Therapeutic Environment of Long-term Rehabilitation Units for Patients
with Chronic Mental Illness: A Participant Observation Study in Four
Hostels in Greece
Despina Sikelianou Psychologist, Ph.d in Social and Community Psychiatry Koumanioti 69, Patras, 26222, Greece
Venetsanos Mavreas Professor of Psychiatry Department of Psychiatry, University of Ioannina, Medical School, Ioannina, Greece
Citation: Sikelianou D & Mavreas V. (2011). Recovery and Self-EsteeThe Therapeutic Environment of Long-term Rehabilitation Units for Patients with Chronic Mental Illness: A Participant Observation Study in Four Hostels in Greece
. International Journal of
Psychosocial Rehabilitation. Vol 15(2) 59-68
aim of this study was the detailed presentation and study of the
factors regarding the organization of the therapeutic environment of
four newly-established long-term units for the rehabilitation of
patients with chronic mental illness, during their first year of
establishment, within the framework of materialization of the ten-year
European programme “Psychargos” 1st Phase 2000-2010 aiming at
modernizing the mental health care system in Greece. The ethnographic
method was used and the research was qualitative using participant
observation, interviews and questionnaires. The research process was
divided into three phases over one year (March 2001 – February 2002).
The results have shown that factors such as good and proper
implementation of internal and external supervision, continuous
training of the therapeutic group, the application of clear and
multidisciplinary roles of the caregivers, the positive attitudes and
positively-expressed emotions of caregivers towards patients, etc. lead
to a well-organized therapeutic environment within a new long-term unit
for patients with chronic mental illness.
Key words: Quality of care, Mental Health Professionals, Organization, Long-term units, rehabilitation
The psychosocial rehabilitation of patients with chronic
mental illness has begun to be realized over the last twenty years in Greece,
initially with the materialization of the programmes Leros I and II aiming at
deinstitutionalizing the chronic mental patients of the mental hospital at the
island of Leros and now continuing with the implementation of the European
programme “Psychargos” lasting 2000-2010. The aim is the gradual replacement of
the institutional system of psychiatric care with a network of alternative
preventive and therapeutic services and structures, on the basis of the
principle of sectorization and developing community mental health services (MYP
2000). Within the framework of this programme, approximately three hundred
sixty nine (369) rehabilitation housing units (104 Long-term units, 91 Boarding
Homes and 174 protected appartments) for patients with chronic mental illness
are currently available in the fifty-two (52) prefectures of our country. The therapeutic environment of a long-term unit provides
appropriate conditions for the residents of these units to be able to regain
the abilities and functions negatively affected by the institutional
environment or mental illness.
The organization of a long-term
unit comprises three developmental phases. In the first phase (Initial Stage),
the therapeutic environment is characterized by flexible organization and
concurrence of caregivers on objectives and a tendency towards
self-administration of the unit while the relations between the therapeutic
group and the main institution (mental hospital) are formal. In the second phase (Expansion
Stage), sub-groups are formed and there
is a climate of optimism for successful rehabilitation. There is also
competition between the sub-groups, and with other similar services and
the main institution (mental hospital).
In the third phase (Establishment and Recognition Stage), the
long-term unit becomes a decentralized unit. The members of the therapeutic
group trust each other and express collective satisfaction, emphasizing on the
organizational and social needs and objectives (Madianos 1994).
The function of a long-term unit therapeutic environment is
efficient when treatment of mental illness is in accordance with the social
changes and developments and the personnel do not show signs of inactivity and
passivity. The difficulty to deal with chronic mental illness faced by
caregivers is due to their ‘fundamental fear of the insane’ (the threat posed
to the mental health of caregivers themselves) with two predominant feelings,
the feeling of intrusionof the
mentally-ill patient on the personal inner space of the caregivers and the
feeling of emptiness, leading to a significant distance from the psychotic
patient. Consequently, patients show signs of institutional behaviour (Hochmann
(2003). In accordance with Katz and Kirkland
(1990) and Curtis and Hodge (1994), the presence of violence and
institutionalized behaviour of the patients results from failure to apply clear
and multidisciplinary caregiver roles. In accordance with Damigos (2003) and
Anderson (2003), the absence of proper internal and external supervision of the
unit leads to the inability of caregivers to play clear and multidisciplinary
roles, whereas Foster (1998) points out that caregivers run a risk when playing
multidisciplinary roles and behaving ‘in the same way as each other’. This can
lead caregivers to experience burn out and failure of the therapeutic
procedure. Lack of empathyexpressed
by caregivers leads them to keep a distancefrom the patients (Minkoff and Stern 1985). The rejection and criticism of
caregivers towards patients results in their receiving poor quality medical
care services (Hastings et al. 1995, Morgan and Hastings 1998, Snyder et al
1994), while expression of negative attitudes and feelings towards the patients
leads to bad relations between the caregivers and the patients and also to the
failure of the latter to accomplish their rehabilitation tasks (Van Humbeek et
al 2001, Tartan and Tarrier 2000, Bebbington and Kuipers 1994, Butzlaff and
Hooley 1998, Kavanagh 1992). The implementation of training programmes for the
personnel of a long-term unit is necessary and effective because it improves
the communication skills between caregivers and patients and between caregivers
themselves and offers caregivers a ‘clear comprehension of their own self-image
and that of others’ and assists in the direct understanding of the actual
therapeutic values of rehabilitation (Van Audenhove and Van Humbeek 2003, Piatt
et al. 2002, Rabkin et al 1998, Neilsen et al 1985).
Aims and research
hypotheses: The aim of this research study is to explore the factors for
the organization of the therapeutic environment in four newly-established
long-term units for rehabilitation of patients with chronic mental illness,
during their first year of establishment.
The evaluations from the European deinstitutionalization
programmes Leros I and Leros II, regarding the communication of the caregivers,
the presence or absence of the internal and external supervision of the
long-term unit, the application of clear and multidisciplinary roles of the
caregivers, the attitudes and expressed emotions of the caregivers towards the
patients, the implementation of training programmes for caregivers at
workplace, the relation of the unit with the Mental Hospital,the level of the long-term unit independence
and the handling of mental illness constituted the research questions of this
Settings and Staff The long-term units began operating in 2001 in accordance
with the European programme “Psychargos” 1st Phase. Long-term units
A and B are located in two cities in Western Greece,
while long-term units C and D are located in the same city as the Mental
Hospital of the area. All four long-term units were established at the same
period of time. 46 mental health professionals worked in these long-term units.
Study Sample The sample consisted of forty-six mental health
professionals: thirty-eight women and eight men of various specializations
(professional and non-professional staff), such as: Psychologists, Social
Workers, Nurses, Occupational Therapists, Trainers and Auxiliary Staff.
Long-term units C and D were also staffed with a Special Teacher and a Health
Visitor. Ages ranged from 18-50 years old and the majority of professionals
In long-term unit A, there were 11 mental health
professionals, aged from 25-50 years old, and 15 residents. 12 mental health
professionals worked in long-term unit B, the number of residents being 14. The
majority of caregivers in both long-term units was between 18-25 years old and
had no university education and all caregivers had no specialization and
experience with regard to the rehabilitation of mentally-ill patients. The only
difference between the two long-term units was that long-term unit A did not
have an Occupational Therapist.
The number of caregivers in long-term unit C was 15 with 22
residents and, in long-term unit D, the caregivers totaled eight with five
residents. The caregivers of both long-term units had experience of working
with chronic mental health patients, all of them being ex-employees of the
Mental Hospital. The personnel of long-term unit D worked simultaneously at the
Day Centre of the hospital, which was in the same building as the long-term
unit. The personnel of both units were not specialized in the rehabilitation of
mentally ill patients. The nursing staff of both long-term units had no
university education and did not include an Occupational Therapist.
Method and Data
Qualitative Analysis The ethnographic method was used for the implementation of
this study, as it is the most appropriate method for qualitative research and
in-depth investigation and analysis of issues studied for the first time. The
approaches used in this study were participant observation and unstructured
interviews. The entire research procedure and data collection was conducted
from March 2001 to February 2002 and divided into three Phases (1st
Phase – A’ trimester, 2nd Phase – B’ semester, 3rd Phase
– C’ trimester), with visits taking place once a week during the morning shift
In the first Phase (March-June 2001) of this study, we were
interested in studying the formation of relations between the members of the
therapeutic group, their efforts to develop a degree of cohesion and specific
therapeutic goals. In accordance with the above-mentioned goals, only long-term
units A and B were studied, because the personnel in these long-term units had
no professional experience and were unacquainted with each other, unlike the
professionals in long-term units C and D, who were skilled and knew each other
from their previous employment in the same department of the Mental Hospital.
The questions were addressed only to psychologists and nurses because the
remaining staff needed time to adjust to their working environment.
The duration of the 2nd Phase (July 2001 –
December 2001) was six months, divided into two terms to serve both the proper
implementation of the research and the best possible data collection. Its aim
was to investigate the maturing of already-existent and established relations
among the members of the therapeutic group and those they had with the patients
(expressed emotions, attitude of caregivers, the communication level among
caregivers and that which they had with the patients, the decision-making
procedure, professional boundaries, the level of satisfaction with the
therapeutic work) and the emergence of new tendencies and needs. All four
long-term units were studied, because at this stage all were progressing and
could be studied simultaneously in terms of the objective of this phase. 46
professionals from all four long-term units participated in this phase.
The aim of the 3rd Phase (December 2001 – February
2002) was to investigate the characteristics for the establishment of the level
of self-administration and independence of each unit from the implementing
body, the ‘opening’ of the unit to the community and a review of therapeutic
Research Results Long-term Unit A Regarding the development of relations among the members of
the therapeutic group in the 1st Phase, strong conflicts and
disputes were ascertained among members of the scientific and nursing staff.
There was no clear designation of internal and external supervisor for the
therapeutic group by the implementing body so that these problems could be
dealt with. In the 2nd Phase, caregivers began to form three
sub-groups, scientific, nursing and auxiliary staff. The conflicts between the
members were significantly reduced because they were ‘transferred’ to the
external environment and specifically to the research process. All the
caregivers refused to continue to participate in the research process because
they feared that “… the results of this study with regard to this particular
long-term unit were to be made known to the Ministry of Health and they might
lose their jobs…..”. The staff nurse, a dynamic and strong personality,
undertook the responsibility and supervision for the proper function of the
unit. The members of the nursing staff had developed very good co-operation,
achieved a large degree of unity and showed flexibility in decision-making and
therapeutic work co-ordination. On the other hand, the members of the
scientific staff showed signs of fragmentation (groups of two or one) and also
signs of a remote and isolated sub-group. In all three phases, it was ascertained
that the therapeutic group of long-term unit A did not manage to achieve a
large degree of cohesion. The members of the scientific group failed to act in
a professional capacity, whereas the members of the nursing staff had adapted
to their clear professional role (1st Phase). During the 2nd
Phase, tendencies to re-determine and re-assign professional responsibilities
were ascertained, a fact that led the members of the nursing staff to have a
positive attitude towards expectations of the efficiency of their role, whereas
the members of the scientific staff had a negative attitude and expectations (3rd Phase)
Regarding the attitudes of caregivers towards the
residents-patients, in all three phases, these were characterized by signs of
rejection (scientific staff) and signs of acceptance (nursing staff). The
members of the nursing staff showed positive attitudes towards the patients,
whereas the members of the scientific staff showed negative attitudes as well
as signs of distance and fear of the patients, resulting in some members of the
latter presenting with symptoms of stress (2nd Phase). The activity
groups working with the patients were introduced in the 2nd Phase
and it was ascertained that they showed signs of not abiding strictly by the working
hours, lack of specific roles and objectives and lack of a stable co-ordinator.
This resulted in signs of violence and institutionalized behaviour from the
patients. The therapeutic groups and the activity groups were assisted by a
(psychologist) during the 3rd Phase but still demonstrated the
above-mentioned characteristics. The main emotions expressed by caregivers
towards the patients were stress and insecurity (1st Phase), verbal
negative expression of emotions (2nd Phase) and a slight reduction
in negative emotions in the 3rd Phase.
All caregivers agreed that there should be training
programmes, with the aim of improving their courage and strength. The attitude
of the community was initially negative (1st Phase), while during
the 2ndrd phases the attitude of the community was
more positive, a fact that coincided with the ‘opening’ of the unit to the
community (e.g. summer vacations in the wider region of the community, patient
walkabouts, etc.). The caregivers showed signs of becoming independent of the
administration of the general hospital in that region; however, independence
was not ultimately achieved.
Long-term Unit B The relations between caregivers of long-term unit Bwere characterized by mutual trust,
high level of cohesion and unity and very good co-operation. The caregivers
were particularly flexible in their co-operation in all three phases, and the
only difference was that traces of dissatisfaction on behalf of the nursing
staff were ascertained during the 2nd Phase,because they believed that the scientific staff did not place due
confidence in their group. At the end of the 2nd Phase, a training
programme for a period of one (1) month took place within the staff working
environment. After the completion of this training programme, the therapeutic
group began functioning as a ‘cohesive group’.
Long-term unit B had an internal supervisor (psychologist),
who was designated by the administration of the local GeneralHospital the unit belongs to,
according to his scientific qualifications. The main characteristic of the
internal supervisor was that he applied himself to flexible co-ordination of
actions by taking direct decisions and developing initiatives and innovations
to solve problems (3rd Phase).
The direct self-assignment of the caregivers according to
their professional roles, the application of their professional and
multidisciplinary roles and the positive expectations of their role efficiency
in the therapeutic work were also ascertained.
The attitudes of caregivers towards the patients of the
long-term unit were generally positive. In particular, the scientific staff
maintained formal and positive attitudes, while the nursing staff expressed
feelings of fear and a distant attitude (1st and 2nd
Phases). After completion of the training programme, more positive attitudes
and expectations of all members of the therapeutic group were ascertained (3rd
The implementation of the therapeutic programme was strictly
enforced through the operation of therapeutic groups and activity groups (1st
Phase). The groups had clear goals and the patients expressed socially
acceptable forms of behaviour. At the same time, caregivers participated in
joint activities with patients (e.g. joint walks into the city for shopping,
having lunch with them, going for a coffee together in the city, etc.) (3rd
Phase). The caregivers agreed on the necessity of training programmes, with the
aim of improving the efficiency of their professional and therapeutic roles.
Initially, attitudes of the community towards the unit were negative (1st
Phase). Later, (2nd and 3rd Phases) it was ascertained
that attitudes changed into positive (‘opening’ of the unit to the community).
In conclusion, tendencies of the caregivers to become independent of the
administration of the general hospital of the city were ascertained and the
long-term unit could be characterized as an independent unit.
Long-term Unit C Co-operation between the caregivers was excellent; they
developed trust in each other and complemented one another’s role.The therapeutic environment was organized
according to the standards of organization of the mental hospital and
caregivers continued to be dependent on the Mental Hospital. The chain of
command between the members of the therapeutic group was the same as that of
the mental hospital, with the staff nurse designated as internal supervisor.
The relations of caregivers with patients were good,
especially on the part of the nursing staff. The scientific staff maintained
more formal relations with the patients. The therapeutic programme of the
therapeutic and activity groups was consistent and strictly enforced. The
nursing staff may possibly have experienced feelings of frustration regarding
the effectiveness of their therapeutic work and had reservations about the
progress of patients (2nd and 3rd Phases), expressed
through an indirect distant or spurning attitude towards the patients. In
contrast, the scientific staff expressed more positive and formal attitudes.
All caregivers expressed a desire for the implementation of training programmes
and were looking for scientific motivation in order to improve their
The attitude of the community was negative regarding the
presence and operation of the unit in all study phases of the long-term unit (2nd
and 3rd Phases). Finally, no tendency for independence
(decentralization) of the unit from the administration of the mental hospital
Long-term Unit D The therapeutic group had developed good relations of
co-operation and trust in each other, showing a high level of cohesion.
However, the pressure put on the members of the therapeutic group by the
administration of the mental hospital to work simultaneously in two units (Day
Centre and long-term unit D) led to a situation characterized by fragmentation
within the group. The fact that on the whole the caregivers were obliged to
render their services to both units simultaneously caused them to feel
discontent with and to spurn the patients in this unit. The nursing staff reacted more negatively to
working simultaneously in the Day Centre and in a therapeutic environment where
the work resembled that of a mental hospital. The scientific staff did not show
negative attitudes as they worked fewer hours in the long-term unit, while the
nursing staff expressed more negative and distant attitudes towards the
patients of the unit. The patients of the unit demonstrated strong negative
behaviour resulting in isolation, as they refused to participate in the
activity groups. The resistance of patients reduced significantly during the 3rd
Phase and this coincided with the simultaneous reduction in the ‘opposition’ of
caregivers to working in both units simultaneously as they complied with the
orders of the mental hospital (3rd Phase).
The therapeutic staff made efforts to change the therapeutic
environment of the long-term unit from that of the Day Centre. This contributed
to re-determining how therapeutic roles should be applied, aiming to achieve
the best possible performance and efficiency of the therapeutic goals for each
unit separately. Moreover, caregivers deemed it necessary to improve their
therapeutic roles through implementation of training programmes. The relations
of dependency maintained between the members of the therapeutic group and the
administration of the mental hospital did not lead to tendencies towards
self-administration of the long-term unit.
Stagnation in the therapeutic environment of long-term unit A
and improper function in terms of the organization of the therapeutic group
made it difficult for caregivers to undertake specific responsibilities
regarding the organization of the therapeutic programme of the unit according
to the needs of in-patients. Flexible organization in combination with the
absence of designated internal and external supervisors of the unit, the
problems in the relations among staff members, lack of collective effort in
therapeutic planning, ambiguity of therapeutic roles and failure in the application
of defined professional and supplementary roles led to unavoidable problems for
both the smooth operation of the programme in the unit and the achievement of
rehabilitation therapeutic goals (Katz & Kirkland 1990). The distance kept
by the scientific group between themselves and their patients and the negative
expectations for the therapeutic outcome (Cottleet al 1995, Herzog 1998, Stark et al 1992,
Kuipers & Moore 1995) led to the development of negative attitudes and
emotions (e.g. critical remarks, incorrect arbitrary evaluations of patients,
defensive attitude – resistance) (Ball et al 1992, Van Humbeek & Van
Audenhove 2003, Snyder et al 1994, Moore et al 1992, Oliver & Kuiper 1996,
Finemma et al 1996, Van Humbeek et al 2002). The loose application of
therapeutic activities (Watson et al 1980) – and the indifference of patients
to what these entailed – led to the development of institutional and violent
behaviour by patients (Butzlaff & Hooley 1998, Wearden et al 2000, Van
Humbeek et al 2001, Barrowclough et al 2001, Tattan & Tarrier 2000, Weigel
& Collins 2000). The expression of negative behaviour by the staff towards
patients may be associated with the possible experience of intrusion and
emptiness of emotions by the staff itself (Hochmann 2003).
In contrast, the effectiveness of the therapeutic programme
in long-term unit B enabled the caregivers to be more flexible and ready to
meet new needs resulting from the changes in the social environment of the
The social sufficiency of the long-term unit environment was
evident by: i. the direct attention paid by the therapeutic group to patients
and ii. the positive interaction between caregivers and patients. The prompt
designation of an internal supervisor for the therapeutic group on the basis of
scientific qualifications contributed to the maintenance of good relations of
co-operation among the staff members, development of therapeutic goals and
efficiency of therapeutic work (purposive system thinking) (Foster &
Roberts 1998, Adair 1983, Hinshelwood 1989, Rushton & Nathan 1996).
The therapeutic environment of long-term unit B was based
upon a well-organized therapeutic plan with the following main characteristics:
i. individualized therapeutic intervention and strict application of the
therapeutic programme (Curtis & Hodge 1994), ii. encouragement of patients
to become independent and express their personal choices (Lavender 1985,
Shepherd 1984), iii. positive expectations of staff for a therapeutic outcome
together with positive attitudes and positively-expressed emotions towards
patients and, finally, iv. socially-acceptable forms of patient behaviour (Betz
1969, McCarthy & Nelson 1991, Hull & Thompson 1981, Kruzich 1985 and
Van Humbeek et al 2001). The presence of capable internal and external unit
supervisors, the organization of the chain of command in the therapeutic group,
the implementation of training programmes and strictly-prescribed therapeutic
goals all appeared to contribute to the development of positive characteristics
in the therapeutic environment of the unit.
The traditional form of administration of units C and D,
based on the standards of administration of the Mental Hospital, was largely
due to relations of dependency that had developed between the caregivers and the
Mental Hospital but also because they had adopted the ‘way of thinking of the
mental hospital’. The fixed views of caregivers on chronic mental illness, the
continuous interventions by the administration of the Mental Hospital in the
organization of the unit and the absence of substantial internal and external
supervision of the unit did not help the therapeutic group of unit C to promote
their therapeutic work for rehabilitation of patients substantially.
Consequently, the members did not use therapeutic techniques and methods for
the rehabilitation of patients and did not proceed to any substantial changes
in the therapeutic environment of the long-term unit, the organization of which
resembled that of the Mental Hospital (Astrachan et al 1970). The therapeutic
group of unit D showed signs of inactivity, passivity and lack of initiative
because of other reasons, too, such as the pressure applied by the Mental
Hospital to work simultaneously in both units (unit D and Day Centre) and the
preference of the therapeutic staff members to work only in the Day Centre.
Such negative attitude and behaviour probably reflects emotions of intrusion
and emptiness experienced in the past due to frequent contact between
caregivers and chronic patients (Searles 2003, Hochmann 2003).
The well-organized therapeutic environment of a long-term
unit for rehabilitation of chronic mental patients is a significant
prerequisite for both normal development of chronic mental illness and
efficiency of rehabilitation of patients. A long-term unit should not be
isolated from the social and cultural developments of its time and the patients
should feel that they are part of the community in which they live and work.
This study showed that the primary and principal factor in a well-organized
long-term unit environment was prompt designation of internal and external
supervisors for the unit by the implementing body, with regard to not only
newly-established long-term units with inexperienced therapeutic staff but also
those employing expert mental health professionals. The internal supervisor
should be a member of the therapeutic group and be designated only by the
implementing body on the basis of his scientific and organizational
qualifications. The presence of an internal supervisor is significant because
any problems and conflicts that may arise within the therapeutic group can be
settled or prevented through regular and weekly meetings with staff. The
presence of an internal supervisor encourages caregivers to understand precisely
their clearly-defined therapeutic and supplementary roles and apply them. In
this way, role ambiguity of caregivers is avoided. Moreover, the presence of a
supervisor serves as a ‘protective umbrella’, because this can help him take
decisions after having ‘listened to’ the needs of the caregivers.
The second yet basic factor in a well-organized long-term
unit environment is the continuous training of the staff. Most mental health
professionals, including skilled ones, have neither undergraduate nor postgraduate
level-specific knowledge in terms of rehabilitation of patients. Of course, it
is undeniable that the training programmes that do take place occasionally and
unsystematically aim only at the provision of knowledge and skills regarding
the treatment of mental illness, based on psychotherapeutic methods and
techniques, not enabling caregivers to develop more positive attitudes and
behaviors towards chronic mentally-ill patients. The implementation of
continuous training programmes within the working environment can help
caregivers to: i. deal much more easily with the intensity of their feelings
and negative emotions developed in their inter-therapeutic relations, ii.be able to identify and settle possible signs
of frustration that may be evident in their inter-therapeutic relations, thus
avoiding burn out, iii. have a positive attitude and show empathy for the
patient and iv. ‘listen to’ the needs of the patients. Consequently, the
therapeutic work becomes more substantial and resident-oriented.
The third factor in achieving a well-organized long-term unit
environment involves the attitude of the implementing body towards the staff of
the unit. The presence of the implementing body in the therapeutic environment
of the long-term unit should be substantial, its role being a subsidiary and
supportive one, not interventional. This can be achieved by: i. prompt
designation of internal and external supervisors for the unit, ii. organization
and implementation of training programmes for the staff members, iii. staffing
of a well-organized therapeutic group, in which all members should be
professionally ready to work in such an environment, either applying their
current specialization skills to the rehabilitation of psychiatric patients or
using their experience from the sector of psychiatric rehabilitation, iv.
substantial rotation of staff to various psychiatric units in order to prevent
the appearance of burn out syndrome, v. promotion of unit independence and
self-administration, vi. substantial support that meets the needs of patients
and caregivers, but which does not serve financial interests such as:
absorption of funds and unequal allotment of resources.
The fourth factor concerns the rotation of staff to various
psychiatric units, in order to prevent the appearance of burn out syndrome.
Rehabilitation is difficult and therefore administration has to use this method
with the assistance of the internal supervisor of the unit.
The fifth and last factor to play a significant role in a
well-organized long-term unit environment concerns the organization of the
chain of command. The therapeutic group of the long-term unit functions better
when there is a clear-cut chain of command. The members of staff are each
separately oriented in accordance with the function of their particular role
and feel safe in complementing one another’s role.
The above-mentioned findings cannot be put into general use,
as they only constitute indicative data with regard to the long-term units
studied in this research. However, they could be taken as an impetus for new
qualitative and quantitative research.
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