Forming Groups

Group formation begins with an idea of how people ought to be assembled and a theory of how, in that context, they might improve their chances for health and happiness. Most ideas for assembling patients spring from perceived similarities based on what people have experienced and how they think and act, with the assumption that the closer the match between the people gathered, the better the outlook for progress. Most theories for improvement share the assumption that people must interact in some way in order for personal changes to come about. Both of these concepts have generally proven quite useful in the practice of group psychotherapy, and have alleviated suffering and enhanced the quality of lives. Let’s take a closer look at the manifold and intricate ways that groups can form.
It has been customary for comprehensive group therapy programs to organize treatment groups on the basis of two criteria: (1) the presenting symptoms or underlying pathology of the patients and (2) the theoretical approach of the therapists conducting the groups— cognitive-behavioral, psycho-educational, psychodynamic, interpersonal, Transactional Analysis, object relations, and systems theories, among others. In practice, this means that treatment groups are formed around the way patients’ needs are perceived by entry personnel and diagnosing clinicians and the way group therapists believe the treatment should proceed. In forming groups, three questions are salient for group therapists: Who shall attend? How will they get there? What will we do once they have arrived? In theory, these three steps should flow as a seamless whole. In practice, their integration is far from seamless, and the details of how each step is accomplished is well worth examining. In this chapter, we look at the complexity of both patient selection and therapist theoretical approach as they combine in the formation of treatment groups. How patients get to the right groups is the focus of Chapter Four.

PATIENT SELECTION: THE COMPLEXITY OF A HOMOGENEOUS GROUP STRUCTURE

Most therapy groups provided by managed mental healthcare systems will be labeled according to the presenting problems of the participating patients (crisis groups, male battering groups, coping-with-loss groups) or their symptoms and illnesses (depression groups, eating disorder groups, posttraumatic stress groups). Entry units or referring clinicians will then send patients to these groups in an attempt more or less to match the homogeneity presupposed by the group names. Various theoretical methods are then applied to the people assembled. It’s important to examine the structure of these homogeneous groups.

Leo Tolstoy commented that “All happy families resemble one another, but each unhappy family is unhappy in its own way.” It seems compelling, then, for group therapists to find out how each of the members in their homogeneous groups suffer in their own characteristic fashion.

Homogeneity is stressed in the literature of short-term or time- limited group therapy as a factor in allowing rapid cohesion to occur. The unifying themes around which groups have traditionally been organized have been age related (mastering an adult developmental task, such as retirement or parenthood), symptom related (managing depression), crisis related (coping with the stress of divorce or job loss), related to chronic illness or death (coping with the loss of a loved one or the pain and anxiety associated with chronic illness), or trauma or violence related (groups for battering males or survivors of abuse). It is important to note that even with the best intentions of clinicians in selecting patients for their groups, in practice the so-called homogeneous groups will have a good number of each of these themes present at any one time. Thus, the person who finds herself referred to a depressed group may discover people in crisis, suffering from a chronic illness, or facing the death of an aging parent. The label given a particular group is most useful to clinicians in organizing people into convenient units for treatment, but the label can never completely define the treatment process that evolves for the individuals in a specific group. As the systems thinker Ludwig von Bertalanffy has said, “The map is not the territory.” We should not mistake useful theoretical constructs, such as homogeneous groups, for the actual groups in which people struggle to affiliate and differentiate from others.

In a certain sense, all people who enter group therapy belong to a homogeneous group, that is, that set of people who have chosen to join a group for whatever reason. We know that people who do, represent a minority—although a significant one—of all the people who seek mental healthcare. We know there are factors, such as access to information about group therapy, the availability of groups, and the general appropriateness of patients, that strongly influence who joins. If there are self-selecting factors at work in the process of why a person chooses to enter group therapy, we know virtually nothing about them. Given that all people who enter group have at least one thing in common by virtue of their membership in a group, it seems important to investigate both what brought them to group and the similarities and differences among them.

Undoubtedly, patients can identify best with others experiencing similar problems—and this is often stated by patients when asked how their group treatment has been helpful or meaningful to them. The phenomenon is known as universalization, and is one of the curative factors in brief group psychotherapy. Yet the identification with similarities in others can prove to be a pseudo-mutuality that, if not confronted or at least acknowledged, can lead to serious misconceptions about what an individual must do in order to make changes in his behavior and better adapt to the social environment in which he lives and works.

This is one of the critical elements that distinguish psychotherapy groups from support groups. Therapy groups can be supportive and often are, but support groups are rarely therapeutic unless they challenge the maladaptive behavior of the individual. To rest in the safety zone of “homogeneity” and never see the very real differences that exist between individuals in a group setting is to retreat from the hard therapeutic work that is possible in short-term group therapy. That work entails perceiving differences within obvious similarities and working through the inevitable conflicts that ensue. This is one of the significant factors in Phase 2 of Ariadne P. Beck’s theory of group therapy development, which I discuss in Chapter Eleven.

PROBLEMS IN FORMING GROUPS

Planning what to do in a particular group will relieve much of the group therapist’s anxiety and is recommended for the clinician, especially in the early stages of his professional development, as I outline in Chapter Nine. But the best efforts at planning are often undone by three phenomena that occur regularly in group therapy: (1) the inevitable uncertainty and imperfections of our criteria for patient selection, (2) the disheartening paradox of unintended consequences, and (3) the surprising tendency for different patients to need different approaches in the same group. The first frustrates our attempts to assess the needs of our patients and classify them as a group in the hope that they will respond positively to our methods. The second undermines our belief that we can be in control of what happens in our group. The third awakens us to the fact of individual difference, which requires us as therapists to be flexible in the application of any of our theories to our groups. These three phenomena are contingency factors, and together they exert considerable power in the functioning of a group. I will give examples of how they affect our ability to assess and treat patients.

Uncertainty in Patient Selection

This contingency does not have to be a major obstacle in organizing a group of patients unless the group therapist is driven to adhere to rigid criteria for selection. Flexibility is the key to negotiating this difficulty. Some patients who do not meet the exact criteria for admission to your group may in fact work out quite well. For example, borderline personalities who somehow manage to make it into your homogeneous depressed group may prove to be a cathartic stimulus to otherwise inert and withdrawn group members. The schizoid person may become deeply loved by fellow group members who are coping with the drama of multiple crises, because they admire how well she contains her emotions. What if a patient presents with dysthymia and yet has a significant anxiety component that complicates the picture? Is she a candidate for a depression group or an anxiety group or another group entirely? Henry Spitz, in his text Group Psychotherapy and Managed Mental Health Care, takes note of dilemmas of this sort and addresses them from the point of view of diagnosis as it relates to treatment protocols for group therapy.

Professional modesty dictates that we recognize our mistakes in patient selection for groups. How we as clinicians respond to our mistakes and how we protect our patients from damage are essential features of our skill as group therapists.

Unintended Consequences

When a group therapist plans a group, he is most often responding to a need perceived among the patients entering the managed mental health system by whatever means. He intends to provide the patients he selects (or who are selected for him by entry personnel or by a group therapy case manager thoroughly acquainted with the criteria for inclusion) with a group experience that addresses their most salient mental health issue. The group therapist believes he can anticipate what that most salient issue will be for the individuals coming to his group. However, as the following incident demonstrates, that is not always the case.

I once designed, after lengthy pre-group interviews, a group of men and women whom I perceived as “depressed outpatients” with no other defining characteristics in common. They became the core group members for an ongoing group, one open to referral with an ever-changing constellation of patients.

After several weeks, I watched the men drop out for various reasons, and I could only come up with women to replace them. One night in group, my female assistant therapist commented on the discrepancy between what we had intended and what was actually happening. We were surprised to learn that the group was pleased with an all-female membership. With that in the open, each woman spontaneously began to uncover for the first time her history of sexual abuse. I was deeply moved when my co-therapist revealed that she herself had been abused as a child. Although I had organized this group, I was the last to discover the purpose for its organization.

In another instance, my co-therapist and I planned to exclude suicidal patients from our ongoing group for people coping with loss. All patients had lost a family member or friend to death and were suffering various degrees of inconsolable bereavement—in some cases com- plicated by the patients’ own loss of physical health or vitality. Although suicidal ideation was a topic of discussion in the group, we had carefully referred to other groups all persons who had a history of suicide attempts or threats. We were not prepared for the suicide of two of our members within the first year—even though we were quite aware that this population was at risk to do so. We had somehow believed that planning would insulate our group from such traumas.

The group task became coping with the loss of group members and discovering personal reasons for living. Seeking a purpose in life had very practical implications for these people and was not in the least an idle philosophical pursuit.

Different Patients Need Different Approaches

Group therapists must always be cautious of a “one size fits all” approach to the treatment of their patients. One example is the limitations of the “here and now” orientation—a method widely recommended for time-limited group therapy. This orientation confines the interaction of the group members and leaders to what is happening among the people in the room during the meeting. Such a practice seeks to avoid time-consuming digressions into the past or patients’ telling stories about what happened “then and there”; this approach, in the presence of a skillful therapist who acts as guide, seeks instead to maximize the potential for patients to work through some of their problems relating with peers and their distortions about how they per- ceive themselves. For example, when a patient reacts strongly in conflict with others in the group, the group therapist does not respond with the question, “Have these kinds of conflicts happened before at other times in your life?” but rather with the question, “What can you do now to resolve this issue for yourself ?” The therapist strives to keep the focus of the work on the members present in the treatment room. In this way, the group concentrates on the stages of its own development, being cognizant of approaching termination and looking for ways to apply outside of group what each member has learned through the group. This can be an excellent process to follow, if all the individuals who compose the group can benefit from staying so narrowly focused.

However, stringent adherence to this method may severely limit what some individuals could accomplish in group, because patients work differently to accomplish their goals. For example, a man whose remembrance of a forgotten, traumatic scene from his past is stimulated by his participation in group will need to return to that scene in a powerful way that will help resolve the issue that feeds his current anxiety. To back away from that work because it does not fit the format of the group is a disservice to the patient, who did not ask to have his memory activated in that way and could not have predicted that it would be recalled with such force. Part of the knowledge and preparation needed to be a group psychotherapist includes a deep appreciation for the distinctive ways in which our patients suffer. In this respect, there is no substitute for the art of listening and responding to the special needs of human beings as they sit together in a group. This skill always demands great flexibility on the part of the clinician and demonstrates the high art of group therapy practice.

Exclusive focus on here-and-now interactions among group members without reference to the historical antecedents that give the interactions deeper meaning can be, in some instances, an abdication of responsibility by the group therapist, who may be missing an opportunity to teach her patients something revealing about themselves. Group therapists must embrace both a here-and-now focus and historical analysis. A high level of skill is required to make interventions of this order in short-term work, yet group therapists must not be discouraged from doing so. (In Chapter Six, I give an example of how this can be done.)

PLANNING FOR A STAFF MODEL HMO

At the Mental Health Service of the Group Health Cooperative of Puget Sound, the goals of treatment were the reduction of presenting symptoms and an increase in the ability to function at work, in family relationships, and in personal friendships. The goal was not personality change.

Treatment Groups

We organized three tiers of treatment groups. The first consisted of crisis-oriented, immediate-access groups that treated relatively homogeneous populations in ongoing groups of ever-changing constellations, ranging from five to twelve persons in each group. Patients averaged eight sessions of group attendance, with a range of one to thirty sessions over the course of a year. Each session was ninety minutes long. Eighteen percent of patients attended just a single session. A patient’s leaving after one session of group was not necessarily considered premature termination for this group. Sometimes, one session was sufficient to address the needs of a particular individual: some wanted simply to know they were not crazy; some decided they did not want to work in the group format. Those dissatisfied with the treatment offered could return to entry personnel for assignment to another mode of treatment.

The second tier consisted of time-limited groups, usually lasting ten to twelve weeks, that focused on a particular topic relevant to the concerns of the individuals selected for the group. Eight to twelve patients were screened for inclusion in these groups by entry personnel and by individual clinicians who referred them directly to the groups. Some groups were psycho-educational in nature, and other groups allowed patients the option of renewing membership for another twelve-week course of treatment, depending on the goals of treatment. Patients committed themselves to coming for the time-limited periods, and changes in the constellation of the groups were not permitted during each twelve-week period. Personality disorders were not excluded from these groups, unless object relations were severely disturbed and precluded the ability to listen and communicate mini- mally in a group setting. The maximum duration of these groups was three to six months. These first two tiers defined short-term group therapy as we practiced it.

We did experiment with a third tier of longer-term groups for less than 10 percent of our treatment population. Roy MacKenzie estimates that 15 percent of the population will be highly disturbed and require ongoing maintenance therapy in groups to prevent hospitalization or decompensation or both. This 15 percent may include a sizable number of high medical utilizers, depending on their diagnoses. It is there- fore in the interest of the organization to develop special groups to give these people a sense of belonging that is denied them in the larger social sphere. Veterans Administration Mental Hygiene Clinics successfully conducted groups of this nature for many years; my mentor Donald Shaskan was one of the clinicians who pioneered their implementation. These patients need a substantial organizational commit- ment and may require years of maintenance doses of group treatment in order to facilitate their adaptation to life.

Time of Group Meetings

In assessing the needs of outpatients, the practitioner of group therapy clearly understands that most people work during the day and are therefore available to meet together only in the evenings. This means that group therapists must plan to meet with their groups at 5 P.M. or after. At Puget Sound, groups were scheduled regularly at 5:30 P.M., and a second round of groups was scheduled at 7:30 P.M.

Group Therapists and Co-Therapists

All crisis-type groups were organized to be led by co-therapy teams. This plan was adopted for two reasons: (1) so that groups could meet every week without interruptions caused by therapist sickness or vacations, and (2) as a provision of therapist self-care. Our Group Therapy Committee judged that it was clinically too challenging, and therefore unwise, for a therapist to contain the trauma of patients week after week without the comfort and collaboration of a co-therapist. In addition, because it takes time to learn how to become a co-therapy team, co-therapists who had worked together before in a number of groups were given priority status to lead crisis-type groups. The group therapy coordinator’s role as consultant and supervisor to crisis teams proved to be invaluable in maintaining the professional equilibrium and personal equanimity of teams exposed to such high levels of stress.

Time-limited groups of a noncrisis nature were usually conducted by a solo therapist. Couples groups were an exception: male-female co-therapy teams were preferred because the patients benefited from seeing a man and woman model equal communication and respect for each other. Weekend groups that met once or twice to address such special topics as Redecision Therapy (see Chapter Six) or assertiveness training were also co-led when the group ranged in number from twelve to twenty-four persons.

A TALE OF TWO GROUPS

In the following section, I will examine two examples of homogeneous groups that were created by two separate mental health clinics to serve the needs of two discrete populations of depressed outpatients. It is instructive to see how both mental health clinics assessed their patients similarly and yet structured group services on theoretically different premises.

I will compare a homogeneous group for depressed outpatients treated at the Central Mental Health Service of Puget Sound with a cognitive psychotherapy group of depressed individuals at the Gundry Hospital of Baltimore, Maryland. Both groups functioned in an open- ended manner, that is, accepted patients into ongoing groups whose constellations were always changing. Both embraced the objectives of helping patients achieve relatively rapid and long-lasting alleviation of depression. Both clinics preferred the open-ended format because it allowed greater flexibility in recognizing the differences among patients regarding the time they required to meet the stated treatment objectives. Co-therapy was a standard of practice in both formats.

It is ironic and therefore important to note that both group approaches reported similar levels of success in the treatment of depressed patients, despite the widely differing theoretical orienta- tions of the respective group leaders. This outcome lends support to one of the more infuriating paradoxes that emerge in groups: “Group members get better in spite of our theories, not because of them.” There are factors inherent in group process itself, some more definable than others, that contribute to the positive outcome of meeting in groups. Those clinicians and managers who assess patient needs and structure group services must keep this idea in mind: it may be the group itself and not our beliefs about how to conduct the group that is most decisive in producing results.

Depressed Group at Puget Sound

This depressed group was called into being in order to meet the needs of depressed outpatients who were referred directly to the group by clinicians or trained entry personnel. The leaders did not interview candidates before they entered group, but trusted the judgments of their colleagues and entry staff. The co-therapists defined their method as analytic-expressive with a touch of behavioral conditioning tossed in.

Although we called the group a homogeneous group, that term must be qualified in light of the people who actually came to the sessions. It might be helpful to refer to the assessment chain that we used to further differentiate the patients who were appropriate referrals to our group. The people who were judged suitable for a homogeneous depressed group were at the same time judged suitable for a heterogeneous group with regard to the presence of the following characteristics:

Assessment Chain for Referrals

Emerging crisis that produces depression

Medical illness that causes reactive depression

Agoraphobic and socially isolated depression

History of trauma

Chronic or organic depression without identifiable crisis

No medical illness

Sociability complicated by anxious depression

No history of trauma


This list of the chain of possibilities that must be considered in the assessment of a patient before entering group illustrates the complexity in structuring a “homogeneous” group for depressed out- patients.

The majority of the patients who attended our group were in their thirties and forties, with an age range of twenty-two to fifty-five years. The majority conformed to the DSM-III diagnosis of Dysthymic Disorder and reported suffering depressive episodes of various duration of two years or longer. In all, 25 percent of group members were pre- scribed medication, mostly tricyclic antidepressants or lithium carbonate. A total of 20 percent were without jobs upon entry into group, and over half stated they lacked a stable love or friend relationship.

Three criteria emerged as indicators of success in overcoming depression for this group of people: (1) the patient discontinued medication upon mutual agreement of therapists and patient that it was no longer needed to maintain control of mood; (2) the patient obtained a job, or found a new position that was more satisfactory from the patient’s point of view; (3) the patient established a relationship or friendship that met some of his needs. On the basis of these criteria, we discovered that a majority of the group members who stayed beyond one session experienced a modicum of success on one or more dimensions. The group met for ninety minutes each week; the average course of treatment was eight sessions.
As co-therapists, we did not avoid using the word depressed to designate our group. It was posted prominently on the group therapy roster board visible as people entered the Mental Health Service. We produced a two-page, five-by-eight-inch salmon-colored flier entitled “Depressed Group,” which was given to each patient referred to the group. The flier stated the following:

Being depressed is a dead-end position. We may feel dead inside and have no energy to be involved with others. We may feel worthless inside with nothing to give. People often isolate themselves during periods of depression. We feel sorry for ourselves and show a lack of interest in other people and things. When depressed, the world becomes a narrow place—and we can see very little that seems exciting, challenging, or pleasurable to us. We may also feel helpless—that whatever could be enjoyable to us is unattainable.

WHY A GROUP?

A group helps you switch focus from the self-absorption of being depressed to re-entry into the world of the living. We will practice using our sense of humor to activate ourselves—but not in a way that group members will feel put down or made fun of. Group leaders will be there to assist and will attempt to help each member. The group will discuss how we often become depressed to avoid taking an action or making a decision. As trust grows and a safe feeling develops, the group will encourage you to take the risk of being undepressed, which may be a new and unfamiliar experience for you.

Characteristically, patients in this group held fast to their depression as a possession—yet spoke as if it controlled them. For these patients, inclinations to rescue others in the group competed with equally strong urges to become withdrawn and self-absorbed in melancholy. Gradually, the members’ distorted beliefs about the experience of anger were challenged through the expression of resentments in the group setting. As co-therapists, we found that being taken seriously was associated with the patients’ ability to accept recognition from self and others. It was not uncommon that patients could state precisely what they needed to do to feel better and yet would categorically avoid doing these things.

In response to the patients’ behavior, the co-therapists employed specific therapeutic strategies and attitudes. Our chief rule was never to make an attempt to cheer up anyone in group. Such an effort invariably proved negative because it repeated what the patients heard on a daily basis from friends and family in their well-intentioned attempts to change the patient. Efforts by patients to cheer up each other were rare and usually met by contempt and bitter resentment. We allowed the patients to be as depressed as they wanted to be in group. Patients reported that they experienced much relief because of this attitude.

We found that deepening trust was not as critical a condition for patient sharing as the common and immediate identification process. To our surprise, veteran members said things to new arrivals that they had not revealed to the therapists, and these testimonies became the chief source of our learning what was helpful in group.

As members improved, we acknowledged the change but were careful to restrain our enthusiasm. Cheerleading and pep talking were strictly forbidden. We stated that we were pleased for them but made it clear nonverbally that we did not expect them to please us by being less depressed. Our attitude was that we would accept them depressed or otherwise. We openly encouraged members to support and befriend each other outside the group setting.

We laughed a lot in this group. There was among the patients a finely developed sense of humor—a dry delivery and exquisite timing of punchlines that guaranteed hilarity. Much of the humor seemed unintentional and came about quite spontaneously. It was characteristic of the group that humor was used to expand the perception of a problem to include other people. Humor also served the social function of making contact with others at a different emotional level. Examples of humor included the patient who with genuine admiration stated, “I don’t see anyone here trying very hard to act happy.”

Much laughter accompanied his statement, signifying relief that a facade was not necessary here.

One woman stated her fear that she might be “drummed out of the depressed group” owing to her belief that she was no longer depressed enough to qualify for membership. Pursuing the metaphor, another person said, “I’d like to make a ritual of the defrocking.” A third stated, “We’ll strip off her brass buttons and take away her Kleenex box!” Paradoxical intent was used to convey the sense of fun and excitement that was possible in a depressed group.

Depressed Group at the Gundry Hospital

The treatment philosophy that informed the leaders of this depressed group was succinctly stated by David Roth and Lino Covi: “Our clinical approach involves the utilization of both accepted cognitive procedures and group process to alter depressogenic beliefs.” The group was effectively used to challenge the cognitive distortions that depressed individuals make in the way they perceive events in their lives. Cognitive theory holds that once these distortions are corrected by the individual, the negative and depressive affects associated with the distortions will diminish. Treatment proceeded along the lines of both long-term and short-term goals for the patients. Long-term goals included the lessening of depressive affect and the learning of skills that allow patients to work cognitive therapy on themselves apart from the group. Short-term goals involved the concrete steps necessary to reach the long-term goals.

At each session, patients reported their score on the Beck Depression Inventory and told what they wanted to accomplish that week. The group therapist was active in helping each patient maintain continuity from week to week, seeing that issues were not just dropped or avoided. Homework assignments were a regular part of the group norms, and members helped each other in formulating individualized assignments that would have a good chance of being achieved, thereby positively reinforcing the individual’s efforts to change. Patients closed each session with a recap of what was important for each person at that meeting.

A rather careful preparation was designed for patients prior to their entry to group, consisting of four to eight meetings with one of the leaders in order to familiarize the new member with the operational procedures and language of the treatment. Patients learned cognitive- behavioral skills and were encouraged to ask questions of their leaders to seek clarification if they found themselves confused.

The group was also carefully prepared to receive a new member, in the belief that many premature terminations could thereby be averted. Members were invited to discuss their thoughts and beliefs about the entry of a new person. Members were also asked to plan a strategy of how to help the new person become a part of the group. Once the person joined the group, the veteran members provided models of how to use the cognitive therapeutic tools by explicitly stating what had been helpful for them. Core group members proved their utility at this juncture because they could assist the new member in questioning the accuracy of her cognitions and expectations about the group. Typical new member cognitions included the following:

“I’m always going to remain an outsider.”
“I’m going to come across as stupid.”
“I will hold the group back.”
“My problems are worse than everybody else’s.”

Once the new member had a sense of belonging to the group, the focus of the group returned to the incremental experiments or homework that group members devised for themselves to test their ability to adapt in the world. Insight attained from exploring member-to- member or member-to-leader interactions was not emphasized or encouraged as in more analytically oriented groups.How did the therapists know that the process was working? Positive signs of the group’s success included patients learning the following: (1) how to nondefensively listen to constructive critical feedback, (2) how to disclose intimate experiences, and (3) how to form stable relationships.

As a patient approached graduation from group, he asked himself, “Have I changed my depressogenic belief system? Can I continue to function as my own cognitive therapist?” The entire group participated in this process, which inevitably led to the question of whether he could manage future episodes of affective disorder. This allowed the patient to develop a strategy for coping with future depressions. Such a strategy must incorporate the belief that reexperiencing depression is not a failure but an opportunity to apply the skills learned in group to further personal growth. As we can see from the Puget Sound and Gundry Hospital examples, there is considerable latitude in the way short-term psychotherapy groups can be structured to meet the needs of patients. This fact carries important implications for group therapy case managers or group therapy coordinators who will structure group services in their respective managed mental healthcare settings. The key is to remain flexible and willing to experiment in the interests of better serving patients.

Once groups are set up, the question of how people find their way to them becomes crucial. The next chapter shows how to make that happen.

Bibliography

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McKay, Matthew, and Paleg, Kim. Focal Group Psychotherapy. Oakland: New Harbinger, 1992.

Roth, David, and Covi, Lino. “Cognitive Group Psychotherapy of Depression: The Open-Ended Group.” International Journal of Group Psychotherapy, 1984, 34(1), 68.

Spitz, Henry. Group Psychotherapy and Managed Mental Health Care. New York: Brunner/Mazel, 1996.

Tolstoy, Leo. Anna Karenina. New York: Bantam Classics, 1981. von Bertalanffy, Ludwig. General Systems Theory: Foundations,

Developments, Applications. New York: Brazilier, 1968.