Impact of Therapeutic Alliance on Treatment Outcome in Patients with Dissociative Disorder: A Case Study of RVI Hospitals, England

This case study investigates the impact of therapeutic alliance on treatment outcome in patients with dissociative disorder at RVI Hospitals, England. It discusses the conceptual understanding of dissociation disorder and therapeutic relationship, difficulties in diagnosis, prognosis, factors responsible for poor diagnosis, and ways to improve outcomes. The report also emphasizes finding the right therapist for dissociative disorder patients.

Running head: HEALTH AND SOCIAL CARE
"An investigation of the impact of the therapeutic alliance on treatment outcome in patients
with the dissociative disorder: A case study of RVI Hospitals, England"

HEALTH AND SOCIAL CARE 2
Title and Abstract
The title of this research is "An investigation of the impact of the therapeutic alliance on
treatment outcome in patients with the dissociative disorder: A case study of RVI Hospitals,
England". In this report, many chapters have been discussed named introduction, literature
review, chosen methods, findings, and conclusion. The introduction section could be effective to
comprehend the rationale of the study and research questions that could be an imperative part of
the study. It could also be supportive of the attainment of the study task. The literature review
could be another chapter that could critically evaluate the impact of the therapeutic alliance on
treatment outcome in patients with the dissociative disorder in the context of RVI Hospitals,
England. This section could also be effective in getting knowledge about the understanding
regarding dissociation disorder and the therapeutic relationship. It could support to get the
information about different kinds of Difficulties faced by the therapist in diagnosis the
dissociation symptoms. Moreover, it can be stated that the best conceptual knowledge about the
research matter could be effective in effectively operate the study and leads to get a favorable
result. Further, the methodology section could support to gain an understanding of the qualitative
and quantitative method, which leads to getting the factual and non-factual data about the
research matter. It could also be effective in making a reliable conclusion in the context of the
research issue. The findings section is effective to demonstrate the evaluated data by graph and
table. The conclusion section demonstrates the whole assignment in a concise form. It could lead
to comprehending the whole research in the least time and cost.

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Table of Contents
Title and Abstract............................................................................................................................2
Introduction......................................................................................................................................4
Research question........................................................................................................................4
Rationale for study.......................................................................................................................5
Literature Review............................................................................................................................5
Chosen method..............................................................................................................................11
Findings.........................................................................................................................................13
Conclusion.....................................................................................................................................15
Evaluation of potential relevance for practice...............................................................................15
Reflection.......................................................................................................................................16
References......................................................................................................................................18
Appendices....................................................................................................................................21
Appendix 1: Survey through questionnaire...............................................................................21
Appendix2: Observation records...............................................................................................23

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Introduction
Research has investigated that therapeutic alliance plays a significant role to improve the
treatment results between individuals with different types of disorders such as posttraumatic
stress disorder (PTSD). But, the therapeutic alliance and treatment outcome is not investigated in
dissociative disorder (Dorahy, et al., 2017). Although professionals in dissociation are a
supporter to focus on therapeutic association as a significant concept for treating the dissociative
individuals, the treatment alliance is not investigated between a person with dissociation
disorders. Since a strong therapeutic alliance favorably affects the treatment results between
general psychiatric patients such as trauma survivors, the upcoming phase will be used to assess
when the alliance is related to favorable results between dissociation disorders (Myrick, et al.,
2015).
The existing investigation aims for assessing the impact of alliance on treatment using a sample
of dissociation disorder therapists who engaged in dissociation disorder investigations. The result
of this researcher will contribute to developing better knowledge regarding the alliance between
dissociation disorder and their therapist. Knowledge associated with how therapeutic alliance
between therapist and dissociation disorder patients associated with treatment results might be
beneficial for enhancing the treatment results for this group.
Research question
RQ1: What are the conceptual understanding regarding dissociation disorder and therapeutic
relationship?
RQ2: Which kinds of Difficulties faced by the therapist in diagnosis the dissociation symptoms?
RQ3: What are the impacts of therapeutic alliance on treatment outcome in patients with the
dissociative disorder in RVI Hospitals, England?

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RQ4: How to improve the treatment outcome of dissociation disorder through a therapeutic
relationship in RVI Hospitals, England?
The rationale for the study
This research is beneficial for academician for gaining the understanding of the dissociation
disorder and therapeutic relationship. It is also effective for the therapist to comprehend the
impacts of therapeutic alliance on treatment outcome in patients with the dissociative disorder in
RVI Hospitals, England. It is beneficial for the future researcher to increase the knowledge in
order to improve the treatment outcome of dissociation disorder through a therapeutic
relationship in RVI Hospitals, England.
Literature Review
According to Myers Vaidya-Mathur and Lancman (2017) dissociation is illustrated as a
disturbance and discontinuity in normal integration related to memory, emotion, consciousness,
motor control, identity, and behavior and body representation. Dissociative disorders have a
fundamental basis, which involves excessive limbic inhibition as well as transformation entailing
the endogenous opioid system between others.
In contrast to this, Brand et al. (2016) evaluated that therapeutic alliance is illustrated as the
collaborative working liaison amid patients as well as therapists. It is one frequently investigated
common factor that is related to psychotherapy results. The therapeutic impact is entailing to
capturing the attention of patients in a way that continues to be productive and memorable
despite several distractions. The effectiveness of therapy relies on both therapeutic impacts as
well as a working alliance among therapist and patients.
In support of this, Kong et al. (2018) stated that the therapeutic relationship is illustrated as a
relationship among healthcare professional and client. It is mean through which, therapist as well

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as a client expect to engage with each other and demonstrates the beneficial changes to the client.
The APA categorizes the dissociative identity disorder as a severe dissociation disorder, which is
characterized through two or more personality. It demonstrates the discontinuity in the sense of
self as well as alteration in memory, feeling, behavior, cognition, and perception as well as
amnesia with respect to everyday events and traumatic experiences.
As per the view of Ormhaug Shirk and Wentzel-Larsen (2015), Dissociative Disorder Not
Otherwise Specified (DDNOS) can create when a patient experiences the wide range of
dissociative symptoms that do not attain the criteria for any of other dissociation disorder such as
DID symptoms related to no amnesia. Expert consensus instruction recommended that DID
therapy can be trauma-informed, staged treatment, and the key objective is to support the patients
for stabilizing the symptoms associated with dissociation and PTSD, suicidal behavior, create
awareness, cooperation with dissociated self-states, tolerance as well as regulation, process and
resolve the traumatic experience and ultimately creates the wisdom of being more whole as well
as integrated.
In opposed to this, Rienecke Richmond and Lebow (2016) evaluated the importance of
practicing the association between the therapist and client as a vehicle for supporting the client’s
needs and resolves their relational issue that is associated with early trauma as well as attachment
issues. In spite of the availability of developed treatment guidelines, there is still a requirement
for research about the treatment results. The self-destructiveness and chronic suicidality
demonstrated the disorders required for long-term treatment in most DID/DDNOS patients, yet
these treatments are complex for investigation, specifically with the randomized clinical trial
design. The inadequate funding related to long-term treatment has further sluggish the treatment
outcome.

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Difficulties in diagnosis
According to Ociskova et al. (2016), mental health evaluation does not involve enquires related
to posttraumatic and dissociation symptoms. An individual who has dissociative disorder may
tend to rationalize the hide the symptoms a may eliminate the disclosing intrusive thoughts,
feeling unreal, inner voices, impulses, lost time, as well as flashbacks because of shame or
anxiety of being crazy. In opposed to this, Ayotte Lanctôt and Tourigny (2017) stated that there
are different self-injurious deeds; dysfunctional association, suicide attempts as well as
additional diagnoses are common. Physical health issue may involve the pain, severe headaches
as well as other somatoform symptoms. Hence, some therapists deny acknowledging the validity
related to dissociation identity disorder and may have some dissociation disorder training.
As per the view of...., the hidden and infrequent switching is characteristic of the vast majority of
persons with dissociation disorder may have caused this skepticism. Symptoms may create an
individual from different cultures and in a diverse location such as every continent except
Antarctica because of inadequate clinical information.
Organized and ritual abuse
As per the view of Goldstein and Mellers (2016) ritual and organized abuse typically involves
the sexually horrific and sadistic abuse as well as conviction for these crimes may exist within
the UK nation. An essential minority of individual with dissociation disorder report this kind of
abuse such as being pressurize and abuse others from early childhood. It can cause the complex
type of dissociation disorder with dozens and hundreds of parts as well as initial amnesia related
to ongoing abuse and past abuse. There are different dissociative parts can hold several aspects
related to each memory together with, individual with the dissociative disorder can be allowed

HEALTH AND SOCIAL CARE 8
for assessing the accuracy of memories themselves such as addressing any indoctrination, tricks,
and lies used like sound effects, fake blood, projector, and costumes.
Prognosis
As per the view of Myrick e al. (2017), there are different prognosis that could be differed in
different groups. These are high-function DID, a patient who has complicated dissociative
disorders and patients who are unable to use the therapeutic relationship.
On the other side, Jaeger et al. (2017) evaluated that high functioning dissociation disorder with
little comorbidity related to personality disorders and learning issues. It could be a good
prognosis. Patients who have complicated dissociative disorders, as well as comorbid personality
disorders and learning complexity, can make slower development. They may not attain the full
combination related to identities such as when integration is their goal. Patients who are unable
to practice the therapeutic relationship can attain the self- soothing as well as appraise the
contribution regarding their issue. These patients have poor prognosis related to crisis
management as well as best for symptom stabilization.
The factor responsible for poor diagnosis in dissociation disorder:
According to Wosket (2016) lack of motivation such as strong investment in secondary
expansion from having dissociation order, and lack of motivation can navigate for a normal life.
Moreover, serious Axis I is related to comorbidity contains different factors such as organic
mental disorder, schizophrenia as well as psychotic disorder. It is assessed that serious Axis II
associated with comorbidity contains personality disorder, particularly paranoid and antisocial
personality disorder.
In opposed to this, Heggdal Fosse and Hammer (2016) illustrated that inadequate healthy
relationship such as current abuse, mental health care employees, barriers in therapy and suicide

HEALTH AND SOCIAL CARE 9
or murder in the family. In addition, an inadequate healthy therapeutic association such as
rigorously harmed competency for developing the therapeutic association, harshly impaired
competency for abiding the treatment rules, and poor closeness between therapist and patients
are related to dissociation disorder. Furthermore, inadequate accountability regarding own share
in the therapeutic procedure, and little cooperation among dissociative parts related to
personality.
In favor of this, Schielke Brand and Marsic (2017) stated that poor attachment such as strongly
involve antisocial behavior and severe attachment issues. Along with this, self-destruction such
as strongly entailed the self-destructiveness can key cause for poor diagnosis in dissociation
disorder. In addition, lack of external and internal resources like amnesia for ongoing abuse,
severe incompetency for distinctive between present and past as well as severe resistance in
against the constructive communication between dissociation personalities.
Improving outcomes
As per the view of Lis and Myhr (2016), there is a different factor that can be practiced for
generating particular treatment goals and gain involvement of client in therapeutic procedure.
Developing a strong therapeutic alliance by empathizing and building trust with abusive,
managing the conflicting priorities and hostile or sabotaging identities can help to improve the
treatment outcome of dissociation disorder. Along with this, the therapist should encourage the
healthy liaison outside the therapy and motivate the client for developing the range of external
support as well as make good liaison with other professionals by considering the client
agreement.
In contrast to this, Jacobson Newman and Goldfried (2016) evaluated that psycho education can
be used for enhancing motivation, developing trust internally as well as empowerment. It can

HEALTH AND SOCIAL CARE 10
enhance communication as well as cooperation among dissociative personality parts. It can also
develop a safety plan and healthy coping competencies. A therapist can also set clear boundaries
for motivating self-reliance, contact, and independence. It can maintain a life outside of illness.
Along with this, working in partnership, learning from it and apply this to the client helps to
improve the treatment outcome related to dissociation disorders.
Finding the Right Therapist
According to…., the therapist should have well-developed interpersonal skills. They should
make feel appreciated, accepted and supported as well as, should be competent for interacting
with the client in a manner that is meaningful for them. They should focus on a sense of trust.
When a therapist know that a client has a pre-existing factor for making the trust difficult for
them, then this could be hard for computing. By creating awareness of the therapist about needs,
the therapist can work for generating safe atmospheres for clients.
In contrast to this, Kleindienst et al. (2016) evaluated that therapist should develop the
personalized plan for supporting the customers to reach out at the goals as well as executing the
best therapeutic modalities for making sure effective treatment. A therapist can also track the
progress by giving the feedback associated with progression related to therapy and keeping the
ongoing dialogue about what is working, what is not as well as how to make amendments in
treatment for making sure, a company is staying on track.
As per the view of Stiefel and Bourquin (2018), the extent of association among outcome and
alliance is not direct functioning of time. It is found that measurement can be obtained at the time
of earliest as well as advanced counseling session can be strong predictors for the outcome as
compared to those achieved at the time of the middle phase of therapy. The outcome of these

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investigations has led an investigator in order to involve the consideration of different phases in
alliances.
In contrast to this, Arntz et al. (2015) evaluated that the first phase involves the initial alliance
development at the time of first five-session related to short-term therapy as well as peaks at the
time of third sessions. At the time of the initial phase, confidences and adequate extent of
collaboration are fostered, as well as therapist and patients can agree on the goal. Along with
this, patients create some degree of confidence in a process that develops the structure related to
therapy. Under the second phase, the therapist can initiate to challenge the dysfunctional thought
regarding patient, behavior as well as affects patterns with the purpose of changing them. The
patient can interpret the more active intervention of the therapist because of a reduction in
empathy and support. It can weaken and break the alliance. The loss in the association should be
repaired by effective therapy.
As per the view of Gómez et al. (2016) residential treatment initiative can offer the best structure
for promptly healing the liaison and creating collaboratively related to a highly skilled therapist.
A therapist can provide different session related to the session of individual psychotherapy in
each week. A high variety related to daily group therapies is chosen particularly for the need to
help the client in order to find relief from symptoms promptly. Clinicians cannot only have the
expertise required for delivering the sophisticated and intervention related to modern therapeutic,
but they should also comprehend the critical role regarding treatment of therapeutic, favorable
and productive associations, and work to generate a safe environment with clients. By offering
the highest standard of care with the therapist, empathy, respect, and warmth, the therapist, as
well as psychiatrists, can help the client for moving forward and addressing the long-lasting
relief from psychiatric distress.

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Chosen method
Research philosophy
In this investigation, interpretivism research philosophy is used to gather the real phenomenon
associated with research concern. It is selected due to the subjective nature of research. This
philosophy is associated with the philosophical position regarding idealism and also enables the
researcher to integrate different approaches into single groups. It is beneficial for obtaining the
authentication information associated with the impact of the therapeutic alliance on treatment
outcome in patients with the dissociative disorder in reference to RVI Hospitals, England. It is
appropriate to identify different ideas and beliefs for concluding the outcomes. The deductive
approach will not be practiced by a researcher because there is no need to prove the evidence in
the context of research (Terock, et al., 2016).
Research approach
For this investigation, the inductive approach is used due to its relevancy with interpretivism
research philosophy. This approach is beneficial for creating a theory regarding the research
issue. It is also selected because of no need to develop the hypothesis.
Research design
In this research, quantitative research design is used to gather numerical information regarding
research issues. This data is pooled through a survey through a questionnaire. It is beneficial for
gathering reliable and valid information (Choi-Kain, et al., 2017).
Data collection method
For this research, primary research is conducted to collect information from fresh and first-hand
sources that are not published earlier. In this way, the researcher is used survey through a
questionnaire for obtaining the information regarding the impact of the therapeutic alliance on

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treatment outcome in patients with the dissociative disorder in reference to RVI Hospitals,
England. In this way, the researcher has used a close-ended questionnaire for encouraging the
participants to give each response in the least time. Furthermore, monkey survey is used for
filling the questionnaire (Bacon and Kennedy 2015).
Sampling method and sample size
For choosing the participants from different geographical location, a researcher has used simple
random probability sampling techniques. As per this technique, a researcher has randomly
chosen the participants for avoiding the biases from research (Corrigan and Hull, 2015). Along
with this, 30 therapists were selected from RVI Hospitals, England to assess the information
regarding research concern.
Data analysis
After collecting the data, data would be analyzed through monkey survey software. It represents
the gathered information through graphs and tables. It helps to understand the data in a
meaningful manner.
Ethical consideration
In this research, a researcher has considered the university guideline for keeping the privacy of
respondents. It aids the researcher in conducting feasible behavior in terms of attaining the aim
and objectives of the investigation. The researcher has faced several ethical challenges related to
copyright, plagiarism and data distribution during the research study (Cassel and Humphreys,
2016). But, it could be avoided by an investigator when the researcher provides credit to the
actual author about the data. In this research, research has kept the confidentiality of participants
for ethically conduct the research. Along with this, an investigator has used own-words for
avoiding the plagiarism issues. In addition, in each paragraph, the researcher has provided a

HEALTH AND SOCIAL CARE 14
proper in-text citation to give credibility to the authors in order to ethical complete the research.
The researcher has also used different databases and journal articles for ethically complete the
research (Webermann, et al., 2016).
Findings
From the data analysis, it can be evaluated that the researcher has selected most of the
participants from female groups. The percentage of the female is 64.29% i.e. higher than the
male groups. It is also found that most of the participants i.e. 14 out of 28 comes under the age of
18-24 years age old. In opposed to this, only 7% of participants come under the 55-64 years age
old.
It is also addressed that the researcher has selected the therapist who has 5-8 years of experience
in this field. In contrast to this, only 7.14% of participants have 5-8 years of experience in
providing the therapy.
It is illustrated that most of the participants i.e. 74% feels that the quality of therapeutic alliance
is linked with the treatment outcomes. In contrast to this, only 25.93% of participants do not
agree with this statement. It is found that most of the participant stated that the goal of
maintaining a therapeutic alliance for treatment of the dissociative disorder is to identify the
dissociative disorders. In contrast to this, there are only 3.57% of participants who feel that the
goal of maintaining a therapeutic alliance related to treatment with dissociative order to
responding the realistic as well as responsible behavior.
It is demonstrated that there are 71.43% of participants were agreed that people with dissociative
disorder uses different kinds of abuse. In contrast to this, only 28.57% of people do not believe in
this statement. It is illustrated that about 46.43% of participants stated that the important
function of the therapist in the therapeutic alliance is creating the trust that permits the clients for

HEALTH AND SOCIAL CARE 15
freely exploring the feeling as well as thoughts. In contrast to this, only 7% of participants do not
agree with this statement. It is found that most of the participants i.e. 74% think that client-
therapist relationship is critical significance, regardless of one’s therapeutic orientation. In
contrast to this, there are only 17% of participants who think that the client is an expert of his/her
own life in a client-therapist relationship.
It is demonstrated that there are 35.71% of participants thinks that poor diagnosis in dissociative
disorder creates a lack of motivation and that may hamper the normal life. It is addressed that
there are 35.71% of respondents thinks that using psychoeducation to enhance motivation is a
key factor that should be considered for obtaining a better treatment outcome from a therapeutic
relationship. In contrast to this, only 14.29% of participants think that improving communication
and cooperation is a key factor for obtaining a favorable treatment outcome with therapeutic
alliances.
Conclusion
From the above interpretation, it can be concluded that a therapist who works with dissociation
disorder patient should comprehend the significance of alliance on treatment results. These
results are reliable as most of the therapists were agreed with this statement. Along with this,
earlier literature depicts the significance of maintaining and developing a strong therapeutic
alliance. Although the effect size of individual who has dissociation disorder was stronger as
compared to another group of patient. A high knowledge regarding the effect of the alliance in
traumatized individuals may aid to create a higher outcome for these persons.
It can be summarised that there are different difficulties faced by the therapist in the diagnosis of
the symptoms of dissociation. These are hiding the symptoms; eliminate the disclosing intrusive
thoughts and anxiety of being crazy. It can be also concluded that therapeutic alliance has a

HEALTH AND SOCIAL CARE 16
positive impact on treatment results in patients with the dissociative disorder in RVI Hospitals,
England. There are different ways for improving the treatment outcome among patient with
dissociation disorder in RVI Hospitals, England. These ways are managing the conflicting
priorities, encourage healthy liaison and enhance the communication as well as cooperation. It
can be also concluded that a researcher should find the right therapist on behalf of his skills,
competencies, and experiences.
Evaluation of potential relevance for practice
The above finding has implication for offering the training to clinicians so they could be
effective in working with a client of dissociation disorder. The therapist should learn for creating
a strong alliance with the patients (Vyskocilova, Prasko, and Sipek, 2016). Future research
should involve the clarifying the procedure that assists in creating and maintaining the strong
alliance with dissociation disorder patients. The success regarding dissociation disorder will be
beneficial for motivating another investigator for conducting similar research by using
naturalistic design related to dissociation disorder patients (Linehan, 2018).
These investigations are required for assessing the additional variable that gains or decline the
possibility of therapeutic success and enhancement in dissociation disorder such as the degree of
social support in outside of therapy association, types of used interventions and skill level of
clinicians. The working alliance should be highly considered as it is a success factor to enhance
the symptoms and overall adaptive competencies in dissociation disorder patients. Further
investigation on the alliance as well as another variable that affect therapeutic results in
dissociation disorders patients can be highly considered (Thiel, et al., 2016).
Reflection

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This project was beneficial for me to gain my understanding regarding the impact of therapeutic
relationship on treatment outcome of a patient with dissociation disorder. This was effective for
me to enhance my career in the health industry. During this project, I faced challenges in terms
of data collection due to lack of communication skills. But, due to good decision-making skills, I
took a feasible decision on time. Throughout this project, I learned that a therapeutic relationship
is beneficial for obtaining the positive treatment outcome related to a patient with dissociation
disorder. This would be effective for my personal and professional career. I have also gained my
learning regarding ways to improve the relationship with the patients (McFetridge, et al., 2015).
This would be effective for satisfying the patients in the least time. I faced challenges in
conducting the survey as some of the therapists were not agree for participating in research due
to a lack of motivation skills. But, due to good technical skills, I have conducted this research.
This research is beneficial for me to become a good therapist in the future. My decision making
and technical skill can provide an opportunity for me for obtaining growth in health and social
care sector. Along with this, lack of motivation and communication skill can be threatened for
me to do further research (Cotter, Kaess, and Yung, 2015).

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Appendices
Appendix 1: Survey through a questionnaire
Please specify your gender
Male
Female
Please mention your age-group
18-24
25-35
35-44
45-54
55-64
65 and Above
Please specify your experience in the treatment of dissociative disorder?
1-4 years
5-8 years

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More than 8 years
Is the Quality of the Therapeutic Alliance Linked to Treatment Outcome?
Yes
No
The goal of your in Therapeutic Alliance for treatment of dissociative disorder
Assisting clients in creating a new life story
Identify the dissociative disorder
Proving symptoms relief in a brief
Responding realistic and responsible behavior
Do you agree that people with dissociative disorder uses different types of abuse?
Yes
No
The important function of the therapist in the Therapeutic Alliance is
Being present for and with the client
Creating a trust that allows the client to freely explore the feeling and thoughts
Interpreting the meaning of the client’s symptoms regarding the dissociative disorder
Providing the specific suggestion for things to do outside the therapy session
Regarding the client-therapist relationship, I think
The client is an expert on his or her own life
The therapist should remain relatively unknown
It is a key factor to get better treatment outcome regarding the dissociative disorder
It is a critical importance, regardless of one’s therapeutic orientation
What is the outcome of poor diagnosis in dissociative disorder?

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Lack of motivation to lead a normal life
Poor attachment
Lack of healthy therapeutic relationships
Self-destruction
Which key factor should be considered to get a better treatment outcome from a
therapeutic relationship?
Encouraging the client
Maintaining healthy relationships
Using psycho education to improve motivation
Improving cooperation and communication
Appendix2: Observation records

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