy, emerged in the early 1900s.  This therapy brought certain [[Psychiatry|psychiatric]] patients out of hospital buildings and into tents on the hospital’s lawn.  Many patients showed improvement during this treatment that prompted a series of studies, which failed to present enough evidence to support efficacy.  Literature on this therapy lasted approximately 20 years and then dropped off completely.<ref name="Berman & Davis-Berman 1995" />
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The use of adventure as a part of healing process can be traced back in history to many cultures including Native American, Jewish and Christian traditions.<ref name="Parker 1992" /> Tent therapy, emerged in the early 1900s.  This therapy brought certain [[Psychiatry|psychiatric]] patients out of hospital buildings and into tents on the hospital’s lawn.  Many patients showed improvement during this treatment that prompted a series of studies, which failed to present enough evidence to support efficacy.  Literature on this therapy lasted approximately 20 years and then dropped off completely.<ref name="Berman & Davis-Berman 1995" />
  
 
In the late 1930s this approach reappeared mainly as camping programs designed for troubled youth.  This era influenced the present day use and extent of adventure therapy programs with [[adolescent]]s.  The format for these programs utilized observation, diagnosis and psychotherapy.  One of the first of these programs was [[Salesmanship Club Camp]] based in [[Dallas, Texas]] and founded by Campbell Loughmiller in 1946.  His philosophy of adventure in therapy included the theory that the “…perception of danger and immediate natural consequences for [a] lack of cooperation on the part of [participants]…[after confronting danger] built self-esteem, [while] suffering natural consequences taught the real need for cooperation.”<ref>Berman & Davis-Berman 1995, p.&nbsp;3</ref> These ideas informed some adventure therapy programs
 
In the late 1930s this approach reappeared mainly as camping programs designed for troubled youth.  This era influenced the present day use and extent of adventure therapy programs with [[adolescent]]s.  The format for these programs utilized observation, diagnosis and psychotherapy.  One of the first of these programs was [[Salesmanship Club Camp]] based in [[Dallas, Texas]] and founded by Campbell Loughmiller in 1946.  His philosophy of adventure in therapy included the theory that the “…perception of danger and immediate natural consequences for [a] lack of cooperation on the part of [participants]…[after confronting danger] built self-esteem, [while] suffering natural consequences taught the real need for cooperation.”<ref>Berman & Davis-Berman 1995, p.&nbsp;3</ref> These ideas informed some adventure therapy programs

Latest revision as of 17:48, 21 March 2011

Adventure Therapy as a distinct and separate form of therapeutic process has only been prominent for less than 40 years. Influences from a variety of learning and psychological theories have contributed to the complex theoretical combination within adventure therapy (AT). The underlying philosophy largely refers to experiential education. Existing research in adventure therapy reports positive outcomes in effectively improving self concept and self esteem, help seeking behavior, increased mutual aid, pro-social behavior, trust behavior and more. Even with research reporting positive outcomes it appears that there are many disagreements about the underlying process that creates these positive outcomes.[1][2][3]

Definition

Adventure therapy is the creation of opportunities to explore the unknown in a safe environment through adventure activities. Often adventure therapy is conducted in a group or family context, though increasingly adventure therapy is being used with individuals.[3][4] Adventure therapy approaches psychological treatment through experience and action within cooperative games, Trust activities, Problem Solving Initiatives, High adventure, outdoor pursuits, and wilderness expeditions. Some believe that in adventure therapy there must be a real or perceived psychological and or physical risk generating a level of challenge or perceived risk. Challenge can be viewed as significant in eliciting desired behavioral changes. Positive behavior changes, which are synonymous with psychological healing, can occur through isomorphic connections. An isomorphic connection is transferring learning from a specific experience to other life experiences. Isomorphic connections occur through the structure of framing and activity.[5][6][3] Framing is the creation of a metaphoric theme for a given activity or a series of activities that relates to a targeted treatment issue. Debriefing or processing the experience is a discussion during or after the activity that is related to the frontload, individual, and group treatment issues designed to facilitate isomorphic connections.[7]

Adventure therapy encompasses varying techniques and environments to elicit change. These include cooperative games, problem solving initiatives, trust building activities,high adventure (rock climbing/rappelling, ropes courses, peak ascents); and wilderness expeditions (backpacking, canoeing, dog sledding, sailing, etc).[2][8] Wilderness therapy, adventure based therapy, and long term residential camping are the most common forms of adventure therapy.[2]

History

The use of adventure as a part of healing process can be traced back in history to many cultures including Native American, Jewish and Christian traditions.[3] Tent therapy, emerged in the early 1900s. This therapy brought certain psychiatric patients out of hospital buildings and into tents on the hospital’s lawn. Many patients showed improvement during this treatment that prompted a series of studies, which failed to present enough evidence to support efficacy. Literature on this therapy lasted approximately 20 years and then dropped off completely.[1]

In the late 1930s this approach reappeared mainly as camping programs designed for troubled youth. This era influenced the present day use and extent of adventure therapy programs with adolescents. The format for these programs utilized observation, diagnosis and psychotherapy. One of the first of these programs was Salesmanship Club Camp based in Dallas, Texas and founded by Campbell Loughmiller in 1946. His philosophy of adventure in therapy included the theory that the “…perception of danger and immediate natural consequences for [a] lack of cooperation on the part of [participants]…[after confronting danger] built self-esteem, [while] suffering natural consequences taught the real need for cooperation.”[9] These ideas informed some adventure therapy programs

This period also saw the creation of Outward Bound (OB) in the 1940s by Kurt Hahn.[10][11][12][13][3][4] Outward Bound was a direct response to Lawrence Holt, part owner of the Blue Funnel Shipping Company, who was looking for a training program for young sailors who seemed to have lost the tenacity and fortitude needed to survive the rigors of war and shipwreck, unlike older sailors who, because of their formative experiences on sailing ships, were more likely to survive.[14] In this way Outward Bound was engaging in a form of adventure therapy - intervening in the lack of tenacity through the use of challenging adventure training.

In the 1960s OB came to the United States through the OB school in Colorado[3][15] Outward Bound programs in Colorado and other schools quickly began to use Outward bound as an adjunctive experience work with adjudicated youth and adults (one of the first programs in 1964 offered recently released prisoners a job at Coors Brewery if they completed a 23 day course). In the late 70's Colorado Outward Bound developed the Mental Health Project. Courses were offered to adults dealing with substance abuse, mental illness, being a survivor of sexual assault and other issues. In 1980 Stephen Bacon wrote the seminal text in Adventure Therapy The Conscious Use of Metaphor in Outward Bound which linked the work of Milton Erickson and Carl Jung to the process of Outward Bound.

Project Adventure, adopted the OB philosophy in a school environment and brought the ropes course developed at the Colorado Outward Bound School into use at schools. Project Adventure staff including Karl Rohnke are credited with developing many of the cooperative games, problem solving initiatives, trust activities, low elements, and high elements. PA first emerged in Hamilton-Wenham High School in Massachusetts in 1972 with a principle named Jerry Peih, son of Robert Pieh founder of the Minnesota OB School. Jerry Peih wanted to bring the concepts behind the Outward Bound schools, developing self-esteem and self-confidence through mentally and physically straining and stressful situations, to classrooms.[10][11][12][16][13][17][3][18][4] PA programs were often used at part of the health curriculum in PE programs.

Eventually Paul Radcliffe, a PA trained facilitator and school psychologist, Mary Smithy a PA staff member along with a social worker from Addison Gilbert Hospital, started a 2 hour weekly outpatient group. Eventually this model was incorporated into school psychological services and was called the Learning Activities Group.[18] This later grew into Adventure-Based Counseling (ABC), a project adventure term that reflects the therapeutic use of adventure activities.[16]

Theory

Adventure therapy theory draws from a mixture of learning and psychological theories. The learning theories include contributions from Albert Bandura, John Dewey, Kurt Hahn, and Kurt Lewin. These theorists also have been credited with contributing to the main theories comprising experiential education. Experiential education is a theoretical component of adventure therapy.[19][11][20] The ideas and thinking of Alfred Adler, Albert Ellis, Milton Erickson, William Glasser, Carl Jung, Abraham Maslow, Jean Piaget, Carl Rogers, B.F. Skinner, Fritz Perls, and Viktor Frankl all appear to have contributed to the thinking in adventure therapy. Adventure therapy is a cognitive-behavioral-affective approach which utilizes a humanistic existential base to strategically enact change through direct experience through challenge.[21][2][22][8][23][24][18][25][26]

This theory, though, has been questioned extensively. These questions cover many issues. With all the importance that is placed upon adventure therapy as a therapeutic intervention, the research is restricted to cooperation and trust, and even less research examines therapeutic techniques with adventure therapy and outcomes on pathology.[11] The adventure therapy research field is having difficulty answering the basic questions of how, what, when, where and who. Further research on the standards, requirements, education, and training for individuals conducting adventure therapy is required.[11] The research is based upon the examination of self-concept and social adjustments.[4] In a meta-analysis study to statistically integrate all the available empirical research on adventure therapy, 99 studies were found covering a 25 year span.[27] Out of the 99 studies located, only 43 studies fit the criteria for analysis. Many of the studies excluded were dissertations and the authors stated that dissertation studies did not accurately represent the field of adventure programming. The 43 studies used varied in design, methods, and treatment goals. They report that the limited amount of studies for their meta-analysis is proof of the limitations in the research in adventure programming.

The major theme of these questions about adventure therapy is effectiveness. A group has emerged arguing that before any other question in adventure therapy can be answered the question what are the properties that influence the effectiveness of adventure therapy must be answered. This group argues that theory driven research instead of outcome driven research will answer this question. Outcome driven research means that outcomes are the source of explanations for AT theoretical structure.[28] Outcome driven research has generated many conflicting findings that confuse theoretical structure and explanations of effectiveness.[28][29] The outcomes in adventure therapy research are linked to existing psychological theories of change to explain, modify, or validate AT theory. The theories of change have upwards of 400 forms of therapy and related practices that have emerged from a conglomeration of psychological theories.[29] When outcomes are tied to existing psychological theories within the 400 forms of therapy it is impossible to understand the underlying influences of AT.

With all the research to date and the numerous reports of positive outcomes, there is still little understanding of the underlying processes influencing these positive outcomes.[28] This has caused extensive discussion concerning why adventure therapy appears effective in treating a multitude of DSM related mental disorders in children, adolescents, and adults.[11][2][6] Several researchers have attempted to explain the underlying process to adventure therapy.[11][20][2][30][6][22][31][32][17][19][4]

Adventure therapy is described as non-traditional therapy allowing for the pre-therapeutic adolescent to experience their mental health issues,[6] with several theoretical aspects: 1) it is a physical augmentation to traditional therapy for the purpose of a shared history with the participants and the therapist, 2) there is a sense of natural and logical consequences in the activities, 3) environment should be structured into the activities, 4) a participant perceives risk, stress, and anxiety so the they can problem solve and generate their own sense of community for feedback and behavior modeling, 5) participants will transfer their present attitudes and behaviors into the activities, 6) works with a small group of participants, and 7) requires a facilitator that models appropriate behaviors and guides the group towards adaptive self regulation that is based upon appropriate behaviors.[6]

Adventure therapy has normalizing effects on deficits in delinquent adolescent’s developmental process,[17] as a process of moving into formal operational thinking which is achieved through the experiential learning theories.[17][31] A therapist holds the skills to make the adventure experience a therapy.[17] The theoretical basis of adventure therapy describes the participant as a learning being who achieves their greatest learning outside the classroom, through challenge and perceived risk, promoting social skills through experiencing a group challenge mixed with affect, cognition, psychomotor activity and formal operational thinking generated through metaphor.[19][11][20] Experiential learning becomes adventure therapy when the activities are planned and implemented as vehicles for patients to address individual treatment goals.[32] Adventure experiences molded into a more therapeutic group model ran by the therapist can have a more significant effect than the one day intervention run by counselors.[32] It is important to have the clinician as an integral part of the adventure therapy process so that there can be a strong transference of the adventure experience to other aspects of the therapeutic process.[4]

Baldwin, Persing, and Magnuson, though, report that many of these explanations are “…folk pedagogies…” that lack thorough empirical evidence.[33] Adventure therapy research has focused on outcomes without exploring theoretical structure.[34] The focus of AT research needs to concentrate on testing and validating theoretical structure.[34] Adventure therapy’s theoretical structure must be studied and documented.[28] After a theoretical structure is validated then a discussion on outcomes can occur.[34]

Effectiveness

Even though there are certain arenas that question the theory of adventure therapy, the practice of adventure therapy continues because of numerous reported positive outcomes in adventure therapy research. A study of the effects of adventure therapy on 266 high risk youth in rural areas reported lasting improvement in behavior over a six-month period.[35] Another study on adventure therapy effectiveness reports that adventure therapy is effective because specifically designed activities can bring about specific outcomes.[36]

Adventure therapy is further viewed as effective because of the apparent positive effects in treating developmental issues with juvenile offenders and adolescent offenders with drug abuse and addiction issues.[31] The effectiveness of adventure therapy with offenders with drug abuse and addiction issues in mental health treatment is related to the characteristics present in addicted offenders. They “…(1) need more structure, [and] (2) they work better with an informal, tactile-kinesthetic design….”[37] Adventure therapy as treatment is equally effective for adjudicated youth and other adolescent populations.[27][31] 62.2% of adolescents who participated in an adventure therapy group are at an advantage for coping with adolescent issues than adolescents that did not.[27] There is a 12.2% improvement in self concept for adolescents who participate in adventure therapy.[27] Adolescents are approximately 30% better off in their ability to cope with mental health issues than those that do not participate in a psychotherapeutic treatment making the implication that adventure therapy effectiveness is comparable to the effectiveness of psychotherapeutic treatment.[27][38]

The concepts contributing to adventure therapy effectiveness are: increases in self esteem, self concept, self efficacy, self perceptions, problem solving, locus of control, behavioral and cognitive development, decreases in depression, decrease in conduct disordered behaviors, overall positive behavioral changes, improved attitude, and that adventure therapy generates a sense of individual reward. Further aspects that contribute to adventure therapy’s effectiveness are that it: increases group cohesion, aids in diagnosing conduct disorders in adolescents, improves psychosocial related difficulties, is effective in treating drug addicted and juvenile youth, treats sensation seeking behaviors, improves clinical functioning, facilitates connecting participants with their therapist and treatment issues, and increases interpersonal relatedness.[39][40][41][11][12][16][42][30][13][19][43][3][30][44][4]

When comparing the reduction in recidivism rates with traditional programs and programs with adventure therapy, programs using adventure therapy have lower recidivism.[1] There is an increases in interpersonal relatedness, which has been describe as the most important factor for improving mental health issues.[11][4]


Notes

  1. ↑ 1.0 1.1 1.2 Berman & Davis-Berman 1995
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 Gass 1993
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 Parker 1992
  4. ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 Ziven 1988
  5. ↑ Bacon 1983
  6. ↑ 6.0 6.1 6.2 6.3 6.4 Gillis 2000
  7. ↑ Weinberg 2002
  8. ↑ 8.0 8.1 Itin 1995
  9. ↑ Berman & Davis-Berman 1995, p. 3
  10. ↑ 10.0 10.1 Aghazarian 1996
  11. ↑ 11.0 11.1 11.2 11.3 11.4 11.5 11.6 11.7 11.8 11.9 Blanchard 1993
  12. ↑ 12.0 12.1 12.2 Dickens 1999
  13. ↑ 13.0 13.1 13.2 Glass 1999
  14. ↑ http://www.outwardbound.net/about/history/ob-birth.html
  15. ↑ see Outward Bound USA
  16. ↑ 16.0 16.1 16.2 Gillis & Simpson 1992
  17. ↑ 17.0 17.1 17.2 17.3 17.4 Maizell 1988
  18. ↑ 18.0 18.1 18.2 Schoel, Prouty, & Radcliffe 1988
  19. ↑ 19.0 19.1 19.2 19.3 Moote & Woodarski 1997
  20. ↑ 20.0 20.1 20.2 Davis, Berman, & Capone 1994
  21. ↑ Calver 1996
  22. ↑ 22.0 22.1 Gillis & Thomsen 1996
  23. ↑ Kimball & Bacon 1993
  24. ↑ Nadler 1993
  25. ↑ Schoel & Maizell 2002
  26. ↑ West-Smith 1997
  27. ↑ 27.0 27.1 27.2 27.3 27.4 Cason & Gillis 1994
  28. ↑ 28.0 28.1 28.2 28.3 Baldwin, Persing, & Magnuson 2004
  29. ↑ 29.0 29.1 Ringer & Gillis 1996
  30. ↑ 30.0 30.1 30.2 Gillis (without year)
  31. ↑ 31.0 31.1 31.2 31.3 Gillis & Mcleod 1992
  32. ↑ 32.0 32.1 32.2 Hatala 1992
  33. ↑ Baldwin, Persing, & Magnuson 2004 p. 172
  34. ↑ 34.0 34.1 34.2 Hattie, Marsh, Neill, & Richards 1997
  35. ↑ Davis, Ray & Sayles 1995
  36. ↑ Haris, Mealy, Mathews, Lucan, & Monczygemba 1993
  37. ↑ Gillis & Mcleod, 1992, p. 151
  38. ↑ Smith, Glass & Miller 1980
  39. ↑ Baucom, Gillis, Durden, Bloom & Thomsen 1996
  40. ↑ Gillis 1992
  41. ↑ Burney 1992
  42. ↑ Gillis, Simpson, Thomsen & Martin 1995
  43. ↑ Newberry & Lindsay 2000
  44. ↑ Teaff & Kablach 1987

References

Aghazarian, T. L., (1996) Use of a challenge course as an intervention tool to adolescent self-esteem. Unpublished doctoral dissertation, San Jose State University, California.
Baldwin, C., Persing, J. & Magnuson, D. (2004). Role of theory, research, and evaluation in adventure education. Journal of Experiential Education, 26(3) 167-183.
Baucom, L., Gillis, L., Durden, J., Bloom, S. & Thomsen, D. (1996). A brief report on project adventure’s project challenge: an alternative to juvenile incarceration funded by the state of Georgia division of children and youth services. Hamilton, MA: Project Adventure.
Berman, D. S. & Davis-Berman, J. (1995). Outdoor education and troubled youth [on line]. Available: http://www.aee.org
Blanchard, C. (1993). Effects of ropes course therapy on interpersonal behavior and self esteem of adolescent psychiatric inpatients. Unpublished doctoral dissertation, New Mexico State University, New Mexico
Burney, J. (1992) Learning the ropes of problem solving and self control: A study of an experiential ropes program for special education students. Unpublished doctoral dissertation, The Union Institute, Cincinnati.
Calver, R. (1996). Theory for practice: A frame work for thinking about experiential education. Journal of Experiential Education, 19 p. 8-13.
Cason, D. & Gillis, H. L. (1994) A meta-analysis of outdoor adventure programming with adolescents. The Journal of Experiential Education Vol 17(1).
Davis, D. Ray, J. & Sayles, C. (1995). Ropes course training for youth in a rural setting: “At first I thought it was going to be boring…” Child & Adolescent Social Work Journal, 12, 445-463.
Davis-Berman, Berman and Capone (1994). Therapeutic wilderness programs: A national survey. Journal of Experiential Education, 17 (2), 49-53.
Dickens, J., C. (1999) Behavioral indicators of conduct disorder in a ropes course initiative. Unpublished doctoral dissertation, The Union Institute, Cincinnati.
Gass, M. A. (1993). Adventure in therapy: Therapeutic applications of adventure programming in mental health settings. Boulder, CO: Association for Experiential Education.
Gillis, H.L. (without year) If I conduct outdoor pursuits with clinical populations, am I an adventure therapist [on line]. Available: http://www.aee.org
Gillis, H.L. (1992) Therapeutic uses of adventure-challenge-outdoor-wilderness: theory and research. Paper presented at the Coalition of Reeducation in the Outdoors Symposium Bradford Woods Indiana University, Martinsville, IN [on line]. Available: http://fsda.gcsu.edu.
Gillis, H.L. (2000) Going around in circles research and program evaluation in therapeutic adventure and adventure in therapy. Paper presented at the Second International Adventure in Therapy Conference: Therapy Within Adventure 23 March 2000 – Augsburg / Germany.
Gillis, H. L. & McLeod, J. (October, 1992) Successful indoor adventure activities for treating substance abuse with adjudicated adolescents and incarcerated adults. Proceedings of the 20th International Conference of the Association for Experiential Education.
Gillis, H. L. & Simpson, C.A. (1992). Project Choices: Adventure based residential drug treatment for court referred youth. In M. A. Gass (Ed) Adventure therapy: Therapeutic applications of adventure programming in mental health settings Boulder, CO: Association for Experiential Education.
Gillis, H.L. Thomsen, D. (1996) A research update of adventure in therapy (1992–1995) Challenge activities and ropes courses, wilderness expedition, and residential camping programs. U.S.: Georgia
Gillis, H.L., Simpson, C. A., Thomsen, D. D., & Martin, B. A. (1995). Final evaluation of project adventure’s co-op program for court referred, drug involved youth. [on line] http://www.aee.org
Glass J. S. (1999) The relationship of participation in a low-element challenge course to adolescent’s self reported perceptions of group cohesion. Unpublished doctoral dissertation, University of North Carolina, Greensboro.
Harris, P. M., Mealy, L., Matthews, H., Lucas, R., & Mcozygemba, M. (1993). A wilderness challenge program as correctional treatment. Journal of Offender Rehabilitation, 19, p. 149-164.
Hatala, E. (1992) Experiential learning and Therapy. In Hanna Glenda (Ed) Celebrating our tradition Charting our Future: Proceedings of the International Conference of the Association for Experiential Education. Alberta, Canada.
Hattie, J., Marsh, H. W., Neill, J. T., & Richards, G. E. (1997). Adventure education and outward bound: Out-of-class experiences that make a lasting difference. Review of Educational Research, 67, 43-97
Itin, C. (1995). Adventure therapy and the addictive process. Journal of Leisurability, 22. http://www.lin.ca/resource/html/Vol22/v22n2a5.htm
Kimball, R.O., & Bacon, S. B. (1993) The wilderness challenge model. In M. Gass (1993) Adventure therapy: Therapeutic applications of adventure programming, Kendall/Hunt, Dubuque, Iowa.
Maizell, R. S. (1988) Adventure-based counseling as a therapeutic intervention with court-involved adolescents. Dissertation Abstracts International, 50/06-B, 2628.
Moote, G. T, Jr., & Woodarski. J. S. (1997). The acquisition of life skills through adventure-based activities and programs: A review of the literature. Adolescence, 32, p. 143-167.
Newbarry, E. H., & Lindsay, J. F. (2000). The impact of social skills training and challenge course training on locus of control of youth from residential care. Journal of Experiential Education 23(1) p. 39-42.
Nadler, R. S. (1993). Therapeutic process of change. In M. Gass (1993) Adventure therapy: Therapeutic applications of adventure programming, Kendall/Hunt, Dubuque, Iowa.
Parker, M. W. (1992). Impact of adventure interventions of traditional counseling interventions (ropes course). Unpublished doctoral dissertation, The University of Oklahoma, Oklahoma.
Ringer, M. & Gillis H. L. (1995). Managing psychological depth in adventure programming. Journal of Experiential Education, 18(1) 42-50.
Schoel, J. & Maizell, S. (2002). Exploring islands of healing: New perspectives on adventure based counseling. Project Adventure; Beverly, MA.
Schoel, J. Prouty, D., & Radcliffe, P. (1988). Islands of Healing: A Guide to Adventure Based Counseling. Hamilton, MA / Project Adventure.
Simpson, C.A. & Gillis, H.L. (without year) Working with those who hurt others: adventure in therapy with juvenile sexual perpetrators [on line]. Available: http://fdsa.gcsu.edu
Smith, M. L., Glass, G. V., & Miller, T. I. (1980). The benefits of psychotherapy. Baltimore: Johns Hopkins University Press.
Teaff, J. & Kablach, J. (1987). Psychological Benefits of outdoor adventure activities. Journal of Experiential Education, 10 n2 p. 43-46
Weinberg, P. (2002). The challenge course as a therapy: A literature review on effectiveness, theory, and research. Unpublished masters thesis, Saybrook Graduate School and Research Institute, San Francisco.
West-Smith, L. (1997). Basic therapeutic communication: Theoretical and practical information for outdoor adventure professionals. Journal of Experiential Education, 20.
Ziven, H. S. (1988) The effects of the challenge group treatment program on psychiatrically hospitalized adolescents. Unpublished doctoral dissertation, Massachusetts School of Professional Psychology, Massachusetts.
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