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This qualitatively)Tj T* -0.0055 Tc -0.0083 Tw (up-graded replacement for Critical Incident Stress)Tj 0 -1.21 TD -0.0062 Tc -0.0468 Tw (Management, Second Edition, presents conceptual)Tj 0 -1.2075 TD -0.0679 Tc -0.0615 Tw (refinements and up-dates that reflect the evolving nature of)Tj T* -0.0368 Tc -0.0613 Tw (crisis intervention and disaster mental health that have)Tj 0 -1.21 TD -0.0677 Tc -0.0615 Tw (revolutionized the field since 1999.)Tj /F7 1 Tf 30 0 0 30 221.01 701.01 Tm /GS1 gs -0.0044 Tc 0.0484 Tw [(A)56.6(vailable NOW!)]TJ /TT9 1 Tf 12 0 0 12 266.01 624.99 Tm /GS2 gs -0.0514 Tc -0.0625 Tw (Catalog #EVE12)Tj 0 -1.125 TD -0.0052 Tc 0.0458 Tw (Paperback 248 pp \(2008\))Tj T* 0.0169 Tc 0.125 Tw (ISBN 978-1-883581-12-1)Tj /F8 1 Tf 14 0 0 14 266.01 579.84 Tm 0.0271 Tc 0 Tw ($38.00)Tj /F6 1 Tf 18 0 3.78 18 147.9 675.66 Tm -0.0062 Tc 0.0416 Tw [(A Ne)8.8(w Book b)32.1(y)0.5( Geor)8.8(ge S.)93.8( Ev)25.5(er)-21.2(ly)72.1(,)98.1( Jr)43.8(.)98.1( and)]TJ 4.8826 -1.0283 TD -0.0044 Tc 0.0148 Tw [( Jeffr)15.6(e)24.6(y)0.8( )73.9(T)78.9(.)99.9( Mitchell)]TJ /TT3 1 Tf 11 0 0 11 145.89 113.01 Tm -0.004 Tc 0.0359 Tw (Get your copy of this important new resource by ordering NOW!)Tj 2.4191 -1.0909 TD -0.0047 Tc 0.0197 Tw (Order by calling Chevron Publishing at 410-418-8002)Tj 3.2045 -1.0909 TD 0.0303 Tw (Order online at chevronpublishing.com)Tj ET q 65.5 631.5 187.5 -278.5 re W n /GS1 gs /Fm6 Do Q /GS1 gs 54.495 732.505 492.01 -673.01 re S endstream endobj 33 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /F6 34 0 R /F7 35 0 R /F8 36 0 R /TT3 10 0 R /TT8 37 0 R /TT9 38 0 R >> /XObject << /Fm6 39 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> /ColorSpace << /Cs10 40 0 R >> >> endobj 41 0 obj << /FunctionType 0 /Domain [0 1] /Range [0 1 0 1 0 1 0 1] /BitsPerSample 8 /Size [255] /Length 701 /Filter /FlateDecode >> stream H P EKl& (&(b` fΛ ZTjUXSIRW[Ejlb7V0zqk%`AV! D$j7Ha$))d\&|&Jn3e4J0YFh2*`UF7X#c !+m21l]&ElL)Sc6Lۙ!] ;3eV줃927`tO;' 7dQE_bY"K.I岢XJY%%7efY'+=lM6a^Vief/6me{^-~gwdV?8Pp<&!rev)GMr#Ƕ9-C '8INnsʤ0iÜ.gt9#Yrȹr(ȅӢ\$%c\*͈q\ʮ8W3\#Ίs\?; r4'r$m.wȝINqȽ=){< ̓4#i<(d_<83<$/Kr,xU^> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 66 59.745 m 558 59.745 l S BT /TT3 1 Tf 8 0 0 8 423.24 42.6 Tm 0 0 0 1 k /GS2 gs -0.0051 Tc 0.0326 Tw [(IJEMH Vol. 10, No. 3 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (169)Tj /TT3 1 Tf 7 0 0 7 120.66 726.66 Tm -0.0061 Tc 0.021 Tw [(International Journal of Emergency Mental Health, Vol. 10, No. 3, pp. 169-176 2008 Chevron Publishing ISSN 1522-4821)]TJ /TT4 1 Tf 10 0 0 10 102.99 357.36 Tm 0.0046 Tc 0 Tw (Abstract: )Tj /TT5 1 Tf 4.2 0 TD 0.005 Tc 0.125 Tw (This paper reviews four empirical investigations into the effectiveness of workplace-based)Tj -4.2 -1.302 TD -0.0039 Tc -0.0114 Tw [(crisis inter)-6.9(vention pr)32.1(ograms designed to enhance psychological r)29.1(esiliency)53.1(. )14.2(As an extension of a pr)29.1(eviously)]TJ 0 -1.299 TD -0.0035 Tc 0.0846 Tw (published review of effect sizes of workplace-based crisis interventions \(Everly et al., 2006\), this paper)Tj T* -0.0034 Tc 0.0132 Tw (extends the expression of intervention effectiveness by proposing, then utilizing, the odds ratio statistic. It)Tj 0 -1.302 TD -0.0035 Tc -0.0047 Tw (is proposed that the odds ratio is a more useful tool by which to express the practical utility of workplace-)Tj 0 -1.299 TD 0.0041 Tc 0.125 Tw (based psychosocial interventions. Thus, the use of odds ratios may be a tool that serves to ease the)Tj T* -0.0035 Tc -0.0006 Tw (translation of research into practice. 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Everly)58.3(, Jr)35(, PhD is af)8.3(filiated with )15.2(The Johns Hopkins Center for Public Health Preparedness; )11.8(The Johns Hopkins Bloombe)]TJ 53.7437 0 TD -0.0167 Tc 0 Tw (rg)Tj -53.7437 -1.2233 TD -0.0049 Tc -0.0395 Tw (School of Public Health; Department of Psychiatry and Behavioral Sciences at The Johns Hopkins School of Medicine; and the Depa)Tj 51.971 0 TD 0 Tw (rtment)Tj -51.971 -1.2233 TD -0.0025 Tc 0.1251 Tw [(of Psychology)64.2(, Loyola College in Maryland. Martin F)77.5(.)0.3( Sherman, PhD serves in the Department of Psychology at Loyola College in)]TJ 0 -1.22 TD -0.0047 Tc 0.0486 Tw [(Maryland. Frederick Nucifora, Jr)48.6(. PhD, DO, MPH is af)12(filiated with the Department of Psychiatry and Behavioral Sciences at )12(The J)]TJ 52.6831 0 TD -0.0052 Tc 0 Tw (ohns)Tj -52.6831 -1.2233 TD -0.0048 Tc -0.0185 Tw [(Hopkins School of Medicine. )52(Alan Langlieb, MD, MPH, MBA)48.5( is with the Department of Psychiatry and Behavioral Sciences at )12(The Joh)]TJ 53.6726 0 TD -0.0051 Tc 0 Tw (ns)Tj -53.6726 -1.2233 TD -0.0049 Tc 0.0265 Tw [(Hopkins School of Medicine. Michael J. Kaminsky)61.8(, MD, MBA)51.8( is in the )-4.8(Department of Psychiatry and Behavioral Sciences at )11.9(The John)]TJ 54.1675 0 TD 0 Tc 0 Tw (s)Tj -54.1675 -1.22 TD -0.0048 Tc 0.0139 Tw (Hopkins School of Medicine. Jonathan M. Links, PhD is affiliated with The Johns Hopkins Center for Public Health Preparedness a)Tj 52.4795 0 TD (t The)Tj -52.4795 -1.2233 TD 0.0062 Tw [(Johns Hopkins Bloomberg School of Public Health. Correspondence regarding the article may be directed to geverly@jhsph.edu.)]TJ /F1 1 Tf 14 0 0 14 112.26 656.34 Tm -0.0056 Tc 0.1336 Tw [( A Quantitative Expression of Resiliency in the )73.8(W)66.3(orkplace:)]TJ 8.3314 -1.1421 TD -0.0009 Tc 0.1381 Tw (An Odds Ratio Analysis)Tj /TT2 1 Tf 12 0 0 12 143.16 515.64 Tm -0.0201 Tc -0.0604 Tw [(Martin F)77.4(.)0.4( Sherman)]TJ 10 0 0 10 129.24 503.01 Tm 0.0021 Tc -0.0534 Tw (Loyola College in Maryland)Tj 12 0 0 12 266.16 593.64 Tm -0.0138 Tc -0.0605 Tw [(Geor)8.7(ge S. Everly)56.2(, Jr)48.7(.)]TJ 10 0 0 10 194.16 581.01 Tm 0.001 Tc 0.02 Tw (The Johns Hopkins Center for Public Health Preparedness;)Tj 0.633 -1.2 TD 0.0009 Tc -0.0179 Tw (The Johns Hopkins Bloomberg School of Public Health;)Tj 2.217 -1.2 TD 0.001 Tc 0.0341 Tw (The Johns Hopkins School of Medicine; and)Tj 3.408 -1.2 TD 0.0021 Tc -0.0534 Tw (Loyola College in Maryland)Tj 12 0 0 12 391.89 467.64 Tm -0.026 Tc -0.0604 Tw (Michael J. 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Links)Tj 10 0 0 10 194.64 414.99 Tm 0.001 Tc 0.02 Tw (The Johns Hopkins Center for Public Health Preparedness;)Tj 0.786 -1.2 TD 0.0009 Tc -0.0214 Tw (The Johns Hopkins Bloomberg School of Public Health)Tj ET endstream endobj 44 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT1 8 0 R /TT2 9 0 R /TT3 10 0 R /TT4 20 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 46 0 obj << /Length 9215 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 54 59.745 m 546 59.745 l S BT /F1 1 Tf 8 0 0 8 54.99 41.64 Tm 0 0 0 1 k /GS2 gs -0.0057 Tc 0.073 Tw [(170 )]TJ /TT3 1 Tf 2.6963 0 TD -0.0054 Tc 0.075 Tw (Everly et al. Odds Ratio Analysis)Tj /TT2 1 Tf 10 0 0 10 72 722.64 Tm -0.0033 Tc -0.0307 Tw (The management of traumatic stress and its related syn-)Tj -1.8 -1.398 TD -0.0037 Tc -0.041 Tw [(dromes has moved from its post-V)56.3(ietnam era roots as a well-)]TJ 0 -1.401 TD -0.0067 Tc -0.0625 Tw (circumscribed clinical challenge to emerge most recently as a)Tj T* -0.0034 Tc 0.0272 Tw (large-scale public health issue. 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Cur-)Tj 0 -1.398 TD 0.0286 Tw [(rently)62.5(, this model is being developed at )14.2(The Johns Hopkins)]TJ 0 -1.401 TD -0.001 Tc 0.1252 Tw [(University)65(. )47.2(At its core, this perspectival model assists in)]TJ T* -0.0035 Tc -0.015 Tw (strategic planning by considering both multiple intervention)Tj 0 -1.398 TD 0.0051 Tc 0.125 Tw (perspectives and subsequently aligning the tactical inter-)Tj 0 -1.401 TD -0.0037 Tc 0.0312 Tw (ventions most suited to achieve the desired outcome within)Tj T* -0.0035 Tc 0.0822 Tw [(an overarching framework, that is, building resistance, en-)]TJ 0 -1.398 TD -0.0031 Tc 0.0119 Tw (hancing resilience, and facilitating the recovery of those af-)Tj 0 -1.401 TD 0.0272 Tc 0.1249 Tw [(fected by the disaster)54.2(. )15.1(This concept is consistent with)]TJ T* -0.0038 Tc 0.0562 Tw [(Millon)50.2(s integrative psychotherapeutic concepts \(Millon)]TJ 0 -1.398 TD -0.0032 Tc 0.055 Tw (et al., 1999\) wherein: )Tj /TT5 1 Tf 8.925 0 TD -0.004 Tc [(potentiating pairings)]TJ /TT2 1 Tf 8.391 0 TD -0.0036 Tc [( \(using interact-)]TJ -17.316 -1.401 TD -0.003 Tc 0.125 Tw (ing combinations of interventions so as to achieve an en-)Tj T* 0.0031 Tc (hancing clinical effect\), )Tj /TT5 1 Tf 10.179 0 TD 0.0029 Tc (catalytic sequences )Tj /TT2 1 Tf 8.31 0 TD 0.0038 Tc 0 Tw (\(sequentially)Tj -18.489 -1.398 TD -0.0033 Tc -0.025 Tw (combining tactical interventions in their most clinically use-)Tj 0 -1.401 TD -0.0023 Tc 0.0117 Tw (ful ways\), and )Tj /TT5 1 Tf 5.946 0 TD -0.0037 Tc 0.01 Tw (polythetic selection)Tj /TT2 1 Tf 7.683 0 TD -0.0032 Tc 0.0125 Tw [( \(selecting the tactical in-)]TJ -13.629 -1.401 TD -0.0129 Tc -0.0622 Tw (terventions as determined by the specific needs of each critical)Tj 0 -1.398 TD -0.0032 Tc -0.028 Tw (event, or mass disaster situation\) are all utilized to create the)Tj 0 -1.401 TD -0.0035 Tc -0.0072 Tw [(intervention approach with the greatest potential for achiev-)]TJ T* -0.0034 Tc 0.016 Tw [(ing a successful outcome. 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This)Tj 0 -1.401 TD -0.0036 Tc 0.0183 Tw (intervention model would appear to be applicable to a wide)Tj T* -0.0032 Tc 0.0414 Tw (variety of settings including hospitals, industrial and finan-)Tj 0 -1.398 TD -0.0099 Tc -0.0625 Tw [(cial or)14.1(ganizations, educational institutions, the military)65.1(, trans-)]TJ 0 -1.401 TD -0.0036 Tc 0.07 Tw [(portation industries, government agencies, etc.)]TJ /TT5 1 Tf 1.8 -2.001 TD -0.0045 Tc 0 Tw (Resistance)Tj /TT2 1 Tf 4.236 0 TD -0.0028 Tc -0.0434 Tw [( refers to the ability of an individual, a group,)]TJ -6.036 -1.398 TD -0.003 Tc -0.0083 Tw (an organization, or even an entire population, to literally )Tj /TT5 1 Tf 22.545 0 TD -0.0055 Tc 0 Tw (re-)Tj -22.545 -1.401 TD -0.0047 Tc (sist)Tj /TT2 1 Tf 1.32 0 TD -0.0035 Tc 0.0217 Tw [( manifestations of impairment or dysfunction associated)]TJ -1.32 -1.401 TD -0.0034 Tc 0.1136 Tw (with critical incidents, terrorism, and even mass disasters.)Tj 0 -1.398 TD -0.0031 Tc 0.1005 Tw (Resistance may be thought of as a form of psychological/)Tj 0 -1.401 TD -0.0471 Tw [(behavioral immunity to distress and dysfunction. )17.8(W)94.6(e)0.5( believe)]TJ T* -0.0033 Tc 0.0107 Tw (that resistance may be built through the following:)Tj 12 0 0 12 321 234.66 Tm 0 Tc 0 Tw ()Tj 10 0 0 10 339 234.66 Tm -0.0035 Tc -0.0086 Tw (Experience \(prior successes in vivo and in vitro\))Tj 12 0 0 12 321 214.65 Tm 0 Tc 0 Tw ()Tj 10 0 0 10 339 214.65 Tm -0.0034 Tc -0.0607 Tw (Expectancy \(being provided information so as to cre-)Tj T* -0.0037 Tc 0.0575 Tw (ate accurate expectations\))Tj 12 0 0 12 321 180.66 Tm 0 Tc 0 Tw ()Tj 10 0 0 10 339 180.66 Tm -0.0044 Tc 0.06 Tw (Encouragement and Support)Tj 12 0 0 12 321 160.65 Tm 0 Tc 0 Tw ()Tj 10 0 0 10 339 160.65 Tm -0.0117 Tc -0.0625 Tw (Self-regulation \(the ability to modulate personal stress)Tj T* 0.0097 Tc 0 Tw (physiology\))Tj 12 0 0 12 321 126.66 Tm 0 Tc ()Tj 10 0 0 10 339 126.66 Tm 0.0011 Tc 0.125 Tw (Constructive cognitions)Tj -1.2 -2.001 TD -0.0032 Tc 0.092 Tw [(Historically)59.8(, this element of disaster mental health re-)]TJ -1.8 -1.401 TD -0.0034 Tc 0.1171 Tw [(sponse was conspicuous in its absence. More specifically)59.6(,)]TJ 0 -1.398 TD -0.0036 Tc -0.0621 Tw (disaster mental health services were almost exclusively reac-)Tj ET endstream endobj 47 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT2 9 0 R /TT3 10 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 49 0 obj << /Length 9207 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 66 59.745 m 558 59.745 l S BT /TT3 1 Tf 8 0 0 8 423.24 42.6 Tm 0 0 0 1 k /GS2 gs -0.0051 Tc 0.0326 Tw [(IJEMH Vol. 10, No. 3 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (171)Tj /TT2 1 Tf 10 0 0 10 66 722.64 Tm -0.0026 Tc 0.125 Tw (tionary in nature. The notion of creating resistance repre-)Tj 0 -1.398 TD -0.0033 Tc 0.0462 Tw (sents a proactive step in emergency mental health. Notions)Tj 0 -1.401 TD -0.0035 Tc 0.074 Tw (of psychological immunization and psychological body)Tj T* -0.0033 Tc 0.0294 Tw (armor are engendered by the introduction of this interven-)Tj 0 -1.398 TD -0.0036 Tc 0.0157 Tw (tion to the pre-incident phase of the temporal continuum.)Tj /TT5 1 Tf 1.8 -2.001 TD -0.0042 Tc 0 Tw (Resilience)Tj /TT2 1 Tf 4.071 0 TD -0.0028 Tc -0.025 Tw [( refers to the ability of an individual, a group,)]TJ -5.871 -1.401 TD -0.0033 Tc -0.0188 Tw (an organization, or even an entire population, to )Tj /TT5 1 Tf 19.125 0 TD -0.0044 Tc -0.02 Tw (rapidly and)Tj -19.125 -1.398 TD 0.0028 Tc 0 Tw (effectively)Tj /TT2 1 Tf 4.086 0 TD 0 Tc ( )Tj /TT5 1 Tf 0.378 0 TD 0.001 Tc (rebound)Tj /TT2 1 Tf 3.345 0 TD 0.0033 Tc 0.125 Tw [( from psychological and/or behavioral)]TJ -7.809 -1.401 TD -0.0093 Tc -0.0625 Tw (perturbations associated with critical incidents, terrorism, and)Tj T* -0.0038 Tc 0.12 Tw (even mass disasters.)Tj 1.8 -1.998 TD -0.0034 Tc -0.0255 Tw [(While resilience is often thought of as an innate quality)59.6(,)]TJ -1.8 -1.401 TD 0.0012 Tc 0.125 Tw (relevant literature underscores the power of interpersonal)Tj T* -0.0032 Tc 0.1025 Tw [(support as a factor believed to enhance resilience \(Everly)59.8(,)]TJ 0 -1.398 TD -0.0126 Tc -0.0622 Tw [(2009; Haglund et al., 2007; Luthar)38.4(, Cicchetti, & Becker)38.4(, 2000;)]TJ 0 -1.401 TD -0.0131 Tc -0.0625 Tw [(McCubbin et al., 1997\). Similarly)61.9(, resilience may be enhanced)]TJ T* -0.003 Tc 0.0962 Tw (by any intervention or process that instills confidence and)Tj 0 -1.398 TD -0.0034 Tc 0.0392 Tw (reduces manifestations of distress, impairment, or dysfunc-)Tj 0 -1.401 TD -0.0036 Tc 0.0171 Tw [(tion \(Bandura, 1997; Rutter)35.4(, 1985\). Interpersonal support is)]TJ T* -0.0033 Tc -0.0311 Tw (believed to exert just such an effect. Crisis interventions are,)Tj 0 -1.398 TD -0.0032 Tc 0.076 Tw (if nothing else, a form of interpersonal support. Thus, it is)Tj 0 -1.401 TD -0.0034 Tc -0.0565 Tw (reasonable to conclude that crisis interventions may improve)Tj T* -0.0106 Tc 0 Tw (resilience.)Tj 1.8 -1.998 TD -0.0026 Tc 0.125 Tw (Psychological crisis intervention techniques were ini-)Tj -1.8 -1.401 TD -0.0023 Tc -0.0055 Tw [(tially developed by military psychiatry during )18.8(W)95.5(orld )15.8(W)98.5(ars I)]TJ T* -0.0071 Tc -0.0625 Tw [(and II \(Artiss, 1963; Kardiner)37.9(, 1941; Salmon, 1919\) and later)]TJ 0 -1.398 TD -0.0043 Tc -0.0621 Tw (applied within the context of community psychiatry \(Caplan,)Tj 0 -1.401 TD -0.0207 Tc [(1961, 1964; Decker & S)18.3(tubblebine, 1972; Langsley)60.3(, Machotka,)]TJ T* -0.0036 Tc -0.0223 Tw [(& Flomenhaft, 1971; Parad & Parad, 1968\). )53.3(A)58.6( recent review)]TJ 0 -1.398 TD -0.0034 Tc 0.0772 Tw (argues that workplace-based crisis intervention may be ef-)Tj 0 -1.401 TD -0.003 Tc -0.0533 Tw [(fective in reducing distress as well \(Everly et al., 2006\).)]TJ 1.8 -2.001 TD -0.0015 Tc 0 Tw [(Finally)64.5(, )]TJ /TT5 1 Tf 3.195 0 TD -0.004 Tc [(r)34.2(ecovery )]TJ /TT2 1 Tf 3.621 0 TD -0.0032 Tc -0.0614 Tw (may be thought of as the application of)Tj -8.616 -1.398 TD -0.0051 Tc -0.0622 Tw (therapy and rehabilitation interventions that facilitate the res-)Tj 0 -1.401 TD -0.0033 Tc 0.01 Tw (toration of functionality once it has been compromised.)Tj 1.8 -2.001 TD -0.0034 Tc 0.1062 Tw [(In this paper)38.6(,)-0.1( we focused on resilience. More specifi-)]TJ -1.8 -1.398 TD -0.0033 Tc 0.0128 Tw [(cally)62.7(, we proposed a quantitative method for the expression)]TJ 0 -1.401 TD -0.0084 Tc -0.0622 Tw (of resilience that is novel to the field of disaster mental health.)Tj /F1 1 Tf 11 0 0 11 66 170.01 Tm -0.0001 Tc 0 Tw (Rationale)Tj /TT2 1 Tf 10 0 0 10 84 146.64 Tm -0.0035 Tc 0.0342 Tw (In conducting studies that affect public health decision)Tj -1.8 -1.398 TD -0.0033 Tc -0.0417 Tw (making, it is not only important to determine whether results)Tj 0 -1.401 TD -0.003 Tc 0.0317 Tw (are statistically significant, but it is also important to deter-)Tj T* -0.0036 Tc 0.055 Tw (mine the magnitude or strength of the relation between the)Tj 0 -1.398 TD -0.0114 Tw (predictor and outcome variables. Statistical significance is a)Tj 25.5 63.198 TD -0.003 Tc 0.0279 Tw (function of sample size and effect size. Hence, a very large)Tj 0 -1.398 TD -0.0035 Tc 0.019 Tw (sample size can compensate for a small effect size and pro-)Tj 0 -1.401 TD -0.0039 Tc -0.062 Tw [(duce statistical significance. )50.3(Alternatively)65.1(, it is possible for a)]TJ T* -0.0035 Tc -0.0072 Tw [(researcher to obtain statistical significance when the sample)]TJ 0 -1.398 TD -0.0031 Tc 0.0379 Tw (size is small but the effect size is large. In other words, the)Tj 0 -1.401 TD 0.1045 Tw (value of the statistical test is equal to an effect size index)Tj T* -0.0033 Tc 0.0741 Tw (times a sample size index. Thus, it is important for the re-)Tj 0 -1.398 TD -0.0028 Tc -0.0329 Tw (searcher as well as the policy maker to pay attention to all of)Tj 0 -1.401 TD -0.0092 Tc -0.0625 Tw (the factors that contribute to statistical significance. The ubiq-)Tj T* -0.003 Tc -0.0514 Tw (uitous, yet overly simplistic, determination that given results)Tj 0 -1.398 TD -0.0031 Tc 0.1182 Tw [(are statistically significant does not tell the whole story)]TJ 0 -1.401 TD -0.0036 Tc 0.0571 Tw (and raises issues concerning clinical versus statistical sig-)Tj T* -0.0026 Tc -0.0131 Tw (nificance i.e., what may be statistically significant may not)Tj 0 -1.398 TD -0.0074 Tc -0.062 Tw (be clinically meaningful, nor programmatically useful.)Tj /F1 1 Tf 11 0 0 11 321 507.99 Tm -0.0048 Tc 0.0454 Tw (Meaningful Expression Of Research Findings)Tj /TT2 1 Tf 10 0 0 10 339 484.65 Tm -0.0033 Tc 0.063 Tw (The power of a research finding may be thought of as)Tj -1.8 -1.401 TD -0.0032 Tc -0.0282 Tw (the effect size. The three most basic forms of effect sizes are)Tj 0 -1.398 TD -0.0057 Tc -0.0622 Tw (the following: when the independent variable is dichotomous)Tj 0 -1.401 TD -0.0033 Tc -0.0255 Tw (\(e.g., treatment vs. control\) and the outcome variable is con-)Tj T* -0.0034 Tc 0.0069 Tw (tinuous, effect sizes that utilize mean differences are appro-)Tj 0 -1.398 TD 0.1151 Tw [(priate \(e.g., Cohen)50.6(s )]TJ /TT5 1 Tf 8.61 0 TD 0 Tc 0 Tw (d)Tj /TT2 1 Tf 0.495 0 TD -0.004 Tc 0.115 Tw [(, Hedges)71( )]TJ /TT5 1 Tf 4.206 0 TD 0 Tc 0 Tw (g)Tj /TT2 1 Tf 0.495 0 TD -0.0039 Tc 0.115 Tw (\); when the independent)Tj -13.806 -1.401 TD -0.0036 Tc 0.0381 Tw (variable is continuous and the outcome variable is continu-)Tj T* 0.0465 Tw (ous the most appropriate measure of effect size tends to be)Tj 0 -1.398 TD 0.0725 Tw (some form of a correlation coefficient \(a Pearson Product-)Tj 0 -1.401 TD -0.0034 Tc 0.0368 Tw [(moment, for example\); and finally)62.6(, when both the indepen-)]TJ T* -0.0041 Tc -0.0625 Tw (dent and dependent variables are dichotomized then the most)Tj 0 -1.398 TD -0.0031 Tc -0.0168 Tw (appropriate measure of effects size for 2 by 2 tables tends to)Tj 0 -1.401 TD -0.0034 Tc -0.0255 Tw [(be odds ratios or relative risks indices. )50.6(Although most, if not)]TJ T* -0.0033 Tc -0.0004 Tw [(all, of the ef)14.7(fect sizes can be converted from one to another)35.7(,)]TJ 0 -1.398 TD -0.0036 Tc -0.0244 Tw (the most common effect sizes reported in the social sciences)Tj 0 -1.401 TD 0.0067 Tc 0.125 Tw [(tends to be Cohen)51.7(s )]TJ /TT5 1 Tf 8.751 0 TD 0 Tc 0 Tw (d)Tj /TT2 1 Tf 0.504 0 TD 0.007 Tc 0.125 Tw [( statistic and the Pearson Product-)]TJ -9.255 -1.401 TD -0.0109 Tc -0.0623 Tw [(moment correlation coef)13.1(ficient. However)37.1(, within the medical/)]TJ 0 -1.398 TD -0.0036 Tc 0.0925 Tw (epidemiological/public health venues, the relative risk and)Tj 0 -1.401 TD 0.0036 Tc 0.1249 Tw [(odds ratios tend to dominate. These measures tend to be)]TJ T* -0.0028 Tc -0.0233 Tw (very popular because they provide a very intuitive and prac-)Tj 0 -1.398 TD -0.0034 Tc 0.02 Tw (tical understanding of effect sizes.)Tj 1.8 -2.001 TD -0.0032 Tc -0.0306 Tw (Relative risk provides the researcher with a way of con-)Tj -1.8 -1.401 TD 0.0989 Tw (veying the likelihood of an outcome given a specific risk.)Tj 0 -1.398 TD -0.0088 Tc -0.0625 Tw (Relative risks are derived by forming a ratio of the probability)Tj 0 -1.401 TD -0.0032 Tc 0.0182 Tw (of an outcome given the risk over the probability of an out-)Tj T* -0.0035 Tc 0.0109 Tw (come given the absence of the risk.)Tj 14.4 0 TD 0.0138 Tc 0.125 Tw (Odds ratios are deter-)Tj -14.4 -1.398 TD -0.0032 Tc 0.1169 Tw (mined by taking the probability of an outcome associated)Tj 0 -1.401 TD -0.0029 Tc 0.0765 Tw (with a specified risk divided by the probability of the out-)Tj T* -0.0034 Tc -0.05 Tw [(come not happening. )50.6(Alternatively)62.6(, one can think of the odds)]TJ ET endstream endobj 50 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT2 9 0 R /TT3 10 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 52 0 obj << /Length 9238 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 54 59.745 m 546 59.745 l S BT /F1 1 Tf 8 0 0 8 54.99 41.64 Tm 0 0 0 1 k /GS2 gs -0.0057 Tc 0.073 Tw [(172 )]TJ /TT3 1 Tf 2.6963 0 TD -0.0054 Tc 0.075 Tw (Everly et al. Odds Ratio Analysis)Tj /TT2 1 Tf 10 0 0 10 54 722.64 Tm -0.0033 Tc -0.037 Tw [(ratio as the ratio of two odds. )53.6(An odds is the number of cases)]TJ 0 -1.398 TD -0.0031 Tc -0.0146 Tw (in the x group divided by the number of cases that are not in)Tj 0 -1.401 TD -0.0036 Tc -0.02 Tw (the x group.)Tj 1.8 -2.001 TD 0.0567 Tw (Although the relative risk has more of an intuitive un-)Tj -1.8 -1.398 TD -0.0032 Tc -0.0017 Tw (derstanding \(the ratio of two probabilities in a cohort study\))Tj 0 -1.401 TD -0.0036 Tc 0.0733 Tw (it does have certain limitations that move the pendulum in)Tj T* -0.0032 Tc -0.0359 Tw (the direction of using odds ratios. First of all, odds ratios can)Tj 0 -1.398 TD -0.003 Tc -0.0394 Tw [(vary between zero and infinity)60(, unlike the relative risk. Odds)]TJ 0 -1.401 TD -0.0028 Tc -0.0539 Tw (ratios also possess a symmetrical property: if you reverse the)Tj T* -0.0037 Tc 0.019 Tw (outcomes - looking for the good outcome as opposed to the)Tj 0 -1.398 TD -0.0032 Tc -0.0119 Tw (bad outcome - the new odds ratio is simply the reciprocal of)Tj 0 -1.401 TD -0.0034 Tc 0.025 Tw (the original odds ratio [unlike the relative risk where this is)Tj T* -0.0033 Tc 0.0055 Tw (not true]. In case control studies the relative risk is inappro-)Tj 0 -1.398 TD -0.0035 Tc 0.0123 Tw (priate because the prevalence of a particular outcome is un-)Tj 0 -1.401 TD -0.0083 Tc -0.0623 Tw (known. The odds ratio is not hindered by this lack of knowing)Tj T* -0.0032 Tc 0.1225 Tw [(the prevalence. )50.8(And finally)62.8(, the odds ratio can be used in)]TJ 0 -1.398 TD -0.0036 Tc -0.0072 Tw (situations where control or confounding variables are incor-)Tj 0 -1.401 TD -0.003 Tc 0.0521 Tw (porated into a regression analysis \(i.e., logistic regression\),)Tj T* -0.0035 Tc 0.0367 Tw (unlike the relative risk which cannot be used in regression-)Tj 0 -1.398 TD -0.0026 Tc -0.0433 Tw (type analyses \(Deeks, 1996\).)Tj /F1 1 Tf 11 0 0 11 54 417.99 Tm -0.0044 Tc 0.0424 Tw (Quantitative Expression of Resiliency)Tj /TT2 1 Tf 10 0 0 10 72 394.65 Tm -0.0037 Tc -0.0623 Tw (It may be argued that mental health has yet to gain parity)Tj -1.8 -1.401 TD -0.003 Tc 0.0883 Tw (with physical health in the domain of public health policy)Tj 0 -1.398 TD -0.0029 Tc -0.0145 Tw (and practice. One reason for this inequity may be the failure)Tj 0 -1.401 TD -0.0034 Tc -0.0122 Tw (of researchers in the mental health field to translate findings)Tj T* -0.0105 Tc -0.0625 Tw (into a terminology that is readily useful to public health policy)Tj 0 -1.398 TD -0.0051 Tc -0.0623 Tw (makers, practitioners, and, in the case of the workplace, man-)Tj 0 -1.401 TD 0.008 Tc 0 Tw (agers.)Tj 1.8 -2.001 TD -0.0028 Tc 0.0175 Tw (It will be recalled that resiliency may be defined as the)Tj -1.8 -1.398 TD -0.003 Tc -0.0135 Tw (ability of an individual, a group, an organization, or even an)Tj 0 -1.401 TD -0.0034 Tc 0.1217 Tw (entire population, to )Tj /TT5 1 Tf 8.625 0 TD -0.0037 Tc 0.1225 Tw (rapidly and effectively)Tj /TT2 1 Tf 9.105 0 TD 0 Tc 0 Tw ( )Tj /TT5 1 Tf 0.369 0 TD -0.0055 Tc (rebound)Tj /TT2 1 Tf 3.3 0 TD -0.0045 Tc 0.125 Tw [( from)]TJ -21.399 -1.401 TD 0.0088 Tc (psychological and/or behavioral perturbations associated)Tj 0 -1.398 TD -0.0034 Tc 0.1136 Tw (with critical incidents, terrorism, and even mass disasters.)Tj 0 -1.401 TD -0.0005 Tc 0.125 Tw [(W)94.3(e)0( indicated that resilience can be enhanced through the)]TJ T* -0.0031 Tc 0.0558 Tw (use of psychological crisis intervention techniques initially)Tj 0 -1.398 TD -0.0025 Tc -0.0372 Tw [(developed by military psychiatry during )15.5(W)98.3(orld )18.5(W)95.3(ars I and II)]TJ 0 -1.401 TD -0.004 Tc -0.0625 Tw (and later applied within the context of community psychiatry)Tj T* -0.0035 Tc 0.0822 Tw (and even the workplace. The challenge is how to translate)Tj 0 -1.398 TD -0.0031 Tc 0.0558 Tw (empirical findings relevant to psychological resiliency into)Tj 0 -1.401 TD -0.0036 Tc -0.0543 Tw (terms more pragmatic than traditional expressions of statisti-)Tj T* -0.0034 Tc 0.002 Tw (cal inference. For the reasons noted above, we chose to em-)Tj 0 -1.398 TD -0.0052 Tc -0.0622 Tw (ploy the odds ratio for our analyses of workplace-based crisis)Tj 0 -1.401 TD 0.0015 Tc 0 Tw (intervention.)Tj /F1 1 Tf 11 0 0 11 403.14 723.99 Tm 0.0198 Tc (METHOD)Tj /TT2 1 Tf 10 0 0 10 327 700.65 Tm -0.0009 Tc 0.125 Tw (In light of the challenge noted above, the current re-)Tj -1.8 -1.401 TD -0.0031 Tc 0.0272 Tw (searchers decided to employ odds ratio analysis as a means)Tj 0 -1.398 TD -0.0033 Tc 0.1165 Tw (of expressing the effect sizes associated with empirically-)Tj 0 -1.401 TD 0.0009 Tc 0.125 Tw (based investigations of crisis intervention-enhanced resil-)Tj T* 0.0025 Tc (iency as engendered through workplace-based initiatives.)Tj 0 -1.398 TD -0.0033 Tc -0.0359 Tw (This analysis was conducted using investigations previously)Tj 0 -1.401 TD -0.0031 Tc -0.0559 Tw [(identified by Everly)62.9(, Sherman, S)17.9(tapleton, Barnett, Hiremath,)]TJ T* 0.0166 Tw (and Links \(2006\) in their analysis of workplace crisis inter-)Tj 0 -1.398 TD -0.0098 Tc -0.0622 Tw (vention. Four studies were extracted from the aforementioned)Tj 0 -1.401 TD -0.0035 Tc 0.0061 Tw (review that were deemed relevant to the investigation of re-)Tj T* -0.0093 Tc 0 Tw [(siliency)59.7(.)]TJ /F1 1 Tf 11 0 0 11 309 528 Tm -0.0032 Tc (Analysis)Tj /TT2 1 Tf 10 0 0 10 327 504.66 Tm -0.0034 Tc -0.0307 Tw (Everly and colleagues \(2006\) converted the various sta-)Tj -1.8 -1.401 TD 0.0732 Tw [(tistics found in their constituent studies into the Cohen)53.6(s )]TJ /TT5 1 Tf 23.205 0 TD 0 Tc 0 Tw (d)Tj /TT2 1 Tf -23.205 -1.401 TD -0.0036 Tc 0.0925 Tw (statistic. This statistic provides information regarding how)Tj 0 -1.398 TD 0.11 Tw (much difference, in standardized units, exists between the)Tj 0 -1.401 TD 0.096 Tw [(means of two groups. )53.4(A)58.6( )]TJ /TT5 1 Tf 10.119 0 TD 0 Tc 0 Tw (d)Tj /TT2 1 Tf 0.495 0 TD -0.0034 Tc 0.0975 Tw [( value of 1 indicates the sample)]TJ -10.614 -1.401 TD -0.0038 Tc 0.0245 Tw [(mean of Group )50.2(A)58.4( is one standard deviation above the mean)]TJ 0 -1.398 TD -0.0037 Tc 0.028 Tw [(of Group B. However)38.3(, what this means in pragmatic terms)]TJ 0 -1.401 TD -0.0038 Tc 0.0357 Tw (becomes somewhat problematic. The degree of overlap be-)Tj T* -0.0035 Tc -0.02 Tw (tween the two distributions is 44.6%, but what this means in)Tj 0 -1.398 TD -0.0034 Tc -0.055 Tw [(terms of likelihood of intervention effectiveness, survival, or)]TJ 0 -1.401 TD -0.0027 Tc 0.0994 Tw [(success, etc., is not easily interpreted. )51.3(A)59.5( partial remedy to)]TJ T* -0.0036 Tc -0.0267 Tw [(this is to convert the Cohen)50.4(s )]TJ /TT5 1 Tf 11.625 0 TD 0 Tc 0 Tw (d)Tj /TT2 1 Tf 0.495 0 TD -0.0029 Tc -0.027 Tw [( into a more readily interpret-)]TJ -12.12 -1.398 TD -0.0035 Tc 0.0028 Tw (able effect size index without too much loss of information.)Tj 0 -1.401 TD -0.0039 Tc -0.008 Tw [(One such approach is the conversion of Cohen)50.1(s )]TJ /TT5 1 Tf 19.314 0 TD 0 Tc 0 Tw (d)Tj /TT2 1 Tf 0.495 0 TD -0.0038 Tc -0.01 Tw [( into odds)]TJ -19.809 -1.401 TD -0.0083 Tc -0.0622 Tw (ratio. Devilly \(2007\) has created a software program that con-)Tj 0 -1.398 TD -0.0035 Tc 0.0721 Tw [(verts the various ef)17.5(fect size measures from one to another)50.5(.)]TJ 0 -1.401 TD 0.0894 Tw (Utilizing this program, the current authors took the values)Tj T* -0.0051 Tc 0 Tw [(\(Cohen)51.9(s )]TJ /TT5 1 Tf 3.861 0 TD 0 Tc (d)Tj /TT2 1 Tf 0.495 0 TD -0.0036 Tc 0.0386 Tw (\) from the identified studies and converted them)Tj -4.356 -1.398 TD 0.075 Tw (into odds ratios. Cohen \(1988\) suggested that )Tj /TT5 1 Tf 18.75 0 TD 0 Tc 0 Tw (d)Tj /TT2 1 Tf 0.495 0 TD -0.0021 Tc 0.0767 Tw [()54.9(s)0( of .2, .5,)]TJ -19.245 -1.401 TD -0.0067 Tc -0.0622 Tw (and .8 represent weak, moderate, and strong effects and when)Tj T* -0.0023 Tc 0.125 Tw (converted to odds ratios the values become roughly 1.50,)Tj 0 -1.398 TD -0.0033 Tc 0.0477 Tw (2.50, and 4.30. Listed below are the identified studies with)Tj 0 -1.401 TD 0.0187 Tw (their resultant odds ratios \()Tj /TT5 1 Tf 10.701 0 TD -0.013 Tc 0 Tw (OR)Tj /TT2 1 Tf 1.32 0 TD -0.004 Tc (\).)Tj /F1 1 Tf 11 0 0 11 401.64 164.01 Tm 0.0198 Tc [(RESUL)82.5(TS)]TJ /TT5 1 Tf 10 0 0 10 327 140.64 Tm -0.0038 Tc -0.055 Tw (Study #1.)Tj /TT2 1 Tf 3.636 0 TD -0.0037 Tc -0.0572 Tw [( )-5.9( Campfield and Hills \(2001\) conducted a puta-)]TJ -5.436 -1.398 TD -0.0035 Tc -0.0072 Tw (tive randomized controlled trial of crisis intervention subse-)Tj 0 -1.401 TD -0.0029 Tc -0.0215 Tw (quent to robbery at the workplace. Employees \()Tj /TT5 1 Tf 18.711 0 TD 0.001 Tc 0 Tw (n )Tj /TT2 1 Tf 0.729 0 TD -0.0039 Tc -0.0225 Tw (= 77\) were)Tj -19.44 -1.401 TD -0.0056 Tc -0.0622 Tw (randomly assigned to an immediate crisis intervention condi-)Tj 0 -1.398 TD -0.0035 Tc -0.0483 Tw (tion \(<10 hours, )Tj /TT5 1 Tf 6.474 0 TD -0.004 Tc 0 Tw (n )Tj /TT2 1 Tf 0.696 0 TD -0.003 Tc -0.0493 Tw (= 36\), or a delayed crisis intervention con-)Tj ET endstream endobj 53 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT2 9 0 R /TT3 10 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 55 0 obj << /Length 13104 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 66 59.745 m 558 59.745 l S BT /TT3 1 Tf 8 0 0 8 423.24 42.6 Tm 0 0 0 1 k /GS2 gs -0.0051 Tc 0.0326 Tw [(IJEMH Vol. 10, No. 3 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (173)Tj /TT2 1 Tf 10 0 0 10 66 722.64 Tm -0.0034 Tc 0.0133 Tw (dition \(>48 hours, )Tj /TT5 1 Tf 7.431 0 TD -0.006 Tc 0 Tw (n )Tj /TT2 1 Tf 0.759 0 TD -0.0033 Tc 0.014 Tw (= 41\). Posttraumatic morbidity was as-)Tj -8.19 -1.398 TD -0.0076 Tc -0.0621 Tw (sessed using the Posttraumatic Stress Diagnostic Scale \(PDS\))Tj 0 -1.401 TD -0.0029 Tc 0.0634 Tw (at intervention, 2 days post intervention, 4 days post inter-)Tj T* -0.0182 Tc -0.0624 Tw [(vention, and 2 weeks post robbery)62.8(. Campfield and Hills \(2001\))]TJ 0 -1.398 TD -0.0032 Tc -0.0439 Tw (noted, For both number of symptoms and severity of symp-)Tj 0 -1.401 TD -0.0081 Tc -0.0622 Tw (toms, there was a significant main effect of group: symptoms,)Tj /TT5 1 Tf T* 0 Tc 0 Tw (F)Tj /TT2 1 Tf 0.585 0 TD -0.0244 Tc -0.0617 Tw (\(1,75\) = 52.92, )Tj /TT5 1 Tf 5.661 0 TD -0.024 Tc 0 Tw (p )Tj /TT2 1 Tf 0.639 0 TD -0.0243 Tc -0.0625 Tw (< .001, )Tj /F9 1 Tf 2.751 0 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 5.8 0 0 5.8 168.09 642 Tm (2)Tj 10 0 0 10 170.85 638.64 Tm -0.023 Tc -0.0619 Tw [( = .41; severity)61(. )]TJ /TT5 1 Tf 5.781 0 TD 0 Tc 0 Tw (F)Tj /TT2 1 Tf 0.585 0 TD -0.0244 Tc -0.0617 Tw (\(1,75\) = 59.48, )Tj /TT5 1 Tf 5.655 0 TD -0.025 Tc 0 Tw (p )Tj /TT2 1 Tf 0.633 0 TD 0 Tc (<)Tj -23.139 -1.398 TD -0.0072 Tc (.001, )Tj /F9 1 Tf 2.151 0 TD 0 Tc ()Tj /TT2 1 Tf 5.8 0 0 5.8 93.39 627.99 Tm -0.0017 Tc (2 )Tj 10 0 0 10 97.35 624.66 Tm -0.0078 Tc -0.0625 Tw (= .44. There was also a significant main effect of time)Tj -3.135 -1.401 TD -0.0046 Tc -0.06 Tw (interval: symptoms, )Tj /TT5 1 Tf 7.98 0 TD 0 Tc 0 Tw (F)Tj /TT2 1 Tf 0.606 0 TD -0.005 Tc -0.0617 Tw (\(3,225\) = 133.46, )Tj /TT5 1 Tf 6.954 0 TD -0.004 Tc 0 Tw (p )Tj /TT2 1 Tf 0.681 0 TD -0.0625 Tw (< .001, )Tj /F9 1 Tf 2.904 0 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 5.8 0 0 5.8 263.16 614.01 Tm -0.0017 Tc (2 )Tj 10 0 0 10 267.15 610.65 Tm -0.0053 Tc -0.0625 Tw (= .64; se-)Tj -20.115 -1.401 TD -0.0011 Tc 0 Tw [(verity)64.9(, )]TJ /TT5 1 Tf 2.769 0 TD 0 Tc (F)Tj /TT2 1 Tf 0.606 0 TD -0.0033 Tc 0.0117 Tw (\(3,225 = 267.28, )Tj /TT5 1 Tf 6.879 0 TD -0.004 Tc 0 Tw (p )Tj /TT2 1 Tf 0.756 0 TD -0.0026 Tc 0.01 Tw (< .001, )Tj /F9 1 Tf 3.066 0 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 5.8 0 0 5.8 212.7 600 Tm (2)Tj 10 0 0 10 215.61 596.64 Tm -0.0032 Tc 0.0125 Tw [( = .78 \(pp. 333-334\).)]TJ -14.961 -1.398 TD -0.0037 Tc 0.1107 Tw (These findings were transformed into the following effect)Tj 0 -1.401 TD -0.0036 Tc 0 Tw (sizes \()Tj /TT5 1 Tf 2.505 0 TD 0 Tc (d)Tj /TT2 1 Tf 0.495 0 TD -0.0034 Tc -0.0025 Tw (\) and odds ratios \()Tj /TT5 1 Tf 7.149 0 TD -0.013 Tc 0 Tw (OR)Tj /TT2 1 Tf 1.32 0 TD -0.0048 Tc (\):)Tj -10.269 -2.001 TD -0.0035 Tc -0.0575 Tw [(1\) For the main ef)17.5(fect of group on symptoms, Cohen)50.5(s )]TJ /TT5 1 Tf 21.255 0 TD 0 Tc 0 Tw (d)Tj /TT2 1 Tf 0.495 0 TD -0.064 Tc ( =)Tj -19.95 -1.398 TD -0.0048 Tc (1.66, )Tj /TT4 1 Tf 2.16 0 TD -0.0182 Tc (OR)Tj /TT1 1 Tf 1.371 0 TD -0.0073 Tc -0.0625 Tw [( = 20.31)]TJ /TT2 1 Tf -5.331 -2.001 TD -0.0033 Tc -0.0617 Tw [(2\) For the main ef)17.7(fect of group on severity)59.7(,)-6( )]TJ /TT5 1 Tf 16.776 0 TD 0 Tc 0 Tw (d)Tj /TT2 1 Tf 0.495 0 TD -0.0022 Tc -0.0617 Tw [( = 1.77, )]TJ /TT4 1 Tf 3.108 0 TD -0.0152 Tc 0 Tw (OR)Tj /TT1 1 Tf 1.377 0 TD -0.0758 Tc ( =)Tj -19.956 -1.401 TD 0.0188 Tc (24.79)Tj /TT5 1 Tf -1.2 -1.998 TD -0.0034 Tc 0.0575 Tw (Study #2. )Tj /TT2 1 Tf 4.056 0 TD -0.0039 Tc 0.0588 Tw (Richards \(2001\) conducted prospective field)Tj -5.856 -1.401 TD -0.0149 Tc -0.0622 Tw (trials wherein he compared two crisis intervention approaches,)Tj T* -0.0036 Tc -0.015 Tw (Critical Incident Stress Debriefing \(CISD\) and Critical Inci-)Tj 0 -1.398 TD -0.0085 Tc -0.0625 Tw (dent Stress Management \(CISM\), following armed robberies.)Tj 0 -1.401 TD -0.0039 Tc -0.0385 Tw [(The CISD approach involved small group crisis intervention)]TJ T* 0.0028 Tc 0.125 Tw (discussions following the robberies. The CISM approach)Tj 0 -1.398 TD -0.0037 Tc 0.079 Tw (reflected an integrated multi-component crisis intervention)Tj 0 -1.401 TD 0.0049 Tc 0.125 Tw [(approach which follows Millon)49.9(s theoretical intervention)]TJ T* -0.0036 Tc 0.0089 Tw (model. The two approaches were applied in a serial manner)Tj 0 -1.398 TD -0.0059 Tc -0.0625 Tw (reflecting the evolution of the human resources program with)Tj 0 -1.401 TD -0.0034 Tc 0.0257 Tw (the employing organization. Post traumatic distress was as-)Tj T* -0.0036 Tc 0 Tw (sessed using the Impact of Events Scale \(IES\) and Posttrau-)Tj 0 -1.398 TD -0.0157 Tc -0.0623 Tw (matic Stress Scale \(PSS\), applied at 3 days, 1 month, 6 months,)Tj 0 -1.401 TD -0.0034 Tc 0.042 Tw (and 12 months post robbery for both groups. In the sample)Tj T* -0.0037 Tc -0.0188 Tw (of 217 \(CISD alone, )Tj /TT5 1 Tf 8.214 0 TD -0.006 Tc 0 Tw (n )Tj /TT2 1 Tf 0.732 0 TD -0.0039 Tc -0.02 Tw (= 75; CISM, )Tj /TT5 1 Tf 5.184 0 TD 0 Tc 0 Tw (n)Tj /TT2 1 Tf 0.495 0 TD -0.0025 Tc -0.019 Tw [( = 142\), analysis of be-)]TJ -14.625 -1.398 TD -0.0033 Tc -0.0415 Tw [(tween groups psychometrics at follow-up \(f/up = mean of 3,)]TJ 0 -1.401 TD -0.0032 Tc 0.0866 Tw (6, 12 month scores\) yielded the following effect sizes and)Tj T* -0.0035 Tc 0.125 Tw (odds ratios:)Tj 1.2 -1.998 TD -0.0037 Tc -0.06 Tw [(1\) IES ef)14.3(fect size, Cohen)53.3(s )]TJ /TT5 1 Tf 10.53 0 TD 0 Tc 0 Tw (d)Tj /TT2 1 Tf 0.495 0 TD -0.0021 Tc -0.06 Tw [( = .31, )]TJ /TT4 1 Tf 2.619 0 TD -0.0152 Tc 0 Tw (OR)Tj /TT1 1 Tf 1.377 0 TD -0.0035 Tc -0.06 Tw [( = 1.75)]TJ /TT2 1 Tf -15.021 -2.001 TD -0.0034 Tc -0.0612 Tw (2\) PSS effect size )Tj /TT5 1 Tf 7.026 0 TD 0 Tc 0 Tw (d)Tj /TT2 1 Tf 0.495 0 TD -0.002 Tc -0.0633 Tw [( = .25, )]TJ /TT4 1 Tf 2.61 0 TD -0.0152 Tc 0 Tw (OR)Tj /TT1 1 Tf 1.374 0 TD -0.0041 Tc -0.0625 Tw [( = 1.57)]TJ /TT5 1 Tf -10.905 -2.001 TD -0.0033 Tc -0.02 Tw [(S)37.7(tudy #3. )]TJ /TT2 1 Tf 3.864 0 TD -0.0039 Tc -0.0198 Tw [( Following Hurricane Iniki, Chemtob, )14.3(T)72.9(omas,)]TJ -5.664 -1.398 TD -0.0083 Tc -0.0623 Tw [(L)5.6(a)5.6(w)60.7(, and Cremniter \(1997\) conducted an evaluation of a brief)]TJ 0 -1.401 TD -0.0034 Tc 0.0693 Tw (psychological crisis intervention applied 6 months post di-)Tj T* -0.0035 Tc 0.0111 Tw [(saster)53.5(. )14.5(T)73.3(wo groups were employed in a time-lagged pre and)]TJ 0 -1.398 TD -0.0037 Tc -0.0072 Tw (post test intervention assessment paradigm wherein the post)Tj 0 -1.401 TD -0.0032 Tc 0.0375 Tw (test of group 1 \()Tj /TT5 1 Tf 6.486 0 TD 0 Tc 0 Tw (n)Tj /TT2 1 Tf 0.495 0 TD -0.0034 Tc 0.0375 Tw [( = 25\) was concurrent with the pre-test of)]TJ -6.981 -1.401 TD -0.0038 Tc 0.0225 Tw (group 2 \()Tj /TT5 1 Tf 3.681 0 TD 0 Tc 0 Tw (n)Tj /TT2 1 Tf 0.495 0 TD -0.0033 Tc 0.025 Tw [( = 18\). Posttraumatic morbidity was assessed us-)]TJ -4.176 -1.398 TD -0.0077 Tc -0.0622 Tw (ing the Impact of Events Scale \(IES\). Three months separated)Tj 0 -1.401 TD -0.0032 Tc 0.1024 Tw [(the pre and post testing for both groups. )50.7(Analysis of vari-)]TJ 25.5 65.199 TD -0.0036 Tc 0.0999 Tw (ance for repeated measures \(within group factor\) was em-)Tj 0 -1.398 TD -0.05 Tw (ployed for both groups. The authors state, The within group)Tj 0 -1.401 TD -0.0098 Tc -0.061 Tw (treatment effect was highly significant \()Tj /TT5 1 Tf 15.264 0 TD 0 Tc 0 Tw (F)Tj /TT2 1 Tf 0.6 0 TD -0.0089 Tc -0.0616 Tw [( = 21.13, )]TJ /TT5 1 Tf 3.54 0 TD -0.0188 Tc 0 Tw (df)Tj /TT2 1 Tf 0.756 0 TD -0.0087 Tc -0.0634 Tw [( = 1,40, )]TJ /TT5 1 Tf 3.045 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf -23.205 -1.401 TD -0.0037 Tc -0.0488 Tw [(< .001\). )17.5(The within group treatment ef)17.3(fect was Cohen)50.3(s )]TJ /TT5 1 Tf 22.446 0 TD 0 Tc 0 Tw (d)Tj /TT2 1 Tf 0.495 0 TD -0.055 Tc ( =)Tj -22.941 -1.398 TD -0.007 Tc (.73,)Tj /TT4 1 Tf 1.476 0 TD -0.0097 Tc -0.06 Tw [( OR )]TJ /TT1 1 Tf 1.74 0 TD -0.0078 Tc -0.065 Tw (= 3.76)Tj /TT2 1 Tf 2.46 0 TD 0 Tc 0 Tw (.)Tj /TT5 1 Tf -3.876 -2.001 TD -0.0032 Tc 0.065 Tw [(S)37.8(tudy #4. )]TJ /TT2 1 Tf 4.035 0 TD -0.0034 Tc 0.0679 Tw [( Boscarino, )50.6(Adams, and Figley \(2005\) con-)]TJ -5.835 -1.401 TD -0.009 Tc -0.0625 Tw (ducted a methodologically robust investigation of workplace-)Tj 0 -1.398 TD -0.0062 Tc -0.0622 Tw (based crisis intervention. This study represents a prospective,)Tj 0 -1.401 TD -0.0114 Tc [(random sample of 1,681 New )27.6(Y)101.8(ork adults interviewed by tele-)]TJ T* -0.0028 Tc 0.0181 Tw (phone at 1 year and 2 years after 9/11 in order to assess the)Tj 0 -1.398 TD -0.0037 Tc 0.1079 Tw [(ef)17.3(fectiveness of workplace-based crisis interventions. W)97.1(e)]TJ 0 -1.401 TD -0.0038 Tc -0.0033 Tw (classified respondents who attended these worksite sessions)Tj T* -0.0033 Tc -0.0159 Tw (as the brief crisis intervention group \()Tj /TT5 1 Tf 14.826 0 TD -0.006 Tc 0 Tw (n )Tj /TT2 1 Tf 0.729 0 TD -0.0035 Tc -0.0175 Tw (= 180\) and all others)Tj -15.555 -1.398 TD -0.0037 Tc 0.0612 Tw (as the non-intervention group \()Tj /TT5 1 Tf 12.519 0 TD -0.005 Tc 0 Tw (n )Tj /TT2 1 Tf 0.81 0 TD -0.0034 Tc 0.0637 Tw (= 1,501\) \(p. 12\). Results)Tj -13.329 -1.401 TD -0.0033 Tc -0.0244 Tw (indicated that crisis interventions in the form of critical inci-)Tj T* 0.0028 Tc 0.125 Tw [(dent stress management had a beneficial impact across a)]TJ 0 -1.398 TD -0.0034 Tc -0.055 Tw (variety of outcomes when assessed using the Brief Symptom)Tj 0 -1.401 TD -0.0032 Tc 0.0008 Tw (Inventory-18 \(BSI\) and various standardized psychiatric in-)Tj T* -0.0037 Tc -0.0622 Tw [(terview guides. More specifically)59.3(, when compared with indi-)]TJ 0 -1.398 TD 0.0446 Tc 0.125 Tw (viduals who did not receive these interventions, the)Tj 0 -1.401 TD -0.002 Tc (workplace-based crisis interventions were associated with)Tj T* -0.0037 Tc -0.0175 Tw (reduced risks for:)Tj 1.2 -1.998 TD -0.0038 Tc -0.055 Tw [()-1453.7(binge drinking \()]TJ /TT5 1 Tf 8.076 0 TD 0 Tc 0 Tw (d)Tj /TT2 1 Tf 0.495 0 TD -0.0022 Tc -0.055 Tw [( = .74\), )]TJ /TT4 1 Tf 2.964 0 TD -0.0152 Tc 0 Tw (OR)Tj /TT1 1 Tf 1.374 0 TD -0.0031 Tc -0.055 Tw [( = 3.83)]TJ /TT2 1 Tf -12.909 -2.001 TD -0.0039 Tc -0.0225 Tw [()-1453.8(alcohol dependence \()]TJ /TT5 1 Tf 10.176 0 TD 0 Tc 0 Tw (d)Tj /TT2 1 Tf 0.495 0 TD -0.0022 Tc -0.025 Tw [( = .92\), )]TJ /TT4 1 Tf 3.054 0 TD -0.0152 Tc 0 Tw (OR)Tj /TT1 1 Tf 1.374 0 TD -0.0031 Tc -0.025 Tw [( = 5.31)]TJ /TT2 1 Tf -15.099 -2.001 TD -0.0037 Tc -0.055 Tw [()-1453.6(PTS symptoms \()]TJ /TT5 1 Tf 8.31 0 TD 0 Tc 0 Tw (d)Tj /TT2 1 Tf 0.495 0 TD -0.002 Tc -0.0567 Tw [( = .56\), )]TJ /TT4 1 Tf 2.961 0 TD -0.0152 Tc 0 Tw (OR)Tj /TT1 1 Tf 1.374 0 TD -0.0033 Tc -0.0575 Tw [( = 2.76)]TJ /TT2 1 Tf -13.14 -1.998 TD -0.0038 Tc -0.0433 Tw [()-1453.7( major depression \()]TJ /TT5 1 Tf 9.294 0 TD 0 Tc 0 Tw (d)Tj /TT2 1 Tf 0.495 0 TD -0.0021 Tc -0.0434 Tw [( = .81\), )]TJ /TT4 1 Tf 3 0 TD -0.0152 Tc 0 Tw (OR)Tj /TT1 1 Tf 1.377 0 TD -0.0035 Tc -0.045 Tw [( = 4.35)]TJ /TT2 1 Tf -14.166 -2.001 TD -0.0019 Tc -0.055 Tw [()-1451.8(anxiety \()]TJ /TT5 1 Tf 5.256 0 TD 0 Tc 0 Tw (d)Tj /TT2 1 Tf 0.495 0 TD -0.0023 Tc -0.0575 Tw [( =.98\), )]TJ /TT4 1 Tf 2.763 0 TD -0.0152 Tc 0 Tw (OR)Tj /TT1 1 Tf 1.377 0 TD -0.0031 Tc -0.055 Tw [( = 5.92)]TJ /TT2 1 Tf 2.688 0 TD -0.0039 Tc -0.06 Tw (; and)Tj -12.579 -2.001 TD -0.007 Tc -0.0616 Tw [()-1456.9( global impairment \()]TJ /TT5 1 Tf 9.669 0 TD 0 Tc 0 Tw (d)Tj /TT2 1 Tf 0.495 0 TD -0.0057 Tc -0.0617 Tw [( = .66\), )]TJ /TT4 1 Tf 2.916 0 TD -0.0182 Tc 0 Tw (OR)Tj /TT1 1 Tf 1.365 0 TD -0.0066 Tc -0.0625 Tw [( = 3.31)]TJ /F1 1 Tf 11 0 0 11 404.25 273.99 Tm 0.0207 Tc 0 Tw (DISCUSSION)Tj /TT2 1 Tf 10 0 0 10 339 250.65 Tm -0.0034 Tc 0.0009 Tw (In this paper we have utilized the odds ratio as a means)Tj -1.8 -1.401 TD -0.0032 Tc -0.0188 Tw (of providing a practical quantitative expression of the utility)Tj 0 -1.398 TD -0.0037 Tc 0.0164 Tw (of workplace based crisis intervention programs to enhance)Tj 0 -1.401 TD -0.0035 Tc -0.0041 Tw [(posttraumatic resiliency)62.5(.)-0.1( In doing so, we have provided evi-)]TJ T* -0.0031 Tc -0.0542 Tw [(dence for the notion that psychological/behavioral resiliency)]TJ 0 -1.398 TD -0.0034 Tc -0.0007 Tw (can indeed be empirically enhanced via such programs.)Tj 1.8 -2.001 TD -0.0224 Tw [(T)73.4(ake for instance the finding by Boscarino, )50.7(Adams, and)]TJ -1.8 -1.401 TD -0.0059 Tc -0.0625 Tw (Figley \(2005\) where they reported that the implementation of)Tj 0 -1.398 TD -0.0012 Tc 0.125 Tw (a workplace-based crisis intervention \(vs. a non-interven-)Tj 0 -1.401 TD -0.0018 Tc (tion control group\) significantly reduced depression com-)Tj T* -0.0034 Tc 0.043 Tw (pared to the control group, )Tj /TT5 1 Tf 11.01 0 TD 0 Tc 0 Tw (d)Tj /TT2 1 Tf 0.495 0 TD -0.0032 Tc 0.044 Tw [( = .81. Converting this )]TJ /TT5 1 Tf 9.405 0 TD 0 Tc 0 Tw (d)Tj /TT2 1 Tf 0.495 0 TD -0.0033 Tc 0.045 Tw [( to an)]TJ -21.405 -1.398 TD -0.0034 Tc 0.12 Tw (odds ratio produces an odds ratio of 4.35. Thus, the odds)Tj 0 -1.401 TD -0.0035 Tc -0.0195 Tw (were more than four times greater for the treatment group to)Tj ET endstream endobj 56 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /F9 57 0 R /TT1 8 0 R /TT2 9 0 R /TT3 10 0 R /TT4 20 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 59 0 obj << /Length 10039 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 54 59.745 m 546 59.745 l S BT /F1 1 Tf 8 0 0 8 54.99 41.64 Tm 0 0 0 1 k /GS2 gs -0.0057 Tc 0.073 Tw [(174 )]TJ /TT3 1 Tf 2.6963 0 TD -0.0054 Tc 0.075 Tw (Everly et al. Odds Ratio Analysis)Tj /TT2 1 Tf 10 0 0 10 54 722.64 Tm -0.0035 Tc -0.0278 Tw (reduce depression in comparison to the control group. If this)Tj 0 -1.398 TD -0.0031 Tc -0.032 Tw (value were a relative risk it would indicate the probability of)Tj 0 -1.401 TD -0.0034 Tc 0.1249 Tw [(reducing depression would be more than four times more)]TJ T* -0.0031 Tc -0.0023 Tw (likely for the treatment group than for the control group.)Tj 1.8 -1.998 TD -0.003 Tc 0.036 Tw [(Similarly)60(, the intervention significantly reduced symp-)]TJ -1.8 -1.401 TD -0.0036 Tc 0.0137 Tw (toms of posttraumatic stress compared to the control group,)Tj /TT5 1 Tf T* 0 Tc 0 Tw (d)Tj /TT2 1 Tf 0.495 0 TD -0.0031 Tc ( = .56. Converting this )Tj /TT5 1 Tf 9.186 0 TD 0 Tc (d)Tj /TT2 1 Tf 0.495 0 TD -0.0036 Tc 0.0008 Tw ( to an odds ratio produces an odds)Tj -10.176 -1.398 TD -0.0091 Tc -0.0622 Tw (ratio of 2.76. Thus, the odds were more than two times greater)Tj 0 -1.401 TD -0.0034 Tc -0.0256 Tw (for the treatment group to reduce posttraumatic stress symp-)Tj T* -0.0282 Tw (toms in comparison to the control group. If this value were a)Tj 0 -1.398 TD -0.0102 Tc -0.0622 Tw (relative risk it would indicate the probability of reducing post-)Tj 0 -1.401 TD -0.0093 Tc -0.0625 Tw (traumatic stress would be more than two times more likely for)Tj T* -0.0035 Tc 0.0329 Tw (the treatment group than for the control group.)Tj 1.8 -1.998 TD 0.0038 Tc 0.125 Tw (Posttraumatic distress subsequent to robberies repre-)Tj -1.8 -1.401 TD -0.0028 Tc -0.0185 Tw [(sents a significant risk in the banking industry)63.2(. )15.2(The study by)]TJ T* -0.0034 Tc 0.085 Tw (Campfield and Hills \(2001\) found early crisis intervention)Tj 0 -1.398 TD 0.087 Tw (\(Critical Incident Stress Debriefings\) significantly reduced)Tj 0 -1.401 TD -0.0035 Tc 0.1085 Tw (symptoms of posttraumatic stress compared to the control)Tj T* -0.0031 Tc 0.0167 Tw (group \(delayed intervention\), )Tj /TT5 1 Tf 11.901 0 TD 0 Tc 0 Tw (d)Tj /TT2 1 Tf 0.495 0 TD -0.0032 Tc 0.018 Tw [( = 1.66. Converting this )]TJ /TT5 1 Tf 9.768 0 TD 0 Tc 0 Tw (d)Tj /TT2 1 Tf 0.495 0 TD -0.0034 Tc 0.02 Tw [( to)]TJ -22.659 -1.398 TD -0.0436 Tw (an odds ratio produces an odds ratio of 20.31. Thus, the odds)Tj 0 -1.401 TD -0.0261 Tw [(were more than twenty times greater for the treatment group)]TJ T* -0.0036 Tc 0.1008 Tw (to reduce posttraumatic stress symptoms in comparison to)Tj 0 -1.398 TD -0.0037 Tc 0.0625 Tw (the control group.)Tj 1.8 -2.001 TD -0.0034 Tc 0.0139 Tw (If studies such as these are indeed representative of the)Tj -1.8 -1.401 TD -0.0028 Tc 0.125 Tw (field of crisis intervention and its ability to exert positive)Tj 0 -1.398 TD -0.0034 Tc -0.0383 Tw (effects upon resilience and the lowering of symptoms of dis-)Tj 0 -1.401 TD 0.0619 Tw (tress related to work-related incidents at the worksite, then)Tj T* -0.0037 Tc -0.0072 Tw (serious consideration must be given to their implementation)Tj 0 -1.398 TD -0.0036 Tc -0.0048 Tw (in high risk industries.)Tj 1.8 -2.001 TD -0.0033 Tc 0.1162 Tw (Findings such as these are not only supportive of the)Tj -1.8 -1.401 TD -0.0088 Tw (constituent investigations, but they tend to support the more)Tj 0 -1.398 TD -0.0037 Tc 0.0792 Tw (global notion that workplace-based crisis intervention pro-)Tj 0 -1.401 TD -0.0032 Tc -0.0267 Tw (grams can enhance posttraumatic resiliency as operationally)Tj T* -0.0035 Tc 0.1188 Tw (defined. Expression of findings such as these in the more)Tj 0 -1.398 TD -0.0029 Tc 0.0878 Tw (user friendly form of odds ratios may ultimately lead to)Tj 0 -1.401 TD -0.0036 Tc 0.0657 Tw (greater understanding of the positive impact that such pro-)Tj T* -0.003 Tc 0.1065 Tw (grams may have, which may in turn further lead to wider)Tj 0 -1.398 TD -0.0037 Tc -0.0233 Tw (utilization of such programs.)Tj 1.8 -2.001 TD -0.0002 Tc 0.125 Tw [(Once considered an innate quality)65.8(, resilience may be)]TJ -1.8 -1.401 TD -0.0031 Tc 0.0963 Tw (fostered by interpersonal support and any process that en-)Tj 0 -1.398 TD -0.0033 Tc -0.0202 Tw [(genders a heightened sense of self-confidence, self-ef)14.7(ficacy)62.7(.)]TJ 0 -1.401 TD -0.0037 Tc 0.106 Tw (From this perspective, workplace-based crisis intervention)Tj T* -0.0034 Tc 0.125 Tw (programs should be considered as one potential means of)Tj 0 -1.398 TD -0.0038 Tc 0.035 Tw (enhancing resilience.)Tj /F1 1 Tf 11 0 0 11 388.89 720.51 Tm 0.021 Tc 0 Tw (REFERENCES)Tj /TT2 1 Tf 10 0 0 10 309 685.14 Tm -0.0113 Tc -0.0625 Tw (Artiss, K. \(1963\). Human behavior under stress: From combat)Tj 1.2 -1.398 TD -0.002 Tc -0.0101 Tw [(to social psychiatry)64(. )]TJ /TT5 1 Tf 8.139 0 TD -0.0042 Tc (Military Medicine)Tj /TT2 1 Tf 7.17 0 TD -0.001 Tc 0 Tw (, )Tj /TT5 1 Tf 0.492 0 TD -0.0075 Tc (128)Tj /TT2 1 Tf 1.485 0 TD -0.0043 Tc -0.0142 Tw [(, 101)31.7(1-1015.)]TJ -18.486 -1.8 TD -0.0036 Tc 0.0566 Tw [(Bandura, A. )-53.7(\(1997\). )]TJ /TT5 1 Tf 8.484 0 TD -0.0038 Tc 0.1126 Tw [(Self-efficacy: The exer)32.2(cise of contr)29.2(ol)]TJ /TT2 1 Tf 14.967 0 TD 0 Tc 0 Tw (.)Tj -22.251 -1.401 TD -0.0198 Tc -0.0937 Tw [(New Y)102.4(ork: )-31.8(Freeman.)]TJ -1.2 -1.8 TD -0.0031 Tc -0.0161 Tw [(Boscarino, J.A., )50.9(Adams, R.E., & Figley)62.9(, C.R. \(2005\). )50.9(A)59.1( pro-)]TJ 1.2 -1.401 TD -0.003 Tc 0.1 Tw (spective cohort study of the effectiveness of employer-)Tj 0 -1.398 TD -0.0034 Tc 0.0763 Tw [(sponsored crisis interventions after a major disaster)53.6(. )]TJ /TT5 1 Tf 21.345 0 TD -0.0055 Tc 0 Tw (In-)Tj -21.345 -1.401 TD -0.004 Tc 0.103 Tw (ternational Journal of Emergency Mental Health)Tj /TT2 1 Tf 19.971 0 TD 0.001 Tc 0 Tw (, )Tj /TT5 1 Tf 0.603 0 TD 0 Tc (7)Tj /TT2 1 Tf 0.495 0 TD -0.0023 Tc 0.105 Tw (, 9-)Tj -21.069 -1.401 TD -0.0625 Tc 0 Tw (22.)Tj -1.2 -1.8 TD -0.0062 Tc -0.0624 Tw [(Campfield, K., & Hills, )53.9(A. \(2001\). Ef)11.8(fect of timing of Critical)]TJ 1.2 -1.398 TD -0.0093 Tc -0.0625 Tw (Incident Stress Debriefing \(CISD\) on posttraumatic symp-)Tj 0 -1.401 TD -0.0042 Tc 0 Tw (toms. )Tj /TT5 1 Tf 2.394 0 TD -0.0046 Tc -0.0297 Tw [(Journal of T)49.4(raumatic S)28.4(t)2.4(r)31.4(ess)]TJ /TT2 1 Tf 10.875 0 TD 0.001 Tc 0 Tw (, )Tj /TT5 1 Tf 0.471 0 TD -0.01 Tc (14)Tj /TT2 1 Tf 0.99 0 TD -0.0037 Tc -0.03 Tw (, 327-340.)Tj -15.93 -1.8 TD -0.0065 Tc -0.0609 Tw [(Caplan, G)113.5(.)-0.8( \(1961\). )]TJ /TT5 1 Tf 7.485 0 TD -0.0073 Tc -0.063 Tw [(An appr)28.7(oach to community mental health)]TJ /TT2 1 Tf 15.966 0 TD 0 Tc 0 Tw (.)Tj -22.251 -1.401 TD -0.0041 Tc -0.0525 Tw [(New )29.4(Y)103.1(ork: Grune and S)16.9(tratton.)]TJ -1.2 -1.8 TD -0.0034 Tc -0.056 Tw [(Caplan, G)116.6(.)-0.7( \(1964\). )]TJ /TT5 1 Tf 7.566 0 TD -0.0038 Tc -0.0583 Tw [(Principles of pr)32.2(eventive psychiatry)]TJ /TT2 1 Tf 13.629 0 TD -0.0036 Tc -0.0575 Tw [(. New)]TJ -19.995 -1.398 TD -0.0096 Tc -0.0616 Tw [(Y)103.6(ork: Basic Books.)]TJ -1.2 -1.8 TD -0.0066 Tc -0.0626 Tw [(Chemtob, C.M., )13.5(T)73.2(omas, S., Law)65.4(, )11.3(W)103.2(., & Cremniter)35.4(, D. \(1997\).)]TJ 1.2 -1.401 TD -0.0031 Tc 0.0059 Tw [(Post disaster psychological intervention: )51.1(A)59.1( field study of)]TJ T* 0.105 Tw (debriefing on psychological distress. )Tj /TT5 1 Tf 15.216 0 TD -0.0046 Tc (American Journal)Tj -15.216 -1.398 TD -0.0128 Tc 0 Tw (of)Tj /TT2 1 Tf 0.759 0 TD 0 Tc ( )Tj /TT5 1 Tf 0.186 0 TD -0.0111 Tc [(Psychiatr)-8.1(y)]TJ /TT2 1 Tf 4.176 0 TD -0.005 Tc (, )Tj /TT5 1 Tf 0.429 0 TD -0.015 Tc (154)Tj /TT2 1 Tf 1.464 0 TD -0.0097 Tc -0.06 Tw (, 415-417.)Tj -8.214 -1.8 TD -0.0033 Tc 0.075 Tw (Cohen, J. \(1988\). )Tj /TT5 1 Tf 7.335 0 TD -0.0037 Tc (Statistical power analysis for the behav-)Tj -6.135 -1.401 TD -0.004 Tc -0.02 Tw (ioral sciences)Tj /TT2 1 Tf 5.454 0 TD -0.008 Tc -0.017 Tw [( \(2)]TJ 5.8 0 0 5.8 386.04 366.51 Tm -0.0017 Tc 0 Tw (nd)Tj 10 0 0 10 391.86 363.15 Tm -0.0036 Tc -0.023 Tw [( ed.\). Hillsdale, NJ: Lawrence Erlbaum)]TJ -7.086 -1.401 TD 0.0198 Tc 0 Tw (Associates.)Tj -1.2 -1.8 TD -0.0038 Tc -0.0037 Tw [(Decker)35.2(, J., & S)14.2(tubblebine, J. \(1972\). Crisis intervention and)]TJ 1.2 -1.398 TD -0.0029 Tc 0.0157 Tw [(prevention of psychiatric disability: )51(A)59.3( follow-up. )]TJ /TT5 1 Tf 19.749 0 TD -0.0052 Tc 0 Tw (Ameri-)Tj -19.749 -1.401 TD -0.0037 Tc -0.0352 Tw (can Journal of Psychiatry)Tj /TT2 1 Tf 10.161 0 TD 0 Tc 0 Tw (, )Tj /TT5 1 Tf 0.465 0 TD -0.0075 Tc (129)Tj /TT2 1 Tf 1.485 0 TD -0.0038 Tc -0.035 Tw (, 725-729.)Tj -13.311 -1.8 TD -0.0128 Tc -0.0625 Tw (Deeks, J.J. \(1996\). What is an odds ratio. Retrieved from http:/)Tj 1.2 -1.401 TD -0.0156 Tc 0 Tw [(/www)59.4(.medicine.ox.ac.uk/bandolier/band25/b25-6.html)]TJ -1.2 -1.8 TD -0.0259 Tc -0.062 Tw [(Devilly)58.1(, G)115.1(.)0.3( \(2007\). \(computer programme\). www)61.1(.clintools.com.)]TJ 1.2 -1.398 TD -0.0042 Tc -0.0198 Tw (Melbourne, Australia.)Tj -1.2 -1.8 TD 0.0188 Tc 0.1242 Tw [(Everly)63.8(, G)114.8(.)-0.7(S., Jr)54.8(. \(2009\). )]TJ /TT5 1 Tf 10.596 0 TD 0.0179 Tc 0.1245 Tw [(The r)29.9(esilient child)]TJ /TT2 1 Tf 7.839 0 TD 0.0174 Tc 0.1258 Tw [(. New )33.2(Y)97.6(ork:)]TJ -17.235 -1.401 TD -0.013 Tc 0 Tw (DiaMedica.)Tj -1.2 -1.8 TD -0.0031 Tc 0.0314 Tw [(Everly)62.9(, G)116.9(.S., Jr)50.9(., & Langlieb, )53.6(A. \(2003\). Evolving nature of)]TJ 1.2 -1.401 TD 0.0025 Tc 0.125 Tw (disaster mental health. )Tj /TT5 1 Tf 9.654 0 TD 0.0019 Tc (International Journal of Emer-)Tj -9.654 -1.398 TD -0.0039 Tc -0.0383 Tw (gency Mental Health, 5)Tj /TT2 1 Tf 9.189 0 TD -0.0036 Tc -0.04 Tw (, 113-119.)Tj -10.389 -1.8 TD -0.0051 Tc -0.0624 Tw [(Everly)66.9(, G)111.9(.S., Jr)48.9(., & Mitchell, J.T)69.9(. \(2008\). )]TJ /TT5 1 Tf 15.789 0 TD -0.0061 Tc -0.0625 Tw (Integrative crisis in-)Tj -14.589 -1.401 TD -0.0038 Tc -0.0001 Tw (tervention and disaster mental health)Tj /TT2 1 Tf 14.805 0 TD -0.0029 Tc 0.0015 Tw [(. Ellicott City)63.1(, MD:)]TJ -14.805 -1.401 TD -0.0043 Tc 0.03 Tw (Chevron Publishing.)Tj ET endstream endobj 60 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT2 9 0 R /TT3 10 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 62 0 obj << /Length 8468 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 66 59.745 m 558 59.745 l S BT /TT3 1 Tf 8 0 0 8 423.24 42.6 Tm 0 0 0 1 k /GS2 gs -0.0051 Tc 0.0326 Tw [(IJEMH Vol. 10, No. 3 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (175)Tj /TT2 1 Tf 10 0 0 10 66 722.64 Tm -0.0029 Tc -0.026 Tw [(Everly)63.1(, G)117.1(.S., Jr)51.1(., Sherman, M.F)78.1(., S)15.1(tapleton, )54.3(A., Barnett, D.J.,)]TJ 1.2 -1.398 TD -0.0167 Tc -0.0622 Tw [(Hiremath, G)112.3(., & Links, J. \(2006\). )19.6(W)96.1(orkplace crisis interven-)]TJ 0 -1.401 TD -0.0031 Tc -0.0583 Tw [(tion: )51.2(A)59.1( systematic review of ef)14.9(fect sizes. )]TJ /TT5 1 Tf 15.885 0 TD -0.0045 Tc -0.0597 Tw [(Journal of W)85.5(ork-)]TJ -15.885 -1.401 TD -0.0039 Tc -0.0133 Tw (place Behavioral Health, 21)Tj /TT2 1 Tf 11.19 0 TD -0.0037 Tc -0.015 Tw (, 153-170.)Tj -12.39 -1.8 TD -0.0213 Tc -0.0621 Tw [(Haglund, M., Cooper)38.7(, N., Southwick, S., & Charney)59.7(, D. \(2007\).)]TJ 1.2 -1.398 TD -0.0025 Tc -0.0011 Tw (6 keys to resilience for PTSD and everyday life. )Tj /TT5 1 Tf 19.365 0 TD -0.0053 Tc 0 Tw (Current)Tj -19.365 -1.401 TD -0.0115 Tc (Psychiatry)Tj /TT2 1 Tf 4.164 0 TD -0.005 Tc (, )Tj /TT5 1 Tf 0.426 0 TD 0 Tc (6)Tj /TT2 1 Tf 0.489 0 TD -0.011 Tc -0.06 Tw (, 23-30.)Tj -6.279 -1.8 TD -0.0033 Tc -0.0281 Tw [(Kardiner)35.7(, )53.9(A., & Spiegel, H. \(1947\). )]TJ /TT5 1 Tf 14.064 0 TD -0.0039 Tc -0.0295 Tw [(W)94.1(a)6.3(r)104.1(,)-1.1( str)32.1(ess, and neur)29.1(otic)]TJ -12.864 -1.401 TD -0.0049 Tc 0 Tw (illness)Tj /TT2 1 Tf 2.526 0 TD -0.0053 Tc -0.0625 Tw [(. New )36.7(Y)101.9(ork: Hoeber)48.7(.)]TJ -3.726 -1.8 TD -0.0239 Tc -0.0624 Tw [(Kaminsky)60.1(,)0( M.J., McCabe, O.L., Langlieb, )50.9(A., & Everly)60.1(, G)117.1(.)-1(S., Jr)48.1(.)]TJ 1.2 -1.398 TD -0.0094 Tc -0.0625 Tw [(\(2007\). )50.6(An evidence-informed model of human resistance,)]TJ 0 -1.401 TD -0.0035 Tc 0.0275 Tw (resilience, and recovery: The Johns Hopkins outcomes-)Tj T* -0.0336 Tw (driven paradigm for disaster mental health services. )Tj /TT5 1 Tf 20.52 0 TD -0.0049 Tc 0 Tw (Brief)Tj -20.52 -1.398 TD -0.0038 Tc 0.01 Tw (Therapy and Crisis Intervention, 7)Tj /TT2 1 Tf 13.776 0 TD -0.0032 Tc (, 1-11.)Tj -14.976 -1.8 TD -0.0164 Tc -0.0619 Tw [(Luthar)37.6(, S.S., Cicchetti, D., & Becker)40.6(, B. \(2000\). )14(The construct)]TJ 1.2 -1.401 TD -0.0034 Tc 0.0393 Tw [(of resilience: )50.5(A)58.8( critical evaluation and guidelines for fu-)]TJ T* -0.045 Tw (ture work, )Tj /TT5 1 Tf 4.236 0 TD -0.0042 Tc (Child Development, 71)Tj /TT2 1 Tf 9.075 0 TD -0.004 Tc -0.05 Tw (, 543562.)Tj -14.511 -1.8 TD -0.0053 Tc -0.0622 Tw [(Langsley)60.7(, D., Machotka, P)105.7(., & Flomenhaft, K. \(1971\). )55(A)74.9(void-)]TJ 1.2 -1.398 TD -0.011 Tc -0.0614 Tw [(ing mental health admission: )49(A)57.2( follow-up. )]TJ /TT5 1 Tf 16.44 0 TD -0.0121 Tc -0.065 Tw [(American Jour)17.9(-)]TJ -16.44 -1.401 TD -0.0075 Tc -0.06 Tw [(nal of Psychiatr)-7.5(y)]TJ /TT2 1 Tf 6.591 0 TD -0.005 Tc 0 Tw (, )Tj /TT5 1 Tf 0.429 0 TD -0.0105 Tc (127)Tj /TT2 1 Tf 1.476 0 TD -0.0081 Tc -0.065 Tw (, 1391-1394.)Tj -9.696 -1.8 TD -0.0047 Tc -0.0618 Tw [(McCubbin, H.I., McCubbin, M.A., )14(Thompson, )56(A.I., Han, S.,)]TJ 1.2 -1.401 TD -0.0029 Tc 0.0026 Tw [(&)7.4( )51.2(Allen, C.T)75.1(. \(1997, June\). )]TJ /TT5 1 Tf 11.325 0 TD -0.0042 Tc 0.0034 Tw [(Families under str)31.8(ess: What)]TJ -11.325 -1.398 TD -0.0013 Tc 0.1242 Tw [(makes them r)28.7(esilient. )]TJ /TT2 1 Tf 9.039 0 TD 0.1254 Tw [(Paper presented to the )47(American)]TJ -9.039 -1.401 TD -0.0037 Tc -0.0457 Tw [(Association of Family and Consumer Sciences. )14.4(W)97.1(ashing-)]TJ T* -0.0081 Tc -0.06 Tw (ton, DC.)Tj -1.2 -1.8 TD -0.0032 Tc 0.035 Tw [(McHugh, P)107.8(.R., & Slavney)59.8(, P)107.8(.R. \(1998\). )]TJ /TT5 1 Tf 15.981 0 TD -0.004 Tc (The perspectives of)Tj -14.781 -1.398 TD -0.0045 Tc 0 Tw (psychiatry)Tj /TT2 1 Tf 4.125 0 TD -0.004 Tc 0.08 Tw [( \(2)]TJ 5.8 0 0 5.8 130.8 333.99 Tm -0.0017 Tc 0 Tw (nd)Tj 10 0 0 10 136.59 330.66 Tm -0.0038 Tc 0.085 Tw (ed.\). Baltimore: The Johns Hopkins Uni-)Tj -5.859 -1.401 TD -0.0025 Tc 0.1 Tw (versity Press.)Tj -1.2 -1.8 TD -0.003 Tc -0.0347 Tw [(Millon, )15.3(T)79.8(., Grossman, S., Meagher)36(, S., Millon, C., & Everly)63(,)]TJ 1.2 -1.401 TD -0.0025 Tc 0.125 Tw [(G)125.7(.S., Jr)51.5(. \(1999\).)]TJ /TT5 1 Tf 6.45 0 TD -0.0037 Tc (Personality-guided therapy)Tj /TT2 1 Tf 11.001 0 TD -0.0036 Tc 0.1258 Tw [(. New )33.2(Y)103.6(ork:)]TJ -17.451 -1.398 TD -0.0178 Tc 0 Tw [(W)62(iley)66.2(.)]TJ 24.3 45.198 TD -0.0025 Tc 0.0813 Tw [(Myers, D. & )18.4(W)95.3(ee, D. \( 2005\). )]TJ /TT5 1 Tf 12.66 0 TD -0.0039 Tc 0.0817 Tw [(Disaster mental health ser)17.1(-)]TJ -11.46 -1.398 TD -0.0069 Tc 0 Tw (vices)Tj /TT2 1 Tf 1.965 0 TD -0.0082 Tc -0.0615 Tw [(. New )31(Y)99(ork: Brunner)12.8(-Rutlegde.)]TJ -3.165 -1.8 TD -0.0034 Tc 0.0858 Tw (National Institute of Mental Health. \(2002\). )Tj /TT5 1 Tf 18.081 0 TD -0.0044 Tc 0.09 Tw (Mental health)Tj -16.881 -1.401 TD -0.0039 Tc 0.07 Tw (and mass violence: Evidence-based early psychological)Tj T* 0.0069 Tc 0.125 Tw (intervention for victims/survivors of mass violence: A)Tj 0 -1.398 TD -0.0038 Tc 0.1075 Tw (workshop to reach consensus on best practices.)Tj /TT2 1 Tf 19.5 0 TD -0.0066 Tc 0.11 Tw [( NIMH)]TJ -19.5 -1.401 TD -0.0085 Tc -0.062 Tw [(\(NIH Publication No 02-5138\). )18.5(W)95.3(ashington, DC.)]TJ -1.2 -1.8 TD -0.0027 Tc -0.0122 Tw [(Nucifora, F)75.3(., Jr)54.3(., Langlieb, )51.6(A., Siegal, E., Everly)63.3(, G)117.3(.S., Jr)51.3(., &)]TJ 1.2 -1.401 TD -0.0144 Tc -0.0624 Tw [(Kaminsky)60.6(, M.J. \(2007\). Building resistance, resilience, and)]TJ 0 -1.398 TD -0.0033 Tc 0.0475 Tw (recovery in the wake of school and workplace violence.)Tj /TT5 1 Tf 0 -1.401 TD 0.0012 Tc 0.125 Tw (Disaster Medicine and Public Health Preparedness, 1)Tj /TT2 1 Tf T* -0.02 Tc -0.06 Tw (\(Supplement_1\): 33-37.)Tj -1.2 -1.8 TD -0.0213 Tc -0.0622 Tw [(Parad, L., & Parad, H. \(1968\). )50.8(A)58.9( study of crisis oriented planned)]TJ 1.2 -1.398 TD -0.0034 Tc 0.0513 Tw (short-term treatment: Part II. )Tj /TT5 1 Tf 11.85 0 TD -0.0045 Tc 0.055 Tw (Social Casework)Tj /TT2 1 Tf 6.741 0 TD -0.001 Tc 0 Tw (, )Tj /TT5 1 Tf 0.549 0 TD -0.01 Tc (49)Tj /TT2 1 Tf 0.99 0 TD -0.0036 Tc 0.055 Tw (, 418-)Tj -20.13 -1.401 TD -0.0583 Tc 0 Tw (426.)Tj -1.2 -1.8 TD -0.0032 Tc -0.0563 Tw (Raphael, B. \(1986\). )Tj /TT5 1 Tf 8.07 0 TD -0.004 Tc -0.055 Tw (When disaster strikes)Tj /TT2 1 Tf 8.364 0 TD -0.0038 Tc -0.0574 Tw [(. 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The subjects)]TJ 0 -1.401 TD -0.0028 Tc 0.0257 Tw (were primarily public sector psychiatric and psychiatric fo-)Tj T* -0.0037 Tc -0.0032 Tw (rensic inpatients. Studies ranged in duration from 4 months)Tj 0 -1.398 TD -0.0031 Tc 0.046 Tw [(to 6 years. )54.1(Assailants were of both genders, were 25 to 35)]TJ 0 -1.401 TD -0.003 Tc -0.0466 Tw (years of age, had a diagnosis primarily of schizophrenia, and)Tj T* -0.0025 Tc 0.09 Tw [(were frequently acutely psychotic. Physical assaults were)]TJ 0 -1.398 TD -0.0035 Tc 0.0065 Tw (the most frequent category and ranged from 35% to 88% of)Tj 0 -1.401 TD -0.003 Tc 0.025 Tw [(assaults in any given study)63(. Reported precipitants included)]TJ T* 0.0073 Tc 0.125 Tw (positive psychotic symptoms, substance use, overcrowd-)Tj 0 -1.398 TD -0.0032 Tc -0.0255 Tw [(ing, and increased levels of ward activity)62.8(. Female assailants)]TJ 0 -1.401 TD -0.0034 Tc 0.0362 Tw (were the most frequent aggressors in two studies \(Flannery)Tj T* -0.0137 Tc -0.0624 Tw [(&)6.6( )16.4(W)96.1(alker)37.3(, 2001; Krakowski & Czobor)34.3(, 2004\). Males were the)]TJ 0 -1.398 TD -0.0033 Tc 0.0411 Tw (more likely aggressors or equal to female aggressors in the)Tj 0 -1.401 TD -0.0037 Tc 0.0829 Tw [(remaining studies. )53.3(Assault victims included other patients)]TJ T* -0.003 Tc 0.0103 Tw [(and, more frequently)60(, staf)18(f. One study reported males to be)]TJ 0 -1.398 TD -0.0039 Tc -0.0622 Tw (the more likely victims of aggression, but that study included)Tj 0 -1.401 TD -0.0113 Tc -0.0625 Tw (all forms of aggression in the aggregate \(Daffern et. al., 2003\).)Tj T* -0.0056 Tc (One study found females to be the more likely perpetrators of)Tj 0 -1.398 TD -0.0006 Tc 0.125 Tw [(aggression in each assault category)62.4(, except for sexual as-)]TJ 0 -1.401 TD -0.0083 Tc -0.0622 Tw [(sault \(Flannery & )19(W)95.5(alker)33.7(, 2001\).)]TJ 1.8 -2.001 TD -0.0033 Tc 0.11 Tw (The purpose of the present study was to continue the)Tj -1.8 -1.398 TD -0.0003 Tc 0.125 Tw [(inquiry into patient and staff victim characteristics of the)]TJ 0 -1.401 TD -0.0032 Tc -0.054 Tw (differing major types of patient assault during the course of a)Tj T* -0.0067 Tc -0.0628 Tw [(15-year retrospective study)62.3(. )-5( )20(These findings will be examined)]TJ 0 -1.398 TD -0.0059 Tc -0.0623 Tw (in the context of earlier research from this database \(Flannery)Tj 0 -1.401 TD -0.0071 Tc -0.0622 Tw [(& )16.9(W)96.7(alker)37.9(, 2001\) that examined patient and staf)19.9(f victims char)16.9(-)]TJ T* -0.0029 Tc -0.0087 Tw (acteristics over a 6-year period.)Tj /F1 1 Tf 11 0 0 11 399.39 723.99 Tm 0.0189 Tc 0 Tw (METHODS)Tj -8.2173 -1.4536 TD -0.0013 Tc (Subjects)Tj /TT2 1 Tf 10 0 0 10 327 684.66 Tm -0.0104 Tc -0.0617 Tw (The subjects were 1,047 male and 1,056)Tj /TT1 1 Tf 15.345 0 TD 0 Tc 0 Tw ( )Tj /TT2 1 Tf 0.18 0 TD -0.0109 Tc -0.0625 Tw (female child and)Tj -17.325 -1.401 TD -0.0028 Tc 0.125 Tw (adult assaultive patients of the Massachusetts Department)Tj T* -0.0037 Tc 0.0733 Tw (of Mental Health \(DMH\) who received care in seven state)Tj 0 -1.398 TD -0.0042 Tc 0.1029 Tw (hospitals and nine DMH state or DMH-vendored commu-)Tj 0 -1.401 TD -0.0034 Tc 0.0094 Tw [(nity programs from )53.6(April 2, 1990, through March 31, 2005.)]TJ T* -0.011 Tc -0.0618 Tw [(There were 806 male and 766 female assaultive inpatients)]TJ /TT1 1 Tf 22.11 0 TD 0 Tc 0 Tw ( )Tj /TT2 1 Tf 0.174 0 TD -0.0139 Tc (and)Tj -22.284 -1.398 TD -0.0192 Tc -0.0612 Tw (241 male and 290 female)Tj /TT1 1 Tf 9.426 0 TD 0 Tc 0 Tw ( )Tj /TT2 1 Tf 0.168 0 TD -0.0186 Tc -0.0625 Tw [(assaultive community patients. Their)]TJ -9.594 -1.401 TD -0.0085 Tc -0.0613 Tw (average age was 36 years)Tj /TT1 1 Tf 9.714 0 TD 0 Tc 0 Tw ( )Tj /TT2 1 Tf 0.18 0 TD -0.009 Tc -0.06 Tw (\(SD = 11.74\).)Tj /TT1 1 Tf 5.277 0 TD 0 Tc 0 Tw ( )Tj /TT2 1 Tf 0.174 0 TD -0.0096 Tc -0.0625 Tw (Subjects were Cauca-)Tj -15.345 -1.401 TD -0.0036 Tc 0.0125 Tw [(sian \(74%\), Black \(16%\), )50.4(Asian \(2%\), and other \(8%\).)]TJ /TT1 1 Tf 21.636 0 TD 0.0125 Tc 0 Tw ( )Tj /TT2 1 Tf 0.525 0 TD -0.0078 Tc (The)Tj -22.161 -1.398 TD -0.0035 Tc 0.055 Tw (primary diagnoses)Tj /TT1 1 Tf 7.359 0 TD 0 Tc 0 Tw ( )Tj /TT2 1 Tf 0.312 0 TD -0.0038 Tc 0.06 Tw (included schizophrenia \(48%\), affective)Tj -7.671 -1.401 TD -0.0034 Tc 0.1216 Tw (disorders \(15%\), personality disorders \(19%\), and various)Tj T* -0.0039 Tc -0.0525 Tw (other diagnoses \(16%\).)Tj /TT1 1 Tf 9.06 0 TD -0.055 Tc 0 Tw ( )Tj /TT2 1 Tf 0.585 0 TD -0.0032 Tc -0.055 Tw (During these years there were 1,068)Tj -9.645 -1.398 TD -0.004 Tc 0.0069 Tw (male and 1,055 female DMH and DMH-vendored staff vic-)Tj 0 -1.401 TD -0.0037 Tc -0.0355 Tw [(tims. )50.4(Assaulted staf)17.3(f included mental health workers \(64%\),)]TJ T* 0.0005 Tc 0.125 Tw (nurses \(25%\),)Tj /TT1 1 Tf 5.691 0 TD 0 Tc 0 Tw ( )Tj /TT2 1 Tf 0.375 0 TD -0.0019 Tc (and)Tj /TT1 1 Tf 1.443 0 TD 0 Tc ( )Tj /TT2 1 Tf 0.381 0 TD 0.001 Tc 0.125 Tw (residential house counselors and other)Tj -7.89 -1.398 TD -0.0036 Tc -0.0293 Tw [(groupings \(3%\). Employees ranged in experience from new)]TJ 0 -1.401 TD -0.0028 Tc 0.0055 Tw [(hires to very seasoned staff. No statistically significant dif-)]TJ T* 0.0017 Tc 0.125 Tw (ferences in patient or staff characteristics emerged in the)Tj 0 -1.398 TD -0.0078 Tc -0.0621 Tw (reductions in force in 1990, 1995, and 1999.)Tj /F1 1 Tf 11 0 0 11 309 399.99 Tm -0.0049 Tc 0.0227 Tw (Measures of Assault)Tj /TT2 1 Tf 10 0 0 10 327 376.65 Tm 0.007 Tc 0.125 Tw (The four types of assaults assessed in this study re-)Tj -1.8 -1.401 TD -0.0027 Tc -0.0112 Tw [(mained constant during the 15 years of this study)63.3(. Physical)]TJ 0 -1.398 TD -0.0036 Tc -0.0169 Tw (assaults were defined as unwanted contact with another per-)Tj 0 -1.401 TD 0.0543 Tw (son with intent to harm, including punching, kicking, slap-)Tj T* -0.003 Tc 0.0419 Tw (ping, biting, spitting, and throwing objects directly at staff.)Tj 0 -1.398 TD -0.0038 Tc -0.0307 Tw (Sexual assaults were unwanted sexual contacts and included)Tj 0 -1.401 TD -0.0034 Tc -0.0443 Tw (rape, attempted rape, fondling, forced kissing, and exposing.)Tj T* 0.0254 Tc 0.125 Tw (Nonverbal intimidation referred to actions intended to)Tj 0 -1.398 TD -0.0034 Tc 0.0272 Tw (threaten and/or frighten staff, such as pounding on the staff)Tj 0 -1.401 TD -0.0038 Tc 0.0315 Tw [(of)17.2(fice door)35.2(, random throwing of objects, and destruction of)]TJ T* -0.0033 Tc 0.0295 Tw [(property)59.7(. )18.3(V)115.9(erbal threats were statements meant to frighten)]TJ 0 -1.398 TD -0.0034 Tc 0.055 Tw (or threaten staff and included threats against life and prop-)Tj 0 -1.401 TD -0.003 Tc 0.0422 Tw (erty as well as racial slurs and other derogatory comments.)Tj T* -0.0034 Tc -0.0161 Tw (Serious incidents other than assaults \(e.g., sudden death of a)Tj 0 -1.398 TD -0.0035 Tc 0.0561 Tw [(patient\) were recorded as other incidents; no data are re-)]TJ 0 -1.401 TD 0.055 Tw (ported here for those incidents.)Tj /F1 1 Tf 11 0 0 11 309 134.01 Tm 0.0039 Tc 0 Tw (Procedure)Tj /TT2 1 Tf 10 0 0 10 327 110.64 Tm -0.0034 Tc 0.1055 Tw [(The data on patient assailants and staff victims were)]TJ -1.8 -1.398 TD 0.0052 Tc 0.125 Tw [(recorded on the )50.2(Assaulted S)17.2(taf)14.2(f )53.2(Action Program \(ASAP;)]TJ 0 -1.401 TD 0.0181 Tc 0.1249 Tw [(Flannery)63.1(, 1998\) report forms in the 16 DMH state and)]TJ ET endstream endobj 94 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT1 8 0 R /TT2 9 0 R /TT3 10 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 96 0 obj << /Length 11922 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 66 59.745 m 558 59.745 l S BT /TT3 1 Tf 8 0 0 8 423.24 42.6 Tm 0 0 0 1 k /GS2 gs -0.0051 Tc 0.0326 Tw [(IJEMH Vol. 10, No. 3 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (179)Tj /TT2 1 Tf 10 0 0 10 66 722.64 Tm -0.0034 Tc -0.045 Tw (vendored facilities that had fielded an )Tj 14.871 0 TD -0.0049 Tc -0.0438 Tw [(ASAP)31.1( team during the)]TJ -14.871 -1.398 TD -0.0019 Tc -0.0105 Tw [(years of this study)61.1(. )]TJ 7.6625 0 TD -0.0053 Tc -0.0074 Tw [( )54.8(ASAP)27.7( is a )]TJ 4.4946 0 TD -0.0026 Tc -0.0107 Tw [(voluntary)63.4(, peer)18.4(-help, system-)]TJ -12.1571 -1.401 TD -0.0035 Tc -0.0069 Tw (wide, crisis intervention program to assist staff victims with)Tj T* -0.0033 Tc 0.0885 Tw [(the psychological sequellae patient assaults. The program)]TJ 0 -1.398 TD -0.0031 Tc 0.0012 Tw (offers individual, group, and staff victim family crisis inter-)Tj 0 -1.401 TD -0.0035 Tc 0.0581 Tw (ventions, an ongoing staff victim support group, and refer-)Tj T* -0.0581 Tw (rals to individual therapists who specialize in treating trauma)Tj 0 -1.398 TD -0.0044 Tc -0.0535 Tw [(victims, when indicated. )50.5(ASAP)]TJ 12.411 0 TD -0.0037 Tc -0.0543 Tw [( has strong empirical support)]TJ -12.411 -1.401 TD -0.0025 Tc 0.0697 Tw [(for its ef)18.5(ficacy \(Flannery)63.5(, 1998; Flannery)63.5(, Farley)60.5(, Rego, &)]TJ T* -0.0276 Tc -0.0593 Tw [(W)97.2(alker)35.4(, 2006\).)]TJ 1.8 -1.998 TD -0.0048 Tc 0.0976 Tw [(All )53.1(ASAP)28.2( team members practiced completing )50.1(ASAP)]TJ -1.8 -1.401 TD -0.0032 Tc 0.0982 Tw (report forms until acceptable levels of reliability were ob-)Tj T* -0.0037 Tc 0.0028 Tw [(tained. )50.3(An upgrade in the software package \(1994\) allowed)]TJ 0 -1.398 TD -0.0034 Tc 0.0533 Tw [(data on staf)14.6(f victim functioning in the domains of mastery)62.6(,)]TJ 0 -1.401 TD 0.068 Tw (attachment, and meaning, as well as in the presence of the)Tj T* -0.003 Tc 0.08 Tw (physical, intrusive, and avoidant symptoms of psychologi-)Tj 0 -1.398 TD -0.0035 Tc -0.0477 Tw [(cal trauma, to be captured between 1994 and 2005. )17.5(T)70.3(o)1.5( guard)]TJ 0 -1.401 TD -0.0034 Tc -0.0599 Tw [(against underreporting \(Lion, Snyder)35.6(, & Merrill, 1981\), each)]TJ T* -0.0032 Tc 0.0082 Tw (facility was required to fill out a DMH report form for each)Tj 0 -1.398 TD -0.0032 Tw (incident, to call the )Tj 7.779 0 TD -0.0042 Tc -0.0014 Tw [(ASAP)28.8( person on duty)]TJ 8.58 0 TD -0.0034 Tc -0.0031 Tw (, and to review the)Tj -16.359 -1.401 TD -0.0033 Tc 0.0244 Tw [(incident at daily staf)14.7(f meetings. )50.6(At times, total numbers do)]TJ T* -0.0038 Tc 0.1206 Tw (not equal 100% because of occasional missing data when)Tj 0 -1.398 TD -0.0045 Tc 0.1209 Tw [(staf)16.5(f victims declined )50.4(ASAP)]TJ 11.559 0 TD -0.0028 Tc 0.12 Tw [( services, declined to identify)]TJ -11.559 -1.401 TD -0.0005 Tc 0.1249 Tw [(the patient assailant, or when the patient)53.5(s record did not)]TJ T* 0.0009 Tc 0.125 Tw [(include suf)15.9(ficient documentation of the study)51.9(s variables.)]TJ 0 -1.398 TD -0.0031 Tc -0.0268 Tw (This analysis assumed that all staff were at equal risk for the)Tj 0 -1.401 TD -0.0225 Tw (full study period, except for some brief hospitalizations dur-)Tj T* -0.0035 Tc 0.0221 Tw (ing which community patients were absent from residential)Tj 0 -1.398 TD -0.0033 Tc 0.0171 Tw [(placements. )50.6(All data are reported as assault incidents.)]TJ /F1 1 Tf 11 0 0 11 158.64 291.99 Tm 0.0198 Tc 0 Tw [(RESUL)82.5(TS)]TJ /TT2 1 Tf 10 0 0 10 84 268.65 Tm -0.004 Tc -0.0621 Tw (During this 15-year time period, )Tj 12.669 0 TD -0.0062 Tc -0.0611 Tw [(ASAP)29.8( teams responded)]TJ -14.469 -1.401 TD -0.0032 Tc 0.0831 Tw [(to 2,152 patient assaults on staf)17.8(f. )]TJ /TT1 1 Tf 13.755 0 TD 0.084 Tc 0 Tw ( )Tj /TT2 1 Tf 0.669 0 TD -0.0051 Tc 0.0877 Tw [(ASAP)27.9( was accepted in)]TJ -14.424 -1.398 TD -0.022 Tc -0.0619 Tw (1,862 incidents \(87%\) and declined in 290 others \(13%\).)Tj /TT1 1 Tf 20.961 0 TD -0.0913 Tc 0 Tw ( )Tj /TT2 1 Tf 0.504 0 TD -0.0241 Tc (There)Tj -21.465 -1.401 TD -0.0036 Tc -0.0395 Tw [(were 1,068 male \(50%\) and 1,055 female \(49%\) victims. Of)]TJ T* -0.0208 Tc -0.0625 Tw (these, 824 were male \(51%\) and 764 female \(47%\) staff victims)Tj 0 -1.398 TD -0.0035 Tc 0.0655 Tw [(in inpatient settings. 240 male \(45%\) and 290 \(54%\) staff)]TJ 0 -1.401 TD -0.0119 Tc -0.0625 Tw [(victims were reported from community settings. Staff victims)]TJ T* -0.0062 Tc -0.0619 Tw [(declined )48.1(ASAP)29.8( services in 187 inpatient \(12%\) and 108 com-)]TJ 0 -1.398 TD -0.0054 Tc -0.0625 Tw (munity \(20%\) incidents.)Tj /F1 1 Tf 11 0 0 11 66 123.99 Tm -0.0048 Tc 0.0621 Tw [(P)34.9(atient Assailant )72.3(V)62.2(ariables)]TJ /TT2 1 Tf 10 0 0 10 84 100.65 Tm -0.0034 Tc 0.0213 Tw [(T)73.4(able 1 presents data on the characteristics of assultive)]TJ -1.8 -1.401 TD -0.0032 Tc -0.0293 Tw [(patients in each of the four types of assaults. )51(Although there)]TJ 25.5 63.501 TD -0.0033 Tc -0.0445 Tw (was a tendency for assailants of nonverbal intimidation to be)Tj 0 -1.401 TD -0.0034 Tc -0.0569 Tw [(somewhat older)38.6(, there were no statistically significant dif)14.6(fer)17.6(-)]TJ 0 -1.398 TD -0.0023 Tc 0.0433 Tw (ences in age by type of assault.)Tj 1.8 -2.001 TD -0.0034 Tc 0.0012 Tw [(W)55.4(ith the exception of sexual assaults, females were the)]TJ -1.8 -1.401 TD -0.0039 Tc -0.0625 Tw (more frequent assailants in all categories of violence [)Tj /TT5 1 Tf 20.886 0 TD 0 Tc 0 Tw (x)Tj 5.8 0 0 5.8 534.24 663 Tm (2)Tj /TT2 1 Tf 10 0 0 10 537.15 659.64 Tm -0.004 Tc -0.0625 Tw [( \(4\) =)]TJ -21.615 -1.398 TD -0.0033 Tc 0 Tw (10.61, )Tj /TT5 1 Tf 2.73 0 TD 0 Tc (p)Tj /TT2 1 Tf 0.495 0 TD -0.0028 Tc 0.0038 Tw ( < .03]. Diagnoses were fairly uniformly across as-)Tj -3.225 -1.401 TD -0.0034 Tc 0.0907 Tw [(sault categories, with a diagnosis of schizophrenia statisti-)]TJ T* 0.0036 Tc 0.125 Tw (cally increasing the association of assault in incidents of)Tj 0 -1.398 TD -0.0033 Tc -0.0614 Tw [(physical, sexual, and nonverbal intimidation. Individuals di-)]TJ 0 -1.401 TD -0.0035 Tc 0.0614 Tw (agnosed with personality disorders were the more frequent)Tj T* 0.103 Tw (assailants in verbal abuse incidents [)Tj /TT5 1 Tf 14.961 0 TD 0 Tc 0 Tw (x)Tj 5.8 0 0 5.8 474.99 579 Tm (2)Tj /TT2 1 Tf 10 0 0 10 477.9 575.64 Tm -0.003 Tc 0.1037 Tw [( \(16\) = 125.43, )]TJ /TT5 1 Tf 6.6 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.495 0 TD 0.101 Tc ( <)Tj -22.785 -1.398 TD -0.0144 Tc -0.0623 Tw [(.0002]. Histories of violence toward others [)]TJ /TT5 1 Tf 17.22 0 TD 0 Tc 0 Tw (x)Tj 5.8 0 0 5.8 497.49 564.99 Tm (2)Tj /TT2 1 Tf 10 0 0 10 500.31 561.66 Tm -0.0139 Tc -0.0625 Tw [( \(8\) = 157.12, )]TJ /TT5 1 Tf 5.274 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf -23.205 -1.401 TD -0.0094 Tc -0.0612 Tw (< .0003], personal victimization [)Tj /TT5 1 Tf 12.834 0 TD 0 Tc 0 Tw (x)Tj 5.8 0 0 5.8 453.69 551.01 Tm (2)Tj /TT2 1 Tf 10 0 0 10 456.54 547.65 Tm -0.0085 Tc -0.0625 Tw [( \(8\) = 25.87, )]TJ /TT5 1 Tf 4.866 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.489 0 TD -0.0092 Tc -0.0633 Tw [( < .001], and)]TJ -18.909 -1.401 TD -0.004 Tc -0.015 Tw (substance use disorder [)Tj /TT5 1 Tf 9.444 0 TD 0 Tc 0 Tw (x)Tj 5.8 0 0 5.8 419.85 537 Tm (2)Tj /TT2 1 Tf 10 0 0 10 422.76 533.64 Tm -0.0026 Tc -0.015 Tw [( \(8\) = 52.99, )]TJ /TT5 1 Tf 5.133 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.495 0 TD -0.0032 Tc -0.015 Tw [( < .0008], as well as)]TJ -15.804 -1.398 TD -0.0036 Tc -0.0608 Tw [(acute intoxication at time of incident [)]TJ /TT5 1 Tf 14.769 0 TD 0 Tc 0 Tw (x)Tj 5.8 0 0 5.8 473.1 522.99 Tm (2)Tj /TT2 1 Tf 10 0 0 10 476.01 519.66 Tm -0.0026 Tc -0.06 Tw [( \(8\) = 15.75, )]TJ /TT5 1 Tf 4.953 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.495 0 TD -0.003 Tc -0.0625 Tw [( < .04],)]TJ -20.949 -1.401 TD -0.0029 Tc 0.0036 Tw [(were statistically significantly associated with assault. )18.1(V)65.3(io-)]TJ T* -0.0034 Tc 0.0225 Tw (lence toward others was most highly associated with denial)Tj 0 -1.398 TD -0.0047 Tc -0.0622 Tw (of services. Denial of services was the more frequent precipi-)Tj 0 -1.401 TD -0.0031 Tc 0.0089 Tw (tant in physical and verbal assaults; psychosis was the most)Tj T* -0.0033 Tc 0.1043 Tw (frequent precipitant in sexual assaults, and excess sensory)Tj 0 -1.398 TD -0.0036 Tc -0.0237 Tw (stimulation was the most frequent precipitant in instances of)Tj 0 -1.401 TD -0.0119 Tc -0.0625 Tw (nonverbal intimidation [)Tj /TT5 1 Tf 9.309 0 TD 0 Tc 0 Tw (x)Tj 5.8 0 0 5.8 418.41 425.01 Tm (2)Tj /TT2 1 Tf 10 0 0 10 421.29 421.65 Tm -0.0111 Tc -0.0625 Tw [( \(28\) = 69.24, )]TJ /TT5 1 Tf 5.322 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.483 0 TD -0.0118 Tc -0.0625 Tw [( < .0002].)]TJ /F1 1 Tf 11 0 0 11 321 389.01 Tm -0.0049 Tc -0.0192 Tw [(Staff Victim V)62.1(ariables)]TJ /TT2 1 Tf 10 0 0 10 339 365.64 Tm -0.0034 Tc 0.0117 Tw [(T)73.4(able 2 presents data on the characteristics of staf)14.6(f vic-)]TJ -1.8 -1.398 TD -0.0032 Tc 0.0805 Tw [(tims for each type of assault. Female staff members were)]TJ 0 -1.401 TD -0.003 Tc -0.0317 Tw (more likely than male staff to be victims of assault in all cat-)Tj T* -0.0034 Tc 0.0984 Tw (egories except physical assault[)Tj /TT5 1 Tf 12.825 0 TD 0 Tc 0 Tw (x)Tj 5.8 0 0 5.8 453.66 327 Tm (2)Tj /TT2 1 Tf 10 0 0 10 456.54 323.64 Tm -0.0026 Tc 0.0975 Tw [( \(4\) = 30.59, )]TJ /TT5 1 Tf 5.586 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.495 0 TD -0.0036 Tc 0.1001 Tw [( < .0004].)]TJ -19.635 -1.398 TD -0.0034 Tc 0.0758 Tw (Nursing personnel, especially mental health workers, were)Tj 0 -1.401 TD -0.0035 Tc 0.0184 Tw (the most frequent victims of assaults across all four catego-)Tj T* -0.006 Tc -0.06 Tw (ries. [)Tj /TT5 1 Tf 2.175 0 TD 0 Tc 0 Tw (x)Tj 5.8 0 0 5.8 347.16 285 Tm (2)Tj /TT2 1 Tf 10 0 0 10 350.01 281.64 Tm -0.0057 Tc -0.0625 Tw [( \(32\) = 243.9, )]TJ /TT5 1 Tf 5.4 0 TD -0.006 Tc 0 Tw (p )Tj /TT2 1 Tf 0.678 0 TD -0.0067 Tc -0.0625 Tw [(< .0003]. Mental health workers were)]TJ -8.979 -1.398 TD -0.0028 Tc -0.06 Tw (more frequently victims of assault than any other category of)Tj 0 -1.401 TD -0.0162 Tc -0.0619 Tw [(impatient or community health care provider)55.8(. )14.4(Whereas bruises)]TJ T* -0.0029 Tc 0.015 Tw (were the more common injury in physical assaults, psycho-)Tj 0 -1.398 TD 0.0018 Tc 0.1249 Tw [(logical stress and trauma were frequently associated as a)]TJ 0 -1.401 TD -0.0035 Tc 0.0938 Tw [(response to the other three categories of assault [)]TJ /TT5 1 Tf 20.07 0 TD 0 Tc 0 Tw (x)Tj 5.8 0 0 5.8 526.11 215.01 Tm (2)Tj /TT2 1 Tf 10 0 0 10 528.99 211.65 Tm -0.0032 Tc 0.095 Tw [( \(28\) =)]TJ -20.799 -1.401 TD -0.0087 Tc 0 Tw (683.16, )Tj /TT5 1 Tf 3.126 0 TD -0.009 Tc (p )Tj /TT2 1 Tf 0.675 0 TD -0.008 Tc -0.0625 Tw [(< .0001]. Severity in all types of incidents was mild)]TJ -3.801 -1.398 TD -0.0074 Tc (to moderate and not statistically significant [)Tj /TT5 1 Tf 17.109 0 TD 0 Tc 0 Tw (x)Tj 5.8 0 0 5.8 496.44 186.99 Tm (2)Tj /TT2 1 Tf 10 0 0 10 499.29 183.66 Tm -0.0072 Tc -0.0625 Tw [( \(16\) = 18.83, )]TJ /TT5 1 Tf 5.376 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf -23.205 -1.401 TD -0.0042 Tc -0.017 Tw [(< .2]. )51.3(ASAP)28.8( services )]TJ 8.6666 0 TD -0.0033 Tc -0.0185 Tw (were most frequently declined in non-)Tj -8.6666 -1.401 TD -0.0082 Tc -0.0617 Tw (verbal intimidation and verbal threat incidents [)Tj /TT5 1 Tf 18.279 0 TD 0 Tc 0 Tw (x)Tj 5.8 0 0 5.8 508.14 159 Tm (2)Tj /TT2 1 Tf 10 0 0 10 511.05 155.64 Tm -0.0079 Tc -0.0633 Tw [( \(4\) = 13.77,)]TJ /TT5 1 Tf -19.005 -1.398 TD -0.021 Tc 0 Tw (p )Tj /TT2 1 Tf 0.654 0 TD -0.0201 Tc -0.06 Tw (< .008].)Tj 1.146 -2.001 TD -0.0032 Tc 0.0885 Tw (In the subanalyses of domains and symptoms, disrup-)Tj -1.8 -1.401 TD -0.0033 Tc 0.1093 Tw [(tions in the domains of reasonable mastery)62.7(, caring attach-)]TJ 0 -1.398 TD -0.0034 Tc -0.0088 Tw (ments, and purposeful meaning as well as the psychological)Tj 0 -1.401 TD 0.0005 Tc 0.1249 Tw [(trauma symptoms of physical, intrusive, and avoidant re-)]TJ ET endstream endobj 97 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT1 8 0 R /TT2 9 0 R /TT3 10 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 99 0 obj << /Length 9344 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 54 59.745 m 546 59.745 l S BT /F1 1 Tf 8 0 0 8 54.99 37.41 Tm 0 0 0 1 k /GS2 gs -0.0054 Tc 0.0938 Tw [(180 )]TJ /TT3 1 Tf 2.7563 0 TD -0.0053 Tc 0.0937 Tw (Flannery and Walker )Tj 9.6786 0 TD 0.0039 Tc 0.0959 Tw [( )6(Four Types of Patient Assaults)]TJ /TT2 1 Tf 10 0 0 10 54.99 337.65 Tm 0.0025 Tc 0.125 Tw (sponses were frequently associated with all categories of)Tj 0 -1.401 TD -0.0032 Tc -0.0172 Tw [(assault. Each category of violence resulted in disruptions in)]TJ 0 -1.398 TD -0.0094 Tc -0.0613 Tw (the domains of mastery [)Tj /TT5 1 Tf 9.477 0 TD 0 Tc 0 Tw (x)Tj 5.8 0 0 5.8 154.11 312.99 Tm (2)Tj /TT2 1 Tf 10 0 0 10 156.96 309.66 Tm -0.0088 Tc -0.0625 Tw [( \(4\) = 13.24, )]TJ /TT5 1 Tf 4.86 0 TD -0.009 Tc 0 Tw (p )Tj /TT2 1 Tf 0.669 0 TD -0.0096 Tc -0.0633 Tw (< .01], caring attach-)Tj -15.726 -1.401 TD -0.0051 Tc -0.055 Tw (ments [)Tj /TT5 1 Tf 2.886 0 TD 0 Tc 0 Tw (x)Tj 5.8 0 0 5.8 88.26 299.01 Tm (2)Tj /TT2 1 Tf 10 0 0 10 91.14 295.65 Tm -0.0026 Tc -0.06 Tw [( \(4\) = 63.87, )]TJ /TT5 1 Tf 4.956 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.495 0 TD -0.0038 Tc -0.06 Tw [( < .0001], and meaningful purpose [)]TJ /TT5 1 Tf 13.905 0 TD 0 Tc 0 Tw (x)Tj 5.8 0 0 5.8 289.11 299.01 Tm (2)Tj /TT2 1 Tf 10 0 0 10 54.99 281.64 Tm -0.0029 Tc 0.0067 Tw (\(4\) = 12.05, )Tj /TT5 1 Tf 4.965 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.495 0 TD -0.0029 Tc 0.0071 Tw [( < .01] and in the physical [)]TJ /TT5 1 Tf 10.977 0 TD 0 Tc 0 Tw (x)Tj 5.8 0 0 5.8 223.74 285 Tm (2)Tj /TT2 1 Tf 10 0 0 10 226.65 281.64 Tm -0.0027 Tc 0.0063 Tw [( \(4\) = 19.59, )]TJ /TT5 1 Tf 5.22 0 TD -0.004 Tc 0 Tw (p )Tj /TT2 1 Tf 0.756 0 TD 0 Tc (<)Tj -23.142 -1.398 TD -0.0189 Tc -0.06 Tw (.0007], intrusive [)Tj /TT5 1 Tf 6.69 0 TD 0 Tc 0 Tw (x)Tj 5.8 0 0 5.8 126.15 270.99 Tm (2)Tj /TT2 1 Tf 10 0 0 10 128.94 267.66 Tm -0.0183 Tc -0.0617 Tw [( \(4\) = 72.90,)]TJ /TT5 1 Tf 4.56 0 TD -0.084 Tc 0 Tw ( p)Tj /TT2 1 Tf 0.651 0 TD -0.0188 Tc -0.061 Tw [( < .0001], and avoidant [)]TJ /TT5 1 Tf 9.096 0 TD 0 Tc 0 Tw (x)Tj 5.8 0 0 5.8 276.24 270.99 Tm (2)Tj /TT2 1 Tf 10 0 0 10 279.09 267.66 Tm -0.0203 Tc -0.065 Tw [( \(4\))]TJ -22.41 -1.401 TD -0.0206 Tc -0.06 Tw (= 290.26, )Tj /TT5 1 Tf 3.741 0 TD -0.019 Tc 0 Tw (p )Tj /TT2 1 Tf 0.645 0 TD -0.021 Tc -0.0625 Tw [(< .0006] symptoms. In general, physical and sexual)]TJ -4.386 -1.401 TD -0.0036 Tc -0.0169 Tw (assaults and verbal threats resulted in more frequent domain)Tj 0 -1.398 TD 0.0583 Tw (disruptions and symptom clusters than nonverbal intimida-)Tj 0 -1.401 TD 0.0963 Tw (tion incidents, which resulted in less disruptions and clus-)Tj T* 0.0078 Tc 0 Tw (ters.)Tj /F1 1 Tf 11 0 0 11 138.24 168.99 Tm 0.0207 Tc (DISCUSSION)Tj /TT2 1 Tf 10 0 0 10 72.99 145.65 Tm -0.003 Tc 0.0379 Tw (This 15-year retrospective study includes at least three)Tj -1.8 -1.401 TD -0.0033 Tc 0.07 Tw [(important findings. First, this study)50.7(s findings support ex-)]TJ 0 -1.398 TD -0.0035 Tc -0.0193 Tw (tensive previous research that patient assaults on caregivers,)Tj 0 -1.401 TD -0.0107 Tc -0.0625 Tw (including emergency medical services \(EMS\) personnel, con-)Tj T* -0.0136 Tc [(stitute a serious and ongoing occupational hazard \(Blair)34.4(, 1991;)]TJ 0 -1.398 TD -0.0185 Tc -0.0622 Tw (Busch & Shore, 2000; Daffern et al., 2003; Daffern et al., 2006;)Tj 25.5 26.199 TD -0.0035 Tc 0.0363 Tw [(Davis, 1991; Dietz & Rada, 1982; Flannery)59.5(, 2001a, 2001b;)]TJ 0 -1.401 TD -0.0028 Tc -0.0248 Tw [(Flannery et al., 1994; Flannery and )15.4(W)95.1(alker)39.2(, 2001; Flannery)60.2(,)]TJ 0 -1.398 TD -0.003 Tc 0.0295 Tw [(Farley)60(, et al., 2006; Flannery)60(, Hanson, Corrigan, & )18.1(W)97.8(alker)36(,)]TJ 0 -1.401 TD -0.0202 Tc -0.0621 Tw [(2006; Grube, 2007; Krakowski & Czobor)33.8(, 2004; Lomoka et al.,)]TJ T* -0.0034 Tc -0.0505 Tw [(2004; Owens et al., 1998\). This research has been consistent)]TJ 0 -1.398 TD -0.0031 Tc 0.0472 Tw (in its findings that patient assaults are most frequently per-)Tj 0 -1.401 TD -0.054 Tw (petrated by either male or female patients with a diagnosis of)Tj T* -0.0033 Tc 0.0111 Tw [(schizophrenia or personality disorder)50.7(. )18.2(The assailant, on av-)]TJ 0 -1.398 TD -0.0028 Tc 0.1091 Tw (erage, is about 35 years old and has a history of violence)Tj 0 -1.401 TD 0.0078 Tc 0.125 Tw [(toward others and substance use. Recent research \(e.g.,)]TJ T* -0.0029 Tc 0.0699 Tw [(Flannery)60.1(, Farley)60.1(, et al., 2006\) has reflected assessment ad-)]TJ 0 -1.398 TD -0.003 Tc 0.0254 Tw [(vances in the field of identifying victims of violence. Per-)]TJ 0 -1.401 TD -0.0031 Tc -0.0511 Tw (sonal victimization, included in this study as a third variable,)Tj T* 0.0019 Tc 0.125 Tw [(was highly associated with subsequent assault. Frequent)]TJ 0 -1.398 TD 0.0028 Tc (precipitants in this study included psychosis, excess sen-)Tj 0 -1.401 TD -0.0032 Tc 0.0631 Tw (sory stimulation, denial of services, and substance use dis-)Tj T* -0.0036 Tc 0.0701 Tw [(order)35.4(, findings consistent with previous studies.)]TJ 1.8 -1.998 TD -0.0032 Tc 0.0084 Tw [(Recent research \(Flannery)62.8(, Hanson, et al., 2006\) exam-)]TJ -1.8 -1.401 TD -0.0034 Tc 0.0894 Tw (ined the three clinical variables of violence toward others,)Tj /F1 1 Tf -4.734 60.735 TD -0.0118 Tc -0.0675 Tw [(T)59.2(ypes of Assaults)]TJ 10 0 2.1256 10 63.99 654.99 Tm -0.0064 Tc -0.1416 Tw [(P)30.6(atient V)60.6(ariables)-21081.4(N)23.6(o)23.6(n)]TJ 30.63 0 TD -0.0252 Tc 0 Tw [(verbal)-2575.2(V)41.8(e)-9(r)-9(b)-8.9(a)-8.9(l)]TJ -15.9749 -1.2 TD -0.0131 Tc [(Physical)-3238.1(Sexual)]TJ 14.4 0 TD -0.0038 Tc (Intimidation)Tj 7.2 0 TD -0.0262 Tc (Threat)Tj 10 0 0 10 495.99 642.99 Tm 0 Tc (p)Tj 10 0 2.1256 10 501.9 642.99 Tm -0.0212 Tc (-value)Tj /TT3 1 Tf 10 0 0 10 207.99 630.99 Tm 0 Tc (\()Tj /F21 1 Tf 10 0 2.1256 10 211.29 630.99 Tm (N)Tj /TT3 1 Tf 10 0 0 10 218.46 630.99 Tm -0.0049 Tc -0.0525 Tw [( = 1,846\))-2326.9(\()]TJ /F21 1 Tf 10 0 2.1256 10 283.29 630.99 Tm 0 Tc 0 Tw (N)Tj /TT3 1 Tf 10 0 0 10 290.46 630.99 Tm -0.0048 Tc -0.04 Tw [( = 33\))-3676.8(\()]TJ /F21 1 Tf 10 0 2.1256 10 355.29 630.99 Tm 0 Tc 0 Tw (N)Tj /TT3 1 Tf 10 0 0 10 362.46 630.99 Tm -0.0048 Tc -0.04 Tw [( = 37\))-3676.8(\()]TJ /F21 1 Tf 10 0 2.1256 10 427.29 630.99 Tm 0 Tc 0 Tw (N)Tj /TT3 1 Tf 10 0 0 10 434.46 630.99 Tm -0.005 Tc -0.0525 Tw [( = 154\))]TJ -37.047 -1.2 TD -0.0315 Tc 0 Tw (_________________________________________________________________________________________)Tj T* -0.006 Tc -0.003 Tw [( Age )-8.3(\(years\))]TJ 14.4 0 TD -0.0256 Tc 0 Tw [(35.54)-4825.6(35.06)-4825.6(37.97)-4825.6(35.30)]TJ /F21 1 Tf 10 0 2.1256 10 495.99 606.99 Tm -0.006 Tc (ns)Tj /TT3 1 Tf 10 0 0 10 63.99 594.99 Tm -0.0371 Tc (Gender)Tj 0 -1.2 TD -0.0104 Tc 0.0222 Tw [( )-5.7(Males)-11185.4(901 )]TJ 16.2169 0 TD -0.0129 Tc -0.0696 Tw [(\(49%\))-2787.9(23 \(70%\))-3312.9(15 \(41%\))-3312.9(64 \(42%\))]TJ -16.2169 -1.2 TD -0.0066 Tc 0.0034 Tw [( )-5.7(Females)]TJ 14.4 0 TD -0.0131 Tc -0.0699 Tw [(907 \(49%\))-2788.1(10 \(30%\))-3313.1(19 \(51%\))-3313.1(90 \(58%\))-3313.1(.)7(0)7(3)]TJ -14.4 -2.4 TD -0.0145 Tc 0 Tw (Diagnosis)Tj 0 -1.2 TD -0.0056 Tc -0.0351 Tw [( )-5.7(Schizophrenia)]TJ 14.4 0 TD -0.0131 Tc -0.0699 Tw [(915 \(50%\))-2788.1(18 \(55%\))-3313.1(19 \(51%\))-3313.1(46 \(30%\))]TJ -14.4 -1.2 TD -0.0049 Tc 0.015 Tw [( Affective Disorder)]TJ 14.4 0 TD -0.0124 Tc -0.0724 Tw [(285 \(15%\))-2787.4(4 )-5.4(\(12%\))-3837.4( )]TJ 14.6592 0 TD -0.0091 Tc -0.0095 Tw [( 5 \(14%\))-3234.1(27 )63.9(\(18%\))]TJ 14.1408 0 TD -0.0256 Tc 0 Tw (.0002)Tj -43.2 -1.2 TD -0.0049 Tc -0.0291 Tw [( )-6.5(Personality Disorder)]TJ 14.4 0 TD -0.0124 Tc -0.0724 Tw [(300 \(16%\))-2787.4(6 )-5.4(\(18%\))-3837.4( )]TJ 14.6592 0 TD -0.0091 Tc -0.0095 Tw [( 5 \(14%\))-3234.1(74 )63.9(\(48%\))]TJ -29.0592 -2.4 TD -0.0051 Tc -0.02 Tw (Violence to Others)Tj 14.4 0 TD -0.0132 Tc -0.0699 Tw [(1,420 \(93%\))-1963.2(28 \(85%\))-3313.2(28 \(80%\))-3313.2(137 \(90%\))]TJ 28.8 0 TD -0.0256 Tc 0 Tw (.0003)Tj -43.2 -2.4 TD -0.0049 Tc 0.0132 Tw [(Personal Victimization)-1054.9( )]TJ 13.0878 0 TD -0.0042 Tc 0.0123 Tw [( 1,012 )]TJ 3.9114 0 TD -0.0073 Tc 0 Tw [(\(66%\))-1957.3(16 )]TJ 5.8834 0 TD -0.0125 Tc -0.07 Tw [(\(49%\))-3312.5(18 \(51%\))]TJ 13.1174 0 TD -0.0148 Tc (111 \()Tj 2.1351 0 TD -0.0193 Tc 0 Tw [(73%\))-2794.3(.001)]TJ -38.1351 -2.4 TD -0.0061 Tc -0.0675 Tw (Substance Use Disorder)Tj 14.4 0 TD -0.0137 Tc -0.0699 Tw [(805 \(52%\))-2788.7(17 \(52%\))-3313.7(11 \(31%\))-3313.7(119 \(78%\))]TJ 28.8 0 TD -0.0256 Tc 0 Tw (.0008)Tj -43.2 -2.4 TD -0.006 Tc -0.021 Tw [(Acute )-87.1(Intoxication)-6531(128 \( 8%\))-2706(4 )52.4(\(12%\))-3831( )]TJ 29.0802 0 TD -0.0088 Tc 0.0112 Tw [( 3 \( 9%\))-3158.8(19 )84.9(\(13%\))-3308.8(.)11.3(0)11.3(4)]TJ -29.0802 -2.4 TD -0.005 Tc -0.04 Tw (Most Frequent )Tj 6.5753 0 TD -0.0035 Tc 0 Tw [(Precipitant)-3153.5(Services)]TJ 15.0247 0 TD 0.0092 Tc (Psychosis)Tj 7.2 0 TD 0.0154 Tc (Excess)Tj 7.2 0 TD -0.0014 Tc (Services)Tj -21.6 -1.2 TD -0.0089 Tc -0.0675 Tw [(Denied \(18%\))]TJ 7.2 0 TD -0.0294 Tc 0 Tw (\(33%\))Tj 7.2 0 TD -0.0142 Tc -0.07 Tw (Stimulation\(44%\)Denied \(37%\))Tj 14.4 0 TD -0.0256 Tc 0 Tw (.0002)Tj /F1 1 Tf -21.348 33.801 TD -0.0055 Tc 0.005 Tw [(T)80.5(a)6.5(b)6.5(le 1.)]TJ -6.561 -1.2 TD -0.0114 Tc -0.0683 Tw (Characteristics of Patient Assailants)Tj ET 0.99 w 1000 M /GS1 gs 54.495 730.505 491.51 -358.51 re S endstream endobj 100 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /F21 101 0 R /TT2 9 0 R /TT3 10 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 103 0 obj << /Length 9105 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 66 59.745 m 558 59.745 l S BT /TT3 1 Tf 8 0 0 8 423.24 42.6 Tm 0 0 0 1 k /GS2 gs -0.0051 Tc 0.0326 Tw [(IJEMH Vol. 10, No. 3 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (181)Tj /TT2 1 Tf 10 0 0 10 66 337.65 Tm -0.0033 Tc 0.0921 Tw (personal victimization, and substance use, both singly and)Tj 0 -1.401 TD -0.0034 Tc 0.015 Tw (in their various combinations, to assess their roles in subse-)Tj 0 -1.398 TD -0.0035 Tc 0.0877 Tw [(quent assaultive behavior)50.5(. Each variable singly was mod-)]TJ 0 -1.401 TD -0.0034 Tc 0.0922 Tw [(estly associated with subsequent assault. )17.7(V)61.8(iolence toward)]TJ T* -0.0081 Tc -0.0625 Tw (others and personal victimization combined greatly enhanced)Tj 0 -1.398 TD -0.0036 Tc 0.1222 Tw (the likelihood of subsequent assault, whereas violence to-)Tj 0 -1.401 TD -0.0236 Tw (ward others, personal victimization, and substance use com-)Tj T* -0.0031 Tc 0.0314 Tw (bined yielded the highest probability of subsequent assault.)Tj 0 -1.398 TD -0.0037 Tc -0.0245 Tw (Care providers and EMS should assess the presence of these)Tj 0 -1.401 TD -0.0032 Tc -0.0321 Tw [(three clinical variables in the patient)50.8(s history and treat them)]TJ T* -0.0033 Tc 0.0608 Tw (as potential warning signs of possible dyscontrol.)Tj 1.8 -1.998 TD -0.0036 Tc 0.0099 Tw [(Similarly)59.4(, other researchers \(Daf)17.4(fern & Howells, 2002;)]TJ -1.8 -1.401 TD -0.0029 Tc 0.1006 Tw [(Flannery)60.1(, Hanson, et al., 2006\) have noted the stability of)]TJ T* -0.0034 Tc 0.1221 Tw (these patient assailant characteristics over time. These as-)Tj 0 -1.398 TD -0.0036 Tc -0.0036 Tw (sailant profiles have remained constant, even with advances)Tj 0 -1.401 TD -0.0031 Tc 0.048 Tw (in psychopharmacology and psychosocial rehabilitation in-)Tj T* 0.0119 Tw [(terventions. This stability of treatment resistance over time)]TJ 0 -1.398 TD -0.0033 Tc 0.0533 Tw (may reflect a true biological component of assault in some)Tj 0 -1.401 TD 0.0025 Tc 0.125 Tw [(cases of untreated schizophrenia. It may also reflect the)]TJ 25.5 25.8 TD -0.0033 Tc 0.0794 Tw [(timing of the assault incident in the patient)50.7(s course of ill-)]TJ 0 -1.401 TD -0.003 Tc 0.0955 Tw [(ness. )54(Assaults during the first few days of treatment may)]TJ 0 -1.398 TD -0.0035 Tc -0.0033 Tw (occur for biological reasons, as medicines will not have had)Tj 0 -1.401 TD 0.0161 Tw [(enough time to address the medical problem. However)38.4(, as-)]TJ T* -0.0033 Tc -0.0609 Tw [(saults later in the course of a patient)53.7(s illness, when appropri-)]TJ 0 -1.398 TD 0.0397 Tc 0.125 Tw (ate medications have been administered, may reflect)Tj 0 -1.401 TD -0.003 Tc 0.1171 Tw [(deliberately intended assaults motivated by anger)39(, fear)36(, or)]TJ T* -0.0034 Tc 0.07 Tw [(denial of services. Future research would benefit from re-)]TJ 0 -1.398 TD 0.0051 Tc 0.125 Tw [(cording the time of assault in the course of the patient)50.1(s)]TJ 0 -1.401 TD -0.0033 Tc 0.0404 Tw [(illness. )50.6(As noted for the clinical variables above, care pro-)]TJ T* -0.0127 Tc -0.0621 Tw (viders encountering a patient with the traditional demographic)Tj 0 -1.398 TD -0.0035 Tc -0.0428 Tw (variable should assume a potential risk for assault until dem-)Tj 0 -1.401 TD -0.0002 Tc 0.125 Tw (onstrated otherwise.)Tj 1.8 -2.001 TD -0.0032 Tc -0.0042 Tw [(Secondly)59.8(, the present study)53.8(s findings also support pre-)]TJ -1.8 -1.398 TD -0.0037 Tc 0.0656 Tw (vious research with regard to the importance of examining)Tj 0 -1.401 TD 0.0288 Tc 0.1249 Tw (the assault characteristics of various types of assaults)Tj T* -0.014 Tc -0.0623 Tw (\(Daffern et al., 2003; Daffern et al., 2006; Dietz & Rada, 1982;)Tj 0 -1.398 TD -0.0143 Tc -0.0626 Tw [(Flannery & )15.6(W)98.6(alker)36.7(, 2001; Grube, 2007; Krakowski & Czobor)36.7(,)]TJ 0 -1.401 TD -0.0036 Tc -0.0625 Tw [(2004\). In these studies, some patient and staff victim charac-)]TJ /F1 1 Tf -4.734 60.735 TD -0.0118 Tc -0.0675 Tw [(T)59.2(ypes of Assaults)]TJ -19.566 -2.601 TD -0.0055 Tc -0.1455 Tw (Staff Victim)Tj /TT3 1 Tf 5.295 0 TD 0 Tc 0 Tw ( )Tj /F1 1 Tf 0.204 0 TD -0.0077 Tc [(V)59.3(ariables)-18982.7(N)22.3(o)22.3(n)]TJ 25.131 0 TD -0.0252 Tc [(verbal)-2575.2(V)41.8(e)-9(r)-9(b)-8.9(a)-9(l)]TJ 10 0 2.1256 10 222 648.99 Tm -0.0131 Tc [(Physical)-3238.1(Sexual)]TJ 14.4 0 TD -0.0038 Tc (Intimidation)Tj 7.2 0 TD -0.0262 Tc (Threat)Tj 10 0 0 10 510 648.99 Tm 0 Tc (p)Tj 10 0 2.1256 10 515.91 648.99 Tm -0.0212 Tc (-value)Tj /TT3 1 Tf 10 0 0 10 222 636.99 Tm 0 Tc (\()Tj /F21 1 Tf 10 0 2.1256 10 225.3 636.99 Tm (N)Tj /TT3 1 Tf 10 0 0 10 232.44 636.99 Tm -0.0049 Tc -0.0525 Tw [( = 1,846\))-2329.9(\()]TJ /F21 1 Tf 10 0 2.1256 10 297.3 636.99 Tm 0 Tc 0 Tw (N)Tj /TT3 1 Tf 10 0 0 10 304.44 636.99 Tm -0.0048 Tc -0.04 Tw [( = 33\))-3679.8(\()]TJ /F21 1 Tf 10 0 2.1256 10 369.3 636.99 Tm 0 Tc 0 Tw (N)Tj /TT3 1 Tf 10 0 0 10 376.44 636.99 Tm -0.0048 Tc -0.04 Tw [( = 37\))-3679.8(\()]TJ /F21 1 Tf 10 0 2.1256 10 441.3 636.99 Tm 0 Tc 0 Tw (N)Tj /TT3 1 Tf 10 0 0 10 448.44 636.99 Tm -0.005 Tc -0.0525 Tw [( = 154\))]TJ -37.044 -1.2 TD -0.0481 Tc 0 Tw (_____________________________________________________________________________________________)Tj T* -0.0371 Tc (Gender)Tj T* -0.0104 Tc 0.0222 Tw [( )-5.7(Males)-11185.4(958 )]TJ 16.2169 0 TD -0.0129 Tc -0.0696 Tw [(\(52%\))-2787.9(11 \(33%\))-3312.9(11 \(30%\))-3312.9(57 \(37%\))]TJ 26.9831 0 TD -0.0256 Tc 0 Tw (.0004)Tj -43.2 -1.2 TD -0.0066 Tc 0.0034 Tw [( )-5.7(Females)]TJ 14.4 0 TD -0.0131 Tc -0.0699 Tw [(866 \(47%\))-2788.1(22 \(67%\))-3313.1(26 \(70%\))-3313.1(95 \(62%\))]TJ -14.4 -2.4 TD -0.0124 Tc -0.07 Tw (Job Group)Tj 0 -1.2 TD -0.0053 Tc -0.0368 Tw [( )-7.1(Mental Health Worker)]TJ 14.4 0 TD -0.0113 Tc -0.0715 Tw [(1,230 \(67%\))-1961.3(15 )]TJ 8.5281 0 TD -0.0083 Tc -0.0424 Tw [( \(45%\))-3008.3(10 )]TJ 7.1545 0 TD -0.0125 Tc -0.07 Tw [(\(27%\))-3312.5(85 \(55%\))]TJ -30.0826 -1.2 TD -0.0061 Tc -0.0154 Tw [( )-10.8( )-16.5(Nurses)-10731.1( 460 \(25%\))-1881.1( )]TJ 21.8691 0 TD -0.0058 Tc -0.0029 Tw ( 4 \(12%\))Tj 6.9309 0 TD -0.0125 Tc -0.07 Tw [(13 \(35%\))-3312.5(35 \(23%\))]TJ 14.4 0 TD -0.0256 Tc 0 Tw (.0003)Tj -43.2 -1.2 TD -0.0051 Tc 0.0063 Tw [( )60.4( )53.7(Residential )58.9(House )58.9(Counselors)-755.1( 27 )]TJ 17.1775 0 TD -0.0061 Tc -0.0026 Tw [(\(2%\))-2331.1( 4 )]TJ 6.05 0 TD -0.0078 Tc 0 Tw [(\(12%\))-2932.8(10 )]TJ 6.8551 0 TD -0.0125 Tc -0.07 Tw [(\(27%\))-3312.5(15 \(10%\))]TJ -30.0826 -2.4 TD -0.0059 Tc -0.0026 Tw [(Injury)-12005.9(Bruises )61.9(\(46%\))-1055.9(Fright \(73%\))-680.9(Fright )]TJ 31.5519 0 TD -0.0043 Tc 0.0007 Tw [( )48.8(\(87%\))-1579.3(Fright \(81%\))]TJ 11.6481 0 TD -0.0256 Tc 0 Tw (.0001)Tj -43.2 -1.2 TD -0.0033 Tc 0.0063 Tw [(Severity)-10803.3(Mild \(40%\))]TJ 21.6 0 TD -0.0141 Tc -0.07 Tw (Moderate\( 6%\))Tj 7.2 0 TD -0.0051 Tc -0.0009 Tw (Mild \(33%\))Tj 7.2 0 TD -0.0154 Tc 0.0383 Tw [(Moderate )108.3(\(36%\))-315.4( )]TJ /F21 1 Tf 10 0 2.1256 10 519.06 492.99 Tm -0.012 Tc 0 Tw (ns)Tj /TT3 1 Tf 10 0 0 10 78 480.99 Tm -0.0046 Tc 0.0189 Tw [(ASAP )35.3(Declined)-7654.6(240 )17.6( )17.6( )17.6( )17.6( )17.6( )17.6( )17.6(\(13%\))-979.6( 1 \( 3%\))-754.6( )8( )8( )8( )8(9 )8( )8( )8( )8(\(24%\))-1729.6( )6.2( )6.2( )6.2( )6.2( )6.2( )6.2( )6.2(31 )6.2( )6.2( )6.2( )6.2(\(20%\))]TJ 43.2 0 TD -0.0238 Tc 0 Tw (.008)Tj -43.2 -2.4 TD -0.0059 Tc -0.07 Tw (Disrupted Mastery)Tj 14.4 0 TD -0.0132 Tc -0.0699 Tw [(1,224 \(66%\))-1963.2(25 \(76%\))-3313.2(18 \(49%\))-3313.2(100 \(65%\))-2788.2(.)6.9(0)6.9(1)]TJ -14.4 -1.2 TD -0.0059 Tc -0.0156 Tw [(Disrupted )18.8(Attachments)-4430.9( 620 \(34%\))-1880.9(19 )]TJ 22.8826 0 TD -0.0125 Tc -0.07 Tw [(\(58%\))-3312.5(11 \(30%\))-3312.5( )]TJ 13.3682 0 TD -0.0054 Tc -0.0216 Tw [( 49 \(32%\))]TJ 6.9492 0 TD -0.0256 Tc 0 Tw (.0001)Tj -43.2 -1.2 TD -0.014 Tc -0.07 Tw [(Disrupted Meaning)-6314( )-62.5( )]TJ 14.9128 0 TD -0.0088 Tc -0.0182 Tw [( )-5.5(975 )-5.5(\(53%\))-1883.8(19 )55.5(\(58%\))-3308.8(13 )55.5(\(35%\))-3308.8( 96 \(62%\))-2708.8(.)11.3(0)11.3(1)]TJ -14.9128 -1.2 TD -0.0062 Tc -0.0153 Tw [(Physical )-155.9(Symptoms)-5631.2( 748 \(47%\))-1881.2(17 )]TJ 22.8826 0 TD -0.0125 Tc -0.07 Tw [(\(52%\))-3312.5(11 \(34%\))-3312.5( )]TJ 13.3682 0 TD -0.0054 Tc -0.0216 Tw [( 57 \(37%\))]TJ 6.9492 0 TD -0.0256 Tc 0 Tw (.0007)Tj -43.2 -1.2 TD -0.006 Tc -0.0155 Tw [(Intrusive )-101.2(Symptoms)-5631( 347 \(22%\))-1881(12 )]TJ 22.8826 0 TD -0.0125 Tc -0.07 Tw [(\(36%\))-3312.5(12 \(38%\))-3312.5( )]TJ 13.3682 0 TD -0.0054 Tc -0.0216 Tw [( 39 \(25%\))]TJ 6.9492 0 TD -0.0256 Tc 0 Tw (.0001)Tj -43.2 -1.2 TD -0.0057 Tc -0.0158 Tw [(Avoidant )-65.7(Symptoms)-5555.7( 357 )]TJ 17.0783 0 TD -0.0091 Tc -0.0095 Tw [(\(23%\))-1884.1(13 )63.9(\(39%\))-3309.1( 8 )]TJ 13.0502 0 TD -0.0054 Tc -0.0216 Tw [(\(25%\))-3230.4( 31 \(20%\))]TJ 13.0714 0 TD -0.0256 Tc 0 Tw (.0006)Tj /F1 1 Tf -21.501 32.052 TD -0.0061 Tc 0.0056 Tw [(T)79.9(a)5.9(ble 2.)]TJ -5.325 -1.2 TD -0.0081 Tc -0.0679 Tw [(Characteristics of Staff )76.3(Victims)]TJ ET 0.99 w 1000 M /GS1 gs 66.495 732.505 493.01 -347.01 re S endstream endobj 104 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /F21 101 0 R /TT2 9 0 R /TT3 10 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 106 0 obj << /Length 8853 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 54 59.745 m 546 59.745 l S BT /F1 1 Tf 8 0 0 8 54.99 37.41 Tm 0 0 0 1 k /GS2 gs -0.0054 Tc 0.0938 Tw [(182 )]TJ /TT3 1 Tf 2.7563 0 TD -0.0053 Tc 0.0937 Tw (Flannery and Walker )Tj 9.6786 0 TD 0.0039 Tc 0.0959 Tw [( )6(Four Types of Patient Assaults)]TJ /TT2 1 Tf 10 0 0 10 54 722.64 Tm -0.0031 Tc 0.0438 Tw [(teristics remained constant across types of assault. For pa-)]TJ 0 -1.398 TD -0.0034 Tc 0.0193 Tw (tient assailants, the average age, diagnosis, violence toward)Tj 0 -1.401 TD -0.0017 Tc 0.125 Tw (others, personal victimization, and substance use disorder)Tj T* -0.0031 Tc 0.017 Tw [(were constants. For staff victims, the present study and the)]TJ 0 -1.398 TD -0.0035 Tc -0.0305 Tw (cited research document that staff most at risk are those who)Tj 0 -1.401 TD -0.0028 Tc -0.0589 Tw (are least experienced, less formally trained, and yet have sig-)Tj T* -0.0033 Tc -0.0108 Tw (nificant direct care responsibilities. Bruises and psychologi-)Tj 0 -1.398 TD -0.0034 Tc -0.0595 Tw (cal fright appear to be the most usual responses to commonly)Tj 0 -1.401 TD -0.0031 Tc 0.1175 Tw (occurring physical assaults.)Tj 1.8 -2.001 TD -0.0034 Tc -0.0388 Tw [(However)35.6(, this study also found dif)17.6(ferences in character)17.6(-)]TJ -1.8 -1.398 TD -0.0206 Tw [(istics across assault categories. Similar to previous research)]TJ 0 -1.401 TD -0.0153 Tc -0.0622 Tw [(\(Flannery & )14.7(W)100.5(alker 2001; Krakowski & Czobor)38.7(, 2004\), in this)]TJ T* -0.0029 Tc 0.0455 Tw (study females were the likely assailants in all categories of)Tj 0 -1.398 TD -0.0033 Tc -0.0538 Tw [(assault except sexual assault. This may reflect females mod-)]TJ 0 -1.401 TD -0.012 Tc -0.0625 Tw [(eling male behavior)33(, fighting for limited resources, or learning)]TJ T* -0.0033 Tc 0.0022 Tw [(that violence often works in obtaining one)50.7(s way)62.7(. Individu-)]TJ 0 -1.398 TD -0.0037 Tc -0.0484 Tw [(als )-7.1(diagnosed with personality disorders committed the most)]TJ 0 -1.401 TD -0.0032 Tc 0.0011 Tw (incidents of nonverbal intimidation. This may reflect a ten-)Tj T* -0.0035 Tc -0.0319 Tw [(dency)59.5(, when such an individual feels overwhelmed, to strike)]TJ 0 -1.398 TD -0.0033 Tc 0.0195 Tw (out at property rather than people. This view receives some)Tj 0 -1.401 TD -0.0036 Tc 0.0619 Tw [(support when examining the precipitants to assault. These)]TJ T* -0.003 Tc 0.0249 Tw [(precipitants varied by category)63(, with denial of services pre-)]TJ 0 -1.398 TD -0.0032 Tc 0.0435 Tw (ceding physical and verbal abuse with psychosis preceding)Tj 0 -1.401 TD -0.0035 Tc 0.09 Tw [(sexual assaults. However)35.5(, excess sensory stimulation was)]TJ T* -0.0034 Tc 0.0142 Tw (highly associated with acts of nonverbal intimidation.)Tj 1.8 -1.998 TD -0.0031 Tc -0.0145 Tw (Unlike Daffern et al. \(2003\), we found in our study that)Tj -1.8 -1.401 TD -0.0163 Tc -0.0622 Tw (females, not males, were the more likely victims of all forms of)Tj T* -0.0031 Tc 0.0483 Tw [(assault. )17.9(W)55.7(ith the exception of physical assaults, where the)]TJ 0 -1.398 TD -0.0033 Tc 0.0663 Tw [(focus was on possible bodily injury)59.7(, most victims reported)]TJ 0 -1.401 TD -0.0032 Tc 0.0087 Tw (psychological fright as their main response; this is reflected)Tj T* -0.0035 Tc 0.0266 Tw (in both the domain and symptom disruptions.)Tj 1.8 -1.998 TD -0.0031 Tc 0.041 Tw (The results of the present study and the six other stud-)Tj -1.8 -1.401 TD 0.0737 Tw [(ies examining differing types of assault present a paradox.)]TJ T* -0.0445 Tw (They are all in agreement in reporting differing assailant and)Tj 0 -1.398 TD -0.0034 Tc 0.0122 Tw (staff victim characteristics across assault categories, but the)Tj 0 -1.401 TD -0.0064 Tc -0.0625 Tw (studies examined differing assailant/victim variables, so gen-)Tj T* -0.0034 Tc 0.0275 Tw [(eralizations across studies are limited. Future research will)]TJ 0 -1.398 TD 0.095 Tw (need to address this issue.)Tj 1.8 -2.001 TD -0.0058 Tc -0.0622 Tw [(Thirdly)63.2(, comparing the present 15-year findings with the)]TJ -1.8 -1.401 TD -0.0198 Tc -0.0623 Tw [(earlier 10-year findings from this database \(Flannery & )19.4(W)96(alker)34.2(,)]TJ 0 -1.398 TD -0.0118 Tc -0.0622 Tw [(2001\) yielded both similarities and differences over time. The)]TJ 0 -1.401 TD -0.0034 Tc 0.0884 Tw (patient assailant variables of age and diagnosis, as well as)Tj T* 0.125 Tw (the three clinical variables associated with subsequent as-)Tj 0 -1.398 TD -0.0033 Tc -0.0115 Tw (saults, remained stable as did the staff victim variable of the)Tj 0 -1.401 TD -0.0034 Tc 0.049 Tw [(least educated and experienced being most at risk. In both)]TJ 25.5 63.999 TD -0.0036 Tc -0.0014 Tw (studies there were appreciable domain and symptom cluster)Tj 0 -1.398 TD -0.0033 Tc -0.0314 Tw [(disruptions across domains. However)35.7(, over the past 5 years,)]TJ 0 -1.401 TD -0.0036 Tc 0.1107 Tw (assailant substance use disorders and histories of personal)Tj T* -0.007 Tc -0.0621 Tw [(victimization have appreciably increased. During these same)]TJ 0 -1.398 TD -0.0034 Tc 0.1007 Tw (years staff victims are reporting fewer domain disruptions)Tj 0 -1.401 TD 0.0023 Tc 0.125 Tw [(but more intense symptom clusters. These findings may)]TJ T* 0.0098 Tc (suggest that the presence of substance use increases the)Tj 0 -1.398 TD -0.003 Tc -0.0067 Tw (intensity of the violent incidents. Even though the staff may)Tj 0 -1.401 TD -0.0034 Tc 0.0211 Tw (have learned better skills of coping with such incidents, the)Tj T* 0.0363 Tw (nature of these incidents may have increased the emotional)Tj 0 -1.398 TD -0.0031 Tc 0.0037 Tw (distress experienced by staff victims.)Tj 1.8 -2.001 TD -0.0175 Tc -0.0625 Tw (These differing outcomes over a 5-year time interval dem-)Tj -1.8 -1.401 TD 0.0014 Tc 0.125 Tw (onstrate the importance of longitudinal rather than cross-)Tj 0 -1.398 TD 0.019 Tc [(sectional studies. )49(As the present study suggests, some)]TJ 0 -1.401 TD 0.0024 Tc (patient assailant/staff victim variables remained constant.)Tj T* -0.003 Tc 0.1164 Tw [(However)36(, a health-care system is an or)18(ganic entity that is)]TJ 0 -1.398 TD -0.0033 Tc -0.0355 Tw (influenced by ongoing changes in the general culture, and as)Tj 0 -1.401 TD 0.002 Tc 0.125 Tw (this study demonstrates, these societal changes may vary)Tj T* -0.0033 Tc -0.017 Tw [(the impact of patient assaults and their aftermath. This field)]TJ 0 -1.398 TD -0.0024 Tc 0.125 Tw (needs longitudinal studies that differentiate the four basic)Tj 0 -1.401 TD -0.0032 Tc -0.0225 Tw (types of assaults, that have similar operational definitions of)Tj T* -0.0035 Tc -0.0033 Tw (these assaults across studies, and that examine at least some)Tj 0 -1.398 TD -0.01 Tw (agreed upon dimensions of patient assailant and staff victim)Tj 0 -1.401 TD -0.0032 Tc -0.0156 Tw (characteristics. Ratings of severity of incident and its victim)Tj T* -0.0035 Tc -0.0013 Tw [(impact should be assessed routinely)62.5(. S)17.5(tudies should also be)]TJ 0 -1.398 TD -0.0034 Tc -0.0582 Tw (expanded to include assaultive patients in private facilities to)Tj 0 -1.401 TD -0.0035 Tc 0.0283 Tw (assess possible public/private sector differences in assaults.)Tj T* -0.0241 Tw (Studies strengthened by these methodological additions will)Tj 0 -1.398 TD -0.0028 Tc 0.1066 Tw (yield a greater ability to generalize across studies and en-)Tj 0 -1.401 TD -0.0036 Tc 0.0886 Tw [(hance our understanding of the process of patient assaults)]TJ 1.8 -2.001 TD 0 Tc 0 Tw (.)Tj /F1 1 Tf 11 0 0 11 309 278.01 Tm -0.0045 Tc 0.0242 Tw (Risk Management Implications for)Tj 0 -1.0909 TD -0.0057 Tc 0.0637 Tw (Emergency Services)Tj /TT2 1 Tf 10 0 0 10 327 242.64 Tm -0.0031 Tc -0.0322 Tw [(The findings of the present study)62.9(, as well as those of the)]TJ -1.8 -1.398 TD -0.0033 Tc -0.0135 Tw (reviewed literature, provide a clear guideline for emergency)Tj 0 -1.401 TD 0.0105 Tw (services personnel who are asked to provide care to psychi-)Tj T* -0.0035 Tc -0.0032 Tw [(atric patients: )50.4(Approach with initial caution until the assess-)]TJ 0 -1.398 TD -0.0037 Tc 0.0611 Tw (ments below are completed and the findings suggest a low)Tj 0 -1.401 TD -0.0029 Tc -0.005 Tw (probability of assault risk.)Tj 1.8 -2.001 TD -0.0035 Tc -0.0081 Tw (Preparation to assist these patients begins when the call)Tj -1.8 -1.398 TD -0.0028 Tc 0.0504 Tw [(is received. In transit to the site, review the nature of psy-)]TJ 0 -1.401 TD -0.0033 Tc 0.0013 Tw (chosis, its symptoms, and its potential association with sub-)Tj T* -0.0035 Tc 0.0917 Tw (stance use, personal victimization, violence toward others,)Tj 0 -1.398 TD -0.0058 Tc -0.0622 Tw [(and violence toward self. Review also the major medications)]TJ 0 -1.401 TD -0.0033 Tc -0.0415 Tw (for these illnesses as well as their possible side effects \(espe-)Tj ET endstream endobj 107 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT2 9 0 R /TT3 10 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 109 0 obj << /Length 9738 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 66 59.745 m 558 59.745 l S BT /TT3 1 Tf 8 0 0 8 423.24 42.6 Tm 0 0 0 1 k /GS2 gs -0.0051 Tc 0.0326 Tw [(IJEMH Vol. 10, No. 3 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (183)Tj /TT2 1 Tf 10 0 0 10 66 722.64 Tm -0.0033 Tc 0.0829 Tw (cially neuromalignant syndrome\) and the signs of medica-)Tj 0 -1.398 TD -0.0034 Tc 0.0405 Tw [(tion noncompliance. If the patient is known to the service,)]TJ 0 -1.401 TD -0.0035 Tc -0.0525 Tw (review the log book for possible incidents of past violence or)Tj T* -0.04 Tw (other behavioral difficulties.)Tj 1.8 -1.998 TD -0.0026 Tc 0.0221 Tw [(Once on site, survey the scene carefully)63.4(. Look for any)]TJ -1.8 -1.401 TD -0.0035 Tc 0.1006 Tw (warning signs of potential loss of control, such as dishev-)Tj T* -0.0034 Tc -0.0076 Tw [(eled dress, pacing, and angry demeanor)50.6(. )51(Assess for signs of)]TJ 0 -1.398 TD -0.0036 Tc 0.1064 Tw (substance use, including the presence of drug parapherna-)Tj 0 -1.401 TD -0.0032 Tc -0.0275 Tw (lia, empty alcohol containers, and medication vials.)Tj 1.8 -2.001 TD 0.0031 Tc 0.125 Tw (Many patients diagnosed with psychoses have histo-)Tj -1.8 -1.398 TD -0.0072 Tc -0.0622 Tw (ries of untreated psychological trauma or posttraumatic stress)Tj 0 -1.401 TD -0.0037 Tc -0.0067 Tw [(disorder)53.3(. Given that this possible co-occurrence is common)]TJ T* -0.0031 Tc 0.0325 Tw (in these patients, if there is no immediately life-threatening)Tj 0 -1.398 TD -0.003 Tc -0.0277 Tw [(medical emer)15(gency)63(, assume initially that the patient is a vic-)]TJ 0 -1.401 TD -0.0028 Tc 0.0013 Tw (tim of trauma as well as psychosis. Stay at a respectful dis-)Tj T* 0.0019 Tc 0.125 Tw (tance, to help the patient maintain his or her boundaries.)Tj 0 -1.398 TD -0.0028 Tc -0.0622 Tw [(Speak in clear)36.2(, simple language. S)18.2(tate who you are, why you)]TJ 0 -1.401 TD -0.0031 Tc 0.0094 Tw [(are there, and explain what procedures you wish to employ)59.9(.)]TJ T* -0.0172 Tc -0.0624 Tw [(Then, with the patient)48.8(s permission, move closer)39.8(, explain again)]TJ 0 -1.398 TD -0.003 Tc 0.0612 Tw [(what you will be doing, and begin. It is helpful to ask the)]TJ 0 -1.401 TD -0.0055 Tc -0.0622 Tw (patient to help you in some small way \(e.g., hold your writing)Tj T* -0.0032 Tc 0.0459 Tw [(pen\), so that the patient)50.8(s sense of control is restored. Per)17.8(-)]TJ 0 -1.398 TD -0.0034 Tc -0.0021 Tw (form the assessments for psychosis, substance use, personal)Tj 0 -1.401 TD -0.0015 Tc 0.125 Tw [(victimization, and potential violence. Then develop your)]TJ T* -0.003 Tc 0.0039 Tw (intervention plan. If it is possible, include the patient in the)Tj 0 -1.398 TD -0.0035 Tc -0.017 Tw [(development of the plan. \(For a more detailed discussion of)]TJ 0 -1.401 TD -0.0032 Tc 0.0498 Tw [(these procedures, see Flannery)62.8(, )-6.4(in press.\))]TJ 1.8 -2.001 TD -0.0023 Tc 0.0643 Tw (Psychosis, especially its early episodes, is very fright-)Tj -1.8 -1.398 TD -0.0034 Tc 0.005 Tw (ening to the patient, and often he or she self-medicates with)Tj 0 -1.401 TD -0.0156 Tw [(alcohol or other drugs. Personal victimization of the patient)]TJ T* -0.0036 Tc 0.0279 Tw (further complicates the presenting problem, and these three)Tj 0 -1.398 TD 0.0028 Tc 0.125 Tw (issues together greatly increase the possibility of assault.)Tj 0 -1.401 TD -0.0036 Tc 0.1068 Tw (The graded approach outlined above often reduces fear in)Tj T* -0.0029 Tc 0.0827 Tw [(the patient, makes the patient your ally)63.1(, and restores some)]TJ 0 -1.398 TD -0.0019 Tc 0.125 Tw [(sense of control to the patient. Finally)61.1(, research findings)]TJ 0 -1.401 TD -0.0032 Tc 0.0912 Tw (indicate that psychological fright is a frequent response to)Tj T* -0.0035 Tc 0.0482 Tw (the various categories of patient assaults. This suggests the)Tj 0 -1.398 TD -0.0038 Tc 0.1066 Tw (importance of critical incident stress management \(CISM\))Tj 0 -1.401 TD -0.0252 Tc -0.0621 Tw [(approaches \(Everly & Mitchell, 1999\), such as )53.2(ASAP)37.8( \(Flannery)58.8(,)]TJ T* -0.0027 Tc 0.125 Tw (1998\), in addressing the aftermath of patient assaults that)Tj 0 -1.398 TD -0.0035 Tc 0.0757 Tw [(befall our colleagues. This overall approach outlined here)]TJ 0 -1.401 TD -0.0029 Tc 0.06 Tw (enhances the safety of everyone on site and results in high)Tj T* 0.0022 Tw [(quality)63.1(, cost-ef)18.1(fective care.)]TJ /F1 1 Tf 11 0 0 11 400.89 723 Tm 0.021 Tc 0 Tw (REFERENCES)Tj /TT2 1 Tf 10 0 0 10 321 705.66 Tm -0.0034 Tc 0.0299 Tw [(American Psychiatric )50.5(Association \(1992\). )]TJ /TT5 1 Tf 17.229 0 TD -0.0039 Tc [(Clinician safety)50.1(.)]TJ /TT2 1 Tf -16.029 -1.401 TD -0.0037 Tc 0.0015 Tw [(T)73.1(ask Force Report #33. )14.6(W)94.1(ashington, DC: )53.1(American Psy-)]TJ T* -0.0035 Tc -0.01 Tw (chiatric Press.)Tj -1.2 -1.8 TD -0.0038 Tc 0.071 Tw [(Blair)35.2(, D.T)71.2(. \(1991\). )50.5(Assaultive behavior: Does provocation)]TJ 1.2 -1.398 TD -0.0029 Tc 0.038 Tw (begin in the front office? )Tj /TT5 1 Tf 10.305 0 TD -0.004 Tc 0.0383 Tw [(Journal of Psychosocial Nurs-)]TJ -10.305 -1.401 TD -0.0093 Tc 0 Tw (ing,)Tj /TT2 1 Tf 1.494 0 TD 0 Tc ( )Tj /TT5 1 Tf 0.186 0 TD -0.01 Tc (29,)Tj /TT2 1 Tf 1.224 0 TD -0.0087 Tc -0.06 Tw [( 21-26.)]TJ -4.104 -1.8 TD -0.0116 Tc -0.0624 Tw [(Busch, )54.5(A.B., & Shore, M.F)78.4(. \(2000\). Seclusion and restraint: )45.5(A)]TJ 1.2 -1.401 TD -0.003 Tc -0.053 Tw [(review of the literature. )]TJ /TT5 1 Tf 9.54 0 TD -0.004 Tc -0.0542 Tw [(Harvar)32(d Review of Psychiatry)55.8(,)-2.7( 8,)]TJ /TT2 1 Tf -9.54 -1.398 TD -0.0511 Tc 0 Tw (261-270.)Tj -1.2 -1.8 TD -0.0034 Tc -0.0623 Tw [(Daffern, M., & Howells, K. \(2002\). Psychiatric inpatient ag-)]TJ 1.2 -1.401 TD 0.0008 Tc 0.1254 Tw [(gression: )52.2(A)57( review of structural and functional assess-)]TJ T* -0.0037 Tc 0.1217 Tw [(ment approaches. )]TJ /TT5 1 Tf 7.8 0 TD -0.0044 Tc 0.1244 Tw [(Aggr)31.6(ession and V)70.6(iolent Behavior)106.6(, 7)]TJ /TT2 1 Tf 14.451 0 TD 0 Tc 0 Tw (,)Tj -22.251 -1.398 TD -0.0511 Tc (477-497.)Tj -1.2 -1.8 TD -0.003 Tc -0.0282 Tw [(Daf)18(fern, M., Mayer)36(, M., & Martin, )18.3(T)76.8(.)-0.4( \(2003\). )51.3(A)59.2( preliminary)]TJ 1.2 -1.401 TD -0.0036 Tc 0.0866 Tw (investigation into patterns of)Tj 13.2 0 TD -0.0092 Tc -0.0614 Tw [(aggression in an )51.1(Austra-)]TJ -13.2 -1.401 TD -0.0014 Tc 0.125 Tw (lian forensic psychiatric hospital. )Tj /TT5 1 Tf 14.349 0 TD -0.0024 Tc [(Journal of Forensic)]TJ -14.349 -1.398 TD 0.0082 Tc 0 Tw (Psychiatry)Tj 6 0 TD -0.004 Tc -0.0219 Tw [(and Psychology)53(, 14,)]TJ /TT2 1 Tf 7.941 0 TD -0.025 Tw [( 67-84.)]TJ -15.141 -1.8 TD -0.0162 Tc -0.0623 Tw [(Daf)19.8(fern, M., Mayer)34.8(, M., & Martin, )20(T)78.6(.)-0.1( \(2006\). S)19.8(taf)19.8(f gender ratio)]TJ 1.2 -1.401 TD -0.0035 Tc 0.0461 Tw [(and aggression in a forensic)-1953.5(hospital. )-49.1( )]TJ /TT5 1 Tf 17.274 0 TD -0.0043 Tc 0 Tw (International)Tj -17.274 -1.401 TD -0.0037 Tc 0.005 Tw (Journal of Forensic Mental Health, 15,)Tj /TT2 1 Tf 15.636 0 TD -0.0033 Tc 0.0043 Tw ( 93-99.)Tj -16.836 -1.8 TD -0.0031 Tc -0.0295 Tw [(Davis, S. \(1991\). )17.8(V)65.1(iolence in psychiatric patients: )50.8(A)59.1( review)62.9(.)]TJ /TT5 1 Tf 1.2 -1.398 TD -0.0042 Tc -0.0085 Tw [(Hospital and Community Psychiatry)52.6(,)-2( 42,)]TJ /TT2 1 Tf 16.089 0 TD -0.004 Tc -0.015 Tw [( 585-590.)]TJ -17.289 -1.8 TD -0.0238 Tc -0.0624 Tw [(Dietz, P)105.2(.E., & Rada, R.T)72.2(. \(1982\). Battery incidents and batterers)]TJ 1.2 -1.401 TD -0.0033 Tc -0.0603 Tw (in a maximum security hospital. )Tj /TT5 1 Tf 12.705 0 TD -0.0041 Tc -0.0634 Tw (Archives of General Psy-)Tj -12.705 -1.401 TD -0.0065 Tc -0.0583 Tw [(chiatry)53.3(,)-1.8( 39,)]TJ /TT2 1 Tf 4.395 0 TD -0.0072 Tc -0.06 Tw [( 31-34.)]TJ -5.595 -1.8 TD -0.0205 Tc -0.0621 Tw [(Everly)60.5(, G)117.5(.S., Jr)48.5(., & Mitchell, J.T)75.5(. \(1999\). )]TJ /TT5 1 Tf 15.114 0 TD -0.0217 Tc -0.0623 Tw [(Critical Incident S)32.3(t)0.3(r)35.3(ess)]TJ -13.914 -1.398 TD -0.0042 Tc 0.0271 Tw (Management \(CISM\):A new era and standard of care in)Tj 0 -1.401 TD -0.0037 Tc 0.0199 Tw (crisis intervention )Tj /TT2 1 Tf 7.47 0 TD -0.0033 Tc [(\(2nd ed.\). Ellicott City)59.7(, MD: Chevron)]TJ -7.47 -1.401 TD -0.0043 Tc -0.04 Tw (Publishing Corp.)Tj -1.2 -1.8 TD -0.0028 Tc 0.0838 Tw [(Flannery)60.2(, R.B., Jr)51.2(. \(1998\). )]TJ /TT5 1 Tf 10.926 0 TD -0.0045 Tc 0.0672 Tw [(The Assaulted )-16.2(S)31.5(taff Action )-16.7(Pr)28.5(o-)]TJ -9.726 -1.398 TD -0.0061 Tc 0.08 Tw (gram \(ASAP\))Tj /TT2 1 Tf 5.379 0 TD -0.0038 Tc 0 Tw (: )Tj /TT5 1 Tf 0.612 0 TD -0.0041 Tc 0.0828 Tw (Coping with the psychological aftermath)Tj -5.991 -1.401 TD -0.0036 Tc -0.045 Tw (of violence.)Tj /TT2 1 Tf 4.524 0 TD -0.0481 Tw [( Ellicott City)62.4(, MD: Chevron Publishing )-6.1(Corp.)]TJ -5.724 -1.8 TD -0.0056 Tc -0.0624 Tw [(Flannery)60.4(, R.B., Jr)48.4(. \(2001a\). 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Underreporting)]TJ 1.2 -1.401 TD -0.0031 Tc -0.0367 Tw (of assaults on staff in a state hospital. )Tj /TT5 1 Tf 14.979 0 TD -0.0044 Tc -0.0375 Tw (Hospital and Com-)Tj -14.979 -1.401 TD -0.0052 Tc -0.0599 Tw [(munity Psychiatr)-5.2(y)54.6(,)-0.2( 32)]TJ /TT2 1 Tf 8.475 0 TD -0.0651 Tw (, 497-498)Tj /TT5 1 Tf 3.726 0 TD 0 Tc 0 Tw (.)Tj /TT2 1 Tf -13.401 -1.8 TD -0.0122 Tc -0.0623 Tw [(Lowoko, S., Soares, J.F)71.8(., & Nolan, P)107.8(.)-0.8( \(2004\). )18(V)65(iolence toward)]TJ 1.2 -1.398 TD -0.0034 Tc 0.0238 Tw [(psychiatric staf)17.6(f: )53.6(A)58.8( comparison )-6.4(of gender)38.6(, job, and envi-)]TJ 0 -1.401 TD -0.0036 Tc 0.0185 Tw (ronmental characteristics in England and Sweden. )Tj /TT5 1 Tf 20.445 0 TD -0.0065 Tc 0 Tw [(W)91.5(ork)]TJ -20.445 -1.401 TD -0.0039 Tc -0.0511 Tw [(and Stress, )8.5(18,)]TJ /TT2 1 Tf 5.724 0 TD -0.0037 Tc -0.06 Tw [( 39-55.)]TJ -6.924 -1.8 TD -0.0084 Tc -0.0622 Tw [(Owens, C., )15.6(T)74.4(arantello, B.A., Jones, M., & )15.6(T)71.4(ennant, C. \(1998\).)]TJ 1.2 -1.398 TD -0.0029 Tc 0.007 Tw (Repetitively violent patients in psychiatric units. )Tj /TT5 1 Tf 19.53 0 TD -0.0048 Tc 0 Tw (Psychi-)Tj -19.53 -1.401 TD -0.008 Tc -0.0616 Tw (atric Services, 49, )Tj /TT2 1 Tf 7.131 0 TD -0.0099 Tc 0 Tw (1458-1461.)Tj /TT5 1 Tf 9 0 0 9 408 444.99 Tm -0.0052 Tc 0.0236 Tw (Manuscript submitted March 23, 2008)Tj 0.3333 -1.7767 TD -0.005 Tc -0.0055 Tw (Manuscript accepted August 14, 2008)Tj ET endstream endobj 113 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT2 9 0 R /TT3 10 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 115 0 obj << /Length 6915 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 66 59.745 m 558 59.745 l S BT /TT3 1 Tf 8 0 0 8 423.24 42.6 Tm 0 0 0 1 k /GS2 gs -0.0051 Tc 0.0326 Tw [(IJEMH Vol. 10, No. 3 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (185)Tj /TT3 1 Tf 7 0 0 7 120.66 726.66 Tm -0.0061 Tc 0.021 Tw [(International Journal of Emergency Mental Health, Vol. 10, No. 3, pp. 185-190 2008 Chevron Publishing ISSN 1522-4821)]TJ /TT4 1 Tf 10 0 0 10 102.99 501.36 Tm -0.0043 Tc 0 Tw (Abstract: )Tj /TT5 1 Tf 4.032 0 TD -0.0036 Tc 0.0447 Tw (Resiliency has emerged as a critical construct in areas as far ranging as child development to)Tj -4.032 -1.302 TD 0.1221 Tw [(disaster mental health. Resiliency may be thought of as the ability to rebound, or bounce back, from)]TJ 0 -1.299 TD -0.004 Tc 0.0586 Tw [(adversity \(Kaminsky)50(, McCabe, Langlieb, & Everly)53(, 2007\). Numer)32(ous interventions have been postulated)]TJ T* -0.0035 Tc 0.0542 Tw [(and/or shown to enhance r)29.5(esiliency)53.5(, e.g., journaling, social suppor)-6.5(t, psychological first aid, and formal)]TJ 0 -1.302 TD 0.0546 Tw (crisis intervention systems, such as Critical Incident Stress Management. As the search to develop more)Tj 0 -1.299 TD 0.0254 Tw (efficient and effective resiliency enhancement interventions continues, it becomes important to search for)Tj T* -0.0212 Tw [(the mechanisms of action that actually serve to account for the ability to r)32.5(ebound after adversity)50.5(. One such)]TJ 0 -1.302 TD 0 Tc 0.125 Tw [(postulated mechanism is that of positive emotionality)48(. 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Correlational analyses revealed that expressed positive emotions,)Tj T* 0.0111 Tc 0.125 Tw (as well as expressed negative emotions, were related to the outcome variables in a significant but)Tj 0 -1.302 TD -0.0038 Tc 0.004 Tw [(complementar)-6.8(y manner)107.2(. [International Journal of Emer)32.2(gency Mental Health, 2008, 10\(3\), pp. 185-190].)]TJ /TT1 1 Tf 9 0 0 9 172.89 272.01 Tm -0.0054 Tc -0.0194 Tw (Key words: )Tj /TT5 1 Tf 5.0733 0 TD -0.0048 Tc -0.0222 Tw (Resilience, positive emotions, psychological first aid, crisis intervention.)Tj ET /GS1 gs 65.49 144.765 m 557.49 144.765 l S BT 9 0 0 9 65.49 126.99 Tm /GS2 gs -0.0047 Tc 0.0728 Tw (Author notes: This research was supported in part by the American Institute of Certified Public Accountants and funding to The )Tj 52.3525 0 TD 0 Tw (Johns)Tj -52.3525 -1.22 TD -0.0098 Tw [(Hopkins Center for Public Health Pr)35.3(epar)32(edness fr)32(om The U.S. Centers for Disease Contr)35.3(ol and Pr)35.3(evention. Geor)35.3(ge S. Everly)52(, PhD, )]TJ 52.2467 0 TD -0.0067 Tc 0 Tw (ABPP)Tj -52.2467 -1.2233 TD -0.0047 Tc 0.0522 Tw (is affiliated with Johns Hopkins Center for Public Health Preparedness, Johns Hopkins School of Medicine and serves on the facu)Tj 52.6106 0 TD (lty of)Tj -52.6106 -1.2233 TD 0.0241 Tw [(Loyola College in Maryland. Kenneth J. Smith, DBA, CP)122(A, CMA)12( serves in the Department of )15.3(Accounting and Legal S)28.6(tudies at Salisb)]TJ 53.3427 0 TD -0.0052 Tc 0 Tw [(ur)-8.5(y)]TJ -53.3427 -1.22 TD -0.005 Tc 0.0346 Tw [(University in Salisbur)-5(y)55.5(,)-0.8( Mar)-5(yland. V)68.3(ictor W)81.7(elzant, PsyD is T)51.7(raining and Education Dir)31.7(ector of the International Critical Incid)]TJ 50.8933 0 TD -0.0061 Tc 0.0358 Tw [(ent S)27.2(t)4.2(r)33.9(ess)]TJ -50.8933 -1.2233 TD -0.0051 Tc -0.0081 Tw [(Foundation in Ellioctt City)48.2(, Mar)-5.1(yland. Cor)-5.1(r)37.4(espondence r)34.9(egar)31.6(ding this article should be dir)34.9(ected to geverly@jhsph.edu.)]TJ /F1 1 Tf 14 0 0 14 135.15 656.34 Tm 0.0035 Tc 0.1375 Tw (Cognitive-Affective Resilience Indicia as Predictors)Tj 3.375 -1.1421 TD 0.0011 Tc [(of Burnout and)-7.5( Job-Related Outcome)]TJ /TT2 1 Tf 10 0 0 10 84.99 239.64 Tm -0.0034 Tc 0.0933 Tw (The experience of positive emotional granularity and)Tj -1.8 -1.398 TD -0.0024 Tc 0.125 Tw (the avoidance of negative affect have been posited to be)Tj 0 -1.401 TD -0.0029 Tc 0.0508 Tw [(essential elements in human resiliency)60.1(. Resiliency may be)]TJ T* -0.0032 Tc 0.0475 Tw (thought of as the ability to bounce back, or rebound, from)Tj 0 -1.398 TD -0.0129 Tc -0.0623 Tw [(adversity \(Kaminsky)62.1(, et al., 2007; Nucifora, Langlieb, Siegel,)]TJ 0 -1.401 TD -0.0185 Tc -0.0626 Tw [(Everly)59.5(, & Kaminsky)62.5(, 2007\). Kaminsky and colleagues \(2007\))]TJ T* -0.0035 Tc 0.0914 Tw (have formulated a tripartite model that deconstructs resil-)Tj 12 0 0 12 406.14 540.66 Tm -0.0275 Tc -0.0725 Tw [(V)59.7(ictor W)83.9(elzant)]TJ 10 0 0 10 342.39 528 Tm 0.0013 Tc 0.0087 Tw (International Critical Incident Stress Foundation)Tj 12 0 0 12 264.66 610.65 Tm -0.0138 Tc -0.0605 Tw [(Geor)8.7(ge S. Everly)56.2(, Jr)48.7(.)]TJ 10 0 0 10 202.41 597.99 Tm 0.0011 Tc 0.0041 Tw (Johns Hopkins Center for Public Health Preparedness,)Tj 2.85 -1.2 TD 0.018 Tw (Johns Hopkins School of Medicine, and)Tj 2.433 -1.2 TD 0.0021 Tc -0.0534 Tw (Loyola College in Maryland)Tj 12 0 0 12 145.89 541.65 Tm -0.0239 Tc -0.0604 Tw (Kenneth J. Smith)Tj 10 0 0 10 143.25 528.99 Tm 0.0024 Tc -0.045 Tw (Salisbury University)Tj 17.775 -28.983 TD -0.0022 Tc 0.0125 Tw (iency into )Tj /TT5 1 Tf 4.224 0 TD -0.0045 Tc 0 Tw (resistance)Tj /TT2 1 Tf 4.017 0 TD -0.0034 Tc 0.015 Tw [( \(protective factors\) and )]TJ /TT5 1 Tf 9.804 0 TD -0.0042 Tc 0 Tw (resilience)Tj /TT2 1 Tf 3.849 0 TD -0.0034 Tc 0.015 Tw [( \(the)]TJ -21.894 -1.401 TD 0.001 Tc 0.125 Tw (ability to rebound from adversity\). These authors believe)Tj T* -0.0032 Tc -0.0078 Tw [(that self-ef)14.8(ficacy \(Bandura, 1997\) serves to build immunity)62.8(,)]TJ 0 -1.398 TD -0.0034 Tc -0.0135 Tw (while interpersonal and organizational support, such as psy-)Tj 0 -1.401 TD -0.0043 Tc -0.0621 Tw [(chological first aid \(PF)70.7(A\) and comprehensive crisis interven-)]TJ T* 0.0194 Tc 0.125 Tw (tion systems such Critical Incident Stress Management)Tj 0 -1.398 TD -0.0034 Tc -0.0511 Tw (\(CISM; Everly & Mitchell, 1999, 2008\) serve to enhance the)Tj ET endstream endobj 116 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT1 8 0 R /TT2 9 0 R /TT3 10 0 R /TT4 20 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 119 0 obj << /Length 8612 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 54 59.745 m 546 59.745 l S BT /F1 1 Tf 8 0 0 8 54 41.49 Tm 0 0 0 1 k /GS2 gs -0.0051 Tc 0.0895 Tw [(186 )]TJ /TT3 1 Tf 2.745 0 TD -0.0054 Tc 0.0911 Tw (Everly, Smith and Welzant Cognitive-Affective Resilience Indicia)Tj /TT2 1 Tf 10 0 0 10 54 722.64 Tm -0.003 Tc -0.0033 Tw [(ability to rebound. )51(As we search for ways in which to build)]TJ 0 -1.398 TD -0.0031 Tc 0.0513 Tw (protective immunity and to enhance the ability to rebound,)Tj 0 -1.401 TD -0.0038 Tc 0.0007 Tw (an understanding of respective mechanisms of action seems)Tj T* -0.0035 Tc 0.0687 Tw (critical. One such postulated mechanism is that of positive)Tj 0 -1.398 TD -0.003 Tc -0.0318 Tw [(emotionality)60(. Positive emotionality may be thought of as the)]TJ 0 -1.401 TD -0.0032 Tc -0.0173 Tw (presence of ambient positive emotions, as well as the ability)Tj T* -0.0033 Tc -0.0009 Tw [(to express positive emotions in the wake of adversity)62.7(. Con-)]TJ 0 -1.398 TD -0.0032 Tc 0.01 Tw (structs such as confidence, optimism, and the ability to find)Tj 0 -1.401 TD -0.0054 Tc -0.0622 Tw (meaning may underlie such expressions. One popular formu-)Tj T* -0.0035 Tc -0.0245 Tw (lation within which an understanding of the useful effects of)Tj 0 -1.398 TD -0.0037 Tc 0.0235 Tw (positive emotions may be found is the broaden-and-build)Tj 0 -1.401 TD -0.0034 Tc -0.0064 Tw (theory of positive emotions \(Fredrickson, 1998, 2001\). This)Tj T* -0.0033 Tc -0.0272 Tw (theory argues that negative emotions narrow the momentary)Tj 0 -1.398 TD -0.0038 Tc 0.0025 Tw (thoughtaction repertoire of the individual, whereas posi-)Tj 0 -1.401 TD 0.0833 Tw [(tive emotions broaden one)50.2(s thoughtaction repertoire, ex-)]TJ T* -0.0036 Tc 0.0245 Tw (panding the range of cognitions and behaviors that are then)Tj 0 -1.398 TD 0.0105 Tc 0.125 Tw (available. These broadened cognitive-behavioral options)Tj 0 -1.401 TD -0.0031 Tc -0.041 Tw [(serve to build the individual)53.9(s psychophysiological, intellec-)]TJ T* 0.0668 Tw (tual, and social resources that then may be operationalized)Tj 0 -1.398 TD -0.0026 Tc -0.025 Tw [(as resiliency)60.4(.)]TJ 1.8 -2.001 TD 0.0027 Tc 0.125 Tw (In a series of three studies designed to more closely)Tj -1.8 -1.401 TD 0.0283 Tc (examine the effects of positive emotions, Tugade and)Tj 0 -1.398 TD -0.0037 Tc 0.0333 Tw (Fredrickson \(2004\) generated findings indicating that those)Tj 0 -1.401 TD -0.005 Tc -0.0625 Tw (demonstrating positive emotions were able to achieve a more)Tj T* -0.0036 Tc -0.0078 Tw [(rapid emotional regulation as evidenced by increased car-)]TJ 0 -1.398 TD -0.0033 Tc -0.0036 Tw (diovascular recovery and by finding some positive meaning)Tj 0 -1.401 TD -0.0037 Tc 0.0528 Tw (in negative circumstances. In another investigation of 46)Tj T* 0.05 Tw [(college students, Fredrickson, )14.3(T)37.1(ugade, )17.3(W)97.1(augh, and Clarkin)]TJ 0 -1.398 TD -0.0036 Tc -0.01 Tw (\(2003\) found that positive emotions served to buffer against)Tj 0 -1.401 TD 0.0183 Tw (depression in the wake of the terrorist attacks of September)Tj T* -0.0394 Tc -0.06 Tw (11, 2001.)Tj 1.8 -1.998 TD -0.0033 Tc -0.0072 Tw (If positive emotionality can indeed build resistance and)Tj -1.8 -1.401 TD -0.0034 Tc 0.125 Tw (enhance resilience, then it seems it would be an effective)Tj T* -0.0035 Tc -0.03 Tw [(pillar upon which PF)71.5(A)58.7( and integrative disaster response sys-)]TJ 0 -1.398 TD -0.0033 Tc 0.0683 Tw [(tems could be constructed. This study attempted to assess)]TJ 0 -1.401 TD -0.0038 Tc -0.0464 Tw (the relationship between the expression of ambient emotions)Tj T* -0.0036 Tc 0.0428 Tw (\(within the last few weeks\) upon measures of practical and)Tj 0 -1.398 TD -0.0031 Tc -0.0521 Tw (highly meaningful outcome: burnout, i.e., physical and men-)Tj 0 -1.401 TD -0.0035 Tc 0.0916 Tw (tal exhaustion \(Maslach, 1982\), job satisfaction, perceived)Tj T* -0.0034 Tc 0.0127 Tw [(performance on the job, and intention to leave one)53.6(s job.)]TJ /F1 1 Tf 11 0 0 11 144.39 132 Tm 0.0189 Tc 0 Tw (METHODS)Tj -8.2173 -1.4536 TD -0.0053 Tc 0.0591 Tw (Subjects and Procedure)Tj /TT2 1 Tf 10 0 0 10 72 92.64 Tm -0.0033 Tc 0.0381 Tw (Subjects were selected from a mailing list provided by)Tj -1.8 -1.398 TD 0.022 Tc 0.1253 Tw [(the )46.3(American Institute of Certified Public )52.3(Accountants)]TJ 25.5 64.398 TD -0.0039 Tc -0.0454 Tw [(\(AICP)86.1(A\). )53.3(A)58.3( randomized sample of 2,500 members out of the)]TJ 0 -1.398 TD -0.0047 Tc -0.062 Tw (approximately 91,333 Institute members currently employed)Tj 0 -1.401 TD 0.002 Tc 0.125 Tw (in public accounting were sent the measures used in this)Tj T* -0.003 Tc 0.1171 Tw [(study)63(.)0.1( Four hundred eighty-nine and four hundred ninety-)]TJ 0 -1.398 TD -0.0037 Tc 0.0086 Tw (one usable responses were received within a pre-designated)Tj 0 -1.401 TD -0.0033 Tc 0.0512 Tw [(eight week response period for inclusion in the study)59.7(.)]TJ 5.8 0 0 5.8 524.85 656.01 Tm 0 Tc 0 Tw (1)Tj 10 0 0 10 527.76 652.65 Tm -0.0078 Tc 0.0428 Tw [( The)]TJ -21.876 -1.401 TD -0.0031 Tc 0.0393 Tw (early-late hypothesis was used to assess non-response bias.)Tj 0 -1.398 TD 0.0077 Tc 0.125 Tw (Independent sample t-tests were conducted to assess the)Tj 0 -1.401 TD -0.0035 Tc 0.045 Tw (significance of mean score differences between the first 50)Tj T* 0.0072 Tc 0.125 Tw (respondents and the final 50 respondents on each of the)Tj 0 -1.398 TD -0.0037 Tc 0.0283 Tw (scales administered. No significant non-response bias asso-)Tj 0 -1.401 TD -0.0031 Tc 0.0175 Tw (ciated with the study emerged.)Tj 1.8 -2.001 TD -0.0036 Tc 0.0912 Tw (Of the initial respondents, 58% were male; 59% indi-)Tj -1.8 -1.398 TD -0.0028 Tc 0 Tw (cated that they were between 26 and 45 years old.)Tj /F1 1 Tf 11 0 0 11 309 501.99 Tm -0.0064 Tc (Measures)Tj /TT2 1 Tf 10 0 0 10 327 478.65 Tm -0.0041 Tc -0.01 Tw (The two predictor scales were designated DISCORD13)Tj -1.8 -1.401 TD -0.02 Tc -0.0622 Tw [(and POSITIVE PERCEPTION. These scales were empirically)]TJ 0 -1.398 TD -0.0037 Tc 0.0594 Tw [(derived from the S)14.3(tress )53.3(Arousal Scale \(SAS\) developed by)]TJ 0 -1.401 TD -0.0036 Tc 0.0285 Tw [(Everly)62.4(, Sherman, and Smith \(1989\). )14.1(The original SAS con-)]TJ T* -0.0037 Tc 0.1206 Tw [(tains 20 items designed to tap the respondent)50.3(s cognitive-)]TJ 0 -1.398 TD 0.0594 Tc 0.4858 Tw (affective domain, i.e., the precipitators of the)Tj 0 -1.401 TD 0.0035 Tc 0.125 Tw (psychophysiological stress response, thereby allowing an)Tj T* 0.0051 Tc [(indirect assessment of one)56.1(s level of stress arousal.)]TJ 5.8 0 0 5.8 523.8 384 Tm 0 Tc 0 Tw (2)Tj 10 0 0 10 526.74 380.64 Tm 0.0027 Tc 0.1133 Tw [( The)]TJ -21.774 -1.398 TD -0.0036 Tc 0.1068 Tw [(conditions that define emotional arousal \(as measured on)]TJ 0 -1.401 TD -0.0031 Tc 0.0829 Tw (the SAS\) are highly correlated with stress-related physical)Tj T* -0.003 Tc 0.0711 Tw [(symptoms \(Smith, Everly)63(, & Johns, 1993; Smith, Davy)63(, &)]TJ 0 -1.398 TD -0.0153 Tc -0.062 Tw (Stewart, 1998; Everly & Sobelman, 1987\).)Tj 1.8 -2.001 TD -0.0037 Tc 0.0811 Tw (The SAS has been utilized in a number of accounting)Tj -1.8 -1.401 TD -0.0114 Tc -0.0622 Tw [(research studies \(e.g., see Smith, Davy)57.6(, & Everly)63.6(, 2006; Smith)]TJ 0 -1.398 TD -0.0029 Tc -0.0554 Tw [(et al., 1998; Smith, Davy)63.1(, & Everly)60.1(, 1995; Smith et al., 1993;)]TJ 0 -1.401 TD -0.0032 Tc -0.0507 Tw [(Smith & Everly)59.8(, 1990\). Factor analysis of the SAS on a lar)17.8(ge)]TJ T* -0.0029 Tc 0.125 Tw (dataset \(Smith et al., 1993\) indicated the presence of two)Tj 0 -1.398 TD -0.004 Tc 0.004 Tw (underlying dimensions, DISCORD13 \(13-items\) and POSI-)Tj 0 -1.401 TD -0.0114 Tc -0.0625 Tw [(TIVE PERCEPTION, \(4-items\). In terms of the present study)63.6(,)]TJ T* -0.0062 Tc -0.0622 Tw (the former may be defined as the state of cognitive-emotional)Tj 0 -1.398 TD -0.0034 Tc 0.0175 Tw (distress experienced as a result of interpretation of environ-)Tj 0 -1.401 TD -0.0033 Tc -0.0094 Tw (mental events, and the latter as a state of cognitive-affective)Tj T* 0.0128 Tc 0.125 Tw (and psychophysiological homeostasis predicated upon a)Tj 0 -1.398 TD -0.0084 Tc -0.0625 Tw (positive psychological assessment of current conditions. Item)Tj 0 -1.401 TD 0.0038 Tc 0.125 Tw (responses were based on instructions to respond as you)Tj T* -0.0096 Tc -0.0623 Tw (generally feel within the last few weeks and were made on 4-)Tj 0 -1.398 TD -0.0091 Tc -0.0625 Tw (point Likert type scales ranging from seldom or never \(1\) to)Tj 0 -1.401 TD -0.0051 Tc (almost always \(4\).)Tj ET endstream endobj 120 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT2 9 0 R /TT3 10 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 122 0 obj << /Length 6722 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 66 59.745 m 558 59.745 l S BT /TT3 1 Tf 8 0 0 8 423.24 42.6 Tm 0 0 0 1 k /GS2 gs -0.0051 Tc 0.0326 Tw [(IJEMH Vol. 10, No. 3 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (187)Tj /TT2 1 Tf 10 0 0 10 84 722.64 Tm -0.0039 Tc 0.024 Tw [(Outcome variables were assessed as follows:)]TJ -0.6 -1.998 TD -0.0122 Tc -0.0621 Tw [(1)62.8(.)-1137.2(Performance: a six-item scale drawn from Dubinski &)]TJ 1.8 -1.401 TD -0.0044 Tc -0.035 Tw (Mattson \(1979\);)Tj -1.8 -2.001 TD -0.0137 Tc -0.0625 Tw [(2)61.3(.)-1138.7(Turnover intentions: three items drawn from Donnelly)]TJ 1.8 -1.398 TD -0.0108 Tc (& Ivancevich \(1975\).)Tj -1.8 -2.001 TD -0.0037 Tc -0.0317 Tw [(3)71.3(.)-1128.7(Job Satisfaction: 27-items drawn from the Churchill,)]TJ 1.8 -1.401 TD -0.0088 Tc -0.0622 Tw [(Ford, Hartley)60.2(, & )15(W)95(alker \(1985\) scale.)]TJ -1.8 -1.998 TD -0.004 Tc 0.0375 Tw [(4)71(.)-1129(Burnout was measured via the 24-item multidimen-)]TJ 1.8 -1.401 TD -0.0038 Tc 0.0008 Tw (sional role-specific \(MROB\) version of the Maslach)Tj T* 0.0045 Tc 0.125 Tw (Burnout Inventory \(MBI\) as developed by Singh,)Tj 0 -1.398 TD -0.0078 Tc -0.0618 Tw [(Goolsby)61.2(, & Rhoads \(1994\).)]TJ -1.2 -2.001 TD -0.0039 Tc 0.105 Tw (Each of these outcome measures was measured using)Tj -1.8 -1.401 TD -0.0072 Tc -0.06 Tw (five-point Likert-scales.)Tj /F1 1 Tf 11 0 0 11 66 492 Tm -0.0039 Tc 0 Tw (Analyses)Tj /TT2 1 Tf 10 0 0 10 84 468.66 Tm 0.0315 Tc 0.125 Tw (The primary analyses used within the study were)Tj -1.8 -1.401 TD 0.0078 Tc (Pearson Product-Moment correlations, subsequent to the)Tj T* -0.0036 Tc 0.0044 Tw [(employment of the Cronbach )53.4(Alpha as an assessment of the)]TJ 0 -1.398 TD -0.0031 Tc 0.053 Tw (internal consistency of the predictor scales.)Tj /F1 1 Tf 11 0 0 11 158.64 393.99 Tm 0.0198 Tc 0 Tw [(RESUL)82.5(TS)]TJ /TT2 1 Tf 10 0 0 10 84 370.65 Tm -0.0038 Tc -0.0619 Tw [(T)73(able 1 lists the Cronbach )50.4(Alpha correlation coef)17.2(ficients)]TJ -1.8 -1.401 TD -0.0033 Tc 0.055 Tw [(as measures of internal consistency)59.7(.)]TJ 1.8 -1.998 TD -0.0278 Tw (As a Cronbach alpha of .70 is generally deemed accept-)Tj -1.8 -1.401 TD -0.0215 Tc -0.0625 Tw (able, the alphas for the DISCORD13 and POSITIVE PERCEP-)Tj T* -0.0033 Tc -0.0417 Tw (TION scales may be considered acceptable. The fact that the)Tj 0 -1.398 TD -0.0235 Tc -0.0622 Tw (4-item POSITIVE PERCEPTION SCALE is comparable to the)Tj 0 -1.401 TD -0.0036 Tc -0.0416 Tw (13-item DISCORD13 scale is also worthy of mention, as the)Tj T* -0.0034 Tc 0.0495 Tw (alpha will be seen to increase as the number of scale items)Tj 0 -1.398 TD 0.0067 Tc 0 Tw (increases.)Tj 1.8 -2.001 TD -0.0014 Tc 0.125 Tw [(T)75.4(able 2 reports the correlations for the variable DIS-)]TJ -1.8 -1.401 TD -0.0037 Tc -0.0482 Tw (CORD13 as a predictor of the designated outcome variables.)Tj 0 -1.398 TD -0.0033 Tc -0.023 Tw [(T)73.5(able 3 reports the levels of significance. )14.7(T)73.5(able 4 reports the)]TJ 0 -1.401 TD -0.0041 Tc 0.0086 Tw (correlations for the variable POSITIVE PERCEPTION as a)Tj T* -0.0037 Tc 0.0388 Tw [(predictor of the designated outcome variables. )50.4(And )17.4(T)73.1(able 5)]TJ 0 -1.398 TD -0.0035 Tc 0.0317 Tw (reports the significance levels.)Tj /F1 1 Tf 11 0 0 11 149.25 129.99 Tm 0.0207 Tc 0 Tw (DISCUSSION)Tj /TT2 1 Tf 10 0 0 10 84 106.65 Tm -0.0034 Tc 0.045 Tw (This study supports the work of previous theorists and)Tj -1.8 -1.401 TD -0.0036 Tc 0.1 Tw (empiricists alike who have for decades concluded that the)Tj /TT3 1 Tf 34.866 62.235 TD -0.0055 Tc -0.05 Tw (Table 1.)Tj -4.617 -1.2 TD -0.0005 Tc -0.0633 Tw (Cronbach Alpha measures of)Tj 1.992 -1.2 TD 0.0001 Tc -0.01 Tw (internal consistency)Tj 10.335 -1.2 TD -0.0136 Tc 0 Tw (ALPHA)Tj -15.126 -1.2 TD -0.0311 Tc [(DISCORD13)-11557.1(.)-11(9)-11(1)]TJ T* 0.0054 Tc [(POSITIVE)-12345.6(.)25.5(8)25.5(8)]TJ 7.44 -3.75 TD -0.0055 Tc -0.05 Tw (Table 2.)Tj -7.275 -1.2 TD -0.0047 Tc -0.0308 Tw [( Pearson correlation matrix for 13 Discord)]TJ 1.761 -1.2 TD -0.0048 Tc 0.0149 Tw [(Items center table in this column)]TJ 11.049 -1.2 TD -0.0311 Tc 0 Tw (DISCORD13)Tj -13.026 -1.2 TD -0.0291 Tc [(DISCORD13)-10655.1(1.000)]TJ T* -0.023 Tc [(Burnout)-12749(0.532)]TJ T* 0.0005 Tc (Satisfaction)Tj 15.801 0 TD -0.0271 Tc (-0.348)Tj -15.801 -1.2 TD -0.0175 Tc (Performance)Tj 15.801 0 TD -0.0271 Tc (-0.170)Tj -15.801 -1.2 TD -0.0254 Tc [(Turnover)-12301.4(0.449)]TJ 7.467 -3.249 TD -0.0055 Tc -0.05 Tw (Table 3.)Tj -6.192 -1.2 TD -0.0044 Tc -0.021 Tw [( Matrix of Bonferroni Probabilities for)]TJ 4.242 -1.2 TD -0.0052 Tc 0 Tw (13 Discord Items)Tj 7.41 -1.2 TD -0.0311 Tc (DISCORD13)Tj -12.876 -1.2 TD -0.0293 Tc [(DISCORD13)-9980.3(0.0001)]TJ T* -0.0237 Tc [(Burnout)-12074.7(0.0001)]TJ T* 0.0005 Tc (Satisfaction)Tj 15.426 0 TD -0.0267 Tc (0.0001)Tj -15.426 -1.2 TD -0.0175 Tc (Performance)Tj 15.951 0 TD -0.0256 Tc (0.002)Tj -15.951 -1.2 TD -0.0258 Tc [(Turnover)-11626.8(0.0001)]TJ T* -0.0051 Tc -0.0388 Tw [( Number of observations: 491)]TJ 7.539 -2.649 TD -0.0055 Tc -0.05 Tw (Table 4.)Tj -7.125 -1.2 TD -0.0046 Tc -0.0075 Tw [( Pearson correlation matrix for 4 Positive)]TJ 5.175 -1.2 TD -0.0052 Tc 0 Tw (Perception Items)Tj 8.31 -1.2 TD 0.0054 Tc (POSITIVE)Tj -13.848 -1.2 TD (POSITIVE)Tj 16.098 0 TD -0.0256 Tc (1.000)Tj -16.098 -1.2 TD -0.0239 Tc [(Burnout)-12446.9(-0.486)]TJ T* 0.0005 Tc (Satisfaction)Tj 16.098 0 TD -0.0256 Tc (0.368)Tj -16.098 -1.2 TD -0.0175 Tc (Performance)Tj 16.098 0 TD -0.0256 Tc (0.227)Tj -16.098 -1.2 TD -0.026 Tc [(Turnover)-11999(-0.371)]TJ 7.413 -4.002 TD -0.0055 Tc -0.05 Tw (Table 5.)Tj -6.45 -1.2 TD -0.0045 Tc -0.026 Tw (Matrix of Bonferroni Probabilities for 4)Tj 2.586 -1.2 TD -0.0049 Tc 0.0425 Tw (Positive Perception Items)Tj 9.951 -1.2 TD 0.0054 Tc 0 Tw (POSITIVE)Tj -13.302 -1.2 TD (POSITIVE)Tj 15.027 0 TD -0.0267 Tc (0.0001)Tj -15.027 -1.2 TD -0.0237 Tc [(Burnout)-11675.7(0.0001)]TJ T* 0.0005 Tc (Satisfaction)Tj 15.027 0 TD -0.0267 Tc (0.0001)Tj -15.027 -1.2 TD -0.0175 Tc (Performance)Tj 15.027 0 TD -0.0267 Tc (0.0001)Tj -15.027 -1.2 TD -0.0258 Tc [(Turnover)-11227.8(0.0001)]TJ T* -0.0051 Tc -0.0388 Tw [( Number of observations: 489)]TJ ET 0.99 w 1000 M /GS1 gs 321.495 730.505 237.01 -83.51 re S 10 M 321 689.505 m 558.99 689.505 l 435.495 689.01 m 435.495 647.01 l S 1000 M 322.495 230.505 236.01 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129.936 631.047 130.509 632.572 130.509 633.631 c f* 134.477 632.121 m 134.463 632.121 l 131.951 636.085 l 131.146 636.085 l 131.146 631.178 l 131.804 631.178 l 131.804 635.142 l 131.818 635.142 l 134.372 631.178 l 135.135 631.178 l 135.135 636.085 l 134.477 636.085 l 134.477 632.121 l f* q 1.0119 0 0 0.9883 0 0 cm 0.137 0.122 0.125 RG 0.291 w 2.613 M 110.561 710.589 m 114.084 710.589 l 114.082 706.975 l 116.999 708.877 l 118.68 706.139 l 115.559 704.322 l 118.703 702.54 l 117.087 699.735 l 114.061 701.488 l 114.061 697.8 l 110.574 697.8 l 110.573 701.406 l 107.486 699.628 l 105.87 702.558 l 108.923 704.297 l 105.813 706.117 l 107.426 708.839 l 110.561 706.974 l 110.561 710.589 l b* Q 1 1 1 rg 114.057 700.685 m 113.633 701.414 113.264 700.675 y 113.622 691.332 l 113.756 691.071 113.813 691.358 y 114.057 700.685 l f* q 1.0119 0 0 0.9883 0 0 cm 0.137 0.122 0.125 RG 0.145 w 2.613 M 112.046 705.986 m 111.807 706.135 111.695 706.264 y 111.087 706.913 111.076 707.411 y 111.059 707.846 111.21 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172.589 651.356 l 169.869 649.03 l 171.05 645.315 l 168.304 647.703 l 165.459 645.315 l f* q 1.0119 0 0 0.9883 0 0 cm 0.137 0.122 0.125 rg 0.137 0.122 0.125 RG 1 j 0.291 w 2.613 M 52.047 660.292 m 51.7 660.219 51.515 660.197 51.298 659.76 c 51.22 659.601 51.138 659.422 51.031 659.277 c 50.603 658.649 50.684 657.9 50.736 657.224 c 50.79 657.127 50.844 656.994 50.844 656.886 c 50.844 656.741 50.993 656.648 51.031 656.499 c 51.111 656.186 51.378 656.065 51.539 655.823 c 51.646 655.727 52.02 655.461 52.02 655.509 c 52.02 656.138 51.833 656.804 51.7 657.321 c 51.512 658.045 51.753 658.746 51.913 659.518 c 52.02 659.808 51.994 660.001 52.047 660.292 c b* Q q 1.0119 0 0 0.9883 0 0 cm 0.137 0.122 0.125 rg 0.137 0.122 0.125 RG 1 j 0.291 w 2.613 M 55.069 652.998 m 55.165 652.687 55.18 652.413 55.675 652.238 c 55.854 652.174 56.056 652.109 56.222 652.02 c 56.936 651.663 57.76 651.769 58.505 651.85 c 58.61 651.903 58.755 651.956 58.875 651.962 c 59.035 651.968 59.13 652.107 59.293 652.148 c 59.637 652.236 59.758 652.482 60.018 652.639 c 60.12 652.74 60.396 653.09 60.342 653.087 c 59.647 653.058 58.92 652.858 58.354 652.714 c 57.561 652.511 56.775 652.695 55.913 652.804 c 55.587 652.887 55.393 652.963 55.069 652.998 c b* Q q 1.0119 0 0 0.9883 0 0 cm 0.137 0.122 0.125 rg 0.137 0.122 0.125 RG 1 j 0.291 w 2.613 M 63.253 655.751 m 63.594 655.843 63.778 655.876 63.962 656.325 c 64.03 656.488 64.098 656.671 64.195 656.822 c 64.578 657.473 64.558 658.23 64.456 658.902 c 64.396 658.995 64.343 659.157 64.335 659.265 c 64.309 659.637 64.018 659.919 64.055 659.808 c 63.952 660.117 63.791 660.047 63.614 660.279 c 63.5 660.369 63.249 660.544 63.253 660.497 c 63.297 659.87 63.363 659.302 63.534 658.794 c 63.772 658.082 63.437 657.31 63.331 656.53 c 63.245 656.234 63.285 656.043 63.253 655.751 c b* Q q 1.0119 0 0 0.9883 0 0 cm 0.137 0.122 0.125 rg 0.137 0.122 0.125 RG 1 j 0.291 w 2.613 M 60.37 662.863 m 60.29 663.176 60.266 663.343 59.783 663.539 c 59.607 663.61 59.408 663.684 59.248 663.781 c 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665.127 52.447 665.02 c 52.374 664.982 52.418 665.181 52.447 665.02 c 54.474 662.02 l 54.606 662.081 54.33 661.933 54.474 662.02 c 54.997 662.232 55.8 662.685 56.365 662.755 c 56.978 662.87 57.631 662.844 58.238 662.772 c 58.284 662.77 59.225 662.615 59.27 662.601 c 59.843 662.424 59.738 662.368 60.449 662.017 c b* Q q 1.0119 0 0 0.9883 0 0 cm 0.137 0.122 0.125 rg 0.137 0.122 0.125 RG 1 j 0.291 w 2.613 M 54.751 654.005 m 52.663 651.273 l 52.884 651.035 53.161 651.31 54.072 650.868 c 54.418 650.702 55.252 650.697 55.654 650.54 c 55.727 650.541 55.582 650.58 55.654 650.54 c 55.837 650.502 56.641 650.149 56.822 650.191 c 56.822 650.151 56.822 650.191 y 57.333 650.075 57.806 650.08 58.315 650.124 c 58.696 650.145 58.78 650.23 60.061 650.548 c 60.387 650.63 61.237 650.943 61.599 651.026 c 61.927 651.109 62.6 651.278 62.891 651.4 c 62.963 651.441 62.928 651.241 62.891 651.4 c 60.718 654.297 l 60.59 654.229 60.857 654.39 60.718 654.297 c 60.206 654.059 59.427 653.568 58.866 653.47 c 58.26 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648.984 55.447 649.536 55.447 649.904 c 55.4 649.858 55.921 649.444 55.873 649.398 c 56.015 649.398 56.204 649.352 56.204 649.398 c 56.582 650.134 56.393 649.766 56.677 650.64 c 56.723 650.779 56.63 651.927 56.724 652.111 c 56.773 652.157 57.34 651.294 57.34 651.192 c 57.34 650.824 57.766 652.157 57.908 651.789 c 58.05 651.514 57.576 650.547 57.814 650.363 c 58.192 650.088 58.428 650.778 58.381 651.146 c 58.57 650.409 58.334 649.858 58.144 649.49 c 57.945 649.102 57.243 649.241 56.914 648.708 c 56.773 648.478 56.773 648.156 56.63 647.926 c 56.535 647.834 56.393 647.88 56.346 647.742 c 55.258 648.616 l f* q 1.0119 0 0 0.9883 0 0 cm 1 1 1 RG 1 J 1 j 0.291 w 2.613 M 54.609 656.312 m 54.561 656.685 54.796 657.243 54.796 657.615 c 54.749 657.568 55.263 657.15 55.216 657.103 c 55.356 657.103 55.543 657.057 55.543 657.103 c 55.917 657.848 55.73 657.475 56.011 658.359 c 56.056 658.5 55.964 659.663 56.058 659.849 c 56.105 659.895 56.666 659.022 56.666 658.919 c 56.666 658.545 57.086 659.895 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106.549 610.116 107.294 610.013 c 107.952 609.908 108.61 609.753 109.268 610.013 c 109.4 610.065 109.531 610.116 109.575 610.325 c 109.609 610.484 109.751 610.481 109.838 610.429 c 110.058 610.221 110.188 609.961 110.408 609.805 c 110.715 609.545 111.022 609.441 111.373 609.284 c 111.549 609.181 111.681 609.284 111.856 609.232 c 112.044 609.226 l b Q 1 g 105.286 608.692 m 109.702 607.641 l 109.68 607.641 109.68 607.667 109.657 607.667 c 109.77 607.333 109.902 606.998 109.992 606.638 c 110.114 606.138 109.992 605.584 109.968 605.07 c 109.747 605.173 109.725 605.327 v 109.635 605.687 109.635 605.945 109.547 606.304 c 109.525 606.329 109.392 606.459 109.37 606.51 c 109.223 606.849 109.037 606.895 108.726 607.075 c 108.371 607.255 108.016 607.539 107.683 607.693 c 106.973 608.001 106.218 608.052 105.531 608.386 c 105.508 608.412 105.441 608.438 105.419 608.515 c 105.404 608.57 105.219 608.566 105.286 608.692 c f 106.374 607.821 m 106.418 607.77 106.462 607.667 106.506 607.641 c 106.707 607.539 106.906 607.564 107.107 607.564 c 107.061 607.589 107.017 607.641 106.973 607.641 c 106.729 607.641 106.574 607.718 106.374 607.821 c f 107.039 607.152 m 107.239 607.152 107.417 607.179 107.617 607.152 c 107.639 607.127 107.617 607.075 107.594 607.05 c 107.417 606.998 107.239 606.895 107.061 606.844 c 107.017 606.818 106.951 606.844 y 106.862 606.767 106.633 606.732 106.663 606.818 c 106.707 606.947 106.862 607.024 106.973 607.101 c f 107.061 606.28 m 107.128 606.28 107.195 606.253 107.261 606.304 c 107.395 606.407 107.617 606.561 107.771 606.587 c f 107.594 605.893 m 107.794 605.893 108.038 605.841 108.194 605.919 c 108.26 605.97 108.348 606.072 108.393 606.201 c 108.104 606.151 107.927 605.97 107.639 605.97 c f 108.971 605.713 m 108.926 605.713 108.881 605.739 108.837 605.713 c 108.682 605.61 108.505 605.584 108.393 605.431 c 108.348 605.353 108.348 605.251 108.348 605.173 c 108.393 605.173 108.438 605.147 108.46 605.173 c 108.571 605.379 108.77 605.431 108.881 605.61 c f 108.571 604.762 m 108.571 604.736 108.571 604.685 108.571 604.659 c 108.837 604.582 109.014 604.813 109.215 604.994 c 109.37 605.122 109.215 605.225 109.081 605.122 c 109.014 605.07 108.904 604.994 108.815 604.916 c 108.749 604.839 108.637 604.89 108.548 604.813 c 108.571 604.787 108.571 604.762 v f 109.414 604.556 m 109.525 604.556 109.547 604.685 109.635 604.736 c f 109.902 604.531 m 109.902 604.48 109.902 604.453 109.902 604.402 c 109.946 604.402 l 109.946 604.35 109.946 604.273 109.946 604.222 c f 100.98 609.544 m 101.115 609.568 101.225 609.518 101.336 609.466 c 101.358 609.466 101.403 609.414 101.447 609.389 c 101.581 609.337 101.713 609.287 101.847 609.235 c 102.268 609.106 102.712 609.131 103.111 608.901 c 103.267 608.823 103.444 608.746 103.599 608.695 c 104.021 608.591 104.398 608.591 104.821 608.515 c 104.887 608.49 104.953 608.412 105.042 608.412 c 104.598 608.438 104.154 608.361 103.689 608.438 c 103.444 608.49 103.2 608.464 102.957 608.542 c 102.89 608.566 102.867 608.643 102.8 608.67 c 102.556 608.746 102.335 608.643 102.113 608.721 c 102.024 608.746 101.913 608.746 101.825 608.798 c 101.514 608.901 101.314 609.183 101.07 609.441 c 101.048 609.466 101.092 609.518 101.048 609.544 c f 101.491 608.643 m 101.581 608.542 101.647 608.412 101.78 608.361 c 102.002 608.308 102.201 608.155 102.424 608.103 c 102.69 608.027 102.934 607.975 103.2 607.949 c 103.533 607.898 103.843 607.898 104.176 607.796 c 104.199 607.796 104.267 607.778 104.288 607.77 c 104.798 607.539 105.331 607.641 105.842 607.641 c 105.863 607.796 105.797 608.001 105.641 608.027 c 105.397 608.078 105.175 607.949 104.931 607.924 c 104.62 607.872 104.332 607.872 104.021 607.924 c 103.91 607.949 103.821 607.975 103.733 608.027 c 103.444 608.155 103.156 608.027 102.867 608.155 c 102.756 608.207 102.668 608.233 102.556 608.284 c 102.246 608.361 101.935 608.412 101.647 608.542 c f 102.556 607.383 m 103.045 607.358 103.555 607.487 104.044 607.333 c 104.132 607.307 104.199 607.179 104.31 607.152 c 104.488 607.127 104.665 607.179 104.842 607.204 c 105.219 607.281 105.597 607.179 105.974 607.255 c 105.309 606.741 104.443 606.922 103.689 606.973 c 103.511 606.973 103.377 607.127 103.222 607.152 c 103.089 607.152 102.934 607.152 102.8 607.204 c 102.734 607.23 102.69 607.281 102.624 607.307 c f 103.843 606.201 m 103.821 606.227 103.866 606.253 103.866 606.28 c 104.266 606.253 104.665 606.381 105.065 606.459 c 105.508 606.536 105.952 606.355 106.396 606.536 c 106.33 606.51 106.26 606.48 106.196 606.459 c 105.419 606.201 104.732 606.253 103.977 606.227 c f 104.709 605.482 m 104.953 605.431 105.264 605.482 105.508 605.482 c 105.819 605.532 106.145 605.46 106.462 605.532 c 106.685 605.584 106.663 605.764 106.929 606.047 c 106.596 606.022 106.44 605.996 106.041 606.022 c 105.788 606.037 105.619 605.867 105.375 605.79 c 105.175 605.739 105.175 605.841 105.02 605.713 c f 105.553 604.864 m 105.908 604.839 106.24 604.864 106.596 604.942 c 106.619 604.968 106.663 604.994 106.685 605.02 c 106.817 605.07 106.973 605.02 107.107 605.122 c 107.198 605.193 107.261 605.276 107.373 605.327 c 107.395 605.353 107.439 605.61 107.417 605.61 c 107.327 605.635 107.195 605.482 107.107 605.431 c 107.039 605.431 107.017 605.353 106.951 605.327 c 106.663 605.225 106.64 605.379 106.374 605.199 c 106.218 605.096 105.708 605.122 105.575 604.942 c f 106.528 604.298 m 106.773 604.273 106.995 604.376 107.217 604.453 c 107.417 604.531 107.639 604.633 107.816 604.813 c 107.439 604.916 107.107 604.607 106.729 604.505 c 106.685 604.505 106.574 604.428 106.596 604.324 c f 107.061 603.991 m 107.107 603.837 107.306 603.862 107.395 603.914 c 107.572 604.042 107.838 604.093 107.883 604.35 c 107.794 604.35 107.727 604.376 107.639 604.324 c 107.572 604.273 107.527 604.222 107.483 604.145 c 107.395 604.016 107.217 604.119 107.128 603.966 c f 107.86 603.579 m 108.038 603.579 108.216 603.579 108.393 603.579 c 108.371 603.785 108.438 603.991 108.571 604.145 c 108.571 604.171 108.571 604.222 108.571 604.249 c 108.46 604.298 108.371 604.171 108.282 604.093 c 108.216 604.016 108.216 603.888 108.238 603.785 c 108.127 603.785 108.016 603.734 107.949 603.631 c f 108.77 603.451 m 108.971 603.503 109.081 603.708 109.259 603.785 c f 109.281 603.477 m 109.414 603.477 109.481 603.682 109.591 603.785 c f 109.792 603.451 m 109.953 603.451 110.124 603.373 110.28 603.451 c 110.28 603.528 l 110.169 603.579 110.124 603.785 109.992 603.734 c 109.968 603.734 109.946 603.605 109.902 603.553 c 109.88 603.553 109.858 603.553 109.836 603.553 c 109.792 603.528 109.77 603.451 109.792 603.451 c f 121.276 608.687 m 116.86 607.635 l 116.882 607.635 116.882 607.661 116.904 607.661 c 116.794 607.327 116.661 606.993 116.572 606.633 c 116.449 606.134 116.572 605.579 116.594 605.066 c 116.817 605.168 116.839 605.323 v 116.927 605.682 116.927 605.94 117.016 606.299 c 117.038 606.325 117.172 606.454 117.193 606.504 c 117.339 606.844 117.527 606.89 117.837 607.071 c 118.192 607.25 118.547 607.534 118.88 607.687 c 119.589 607.996 120.344 608.048 121.033 608.381 c 121.054 608.408 121.121 608.434 121.143 608.511 c 121.159 608.565 121.342 608.563 121.276 608.687 c f 120.189 607.817 m 120.145 607.765 120.1 607.662 120.056 607.637 c 119.856 607.534 119.657 607.559 119.458 607.559 c 119.502 607.586 119.545 607.637 119.589 607.637 c 119.834 607.637 119.989 607.714 120.189 607.817 c f 119.524 607.148 m 119.323 607.148 119.146 607.174 118.947 607.148 c 118.925 607.122 118.947 607.071 118.969 607.045 c 119.146 606.993 119.323 606.891 119.502 606.839 c 119.545 606.814 119.612 606.839 y 119.701 606.763 119.931 606.728 119.901 606.814 c 119.856 606.942 119.701 607.02 119.589 607.096 c f 119.502 606.275 m 119.436 606.275 119.369 606.248 119.301 606.3 c 119.168 606.402 118.947 606.557 118.791 606.583 c f 118.969 605.888 m 118.768 605.888 118.525 605.836 118.37 605.914 c 118.304 605.965 118.214 606.068 118.17 606.197 c 118.458 606.145 118.637 605.965 118.925 605.965 c f 117.593 605.708 m 117.638 605.708 117.682 605.734 117.726 605.708 c 117.881 605.604 118.06 605.579 118.17 605.426 c 118.214 605.348 118.214 605.246 118.214 605.168 c 118.17 605.168 118.126 605.143 118.104 605.168 c 117.992 605.373 117.793 605.425 117.682 605.604 c f 117.992 604.757 m 117.992 604.732 117.992 604.68 117.992 604.654 c 117.726 604.576 117.549 604.809 117.349 604.988 c 117.193 605.116 117.349 605.22 117.482 605.116 c 117.549 605.066 117.66 604.988 117.748 604.911 c 117.816 604.833 117.926 604.885 118.015 604.809 c 117.992 604.783 117.992 604.757 v f 117.149 604.551 m 117.039 604.551 117.016 604.679 116.927 604.731 c f 116.661 604.526 m 116.661 604.474 116.661 604.448 116.661 604.396 c 116.616 604.396 l 116.616 604.345 116.616 604.268 116.616 604.217 c f 125.581 609.54 m 125.448 609.566 125.337 609.515 125.226 609.463 c 125.204 609.463 125.16 609.411 125.115 609.385 c 124.983 609.335 124.849 609.283 124.716 609.231 c 124.294 609.103 123.85 609.128 123.451 608.897 c 123.296 608.821 123.119 608.743 122.963 608.691 c 122.541 608.589 122.164 608.589 121.743 608.511 c 121.675 608.485 121.61 608.408 121.522 608.408 c 121.964 608.434 122.409 608.356 122.874 608.434 c 123.119 608.486 123.363 608.46 123.607 608.537 c 123.673 608.563 123.695 608.64 123.761 608.665 c 124.006 608.743 124.228 608.64 124.449 608.717 c 124.538 608.743 124.65 608.743 124.738 608.795 c 125.048 608.897 125.249 609.18 125.493 609.437 c 125.515 609.463 125.471 609.515 125.515 609.54 c f 125.071 608.64 m 124.983 608.538 124.917 608.408 124.783 608.357 c 124.56 608.307 124.361 608.151 124.139 608.099 c 123.874 608.023 123.629 607.972 123.363 607.945 c 123.03 607.893 122.719 607.893 122.386 607.792 c 122.364 607.792 122.296 607.775 122.275 607.765 c 121.765 607.534 121.232 607.637 120.723 607.637 c 120.7 607.791 120.766 607.997 120.921 608.022 c 121.165 608.075 121.387 607.945 121.632 607.919 c 121.942 607.868 122.23 607.868 122.541 607.92 c 122.653 607.945 122.741 607.972 122.831 608.022 c 123.119 608.151 123.407 608.023 123.695 608.151 c 123.806 608.202 123.896 608.228 124.006 608.281 c 124.316 608.357 124.628 608.408 124.917 608.537 c f 124.006 607.38 m 123.517 607.354 123.007 607.483 122.52 607.328 c 122.43 607.303 122.364 607.174 122.253 607.149 c 122.076 607.122 121.898 607.174 121.721 607.2 c 121.343 607.278 120.966 607.174 120.588 607.251 c 121.255 606.737 122.12 606.917 122.874 606.969 c 123.053 606.969 123.185 607.123 123.341 607.149 c 123.473 607.149 123.629 607.149 123.762 607.2 c 123.829 607.226 123.874 607.278 123.94 607.303 c f 122.719 606.197 m 122.741 606.224 122.696 606.249 122.696 606.275 c 122.297 606.249 121.898 606.377 121.499 606.454 c 121.054 606.531 120.611 606.351 120.167 606.531 c 120.234 606.506 120.303 606.476 120.366 606.454 c 121.144 606.197 121.832 606.249 122.586 606.224 c f 121.854 605.478 m 121.61 605.426 121.299 605.478 121.056 605.478 c 120.745 605.529 120.417 605.456 120.1 605.529 c 119.879 605.581 119.901 605.76 119.635 606.043 c 119.968 606.018 120.122 605.992 120.522 606.018 c 120.775 606.033 120.944 605.862 121.188 605.787 c 121.387 605.735 121.387 605.837 121.543 605.709 c f 121.011 604.86 m 120.656 604.834 120.323 604.86 119.968 604.938 c 119.946 604.963 119.901 604.989 119.879 605.015 c 119.746 605.067 119.589 605.015 119.458 605.117 c 119.365 605.189 119.301 605.271 119.191 605.323 c 119.169 605.348 119.125 605.605 119.147 605.605 c 119.235 605.631 119.369 605.478 119.458 605.426 c 119.524 605.426 119.545 605.348 119.612 605.323 c 119.901 605.22 119.924 605.374 120.189 605.195 c 120.345 605.091 120.855 605.117 120.989 604.938 c f 120.034 604.295 m 119.79 604.269 119.568 604.372 119.346 604.449 c 119.147 604.526 118.925 604.628 118.747 604.809 c 119.125 604.911 119.458 604.603 119.834 604.5 c 119.879 604.5 119.99 604.423 119.968 604.32 c f 119.502 603.986 m 119.458 603.832 119.258 603.857 119.169 603.908 c 118.991 604.038 118.725 604.089 118.681 604.346 c 118.768 604.346 118.836 604.372 118.925 604.32 c 118.991 604.269 119.036 604.218 119.08 604.14 c 119.169 604.012 119.346 604.114 119.436 603.961 c f 118.703 603.575 m 118.525 603.575 118.348 603.575 118.17 603.575 c 118.192 603.781 118.126 603.986 117.992 604.139 c 117.992 604.165 117.992 604.217 117.992 604.243 c 118.104 604.294 118.192 604.165 118.28 604.088 c 118.348 604.011 118.348 603.883 118.326 603.781 c 118.437 603.781 118.547 603.729 118.615 603.626 c f 117.794 603.446 m 117.594 603.498 117.482 603.703 117.305 603.78 c f 117.284 603.471 m 117.149 603.471 117.083 603.677 116.971 603.78 c f 116.773 603.446 m 116.61 603.446 116.439 603.368 116.284 603.446 c 116.284 603.523 l 116.394 603.574 116.439 603.78 116.572 603.729 c 116.594 603.729 116.616 603.6 116.661 603.549 c 116.683 603.549 116.705 603.549 116.728 603.549 c 116.773 603.523 116.794 603.446 116.773 603.446 c f q 1.0119 0 0 0.9883 0 0 cm 0.11 G 1 J 1 j 0.291 w 4 M 111.298 614.442 m 111.495 614.377 111.707 614.343 111.928 614.343 c 113.007 614.343 113.882 615.182 113.882 616.219 c 113.882 617.255 113.007 618.095 111.928 618.095 c 110.849 618.095 109.974 617.255 109.974 616.219 c 109.974 615.394 110.527 614.695 111.298 614.442 c B Q q 1.0119 0 0 0.9883 0 0 cm 0.158 G 0.145 w 4 M 111.146 615.176 m 111.466 616.224 l 110.656 616.806 l 111.673 616.808 l 111.993 617.773 l 112.365 616.803 l 113.462 616.805 l 112.579 616.178 l 112.962 615.176 l 112.07 615.82 l 111.146 615.176 l b Q q 1.0119 0 0 0.9883 0 0 cm 0 G 2 j 0.029 w 112.005 613.138 m 112.246 613.138 112.44 613.279 112.44 613.456 c 112.44 613.631 112.246 613.774 112.005 613.774 c 111.766 613.774 111.571 613.631 111.571 613.456 c 111.571 613.279 111.766 613.138 112.005 613.138 c b Q q 1.0119 0 0 0.9883 0 0 cm 0 G 2 j 0.029 w 112.005 613.456 m B Q q 1.0119 0 0 0.9883 0 0 cm 0 G 2 j 0.029 w 111.746 613.203 m 111.746 613.139 111.861 613.087 112.005 613.087 c 112.15 613.087 112.267 613.139 112.267 613.203 c B Q q 1.0119 0 0 0.9883 0 0 cm 0 G 2 j 0.029 w 112.124 613.107 m 112.005 609.387 l 111.888 613.107 l B Q q 1.0119 0 0 0.9883 0 0 cm 0 G 2 j 0.029 w 111.886 612.916 m 111.676 612.9 111.347 612.975 111.353 613.193 c 111.361 613.41 111.173 613.936 110.634 613.71 c 110.093 613.485 110.558 613.545 110.723 613.576 c B Q q 1.0119 0 0 0.9883 0 0 cm 0 G 2 j 0.029 w 110.483 613.545 m 110.468 613.456 110.678 613.456 110.858 613.515 c B Q q 1.0119 0 0 0.9883 0 0 cm 0 G 2 j 0.029 w 110.618 613.47 m 110.634 613.41 110.858 613.425 110.993 613.456 c B Q q 1.0119 0 0 0.9883 0 0 cm 0 G 2 j 0.029 w 110.813 613.425 m 110.858 613.305 111.009 613.425 111.039 613.366 c 111.068 613.305 111.249 613.41 111.278 613.126 c 111.308 612.841 111.833 612.871 111.894 612.841 c B Q q 1.0119 0 0 0.9883 0 0 cm 0 G 2 j 0.029 w 110.363 613.545 m 109.973 613.441 109.568 613.201 109.568 613.11 c 109.568 613.02 110.154 613.35 110.288 613.395 c B Q q 1.0119 0 0 0.9883 0 0 cm 0 G 2 j 0.029 w 109.688 613.096 m 109.688 613.02 109.899 613.096 110.408 613.321 c B Q q 1.0119 0 0 0.9883 0 0 cm 0 G 2 j 0.029 w 109.928 613.126 m 109.928 613.051 110.138 613.051 110.648 613.276 c B Q q 1.0119 0 0 0.9883 0 0 cm 0 G 2 j 0.029 w 110.123 613.051 m 110.123 612.975 110.423 613.02 110.874 613.276 c B Q q 1.0119 0 0 0.9883 0 0 cm 0 G 2 j 0.029 w 110.408 613.036 m 110.408 612.961 110.604 612.93 111.023 613.215 c B Q q 1.0119 0 0 0.9883 0 0 cm 0 G 2 j 0.029 w 110.604 613.006 m 110.558 612.856 110.903 612.975 111.143 613.14 c B Q q 1.0119 0 0 0.9883 0 0 cm 0 G 2 j 0.029 w 110.769 612.961 m 110.769 612.886 111.053 612.93 111.204 613.065 c B Q q 1.0119 0 0 0.9883 0 0 cm 0 G 2 j 0.029 w 111.009 612.916 m 111.009 612.841 111.204 612.841 111.263 612.961 c B Q q 1.0119 0 0 0.9883 0 0 cm 0 G 2 j 0.029 w 111.204 612.856 m 111.204 612.78 111.383 612.796 111.428 612.886 c B Q q 1.0119 0 0 0.9883 0 0 cm 0 G 2 j 0.029 w 111.204 612.856 m 111.204 612.78 111.383 612.796 111.428 612.886 c B Q q 1.0119 0 0 0.9883 0 0 cm 0 G 2 j 0.029 w 111.368 612.811 m 111.368 612.736 111.548 612.751 111.593 612.841 c B Q q 1.0119 0 0 0.9883 0 0 cm 0 G 2 j 0.029 w 111.518 612.78 m 111.518 612.706 111.698 612.721 111.743 612.811 c B Q q 1.0119 0 0 0.9883 0 0 cm 0 G 2 j 0.029 w 111.683 612.736 m 111.683 612.66 111.863 612.676 111.908 612.766 c B Q q 1.0119 0 0 0.9883 0 0 cm 0 G 2 j 0.029 w 112.389 611.48 m 112.462 611.487 112.643 611.581 112.688 611.64 c 112.939 611.974 112.508 612.098 112.313 612.098 c 112.228 612.098 111.957 612.046 111.588 612.091 c 111.221 612.136 111.158 612.24 111.189 612.346 c 111.201 612.383 111.347 612.427 111.378 612.391 c 111.411 612.353 111.473 612.301 111.546 612.315 c 111.62 612.33 111.777 612.361 111.788 612.397 c 111.799 612.436 111.721 612.548 111.668 612.571 c 111.615 612.593 111.376 612.66 111.219 612.585 c 111.159 612.558 110.746 612.301 111.113 612.031 c 111.48 611.761 112.023 611.911 112.208 611.897 c 112.583 611.866 112.651 611.625 112.126 611.565 c 112.193 611.562 112.344 611.532 112.389 611.48 c b Q q 1.0119 0 0 0.9883 0 0 cm 0 G 2 j 0.029 w 112.313 612.098 m 112.68 612.143 112.859 612.24 112.827 612.346 c 112.817 612.383 112.67 612.427 112.638 612.391 c 112.608 612.353 112.544 612.301 112.47 612.315 c 112.397 612.33 112.24 612.361 112.228 612.397 c 112.218 612.436 112.321 612.548 112.372 612.571 c 112.425 612.593 112.696 612.645 112.853 612.571 c 112.911 612.542 113.284 612.372 112.911 612.106 c 112.818 612.039 112.69 612.016 112.657 612.016 c B Q q 1.0119 0 0 0.9883 0 0 cm 0 G 2 j 0.029 w 112.309 611.123 m 112.504 611.093 112.59 611.491 112.245 611.546 c 111.872 611.607 111.786 611.612 111.694 611.621 c 111.522 611.64 111.534 611.881 111.916 611.873 c 111.634 611.87 l 111.161 611.858 111.323 611.443 111.698 611.464 c 112.074 611.487 112.355 611.412 112.261 611.269 c 112.204 611.182 112.149 611.161 y 112.236 611.161 112.291 611.135 112.309 611.123 c b Q q 1.0119 0 0 0.9883 0 0 cm 0 G 2 j 0.029 w 112.265 610.782 m 112.395 610.752 112.562 611.092 112.218 611.153 c 111.885 611.213 111.83 611.177 111.76 611.219 c 111.657 611.28 111.69 611.487 111.934 611.464 c 111.758 611.461 l 111.406 611.509 111.417 611.097 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However)104.3(, many patients with these same characteristics ar)29.3(e not)]TJ 0 -1.299 TD -0.0036 Tc 0.0861 Tw [(r)34.6(estrained. Thus, these variables have yielded little pr)32.4(edictive power)104.4(. This study compar)32.4(ed r)32.4(estrained/)]TJ T* 0.0047 Tc 0.125 Tw (nonrestrained subjects on the demographic, precipitant variables and added three clinical variables)Tj 0 -1.302 TD -0.0061 Tc -0.0625 Tw (\(past violence to others, personal victimization, and substance use disorder\) to assess the possible predictive)Tj 0 -1.299 TD -0.0036 Tc 0.125 Tw (power of clinical variables. Demographic and precipitant variables were similar to previous research)Tj T* -0.0039 Tc 0.0758 Tw [(findings. V)71.1(iolence towar)32.1(d others in combination with personal victimization was associated with higher)]TJ 0 -1.302 TD 0.0057 Tc 0.125 Tw (restraint usage. The implications of the findings for emergency services are outlined.)Tj /TT4 1 Tf 35.889 0 TD 0 Tc 0 Tw ( )Tj /TT5 1 Tf 0.381 0 TD 0.0049 Tc ([International)Tj -36.27 -1.299 TD -0.0035 Tc 0.0762 Tw (Journal of Emergency Mental Health, 2008, 10\(3\), pp. 191-196].)Tj /TT4 1 Tf 9 0 0 9 125.16 333.99 Tm -0.0051 Tc -0.0111 Tw (Key words: )Tj /TT5 1 Tf 4.76 0 TD -0.0049 Tc -0.0128 Tw (Assaulted Staff Action Program \(ASAP\), emergency services, patients, restraints, restraint reduction)Tj ET /GS1 gs 66 209.745 m 299.01 209.745 l S BT /TT2 1 Tf 9 0 0 9 66 192 Tm /GS2 gs 0.0582 Tc 0.1365 Tw [(Raymond B. Flannery)58.2(, Jr)31.5(, PhD, is Senior Psychologist,)]TJ 0 -1.2233 TD 0.0098 Tc 0.1251 Tw [(Massachusetts Department of Mental Health, )9.9(W)87(orcester S)9.8(tate)]TJ 0 -1.22 TD -0.0062 Tc -0.0626 Tw [(Hospital; Director of )10.4(The )53.7(Assaulted S)10.5(t)7.8(a)7.8(f)7.1(f)7.6( )50.4(Action Program \(ASAP\);)]TJ 0 -1.2233 TD -0.0049 Tc -0.003 Tw [(and )51.9(Associate Clinical Professor of Psychology)61.8(, Harvard Medical)]TJ T* 0.0098 Tc 0.0685 Tw [(School. Andrew )-56.8(P)109.8(.)-5.2( )-46.7(W)93.6(alker)]TJ 11.0567 0 TD 0.0091 Tc 0.1268 Tw [(, BA, is an )57.6(Automated Information)]TJ -11.0567 -1.22 TD 0.0179 Tc 0.1255 Tw [(T)68.7(echnology Specialist, Massachusetts Department of Mental)]TJ 0 -1.2233 TD 0.0045 Tc 0.1252 Tw [(Health, Boston, MA, and Consulting S)17.8(tatistician to the )54.7(ASAP)]TJ T* 0.0269 Tc 0.125 Tw (program. Correspondence concerning this article should be)Tj 0 -1.22 TD 0.0147 Tc [(addressed to: Raymond B. Flannery)64.7(, Jr)38(, PhD, Department of)]TJ 0 -1.2233 TD -0.0063 Tc -0.0632 Tw [(Psychology)67(,)-9( )9.9(W)87.5(orcester S)13.7(tate Hospital, 305 Belmont S)10.4(t., )13.2(W)87.5(orcester)30.4(,)]TJ T* -0.0049 Tc 0.0346 Tw [(M)13.1(A)48.4( 01604. )15.3(T)65.9(el: 508-368-3517; Fax: 508-363-1512.)]TJ /F1 1 Tf 14 0 0 14 178.5 638.34 Tm -0.0046 Tc 0.1375 Tw [(Characteristics of P)23.3(atients in Restraint:)]TJ 2.8136 -1.1421 TD -0.0022 Tc 0.1382 Tw [(Fifteen-Y)70.7(ear Anal)8.5(ysis of the)]TJ -8.4921 -1.1421 TD -0.0039 Tc 0.1377 Tw [(Assaulted Staff Action Pr)13.2(ogram \(ASAP\) )75.3(With EMS Implications)]TJ /TT2 1 Tf 10 0 0 10 84 283.65 Tm -0.0037 Tc -0.0584 Tw (Emergency medical services \(EMS\) providers and men-)Tj -1.8 -1.401 TD -0.0035 Tc 0.0244 Tw (tal health care staff at times encounter behavioral emergen-)Tj 0 -1.398 TD 0.0113 Tc 0.125 Tw (cies in which patients are out of control and present an)Tj 0 -1.401 TD -0.015 Tc -0.0625 Tw (imminent risk of harm to self or others. In these circumstances,)Tj T* -0.0031 Tc 0.045 Tw (if other alternatives to restraint have failed \(e.g., taking the)Tj 12 0 0 12 396.51 555.66 Tm -0.0099 Tc -0.0611 Tw [(Andrew P)105.1(.)-0.3( )9.4(W)83.9(alker)]TJ 10 0 0 10 347.4 543 Tm 0.0009 Tc 0.09 Tw (Massachusetts Department of Mental Health)Tj 12 0 0 12 126.15 555.66 Tm -0.0206 Tc -0.061 Tw [(Raymond B. Flannery)59.4(, Jr)49.4(.)]TJ 10 0 0 10 92.4 543 Tm 0.0009 Tc 0.09 Tw (Massachusetts Department of Mental Health)Tj 3.336 -1.2 TD 0.0008 Tc 0.0017 Tw (and Harvard Medical School)Tj 19.524 -24.636 TD 0.0048 Tc 0.125 Tw (patient down\), physical, mechanical, and/or chemical re-)Tj 0 -1.398 TD -0.0032 Tc -0.0479 Tw [(straints may be employed to restrict the patient)53.8(s movements)]TJ 0 -1.401 TD -0.0029 Tc 0.1249 Tw [(in order to ensure safety)63.1(. Restraint is neither a treatment)]TJ T* -0.0032 Tc 0.023 Tw (intervention nor a form of punishment but a strategy of last)Tj 0 -1.398 TD 0.0619 Tw (resort to be used infrequently when safety is compromised)Tj 0 -1.401 TD -0.0091 Tc -0.0617 Tw (\(Busch & Shore, 2000\).)Tj 1.8 -2.001 TD -0.0031 Tc 0.0014 Tw [(Restraints increase the risk of death, disability)62.9(, medical)]TJ -1.8 -1.398 TD -0.0029 Tc -0.0343 Tw [(injury)60.1(, intense psychological suf)18.1(fering, and lost productivity)]TJ 0 -1.401 TD -0.0032 Tc 0.0194 Tw (for the restrained individual as well as for family members,)Tj T* -0.0034 Tc 0.035 Tw (care providers, and innocent bystanders \(Medical Directors)Tj 0 -1.398 TD -0.0135 Tc -0.0625 Tw [(Council, 2000; Zun, 2005\). Efforts are now under way nation-)]TJ 0 -1.401 TD -0.0028 Tc 0.0233 Tw (ally to move toward restraint-free systems of care \(e.g., see)Tj T* -0.0038 Tc 0.0157 Tw [(Massachusetts Department of Mental Health, 1996\). These)]TJ 0 -1.398 TD -0.0161 Tc -0.0623 Tw [(restraint-free initiatives )-6.4(are in place in community)64.9(, prehospital,)]TJ 0 -1.401 TD 0.0095 Tc 0.125 Tw [(and hospital settings. The ability to assess and manage)]TJ T* -0.003 Tc 0 Tw (potentially violent patients early on would enhance the effi-)Tj ET endstream endobj 154 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT2 9 0 R /TT3 10 0 R /TT4 20 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 156 0 obj << /Length 9198 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 54 59.745 m 546 59.745 l S BT /F1 1 Tf 8 0 0 8 54.99 41.64 Tm 0 0 0 1 k /GS2 gs -0.0054 Tc 0.1 Tw [(192 )]TJ /TT3 1 Tf 2.775 0 TD 0.1016 Tw (Flannery and Walker )Tj 10.425 0 TD 0.0049 Tc (Characteristics of Patients in Restraint)Tj /TT2 1 Tf 10 0 0 10 54 722.64 Tm -0.0032 Tc 0.0717 Tw (cacy of initiatives and policies to reduce and eliminate the)Tj 0 -1.398 TD -0.0033 Tc 0.075 Tw (use of restraints.)Tj 1.8 -2.001 TD -0.0031 Tc 0.0085 Tw [(T)73.7(oward this end, over 30 years of research on the char)14.9(-)]TJ -1.8 -1.401 TD 0.0017 Tc 0.125 Tw [(acteristics of patients who have been restrained has been)]TJ 0 -1.398 TD -0.0037 Tc -0.0237 Tw (conducted; the findings have been summarized in five print-)Tj 0 -1.401 TD 0.0109 Tc 0.125 Tw (journal review articles \(Busch & Shore, 2000; Evans &)Tj T* -0.0232 Tc -0.0623 Tw [(Fitzgerald, 2002; Fisher)36.8(, 1994; Solof)18.8(f, Gutheil, & )10(W)95.6(exler)36.8(, 1985;)]TJ 0 -1.398 TD -0.0046 Tc -0.0621 Tw (Zun, 2005\). This research has found that there is an increased)Tj 0 -1.401 TD -0.0099 Tc [(probability of risk with younger)35.1(, male or female, patients with)]TJ T* -0.0036 Tc -0.0307 Tw [(a diagnosis of schizophrenia, af)14.4(fective disorder)35.4(, or personal-)]TJ 0 -1.398 TD -0.0031 Tc 0.0264 Tw [(ity disorder)38.9(, in either acute or extended care settings. Com-)]TJ 0 -1.401 TD -0.0036 Tc 0.0043 Tw (mon precipitants of these assault incidents, with subsequent)Tj T* -0.0032 Tc 0.0187 Tw (loss of patient control, have included acute psychotic activ-)Tj 0 -1.398 TD -0.0029 Tc 0.0782 Tw [(ity)60.1(, excess sensory stimulation, staf)18.1(f restrictions on patient)]TJ 0 -1.401 TD -0.0033 Tc -0.0333 Tw [(behaviors, and denial of services \(Flannery)59.7(, 2007\).)]TJ 1.8 -2.001 TD 0.0083 Tc 0.125 Tw [( )53.3(Although the restrained patient characteristics have)]TJ -1.8 -1.398 TD -0.0033 Tc 0.0257 Tw (been consistent over the years, research has focused prima-)Tj 0 -1.401 TD 0.0944 Tw [(rily on demographic and precipitant variables. Given that)]TJ T* -0.0034 Tc 0.0245 Tw (there are patients with these same variables who are not re-)Tj 0 -1.398 TD -0.0019 Tc 0.125 Tw (strained, these variables by themselves have yielded little)Tj 0 -1.401 TD -0.0035 Tc 0.1137 Tw (appreciable predictive power in assessing the need for re-)Tj T* 0.0108 Tc 0 Tw (straints.)Tj 1.8 -1.998 TD -0.0075 Tc -0.0622 Tw (One recent study included the common clinical variables)Tj -1.8 -1.401 TD -0.0035 Tc 0.1143 Tw (of histories of violence toward others, personal victimiza-)Tj T* 0.12 Tw [(tion, and substance use disorder)38.5(, in addition to the demo-)]TJ 0 -1.398 TD -0.0036 Tw (graphic variables, to assess whether clinical variables might)Tj 0 -1.401 TD -0.0205 Tc -0.062 Tw [(enhance predictive power \(Flannery)66.5(, Rachlin, & )12.6(W)92.3(alker)36.5(, 2001\).)]TJ T* -0.0033 Tc 0.0819 Tw [(Assessing the impact of these clinical variables singly)62.7(, the)]TJ 0 -1.398 TD -0.0017 Tw (study found that female patients with a diagnosis of person-)Tj 0 -1.401 TD 0.0221 Tw (ality disorder and personal victimization required more fre-)Tj T* 0.0007 Tc 0.125 Tw (quent restraints in community settings than did male and)Tj 0 -1.398 TD 0.0025 Tc (female patients with substance use disorder and personal)Tj 0 -1.401 TD -0.0035 Tc 0.023 Tw (victimization in state hospital inpatient settings.)Tj 1.8 -2.001 TD -0.0039 Tc 0.0521 Tw [(T)72.9(wo studies have examined both the demographic and)]TJ -1.8 -1.398 TD -0.0035 Tc -0.0169 Tw (three common clinical variables in their association with as-)Tj 0 -1.401 TD -0.0032 Tc 0.0268 Tw [(sault in samples of assaultive, public sector)35.8(, psychiatric pa-)]TJ T* -0.0018 Tc 0.1249 Tw [(tients, some of whom were restrained \(Flannery)58.2(, S)13.2(t)0.6(evens,)]TJ 0 -1.398 TD -0.028 Tc -0.0621 Tw [(Juliano, & )17.4(W)96.8(alker)38(, 2000; Flannery)62(, Hanson, Corrigan, & )20.4(W)93.9(alker)38(,)]TJ 0 -1.401 TD -0.0033 Tc 0.0605 Tw [(2006\). In these studies, the clinical variables were studied)]TJ T* -0.0113 Tc -0.0618 Tw [(singly and in combinations with each other)51.7(. )13.1(The demographic)]TJ 0 -1.398 TD 0.0061 Tc 0.125 Tw (variables associated with patient assault were essentially)Tj 0 -1.401 TD -0.0034 Tc -0.0014 Tw (consistent with the previously reported research findings on)Tj T* -0.003 Tc -0.0405 Tw [(restrained patients. Each of the clinical variables singly had)]TJ 0 -1.398 TD -0.0036 Tc 0.0012 Tw [(a low correlation with assaultiveness. However)35.4(, the combi-)]TJ 0 -1.401 TD -0.0037 Tc 0.0164 Tw (nation of violence toward others and personal victimization)Tj 25.5 63.999 TD -0.0032 Tc -0.0362 Tw (appreciably increased the strength of the correlation, and the)Tj 0 -1.398 TD -0.0037 Tc 0.0467 Tw (combination of violence toward others, personal victimiza-)Tj 0 -1.401 TD -0.0032 Tc -0.0019 Tw (tion, and substance use disorder yielded the highest correla-)Tj T* -0.0035 Tc 0.04 Tw (tion with assault.)Tj 1.8 -1.998 TD -0.0031 Tc 0.0379 Tw (The purpose of the present 15-year retrospective study)Tj -1.8 -1.401 TD -0.0029 Tc 0.125 Tw (was to continue the inquiry into the characteristics of pa-)Tj T* -0.008 Tc -0.0625 Tw (tients who are restrained. This study utilized the demographic)Tj 0 -1.398 TD -0.0036 Tc 0.0164 Tw (and precipitant variables and the common clinical variables)Tj 0 -1.401 TD -0.0034 Tc -0.0567 Tw (singly and in combinations in a comparison of restrained and)Tj T* -0.0024 Tc 0.125 Tw (nonrestrained assaultive psychiatric patients.)Tj /F1 1 Tf 11 0 0 11 399.39 558 Tm 0.0189 Tc 0 Tw (METHODS)Tj -8.2173 -1.4536 TD -0.0013 Tc (Subjects)Tj /TT2 1 Tf 10 0 0 10 327 518.64 Tm -0.0037 Tc -0.0358 Tw (The subjects were 1,047 male and 1,056)Tj /TT1 1 Tf 15.756 0 TD 0 Tc 0 Tw ( )Tj /TT2 1 Tf 0.213 0 TD -0.0038 Tc -0.04 Tw (female assault-)Tj -17.769 -1.398 TD 0.0099 Tc 0.125 Tw (ive patients of the Massachusetts Department of Mental)Tj 0 -1.401 TD -0.0033 Tc 0.1249 Tw [(Health \(DMH\) who received care in seven state hospitals)]TJ T* -0.0096 Tc -0.0621 Tw (and nine DMH state or DMH-vendored community programs)Tj 0 -1.398 TD -0.0038 Tc -0.0517 Tw [(from )50.3(April 2, 1990 through March 31, 2005. )14.3(There were 806)]TJ 0 -1.401 TD -0.0037 Tc -0.012 Tw (male and 766 female assaultive inpatients)Tj /TT1 1 Tf 16.479 0 TD 0 Tc 0 Tw ( )Tj /TT2 1 Tf 0.24 0 TD -0.004 Tc -0.0133 Tw (and 241 male and)Tj -16.719 -1.401 TD -0.01 Tc -0.06 Tw (290 female)Tj /TT1 1 Tf 4.314 0 TD 0 Tc 0 Tw ( )Tj /TT2 1 Tf 0.186 0 TD -0.0093 Tc -0.0625 Tw [(assaultive community patients. Their average age)]TJ -4.5 -1.398 TD -0.0027 Tc -0.0175 Tw (was 36 years)Tj /TT1 1 Tf 5.1 0 TD 0 Tc 0 Tw ( )Tj /TT2 1 Tf 0.231 0 TD (\()Tj /TT5 1 Tf 0.33 0 TD -0.0132 Tc (SD)Tj /TT2 1 Tf 1.209 0 TD -0.0031 Tc -0.0175 Tw [( = 11.77\).)]TJ /TT1 1 Tf 3.834 0 TD 0 Tc 0 Tw ( )Tj /TT2 1 Tf 0.231 0 TD -0.004 Tc -0.02 Tw (Subjects were Caucasian \(74%\),)Tj -10.935 -1.401 TD -0.0057 Tc -0.0616 Tw [(Black \(16%\), )54.4(Asian \(2%\), and other \(8%\).)]TJ /TT1 1 Tf 16.266 0 TD -0.0685 Tc 0 Tw ( )Tj /TT2 1 Tf 0.369 0 TD -0.0093 Tc (The)Tj /TT1 1 Tf 1.536 0 TD 0 Tc ( )Tj /TT2 1 Tf 0.183 0 TD -0.0049 Tc -0.065 Tw (primary diag-)Tj -18.354 -1.401 TD -0.017 Tc 0 Tw (noses)Tj /TT1 1 Tf 2.145 0 TD 0 Tc ( )Tj /TT2 1 Tf 0.174 0 TD -0.0153 Tc -0.062 Tw (included schizophrenia \(48%\), affective disorder \(15%\),)Tj -2.319 -1.398 TD 0.011 Tc 0.125 Tw (personality disorder \(19%\), and various other diagnoses)Tj 0 -1.401 TD -0.0053 Tc -0.0622 Tw [(\(16%\). Restraints were employed for safety in 924 incidents.)]TJ /F1 1 Tf 11 0 0 11 309 332.01 Tm -0.0049 Tc 0.0227 Tw (Measures of Assault)Tj /TT2 1 Tf 10 0 0 10 327 308.64 Tm 0.007 Tc 0.125 Tw (The four types of assaults assessed in this study re-)Tj -1.8 -1.398 TD -0.0027 Tc -0.0112 Tw [(mained constant during the 15 years of this study)63.3(. Physical)]TJ 0 -1.401 TD -0.0036 Tc -0.0169 Tw (assaults were defined as unwanted contact with another per-)Tj T* 0.0543 Tw (son with intent to harm, including punching, kicking, slap-)Tj 0 -1.398 TD -0.003 Tc 0.0419 Tw (ping, biting, spitting, and throwing objects directly at staff.)Tj 0 -1.401 TD -0.0038 Tc -0.0307 Tw (Sexual assaults were unwanted sexual contacts and included)Tj T* -0.0034 Tc -0.0443 Tw (rape, attempted rape, fondling, forced kissing, and exposing.)Tj 0 -1.398 TD 0.0254 Tc 0.125 Tw (Nonverbal intimidation referred to actions intended to)Tj 0 -1.401 TD -0.0034 Tc 0.0272 Tw (threaten and/or frighten staff, such as pounding on the staff)Tj T* -0.0038 Tc 0.0315 Tw [(of)17.2(fice door)35.2(, random throwing of objects, and destruction of)]TJ 0 -1.398 TD -0.0033 Tc 0.0295 Tw [(property)59.7(. )18.3(V)115.9(erbal threats were statements meant to frighten)]TJ 0 -1.401 TD -0.0034 Tc 0.055 Tw (or threaten staff and included threats against life and prop-)Tj T* -0.003 Tc 0.0422 Tw (erty as well as racial slurs and other derogatory comments.)Tj 0 -1.398 TD -0.0034 Tc -0.0161 Tw (Serious incidents other than assaults \(e.g., sudden death of a)Tj 0 -1.401 TD -0.0036 Tc 0.0769 Tw (patient\) were recorded as other incidents, and these data)Tj T* 0.0525 Tw (not reported here.)Tj ET endstream endobj 157 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT1 8 0 R /TT2 9 0 R /TT3 10 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 159 0 obj << /Length 10547 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 66 59.745 m 558 59.745 l S BT /TT3 1 Tf 8 0 0 8 423.24 42.6 Tm 0 0 0 1 k /GS2 gs -0.0051 Tc 0.0326 Tw [(IJEMH Vol. 10, No. 3 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (193)Tj 11 0 0 11 66 723.99 Tm 0.0039 Tc (Procedure)Tj /TT2 1 Tf 10 0 0 10 84 700.65 Tm -0.0034 Tc 0.1055 Tw [(The data on patient assailants and staff victims were)]TJ -1.8 -1.401 TD 0.0052 Tc 0.125 Tw [(recorded on the )50.2(Assaulted S)17.2(taf)14.2(f )53.2(Action Program \(ASAP;)]TJ 0 -1.398 TD 0.0181 Tc 0.1249 Tw [(Flannery)63.1(, 1998\) report forms in the 16 DMH state and)]TJ 0 -1.401 TD -0.0034 Tc -0.045 Tw (vendored facilities that had fielded an )Tj 14.871 0 TD -0.0049 Tc -0.0438 Tw [(ASAP)31.1( team during the)]TJ -14.871 -1.401 TD -0.003 Tc -0.0312 Tw [(years of this study)63(. )17.9(These included data on the demographic,)]TJ 0 -1.398 TD -0.0032 Tc -0.0588 Tw (precipitant, and three clinical )Tj 11.5727 0 TD -0.0044 Tc -0.1113 Tw [(variables. ASAP)28.6( )-54.6(is )]TJ 7.4973 0 TD -0.0024 Tc -0.0587 Tw [(a voluntary)60.6(,)]TJ -19.07 -1.401 TD -0.0033 Tc -0.0342 Tw (peer-help, system-wide, crisis intervention program to assist)Tj T* 0.0569 Tw (staff victims with the psychological sequelae of patient as-)Tj 0 -1.398 TD -0.0074 Tc -0.0622 Tw [(saults. The program offers individual, group, and staff victim)]TJ 0 -1.401 TD -0.0033 Tc -0.045 Tw (family crisis interventions, an ongoing staff victims support)Tj T* -0.0043 Tc -0.0625 Tw (group, and referrals to individual therapists who specialize in)Tj 0 -1.398 TD -0.0035 Tc 0.0625 Tw (treating trauma victims, when indicated. )Tj 16.5265 0 TD -0.0054 Tc 0.064 Tw [( )50.1(ASAP)27.6( has strong)]TJ -16.5265 -1.401 TD -0.003 Tc 0.01 Tw (empirical support for its efficacy \(Everly & Mitchell, 1999;)Tj T* -0.0111 Tc -0.062 Tw [(Flannery)63.9(, 1998; Flannery)60.9(, Farley)57.9(, Rego, & )19(W)92.7(alker)39.9(, 2006\).)]TJ 1.8 -1.998 TD -0.0048 Tc 0.0976 Tw [(All )53.1(ASAP)28.2( team members practiced completing )50.1(ASAP)]TJ -1.8 -1.401 TD -0.0032 Tc 0.0982 Tw (report forms until acceptable levels of reliability were ob-)Tj T* -0.0037 Tc 0.0342 Tw [(tained. )50.1(An upgrade in the software package \(1994\) allowed)]TJ 0 -1.398 TD -0.0034 Tc -0.0094 Tw (data on the clinical variables of violence toward others, per-)Tj 0 -1.401 TD -0.0035 Tc 0.0687 Tw (sonal victimization, and substance use disorder to be gath-)Tj T* -0.0122 Tc -0.0623 Tw (ered from 1994 to 2005 and data on precipitants to be gathered)Tj 0 -1.398 TD -0.0037 Tc 0.0157 Tw [(from 2000 to 2005. )17.4(T)70.1(o)0.1( guard against underreporting \(Lion,)]TJ 0 -1.401 TD -0.0069 Tc -0.0625 Tw [(Snyder)38.1(, & Merrill, 1981\), each facility was required to fill out)]TJ T* -0.0086 Tc -0.0623 Tw (a DMH report form for each incident, )Tj 14.5743 0 TD -0.0098 Tc -0.0612 Tw [(to call the )51.3(ASAP)29.2( person)]TJ -14.5743 -1.398 TD -0.0029 Tc -0.0625 Tw [(on duty)60.1(, and to review the incident at daily staf)18.1(f meetings. )51.1(A)7.1(t)]TJ 0 -1.401 TD -0.0036 Tc 0.1189 Tw (times, total numbers do not equal 100% because of occa-)Tj T* -0.0039 Tc 0.0682 Tw [(sional missing data when staf)17.1(f )]TJ 12.5629 0 TD -0.0044 Tc 0.0693 Tw [(victims declined )50.8(ASAP)28.6( ser)16.6(-)]TJ -12.5629 -1.398 TD -0.0031 Tc 0.0223 Tw (vices, declined to identify the patient assailant, or when the)Tj 0 -1.401 TD -0.0038 Tc 0.0273 Tw [(patient)50.2(s record did not include suf)17.2(ficient documentation of)]TJ T* -0.0031 Tc 0.0975 Tw [(the study)50.9(s variables.)]TJ 1.8 -1.998 TD 0.0037 Tw (In this study a restraint incident was defined operation-)Tj -1.8 -1.401 TD -0.0028 Tc 0.0218 Tw (ally as any patient assault or threat of assault in which staff)Tj T* -0.0035 Tc 0.1 Tw (determined the need for restraining the assailant to ensure)Tj 0 -1.398 TD -0.0032 Tc 0.0411 Tw (safety in accordance with the guidelines noted in the Intro-)Tj 0 -1.401 TD 0.0928 Tw (duction. This analysis assumed that all staff were at equal)Tj T* -0.0034 Tc -0.0522 Tw (risk for the full period, except for some brief hospitalizations)Tj 0 -1.398 TD -0.0036 Tc -0.0329 Tw (during which community patients were absent from residen-)Tj 0 -1.401 TD -0.0032 Tc 0.0064 Tw [(tial placements. )53.7(All data are reported as assault incidents.)]TJ /F1 1 Tf 11 0 0 11 158.64 152.01 Tm 0.0198 Tc 0 Tw [(RESUL)82.5(TS)]TJ /TT2 1 Tf 10 0 0 10 84 128.64 Tm -0.004 Tc -0.0621 Tw (During this 15-year time period, )Tj 12.669 0 TD -0.0062 Tc -0.0611 Tw [(ASAP)29.8( teams responded)]TJ -14.469 -1.398 TD -0.0032 Tc 0.1172 Tw [(to 2,152 patient assaults on staf)14.8(f. )]TJ /TT1 1 Tf 13.959 0 TD 0 Tc 0 Tw ( )Tj /TT2 1 Tf 0.366 0 TD -0.0049 Tc 0.1195 Tw [(ASAP)28.1( was accepted in)]TJ -14.325 -1.401 TD -0.022 Tc -0.0619 Tw (1,862 incidents \(87%\) and declined in 290 others \(13%\).)Tj /TT1 1 Tf 20.961 0 TD -0.0913 Tc 0 Tw ( )Tj /TT2 1 Tf 0.504 0 TD -0.0241 Tc (There)Tj -21.465 -1.401 TD -0.0036 Tc -0.0395 Tw [(were 1,071 male \(50%\) and 1,049 female \(49%\) victims. Of)]TJ 25.5 63.6 TD -0.0208 Tc -0.0625 Tw (these, 827 were male \(51%\) and 758 female \(47%\) staff victims)Tj 0 -1.398 TD -0.0034 Tc -0.0363 Tw [(in inpatient settings. Community settings reported 244 male)]TJ 0 -1.401 TD -0.0035 Tc -0.039 Tw [(\(45%\) and 291 female \(54%\) staff victims. Staff victims de-)]TJ T* -0.0126 Tc -0.1156 Tw [(clined ASAP)26.4( )]TJ 5.1479 0 TD -0.0113 Tc -0.0622 Tw [(services in 181 inpatient \(1)27.7(1%\) and 109 commu-)]TJ -5.1479 -1.398 TD -0.003 Tc -0.0525 Tw (nity \(20%\) incidents.)Tj 1.8 -2.001 TD 0.0009 Tc 0.125 Tw [(In this study)60.9(, restraint was involved in 924 incidents)]TJ -1.8 -1.401 TD -0.0036 Tc -0.0199 Tw [(\(43%\) and was not utilized in 1,228 incidents \(57%\). Males)]TJ 0 -1.398 TD 0.0306 Tw (were restrained in 476 assaults \(52%\) and females were re-)Tj 0 -1.401 TD -0.06 Tw (strained in 428 incidents \(46%\).)Tj 1.8 -2.001 TD -0.0033 Tc 0.0744 Tw [(T)73.5(able 1 presents an analysis of the basic demographic)]TJ -1.8 -1.398 TD -0.0032 Tc 0.1023 Tw [(and clinical variables in this study for both restrained and)]TJ 0 -1.401 TD -0.0036 Tc -0.0267 Tw (nonrestrained subjects. The subjects requiring restraint were)Tj T* -0.0021 Tc 0.11 Tw [(younger \()]TJ /TT5 1 Tf 4.311 0 TD -0.0033 Tc 0 Tw (t= )Tj /TT2 1 Tf 1.308 0 TD -0.0036 Tc (5.70; )Tj /TT5 1 Tf 2.37 0 TD -0.0039 Tc 0.115 Tw (df =)Tj /TT2 1 Tf 1.806 0 TD -0.006 Tc 0 Tw (1,)Tj /TT5 1 Tf 0.744 0 TD 0.105 Tc ( p)Tj /TT2 1 Tf 0.855 0 TD -0.0036 Tc 0.113 Tw [( < .0001\) and were diagnosed)]TJ -11.394 -1.398 TD -0.0366 Tw (primarily with schizophrenia [)Tj /TT5 1 Tf 11.925 0 TD 0 Tc 0 Tw (x)Tj 5.8 0 0 5.8 444.66 531.99 Tm (2)Tj /TT2 1 Tf 10 0 0 10 447.54 528.66 Tm -0.0026 Tc -0.0375 Tw [( \(4\) =13.85, )]TJ /TT5 1 Tf 5.046 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.495 0 TD -0.0034 Tc -0.0375 Tw [( < .01] in both)]TJ -18.195 -1.401 TD -0.0046 Tc -0.0622 Tw [(acute and extended care facilities. The primary precipitant in)]TJ T* -0.0034 Tc 0 Tw (restraint episodes was negative staff attitudes, and in nonre-)Tj 0 -1.398 TD -0.0035 Tc -0.0007 Tw (straint episodes it was denial of services [)Tj /TT5 1 Tf 16.479 0 TD 0 Tc 0 Tw (x)Tj 5.8 0 0 5.8 490.2 489.99 Tm (2)Tj /TT2 1 Tf 10 0 0 10 493.11 486.66 Tm -0.0028 Tc -0.0011 Tw ( \(8\) = 80.21, )Tj /TT5 1 Tf 5.19 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.495 0 TD -0.01 Tc ( <)Tj -22.896 -1.401 TD -0.0032 Tc 0.1164 Tw [(.0001]. Chi-square analyses revealed no statistical differ-)]TJ T* -0.0033 Tc 0.025 Tw (ences for assailant gender or site of incident.)Tj 1.8 -1.998 TD -0.0158 Tc -0.0621 Tw (Those patients who were restrained committed 873 physi-)Tj -1.8 -1.401 TD -0.0049 Tc -0.0623 Tw (cal assaults \(95%\), 11 sexual assaults \(1 %\), 5 acts of nonver-)Tj T* 0.0333 Tc 0.125 Tw (bal intimidation \(0.5 %\), and 20 verbal threats \(2%\).)Tj 0 -1.398 TD 0.0157 Tc (Nonrestrained patients committed 973 physical assaults)Tj 0 -1.401 TD -0.0053 Tc -0.0622 Tw (\(79%\), 22 sexual assaults \(2%\), 32 act of nonverbal intimida-)Tj T* -0.0034 Tc -0.02 Tw [(tion assaults \(3%\), and 134 verbal threats \(11%\). These dif-)]TJ 0 -1.398 TD -0.0032 Tc 0.08 Tw (ferences were statistically significant [)Tj /TT5 1 Tf 15.576 0 TD 0 Tc 0 Tw (x)Tj 5.8 0 0 5.8 481.14 357.99 Tm (2)Tj /TT2 1 Tf 10 0 0 10 484.05 354.66 Tm -0.0029 Tc 0.08 Tw [( \(5\) = 108.28, )]TJ /TT5 1 Tf 6.009 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.495 0 TD 0.077 Tc ( <)Tj -22.809 -1.401 TD -0.003 Tc -0.0169 Tw [(.0001]. )18.1(W)55.8(ith the exception of physical assault, all other cat-)]TJ T* -0.0055 Tc -0.0621 Tw (egories revealed a disproportionately high frequency in cases)Tj 0 -1.398 TD -0.0034 Tc 0.018 Tw (where restraint was not in use.)Tj 1.8 -2.001 TD -0.0032 Tc -0.0107 Tw [(W)55.6(ith regards to the clinical variables considered singly)59.8(,)]TJ -1.8 -1.401 TD -0.0052 Tc -0.0621 Tw (there were no statistically significant differences for personal)Tj 0 -1.398 TD [(victimization and substance use disorder)54.9(. Both groups scored)]TJ 0 -1.401 TD -0.0032 Tc -0.01 Tw [(highly on histories of violence toward others. However)38.8(, the)]TJ T* -0.0542 Tw (restrained group had statistically significantly more histories)Tj 0 -1.398 TD -0.0101 Tc -0.0616 Tw (of such violence [)Tj /TT5 1 Tf 6.774 0 TD 0 Tc 0 Tw (x)Tj 5.8 0 0 5.8 393.09 225.99 Tm (2)Tj /TT2 1 Tf 10 0 0 10 395.94 222.66 Tm -0.009 Tc -0.0626 Tw [( \(2\) = 16.1)30(1, )]TJ /TT5 1 Tf 4.827 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.489 0 TD -0.0091 Tc -0.0621 Tw [( < .0001]. )56.9(An analysis of the)]TJ -12.81 -1.401 TD -0.0035 Tc -0.0307 Tw (clinical variables in their various combinations revealed that)Tj T* -0.0072 Tc -0.0625 Tw (violence toward others combined with personal victimization)Tj 0 -1.398 TD -0.003 Tc -0.0507 Tw (was statistically significantly more frequent in restrained pa-)Tj 0 -1.401 TD -0.0101 Tc -0.06 Tw (tients [)Tj /TT5 1 Tf 2.616 0 TD 0 Tc 0 Tw (x)Tj 5.8 0 0 5.8 351.51 170.01 Tm (2)Tj /TT2 1 Tf 10 0 0 10 354.39 166.65 Tm -0.0083 Tc -0.0625 Tw [( \(2\) = 8.89, )]TJ /TT5 1 Tf 4.377 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.489 0 TD -0.0096 Tc -0.0625 Tw [( < .003].)]TJ /F1 1 Tf 11 0 0 11 404.25 134.01 Tm 0.0207 Tc 0 Tw (DISCUSSION)Tj /TT2 1 Tf 10 0 0 10 339 110.64 Tm -0.001 Tc 0.1249 Tw [(W)51.8(ith regard to the demographic and precipitant vari-)]TJ -1.8 -1.398 TD -0.0002 Tc 0.125 Tw [(ables, this study)50.8(s findings are consistent with previously)]TJ 0 -1.401 TD -0.0044 Tc -0.0627 Tw [(reported )-188.2(research)-229.4(\(Bush & Shore, 2000; Evans & Fitzgerald,)]TJ ET endstream endobj 160 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT1 8 0 R /TT2 9 0 R /TT3 10 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 162 0 obj << /Length 6402 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 54 59.745 m 546 59.745 l S BT /F1 1 Tf 8 0 0 8 54.99 41.64 Tm 0 0 0 1 k /GS2 gs -0.0054 Tc 0.1 Tw [(194 )]TJ /TT3 1 Tf 2.775 0 TD 0.1016 Tw (Flannery and Walker )Tj 10.425 0 TD 0.0049 Tc (Characteristics of Patients in Restraint)Tj /TT2 1 Tf 10 0 0 10 54 292.14 Tm -0.0034 Tc -0.002 Tw [(2002; Fisher)35.6(, 1994; Flannery 2007; Solof)17.6(f et al., 1985; Zun,)]TJ 0 -1.398 TD -0.0029 Tc 0.0959 Tw [(2005\). In this study)63.1(, as in the earlier work, the restrained)]TJ 0 -1.401 TD -0.0035 Tc -0.0486 Tw (subjects were younger male/female patients with a diagnosis)Tj T* -0.0033 Tc 0.005 Tw [(of schizophrenia, af)14.7(fective disorder)38.7(, or personality disorder)35.7(,)]TJ 0 -1.398 TD -0.0037 Tc 0.0925 Tw (and common precipitants included negative staff attitudes,)Tj 0 -1.401 TD -0.0031 Tc -0.0023 Tw (acute psychosis, and denial of services. These present find-)Tj T* -0.0155 Tc -0.0623 Tw [(ings were true in both acute and extended care facilities. These)]TJ 0 -1.398 TD -0.0036 Tc 0.0313 Tw (findings have been stable for several decades and represent)Tj 0 -1.401 TD -0.0149 Tw [(risk factors to be monitored. However)38.5(, as was noted earlier)35.5(,)]TJ T* -0.0122 Tw (some patients with these same characteristics do not need to)Tj 0 -1.398 TD -0.0033 Tc 0.055 Tw [(be restrained. )17.7(Thus, this study)50.7(s findings are again consis-)]TJ 0 -1.401 TD -0.0036 Tc -0.0513 Tw (tent with previous findings that the demographic variables in)Tj T* -0.0029 Tc 0.0089 Tw (their own right yield little predictive validity of incidents in)Tj 0 -1.398 TD -0.0034 Tc -0.035 Tw (which restraints will need to be utilized.)Tj 1.8 -2.001 TD -0.0031 Tc -0.0616 Tw [(W)55.7(ith regard to the clinical variables in this study consid-)]TJ -1.8 -1.401 TD 0.0104 Tw [(ered singly)62.8(, the present findings are not consistent with ear)17.8(-)]TJ 25.5 21.6 TD -0.0625 Tw [(lier findings on restrained subjects \(Flannery et al., 2001\). In)]TJ 0 -1.398 TD -0.003 Tc 0.0371 Tw [(this study)63(, there was a strong association between a history)]TJ 0 -1.401 TD -0.0034 Tc 0.115 Tw [(of violence toward others and the need for restraint. The)]TJ T* -0.0028 Tc -0.045 Tw (earlier study \(Flannery et al., 2001\) found that females in the)Tj 0 -1.398 TD -0.0063 Tc -0.0625 Tw (community with personality disorder and personal victimiza-)Tj 0 -1.401 TD -0.0037 Tc 0.095 Tw (tion and female inpatients with personal victimization and)Tj T* -0.0032 Tc -0.0356 Tw (substance use disorder were more likely to be restrained, but)Tj 0 -1.398 TD -0.0034 Tc 0.0134 Tw [(these associations were not as strong as those in the present)]TJ 0 -1.401 TD -0.0043 Tc -0.0625 Tw [(findings. These findings for the clinical variables considered)]TJ T* 0.0037 Tc 0.1249 Tw (singly suggest that there may be strong relationships be-)Tj 0 -1.398 TD -0.0036 Tc -0.0507 Tw (tween the various clinical and demographic variable subsets,)Tj 0 -1.401 TD -0.0037 Tc 0.0287 Tw [(which need to be delineated. However)35.3(, the present findings)]TJ T* -0.0034 Tc 0.0839 Tw (may also reflect the more recent admissions of more male)Tj 0 -1.398 TD -0.0032 Tc -0.0625 Tw (patients with histories of violence toward others, or it may be)Tj 0 -1.401 TD 0.0294 Tw (that the present findings more accurately reflect the limited)Tj T* -0.0033 Tc -0.0025 Tw [(predictive values of clinical variables considered singly)59.7(.)]TJ /F1 1 Tf -2.7 63.486 TD -0.0061 Tc 0.0056 Tw [(T)79.9(a)5.9(ble 1.)]TJ -13.875 -1.2 TD -0.0105 Tc -0.0683 Tw (Characteristics of Restrained and Nonrestrained Assaultive Patients)Tj -8.274 -2.4 TD -0.0147 Tc 0 Tw [(V)58.3(ariables)]TJ 14.349 0 TD -0.0261 Tc (Restraint)Tj 16.8 0 TD -0.0212 Tc (Nonrestrained)Tj 10 0 2.1256 10 496.5 681 Tm 0 Tc (p)Tj 10 0 0 10 502.41 681 Tm -0.0212 Tc (-value)Tj -29.841 -1.2 TD -0.0144 Tc [(Incidents)-12539.4(Incidents)]TJ /TT3 1 Tf T* 0 Tc (\()Tj /F21 1 Tf 10 0 2.1256 10 207.24 657 Tm (N)Tj /TT3 1 Tf 10 0 0 10 214.29 657 Tm -0.0145 Tc -0.07 Tw [( =924\))-13064.5(\()]TJ /F21 1 Tf 10 0 2.1256 10 375.3 657 Tm 0 Tc 0 Tw (N)Tj /TT3 1 Tf 10 0 0 10 382.44 657 Tm -0.0049 Tc -0.0525 Tw [( = 1,228\))]TJ -32.193 -2.4 TD -0.0137 Tc -0.07 Tw (Demographic Variables)Tj 2.949 -2.4 TD -0.0259 Tc 0 Tw [(Age)-9700.9(33.96)-14425.9(36.89)-10075.9(.0001)]TJ 11.4 -1.2 TD 0 Tc (\()Tj ET 500 w 213.03 -403 m 207.3 -403 l S BT 10 0 0 10 207.3 597 Tm -0.0082 Tc -0.07 Tw [(+ 11.29\))-12908.2(\()]TJ ET 381.03 -403 m 375.3 -403 l S BT 10 0 0 10 375.3 597 Tm (+ 11.97\))Tj -28.53 -2.4 TD -0.0371 Tc 0 Tw (Gender)Tj 9 0 TD -0.0056 Tc -0.065 Tw [(476 Males \(52%\))-10055.6(571 Males \(47%\))]TJ /F21 1 Tf 10 0 2.1256 10 496.5 573 Tm -0.006 Tc 0 Tw (ns)Tj /TT3 1 Tf 10 0 0 10 180 561 Tm -0.0073 Tc -0.0675 Tw [(428 Females \(46%\))-8932.3(629 Females \(51%\))]TJ -9 -2.4 TD -0.0131 Tc 0 Tw [(Diagnosis)-4738.1(411 )]TJ 10.839 0 TD -0.01 Tc -0.0675 Tw [(Schizophrenia \(45%\))-6535(616 Schizophrenia \(50%\))-3385(.)10.1(0)10.1(1)]TJ -1.839 -1.2 TD -0.0049 Tc -0.0417 Tw [(170 Affective Disorder \(18%\))-4879.9(161 Affective Disorder \(13%\))]TJ T* -0.0066 Tc -0.0683 Tw [(180 Personality Disorder \(20%\))-3906.6(220 Personality Disorder \(18%\))]TJ -9 -2.4 TD -0.0049 Tc -0.0012 Tw [(Precipitants)-3829.9(56 Negative Staff Attitudes \(21%\))-2779.9(83 )27.6(Denial )27.6(of )27.6(Services )27.6(\(24%\))]TJ 9 -1.2 TD 0.0095 Tw [(46 )-15.3(Acute )-15.3(Psychosis )-15.3( )-15.3(\(17%\))-5480(61 Excess Stimulation \(17%\) .0001)]TJ T* 0.0249 Tw [(31 )53.6(Denial )53.6(of )53.6(Services )53.6(\(12%\))-5255(55 Acute Psychosis \(16%\))]TJ -11.949 -2.4 TD -0.0059 Tc -0.07 Tw (Clinical Variables)Tj 2.949 -2.4 TD -0.0053 Tc -0.02 Tw (Violence to)Tj 9 0 TD -0.0148 Tc -0.07 Tw [(746 \(93%\))-12989.8(904 \(88%\))]TJ 31.65 0 TD -0.0238 Tc 0 Tw (.001)Tj -40.65 -1.2 TD -0.0152 Tc (Others)Tj 0 -2.4 TD -0.0156 Tc -0.0692 Tw [(Personal)-5190.6(534 \(67%\))-12990.6(658 \(64%\))]TJ /F21 1 Tf 10 0 2.1256 10 496.5 381 Tm -0.006 Tc 0 Tw (ns)Tj /TT3 1 Tf 10 0 0 10 90 369 Tm 0.001 Tc (Victimization)Tj T* -0.006 Tc -0.035 Tw (Substance Use)Tj 9 0 TD -0.0148 Tc -0.07 Tw [(441 \(55%\))-12989.8(547 \(53%\))]TJ /F21 1 Tf 10 0 2.1256 10 496.5 345 Tm -0.006 Tc 0 Tw (ns)Tj /TT3 1 Tf 10 0 0 10 90 333 Tm -0.0255 Tc (Disorder)Tj ET 0.99 w 1000 M /GS1 gs 54.495 732.505 492.01 -406.01 re S 10 M 54 696.495 m 546 696.495 l 54 648.495 m 546 648.495 l S endstream endobj 163 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /F21 101 0 R /TT2 9 0 R /TT3 10 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 165 0 obj << /Length 9000 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 66 59.745 m 558 59.745 l S BT /TT3 1 Tf 8 0 0 8 423.24 42.6 Tm 0 0 0 1 k /GS2 gs -0.0051 Tc 0.0326 Tw [(IJEMH Vol. 10, No. 3 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (195)Tj /TT2 1 Tf 10 0 0 10 84 722.64 Tm -0.0032 Tc 0.0792 Tw [(This study)53.8(s findings for the clinical variables consid-)]TJ -1.8 -1.398 TD -0.0035 Tc -0.0367 Tw (ered in their various combinations are consistent in part with)Tj 0 -1.401 TD -0.0056 Tc -0.0621 Tw [(earlier findings \(Flannery et al., 2000; Flannery)57.4(, Farley)60.4(, et al.,)]TJ T* -0.0036 Tc -0.0427 Tw (2006\) in that histories of violence in combination with histo-)Tj 0 -1.398 TD 0.0519 Tw (ries of personal victimization resulted in the more frequent)Tj 0 -1.401 TD -0.0033 Tc 0.0311 Tw [(need for restraints. However)38.7(, unlike the earlier studies, the)]TJ T* -0.0034 Tc -0.014 Tw (addition of substance use disorder as a third variable did not)Tj 0 -1.398 TD 0.0833 Tw (further strengthen the association with restraint utilization.)Tj 0 -1.401 TD -0.0036 Tc 0.0725 Tw (Although it is possible that extensive exposure to violence)Tj T* 0.0045 Tc 0.125 Tw (itself may result in violent incidents where restraints are)Tj 0 -1.398 TD -0.0032 Tc 0.0867 Tw (needed, in this study there were great variations in gender)Tj 0 -1.401 TD -0.0076 Tc -0.0621 Tw [(among the various clinical combinations. )49.5(As with the clinical)]TJ T* -0.0034 Tc 0.0272 Tw [(variables considered singly)59.6(, the clinical variables in combi-)]TJ 0 -1.398 TD -0.0035 Tc 0.0981 Tw (nation may need to be considered in various demographic)Tj 0 -1.401 TD -0.0034 Tc 0.1093 Tw [(variable subsets to yield true predictive power)50.6(. However)35.6(,)]TJ T* 0.0008 Tc 0.1249 Tw (these early research findings on the clinical variables are)Tj 0 -1.398 TD -0.0035 Tc 0.027 Tw (encouraging, and further research is warranted.)Tj 1.8 -2.001 TD -0.003 Tc 0.003 Tw [(T)73.8(aken collectively)60(, the clinical variables at this point in)]TJ -1.8 -1.401 TD -0.01 Tc -0.0621 Tw [(field do not yield significant predictive power)50(. However)35(, they)]TJ 0 -1.398 TD -0.0033 Tc -0.0119 Tw (are highly associated with violence with or without restraint)Tj 0 -1.401 TD -0.0036 Tc 0.0206 Tw (and should be considered important risk factors, along with)Tj T* -0.0032 Tc -0.0019 Tw (the demographic and precipitant variables, if they are deter-)Tj 0 -1.398 TD 0.0179 Tw (mined to be present in any given patient.)Tj /F1 1 Tf 11 0 0 11 66 375.99 Tm -0.0049 Tc 0.0091 Tw (Methodological Issues)Tj /TT2 1 Tf 10 0 0 10 84 352.65 Tm -0.0035 Tc 0.0713 Tw [(This study)50.5(s findings suggest the importance of longi-)]TJ -1.8 -1.401 TD 0.1138 Tw (tudinal prospective or retrospective studies over time as a)Tj 0 -1.398 TD -0.0033 Tc 0.0462 Tw [(method of enhancing the generalizability of findings. This)]TJ 0 -1.401 TD -0.0035 Tc 0.0661 Tw [(study)50.5(s findings dif)17.5(fer from the previous findings from the)]TJ T* -0.0027 Tc 0.051 Tw [(same database 5 years earlier \(Flannery et al., 2001\). This)]TJ 0 -1.398 TD -0.0032 Tc 0.0806 Tw (may reflect methodological flaws, but it might also reflect)Tj 0 -1.401 TD -0.0034 Tc -0.0031 Tw (true change in the characteristics of restrained patient popu-)Tj T* -0.0087 Tc 0 Tw (lation.)Tj 1.8 -1.998 TD -0.0083 Tc -0.0625 Tw (This field of characteristics inquiry would benefit in gen-)Tj -1.8 -1.401 TD -0.0033 Tc -0.0157 Tw (eral from clear operational definitions of assaults, restraints,)Tj T* -0.0034 Tc 0 Tw (and the relevant demographic, precipitant, and clinical vari-)Tj 0 -1.398 TD -0.0035 Tc 0.015 Tw [(ables. Studies need to include different populations in both)]TJ 0 -1.401 TD -0.0033 Tc 0.0778 Tw (public and private sector settings and may need to include)Tj T* -0.0035 Tc 0.0043 Tw (additional clinical variables considered to be more relevant.)Tj 0 -1.398 TD 0.0025 Tc 0.125 Tw (Control groups, for comparison purposes, should be rou-)Tj 0 -1.401 TD -0.0033 Tc 0.0463 Tw [(tinely included in the findings presented. Research studies)]TJ T* -0.0034 Tc 0.0525 Tw (that include a person )Tj /TT5 1 Tf 8.691 0 TD 0 Tc 0 Tw (x)Tj /TT2 1 Tf 0.438 0 TD -0.0036 Tc 0.055 Tw [( event )]TJ /TT5 1 Tf 2.757 0 TD 0 Tc 0 Tw (x)Tj /TT2 1 Tf 0.438 0 TD -0.0036 Tc 0.0533 Tw [( environment paradigm may)]TJ -12.324 -1.398 TD -0.0034 Tc 0.0794 Tw (prove of assistance in delineating the salient variables that)Tj 0 -1.401 TD -0.0032 Tc 0.0284 Tw [(will in time enhance our ability in the field to predict when)]TJ T* -0.003 Tc -0.001 Tw [(restraints will be needed for safety)60(.)]TJ /F1 1 Tf 11 0 0 11 321 723.99 Tm -0.0046 Tc 0.0348 Tw (Implications for Emergency Services)Tj /TT2 1 Tf 10 0 0 10 339 700.65 Tm -0.0036 Tc 0.05 Tw (Similar to previous research findings on restrained pa-)Tj -1.8 -1.401 TD -0.0188 Tc -0.0622 Tw [(tients \(Busch & Shore, 2000; Evans & Fitzgerald, 2002; Fisher)35.2(,)]TJ 0 -1.398 TD -0.0126 Tc -0.0623 Tw (1994; Flannery et al., 2001; Soloff et al., 1985; Zun, 2005\), the)Tj 0 -1.401 TD -0.0086 Tc -0.0625 Tw [(present study)51.4(s findings confirm two important themes. First,)]TJ T* -0.0034 Tc -0.0407 Tw (although there are commonly recurring characteristics in pa-)Tj 0 -1.398 TD -0.0486 Tw (tients who are restrained \(younger male/female patients with)Tj 0 -1.401 TD 0.0014 Tc 0.125 Tw (a diagnosis of schizophrenia or personality disorders and)Tj T* -0.0036 Tc -0.0193 Tw (with histories of violence toward others, personal victimiza-)Tj 0 -1.398 TD -0.0034 Tc 0.0542 Tw [(tion, and substance use disorder)35.6(, who encounter psychosis,)]TJ 0 -1.401 TD -0.0032 Tc 0.0135 Tw (excess sensory stimulation, and/or denial of services\), there)Tj T* -0.0034 Tc -0.0187 Tw (are again many patients with these same characteristics who)Tj 0 -1.398 TD -0.0382 Tw [(are not restrained. Thus, predicting which individual patient)]TJ 0 -1.401 TD -0.0032 Tc 0.0493 Tw (may need restraint is problematic. Second, the findings are)Tj T* -0.0034 Tc 0.0312 Tw (also clear that restraint procedures are fraught with danger-)Tj 0 -1.398 TD -0.0053 Tc -0.0625 Tw (ous outcomes \(including death\) for the patient, innocent fam-)Tj 0 -1.401 TD 0.0088 Tc 0.125 Tw (ily members, and bystanders as well as EMS caregivers)Tj T* -0.0066 Tc -0.0625 Tw (\(Medical Directors Council, 2000; Zun, 2005\). Restraint-free)Tj 0 -1.398 TD -0.0034 Tc 0.0291 Tw (care is the better alternative whenever possible.)Tj 1.8 -2.001 TD -0.0035 Tc 0.0395 Tw [(As a first step toward this end, all EMS personnel will)]TJ -1.8 -1.401 TD -0.003 Tc 0.0585 Tw [(want to be fully trained in alternatives to restraints. These)]TJ 0 -1.398 TD 0.0394 Tw (strategies vary widely and can be adapted to individual pa-)Tj 0 -1.401 TD -0.0035 Tc 0 Tw (tient needs. Common alternatives to restraint include offer-)Tj T* 0.0761 Tw (ing the patient some space, allowing the person to express)Tj 0 -1.398 TD 0.0687 Tw (his or her feelings, providing options in collaboration with)Tj 0 -1.401 TD -0.0034 Tc 0.0794 Tw [(the patient that restore the patient)50.6(s sense of personal con-)]TJ T* -0.0033 Tc 0.0943 Tw (trol, offering calming activities \(a cigarette, writing things)Tj 0 -1.398 TD 0.007 Tc 0.125 Tw (down, listening to music, smoking a cigarette, breathing)Tj 0 -1.401 TD -0.0037 Tc -0.0624 Tw [(deeply\), and one-to-one opportunities to speak with the EMS)]TJ T* -0.0033 Tc 0.0307 Tw [(personnel onsite. EMS personnel may actually know in ad-)]TJ 0 -1.398 TD -0.0036 Tc 0.0588 Tw (vance the preferred mode of calming strategies of frequent)Tj 0 -1.401 TD -0.0039 Tc -0.0625 Tw (utilizers of emergency medical services.)Tj 1.8 -2.001 TD -0.0032 Tc 0.1178 Tw (If the various alternatives to restraint are of no assis-)Tj -1.8 -1.398 TD -0.003 Tc 0.01 Tw (tance and safety is truly being compromised, then restraints)Tj 0 -1.401 TD -0.0035 Tc -0.0139 Tw [(should be considered, as a final resort. EMS caregivers will)]TJ T* -0.004 Tc -0.0623 Tw (want to be familiar with the warning signs of potential loss of)Tj 0 -1.398 TD -0.0033 Tc 0.1033 Tw [(control \(Flannery)62.7(, in press\), and all EMS personnel in the)]TJ 0 -1.401 TD -0.003 Tc 0.027 Tw (same health-care system will want to be trained in one sys-)Tj T* -0.0035 Tc -0.028 Tw (tem of restraint, so that various team members are not work-)Tj 0 -1.398 TD 0.019 Tc 0.125 Tw (ing at cross-purposes with one another during restraint)Tj 0 -1.401 TD 0.0061 Tc (procedures. Restraints should not be undertaken by only)Tj T* -0.0033 Tc 0.0694 Tw [(two E)7.8(M)7.8(S)-3.3( )-4.9(personnel. The health-care agency or the police)]TJ 0 -1.398 TD -0.0006 Tc 0.125 Tw [(should be called to provide backup. The judicious use of)]TJ 0 -1.401 TD -0.0033 Tc -0.0506 Tw (restraints should result in enhanced safety and minimal or no)Tj T* -0.0032 Tc -0.0295 Tw [(injury to those involved. Given the serious risks involved in)]TJ 0 -1.398 TD -0.0034 Tc 0.0829 Tw (using restraints, it is important that prehospital health-care)Tj ET endstream endobj 166 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT2 9 0 R /TT3 10 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 169 0 obj << /Length 8396 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 54 59.745 m 546 59.745 l S BT /F1 1 Tf 8 0 0 8 54.99 41.64 Tm 0 0 0 1 k /GS2 gs -0.0054 Tc 0.1 Tw [(196 )]TJ /TT3 1 Tf 2.775 0 TD 0.1016 Tw (Flannery and Walker )Tj 10.425 0 TD 0.0049 Tc (Characteristics of Patients in Restraint)Tj /TT2 1 Tf 10 0 0 10 54 722.64 Tm -0.0035 Tc 0.0931 Tw (providers work toward the national health-care goal of re-)Tj 0 -1.398 TD -0.04 Tw (straint-free interventions as hospitals and outpatient services)Tj 0 -1.401 TD -0.0037 Tc 0.075 Tw (have begun to do.)Tj /F1 1 Tf 11 0 0 11 133.89 662.01 Tm 0.021 Tc 0 Tw (REFERENCES)Tj /TT2 1 Tf 10 0 0 10 54 644.64 Tm -0.0116 Tc -0.0624 Tw [(Busch, )54.5(A.B., & Shore, M.F)78.4(. \(2000\). Seclusion and restraint: )45.5(A)]TJ 1.2 -1.398 TD -0.003 Tc -0.053 Tw [(review of the literature. )]TJ /TT5 1 Tf 9.54 0 TD -0.004 Tc -0.0542 Tw [(Harvar)32(d Review of Psychiatry)55.8(,)-2.7( 8,)]TJ /TT2 1 Tf -9.54 -1.401 TD -0.0511 Tc 0 Tw (261-270.)Tj -1.2 -1.8 TD -0.0029 Tc 0.0256 Tw (Evans, D., & Fitzgerald, M. \(2002\). Reasons for physically)Tj 1.2 -1.401 TD -0.0033 Tc 0.1021 Tw [(restraining patients and residents: )53.7(A)58.9( systematic review)]TJ 0 -1.398 TD -0.0027 Tc 0.0975 Tw (and content analysis. )Tj /TT5 1 Tf 9.189 0 TD -0.004 Tc 0.0984 Tw (International Journal of Nursing)Tj -9.189 -1.401 TD -0.0085 Tc -0.06 Tw (Studies, 39,)Tj /TT2 1 Tf 4.479 0 TD -0.0096 Tc [( 735-743.)]TJ -5.679 -1.8 TD -0.0228 Tc -0.0628 Tw [(Everly)64.2(, G)115.2(.S., Jr)52.2(., & Mitchell, J.T)73.2(. \(1999\). )]TJ /TT5 1 Tf 15.171 0 TD -0.0243 Tc -0.0622 Tw [(Critical Incident S)32.7(t)3.7(r)29.7(ess)]TJ -13.971 -1.401 TD -0.0041 Tc -0.0039 Tw (Management \(CISM\): A new era and standard of care in)Tj 0 -1.398 TD -0.0037 Tc 0.1099 Tw (crisis intervention.)Tj /TT2 1 Tf 7.539 0 TD -0.0033 Tc 0.1151 Tw [( 2nd ed. Ellicott City)62.7(, MD: Chevron)]TJ -7.539 -1.401 TD -0.0043 Tc -0.04 Tw (Publishing Corp.)Tj -1.2 -1.8 TD -0.0035 Tc -0.0504 Tw [(Fisher)35.5(, )17.7(W)106.3(.A. \(1994\). Restraint and seclusion: )50.7(A)58.7( review of the)]TJ 1.2 -1.401 TD -0.0176 Tc 0 Tw (literature. )Tj /TT5 1 Tf 3.84 0 TD -0.0185 Tc -0.0619 Tw [(American Journal of Psychiatry)56.3(,)-1( 151, )]TJ /TT2 1 Tf 14.256 0 TD -0.0199 Tc 0 Tw (1584-1591.)Tj -19.296 -1.8 TD -0.0028 Tc 0.0838 Tw [(Flannery)60.2(, R.B., Jr)51.2(. \(1998\). )]TJ /TT5 1 Tf 10.926 0 TD -0.0045 Tc 0.0672 Tw [(The Assaulted )-16.2(S)31.5(taff Action )-16.7(Pr)28.5(o-)]TJ -9.726 -1.398 TD -0.0061 Tc 0.08 Tw (gram \(ASAP\))Tj /TT2 1 Tf 5.379 0 TD -0.0038 Tc 0 Tw (: )Tj /TT5 1 Tf 0.612 0 TD -0.004 Tc 0.0825 Tw (Coping with the psychological aftermath)Tj -5.991 -1.401 TD -0.0035 Tc -0.04 Tw (of violence.)Tj /TT2 1 Tf 4.53 0 TD -0.0034 Tc -0.0443 Tw [( Ellicott City MD: Chevron Publishing Corp.)]TJ -5.73 -1.8 TD -0.0029 Tc -0.0486 Tw [(Flannery)60.1(, R.B., Jr)54.1(. \(2007\). Precipitants to psychiatric patient)]TJ 1.2 -1.401 TD -0.0058 Tc -0.0625 Tw (assaults on staff: Review of findings, 2004-2006, with im-)Tj 0 -1.398 TD -0.0035 Tc -0.04 Tw (plications for EMS and other health care providers. )Tj /TT5 1 Tf 20.244 0 TD -0.0042 Tc 0 Tw (Inter-)Tj -20.244 -1.401 TD -0.0037 Tc 0.03 Tw (national Journal of Emergency Mental Health, 9, )Tj /TT2 1 Tf 20.061 0 TD -0.0048 Tc 0 Tw (5-11.)Tj -21.261 -1.8 TD -0.0089 Tc -0.0607 Tw [(Flannery)60.1(, R.B., Jr)57.1(. \(in press\). )]TJ /TT5 1 Tf 11.16 0 TD -0.0103 Tc -0.0631 Tw [(The violent person: Pr)34.7(ofessional)]TJ -9.96 -1.401 TD -0.0098 Tc -0.0625 Tw [(risk management strategies for safety and car)35.2(e.)]TJ /TT2 1 Tf 18.159 0 TD -0.0108 Tc [( New )28.2(Y)102.4(ork,)]TJ -18.159 -1.398 TD -0.004 Tc -0.0614 Tw [(N)9.3(Y)86(: )52.8(American Mental Health Foundation.)]TJ -1.2 -1.8 TD -0.0319 Tc -0.0619 Tw [( )-8.8(Flannery)64.1(, R.B., Jr)52.1(., Farley)64.1(, E.M., Rego, S., & )16.7(W)98.9(alker)31.1(, )55.7(A.P)103.1(. \(2006\).)]TJ 1.2 -1.401 TD -0.0032 Tc 0.0472 Tw (Characteristics of staff victims of psychiatric patient as-)Tj T* -0.0033 Tc -0.0353 Tw [(saults: Fifteen-year analysis of the )51.1(Assaulted S)17.7(taf)17.7(f )51.1(Action)]TJ 0 -1.398 TD -0.0048 Tc -0.06 Tw (Program \(ASAP\). )Tj /TT5 1 Tf 7.224 0 TD -0.062 Tw [(Psychiatric Quar)-7.8(terly)52.2(, 78,)]TJ /TT2 1 Tf 10.212 0 TD -0.065 Tw [( 25-37.)]TJ 6.864 46.899 TD -0.0031 Tc 0.0246 Tw [(Flannery)59.9(, R.B., Jr)53.9(., Hanson, M.A., Corrigan, M., & )18.1(W)94.8(alker)35.9(,)]TJ 1.2 -1.401 TD -0.0034 Tc 0.0964 Tw [(A.P)107.6(. \(2006\). Past violence, substance use, and precipi-)]TJ 0 -1.398 TD -0.0027 Tc 0.0458 Tw (tants to psychiatric patients assaults: Eleven-year analy-)Tj 0 -1.401 TD -0.0039 Tc -0.0321 Tw [(sis of the )50.2(Assaulted S)17.1(taf)17.1(f )50.2(Action Program \(ASAP\). )]TJ /TT5 1 Tf 20.265 0 TD -0.0045 Tc 0 Tw [(Inter)16.5(-)]TJ -20.265 -1.401 TD -0.0037 Tc 0.1193 Tw (national Journal of Emergency Mental Health, 8, )Tj /TT2 1 Tf 20.685 0 TD -0.006 Tc 0 Tw (157-)Tj -20.685 -1.398 TD -0.0583 Tc (163.)Tj -1.2 -1.8 TD -0.0175 Tc -0.0622 Tw [(Flannery)63.5(, R.B., Jr)45.5(., Rachlin, S., & )18.8(W)95.3(alker)39.5(, )51.8(A.P)102.5(. \(2001\). Charac-)]TJ 1.2 -1.401 TD -0.0028 Tc 0.0287 Tw (teristics of patients in restraints: Six-year analysis of the)Tj T* -0.0041 Tc 0.0823 Tw [(Assaulted S)16.9(taf)13.9(f )52.7(Action Program \(ASAP\). )]TJ /TT5 1 Tf 17.274 0 TD -0.0043 Tc 0 Tw (International)Tj -17.274 -1.398 TD -0.0038 Tc -0.02 Tw (Journal of Emergency Mental Health, 3,)Tj /TT2 1 Tf 15.951 0 TD -0.0042 Tc -0.0251 Tw [( 211-216.)]TJ -17.151 -1.8 TD -0.0029 Tc 0.0504 Tw [(Flannery)60.1(, R.B., Jr)54.1(., S)18.1(tevens, )16(V)134.3(., Juliano, J., & )19(W)95(alker)39.1(, )52(A.P)105.1(.)]TJ 1.2 -1.401 TD -0.0035 Tc -0.0025 Tw (\(2000\). Past violence, substance use disorder and subse-)Tj T* 0.002 Tc 0.125 Tw (quent violence toward others: Six-year analysis of the)Tj 0 -1.398 TD -0.0041 Tc 0.0823 Tw [(Assaulted S)16.9(taf)13.9(f )52.7(Action Program \(ASAP\). )]TJ /TT5 1 Tf 17.274 0 TD -0.0043 Tc 0 Tw (International)Tj -17.274 -1.401 TD -0.0038 Tc -0.02 Tw (Journal of Emergency Mental Health, 2,)Tj /TT2 1 Tf 15.951 0 TD -0.0042 Tc -0.0251 Tw [( 241-247.)]TJ -17.151 -1.8 TD -0.0164 Tc -0.0622 Tw [(Lion, J.R., Snyder)37.6(,)-7.6( )19.6(W)105.4(., & Merrill, G)118.6(.C. \(1981\). Underreporting)]TJ 1.2 -1.401 TD -0.003 Tc -0.0373 Tw (of assaults on staff in a state hospital. )Tj /TT5 1 Tf 14.979 0 TD -0.0044 Tc -0.0375 Tw (Hospital and Com-)Tj -14.979 -1.398 TD -0.0039 Tc 0.1181 Tw [(munity Psychiatry)55.9(,)-1.7( 32)]TJ /TT2 1 Tf 8.85 0 TD -0.0041 Tc 0.115 Tw (, 497-498)Tj /TT5 1 Tf 3.915 0 TD 0 Tc 0 Tw (.)Tj /TT2 1 Tf 0.249 0 TD -0.004 Tc 0.12 Tw [( Massachusetts Depart-)]TJ -13.014 -1.401 TD -0.0036 Tc -0.06 Tw (ment of Mental Health \(1996\). )Tj /TT5 1 Tf 12.279 0 TD -0.0042 Tc -0.0625 Tw (Clinical guidelines: DMH)Tj -12.279 -1.401 TD -0.0035 Tc 0.0318 Tw (clients with a history of trauma.)Tj /TT2 1 Tf 12.825 0 TD -0.0044 Tc 0.0331 Tw [( Boston, MA: )50.2(Author)49.6(.)]TJ -14.025 -1.8 TD 0.0019 Tc 0.125 Tw [(Medical Directors Council, National )49.9(Association of S)13.9(tate)]TJ 1.2 -1.398 TD -0.0142 Tc -0.0621 Tw (Mental Health Program Directors \(2000\). Reducing the use)Tj 0 -1.401 TD -0.0034 Tc 0.0879 Tw (of seclusion and restraint: Findings, strategies, and rec-)Tj T* -0.0046 Tc 0 Tw (ommendations. )Tj /TT5 1 Tf 6.294 0 TD -0.0044 Tc -0.0336 Tw [(Emer)28.6(gency Psychiatry)52.5(,)-2.4( 6,)]TJ /TT2 1 Tf 10.026 0 TD -0.0036 Tc -0.035 Tw [( 7-13.)]TJ -17.52 -1.8 TD -0.0049 Tc -0.0618 Tw [(Solof)13.1(f, P)106.1(.H., Gutheil, )13.5(T)77.9(.)1.3(G)115.1(., & )16.5(W)92.9(exler)34.1(, D.B. \(1985\). Seclusion)]TJ 1.2 -1.398 TD -0.0034 Tc 0.0037 Tw [(and restraint in 1995: )50.5(A)58.8( review and update. )]TJ /TT5 1 Tf 17.349 0 TD -0.0044 Tc 0.005 Tw (Hospital and)Tj -17.349 -1.401 TD -0.005 Tc -0.0595 Tw [(Community Psychiatr)-5(y)54.8(,)-1( 36,)]TJ /TT2 1 Tf 10.599 0 TD -0.0053 Tc -0.0649 Tw [( 652-657.)]TJ -11.799 -1.8 TD -0.0033 Tc 0.1025 Tw (Zun, L.S. \(2005\). Evidence-based treatment of psychiatric)Tj 1.2 -1.401 TD -0.0028 Tc -0.0175 Tw (patient. )Tj /TT5 1 Tf 3.411 0 TD -0.0039 Tc (Journal of Emergency Medicine, 28,)Tj /TT2 1 Tf 14.409 0 TD -0.0041 Tc -0.02 Tw [( 277-283.)]TJ /TT5 1 Tf 9 0 0 9 408 269.01 Tm -0.0052 Tc 0.0236 Tw (Manuscript submitted March 23, 2008)Tj 0.3333 -1.78 TD -0.005 Tc -0.0055 Tw (Manuscript accepted August 14, 2008)Tj ET endstream endobj 170 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT2 9 0 R /TT3 10 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 172 0 obj << /Length 5315 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 66 59.745 m 558 59.745 l S BT /TT3 1 Tf 8 0 0 8 423.24 42.6 Tm 0 0 0 1 k /GS2 gs -0.0051 Tc 0.0326 Tw [(IJEMH Vol. 10, No. 3 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (197)Tj /TT3 1 Tf 7 0 0 7 120.66 726.66 Tm -0.0061 Tc 0.021 Tw [(International Journal of Emergency Mental Health, Vol. 10, No. 3, pp. 197-202 2008 Chevron Publishing ISSN 1522-4821)]TJ /TT4 1 Tf 10 0 0 10 102.99 459.36 Tm 0.0026 Tc 0 Tw (Abstract: )Tj /TT5 1 Tf 4.185 0 TD 0.0037 Tc 0.125 Tw (Approaching an individual or a family with bad news, but without an appropriate plan to)Tj -4.185 -1.302 TD 0.0009 Tc 0.1252 Tw [(pr)30.9(esent the information in a str)-5.1(uctur)30.9(ed manner)105.9(, is almost a guarantee of gr)30.9(eater emotional pain and)]TJ 0 -1.299 TD 0.0166 Tc 0.125 Tw (disruption for the recipients of the news. Crisis interveners must develop a strategic plan for the)Tj T* -0.0036 Tc 0.0023 Tw (announcement of bad news. That plan should entail a lead-up phase, a transmission phase, and a follow-)Tj 0 -1.302 TD -0.0024 Tw (up phase. The lead-up phase encompasses the gathering of accurate, verifiable information and the clear)Tj 0 -1.299 TD -0.0037 Tc 0.0896 Tw (identification of the targets of the information. The transmission phase includes immediate preparation)Tj T* 0.0036 Tc 0.1249 Tw [(for the presentation of the information, the actual announcement, and the presentation of additional)]TJ 0 -1.302 TD 0.0011 Tc 0.125 Tw (details as questions arise. The follow-up phase includes a range of supportive interventions to assist)Tj 0 -1.299 TD -0.0035 Tc -0.0144 Tw [(people in the immediate crisis reaction. It also includes a system of referrals for people who might benefit)]TJ T* 0.0764 Tw [(from additional professional care. This article provides practical guidelines for providing bad news to)]TJ 0 -1.302 TD 0.0939 Tw [(the loved ones of injured, ill, or deceased people. )-6.6([International Journal of Emergency Mental Health,)]TJ 0 -1.299 TD -0.0025 Tc 0.125 Tw (2008, 10\(3\), pp. 197-202].)Tj /TT1 1 Tf 9 0 0 9 117.39 287.01 Tm -0.0055 Tc -0.0139 Tw (Key words: )Tj /TT5 1 Tf 5.0833 0 TD -0.0048 Tc -0.0169 Tw (Crisis intervention, death notification, injury notification, crisis communications, announcing bad news)Tj ET /GS1 gs 66 125.745 m 299.01 125.745 l S BT 9 0 0 9 66 108 Tm /GS2 gs -0.0156 Tc -0.0619 Tw [(Jeffr)27.7(ey T)67.7(.)-0.6( Mitchell, PhD is a Clinical Pr)34.4(ofessor of Emer)34.4(gency Health)]TJ 0 -1.2233 TD 0.0144 Tc 0.125 Tw [(Services at the University of Maryland in Baltimor)31.1(e County)47.7(.)]TJ 0 -1.22 TD -0.0197 Tc -0.0627 Tw (Correspondence this article should be directed to jmitch@umbc.edu.)Tj /F1 1 Tf 14 0 0 14 193.41 629.34 Tm -0.0057 Tc 0.1101 Tw (A Short Guide to Giving Bad News)Tj /TT2 1 Tf 10 0 0 10 84.99 241.65 Tm -0.0032 Tc -0.006 Tw [(Death, you know)62.8(, is awfully permanent. It was with)]TJ -1.8 -1.401 TD -0.0037 Tc 0.0625 Tw (these words that the famous thoracic surgeon and founder)Tj 0 -1.398 TD -0.0035 Tc 0.0265 Tw [(of the Maryland Shock )14.7(T)37.3(rauma Center)38.5(, R. )53.8(Adams Cowley)59.5(,)]TJ 0 -1.401 TD -0.0037 Tc 0.0212 Tw (began his welcoming talk to the new regional coordinators)Tj T* -0.0032 Tc 0.0782 Tw [(in 1974. I was one of the five eager Emergency Medical)]TJ 0 -1.398 TD 0.0022 Tc 0.125 Tw (Services coordinators who had recently been selected to)Tj 0 -1.401 TD -0.0089 Tc -0.0622 Tw [(help develop the statewide EMS system. Little did I know)66.1(, at)]TJ T* -0.0036 Tc 0.0106 Tw (that particular moment, the driving force those words were)Tj 12 0 0 12 272.01 593.64 Tm -0.0309 Tc -0.072 Tw [(Jef)11.6(frey T)79.9(.)-0.9( )-12.5(Mitchell)]TJ 10 0 0 10 265.26 581.01 Tm 0.0023 Tc -0.02 Tw (University of Maryland)Tj /TT5 1 Tf 12 0 0 12 117.75 528.66 Tm -0.0049 Tc 0.0268 Tw [(It is my painful duty to inform you that a r)32.6(epor)-4.9(t has this day been r)30.1(eceived fr)32.6(o)9.8(m)]TJ 8.1875 -1.1675 TD -0.0047 Tc 0.0511 Tw [(the W)87.8(ar Office notifying the death of...)]TJ /TT2 1 Tf 10 0 0 10 102.75 495.69 Tm 0.0003 Tc -0.0623 Tw [( - )-5.5(From a standard British Army Form B 104-82 in use in October)36.3(, 1914. )21.5(W)95.1(ar Of)12.3(fice, )18.5(Whitehall, London.)]TJ 21.825 -25.404 TD -0.0033 Tc 0.0254 Tw [(for Dr)50.7(. Cowley and would later become for each one of the)]TJ 0 -1.401 TD 0.0064 Tc 0 Tw (coordinators.)Tj 1.8 -1.998 TD -0.0038 Tc -0.035 Tw (Once we had exposures in our work to numerous severe)Tj -1.8 -1.401 TD 0.0198 Tc 0.1249 Tw [(injuries and deaths, Dr)49.8(. Cowley)52.8(s words echoed in our)]TJ T* -0.0037 Tc -0.0183 Tw (thoughts and reminded us that the alleviation of human mis-)Tj 0 -1.398 TD -0.0033 Tc 0.0035 Tw (ery and the saving of lives was our most important mission.)Tj 0 -1.401 TD -0.0027 Tc -0.02 Tw [(Probably because of my training in psychology)60.3(, another les-)]TJ T* -0.0032 Tc 0.0237 Tw [(son was in store for me. Death, of course, is permanent, as)]TJ 0 -1.398 TD -0.0033 Tc -0.0188 Tw [(D)7.9(r)50.7(. Cowley warned. )14.9(That was beyond doubt; no one ar)17.7(gued)]TJ 0 -1.401 TD -0.0034 Tc 0.0066 Tw [(against that fact. I found, however)38.6(, that the announcements)]TJ T* -0.0036 Tc 0.0794 Tw (concerning the misfortunes of others also left a permanent)Tj ET endstream endobj 173 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT1 8 0 R /TT2 9 0 R /TT3 10 0 R /TT4 20 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 175 0 obj << /Length 8722 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 54 59.745 m 546 59.745 l S BT /F1 1 Tf 8 0 0 8 54.99 41.64 Tm 0 0 0 1 k /GS2 gs -0.0054 Tc 0.0563 Tw [(198 )]TJ /TT3 1 Tf 2.6437 0 TD -0.0056 Tc 0.057 Tw (Mitchell A Short Guide to Giving Bad News)Tj /TT2 1 Tf 10 0 0 10 54 722.64 Tm -0.0035 Tc -0.0146 Tw [(mark on the minds of the recipients of the bad news. Some-)]TJ 0 -1.398 TD -0.0033 Tc -0.0543 Tw (times it even left its mark on me.)Tj 1.8 -2.001 TD -0.014 Tc -0.0625 Tw (Early in my career experience, I concluded that informing)Tj -1.8 -1.401 TD -0.0038 Tc -0.0622 Tw (people of terrible things that will scar and distort their lives is)Tj 0 -1.398 TD -0.0031 Tc 0.1249 Tw [(among the most unpleasant of tasks. )50.8(Although I am cur)17.9(-)]TJ 0 -1.401 TD -0.003 Tc 0.0116 Tw (rently more skillful in providing various types of bad news,)Tj T* -0.0057 Tc -0.0622 Tw (the task remains for me a challenging and painful experience.)Tj 0 -1.398 TD -0.0034 Tc -0.0454 Tw (I have long ago given up the idea that further experience will)Tj 0 -1.401 TD -0.0029 Tc -0.0354 Tw [(make it less painful. My hope for this article, however)36.1(, is to)]TJ T* -0.0106 Tc -0.0625 Tw (pass along some practical guidelines that can make announce-)Tj 0 -1.398 TD -0.0037 Tc -0.0367 Tw (ments of bad news a more organized approach that mitigates)Tj 0 -1.401 TD -0.0034 Tc -0.0155 Tw (the pain both for the messenger and for the recipients of bad)Tj T* 0.005 Tc 0 Tw (news.)Tj /F1 1 Tf 11 0 0 11 54 516 Tm -0.0054 Tc 0.0613 Tw (Who Should Provide Bad News?)Tj /TT2 1 Tf 10 0 0 10 72 492.66 Tm -0.0032 Tc 0.1085 Tw (Some may hold tenaciously to the unsupported belief)Tj -1.8 -1.401 TD -0.0033 Tc 0.0018 Tw (that only medical doctors or mental health professionals are)Tj T* -0.0056 Tc -0.0622 Tw [(properly trained to give bad news. In reality)57.4(, few profession-)]TJ 0 -1.398 TD -0.0035 Tc -0.0306 Tw (als receive training in their graduate programs to allow them)Tj 0 -1.401 TD 0.0167 Tw (to skillfully provide announcements of painful information.)Tj T* -0.0034 Tc 0.035 Tw (There is evidence, on the other hand, to suggest that caring)Tj 0 -1.398 TD -0.0029 Tc 0.0388 Tw [(emergency personnel, as well as many others, are quite ca-)]TJ 0 -1.401 TD -0.0037 Tc -0.0193 Tw (pable of making appropriate announcements of deaths, inju-)Tj T* -0.0065 Tc -0.0623 Tw [(ries, and other disturbing news. For instance, in a 2005 study)62.5(,)]TJ 0 -1.398 TD -0.0038 Tc 0.1133 Tw (family members who received death announcements from)Tj 0 -1.401 TD -0.0035 Tc 0.0087 Tw (emergency personnel concerning a loved one were asked to)Tj T* -0.0033 Tc -0.0232 Tw [(evaluate their helpfulness at the scene. 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Gerald)]TJ 0 -1.398 TD -0.0068 Tc -0.0625 Tw (Caplan \(1961; 1964; 1969\) accurately predicted long ago that)Tj 0 -1.401 TD (excellent help could be provided by family members, friends,)Tj T* -0.0037 Tc 0.0233 Tw (colleagues, and others without advanced academic degrees.)Tj 0 -1.398 TD -0.0033 Tc -0.0375 Tw [(His encouragement of family and peer support in crisis situ-)]TJ 0 -1.401 TD -0.0035 Tc 0.0244 Tw (ations set the foundation for current Critical Incident Stress)Tj T* -0.0041 Tc 0.0175 Tw (Management programs around the world.)Tj /F1 1 Tf 11 0 0 11 54 132 Tm -0.0045 Tc 0.0534 Tw (General Principles of Crisis Communications)Tj /TT2 1 Tf 10 0 0 10 72 108.66 Tm -0.0032 Tc 0.0373 Tw [(In both )15(W)97.6(orld )18(W)94.6(ar I and )18(W)94.6(orld )15(W)97.6(ar II, the receipt of a)]TJ -1.8 -1.401 TD -0.0028 Tc 0.0515 Tw (death notification by telegram or mail, instead of by a per-)Tj T* -0.0037 Tc -0.0413 Tw [(sonal messenger)35.3(, must have been a horrible shock. )17.5(The quo-)]TJ 25.5 64.2 TD -0.0061 Tc -0.0622 Tw (tation above from a British standard 1914 military death noti-)Tj 0 -1.398 TD -0.0034 Tc -0.003 Tw (fication form is evidence of the starkness of such a notifica-)Tj 0 -1.401 TD -0.0095 Tc -0.062 Tw [(tion process \(British )50.7(Army)59.5(, 1914\). )20.7(The notification form does)]TJ T* 0.0025 Tc 0.125 Tw (nothing to prepare the recipient to receive the bad news.)Tj 0 -1.398 TD -0.0037 Tc 0.0043 Tw (Furthermore, it provides no support after the announcement)Tj 0 -1.401 TD -0.0025 Tc 0.0195 Tw [(of the tragedy)60.5(. It is only barely adequate in one thing the)]TJ T* -0.0039 Tc 0.0488 Tw (actual announcement of bad news.)Tj 1.8 -1.998 TD -0.0031 Tc 0.104 Tw [(For the bearer of bad news, there should always be a)]TJ -1.8 -1.401 TD -0.0036 Tc -0.055 Tw (three-phase approach. Begin with a )Tj /TT5 1 Tf 13.986 0 TD -0.0051 Tc 0 Tw (lead-up)Tj /TT2 1 Tf 3.024 0 TD -0.0037 Tc -0.055 Tw [( to the announce-)]TJ -17.01 -1.401 TD -0.003 Tc -0.0544 Tw [(ment. This is then followed by the actual )]TJ /TT5 1 Tf 16.215 0 TD -0.0047 Tc 0 Tw (transmission)Tj /TT2 1 Tf 5.061 0 TD -0.0034 Tc -0.055 Tw [( of the)]TJ -21.276 -1.398 TD -0.0028 Tc 0.02 Tw [(news. Finally there must be a )]TJ /TT5 1 Tf 12.276 0 TD -0.0043 Tc 0 Tw (follow-up )Tj /TT2 1 Tf 4.065 0 TD -0.0035 Tc 0.0217 Tw (phase after the an-)Tj -16.341 -1.401 TD 0.0038 Tc 0 Tw (nouncement.)Tj 1.8 -2.001 TD -0.0037 Tc 0.1129 Tw (The lead-up phase includes the gathering of adequate)Tj -1.8 -1.398 TD -0.0036 Tc 0.1221 Tw (information regarding the event and its consequences, the)Tj 0 -1.401 TD -0.0034 Tc 0.071 Tw (preparation of an individual or a team to deliver the news,)Tj T* -0.0029 Tc 0.049 Tw (and the development of a strategy for the delivery of crisis)Tj 0 -1.398 TD -0.0036 Tc 0.02 Tw (intervention services in the aftermath of the announcement.)Tj 0 -1.401 TD 0.0978 Tw (The lead up also includes obtaining the correct address or)Tj T* -0.0028 Tc 0.005 Tw (delivery site of the news.)Tj 1.8 -1.998 TD -0.0036 Tc 0.0606 Tw (The transmission phase of the process includes a brief)Tj -1.8 -1.401 TD 0.1206 Tw (introduction and initial preparation of the people about to)Tj T* -0.0123 Tc -0.0625 Tw (receive disturbing information. Next, carefully selected words)Tj 0 -1.398 TD -0.0035 Tc 0.0822 Tw (are delivered to assure as complete a message as possible.)Tj 0 -1.401 TD -0.0033 Tc -0.0346 Tw [(Finally)62.7(, it is important to provide answers to questions about)]TJ T* 0.0007 Tc 0.125 Tw (the circumstances of the disturbing event and the current)Tj 0 -1.398 TD -0.0035 Tc 0.0325 Tw (condition of their loved ones.)Tj 1.8 -2.001 TD -0.0034 Tc 0.0864 Tw (The approach you take toward shocked, grieving, and)Tj -1.8 -1.401 TD -0.0084 Tc -0.0622 Tw (emotionally overwhelmed people in the aftermath of distress-)Tj 0 -1.398 TD -0.0032 Tc 0.1205 Tw (ing information regarding the serious injury or death of a)Tj 0 -1.401 TD -0.0033 Tc 0.0505 Tw (loved one can leave lasting effects on those who hear your)Tj T* -0.0034 Tc 0.0394 Tw [(news. Emergency personnel and other crisis workers enter)]TJ 0 -1.398 TD -0.003 Tc 0.0395 Tw (the lives of distressed people when they are especially vul-)Tj 0 -1.401 TD -0.0034 Tc -0.0068 Tw (nerable to further duress. If crisis intervention personnel are)Tj T* -0.0031 Tc 0.0731 Tw (professional, sensitive, and caring, they do make a signifi-)Tj 0 -1.398 TD -0.0033 Tc 0.0517 Tw (cant difference in assisting people through a state of crisis.)Tj 0 -1.401 TD -0.0036 Tc 0.0492 Tw (Emergency personnel and crisis interventionists need com-)Tj T* 0.0021 Tc 0.125 Tw (mon sense, compassion, confidence, and courage as they)Tj 0 -1.398 TD -0.003 Tc -0.0619 Tw [(assist in a crisis. If they act in a haphazard manner)39(, with little)]TJ 0 -1.401 TD -0.0616 Tw (regard for the people they should be serving, irreparable psy-)Tj T* -0.0036 Tc -0.0158 Tw (chological harm might be the end result.)Tj 1.8 -1.998 TD -0.0488 Tw [(From the very moment that the task of informing people)]TJ -1.8 -1.401 TD -0.0139 Tc -0.0625 Tw (of bad news is recognized, assessment skills as well as people)Tj T* -0.0035 Tc -0.0523 Tw [(skills become paramount. It is important to gather informa-)]TJ 0 -1.398 TD -0.0032 Tc 0.0191 Tw (tion, make plans, and initiate the right care at the right time)Tj 0 -1.401 TD 0.0044 Tc 0.125 Tw [(and under the best circumstances. Messengers must use)]TJ ET endstream endobj 176 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT2 9 0 R /TT3 10 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 178 0 obj << /Length 8580 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 66 59.745 m 558 59.745 l S BT /TT3 1 Tf 8 0 0 8 423.24 42.6 Tm 0 0 0 1 k /GS2 gs -0.0051 Tc 0.0326 Tw [(IJEMH Vol. 10, No. 3 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (199)Tj /TT2 1 Tf 10 0 0 10 66 722.64 Tm -0.0034 Tc -0.0256 Tw (their skills in combination with the seven primary principles)Tj 0 -1.398 TD -0.0033 Tc 0.0886 Tw [(of crisis intervention. )17.7(Those principles include simplicity)59.7(,)]TJ 0 -1.401 TD -0.0028 Tc 0.0339 Tw [(brevity)63.2(, innovation, practicality)60.2(, proximity)60.2(, immediacy)63.2(, and)]TJ T* -0.0032 Tc -0.0164 Tw [(expectancy \(Aguilera, 1998; Mitchell, 2004\). )50.8(A)59( summary of)]TJ 0 -1.398 TD -0.0035 Tc -0.01 Tw (the seven principles of crisis intervention are presented here)Tj 0 -1.401 TD 0.028 Tw (for the convenience of the readers:)Tj 12 0 0 12 78 632.64 Tm 0 Tc 0 Tw ()Tj 10 0 0 10 96 632.64 Tm -0.003 Tc -0.055 Tw (Simplicity When they are in a state of crisis, people)Tj 0 -1.398 TD -0.0037 Tc 0.0967 Tw (respond to simple instructions, not complex proce-)Tj 0 -1.401 TD 0.0118 Tc 0 Tw (dures.)Tj 12 0 0 12 78 584.64 Tm 0 Tc ()Tj 10 0 0 10 96 584.64 Tm -0.0029 Tc 0.0237 Tw (Brevity Most crisis interventions are very short in)Tj 0 -1.398 TD -0.0032 Tc -0.0342 Tw [(duration. Some take only a few minutes.)]TJ 12 0 0 12 78 550.65 Tm 0 Tc 0 Tw ()Tj 10 0 0 10 96 550.65 Tm -0.0038 Tc 0.075 Tw (Innovation Providers must be creative to manage)Tj 0 -1.401 TD -0.0035 Tc 0.125 Tw (new situations.)Tj 12 0 0 12 78 516.66 Tm 0 Tc 0 Tw ()Tj 10 0 0 10 96 516.66 Tm -0.0035 Tc 0.0493 Tw (Pragmatism Suggestions must be practical if they)Tj T* -0.0575 Tw (are to work.)Tj 12 0 0 12 78 482.64 Tm 0 Tc 0 Tw ()Tj 10 0 0 10 96 482.64 Tm -0.0033 Tc -0.0225 Tw (Proximity Most effective contacts are closer to op-)Tj 0 -1.398 TD -0.0037 Tc 0.005 Tw (erational zones.)Tj 12 0 0 12 78 448.65 Tm 0 Tc 0 Tw ()Tj 10 0 0 10 96 448.65 Tm -0.0078 Tc -0.0624 Tw [(Immediacy )52.3(A)57.4( state of crisis demands rapid interven-)]TJ 0 -1.401 TD -0.0014 Tc 0 Tw (tion.)Tj 12 0 0 12 78 414.66 Tm 0 Tc ()Tj 10 0 0 10 96 414.66 Tm -0.0034 Tc -0.0057 Tw (Expectancy The crisis worker sets up expectations)Tj T* -0.0037 Tc 0.0325 Tw (of a reasonable positive outcome.)Tj -1.2 -2.001 TD -0.0035 Tc 0.023 Tw [(Bad news should be accurate and current. It should be)]TJ -1.8 -1.398 TD -0.0033 Tc 0.0082 Tw [(as complete as possible at the time of its delivery)59.7(. )17.7(The mes-)]TJ 0 -1.401 TD 0.0141 Tc 0.125 Tw (senger should be sensitive toward and respectful of the)Tj T* 0.0007 Tc [(people who are receiving the news. No one should rush)]TJ 0 -1.398 TD -0.0038 Tc 0.0435 Tw [(through an announcement of disturbing news. Information)]TJ 0 -1.401 TD -0.0037 Tc 0.0122 Tw (should be given in small segments and the people receiving)Tj T* -0.0169 Tw (the information should be allowed brief pauses between bits)Tj 0 -1.398 TD -0.0034 Tc 0.0195 Tw [(of information. These pauses usually allow enough time to)]TJ 0 -1.401 TD 0.125 Tw (absorb one or two sentences before the messenger moves)Tj T* -0.0035 Tc 0.055 Tw [(on. Some people refer to this as giving bad news in bite-)]TJ 0 -1.398 TD -0.0034 Tc 0.0137 Tw [(sized pieces. Questions and repetitions or clarifications of)]TJ 0 -1.401 TD 0.1206 Tw (information should be allowed at any time during the an-)Tj T* 0.0393 Tc 0.125 Tw [(nouncement \(Greenber)15.3(g, Ochsensshlager)39.3(, ODonnell,)]TJ 0 -1.398 TD -0.0037 Tc -0.0282 Tw (Mastruserio, & Cohen, 1999; Iserson, 1999; Nardi & Keefe-)Tj 0 -1.401 TD -0.0212 Tc -0.06 Tw (Cooperman, 2006\).)Tj /F1 1 Tf 11 0 0 11 66 152.01 Tm -0.0059 Tc 0.0455 Tw (The Lead-up)Tj /TT2 1 Tf 10 0 0 10 84 128.64 Tm -0.0034 Tc -0.0044 Tw (All the pertinent facts of a situation should be available)Tj -1.8 -1.398 TD 0.002 Tc 0.125 Tw [(to the person or team delivering the news before anyone)]TJ 0 -1.401 TD -0.0034 Tc -0.0172 Tw [(approaches the family members or friends. Cell phones and)]TJ T* -0.0433 Tw (emails can be a problem because friends, distant relatives, or)Tj 0 -1.398 TD -0.003 Tc -0.0362 Tw (acquaintances may contact the primary family and make un-)Tj 25.5 64.998 TD -0.0037 Tc -0.0592 Tw (authorized, premature announcements that cause great harm.)Tj 0 -1.398 TD 0.0046 Tc 0.125 Tw (The gathering of information must, therefore, be accom-)Tj 0 -1.401 TD -0.0059 Tc -0.0625 Tw [(plished quickly)60.1(.)0( Important, potentially upsetting information)]TJ T* -0.0034 Tc 0.0118 Tw [(regarding a loved one should be as precise as possible. Ev-)]TJ 0 -1.398 TD -0.0623 Tw (ery reasonable attempt should be made to verify the informa-)Tj 0 -1.401 TD -0.0033 Tc 0.1092 Tw [(tion before it is given to others. Make sure the names of)]TJ T* -0.0028 Tc 0.125 Tw [(those involved are correct. Most people remember every)]TJ 0 -1.398 TD -0.0051 Tc -0.0622 Tw [(detail about a painful announcement. It is best, therefore, if it)]TJ 0 -1.401 TD -0.0123 Tc (is right the first time \(Smith-Cumberland, 1994; 2007\).)Tj 1.8 -2.001 TD -0.0033 Tc -0.0125 Tw (If a team approach is utilized for the presentation of the)Tj -1.8 -1.398 TD -0.0065 Tc -0.0625 Tw (information, the team should briefly meet and determine who)Tj 0 -1.401 TD -0.0097 Tc -0.0623 Tw [(will be providing what aspects of the information. It is impor-)]TJ T* -0.0038 Tc 0.1039 Tw [(tant to know who is designated as the team)50.2(s leader)50.2(. )14.5(The)]TJ 0 -1.398 TD -0.0066 Tc -0.0622 Tw (primary messenger should be identified before the announce-)Tj 0 -1.401 TD -0.0034 Tc 0.0168 Tw [(ment process begins. It is also important to know the crisis)]TJ T* -0.0126 Tc -0.0625 Tw (intervention strategy for the follow-up segment after the trans-)Tj 0 -1.398 TD -0.0036 Tc 0.1032 Tw [(mission of the information. The overall presentation plan)]TJ 0 -1.401 TD -0.0083 Tc -0.0621 Tw [(should remain flexible, however)33.7(, since the circumstances sur)15.7(-)]TJ T* -0.0036 Tc 0.121 Tw (rounding these announcements are constantly changing.)Tj /F1 1 Tf 11 0 0 11 321 432 Tm -0.0049 Tc 0.0614 Tw [(The )94.1(T)79.7(ransmission of Inf)14.2(ormation)]TJ /TT2 1 Tf 10 0 0 10 339 408.66 Tm -0.0025 Tc 0.0195 Tw [(If many people are gathered with a family)63.5(, it is usually)]TJ -1.8 -1.401 TD -0.0035 Tc 0.0794 Tw (helpful to ask friends and acquaintances to step outside so)Tj T* -0.0034 Tc 0.0362 Tw (that important information might be shared with the family)Tj 0 -1.398 TD -0.0035 Tc 0.0737 Tw [(members in a private setting. Sometimes family members)]TJ 0 -1.401 TD 0.0022 Tc 0.125 Tw (request that a specific friend be allowed to stay with the)Tj T* -0.0036 Tc -0.0087 Tw [(family when announcements are made. This request should)]TJ 0 -1.398 TD -0.0034 Tc 0.0928 Tw [(be accommodated. Try to make people as comfortable as)]TJ 0 -1.401 TD 0.0463 Tw (they can be under the circumstances \(Schmidt & Harrahill,)Tj T* -0.0516 Tc 0 Tw (1995\).)Tj 1.8 -1.998 TD -0.0033 Tc 0.0725 Tw (As harsh as the standard army death notification form)Tj -1.8 -1.401 TD -0.0025 Tc -0.056 Tw (discussed previously may be, it still covered many of the key)Tj T* -0.0036 Tc 0.0061 Tw (pieces of information that a notification of bad news should)Tj 0 -1.398 TD 0.0456 Tw [(contain. The form provides some insight into the informa-)]TJ 0 -1.401 TD -0.0056 Tc -0.0625 Tw (tion contained within almost any announcement of bad news.)Tj 1.8 -2.001 TD -0.0031 Tc 0.1119 Tw [(It starts of)17.9(f with an expression of personal sympathy)59.9(.)]TJ /TT5 1 Tf -1.8 -1.398 TD -0.0039 Tc -0.025 Tw (It is my painful duty)Tj /TT2 1 Tf 9.81 0 TD -0.0033 Tc -0.0266 Tw [( It then goes on to present the most)]TJ -9.81 -1.401 TD -0.0044 Tc 0.0225 Tw (important facts. )Tj /TT5 1 Tf 7.935 0 TD -0.0035 Tc (to inform you that a report has this day)Tj -7.935 -1.401 TD 0.0199 Tw [(been r)32.4(eceived fr)32.4(om the W)86.4(ar Office notifying the death of...)]TJ /TT2 1 Tf 0 -1.398 TD -0.0047 Tc -0.0622 Tw (Next, the form states specific identifying information so as to)Tj 0 -1.401 TD -0.0035 Tc 0.074 Tw (leave no doubt about the person being discussed in the re-)Tj T* 0.0118 Tc 0 Tw (port. )Tj /TT5 1 Tf 2.31 0 TD 0.0108 Tc 0.125 Tw (RankNameRegimentWhich occurred aton)Tj -2.31 -1.398 TD -0.007 Tc 0 Tw (Date)Tj /TT2 1 Tf 3.354 0 TD -0.0037 Tc 0.04 Tw [( The form adds additional information to complete)]TJ -3.354 -1.401 TD -0.0036 Tc 0.0893 Tw [(the announcement and offers a final word of condolences.)]TJ /TT5 1 Tf T* -0.0442 Tw (and I am to express to you the sympathy and regret of the)Tj ET endstream endobj 179 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT2 9 0 R /TT3 10 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 181 0 obj << /Length 9158 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 54 59.745 m 546 59.745 l S BT /F1 1 Tf 8 0 0 8 54.99 41.64 Tm 0 0 0 1 k /GS2 gs -0.0054 Tc 0.0563 Tw [(200 )]TJ /TT3 1 Tf 2.6437 0 TD -0.0056 Tc 0.057 Tw (Mitchell A Short Guide to Giving Bad News)Tj /TT5 1 Tf 10 0 0 10 54 722.64 Tm -0.0035 Tc -0.0232 Tw (Army Council at your loss. The cause of death was killed in)Tj 0 -1.398 TD 0.0047 Tc 0 Tw (action. )Tj /TT2 1 Tf 4.059 0 TD 0.0044 Tc 0.125 Tw (The form ends with one sentence providing an)Tj -4.059 -1.401 TD -0.0033 Tc -0.0615 Tw [(address for the family to obtain the soldier)-39.3()53.7(s)0.6( personal ef)17.7(fects.)]TJ T* 0.0615 Tw (It is signed by the records officer and the commanding of-)Tj 0 -1.398 TD -0.0078 Tc -0.0622 Tw [(ficer of the soldier who was killed \(British )52.2(Army)61.2(, 1914\).)]TJ 1.8 -2.001 TD -0.0034 Tc 0.1217 Tw (When you meet a family or an individual who needs)Tj -1.8 -1.401 TD -0.001 Tc 0.125 Tw (information about a loved one, always introduce yourself)Tj 0 -1.398 TD -0.0081 Tc -0.0625 Tw [(and your team, if you are working with others. )18.9(T)77.7(ell the family)]TJ 0 -1.401 TD -0.0034 Tc 0.0285 Tw (members and friends that you have asked them to come to-)Tj T* -0.0031 Tc -0.0445 Tw (gether so that you can go over some very important informa-)Tj 0 -1.398 TD -0.0026 Tc -0.0107 Tw [(tion. 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Be sure to)]TJ T* -0.0021 Tc 0.0425 Tw [(express your sympathy)60.9(.)]TJ 1.8 -1.998 TD -0.0033 Tc 0.0295 Tw (Most people are a bit shocked by bad news and need a)Tj -1.8 -1.401 TD -0.003 Tc -0.0342 Tw [(little time to take it all in. Sometimes they have questions as)]TJ T* -0.0031 Tc 0.0025 Tw (you go along. More details such as medical care thus far or)Tj 0 -1.398 TD -0.0035 Tc 0.0381 Tw (resuscitation efforts can be added after the main announce-)Tj 0 -1.401 TD 0.1006 Tw [(ment is completed. Be supportive if the person expresses)]TJ T* -0.0531 Tw (emotions while you are making the announcement of painful)Tj 0 -1.398 TD -0.0445 Tw (news. It is advisable to summarize the information at the end)Tj 0 -1.401 TD -0.0146 Tc -0.0625 Tw [(of the announcement \(Miller)33.4(, 1996; Smith-Cumberland, 1994;)]TJ T* -0.0516 Tc 0 Tw (2007\).)Tj /F1 1 Tf 11 0 0 11 54 258 Tm 0.0063 Tc (Follow-up)Tj /TT2 1 Tf 10 0 0 10 72 234.66 Tm -0.0035 Tc 0.0975 Tw (Follow-up begins immediately after the conclusion of)Tj -1.8 -1.401 TD 0.0439 Tw [(the announcement of bad news. People may become more)]TJ T* -0.0049 Tc -0.0625 Tw (emotional or they might appear to be numb or withdraw from)Tj 0 -1.398 TD -0.003 Tc -0.016 Tw [(the family or friends. Some may become quite loud and ex-)]TJ 0 -1.401 TD -0.0034 Tc 0.0944 Tw (press anger and frustration. Others have many more ques-)Tj T* -0.0033 Tc -0.002 Tw (tions and seek answers from the notification team. Do your)Tj 0 -1.398 TD -0.0029 Tc -0.0432 Tw (best to provide any additional information if you have it or if)Tj 0 -1.401 TD -0.0031 Tc 0.019 Tw [(it can be easily obtained. )54(Acknowledge, validate, and reas-)]TJ T* -0.0036 Tc 0.008 Tw (sure people regarding their emotional reactions.)Tj 1.8 -1.998 TD -0.0038 Tc 0.0475 Tw (Use the )Tj /TT5 1 Tf 3.345 0 TD 0.05 Tw [(five T)125.2(s)]TJ /TT2 1 Tf 2.865 0 TD -0.003 Tc 0.0486 Tw [( to determine the best strategy to assist)]TJ -8.01 -1.401 TD -0.0031 Tc 0.0725 Tw [(the people in a state of crisis. Explore the )]TJ /TT5 1 Tf 17.61 0 TD -0.0052 Tc 0 Tw (themes)Tj /TT2 1 Tf 2.751 0 TD -0.0033 Tc 0.0725 Tw [( that are)]TJ -20.361 -1.401 TD 0.0875 Tw [(present in the current circumstances. Themes include any)]TJ 25.5 64.8 TD -0.0029 Tc 0.125 Tw (circumstances, concerns, considerations, conflicts, and in-)Tj 0 -1.398 TD -0.0114 Tc -0.0625 Tw (ternal or external influences that will cause a crisis team mem-)Tj 0 -1.401 TD -0.0033 Tc -0.0304 Tw (ber to alter either the choice of interventions or the timing of)Tj T* -0.0036 Tc 0.025 Tw [(those interventions. Determine the )]TJ /TT5 1 Tf 14.274 0 TD -0.0032 Tc (targets. )Tj /TT2 1 Tf 3.552 0 TD -0.0052 Tc (Who needs as-)Tj -17.826 -1.398 TD -0.0032 Tc 0.075 Tw (sistance and who does not? Next, select the )Tj /TT5 1 Tf 18.039 0 TD -0.0037 Tc 0 Tw (types )Tj /TT2 1 Tf 2.361 0 TD -0.0036 Tc 0.08 Tw (of inter-)Tj -20.4 -1.401 TD -0.0101 Tc -0.0614 Tw (ventions that will be most helpful. )Tj /TT5 1 Tf 13.365 0 TD -0.013 Tc 0 Tw [(T)54.2(iming)]TJ /TT2 1 Tf 2.709 0 TD -0.0105 Tc -0.0633 Tw [( of the interventions)]TJ -16.074 -1.401 TD -0.0034 Tc -0.0049 Tw (is very important. Interventions provided at the wrong time)Tj 0 -1.398 TD -0.0025 Tc 0.0689 Tw [(are usually not very helpful. Finally)63.5(, the appropriate )]TJ /TT5 1 Tf 21.774 0 TD -0.006 Tc 0 Tw (team)Tj /TT2 1 Tf -21.774 -1.401 TD -0.0037 Tc -0.05 Tw [(must be chosen to provide the best possible outcome. Some-)]TJ T* -0.0033 Tc 0.0581 Tw (times only one person from a team works alone on the an-)Tj 0 -1.398 TD -0.0004 Tc 0.1252 Tw [(nouncement. However)38.6(, it is usually better to use several)]TJ 0 -1.401 TD -0.0035 Tc -0.0072 Tw (members of the team to provide services during a crisis.)Tj 1.8 -2.001 TD -0.0032 Tc -0.0523 Tw (In the case of injuries, family members and friends want)Tj -1.8 -1.398 TD -0.0036 Tc 0.0795 Tw (to know the name of the hospital to which the person was)Tj 0 -1.401 TD -0.0029 Tc 0.0328 Tw (taken. They may need assistance in getting to that hospital.)Tj T* -0.0025 Tc -0.0515 Tw (In the case of a death, the family may want to see the body or)Tj 0 -1.398 TD -0.0034 Tc -0.0256 Tw (may need information concerning the current location of the)Tj 0 -1.401 TD 0.0002 Tc 0.1249 Tw [(body)60.2(, or)21.2(gan donations, autopsies, and other concerns. In)]TJ T* -0.0031 Tc 0.0145 Tw (addition, the notification team may need to provide a list of)Tj 0 -1.398 TD -0.0034 Tc -0.01 Tw (appropriate referrals for additional services.)Tj 1.8 -2.001 TD -0.003 Tc 0.1083 Tw [( The emotions and reactions you will most likely en-)]TJ -1.8 -1.401 TD -0.0035 Tc 0.0761 Tw (counter after the provision of bad news include shock, de-)Tj 0 -1.398 TD -0.0027 Tc 0.04 Tw [(nial, anxiety)63.3(, crying, anger)39.3(, sadness, guilt, fainting, nausea,)]TJ 0 -1.401 TD -0.0033 Tc 0.0054 Tw [(worry)59.7(, and lightheadedness. In some extreme cases, people)]TJ T* 0.05 Tw (require the care of emergency medical technicians or para-)Tj 0 -1.398 TD -0.0034 Tc 0.01 Tw [(medics. Find out what resources the family members need.)]TJ 0 -1.401 TD -0.0035 Tc 0.0243 Tw (Resources include assistance with child care during the cri-)Tj T* -0.003 Tc 0.0029 Tw (sis, clergy personnel, other family members, friends, neigh-)Tj 0 -1.398 TD 0.0092 Tc 0.125 Tw [(bors, and resources for those with special needs. Some)]TJ 0 -1.401 TD -0.0032 Tc 0.1143 Tw (people need assistance in notifying other family members)Tj T* 0.0017 Tc 0.125 Tw [(and friends. Whenever possible, first requests should be)]TJ 0 -1.398 TD -0.0274 Tc 0 Tw (fulfilled.)Tj 1.8 -2.001 TD -0.0033 Tc 0.0905 Tw (Do not expect that bad news will always be met with)Tj -1.8 -1.401 TD -0.0047 Tc -0.0625 Tw (disorganization and dysfunction. Some families actually per-)Tj 0 -1.398 TD -0.0033 Tc -0.0523 Tw [(form better than expected. )29.7(Y)103.9(ou may find them in control and)]TJ 0 -1.401 TD -0.0028 Tc 0.01 Tw [(reasonably well organized. They may begin taking steps to)]TJ T* -0.0069 Tc -0.0625 Tw (manage the crisis immediately after the announcement of bad)Tj 0 -1.398 TD -0.0029 Tc 0.0537 Tw [(news. )51.1(Assist them only as much as they appear to need it,)]TJ 0 -1.401 TD -0.0035 Tc 0.0095 Tw (allowing them to manage the crisis in a manner that is most)Tj T* -0.0073 Tc -0.0625 Tw (comfortable for them.)Tj 1.8 -1.998 TD -0.0034 Tc -0.0291 Tw (It would be a mistake to disregard the impact the loss of)Tj -1.8 -1.401 TD -0.003 Tc 0.0788 Tw [(a pet can have on individuals or an entire family)63(. Pets, in)]TJ T* -0.0142 Tc -0.0624 Tw [(many ways, are truly an integral part of a person)51.8(s or a family)48.8(s)]TJ 0 -1.398 TD -0.0083 Tc [(social network. For some families, the loss of a pet may be on)]TJ 0 -1.401 TD -0.0032 Tc 0.0854 Tw [(a par with the loss of a human member of the family)59.8(. Be)]TJ ET endstream endobj 182 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT2 9 0 R /TT3 10 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 184 0 obj << /Length 7233 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 66 59.745 m 558 59.745 l S BT /TT3 1 Tf 8 0 0 8 423.24 42.6 Tm 0 0 0 1 k /GS2 gs -0.0051 Tc 0.0326 Tw [(IJEMH Vol. 10, No. 3 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (201)Tj /TT2 1 Tf 10 0 0 10 66 722.64 Tm -0.0034 Tc 0.0473 Tw (sensitive to such losses and mange them with carefully ap-)Tj 0 -1.398 TD -0.0032 Tc -0.0172 Tw (plied crisis intervention techniques, just as you might with a)Tj 0 -1.401 TD -0.0139 Tc -0.06 Tw (human victim.)Tj 1.8 -2.001 TD -0.0033 Tc -0.0242 Tw (Field emergency medical personnel may complete their)Tj -1.8 -1.398 TD -0.0036 Tc 0.055 Tw (support services when the person is delivered to the hospi-)Tj 0 -1.401 TD -0.0034 Tc 0.0333 Tw (tal. Other crisis workers will need to continue their support)Tj T* -0.0007 Tc 0.1249 Tw (and, under certain circumstances, follow-up services may)Tj 0 -1.398 TD -0.0034 Tc 0.1219 Tw [(continue for several weeks. Family members and friends)]TJ 0 -1.401 TD -0.0462 Tw (should have contact information in case they need additional)Tj T* -0.0033 Tc 0.1206 Tw (information or in the event that they would need services)Tj 0 -1.398 TD 0.0032 Tc 0 Tw (themselves.)Tj /F1 1 Tf 11 0 0 11 66 543.99 Tm 0.0011 Tc (Conclusion)Tj /TT2 1 Tf 10 0 0 10 84 520.65 Tm -0.0038 Tc 0.0263 Tw (Providing an announcement of bad news is a challeng-)Tj -1.8 -1.401 TD -0.0034 Tc -0.0036 Tw [(ing process and an enormous responsibility)59.6(. It takes careful)]TJ 0 -1.398 TD -0.0008 Tc 0.125 Tw (thought, preparation, skill, and sensitivity to the needs of)Tj 0 -1.401 TD -0.0036 Tc -0.0068 Tw (others. Following the simple guidelines presented in this ar-)Tj T* -0.0137 Tc -0.0625 Tw (ticle will help to reduce the complexity of bad news announce-)Tj 0 -1.398 TD -0.0034 Tc 0.0435 Tw [(ments. These useful guidelines can also help to reduce the)]TJ 0 -1.401 TD 0.0059 Tc 0.125 Tw (extreme distress that arises in those who receive the an-)Tj T* -0.0034 Tc -0.0184 Tw [(nouncement. Finally)59.6(, these comments may enhance the skill)]TJ 0 -1.398 TD 0.0029 Tc 0.125 Tw (of the messengers and mitigate their own distress in this)Tj 0 -1.401 TD -0.0037 Tc -0.01 Tw (difficult and most unpleasant work.)Tj /F1 1 Tf 11 0 0 11 145.89 362.01 Tm 0.021 Tc 0 Tw (REFERENCES)Tj /TT2 1 Tf 10 0 0 10 66 344.64 Tm -0.0051 Tc -0.0617 Tw (Aguilera, D.C. \(1998\). )Tj /TT5 1 Tf 9 0 TD -0.006 Tc -0.0625 Tw (Crisis intervention: Theory and meth-)Tj -7.8 -1.398 TD -0.0054 Tc 0 Tw (odology)Tj /TT2 1 Tf 3.189 0 TD -0.0026 Tc 0.0039 Tw [(, 8th ed. S)18.4(t. Louis: Mosby)60.4(.)]TJ -4.389 -1.8 TD -0.0033 Tc -0.1057 Tw [(British Army)62.7(. )-51.2(\(1914\). )]TJ /TT5 1 Tf 8.625 0 TD -0.0044 Tc -0.0567 Tw (Army Form 104 -82)Tj /TT2 1 Tf 7.731 0 TD -0.0036 Tc -0.0575 Tw [(. London: )17.4(W)94.2(ar Of-)]TJ -15.156 -1.401 TD -0.0076 Tc -0.06 Tw (fice, Whitehall)Tj -1.2 -1.8 TD -0.0037 Tc [(Caplan, G)116.3(.)-0.7( \(1961\). )]TJ /TT5 1 Tf 7.359 0 TD -0.0042 Tc -0.061 Tw [(An appr)28.8(oach to community mental health)]TJ /TT2 1 Tf 16.092 0 TD 0 Tc 0 Tw (.)Tj -22.251 -1.401 TD -0.0043 Tc -0.0519 Tw [(New )30.5(Y)102.9(ork: Grune and S)23.9(tratton)]TJ -1.2 -1.8 TD -0.0035 Tc -0.025 Tw [(Caplan, G)116.5(.)-0.7( \(1964\). )]TJ /TT5 1 Tf 7.464 0 TD -0.0038 Tc -0.0263 Tw [(Principles of pr)29.2(eventive psychiatry)56(.)-4( )]TJ /TT2 1 Tf 14.145 0 TD -0.0057 Tc -0.03 Tw [( New)]TJ -20.409 -1.398 TD -0.0122 Tc -0.0625 Tw [(Y)104(ork: Basic Books.)]TJ 24.3 48.798 TD -0.0035 Tc -0.0284 Tw [(Caplan, G)116.5(.)-0.2( \(1969\). Opportunities for school psychologists in)]TJ 1.2 -1.398 TD -0.0033 Tc -0.0309 Tw (the primary prevention of mental health disorders in chil-)Tj 0 -1.401 TD -0.0044 Tc -0.0619 Tw [(dren, In )49.6(A. Bindman and )49.6(A. Spiegel \(Eds.\) )]TJ /TT5 1 Tf 16.554 0 TD -0.005 Tc -0.065 Tw (Perspectives in)Tj -16.554 -1.401 TD -0.0052 Tc -0.0625 Tw (community mental health)Tj /TT2 1 Tf 9.87 0 TD -0.0049 Tc -0.0624 Tw [( \(pp.420-436\). Chicago: )49.2(Aldine.)]TJ -11.07 -1.8 TD -0.0081 Tc -0.0619 Tw [(Eckstein, M., S)18.9(t)-0.5(ratton, S.J., & Chan, L.S \(2005\). )16.2(T)71.7(ermination)]TJ 1.2 -1.398 TD -0.0034 Tc -0.0158 Tw (of resuscitative efforts for out-of-hospital cardiac arrests.)Tj /TT5 1 Tf 0 -1.401 TD -0.004 Tc -0.045 Tw [(Academy of Emergency Medicine,)]TJ /TT2 1 Tf 13.611 0 TD 0 Tc 0 Tw ( )Tj /TT5 1 Tf 0.204 0 TD -0.01 Tc (12)Tj /TT2 1 Tf 0.99 0 TD -0.0034 Tc -0.045 Tw (\(1\), 65-70.)Tj -16.005 -1.8 TD 0.0338 Tc 0.1251 Tw [(Greenber)18.8(g, L.W)84.8(., Ochsenschlager)33.8(, D., ODonnell, R.,)]TJ 1.2 -1.401 TD -0.0034 Tc 0.0036 Tw [(Mastruserio, J., & Cohen, G)116.6(.J.. \(1999\). Communicating)]TJ 0 -1.398 TD -0.0037 Tc -0.0355 Tw [(bad news: )50.4(A)58.5( pediatric department)50.3(s evaluation of a simu-)]TJ 0 -1.401 TD -0.0048 Tc -0.06 Tw (lated intervention. )Tj /TT5 1 Tf 7.5 0 TD -0.006 Tc 0 Tw (Pediatrics)Tj /TT2 1 Tf 4.056 0 TD 0.001 Tc (. )Tj /TT5 1 Tf 0.435 0 TD -0.0105 Tc (103)Tj /TT2 1 Tf 1.479 0 TD -0.0056 Tc -0.065 Tw (\(6\), 1210-1217.)Tj -14.67 -1.8 TD -0.0032 Tc 0.0183 Tw [(Iserson, K.\(1999\). )]TJ /TT5 1 Tf 7.77 0 TD -0.004 Tc 0.02 Tw (Grave words: Notifying survivors about)Tj -6.57 -1.401 TD 0.0525 Tw (sudden, unexpected deaths)Tj /TT2 1 Tf 10.701 0 TD -0.0037 Tc 0.0546 Tw [(. )16.9(T)37.1(ucson, )49.9(AZ: Galen Press.)]TJ -11.901 -1.8 TD -0.0033 Tc -0.0193 Tw [(Miller)35.7(, J.E. \(1996\). )]TJ /TT5 1 Tf 7.755 0 TD -0.004 Tc -0.02 Tw (Grief tips)Tj /TT2 1 Tf 3.75 0 TD -0.0031 Tc -0.0205 Tw [(. Fort )18.6(W)94.8(ayne, IN: )18.7(W)55.7(illowgreen)]TJ -10.305 -1.398 TD 0.0066 Tc 0 Tw (Productions.)Tj -1.2 -1.8 TD -0.0098 Tc -0.0621 Tw [(Mitchell, J.T)71.2(. \(2004\). Characteristics of successful early inter)14.2(-)]TJ 1.2 -1.401 TD -0.0013 Tc 0.125 Tw (vention programs. )Tj /TT5 1 Tf 7.755 0 TD (International Journal of Emergency)Tj -7.755 -1.401 TD -0.009 Tc -0.06 Tw (Mental Health, 6)Tj /TT2 1 Tf 6.546 0 TD -0.0646 Tw (\(4\), 175-184.)Tj -7.746 -1.8 TD -0.0053 Tc -0.062 Tw [(Nardi , )15.8(T)80.5(.J. & Keefe-Cooperman, K. \(2006\). Communicating)]TJ 1.2 -1.398 TD -0.0035 Tc -0.005 Tw [(bad news: )50.5(A)58.7( model for emer)17.5(gency mental health helpers.)]TJ /TT5 1 Tf 0 -1.401 TD -0.0039 Tc -0.0608 Tw [(International Journal of Emergency Mental Health)]TJ /TT2 1 Tf 20.166 0 TD 0 Tc 0 Tw (. )Tj /TT5 1 Tf 0.435 0 TD -0.008 Tc (8\()Tj /TT2 1 Tf 0.825 0 TD -0.0045 Tc (3\),)Tj -21.426 -1.401 TD -0.0511 Tc (203-207.)Tj -1.2 -1.8 TD -0.0032 Tc -0.051 Tw [(Schmidt, )17.9(T)76.6(.A. & Harrahill, M.A. \(1995\). Family response to)]TJ 1.2 -1.398 TD -0.0036 Tc -0.02 Tw (out-of-hospital death. )Tj /TT5 1 Tf 8.739 0 TD -0.004 Tc -0.0213 Tw [(Acadamy of Emergency Medicine,)]TJ -8.739 -1.401 TD 0 Tc 0 Tw (2)Tj /TT2 1 Tf 0.471 0 TD -0.0327 Tc -0.06 Tw (, 513-518.)Tj -1.671 -1.8 TD -0.0173 Tc -0.0619 Tw [(Smith-Cumberland, )18.9(T)71.5(.L. \(1994; 2007\). Course lecture notes on)]TJ 1.2 -1.401 TD -0.0028 Tc -0.0086 Tw (death and dying: Death notification. 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101.743 650.256 l 101.764 650.309 l 101.789 650.366 l 101.821 650.429 l 101.852 650.5 l 101.888 650.581 l 101.928 650.673 l 102.157 650.766 l 102.391 650.862 l 102.632 650.964 l 102.88 651.074 l 103.128 651.187 l 103.377 651.308 l 103.631 651.435 l 103.886 651.566 l 104.142 651.701 l 104.396 651.846 l 104.648 651.991 l 104.903 652.147 l 105.154 652.303 l 105.402 652.467 l 105.646 652.636 l 105.887 652.809 l 106.125 652.986 l 106.355 653.171 l 106.578 653.355 l 106.797 653.55 l 107.01 653.745 l 107.212 653.943 l 107.407 654.148 l 107.591 654.357 l 107.765 654.57 l 107.928 654.786 l 108.08 655.009 l 108.221 655.233 l 108.349 655.462 l 108.463 655.692 l 108.565 655.926 l 108.65 656.167 l 108.763 656.153 l 108.877 656.136 l 108.991 656.118 l 109.104 656.096 l 109.22 656.072 l 109.337 656.05 l 109.457 656.025 l 109.581 656 l 109.84 655.37 l 110.106 654.712 l 110.386 654.031 l 110.669 653.333 l 110.956 652.618 l 111.246 651.889 l 111.387 651.517 l 111.53 651.145 l 111.671 650.773 l 111.813 650.394 l 111.951 650.019 l 112.086 649.64 l 112.348 648.882 l 112.475 648.5 l 112.596 648.12 l 112.716 647.741 l 112.83 647.366 l 112.94 646.987 l 113.046 646.611 l 113.145 646.239 l 113.237 645.867 l 113.322 645.502 l 113.403 645.135 l 113.478 644.773 l 113.542 644.416 l 112.645 644.416 l f* 69.805 651.272 m 69.805 652.604 l 70.102 652.792 l 70.386 653.001 l 70.655 653.238 l 70.917 653.496 l 71.168 653.776 l 71.408 654.074 l 71.64 654.389 l 71.866 654.722 l 72.086 655.065 l 72.298 655.424 l 72.503 655.792 l 72.706 656.167 l 72.907 656.553 l 73.102 656.939 l 73.297 657.332 l 73.491 657.725 l 73.684 658.119 l 73.879 658.512 l 74.073 658.901 l 74.271 659.284 l 74.474 659.659 l 74.678 660.024 l 74.888 660.382 l 75.104 660.725 l 75.327 661.055 l 75.554 661.37 l 75.79 661.668 l 76.038 661.944 l 76.293 662.199 l 76.56 662.433 l 76.839 662.642 l 77.126 662.823 l 77.222 662.401 l 77.328 661.94 l 77.385 661.696 l 77.445 661.445 l 77.512 661.189 l 77.583 660.927 l 77.657 660.658 l 77.735 660.389 l 77.817 660.116 l 77.905 659.843 l 78 659.57 l 78.1 659.294 l 78.203 659.026 l 78.313 658.752 l 78.429 658.487 l 78.553 658.225 l 78.681 657.97 l 78.815 657.719 l 78.957 657.474 l 79.106 657.236 l 79.261 657.01 l 79.424 656.794 l 79.598 656.588 l 79.776 656.394 l 79.963 656.213 l 80.158 656.047 l 80.36 655.894 l 80.572 655.757 l 80.792 655.636 l 81.022 655.534 l 81.089 655.303 l 81.136 655.119 l 81.153 655.04 l 81.168 654.97 l 81.178 654.903 l 81.185 654.839 l 81.188 654.775 l 81.185 654.707 l 81.181 654.641 l 81.178 654.566 l 81.153 654.389 l 81.121 654.169 l 79.637 653.798 l 78.327 653.465 l 77.179 653.171 l 76.177 652.912 l 75.302 652.682 l 74.544 652.479 l 73.881 652.303 l 73.305 652.147 l 72.794 652.009 l 72.334 651.885 l 71.912 651.772 l 71.512 651.669 l 71.115 651.57 l 70.711 651.474 l 70.279 651.375 l 69.805 651.272 l f* 92.906 651.938 m 92.63 652.013 l 92.356 652.087 l 92.081 652.161 l 91.808 652.232 l 91.534 652.306 l 91.259 652.378 l 90.986 652.448 l 90.713 652.519 l 90.441 652.586 l 90.168 652.657 l 89.894 652.728 l 89.626 652.795 l 89.353 652.866 l 89.085 652.933 l 88.815 653.001 l 88.546 653.072 l 87.912 653.475 l 87.31 653.883 l 86.736 654.293 l 86.19 654.705 l 85.677 655.119 l 85.191 655.537 l 84.731 655.958 l 84.302 656.387 l 83.898 656.819 l 83.524 657.258 l 83.177 657.704 l 82.85 658.158 l 82.556 658.618 l 82.283 659.089 l 82.035 659.567 l 81.812 660.056 l 81.614 660.555 l 81.44 661.066 l 81.287 661.586 l 81.156 662.121 l 81.051 662.669 l 80.965 663.23 l 80.901 663.803 l 80.859 664.394 l 80.838 664.996 l 80.834 665.62 l 80.853 666.254 l 80.888 666.909 l 80.945 667.582 l 81.019 668.273 l 81.111 668.985 l 81.22 669.715 l 81.458 670.182 l 81.684 670.635 l 81.904 671.068 l 82.12 671.485 l 82.33 671.882 l 82.535 672.264 l 82.737 672.633 l 82.935 672.984 l 83.137 673.32 l 83.336 673.646 l 83.537 673.957 l 83.742 674.258 l 83.948 674.549 l 84.161 674.829 l 84.381 675.098 l 84.604 675.36 l 84.837 675.611 l 85.078 675.856 l 85.33 676.097 l 85.595 676.327 l 85.868 676.557 l 86.158 676.78 l 86.46 677 l 86.779 677.216 l 87.114 677.432 l 87.465 677.645 l 87.837 677.857 l 88.227 678.07 l 88.638 678.282 l 89.073 678.494 l 89.531 678.714 l 90.008 678.934 l 90.582 679.033 l 91.139 679.121 l 91.673 679.196 l 92.194 679.263 l 92.697 679.312 l 93.183 679.352 l 93.657 679.38 l 94.12 679.394 l 94.571 679.394 l 95.014 679.384 l 95.445 679.359 l 95.867 679.32 l 96.285 679.27 l 96.696 679.203 l 97.104 679.126 l 97.508 679.033 l 97.91 678.927 l 98.311 678.803 l 98.711 678.668 l 99.111 678.519 l 99.518 678.353 l 99.926 678.176 l 100.336 677.981 l 100.759 677.772 l 101.183 677.549 l 101.616 677.308 l 102.058 677.053 l 102.515 676.78 l 102.979 676.494 l 103.457 676.193 l 103.95 675.874 l 104.457 675.537 l 104.505 675.414 l 104.556 675.29 l 104.605 675.162 l 104.655 675.038 l 105.087 675.038 l 105.544 674.124 l 105.763 673.678 l 105.983 673.239 l 106.199 672.803 l 106.412 672.368 l 106.62 671.928 l 106.826 671.485 l 107.032 671.036 l 107.237 670.575 l 107.435 670.104 l 107.633 669.619 l 107.733 669.368 l 107.832 669.116 l 107.931 668.857 l 108.027 668.595 l 108.126 668.326 l 108.221 668.05 l 108.32 667.77 l 108.416 667.483 l 108.466 667.469 l 108.516 667.452 l 108.565 667.434 l 108.618 667.412 l 108.717 667.366 l 108.816 667.316 l 108.753 666.484 l 108.686 665.677 l 108.65 665.284 l 108.61 664.891 l 108.568 664.504 l 108.526 664.126 l 108.473 663.75 l 108.419 663.378 l 108.359 663.01 l 108.292 662.649 l 108.218 662.287 l 108.141 661.933 l 108.052 661.583 l 107.956 661.236 l 107.849 660.889 l 107.737 660.548 l 107.613 660.208 l 107.474 659.872 l 107.329 659.539 l 107.17 659.209 l 106.999 658.88 l 106.819 658.555 l 106.62 658.228 l 106.412 657.906 l 106.185 657.588 l 105.944 657.268 l 105.689 656.95 l 105.416 656.631 l 105.129 656.316 l 104.821 656 l 104.775 655.859 l 104.69 655.714 l 104.573 655.565 l 104.424 655.416 l 104.243 655.264 l 104.034 655.108 l 103.801 654.956 l 103.546 654.8 l 103.269 654.648 l 102.973 654.492 l 102.661 654.34 l 102.335 654.188 l 101.995 654.035 l 101.644 653.886 l 101.291 653.741 l 100.929 653.599 l 100.563 653.461 l 100.199 653.323 l 99.833 653.192 l 99.473 653.068 l 99.119 652.944 l 98.772 652.83 l 98.435 652.717 l 98.109 652.615 l 97.801 652.519 l 97.508 652.43 l 97.234 652.349 l 96.983 652.274 l 96.756 652.211 l 96.55 652.154 l 96.377 652.108 l 96.235 652.073 l 95.811 652.059 l 95.601 652.055 l 95.392 652.048 l 95.183 652.041 l 94.974 652.034 l 94.766 652.027 l 94.556 652.02 l 94.352 652.009 l 94.142 652.002 l 93.936 651.991 l 93.731 651.984 l 93.521 651.974 l 93.317 651.963 l 93.111 651.952 l 92.906 651.938 l f* 110.881 659.726 m 110.867 660.002 l 110.86 660.272 l 110.86 660.545 l 110.867 660.81 l 110.881 661.079 l 110.899 661.345 l 110.924 661.607 l 110.956 661.873 l 110.988 662.135 l 111.027 662.397 l 111.065 662.655 l 111.112 662.915 l 111.204 663.435 l 111.3 663.952 l 111.399 664.465 l 111.537 665.241 l 111.579 665.503 l 111.619 665.762 l 111.654 666.024 l 111.682 666.286 l 111.709 666.548 l 111.731 666.81 l 111.749 667.076 l 111.756 667.341 l 111.759 667.611 l 111.756 667.876 l 111.746 668.149 l 111.835 668.174 l 111.919 668.199 l 112.008 668.224 l 112.096 668.248 l 112.182 668.273 l 112.27 668.298 l 112.358 668.323 l 112.443 668.348 l 112.493 668.248 l 112.546 668.146 l 112.596 668.036 l 112.645 667.915 l 112.943 667.848 l 113.244 667.773 l 113.545 667.696 l 113.845 667.614 l 114.148 667.526 l 114.453 667.434 l 114.753 667.338 l 115.058 667.243 l 115.363 667.14 l 115.666 667.033 l 115.972 666.927 l 116.28 666.817 l 116.892 666.594 l 117.512 666.364 l 118.135 666.131 l 118.762 665.896 l 119.392 665.659 l 120.03 665.429 l 120.349 665.316 l 120.672 665.206 l 120.994 665.096 l 121.32 664.99 l 121.646 664.883 l 121.972 664.781 l 122.301 664.682 l 122.63 664.586 l 122.63 663.488 l 122.443 663.467 l 122.247 663.446 l 122.046 663.418 l 121.837 663.385 l 121.624 663.35 l 121.408 663.311 l 121.185 663.272 l 120.962 663.226 l 120.736 663.176 l 120.505 663.127 l 120.275 663.073 l 120.045 663.014 l 119.814 662.953 l 119.587 662.892 l 119.361 662.826 l 119.134 662.755 l 118.915 662.684 l 118.695 662.61 l 118.482 662.535 l 118.274 662.453 l 118.071 662.373 l 117.877 662.287 l 117.689 662.202 l 117.508 662.114 l 117.338 662.022 l 117.176 661.93 l 117.023 661.834 l 116.881 661.735 l 116.753 661.636 l 116.634 661.533 l 116.53 661.43 l 116.438 661.324 l 116.389 661.327 l 116.333 661.327 l 116.262 661.321 l 116.183 661.307 l 116.096 661.289 l 116 661.267 l 115.893 661.243 l 115.777 661.21 l 115.521 661.14 l 115.231 661.052 l 114.909 660.952 l 114.558 660.839 l 114.179 660.718 l 113.775 660.587 l 113.343 660.449 l 112.89 660.311 l 112.415 660.166 l 111.923 660.021 l 111.409 659.872 l 110.881 659.726 l f* 76.464 664.586 m 76.308 664.767 l 76.12 664.95 l 75.908 665.139 l 75.67 665.33 l 75.408 665.521 l 75.125 665.716 l 74.821 665.914 l 74.498 666.113 l 74.158 666.311 l 73.803 666.509 l 73.439 666.708 l 73.06 666.906 l 72.674 667.104 l 72.28 667.302 l 71.88 667.497 l 71.477 667.692 l 70.669 668.068 l 70.265 668.252 l 69.865 668.433 l 69.085 668.783 l 67.655 669.413 l 67.031 669.69 l 66.748 669.814 l 66.49 669.934 l 66.252 670.044 l 66.042 670.147 l 66 670.334 l 65.972 670.487 l 65.962 670.554 l 65.958 670.618 l 65.958 670.681 l 65.965 670.745 l 65.975 670.813 l 65.99 670.884 l 66.011 670.965 l 66.039 671.053 l 66.111 671.269 l 66.21 671.542 l 66.918 671.708 l 67.637 671.875 l 68.36 672.041 l 69.093 672.208 l 69.826 672.371 l 70.567 672.527 l 70.939 672.601 l 71.313 672.676 l 71.685 672.747 l 72.061 672.814 l 72.433 672.877 l 72.808 672.938 l 73.184 672.998 l 73.563 673.051 l 73.938 673.1 l 74.314 673.147 l 74.688 673.189 l 75.064 673.224 l 75.44 673.256 l 75.819 673.281 l 76.191 673.303 l 76.566 673.317 l 76.942 673.323 l 77.314 673.323 l 77.688 673.32 l 78.061 673.309 l 78.058 673.189 l 78.054 673.068 l 78.05 672.952 l 78.04 672.831 l 78.019 672.587 l 77.99 672.346 l 77.955 672.102 l 77.911 671.854 l 77.869 671.603 l 77.824 671.351 l 77.774 671.1 l 77.725 670.841 l 77.672 670.582 l 77.625 670.32 l 77.576 670.058 l 77.534 669.789 l 77.494 669.52 l 77.459 669.247 l 77.462 669.12 l 77.469 668.981 l 77.48 668.836 l 77.494 668.688 l 77.529 668.369 l 77.573 668.033 l 77.611 667.686 l 77.643 667.327 l 77.657 667.15 l 77.668 666.969 l 77.672 666.793 l 77.672 666.619 l 77.668 666.445 l 77.657 666.272 l 77.636 666.105 l 77.611 665.946 l 77.576 665.786 l 77.534 665.634 l 77.48 665.49 l 77.42 665.351 l 77.346 665.224 l 77.257 665.1 l 77.162 664.99 l 77.048 664.887 l 76.923 664.796 l 76.786 664.713 l 76.631 664.643 l 76.464 664.586 l f* 110.881 670.147 m 110.857 670.182 l 110.832 670.225 l 110.811 670.274 l 110.786 670.33 l 110.765 670.391 l 110.743 670.462 l 110.725 670.537 l 110.704 670.618 l 110.665 670.798 l 110.623 670.993 l 110.584 671.209 l 110.542 671.436 l 110.453 671.925 l 110.403 672.179 l 110.351 672.438 l 110.294 672.7 l 110.23 672.962 l 110.195 673.094 l 110.158 673.221 l 110.119 673.348 l 110.081 673.472 l 110.01 673.586 l 109.935 673.702 l 109.851 673.827 l 109.762 673.954 l 109.564 674.231 l 109.355 674.527 l 109.132 674.836 l 108.905 675.151 l 108.674 675.477 l 108.455 675.799 l 108.349 675.962 l 108.243 676.121 l 108.144 676.278 l 108.052 676.433 l 107.963 676.586 l 107.878 676.734 l 107.804 676.876 l 107.737 677.017 l 107.676 677.153 l 107.626 677.28 l 107.584 677.404 l 107.556 677.517 l 107.534 677.627 l 107.527 677.726 l 107.534 677.818 l 107.552 677.9 l 107.861 677.932 l 108.171 677.967 l 108.483 678.006 l 108.795 678.052 l 109.107 678.102 l 109.422 678.155 l 109.737 678.211 l 110.052 678.271 l 110.368 678.335 l 110.683 678.403 l 111.002 678.473 l 111.317 678.548 l 111.635 678.626 l 111.954 678.704 l 112.273 678.785 l 112.596 678.87 l 113.233 679.044 l 113.878 679.225 l 114.519 679.412 l 115.164 679.6 l 115.805 679.791 l 116.45 679.982 l 117.094 680.173 l 117.739 680.365 l 117.739 680.506 l 117.743 680.613 l 117.746 680.655 l 117.75 680.691 l 117.756 680.719 l 117.767 680.744 l 117.778 680.761 l 117.795 680.776 l 117.813 680.783 l 117.835 680.79 l 117.895 680.797 l 117.969 680.797 l 118.001 680.715 l 118.04 680.627 l 118.086 680.532 l 118.135 680.432 l 118.901 680.432 l 118.89 680.301 l 118.854 680.153 l 118.794 679.982 l 118.713 679.795 l 118.614 679.589 l 118.497 679.373 l 118.362 679.139 l 118.21 678.895 l 118.046 678.636 l 117.87 678.371 l 117.682 678.094 l 117.485 677.814 l 117.279 677.528 l 117.065 677.234 l 116.847 676.94 l 116.623 676.646 l 116.169 676.054 l 115.717 675.47 l 115.277 674.911 l 114.86 674.382 l 114.473 673.898 l 114.137 673.465 l 113.988 673.274 l 113.857 673.1 l 113.74 672.944 l 113.644 672.81 l 113.336 672.534 l 113.039 672.276 l 112.893 672.148 l 112.756 672.02 l 112.62 671.889 l 112.493 671.754 l 112.432 671.688 l 112.373 671.616 l 112.316 671.546 l 112.259 671.471 l 112.202 671.397 l 112.149 671.319 l 112.1 671.237 l 112.05 671.156 l 112.004 671.071 l 111.962 670.982 l 111.919 670.89 l 111.88 670.795 l 111.842 670.695 l 111.806 670.596 l 111.774 670.49 l 111.746 670.38 l 111.632 670.352 l 111.523 670.328 l 111.409 670.302 l 111.3 670.274 l 111.193 670.245 l 111.087 670.214 l 110.981 670.182 l 110.881 670.147 l f* 79.789 676.37 m 79.672 676.419 l 79.563 676.469 l 79.456 676.518 l 79.357 676.568 l 79.273 676.876 l 79.184 677.188 l 79.091 677.506 l 78.993 677.833 l 78.786 678.499 l 78.567 679.178 l 78.344 679.873 l 78.114 680.577 l 77.884 681.285 l 77.661 681.994 l 77.551 682.348 l 77.445 682.702 l 77.338 683.053 l 77.14 683.747 l 77.048 684.087 l 76.959 684.427 l 76.878 684.76 l 76.192 686.305 l 76.121 686.63 l 76.058 686.949 l 76.001 687.261 l 75.952 687.566 l 75.909 687.863 l 75.877 688.154 l 75.857 688.437 l 76.118 688.465 l 76.391 688.462 l 76.675 688.42 l 76.969 688.348 l 77.265 688.249 l 77.574 688.122 l 77.889 687.969 l 78.207 687.795 l 78.533 687.601 l 78.867 687.388 l 79.811 685.95 l 80.15 685.713 l 80.491 685.465 l 80.838 685.21 l 81.538 684.686 l 81.89 684.424 l 82.241 684.165 l 82.595 683.91 l 82.945 683.659 l 83.296 683.421 l 83.643 683.195 l 83.99 682.982 l 84.334 682.787 l 84.674 682.614 l 85.011 682.458 l 85.344 682.327 l 85.67 682.224 l 85.992 682.15 l 86.307 682.107 l 86.614 682.101 l 86.913 682.128 l 86.945 681.951 l 86.966 681.806 l 86.97 681.742 l 86.973 681.682 l 86.97 681.622 l 86.959 681.562 l 86.945 681.498 l 86.926 681.427 l 86.903 681.352 l 86.792 681.062 l 86.683 680.797 l 86.544 680.769 l 86.4 680.726 l 86.244 680.672 l 86.076 680.609 l 85.903 680.535 l 85.726 680.449 l 85.542 680.354 l 85.351 680.252 l 85.159 680.142 l 84.961 680.021 l 84.763 679.897 l 84.56 679.766 l 84.359 679.632 l 84.157 679.493 l 83.958 679.349 l 83.761 679.203 l 83.566 679.054 l 83.374 678.906 l 83.187 678.754 l 83.006 678.604 l 82.832 678.452 l 82.665 678.303 l 82.506 678.155 l 82.354 678.013 l 82.216 677.871 l 82.085 677.733 l 81.968 677.602 l 81.865 677.474 l 81.773 677.354 l 81.695 677.241 l 81.634 677.134 l 81.589 677.035 l 81.121 677.035 l 81.072 676.911 l 81.025 676.788 l 81.004 676.724 l 80.987 676.66 l 80.969 676.6 l 80.955 676.536 l 80.806 676.522 l 80.658 676.504 l 80.509 676.486 l 80.36 676.465 l 80.214 676.444 l 80.069 676.419 l 79.927 676.394 l 79.789 676.37 l f* q 61.682 693.442 67.028 -87.001 re W n 105.087 678.367 m 104.995 678.583 l 104.884 678.795 l 104.762 678.997 l 104.619 679.196 l 104.463 679.384 l 104.297 679.568 l 104.116 679.745 l 103.925 679.911 l 103.719 680.078 l 103.507 680.234 l 103.288 680.382 l 103.061 680.528 l 102.823 680.666 l 102.584 680.8 l 102.335 680.927 l 102.084 681.051 l 101.832 681.169 l 101.573 681.279 l 101.314 681.384 l 101.056 681.488 l 100.798 681.583 l 100.539 681.675 l 100.284 681.76 l 100.033 681.845 l 99.785 681.923 l 99.54 681.997 l 99.303 682.069 l 99.072 682.132 l 98.633 682.252 l 98.234 682.362 l 98.311 682.72 l 98.403 683.067 l 98.509 683.407 l 98.629 683.733 l 98.761 684.051 l 98.902 684.364 l 99.055 684.664 l 99.214 684.962 l 99.384 685.249 l 99.565 685.529 l 99.749 685.808 l 100.138 686.346 l 100.549 686.872 l 100.762 687.13 l 101.19 687.639 l 101.623 688.15 l 101.839 688.408 l 102.055 688.663 l 102.271 688.922 l 102.48 689.184 l 102.689 689.45 l 102.894 689.719 l 103.093 689.991 l 103.288 690.271 l 103.475 690.555 l 103.652 690.845 l 103.826 691.142 l 103.989 691.447 l 104.135 691.49 l 104.247 691.521 l 104.301 691.536 l 104.346 691.542 l 104.393 691.55 l 104.438 691.554 l 104.489 691.554 l 104.537 691.55 l 104.594 691.542 l 104.655 691.536 l 104.8 691.514 l 104.988 691.483 l 105.104 690.764 l 105.221 690.016 l 105.338 689.241 l 105.456 688.443 l 105.512 688.036 l 105.569 687.625 l 105.675 686.79 l 105.774 685.946 l 105.824 685.522 l 105.865 685.093 l 105.909 684.668 l 105.948 684.24 l 105.983 683.814 l 106.011 683.386 l 106.04 682.965 l 106.064 682.539 l 106.082 682.121 l 106.097 681.704 l 106.107 681.289 l 106.114 680.878 l 106.11 680.475 l 106.107 680.074 l 106.093 679.678 l 106.075 679.292 l 106.05 678.909 l 106.021 678.533 l 105.898 678.519 l 105.778 678.502 l 105.657 678.484 l 105.54 678.462 l 105.426 678.441 l 105.313 678.417 l 105.087 678.367 l f* 88.244 681.895 m 88.223 682.259 l 88.209 682.628 l 88.209 683 l 88.216 683.371 l 88.231 683.744 l 88.259 684.116 l 88.291 684.491 l 88.33 684.867 l 88.379 685.242 l 88.435 685.617 l 88.496 685.989 l 88.563 686.364 l 88.635 686.74 l 88.712 687.112 l 88.797 687.488 l 88.882 687.856 l 88.971 688.228 l 89.066 688.596 l 89.162 688.961 l 89.257 689.325 l 89.46 690.044 l 89.665 690.756 l 89.866 691.45 l 90.069 692.134 l 90.26 692.797 l 90.444 693.445 l 90.625 693.35 l 90.798 693.221 l 90.972 693.058 l 91.139 692.867 l 91.301 692.651 l 91.461 692.407 l 91.617 692.141 l 91.772 691.854 l 91.928 691.546 l 92.081 691.224 l 92.232 690.884 l 92.69 689.793 l 93.002 689.031 l 93.161 688.642 l 93.324 688.256 l 93.49 687.87 l 93.66 687.483 l 93.837 687.108 l 94.018 686.736 l 94.206 686.375 l 94.397 686.024 l 94.598 685.691 l 94.804 685.37 l 95.021 685.068 l 95.244 684.785 l 95.477 684.522 l 95.718 684.286 l 95.969 684.077 l 96.235 683.892 l 96.203 683.673 l 96.178 683.467 l 96.164 683.368 l 96.147 683.272 l 96.126 683.18 l 96.101 683.089 l 96.087 683.046 l 96.069 683 l 96.051 682.957 l 96.03 682.915 l 96.009 682.876 l 95.983 682.833 l 95.955 682.795 l 95.924 682.756 l 95.891 682.716 l 95.856 682.677 l 95.817 682.639 l 95.775 682.603 l 95.729 682.567 l 95.68 682.532 l 95.626 682.497 l 95.569 682.462 l 95.105 682.429 l 94.645 682.397 l 94.184 682.362 l 93.728 682.33 l 93.267 682.295 l 92.811 682.259 l 92.353 682.228 l 91.893 682.188 l 91.436 682.153 l 90.982 682.118 l 90.525 682.083 l 90.069 682.044 l 89.611 682.008 l 89.158 681.969 l 88.702 681.934 l 88.244 681.895 l f* Q 1 1 1 rg 512.31 508.996 m 496.241 490.008 l 470.479 477.374 l 470.091 477.248 l 496.395 464.381 l 512.484 444.961 l 529.537 465.305 l 529.537 465.367 l 553.809 476.887 l 554.141 477.131 l 529.29 489.453 l 512.31 508.996 l f q 469.99 509.147 84.592 -64.498 re W n 0 0.286 0.388 RG 0.46 w 2.613 M /GS3 gs 512.31 508.996 m 496.241 490.008 l 470.479 477.374 l 470.091 477.248 l 496.395 464.381 l 512.484 444.961 l 529.537 465.305 l 529.537 465.367 l 553.809 476.887 l 554.141 477.131 l 529.29 489.453 l 512.31 508.996 l S Q 0 0.286 0.388 RG 1.381 w 2.613 M /GS3 gs 512.484 458.676 m 524.719 458.676 534.637 466.993 534.637 477.253 c 534.637 487.512 524.719 495.828 512.484 495.828 c 500.249 495.828 490.331 487.512 490.331 477.253 c 490.331 466.993 500.249 458.676 512.484 458.676 c S 0.46 w 512.659 460.286 m 524.893 460.286 533.023 468.703 533.023 477.253 c 533.023 485.802 524.545 494.219 512.31 494.219 c 500.076 494.219 491.946 485.802 491.946 477.253 c 491.946 468.703 500.424 460.286 512.659 460.286 c S 0.137 0.122 0.125 RG 512.659 460.286 m 512.659 460.286 l S 0 0.286 0.388 rg 499.073 486.988 0.354 -2.62 re f 501.736 484.872 m 501.729 484.872 l 500.419 486.988 l 499.999 486.988 l 499.999 484.368 l 500.342 484.368 l 500.342 486.485 l 500.35 486.485 l 501.682 484.368 l 502.079 484.368 l 502.079 486.988 l 501.736 486.988 l 501.736 484.872 l f* 502.323 486.674 m 503.21 486.674 l 503.21 484.368 l 503.564 484.368 l 503.564 486.674 l 504.451 486.674 l 504.451 486.988 l 502.323 486.988 l 502.323 486.674 l f* 506.68 484.682 m 505.1 484.682 l 505.1 485.558 l 506.534 485.558 l 506.534 485.872 l 505.1 485.872 l 505.1 486.674 l 506.655 486.674 l 506.655 486.988 l 504.746 486.988 l 504.746 484.368 l 506.68 484.368 l 506.68 484.682 l f* 507.464 486.685 m 508.348 486.685 l 508.523 486.685 508.818 486.652 508.818 486.247 c 508.818 485.861 508.545 485.795 508.286 485.795 c 507.464 485.795 l 507.464 486.685 l h 507.464 485.492 m 508.322 485.492 l 508.745 485.492 508.789 485.24 508.789 485.025 c 508.789 484.927 508.8 484.529 508.851 484.368 c 509.285 484.368 l 509.285 484.427 l 509.176 484.489 509.158 484.544 509.154 484.689 c 509.132 485.164 l 509.117 485.529 508.968 485.594 508.818 485.657 c 508.986 485.755 509.183 485.897 509.183 486.284 c 509.183 486.839 508.753 486.988 508.322 486.988 c 507.111 486.988 l 507.111 484.368 l 507.464 484.368 l 507.464 485.492 l f* 511.354 484.872 m 511.347 484.872 l 510.037 486.988 l 509.617 486.988 l 509.617 484.368 l 509.96 484.368 l 509.96 486.485 l 509.967 486.485 l 511.299 484.368 l 511.697 484.368 l 511.697 486.988 l 511.354 486.988 l 511.354 484.872 l f* 512.689 485.445 m 513.109 486.598 l 513.116 486.598 l 513.503 485.445 l 512.689 485.445 l h 513.631 485.131 m 513.89 484.368 l 514.277 484.368 l 513.328 486.988 l 512.927 486.988 l 511.941 484.368 l 512.306 484.368 l 512.58 485.131 l 513.631 485.131 l f* 513.861 486.674 m 514.747 486.674 l 514.747 484.368 l 515.101 484.368 l 515.101 486.674 l 515.988 486.674 l 515.988 486.988 l 513.861 486.988 l 513.861 486.674 l f* 516.302 486.988 0.353 -2.62 re f 519.648 485.678 m 519.648 486.244 519.348 487.058 518.371 487.058 c 517.393 487.058 517.094 486.244 517.094 485.678 c 517.094 485.113 517.393 484.299 518.371 484.299 c 519.348 484.299 519.648 485.113 519.648 485.678 c h 519.283 485.678 m 519.283 485.062 518.94 484.613 518.371 484.613 c 517.801 484.613 517.458 485.062 517.458 485.678 c 517.458 486.295 517.801 486.744 518.371 486.744 c 518.94 486.744 519.283 486.295 519.283 485.678 c f* 521.717 484.872 m 521.709 484.872 l 520.399 486.988 l 519.979 486.988 l 519.979 484.368 l 520.323 484.368 l 520.323 486.485 l 520.33 486.485 l 521.662 484.368 l 522.059 484.368 l 522.059 486.988 l 521.717 486.988 l 521.717 484.872 l f* 523.052 485.445 m 523.471 486.598 l 523.479 486.598 l 523.866 485.445 l 523.052 485.445 l h 523.993 485.131 m 524.252 484.368 l 524.639 484.368 l 523.69 486.988 l 523.289 486.988 l 522.304 484.368 l 522.669 484.368 l 522.942 485.131 l 523.993 485.131 l f* 525.241 486.988 m 524.887 486.988 l 524.887 484.368 l 526.569 484.368 l 526.569 484.682 l 525.241 484.682 l 525.241 486.988 l f* 507.069 481.812 m 507.018 482.25 506.667 482.669 505.992 482.669 c 505.23 482.669 504.77 482.111 504.77 481.305 c 504.77 480.298 505.354 479.91 505.949 479.91 c 506.146 479.91 506.948 479.954 507.094 480.944 c 506.751 480.944 l 506.631 480.334 506.233 480.225 506.003 480.225 c 505.354 480.225 505.135 480.699 505.135 481.316 c 505.135 482.005 505.518 482.356 505.992 482.356 c 506.244 482.356 506.627 482.272 506.726 481.812 c 507.069 481.812 l f* 507.835 482.297 m 508.718 482.297 l 508.893 482.297 509.189 482.264 509.189 481.86 c 509.189 481.473 508.915 481.407 508.656 481.407 c 507.835 481.407 l 507.835 482.297 l h 507.835 481.104 m 508.693 481.104 l 509.116 481.104 509.159 480.852 509.159 480.637 c 509.159 480.538 509.17 480.141 509.221 479.981 c 509.656 479.981 l 509.656 480.039 l 509.546 480.101 509.528 480.156 509.524 480.301 c 509.502 480.776 l 509.488 481.141 509.338 481.206 509.189 481.268 c 509.357 481.367 509.554 481.509 509.554 481.896 c 509.554 482.45 509.123 482.6 508.693 482.6 c 507.481 482.6 l 507.481 479.981 l 507.835 479.981 l 507.835 481.104 l f* 510.042 482.6 0.354 -2.62 re f 510.743 482.286 m 511.63 482.286 l 511.63 479.98 l 511.984 479.98 l 511.984 482.286 l 512.87 482.286 l 512.87 482.6 l 510.743 482.6 l 510.743 482.286 l f* 513.184 482.6 0.354 -2.62 re f 516.292 481.812 m 516.242 482.25 515.891 482.669 515.216 482.669 c 514.454 482.669 513.994 482.111 513.994 481.305 c 513.994 480.298 514.578 479.91 515.172 479.91 c 515.37 479.91 516.172 479.954 516.318 480.944 c 515.975 480.944 l 515.855 480.334 515.457 480.225 515.227 480.225 c 514.578 480.225 514.359 480.699 514.359 481.316 c 514.359 482.005 514.742 482.356 515.216 482.356 c 515.468 482.356 515.851 482.272 515.95 481.812 c 516.292 481.812 l f* 517.183 481.057 m 517.602 482.21 l 517.61 482.21 l 517.996 481.057 l 517.183 481.057 l h 518.124 480.743 m 518.383 479.98 l 518.77 479.98 l 517.822 482.6 l 517.42 482.6 l 516.435 479.98 l 516.799 479.98 l 517.073 480.743 l 518.124 480.743 l f* 519.372 482.6 m 519.018 482.6 l 519.018 479.981 l 520.701 479.981 l 520.701 480.294 l 519.372 480.294 l 519.372 482.6 l f* 504.65 478.213 0.354 -2.621 re f 507.313 476.096 m 507.306 476.096 l 505.996 478.212 l 505.576 478.212 l 505.576 475.593 l 505.919 475.593 l 505.919 477.709 l 505.927 477.709 l 507.258 475.593 l 507.656 475.593 l 507.656 478.212 l 507.313 478.212 l 507.313 476.096 l f* 510.309 477.424 m 510.258 477.862 509.907 478.282 509.232 478.282 c 508.47 478.282 508.01 477.723 508.01 476.917 c 508.01 475.91 508.594 475.522 509.189 475.522 c 509.386 475.522 510.188 475.566 510.334 476.556 c 509.991 476.556 l 509.871 475.946 509.473 475.837 509.243 475.837 c 508.594 475.837 508.375 476.311 508.375 476.928 c 508.375 477.617 508.758 477.968 509.232 477.968 c 509.484 477.968 509.867 477.884 509.966 477.424 c 510.309 477.424 l f* 510.732 478.213 0.354 -2.621 re f 512.031 477.909 m 512.691 477.909 l 513.173 477.909 513.476 477.577 513.476 476.917 c 513.476 476.257 513.177 475.895 512.717 475.895 c 512.031 475.895 l 512.031 477.909 l h 511.677 475.593 m 512.724 475.593 l 513.585 475.593 513.84 476.351 513.84 476.939 c 513.84 477.694 513.421 478.212 512.739 478.212 c 511.677 478.212 l 511.677 475.593 l f* 516.18 475.906 m 514.6 475.906 l 514.6 476.782 l 516.034 476.782 l 516.034 477.096 l 514.6 477.096 l 514.6 477.898 l 516.154 477.898 l 516.154 478.212 l 514.246 478.212 l 514.246 475.593 l 516.18 475.593 l 516.18 475.906 l f* 518.303 476.096 m 518.296 476.096 l 516.986 478.212 l 516.566 478.212 l 516.566 475.593 l 516.909 475.593 l 516.909 477.709 l 516.917 477.709 l 518.249 475.593 l 518.646 475.593 l 518.646 478.212 l 518.303 478.212 l 518.303 476.096 l f* 518.891 477.898 m 519.777 477.898 l 519.777 475.592 l 520.131 475.592 l 520.131 477.898 l 521.018 477.898 l 521.018 478.212 l 518.891 478.212 l 518.891 477.898 l f* 507.778 473.058 m 507.764 473.346 507.673 473.894 506.757 473.894 c 506.122 473.894 505.856 473.492 505.856 473.083 c 505.856 472.627 506.242 472.507 506.414 472.467 c 506.95 472.343 l 507.381 472.241 507.508 472.153 507.508 471.879 c 507.508 471.504 507.078 471.438 506.823 471.438 c 506.487 471.438 506.1 471.576 506.1 472.051 c 505.768 472.051 l 505.768 471.807 505.812 471.588 506.034 471.387 c 506.151 471.281 506.341 471.135 506.826 471.135 c 507.275 471.135 507.851 471.307 507.851 471.927 c 507.851 472.343 507.596 472.547 507.257 472.627 c 506.509 472.799 l 506.355 472.835 506.199 472.908 506.199 473.131 c 506.199 473.529 506.574 473.591 506.797 473.591 c 507.092 473.591 507.428 473.463 507.446 473.058 c 507.778 473.058 l f* 507.997 473.51 m 508.884 473.51 l 508.884 471.204 l 509.238 471.204 l 509.238 473.51 l 510.125 473.51 l 510.125 473.824 l 507.997 473.824 l 507.997 473.51 l f* 510.781 473.521 m 511.664 473.521 l 511.839 473.521 512.135 473.488 512.135 473.083 c 512.135 472.697 511.861 472.631 511.602 472.631 c 510.781 472.631 l 510.781 473.521 l h 510.781 472.328 m 511.639 472.328 l 512.062 472.328 512.106 472.076 512.106 471.861 c 512.106 471.762 512.117 471.365 512.168 471.204 c 512.602 471.204 l 512.602 471.263 l 512.492 471.325 512.474 471.38 512.47 471.525 c 512.449 472 l 512.434 472.365 512.284 472.43 512.135 472.492 c 512.303 472.591 512.5 472.733 512.5 473.12 c 512.5 473.674 512.069 473.824 511.639 473.824 c 510.427 473.824 l 510.427 471.204 l 510.781 471.204 l 510.781 472.328 l f* 514.904 471.518 m 513.324 471.518 l 513.324 472.394 l 514.758 472.394 l 514.758 472.708 l 513.324 472.708 l 513.324 473.51 l 514.879 473.51 l 514.879 473.824 l 512.97 473.824 l 512.97 471.204 l 514.904 471.204 l 514.904 471.518 l f* 517.203 473.058 m 517.188 473.346 517.097 473.894 516.181 473.894 c 515.546 473.894 515.28 473.492 515.28 473.083 c 515.28 472.627 515.667 472.507 515.839 472.467 c 516.375 472.343 l 516.805 472.241 516.933 472.153 516.933 471.879 c 516.933 471.504 516.503 471.438 516.247 471.438 c 515.911 471.438 515.524 471.576 515.524 472.051 c 515.193 472.051 l 515.193 471.807 515.236 471.588 515.459 471.387 c 515.576 471.281 515.765 471.135 516.25 471.135 c 516.7 471.135 517.276 471.307 517.276 471.927 c 517.276 472.343 517.02 472.547 516.681 472.627 c 515.933 472.799 l 515.78 472.835 515.623 472.908 515.623 473.131 c 515.623 473.529 515.999 473.591 516.221 473.591 c 516.517 473.591 516.853 473.463 516.871 473.058 c 517.203 473.058 l f* 519.56 473.058 m 519.545 473.346 519.454 473.894 518.539 473.894 c 517.903 473.894 517.637 473.492 517.637 473.083 c 517.637 472.627 518.024 472.507 518.195 472.467 c 518.732 472.343 l 519.163 472.241 519.29 472.153 519.29 471.879 c 519.29 471.504 518.86 471.438 518.604 471.438 c 518.268 471.438 517.882 471.576 517.882 472.051 c 517.55 472.051 l 517.55 471.807 517.593 471.588 517.816 471.387 c 517.932 471.281 518.123 471.135 518.608 471.135 c 519.057 471.135 519.633 471.307 519.633 471.927 c 519.633 472.343 519.377 472.547 519.038 472.627 c 518.29 472.799 l 518.137 472.835 517.98 472.908 517.98 473.131 c 517.98 473.529 518.356 473.591 518.579 473.591 c 518.874 473.591 519.21 473.463 519.228 473.058 c 519.56 473.058 l f* 501.937 468.006 m 503.221 468.006 l 503.221 468.32 l 501.937 468.32 l 501.937 469.122 l 503.396 469.122 l 503.396 469.436 l 501.583 469.436 l 501.583 466.816 l 501.937 466.816 l 501.937 468.006 l f* 506.125 468.126 m 506.125 468.692 505.826 469.506 504.849 469.506 c 503.871 469.506 503.572 468.692 503.572 468.126 c 503.572 467.561 503.871 466.746 504.849 466.746 c 505.826 466.746 506.125 467.561 506.125 468.126 c h 505.761 468.126 m 505.761 467.51 505.418 467.061 504.849 467.061 c 504.279 467.061 503.936 467.51 503.936 468.126 c 503.936 468.743 504.279 469.192 504.849 469.192 c 505.418 469.192 505.761 468.743 505.761 468.126 c f* 508.176 469.436 m 508.176 467.78 l 508.176 467.21 507.811 467.061 507.487 467.061 c 507.169 467.061 506.823 467.218 506.823 467.787 c 506.823 469.436 l 506.468 469.436 l 506.468 467.689 l 506.468 467.199 506.771 466.746 507.476 466.746 c 508.194 466.746 508.53 467.199 508.53 467.736 c 508.53 469.436 l 508.176 469.436 l f* 510.745 467.32 m 510.737 467.32 l 509.428 469.436 l 509.008 469.436 l 509.008 466.817 l 509.351 466.817 l 509.351 468.933 l 509.358 468.933 l 510.69 466.817 l 511.088 466.817 l 511.088 469.436 l 510.745 469.436 l 510.745 467.32 l f* 511.93 469.133 m 512.591 469.133 l 513.072 469.133 513.375 468.801 513.375 468.141 c 513.375 467.481 513.076 467.119 512.616 467.119 c 511.93 467.119 l 511.93 469.133 l h 511.577 466.817 m 512.624 466.817 l 513.485 466.817 513.74 467.575 513.74 468.163 c 513.74 468.918 513.321 469.436 512.638 469.436 c 511.577 469.436 l 511.577 466.817 l f* 514.485 467.893 m 514.904 469.046 l 514.911 469.046 l 515.298 467.893 l 514.485 467.893 l h 515.426 467.579 m 515.685 466.816 l 516.072 466.816 l 515.123 469.436 l 514.722 469.436 l 513.737 466.816 l 514.102 466.816 l 514.375 467.579 l 515.426 467.579 l f* 515.656 469.122 m 516.543 469.122 l 516.543 466.816 l 516.897 466.816 l 516.897 469.122 l 517.783 469.122 l 517.783 469.436 l 515.656 469.436 l 515.656 469.122 l f* 518.097 469.436 0.354 -2.62 re f 521.443 468.126 m 521.443 468.692 521.144 469.506 520.165 469.506 c 519.188 469.506 518.888 468.692 518.888 468.126 c 518.888 467.561 519.188 466.746 520.165 466.746 c 521.144 466.746 521.443 467.561 521.443 468.126 c h 521.078 468.126 m 521.078 467.51 520.735 467.061 520.165 467.061 c 519.597 467.061 519.253 467.51 519.253 468.126 c 519.253 468.743 519.597 469.192 520.165 469.192 c 520.735 469.192 521.078 468.743 521.078 468.126 c f* 523.511 467.32 m 523.504 467.32 l 522.194 469.436 l 521.775 469.436 l 521.775 466.817 l 522.118 466.817 l 522.118 468.933 l 522.125 468.933 l 523.457 466.817 l 523.854 466.817 l 523.854 469.436 l 523.511 469.436 l 523.511 467.32 l f* 511.727 504.763 m 513.586 504.763 l 513.585 502.856 l 515.124 503.859 l 516.011 502.415 l 514.364 501.456 l 516.023 500.516 l 515.17 499.036 l 513.574 499.961 l 513.574 498.015 l 511.734 498.015 l 511.733 499.918 l 510.105 498.979 l 509.252 500.525 l 510.863 501.443 l 509.222 502.403 l 510.073 503.839 l 511.727 502.856 l 511.727 504.763 l f* 0 0.286 0.388 RG 511.727 504.763 m 513.586 504.763 l 513.585 502.856 l 515.124 503.859 l 516.011 502.415 l 514.364 501.456 l 516.023 500.516 l 515.17 499.036 l 513.574 499.961 l 513.574 498.015 l 511.734 498.015 l 511.733 499.918 l 510.105 498.979 l 509.252 500.525 l 510.863 501.443 l 509.222 502.403 l 510.073 503.839 l 511.727 502.856 l 511.727 504.763 l s 1 1 1 rg 512.864 503.924 m 512.643 504.313 512.451 503.918 y 512.637 498.93 l 512.707 498.791 512.737 498.944 y 512.864 503.924 l f* 512.511 502.334 m 512.384 502.413 512.326 502.481 y 512.005 502.823 511.999 503.086 y 511.99 503.316 512.07 503.448 y 512.135 503.59 512.339 503.665 y 512.46 503.712 512.476 503.7 y 512.637 503.697 512.715 503.568 y 512.976 503.381 512.637 503.386 y 512.476 503.41 512.428 503.446 y 512.228 503.392 512.269 503.097 y 512.308 502.921 512.414 502.729 512.499 502.685 c 512.511 502.334 l f* 1 1 1 RG 0.23 w 512.511 502.334 m 512.384 502.413 512.326 502.481 y 512.005 502.823 511.999 503.086 y 511.99 503.316 512.07 503.448 y 512.135 503.59 512.339 503.665 y 512.46 503.712 512.476 503.7 y 512.637 503.697 512.715 503.568 y 512.976 503.381 512.637 503.386 y 512.476 503.41 512.428 503.446 y 512.228 503.392 512.269 503.097 y 512.308 502.921 512.414 502.729 512.499 502.685 c 512.511 502.334 l s 512.636 503.555 m 512.61 503.558 512.582 503.547 512.559 503.559 c 512.547 503.564 512.543 503.578 512.547 503.588 c 512.55 503.595 512.568 503.607 512.58 503.602 c 512.604 503.593 512.61 503.563 512.636 503.555 c f* 512.636 503.555 m 512.61 503.558 512.582 503.547 512.559 503.559 c 512.547 503.564 512.543 503.578 512.547 503.588 c 512.55 503.595 512.568 503.607 512.58 503.602 c 512.604 503.593 512.61 503.563 512.636 503.555 c s 512.619 499.934 m 512.635 500.026 512.679 500.096 v 512.718 500.157 512.75 500.189 512.814 500.256 c 512.849 500.293 512.899 500.363 512.935 500.406 c 513.059 500.562 512.956 500.729 v 512.909 500.8 512.781 500.911 v 512.784 500.57 l 512.783 500.489 512.566 500.243 y 512.511 500.174 512.484 500.141 512.458 499.946 c 512.437 499.722 512.621 499.483 v 512.61 499.844 l 512.613 499.904 512.619 499.934 v f* 512.619 499.934 m 512.635 500.026 512.679 500.096 v 512.718 500.157 512.75 500.189 512.814 500.256 c 512.849 500.293 512.899 500.363 512.935 500.406 c 513.059 500.562 512.956 500.729 v 512.909 500.8 512.781 500.911 v 512.784 500.57 l 512.783 500.489 512.566 500.243 y 512.511 500.174 512.484 500.141 512.458 499.946 c 512.437 499.722 512.621 499.483 v 512.61 499.844 l 512.613 499.904 512.619 499.934 v s 512.819 502.118 m 512.838 502.061 512.538 501.746 y 512.512 501.716 512.482 501.682 512.447 501.644 c 512.259 501.44 512.268 501.271 v 512.278 501.036 512.508 500.815 v 512.536 500.792 512.575 500.75 v 512.565 501.072 l 512.54 501.103 512.512 501.15 512.488 501.221 c 512.463 501.272 512.532 501.381 v 512.653 501.491 513.044 501.955 v 513.158 502.148 513.068 502.276 v 512.981 502.403 512.829 502.504 v 512.819 502.118 l f* 512.819 502.118 m 512.838 502.061 512.538 501.746 y 512.512 501.716 512.482 501.682 512.447 501.644 c 512.259 501.44 512.268 501.271 v 512.278 501.036 512.508 500.815 v 512.536 500.792 512.575 500.75 v 512.565 501.072 l 512.54 501.103 512.512 501.15 512.488 501.221 c 512.463 501.272 512.532 501.381 v 512.653 501.491 513.044 501.955 v 513.158 502.148 513.068 502.276 v 512.981 502.403 512.829 502.504 v 512.819 502.118 l s 512.744 499.325 m 512.755 499.284 512.749 499.233 512.699 499.175 c 512.59 499.018 l 512.712 499.07 512.77 499.143 v 512.843 499.215 512.826 499.348 v 512.813 499.411 512.75 499.513 v 512.744 499.325 l f* 512.744 499.325 m 512.755 499.284 512.749 499.233 512.699 499.175 c 512.59 499.018 l 512.712 499.07 512.77 499.143 v 512.843 499.215 512.826 499.348 v 512.813 499.411 512.75 499.513 v 512.744 499.325 l s 0 0.286 0.388 rg 537.61 479.658 m 537.756 479.747 538.203 480.422 538.22 480.394 c 538.487 479.97 538.853 479.542 539.633 479.542 c 540.414 479.542 541.047 479.924 541.047 480.394 c 541.047 479.924 541.656 479.565 542.437 479.565 c 543.217 479.565 543.607 479.926 543.85 480.417 c 543.86 480.459 l 544.004 480.367 544.702 479.906 544.68 479.881 c 542.486 478.319 547.02 475.061 541.71 473.18 c 541.438 473.103 541.315 472.918 v 541.266 473.008 540.876 473.186 y 535.147 474.436 539.974 478.096 537.61 479.658 c f* 0 0.286 0.388 RG 1 J 1 j 0.46 w 537.61 479.658 m 537.756 479.747 538.203 480.422 538.22 480.394 c 538.487 479.97 538.853 479.542 539.633 479.542 c 540.414 479.542 541.047 479.924 541.047 480.394 c S 0.137 0.122 0.125 RG 541.047 480.394 m 541.047 480.394 l S 0 0.286 0.388 RG 541.047 480.394 m 541.047 479.924 541.656 479.565 542.437 479.565 c 543.217 479.565 543.607 479.926 543.85 480.417 c S 0.137 0.122 0.125 RG 543.85 480.417 m 543.86 480.459 l S 0 0.286 0.388 RG 543.86 480.459 m 544.004 480.367 544.702 479.906 544.68 479.881 c 542.486 478.319 547.02 475.061 541.71 473.18 c 541.438 473.103 541.315 472.918 v S 0.137 0.122 0.125 RG 541.315 472.918 m 541.315 472.918 l S 0 0.286 0.388 RG 541.315 472.918 m 541.266 473.008 540.876 473.186 y 535.147 474.436 539.974 478.096 537.61 479.658 c S 1 1 1 rg 539.666 474.364 m 540.179 476.44 l 538.877 477.591 l 540.51 477.593 l 541.026 479.505 l 541.623 477.585 l 543.383 477.589 l 541.965 476.348 l 542.581 474.364 l 541.149 475.639 l 539.666 474.364 l f* 0.137 0.122 0.125 rg 480.854 478.226 m 480.671 478.188 480.573 478.176 480.459 477.945 c 480.418 477.862 480.375 477.767 480.318 477.691 c 480.092 477.359 480.135 476.964 480.163 476.608 c 480.191 476.557 480.22 476.486 480.22 476.429 c 480.22 476.353 480.298 476.304 480.318 476.225 c 480.361 476.059 480.502 475.996 480.586 475.869 c 480.643 475.817 480.84 475.677 480.84 475.703 c 480.84 476.034 480.742 476.386 480.671 476.659 c 480.572 477.041 480.699 477.41 480.784 477.818 c 480.84 477.971 480.826 478.073 480.854 478.226 c f* 0.137 0.122 0.125 RG 0 J 480.854 478.226 m 480.671 478.188 480.573 478.176 480.459 477.945 c 480.418 477.862 480.375 477.767 480.318 477.691 c 480.092 477.359 480.135 476.964 480.163 476.608 c 480.191 476.557 480.22 476.486 480.22 476.429 c 480.22 476.353 480.298 476.304 480.318 476.225 c 480.361 476.059 480.502 475.996 480.586 475.869 c 480.643 475.817 480.84 475.677 480.84 475.703 c 480.84 476.034 480.742 476.386 480.671 476.659 c 480.572 477.041 480.699 477.41 480.784 477.818 c 480.84 477.971 480.826 478.073 480.854 478.226 c s 482.449 474.378 m 482.5 474.214 482.508 474.069 482.768 473.977 c 482.863 473.943 482.97 473.909 483.057 473.861 c 483.434 473.673 483.869 473.73 484.262 473.772 c 484.317 473.8 484.394 473.828 484.457 473.831 c 484.541 473.835 484.592 473.908 484.678 473.93 c 484.859 473.976 484.923 474.106 485.06 474.188 c 485.113 474.241 485.26 474.426 485.231 474.425 c 484.865 474.41 484.481 474.304 484.182 474.228 c 483.764 474.121 483.349 474.218 482.894 474.276 c 482.722 474.319 482.619 474.359 482.449 474.378 c f* 482.449 474.378 m 482.5 474.214 482.508 474.069 482.768 473.977 c 482.863 473.943 482.97 473.909 483.057 473.861 c 483.434 473.673 483.869 473.73 484.262 473.772 c 484.317 473.8 484.394 473.828 484.457 473.831 c 484.541 473.835 484.592 473.908 484.678 473.93 c 484.859 473.976 484.923 474.106 485.06 474.188 c 485.113 474.241 485.26 474.426 485.231 474.425 c 484.865 474.41 484.481 474.304 484.182 474.228 c 483.764 474.121 483.349 474.218 482.894 474.276 c 482.722 474.319 482.619 474.359 482.449 474.378 c s 486.767 475.83 m 486.947 475.879 487.043 475.896 487.141 476.133 c 487.176 476.219 487.213 476.316 487.264 476.395 c 487.466 476.739 487.455 477.139 487.402 477.493 c 487.37 477.542 487.342 477.627 487.338 477.684 c 487.324 477.881 487.171 478.03 487.19 477.971 c 487.136 478.134 487.051 478.097 486.957 478.22 c 486.897 478.267 486.765 478.36 486.767 478.334 c 486.79 478.004 486.825 477.704 486.915 477.436 c 487.041 477.06 486.864 476.653 486.808 476.241 c 486.763 476.085 486.784 475.984 486.767 475.83 c f* 486.767 475.83 m 486.947 475.879 487.043 475.896 487.141 476.133 c 487.176 476.219 487.213 476.316 487.264 476.395 c 487.466 476.739 487.455 477.139 487.402 477.493 c 487.37 477.542 487.342 477.627 487.338 477.684 c 487.324 477.881 487.171 478.03 487.19 477.971 c 487.136 478.134 487.051 478.097 486.957 478.22 c 486.897 478.267 486.765 478.36 486.767 478.334 c 486.79 478.004 486.825 477.704 486.915 477.436 c 487.041 477.06 486.864 476.653 486.808 476.241 c 486.763 476.085 486.784 475.984 486.767 475.83 c s 485.246 479.582 m 485.204 479.748 485.191 479.836 484.936 479.939 c 484.843 479.977 484.738 480.016 484.654 480.067 c 484.287 480.272 483.85 480.234 483.454 480.208 c 483.398 480.183 483.32 480.158 483.257 480.158 c 483.172 480.158 483.118 480.087 483.031 480.069 c 482.848 480.031 482.777 479.903 482.636 479.827 c 482.579 479.776 482.424 479.598 482.452 479.598 c 482.819 479.597 483.208 479.686 483.51 479.75 c 483.934 479.838 484.343 479.723 484.794 479.646 c 484.964 479.595 485.077 479.608 485.246 479.582 c f* 485.246 479.582 m 485.204 479.748 485.191 479.836 484.936 479.939 c 484.843 479.977 484.738 480.016 484.654 480.067 c 484.287 480.272 483.85 480.234 483.454 480.208 c 483.398 480.183 483.32 480.158 483.257 480.158 c 483.172 480.158 483.118 480.087 483.031 480.069 c 482.848 480.031 482.777 479.903 482.636 479.827 c 482.579 479.776 482.424 479.598 482.452 479.598 c 482.819 479.597 483.208 479.686 483.51 479.75 c 483.934 479.838 484.343 479.723 484.794 479.646 c 484.964 479.595 485.077 479.608 485.246 479.582 c s 0 0.286 0.388 rg 483.761 474.555 m 485.298 474.555 486.545 475.686 486.545 477.082 c 486.545 478.478 485.298 479.61 483.761 479.61 c 482.224 479.61 480.978 478.478 480.978 477.082 c 480.978 475.686 482.224 474.555 483.761 474.555 c f* 0 0.286 0.388 RG 1.841 w 483.761 474.555 m 485.298 474.555 486.545 475.686 486.545 477.082 c 486.545 478.478 485.298 479.61 483.761 479.61 c 482.224 479.61 480.978 478.478 480.978 477.082 c 480.978 475.686 482.224 474.555 483.761 474.555 c s 481.495 478.558 m 480.056 479.667 l 479.929 479.552 480.073 479.405 479.835 478.929 c 479.745 478.748 479.739 478.309 479.654 478.099 c 479.654 478.061 479.675 478.138 479.654 478.099 c 479.633 478.004 479.442 477.583 479.464 477.488 c 479.442 477.488 479.464 477.488 y 479.4 477.22 479.4 476.972 479.421 476.704 c 479.431 476.504 479.476 476.459 479.638 475.786 c 479.681 475.614 479.843 475.166 479.885 474.975 c 479.927 474.803 480.014 474.449 480.077 474.296 c 480.099 474.258 479.993 474.277 480.077 474.296 c 481.622 475.423 l 481.587 475.491 481.672 475.35 481.622 475.423 c 481.499 475.693 481.242 476.105 481.192 476.399 c 481.118 476.719 481.118 477.062 481.143 477.382 c 481.143 477.406 481.285 477.849 481.291 477.873 c 481.375 478.184 481.341 478.192 481.495 478.558 c f* 0.46 w 481.495 478.558 m 480.056 479.667 l 479.929 479.552 480.073 479.405 479.835 478.929 c 479.745 478.748 479.739 478.309 479.654 478.099 c 479.654 478.061 479.675 478.138 479.654 478.099 c 479.633 478.004 479.442 477.583 479.464 477.488 c 479.442 477.488 479.464 477.488 y 479.4 477.22 479.4 476.972 479.421 476.704 c 479.431 476.504 479.476 476.459 479.638 475.786 c 479.681 475.614 479.843 475.166 479.885 474.975 c 479.927 474.803 480.014 474.449 480.077 474.296 c 480.099 474.258 479.993 474.277 480.077 474.296 c 481.622 475.423 l 481.587 475.491 481.672 475.35 481.622 475.423 c 481.499 475.693 481.242 476.105 481.192 476.399 c 481.118 476.719 481.118 477.062 481.143 477.382 c 481.143 477.406 481.285 477.849 481.291 477.873 c 481.375 478.184 481.341 478.192 481.495 478.558 c s 485.287 479.137 m 486.459 480.523 l 486.349 480.654 486.195 480.516 485.727 480.772 c 485.549 480.869 485.109 480.894 484.902 480.987 c 484.863 480.988 484.939 480.964 484.902 480.987 c 484.807 481.012 484.392 481.218 484.295 481.201 c 484.296 481.222 484.295 481.201 y 484.029 481.275 483.78 481.285 483.51 481.275 c 483.309 481.274 483.263 481.231 482.579 481.097 c 482.405 481.062 481.949 480.919 481.756 480.884 c 481.581 480.849 481.222 480.778 481.066 480.721 c 481.026 480.701 481.05 480.806 481.066 480.721 c 482.135 479.138 l 482.204 479.171 482.059 479.092 482.135 479.138 c 482.411 479.25 482.834 479.489 483.132 479.526 c 483.456 479.587 483.801 479.573 484.12 479.535 c 484.145 479.534 484.642 479.452 484.665 479.444 c 484.968 479.351 484.912 479.322 485.287 479.137 c f* 485.287 479.137 m 486.459 480.523 l 486.349 480.654 486.195 480.516 485.727 480.772 c 485.549 480.869 485.109 480.894 484.902 480.987 c 484.863 480.988 484.939 480.964 484.902 480.987 c 484.807 481.012 484.392 481.218 484.295 481.201 c 484.296 481.222 484.295 481.201 y 484.029 481.275 483.78 481.285 483.51 481.275 c 483.309 481.274 483.263 481.231 482.579 481.097 c 482.405 481.062 481.949 480.919 481.756 480.884 c 481.581 480.849 481.222 480.778 481.066 480.721 c 481.026 480.701 481.05 480.806 481.066 480.721 c 482.135 479.138 l 482.204 479.171 482.059 479.092 482.135 479.138 c 482.411 479.25 482.834 479.489 483.132 479.526 c 483.456 479.587 483.801 479.573 484.12 479.535 c 484.145 479.534 484.642 479.452 484.665 479.444 c 484.968 479.351 484.912 479.322 485.287 479.137 c s 482.281 474.909 m 481.18 473.468 l 481.296 473.342 481.442 473.487 481.923 473.254 c 482.105 473.166 482.546 473.164 482.758 473.081 c 482.796 473.081 482.719 473.102 482.758 473.081 c 482.854 473.061 483.278 472.875 483.374 472.897 c 483.374 472.876 483.374 472.897 y 483.643 472.836 483.893 472.838 484.162 472.861 c 484.363 472.873 484.407 472.918 485.082 473.085 c 485.255 473.128 485.703 473.294 485.894 473.337 c 486.067 473.381 486.423 473.47 486.576 473.535 c 486.614 473.556 486.596 473.451 486.576 473.535 c 485.429 475.063 l 485.362 475.027 485.503 475.113 485.429 475.063 c 485.159 474.938 484.748 474.678 484.452 474.627 c 484.132 474.55 483.787 474.547 483.466 474.569 c 483.441 474.569 482.995 474.706 482.971 474.712 c 482.6 474.807 482.659 474.808 482.281 474.909 c f* 482.281 474.909 m 481.18 473.468 l 481.296 473.342 481.442 473.487 481.923 473.254 c 482.105 473.166 482.546 473.164 482.758 473.081 c 482.796 473.081 482.719 473.102 482.758 473.081 c 482.854 473.061 483.278 472.875 483.374 472.897 c 483.374 472.876 483.374 472.897 y 483.643 472.836 483.893 472.838 484.162 472.861 c 484.363 472.873 484.407 472.918 485.082 473.085 c 485.255 473.128 485.703 473.294 485.894 473.337 c 486.067 473.381 486.423 473.47 486.576 473.535 c 486.614 473.556 486.596 473.451 486.576 473.535 c 485.429 475.063 l 485.362 475.027 485.503 475.113 485.429 475.063 c 485.159 474.938 484.748 474.678 484.452 474.627 c 484.132 474.55 483.787 474.547 483.466 474.569 c 483.441 474.569 482.995 474.706 482.971 474.712 c 482.6 474.807 482.659 474.808 482.281 474.909 c s 486.022 475.737 m 487.899 474.595 l 488.014 474.722 487.857 474.854 488.046 475.351 c 488.118 475.54 488.082 475.977 488.145 476.194 c 488.141 476.233 488.128 476.154 488.145 476.194 c 488.157 476.291 488.305 476.728 488.275 476.821 c 488.296 476.824 488.275 476.821 y 488.311 477.094 488.287 477.341 488.24 477.605 c 488.21 477.804 488.161 477.843 487.933 478.498 c 487.874 478.666 487.669 479.095 487.608 479.281 c 487.549 479.448 487.428 479.792 487.35 479.939 c 487.325 479.974 487.432 479.966 487.35 479.939 c 485.923 478.666 l 485.965 478.602 485.867 478.734 485.923 478.666 c 486.073 478.409 486.369 478.025 486.447 477.736 c 486.552 477.426 486.46 477.088 486.466 476.768 c 486.469 476.743 486.397 476.301 486.392 476.277 c 486.33 475.901 486.244 476.056 486.047 475.737 c 486.022 475.737 l f* 486.022 475.737 m 487.899 474.595 l 488.014 474.722 487.857 474.854 488.046 475.351 c 488.118 475.54 488.082 475.977 488.145 476.194 c 488.141 476.233 488.128 476.154 488.145 476.194 c 488.157 476.291 488.305 476.728 488.275 476.821 c 488.296 476.824 488.275 476.821 y 488.311 477.094 488.287 477.341 488.24 477.605 c 488.21 477.804 488.161 477.843 487.933 478.498 c 487.874 478.666 487.669 479.095 487.608 479.281 c 487.549 479.448 487.428 479.792 487.35 479.939 c 487.325 479.974 487.432 479.966 487.35 479.939 c 485.923 478.666 l 485.965 478.602 485.867 478.734 485.923 478.666 c 486.073 478.409 486.369 478.025 486.447 477.736 c 486.552 477.426 486.46 477.088 486.466 476.768 c 486.469 476.743 486.397 476.301 486.392 476.277 c 486.33 475.901 486.244 476.056 486.047 475.737 c 486.022 475.737 l s 1 1 1 rg 482.206 476.126 m 482.181 476.323 482.304 476.617 482.304 476.814 c 482.28 476.789 482.551 476.568 482.526 476.544 c 482.6 476.544 482.699 476.519 482.699 476.544 c 482.897 476.937 482.798 476.74 482.946 477.207 c 482.969 477.281 482.921 477.894 482.97 477.992 c 482.995 478.017 483.291 477.557 483.291 477.501 c 483.291 477.305 483.513 478.017 483.587 477.82 c 483.661 477.673 483.415 477.158 483.538 477.059 c 483.735 476.912 483.859 477.28 483.834 477.477 c 483.933 477.084 483.809 476.789 483.711 476.593 c 483.607 476.386 483.241 476.46 483.069 476.175 c 482.995 476.053 482.995 475.881 482.921 475.758 c 482.872 475.709 482.798 475.733 482.773 475.66 c 482.206 476.126 l f* 1 1 1 RG 1 J 482.206 476.126 m 482.181 476.323 482.304 476.617 482.304 476.814 c 482.28 476.789 482.551 476.568 482.526 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485.035 476.154 c 484.863 475.933 484.69 475.687 484.394 475.564 c 483.283 475.393 l f* 483.283 475.393 m 483.283 475.466 483.358 475.466 483.382 475.515 c 483.678 475.712 484.049 475.761 484.196 476.08 c 484.295 476.301 484.271 476.522 484.221 476.743 c 484.221 476.841 484.073 476.915 484.098 477.038 c 484.172 477.013 484.419 476.891 484.468 476.964 c 484.616 477.161 484.69 477.627 484.616 477.873 c 484.838 477.48 484.887 476.891 484.739 476.399 c 484.789 476.399 485.085 476.768 485.134 476.743 c 485.159 476.719 485.06 476.203 485.035 476.154 c 484.863 475.933 484.69 475.687 484.394 475.564 c S 0 0.286 0.388 rg 512.51 451.284 m 512.602 451.311 512.672 451.256 512.764 451.311 c 512.949 451.393 513.112 451.448 513.273 451.585 c 513.389 451.668 513.458 451.805 513.574 451.915 c 513.62 451.943 513.695 451.944 513.713 451.86 c 513.736 451.75 513.806 451.723 513.875 451.695 c 514.222 451.558 514.569 451.641 514.916 451.695 c 515.31 451.75 515.587 452.107 515.958 452.272 c 516.143 452.382 516.283 452.593 516.467 452.63 c 516.606 452.657 516.768 452.657 516.884 452.766 c 516.953 452.822 516.93 452.904 v 517.184 452.932 517.369 453.124 517.532 453.343 c 517.578 453.371 517.647 453.425 517.716 453.398 c 517.693 453.398 l 519.406 455.567 l 519.382 455.621 l 519.359 455.704 519.405 455.787 519.359 455.868 c 514.199 454.468 l 514.175 454.275 513.967 454.029 513.851 453.863 c 513.873 453.893 513.461 454.132 513.499 454.209 c 513.745 454.701 513.683 455.157 513.429 455.596 c 513.382 455.706 513.336 455.747 513.267 455.843 c 513.09 456.087 512.804 456.227 512.503 456.172 c 512.434 456.172 l 512.133 456.227 511.924 456.09 511.704 455.897 c 511.604 455.81 511.427 455.623 511.381 455.513 c 511.126 455.074 511.231 454.538 511.428 454.11 c 511.463 454.032 511.047 453.896 511.068 453.867 c 510.953 454.031 510.744 454.278 510.721 454.471 c 505.56 455.871 l 505.514 455.788 505.56 455.706 505.537 455.623 c 505.514 455.568 l 507.227 453.4 l 507.203 453.4 l 507.273 453.428 507.342 453.372 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516.606 452.657 516.768 452.657 516.884 452.766 c 516.953 452.822 516.93 452.904 v 517.184 452.932 517.369 453.124 517.532 453.343 c 517.578 453.371 517.647 453.425 517.716 453.398 c 517.693 453.398 l 519.406 455.567 l 519.382 455.621 l 519.359 455.704 519.405 455.787 519.359 455.868 c 514.199 454.468 l 514.175 454.275 513.967 454.029 513.851 453.863 c 513.873 453.893 513.461 454.132 513.499 454.209 c 513.745 454.701 513.683 455.157 513.429 455.596 c 513.382 455.706 513.336 455.747 513.267 455.843 c 513.09 456.087 512.804 456.227 512.503 456.172 c 512.434 456.172 l 512.133 456.227 511.924 456.09 511.704 455.897 c 511.604 455.81 511.427 455.623 511.381 455.513 c 511.126 455.074 511.231 454.538 511.428 454.11 c 511.463 454.032 511.047 453.896 511.068 453.867 c 510.953 454.031 510.744 454.278 510.721 454.471 c 505.56 455.871 l 505.514 455.788 505.56 455.706 505.537 455.623 c 505.514 455.568 l 507.227 453.4 l 507.203 453.4 l 507.273 453.428 507.342 453.372 507.389 453.345 c 507.551 453.126 507.736 452.933 507.99 452.906 c 507.967 452.823 508.037 452.769 y 508.152 452.659 508.314 452.659 508.453 452.631 c 508.637 452.595 508.777 452.384 508.962 452.275 c 509.332 452.11 509.61 451.753 510.004 451.698 c 510.351 451.643 510.698 451.561 511.045 451.698 c 511.114 451.725 511.184 451.753 511.207 451.863 c 511.225 451.947 511.3 451.945 511.346 451.918 c 511.462 451.808 511.531 451.671 511.647 451.588 c 511.809 451.451 511.97 451.396 512.156 451.314 c 512.249 451.259 512.318 451.314 512.411 451.286 c 512.51 451.284 l s 1 1 1 rg 508.291 454.812 m 510.594 454.251 l 510.582 454.251 510.582 454.265 510.57 454.265 c 510.629 454.087 510.698 453.908 510.744 453.716 c 510.808 453.448 510.744 453.153 510.733 452.879 c 510.617 452.933 510.605 453.016 v 510.559 453.208 510.559 453.345 510.513 453.537 c 510.501 453.551 510.432 453.619 510.42 453.647 c 510.344 453.828 510.247 453.853 510.085 453.949 c 509.899 454.045 509.714 454.196 509.541 454.278 c 509.171 454.443 508.777 454.471 508.418 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453.342 514.407 453.534 c 514.419 453.548 514.488 453.617 514.499 453.644 c 514.576 453.825 514.673 453.85 514.835 453.946 c 515.02 454.042 515.205 454.193 515.379 454.276 c 515.749 454.44 516.143 454.468 516.501 454.646 c 516.513 454.66 516.547 454.674 516.559 454.715 c 516.567 454.744 516.663 454.743 516.628 454.81 c f 516.062 454.345 m 516.038 454.317 516.015 454.262 515.992 454.249 c 515.888 454.193 515.784 454.207 515.68 454.207 c 515.703 454.221 515.726 454.249 515.749 454.249 c 515.876 454.249 515.957 454.29 516.062 454.345 c f 515.715 453.988 m 515.61 453.988 515.518 454.001 515.414 453.988 c 515.402 453.974 515.414 453.946 515.425 453.932 c 515.518 453.905 515.61 453.851 515.703 453.823 c 515.726 453.81 515.761 453.823 y 515.807 453.782 515.927 453.764 515.911 453.81 c 515.888 453.878 515.807 453.919 515.749 453.96 c f 515.703 453.521 m 515.669 453.521 515.634 453.507 515.599 453.534 c 515.529 453.59 515.414 453.672 515.333 453.686 c f 515.425 453.315 m 515.321 453.315 515.194 453.288 515.113 453.329 c 515.078 453.356 515.032 453.411 515.009 453.48 c 515.159 453.452 515.252 453.356 515.402 453.356 c f 514.708 453.219 m 514.731 453.219 514.754 453.233 514.777 453.219 c 514.858 453.164 514.951 453.15 515.009 453.068 c 515.032 453.027 515.032 452.972 515.032 452.931 c 515.009 452.931 514.986 452.917 514.974 452.931 c 514.916 453.041 514.812 453.068 514.754 453.164 c f 514.916 452.711 m 514.916 452.697 514.916 452.67 514.916 452.656 c 514.777 452.615 514.685 452.739 514.581 452.834 c 514.499 452.903 514.581 452.958 514.65 452.903 c 514.685 452.876 514.743 452.834 514.789 452.793 c 514.824 452.752 514.882 452.78 514.928 452.739 c 514.916 452.725 514.916 452.711 v f 514.477 452.601 m 514.419 452.601 514.407 452.67 514.361 452.697 c f 514.222 452.587 m 514.222 452.56 514.222 452.546 514.222 452.519 c 514.199 452.519 l 514.199 452.492 514.199 452.45 514.199 452.423 c f 518.873 455.265 m 518.804 455.278 518.746 455.251 518.688 455.224 c 518.676 455.224 518.654 455.196 518.63 455.182 c 518.561 455.155 518.492 455.128 518.422 455.1 c 518.202 455.031 517.97 455.045 517.763 454.921 c 517.681 454.88 517.589 454.839 517.508 454.812 c 517.288 454.757 517.092 454.757 516.872 454.715 c 516.837 454.701 516.802 454.66 516.756 454.66 c 516.987 454.674 517.219 454.633 517.461 454.674 c 517.589 454.701 517.716 454.688 517.843 454.729 c 517.878 454.743 517.89 454.784 517.924 454.798 c 518.052 454.839 518.167 454.784 518.283 454.826 c 518.33 454.839 518.387 454.839 518.434 454.867 c 518.595 454.921 518.7 455.072 518.827 455.209 c 518.839 455.224 518.816 455.251 518.839 455.265 c f 518.607 454.784 m 518.561 454.729 518.526 454.66 518.457 454.633 c 518.341 454.606 518.237 454.524 518.121 454.496 c 517.983 454.455 517.855 454.428 517.716 454.413 c 517.543 454.386 517.381 454.386 517.207 454.331 c 517.196 454.331 517.16 454.322 517.149 454.318 c 516.883 454.194 516.605 454.249 516.34 454.249 c 516.328 454.331 516.362 454.441 516.444 454.454 c 516.571 454.482 516.687 454.413 516.814 454.4 c 516.976 454.372 517.126 454.372 517.288 454.4 c 517.346 454.413 517.393 454.428 517.439 454.454 c 517.589 454.523 517.739 454.455 517.89 454.523 c 517.948 454.55 517.994 454.565 518.052 454.592 c 518.214 454.633 518.376 454.66 518.526 454.729 c f 518.052 454.112 m 517.797 454.098 517.531 454.166 517.277 454.084 c 517.23 454.07 517.196 454.001 517.138 453.988 c 517.045 453.974 516.953 454.001 516.86 454.015 c 516.663 454.057 516.467 454.001 516.27 454.042 c 516.617 453.768 517.068 453.864 517.461 453.892 c 517.555 453.892 517.624 453.974 517.705 453.988 c 517.774 453.988 517.855 453.988 517.925 454.015 c 517.96 454.03 517.983 454.057 518.017 454.07 c f 517.381 453.481 m 517.393 453.494 517.369 453.508 517.369 453.521 c 517.161 453.508 516.953 453.576 516.744 453.618 c 516.513 453.658 516.282 453.562 516.05 453.658 c 516.085 453.645 516.121 453.629 516.154 453.617 c 516.559 453.48 516.918 453.508 517.311 453.494 c f 516.93 453.096 m 516.803 453.069 516.64 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/DeviceRGB 0 229 0 R] endobj 229 0 obj << /Length 4 >> stream endstream endobj 224 0 obj [/Indexed /DeviceRGB 0 230 0 R] endobj 230 0 obj << /Length 4 >> stream # endstream endobj 232 0 obj << /Length 5429 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 66 59.745 m 558 59.745 l S BT /TT3 1 Tf 8 0 0 8 423.24 42.6 Tm 0 0 0 1 k /GS2 gs -0.0051 Tc 0.0326 Tw [(IJEMH Vol. 10, No. 3 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (203)Tj /TT3 1 Tf 7 0 0 7 121.74 726.66 Tm -0.0061 Tc 0.0193 Tw [(International Journal of Emergency Mental Health, Vol. 10, No. 3, pp.203-218 2008 Chevron Publishing ISSN 1522-4821)]TJ /TT4 1 Tf 10 0 0 10 104.01 510.36 Tm -0.0043 Tc 0 Tw (Abstract: )Tj /TT5 1 Tf 4.044 0 TD -0.0034 Tc 0.0578 Tw (As civic duties go, jury service can be among the most stressful experiences that a citizen can)Tj -4.044 -1.302 TD -0.0036 Tc -0.0576 Tw [(undergo. This article describes the common sources of juror stress, including jury summons, jury selection,)]TJ 0 -1.299 TD -0.0037 Tc 0.0441 Tw [(understanding and coping with complex or disturbing evidence and testimony)53.3(,)0.4( jury deliberation, and the)]TJ T* -0.0034 Tc 0.005 Tw (pressure to arrive at a just verdict. The article then goes on to delineate a number of intervention models)Tj 0 -1.302 TD -0.0037 Tc 0.0314 Tw (for helping jurors manage stress reactions and prevent the development of more serious traumatic stress)Tj 0 -1.299 TD -0.004 Tc -0.0269 Tw [(syndr)32(omes. Finally)50(, some r)29(ecommendations ar)32(e offer)29(ed for pr)32(ofessionalizing jury service that would act in)]TJ T* 0.0016 Tc 0.125 Tw (the interests of civil and criminal justice. [International Journal of Emergency Mental Health, 2008,)Tj 0 -1.302 TD 0.009 Tc (10\(3\), pp.203-218].)Tj /TT1 1 Tf 9 0 0 9 131.64 393.99 Tm -0.0056 Tc 0.025 Tw (Key words: )Tj /TT5 1 Tf 5.1633 0 TD -0.005 Tc 0.0263 Tw [(for)35(ensic psychology)51.7(, criminal justice, jur)31.7(or str)31.7(ess, jury system, legal str)35(ess, str)31.7(ess management)]TJ ET /GS1 gs 66 116.745 m 299.01 116.745 l S BT 9 0 0 9 66 99 Tm /GS2 gs 0.0174 Tc 0.1251 Tw [(Cor)-5.9(r)39.9(espondence concerning this article to: Laur)34.1(ence Miller)104.1(,)]TJ 0 -1.2233 TD -0.0046 Tc 0.0984 Tw [(PhD,Plaza Four)105.4(, Suite 101,399 W)85.4(.)0.1( Camino Gar)35.4(dens Blvd.,Boca)]TJ 0 -1.22 TD -0.0049 Tc 0.0185 Tw (Raton, Florida 33432,561-392-8881. docmilphd@aol.com)Tj /F1 1 Tf 14 0 0 14 266.91 629.85 Tm 0.001 Tc 0.1393 Tw (Juror Stress:)Tj -6.2143 -1.1421 TD 0.0033 Tc 0.138 Tw (Symptoms, Syndromes, and Solutions)Tj /TT2 1 Tf 10 0 0 10 84 325.65 Tm -0.0032 Tc -0.0187 Tw (Imagine you awaken one night with a mysterious pain.)Tj -1.8 -1.401 TD -0.0029 Tc -0.031 Tw [(Y)104.3(ou make your way to the nearest emer)18.1(gency room and ask)]TJ 0 -1.398 TD -0.0206 Tw [(to see a doctor)54.1(. )33.3(Y)104.3(oure told that, instead, you will be exam-)]TJ 0 -1.401 TD -0.0032 Tc -0.0041 Tw (ined by 12 citizens who have been pulled off their jobs and)Tj T* -0.0034 Tc -0.0049 Tw (ordered to the emergency room to decide your case. 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When you)]TJ 12 0 0 12 278.4 567.15 Tm -0.0335 Tc -0.0625 Tw (Laurence Miller)Tj 10 0 0 10 228.9 554.49 Tm 0.0013 Tc -0.005 Tw (Independent Practice, Boca Raton, Florida)Tj 9.21 -22.884 TD -0.0025 Tc 0.0577 Tw (try to protest that this is no way to practice medicine, they)Tj 0 -1.401 TD 0.0007 Tc 0.125 Tw (tell you to feel lucky to live in a country where you can)Tj 0 -1.398 TD -0.0035 Tc 0.12 Tw (receive a fair examination and have your diagnosis and)Tj 0 -1.401 TD -0.0027 Tc -0.0017 Tw (treatment decided by 12 of your peers.)Tj 1.8 -2.001 TD -0.0072 Tc -0.0625 Tw [(Sound ridiculous? )34.8(Y)100(et, these kinds of complex life-alter)16.8(-)]TJ -1.8 -1.398 TD -0.0031 Tc 0.0822 Tw (ing decisions are made every day in courts throughout the)Tj 0 -1.401 TD 0.125 Tw (United States and many other countries by juries with no)Tj T* -0.0064 Tc -0.0622 Tw (more knowledge of the law than the above hypothetical panel)Tj 0 -1.398 TD -0.0032 Tc -0.0059 Tw [(has of medicine. While the merit of this kind of justice sys-)]TJ 0 -1.401 TD -0.0033 Tc 0.0969 Tw [(tem is a topic for another venue, this article will focus on)]TJ T* -0.003 Tc 0.0404 Tw (what those 12 souls may go though in trying to do the best)Tj 0 -1.398 TD -0.0028 Tc 0.0295 Tw [(they can in negotiating the justice system. This article will)]TJ 0 -1.401 TD -0.0034 Tc 0.0912 Tw (delineate some of the major stresses and stress syndromes)Tj T* -0.0035 Tc 0.1164 Tw (associated with jury service and offer some recommenda-)Tj 0 -1.398 TD -0.0034 Tc -0.0305 Tw (tions for helping jurors cope with the ordeals of their service)Tj 0 -1.401 TD 0.0375 Tw (and the pressures associated with certain kinds of trials.)Tj ET endstream endobj 233 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT1 8 0 R /TT2 9 0 R /TT3 10 0 R /TT4 20 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 235 0 obj << /Length 9000 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 54 59.745 m 546 59.745 l S BT /F1 1 Tf 8 0 0 8 54.99 41.64 Tm 0 0 0 1 k /GS2 gs -0.0052 Tc 0.0896 Tw [(204 )]TJ /TT3 1 Tf 2.745 0 TD -0.005 Tc (Millers Juror Stress)Tj /F1 1 Tf 11 0 0 11 54 723.99 Tm -0.0044 Tc 0.0227 Tw [(Juror Stress: Scope of the Problem)]TJ /TT2 1 Tf 10 0 0 10 72 700.65 Tm -0.0034 Tc -0.0471 Tw [(A)58.8( core feature of the )53.7(American civil and criminal justice)]TJ -1.8 -1.401 TD -0.0025 Tc -0.0227 Tw [(systems is the right of a defendant to a trial by jury)63.5(. Serving)]TJ 0 -1.398 TD -0.003 Tc -0.0087 Tw [(as a juror is considered a civic duty and a citizen)51(s failure to)]TJ 0 -1.401 TD -0.0032 Tc -0.01 Tw (respond to this call may result in judicial sanctions and pen-)Tj T* -0.003 Tc -0.0327 Tw [(alties. Other than the occasional traffic citation, jury service)]TJ 0 -1.398 TD -0.0365 Tw (is one of the primary means by which the average, law-abid-)Tj 0 -1.401 TD -0.007 Tc -0.0623 Tw [(ing citizen comes into contact with the )52.9(American judicial sys-)]TJ T* -0.0008 Tc 0.125 Tw [(tem. Most jurors take their responsibilities seriously and)]TJ 0 -1.398 TD -0.0026 Tc 0.0104 Tw [(carry out their jury service to the best of their abilities. But)]TJ 0 -1.401 TD -0.0029 Tc 0.0006 Tw [(until recently)63.1(, little consideration has been given to the psy-)]TJ T* -0.0033 Tc 0.0912 Tw (chological impact of jury service on the jurors themselves)Tj 0 -1.398 TD -0.0227 Tc -0.0613 Tw [(\(Butler)34.3(, 2007; Hafemeister)37.3(, 1993\).)]TJ 1.8 -2.001 TD -0.0033 Tc -0.0268 Tw [(Ironically)59.7(, much of this attention has come from the ob-)]TJ -1.8 -1.401 TD -0.0036 Tc 0.0489 Tw (servations of judges who have to deal with stressed-out ju-)Tj 0 -1.398 TD -0.0128 Tc -0.0625 Tw (ries on a regular basis and who are subject to their own judicial)Tj 0 -1.401 TD -0.0218 Tc (stresses and challenges \(Miller et al., 2007; Zimmerman, 2006\),)Tj T* -0.0032 Tc -0.0369 Tw [(which will be the subject of a future article in this series. On)]TJ 0 -1.398 TD 0.0737 Tw (a practical level, heightened awareness of juror stress may)Tj 0 -1.401 TD -0.0034 Tc -0.0604 Tw (result in a shrinking pool of citizens who are willing to report)Tj T* -0.0032 Tc 0.0475 Tw [(for jury service. )53.8(As greater numbers of citizens manage to)]TJ 0 -1.398 TD -0.05 Tw (avoid jury service, juries become less and less representative)Tj 0 -1.401 TD -0.0072 Tc -0.0623 Tw (of their communities, leading to a deterioration of public trust)Tj T* -0.0032 Tc -0.0356 Tw (and confidence in jury verdicts, making still more people re-)Tj 0 -1.398 TD -0.0028 Tc 0.05 Tw [(luctant to serve, and so on, in a vicious cycle. In addition,)]TJ 0 -1.401 TD -0.0031 Tc 0.0413 Tw (extreme juror stress levels may compromise their ability to)Tj T* -0.0127 Tc -0.0625 Tw (render a fair judgment or impel jurors to make premature deci-)Tj 0 -1.398 TD -0.0033 Tc 0.0928 Tw (sions, resulting in the appeals of many more verdicts than)Tj 0 -1.401 TD -0.0032 Tc -0.0144 Tw (necessary and, in some cases, the corruption of justice \(But-)Tj T* -0.0048 Tc -0.0621 Tw [(ler)40.2(, 2007; Curridan, 1995; Hafemeister)40.2(, 1993; Hafemeister &)]TJ 0 -1.398 TD -0.0082 Tc -0.0614 Tw [(V)114(entis, 1992; S)9.8(tur)15.8(gess, 1990\).)]TJ /F1 1 Tf 11 0 0 11 54 255.99 Tm -0.0052 Tc 0.0197 Tw [(The Jury Process)]TJ /TT2 1 Tf 10 0 0 10 72 232.65 Tm 0.0026 Tc 0.125 Tw (The odyssey of jury service typically begins when a)Tj -1.8 -1.401 TD -0.0033 Tc -0.05 Tw (citizen receives a )Tj /TT5 1 Tf 6.924 0 TD -0.0048 Tc (jury summons)Tj /TT2 1 Tf 5.481 0 TD -0.0035 Tc [(. The very term, summons)]TJ -12.405 -1.398 TD -0.0027 Tc 0.045 Tw (can make the citizen feel like he or she is already guilty of)Tj 0 -1.401 TD -0.0032 Tc 0.09 Tw (something and conveys to the recipient that this service is)Tj T* -0.0028 Tc -0.031 Tw (not optional; indeed, failing to report for jury duty can result)Tj 0 -1.398 TD -0.0032 Tc -0.024 Tw (in the citizen being held in contempt of court, possibly fined)Tj 0 -1.401 TD -0.0033 Tc 0.0029 Tw [(and jailed, and ultimately being forced to appear)50.7(. )18.1(The sum-)]TJ T* -0.0034 Tc 0.0025 Tw (mons either orders the citizen to report to the courthouse on)Tj 0 -1.398 TD 0.0355 Tw (a specific date or instructs them to call the courthouse over)Tj 0 -1.401 TD -0.0022 Tc 0.125 Tw [(several days to see when their service is required. Some)]TJ T* -0.0033 Tc 0.0019 Tw (jurisdictions give citizens the option of postponing jury ser-)Tj 0 -1.398 TD -0.006 Tc -0.0625 Tw (vice for a limited period of time.)Tj 27.3 64.398 TD -0.0037 Tc 0.0078 Tw (When arriving at the courthouse, prospective jurors are)Tj -1.8 -1.398 TD -0.0034 Tc -0.0622 Tw (typically herded into a large auditorium where they are given)Tj 0 -1.401 TD -0.003 Tc 0.0164 Tw [(a brief orientation, by video or live speaker)39(, to the civil and)]TJ T* 0.0368 Tc 0.125 Tw [(criminal justice systems. They wait to be called for)]TJ 0 -1.398 TD -0.003 Tc 0.0562 Tw (empanelment, which may be almost immediately or at any)Tj 0 -1.401 TD -0.0031 Tc 0.0286 Tw [(time throughout the day)59.9(. In some jurisdictions, if a juror is)]TJ T* -0.0562 Tw [(not empaneled on that day)62.9(, his or her service is done; in other)]TJ 0 -1.398 TD -0.0028 Tc -0.0622 Tw (jurisdictions, they must return day after day until selected for)Tj 0 -1.401 TD -0.0026 Tc -0.0166 Tw (a jury or rejected during jury selection.)Tj 1.8 -2.001 TD -0.0032 Tc 0.0043 Tw (Jury selection involves the careful examination, or )Tj /TT5 1 Tf 20.304 0 TD -0.0049 Tc 0 Tw (voir)Tj -22.104 -1.398 TD (dire)Tj /TT2 1 Tf 1.596 0 TD -0.0029 Tc 0.0239 Tw (, of each prospective juror by the opposing attorneys in)Tj -1.596 -1.401 TD -0.003 Tc 0.1235 Tw [(the case. Ostensibly)63(, the goal is to select jurors who can)]TJ T* -0.0056 Tc -0.0622 Tw (make an impartial decision, free of personal biases that might)Tj 0 -1.398 TD -0.007 Tc -0.0625 Tw [(taint their careful, objective weighing of the issues. In reality)62(,)]TJ 0 -1.401 TD -0.0036 Tc (voir dire often represents a way for attorneys from either side)Tj T* -0.0032 Tc 0.017 Tw (to stack the jury with individuals who most likely will be)Tj 0 -1.398 TD -0.0033 Tc 0.068 Tw [(favorable to their case \(Kressel & Kressel, 2002\). Since a)]TJ 0 -1.401 TD -0.003 Tc 0.0482 Tw (wide range of jury characteristics may affect their thinking)Tj T* -0.0033 Tc -0.0405 Tw (about a given case, voir dire questions may range from opin-)Tj 0 -1.398 TD -0.0032 Tc 0.006 Tw (ions about points of law \(Do you believe the death penalty)Tj 0 -1.401 TD -0.0034 Tc 0.0919 Tw (is ever an appropriate punishment?\) to personal habits or)Tj T* 0.017 Tw (preferences \(How many hours a week do you think is nor-)Tj 0 -1.398 TD -0.0032 Tc 0.0656 Tw (mal for someone to be looking at internet pornography?\).)Tj 0 -1.401 TD -0.0022 Tc -0.0154 Tw [(T)74.6(ypically)60.8(, the initial )]TJ 8.1553 0 TD -0.0033 Tc -0.0143 Tw (weeding-out is accomplished by means)Tj -8.1553 -1.401 TD -0.0032 Tc 0.085 Tw [(of a written interrogatory)62.8(, or questionnaire, and those pro-)]TJ 0 -1.398 TD -0.0051 Tc -0.0622 Tw (spective jurors who pass this first hurdle are then interviewed)Tj 0 -1.401 TD -0.0068 Tc -0.0623 Tw [(in vior dire. The law also allows a limited number of jurors to)]TJ T* -0.0034 Tc -0.0039 Tw (be rejected on a peremptory basis, which means the attor-)Tj 0 -1.398 TD -0.003 Tc -0.009 Tw (ney doesnt have to give a reason, and which usually occurs)Tj 0 -1.401 TD -0.0035 Tc 0.019 Tw (to exclude a juror because of some personal feature such as)Tj T* 0.0018 Tc 0.125 Tw [(ethnicity or social background. The acceptance/rejection)]TJ 0 -1.398 TD -0.0084 Tc -0.0622 Tw (ratio of jury selection explains the cattle-call nature of sum-)Tj 0 -1.401 TD -0.0037 Tc 0.0931 Tw (moning vast numbers of potential jurors to the courthouse)Tj T* -0.002 Tc 0.0366 Tw [(on any given day)61(.)]TJ 1.8 -1.998 TD -0.0007 Tc 0.125 Tw (After a jury is empaneled, the case generally begins.)Tj -1.8 -1.401 TD -0.0038 Tc -0.0046 Tw (Depending on the nature of the case, jurors spend anywhere)Tj T* -0.0115 Tc -0.0625 Tw (from a few days to many weeks hearing complex and conflict-)Tj 0 -1.398 TD -0.0032 Tc 0.0256 Tw (ing testimony from plaintiff and defendant \(in a civil case\),)Tj 0 -1.401 TD -0.0035 Tc -0.0275 Tw (prosecutor and defendant \(in a criminal case\), fact witnesses)Tj T* -0.0092 Tc -0.0625 Tw (\(who have observed or have personal knowledge about some-)Tj 0 -1.398 TD -0.0026 Tc 0.1249 Tw [(thing pertinent to the case\), and expert witnesses \(profes-)]TJ 0 -1.401 TD -0.0025 Tc 0.125 Tw (sionals with specialized training who can render opinions)Tj T* -0.0026 Tc 0.0525 Tw [(about technical issues of the case\). )51.1(Attorneys naturally try)]TJ 0 -1.398 TD -0.0034 Tc 0.0245 Tw (to present evidence that will be most favorable to their side)Tj 0 -1.401 TD -0.003 Tc -0.0175 Tw (of the case to sway the jury \(Kressel & Kressel, 2002\).)Tj ET endstream endobj 236 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT2 9 0 R /TT3 10 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 238 0 obj << /Length 8947 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 66 59.745 m 558 59.745 l S BT /TT3 1 Tf 8 0 0 8 423.24 42.6 Tm 0 0 0 1 k /GS2 gs -0.0051 Tc 0.0326 Tw [(IJEMH Vol. 10, No. 3 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (205)Tj /TT2 1 Tf 10 0 0 10 84 722.64 Tm -0.0031 Tc -0.029 Tw [(T)37.7(raditionally)62.9(, jurors are not allowed to take notes or ask)]TJ -1.8 -1.398 TD -0.002 Tc 0.125 Tw (questions and are supposed to process all this material in)Tj 0 -1.401 TD -0.0035 Tc 0.0275 Tw [(their heads to prepare for deliberation. Perhaps responding)]TJ T* 0.0481 Tw (to the realities of human cognition, some jurisdictions now)Tj 0 -1.398 TD -0.0032 Tc -0.0265 Tw (permit limited questions by jurors during the trial in order to)Tj 0 -1.401 TD -0.0093 Tc -0.0623 Tw [(help clarify crucial points that they will deliberate on. In most)]TJ T* -0.0029 Tc -0.0493 Tw (trials, jurors get to go home at the end of each day but are not)Tj 0 -1.398 TD 0.0038 Tc 0.125 Tw [(allowed to discuss the case with anyone. In some high-)]TJ 0 -1.401 TD -0.0028 Tc -0.055 Tw (profile cases, juries may be )Tj /TT5 1 Tf 10.809 0 TD -0.0047 Tc 0 Tw (sequestered)Tj /TT2 1 Tf 4.677 0 TD -0.0026 Tc -0.0562 Tw [( literally isolated in)]TJ -15.486 -1.401 TD -0.0028 Tc 0.125 Tw (a hotel room between court appearances, and deprived of)Tj 0 -1.398 TD -0.0032 Tc 0.0452 Tw [(newspapers, )18(T)9.8(V)125.8(, or any contact with the outside world that)]TJ 0 -1.401 TD -0.0033 Tc -0.0167 Tw (might taint their view of the case.)Tj 1.8 -2.001 TD -0.0032 Tc 0.0309 Tw [(After testimony and each attorney)53.8(s closing statements)]TJ -1.8 -1.398 TD -0.003 Tc 0.0805 Tw (are completed, the jury retires to a separate room for their)Tj 0 -1.401 TD -0.0057 Tc -0.0625 Tw (deliberation, which may take a couple of hours or many days.)Tj T* -0.0035 Tc 0.0633 Tw (Since, in most cases, verdicts must be unanimous, this can)Tj 0 -1.398 TD -0.003 Tc -0.0434 Tw (be an extremely grueling process, as jurors may change their)Tj 0 -1.401 TD -0.0037 Tc 0.095 Tw (minds several times throughout the deliberations and their)Tj T* -0.0031 Tc 0.0808 Tw (decision-making processes may be influenced by anything)Tj 0 -1.398 TD -0.0035 Tc 0.0521 Tw (from new insights on the case to what will get them out of)Tj 0 -1.401 TD -0.0031 Tc 0.0773 Tw [(there the quickest. Prior to deliberation, the judge usually)]TJ T* 0.0031 Tw (provides a set of jury instructions as to which aspects of the)Tj 0 -1.398 TD -0.003 Tc 0.005 Tw (case they just heard can be considered and which parts they)Tj 0 -1.401 TD -0.0035 Tc -0.0249 Tw (should disregard; admittedly this kind of cognitive compart-)Tj T* -0.0236 Tw (mentalization can be extremely difficult to accomplish \(Do)Tj 0 -1.398 TD 0.1144 Tw [(not assign any weight to the bereaved mother)-39.5()53.5(s)0.7( spontane-)]TJ 0 -1.401 TD 0.0568 Tw (ous crying and unsolicited comment about how she misses)Tj T* -0.004 Tc -0.0076 Tw [(her murdered daughter)50(.\))]TJ 1.8 -1.998 TD -0.0029 Tc -0.035 Tw (At any point in the trial prior to the actual reading of the)Tj -1.8 -1.401 TD -0.0033 Tc 0.0068 Tw (verdict, the two sides of the case can arrive at an agreement)Tj T* -0.003 Tc 0.0768 Tw [(that obviates the need for a jury)60(. )54.1(A)59.2( number of juries have)]TJ 0 -1.398 TD -0.0163 Tc -0.0625 Tw (been in the position of sweating over a weeks-long trial, spend-)Tj 0 -1.401 TD -0.003 Tc -0.0127 Tw (ing several more hectic days in heated deliberations, only to)Tj T* -0.0033 Tc 0.0062 Tw (be told at the last moment that the case has been settled and)Tj 0 -1.398 TD -0.003 Tc 0.0525 Tw [(thank you for your service. It is hard to imagine a more)]TJ 0 -1.401 TD -0.0032 Tc 0.125 Tw [(frustrating set of circumstances than to have placed one)50.8(s)]TJ T* -0.0037 Tc -0.0169 Tw [(whole life on hold, to have had one)50.3(s thoughts and emotions)]TJ 0 -1.398 TD -0.0029 Tc 0.0561 Tw (wrenched by days of testimony that ranged from the sopo-)Tj 0 -1.401 TD -0.003 Tc 0.0589 Tw (rific to the horrific, to have deliberated earnestly and hard,)Tj T* -0.0031 Tc 0.0427 Tw (only to be told, often at the brink of a unanimous decision,)Tj 0 -1.398 TD -0.0034 Tc -0.023 Tw [(the judicial version of never mind. Perhaps the only thing)]TJ 0 -1.401 TD -0.0035 Tc 0.026 Tw [(worse are cases where the judge sets aside the jury)50.5(s ver)17.5(-)]TJ T* -0.0004 Tc 0.1249 Tw [(dict after it has been read because he or she decides that)]TJ 0 -1.398 TD -0.0033 Tc 0.0534 Tw (these 12 citizens could not possibly have reached this con-)Tj 0 -1.401 TD -0.0029 Tc -0.0462 Tw (clusion if they had properly considered all the pertinent facts)Tj T* -0.0033 Tc -0.0009 Tw (and points of law in the case. In these circumstances, juries)Tj 25.5 64.2 TD -0.0172 Tw (understandably feel like bad little schoolchildren who failed)Tj 0 -1.398 TD -0.0025 Tc 0.125 Tw [(their class assignment. Even where the court accepts the)]TJ 0 -1.401 TD 0.0037 Tc 0.1248 Tw [(jury)48.7(s verdict, they know it)48.7(s not over yet, because most)]TJ T* -0.0035 Tc 0.06 Tw (serious verdicts are appealed.)Tj /F1 1 Tf 11 0 0 11 321 648 Tm -0.0047 Tc 0.0138 Tw [(P)43.2(ositive Aspects of J)14.4(u)5.3(r)-15.6(y)1.3( Ser)-12.9(vice)]TJ /TT2 1 Tf 10 0 0 10 339 624.66 Tm -0.0033 Tc -0.0169 Tw (Although this article will focus on the negative psycho-)Tj -1.8 -1.401 TD -0.0028 Tc -0.0431 Tw [(logical ef)15.2(fects of jury service, to be fair)39.2(,)0.1( a number of surveys)]TJ T* -0.0039 Tc 0.1137 Tw [(and studies have found that most )50.1(American and Canadian)]TJ 0 -1.398 TD -0.0145 Tc -0.0624 Tw [(jurors view their service positively \(Butler)42.5(, 2007; Casey)60.5(, 1998;)]TJ 0 -1.401 TD -0.0133 Tc -0.0625 Tw [(Diamond, 1993\). For many citizens, this is the most important)]TJ T* -0.0034 Tc (thing they have done in terms of having a real impact on their)Tj 0 -1.398 TD -0.006 Tc -0.0622 Tw [(communities. Individuals who may feel that they plod mean-)]TJ 0 -1.401 TD -0.0035 Tc 0.1225 Tw (inglessly through life and receive scant acknowledgement)Tj T* -0.003 Tc 0.0381 Tw (for their efforts at their jobs or at home are suddenly thrust)Tj 0 -1.398 TD -0.0032 Tc -0.0585 Tw (into a position of trust, treated like adults, and accorded great)Tj 0 -1.401 TD -0.0058 Tc -0.0621 Tw [(respect, with the weight of another human being)54.2(s fate placed)]TJ T* -0.0035 Tc 0.125 Tw [(in their collective hands. Jurors often emerge with much)]TJ 0 -1.398 TD -0.0032 Tc 0.0044 Tw (enhanced respect for the legal system after seeing how seri-)Tj 0 -1.401 TD -0.0029 Tc 0.0239 Tw (ously and carefully most cases are tried, with learned attor-)Tj T* 0.0098 Tc 0.125 Tw (neys in expensive suits vying for their decision through)Tj 0 -1.398 TD -0.0033 Tc 0.012 Tw (meticulously researched and cogently presented arguments,)Tj 0 -1.401 TD -0.003 Tw (all parties forced to follow strict rules of evidence under the)Tj T* 0.0017 Tc 0.125 Tw [(watchful gaze of an enrobed judge sitting on high. This)]TJ 0 -1.398 TD -0.0036 Tc 0.1138 Tw (experience often inculcates in jurors a sense of empower-)Tj 0 -1.401 TD -0.008 Tc -0.0623 Tw (ment and engagement with civic life; in fact, serving on a jury)Tj T* -0.0026 Tc -0.056 Tw [(makes people more likely to vote. Many jurors surveyed say)]TJ 0 -1.398 TD -0.0048 Tc -0.0621 Tw [(they would like to serve again \(Butler)34.2(, 2007; Casey)67.2(,)-0.5( 1998\).)]TJ 1.8 -2.001 TD -0.0035 Tc 0.0027 Tw [( However)35.5(, some of the positive feelings reported on ju-)]TJ -1.8 -1.401 TD -0.003 Tc -0.0522 Tw (ror surveys may be the result of rationalization and cognitive)Tj 0 -1.398 TD -0.0036 Tc 0.1028 Tw (dissonance: having been conscripted to legal servitude for)Tj 0 -1.401 TD -0.0031 Tc -0.0096 Tw (days or weeks at a time, suffered loss of income and restric-)Tj T* -0.0028 Tc -0.0545 Tw (tions in their family time, many jurors may feel compelled to)Tj 0 -1.398 TD -0.0032 Tc 0.067 Tw (justify to themselves that this all must have been for some)Tj 0 -1.401 TD -0.0035 Tc -0.0049 Tw [(greater good in order not to feel like chumps \(Butler)35.5(, 2007\).)]TJ T* 0.025 Tw [(And, as will be discussed below)62.4(, this positive perception of)]TJ 0 -1.398 TD -0.0031 Tc -0.024 Tw (jury service is far from universal; indeed, from the results of)Tj 0 -1.401 TD -0.0029 Tc 0.1 Tw (other surveys and studies, one can only conclude that, for)Tj T* -0.0031 Tc 0.005 Tw (many jurors, their service amounts to a descent into hell.)Tj /F1 1 Tf 11 0 0 11 321 138 Tm -0.0047 Tc 0.0273 Tw (Stresses of Jury Service)Tj /TT2 1 Tf 10 0 0 10 339 114.66 Tm -0.0032 Tc 0 Tw (Even short of hell, many jurors experience stresses that)Tj -1.8 -1.401 TD -0.0037 Tc -0.0023 Tw (range from mild to severe. While trials containing complex)Tj T* -0.0029 Tc 0.0738 Tw (and/or grisly evidence may be understood to be inherently)Tj 0 -1.398 TD -0.0035 Tc -0.0066 Tw (stressful, even more mundane cases can take a grueling toll.)Tj ET endstream endobj 239 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT2 9 0 R /TT3 10 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 242 0 obj << /Length 8867 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 54 59.745 m 546 59.745 l S BT /F1 1 Tf 8 0 0 8 54.99 41.64 Tm 0 0 0 1 k /GS2 gs -0.0052 Tc 0.0896 Tw [(206 )]TJ /TT3 1 Tf 2.745 0 TD -0.005 Tc (Millers Juror Stress)Tj /TT2 1 Tf 10 0 0 10 54 722.64 Tm -0.0044 Tc -0.0622 Tw (For all the lip service about their noble mission, courts can be)Tj 0 -1.398 TD -0.0035 Tc 0.0693 Tw (surprisingly unaccommodating to jurors who are often rel-)Tj 0 -1.401 TD -0.0037 Tc 0.0513 Tw [(egated to the bottom of the courtroom pecking order)50.3(. )17.6(This)]TJ T* -0.0032 Tc 0.09 Tw (may be due to a strong social identification factor: Judges)Tj 0 -1.398 TD -0.0053 Tc -0.0623 Tw (and lawyers share a common level of education, training, and)Tj 0 -1.401 TD -0.0034 Tc 0.0257 Tw (experience; indeed, many judges were once practicing law-)Tj T* -0.0031 Tc 0.0505 Tw (yers and career shifts in the other direction are not uncom-)Tj 0 -1.398 TD -0.003 Tc -0.0494 Tw [(mon either)51(. )18.6(Thus, they understand that they are in a dif)18(ferent)]TJ 0 -1.401 TD -0.0037 Tc -0.0184 Tw (social and demographic league than most jurors who tend to)Tj T* -0.004 Tc -0.0307 Tw (come from a more working-class and nonprofessional popu-)Tj 0 -1.398 TD -0.0027 Tc 0.0308 Tw (lation i.e. the type of people who cannot easily get out of)Tj 0 -1.401 TD -0.0026 Tc 0.0207 Tw [(jury duty)60.4(. In addition, the same judges and lawyers tend to)]TJ T* -0.002 Tc 0.125 Tw (interact with one another repeatedly in the same kinds of)Tj 0 -1.398 TD -0.0033 Tc 0.054 Tw (cases, whereas jurors are here for one case, and then gone.)Tj 0 -1.401 TD -0.0066 Tc -0.0622 Tw (Thus, it is easy for the courtroom regulars to unconsciously)Tj T* -0.0034 Tc 0.063 Tw (treat the newcomers as transients who are there to do their)Tj 0 -1.398 TD -0.0074 Tc -0.0621 Tw [(jobs and then scram \(Butler)37.6(, 2007; Curridan, 1995\).)]TJ 1.8 -2.001 TD -0.0043 Tc [(A)57.9( survey by the National Center for S)16.7(tate Courts \(Casey)58.7(,)]TJ -1.8 -1.401 TD -0.0066 Tc -0.0623 Tw (1998\) asked a large sample of jurors or alternate jurors from a)Tj 0 -1.398 TD -0.0032 Tc 0.0627 Tw [(wide range of civil and criminal cases \(e.g. robbery)59.8(, drunk)]TJ 0 -1.401 TD -0.0266 Tw (driving, malpractice, and personal injury\) to rate the level of)Tj T* -0.0017 Tc 0.125 Tw (perceived stress they experienced from a list of stressors.)Tj 0 -1.398 TD 0.0103 Tc (The top ten sources of stress for jurors serving on non-)Tj 0 -1.401 TD -0.003 Tc 0.0275 Tw (death-penalty cases were: deciding on a verdict; jury delib-)Tj T* -0.0033 Tc 0.0614 Tw (erations and discussions; disruptions to daily routines; fear)Tj 0 -1.398 TD 0.0228 Tw (of making a mistake; violent crimes; the jury selection pro-)Tj 0 -1.401 TD -0.0036 Tc 0.0793 Tw (cess; crimes against children; answering questions in front)Tj T* 0.1068 Tw [(of other people; sentencing a criminal defendant; and dis-)]TJ 0 -1.398 TD 0.0137 Tw [(sension/differences among jurors. Looking at the top items)]TJ 0 -1.401 TD -0.0031 Tc 0.053 Tw (on the list should remind us that, even in relatively routine)Tj T* -0.003 Tc 0.0786 Tw (cases, most jurors take their responsibilities very seriously)Tj 0 -1.398 TD -0.0054 Tc -0.0625 Tw (and are acutely aware that they are making decisions that will)Tj 0 -1.401 TD -0.0034 Tc 0.0206 Tw [(greatly af)14.6(fect people)53.6(s lives, what Bornstein and colleagues)]TJ T* -0.0031 Tc -0.0584 Tw [(\(2005\) refer to as the burden of justice. It is this very sense)]TJ 0 -1.398 TD 0.0104 Tc 0.125 Tw (of responsibility that often makes their jobs so stressful)Tj 0 -1.401 TD -0.0254 Tc -0.0593 Tw [(\(Hafemeister)34.6(, 1993\).)]TJ 1.8 -2.001 TD -0.0032 Tc -0.0195 Tw [(But how stressful? Most surveys have found that about)]TJ -1.8 -1.398 TD -0.0046 Tc -0.0625 Tw (40% of jurors report stress levels hovering around the mild to)Tj 0 -1.401 TD -0.0029 Tc -0.0106 Tw (moderate range, but that clinically significant anxiety or de-)Tj T* -0.0053 Tc -0.0622 Tw [(pressive disorders are rare \(Antonio, 2006; Bornstein, Miller)33.7(,)]TJ 0 -1.398 TD -0.0164 Tc [(Nemeth, Page, & Musil, 2005; Casey)61.6(, 1998; Kaplan & )19.7(W)54.4(inget,)]TJ 0 -1.401 TD -0.0103 Tc -0.0625 Tw [(1992; Kelly)64.7(, 1994; Casey)58.7(, 1998; Shuman, Hamilton, & Daley)58.7(,)]TJ T* -0.0032 Tc 0.12 Tw [(1994\). So, even though most jurors arent actually being)]TJ 0 -1.398 TD -0.0027 Tc 0.0966 Tw (driven crazy by their ordeal, the stresses of jury service)Tj 0 -1.401 TD -0.0031 Tc 0.0945 Tw (can have a sufficient effect on their daily lives to demand)Tj T* 0.0011 Tc 0.125 Tw (serious attention.)Tj /F1 1 Tf 11 0 0 11 309 723.99 Tm -0.0048 Tc 0.0515 Tw (Sources of Juror Stress)Tj /TT2 1 Tf 10 0 0 10 327 700.65 Tm 0.0012 Tc 0.125 Tw (Jurors experience stressors from a variety of sources)Tj -1.8 -1.401 TD -0.0033 Tc -0.039 Tw [(associated with their service. )50.7(A)58.9( review of the relevant litera-)]TJ 0 -1.398 TD -0.0038 Tc 0.0475 Tw (ture \(Antonio, 2006; Bell & Feldman, 1992; Bishop, 1992;)Tj 0 -1.401 TD -0.0234 Tc -0.0622 Tw [(Bornstein & Nemeth, 1999; Bornstein et al., 2005; Butler)36.6(, 2007;)]TJ T* -0.0036 Tc 0.0705 Tw [(Casey)62.4(, 1998; Diamond, 1993; Fishfader)35.4(, Howells, Katz, &)]TJ 0 -1.398 TD -0.0037 Tc 0.1078 Tw [(T)73.1(e)0(rese, 1996; Goleman, 1991; Greene & Bornstein, 2000;)]TJ 0 -1.401 TD -0.012 Tc -0.0618 Tw [(Hafemeister)39(, 1993; Haney)63(, Sontag, & Costanzo, 1994; Kelley)63(,)]TJ T* -0.0125 Tc -0.0624 Tw [(1994; McAree, 2004; Miller)32.5(, Flores, & Dolezilek, 2007; Mott,)]TJ 0 -1.398 TD -0.0038 Tc 0.0888 Tw (Hans, & Simpson, 2000; Rauch, 1992\) suggests that these)Tj 0 -1.401 TD -0.0036 Tc 0.1238 Tw (can be divided into two main categories, those associated)Tj T* -0.0033 Tc -0.0225 Tw (with the judicial process of jury selection and empanelment,)Tj 0 -1.398 TD 0.001 Tc 0.125 Tw (and those associated with the content and conduct of the)Tj 0 -1.401 TD -0.0125 Tc -0.06 Tw (trial itself.)Tj /TT5 1 Tf 11 0 0 11 309 499.35 Tm 0.0169 Tc 0.1287 Tw [(Court Pr)36(ocedur)36(es)]TJ 10 0 0 10 327 479.64 Tm -0.0037 Tc -0.02 Tw (Physical setting.)Tj /TT2 1 Tf 6.531 0 TD -0.0031 Tc -0.0219 Tw [( The physical environment in various)]TJ -8.331 -1.398 TD 0.0097 Tc 0.1249 Tw [(courthouses throughout the country ranges from reason-)]TJ 0 -1.401 TD -0.0029 Tc -0.0006 Tw (ably comfortable to atrocious. Stress factors cited by jurors)Tj T* 0.001 Tc 0.125 Tw (include poor temperature controls, limited access to food)Tj 0 -1.398 TD -0.0038 Tc 0.0558 Tw (and bathroom facilities, cramped and overcrowded waiting)Tj 0 -1.401 TD 0.0003 Tc 0.125 Tw (areas \(cattle pens\), and the inconvenience of getting to)Tj T* -0.0036 Tc -0.0068 Tw (and from the courthouse \(lack of public transportation, poor)Tj 0 -1.398 TD -0.0038 Tc 0.0688 Tw (parking, courthouse in bad neighborhood\).)Tj /TT5 1 Tf 1.8 -2.001 TD -0.0041 Tc 0 Tw (Payment. )Tj /TT2 1 Tf 3.921 0 TD -0.0035 Tc -0.0489 Tw [( For all the high-minded talk of how jurors are)]TJ -5.721 -1.401 TD -0.003 Tc -0.0585 Tw (a vital component in our system of justice, the daily compen-)Tj 0 -1.398 TD -0.0031 Tc -0.006 Tw (sation rate for jurors typically far below minimum wage )Tj 0 -1.401 TD -0.0033 Tc 0.078 Tw (can only be seen as diluting the supposed high regard that)Tj T* -0.015 Tw [(the court has for them. I couldnt get someone to clean my)]TJ 0 -1.398 TD -0.0029 Tc -0.028 Tw [(toilets for this kind of money)60.1(, is a typical complaint. )51(A)59.3( few)]TJ 0 -1.401 TD -0.0033 Tc 0.045 Tw (jurors have commented that they tore up the check when it)Tj T* -0.0029 Tc 0.0044 Tw (came or sent it back with a nasty note.)Tj /TT5 1 Tf 1.8 -1.998 TD -0.0023 Tc 0.1246 Tw (Life disruption. )Tj /TT2 1 Tf 6.63 0 TD -0.0024 Tc 0.1249 Tw [( )51.5(A)56.8( near)15.6(-universal complaint of jurors)]TJ -8.43 -1.401 TD -0.0033 Tc 0.0411 Tw (and prospective jurors is the disruption of work and family)Tj T* -0.0032 Tc -0.0295 Tw [(schedules necessitated by their service. Under the mantle of)]TJ 0 -1.398 TD -0.0066 Tc -0.0622 Tw [(civic responsibility)62.4(, jurors may lose days or weeks from work)]TJ 0 -1.401 TD -0.0036 Tc 0.0243 Tw [(and have to delegate childcare and other household respon-)]TJ T* 0.0006 Tc 0.1249 Tw [(sibilities. )51.5(Although employers, as an expression of good)]TJ 0 -1.398 TD -0.003 Tc 0.0925 Tw (citizenship, are supposed to give their employees days off)Tj 0 -1.401 TD 0.0026 Tc 0.1249 Tw [(with compensation to attend jury duty)62.6(, in most cases the)]TJ T* -0.0031 Tc -0.0326 Tw [(worker absorbs a pay loss. )51(Adding insult to injury)62.9(, when the)]TJ 0 -1.398 TD -0.0064 Tc -0.0623 Tw (term of jury service extends more than a few days, the worker)Tj 0 -1.401 TD -0.0029 Tc -0.0538 Tw (may return to find that his or her job has been filled by some-)Tj T* -0.0036 Tc 0.055 Tw (one else.)Tj ET endstream endobj 243 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT2 9 0 R /TT3 10 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 245 0 obj << /Length 8807 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 66 59.745 m 558 59.745 l S BT /TT3 1 Tf 8 0 0 8 423.24 42.6 Tm 0 0 0 1 k /GS2 gs -0.0051 Tc 0.0326 Tw [(IJEMH Vol. 10, No. 3 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (207)Tj /TT2 1 Tf 10 0 0 10 84 722.64 Tm -0.0032 Tc -0.0038 Tw (For the self-employed, the situation can be even worse.)Tj -1.8 -1.398 TD -0.0035 Tc 0.0018 Tw (Salespeople live by their commissions and most small busi-)Tj 0 -1.401 TD -0.0031 Tc -0.025 Tw [(nesses cant afford to close down for even a few days. Even)]TJ T* -0.0033 Tc 0.0238 Tw (in medium-sized companies, the worker may not have any-)Tj 0 -1.398 TD -0.0029 Tc 0.0315 Tw (body to take his or her place if he or she is in court; clients)Tj 0 -1.401 TD -0.0079 Tc -0.0622 Tw [(and customers may quickly go elsewhere. Some jurors report)]TJ T* -0.0028 Tc -0.0075 Tw (that they have had their businesses ruined by a lengthy term)Tj 0 -1.398 TD -0.0035 Tc -0.005 Tw (of service.)Tj 1.8 -2.001 TD 0.0931 Tw [(And it)53.5(s not just work. )14.6(T)37.3(ime away from spouses and)]TJ -1.8 -1.401 TD -0.0096 Tc -0.0625 Tw (children strains family relationships; women jurors especially)Tj 0 -1.398 TD -0.0028 Tc -0.01 Tw [(appear to feel the strain of isolation very acutely)63.2(. Not being)]TJ 0 -1.401 TD -0.0037 Tc -0.0555 Tw (allowed to discuss the case when he or she comes home from)Tj T* -0.0035 Tc -0.058 Tw (court deprives the juror of a main source of tension reduction)Tj 0 -1.398 TD -0.0032 Tc 0.0805 Tw (that most people have for unloading their daily stress, and)Tj 0 -1.401 TD -0.0063 Tc -0.0625 Tw (further marginalizes the rest of the family who see their loved)Tj T* -0.0032 Tc 0.0882 Tw (one in distress but are unable to do anything to help them)Tj 0 -1.398 TD -0.0209 Tc -0.0621 Tw [(\(Feldman & Bell, 1991; Hafemeister)39.1(, 1993; Slind-Flor)33.1(, 1992\).)]TJ 1.8 -2.001 TD -0.0077 Tc -0.0625 Tw (As previously noted, in some high-profile cases, to avoid)Tj -1.8 -1.401 TD -0.0032 Tc 0.0442 Tw [(contamination of the jury by media, casual conversation,)]TJ 0 -1.398 TD -0.003 Tc 0.07 Tw (etc., jurors may be sequestered, which essentially amounts)Tj 0 -1.401 TD -0.0033 Tc 0.0545 Tw [(to enforced isolation during the trial. Because of state and)]TJ T* -0.0032 Tc 0.0842 Tw [(local budgets, accommodations are rarely first-class. This)]TJ 0 -1.398 TD -0.014 Tc -0.0625 Tw [(heightened isolation from work, family)61(, and friends may cause)]TJ 0 -1.401 TD -0.003 Tc 0.0775 Tw (many jurors to feel that they are being treated like crimi-)Tj T* -0.0041 Tc -0.0385 Tw [(nals, POW)49.9(s, or terrorists at Guantanomo Bay)61.9(, as some)]TJ 0 -1.398 TD -0.0032 Tc -0.0054 Tw [(jurors have put it. It is these conditions that most often lead)]TJ 0 -1.401 TD 0.0004 Tc 0.125 Tw (some jurors to fear they are losing their minds \(Antonio,)Tj T* -0.0516 Tc 0 Tw (2006\).)Tj 1.8 -1.998 TD -0.0034 Tc -0.0625 Tw [(But, at least for )50.6(American jurors, the ordeal is over when)]TJ -1.8 -1.401 TD -0.0029 Tc -0.0575 Tw (the trial ends, at which time they are free to talk, write books,)Tj T* -0.0035 Tc -0.0605 Tw (or expound on TV about their role in a famous trial \(although)Tj 0 -1.398 TD -0.0034 Tc 0.1 Tw [(most jurors just want to go home and forget it\). No such)]TJ 0 -1.401 TD 0.0206 Tw (consideration is afforded their northern brethren, as the Ca-)Tj T* -0.0035 Tc -0.003 Tw (nadian Criminal Code makes it an offense for their jurors to)Tj 0 -1.398 TD -0.0034 Tc -0.0607 Tw [(ever disclose information regarding jury proceedings. Cana-)]TJ 0 -1.401 TD -0.0033 Tc -0.0166 Tw (dian jurors cite this ban as one of the most difficult things to)Tj T* -0.0211 Tc -0.0623 Tw [(deal with \(Butler)32.9(, 2007; Hafemeister)32.9(, 1993\). On the other hand,)]TJ 0 -1.398 TD -0.0032 Tc 0.023 Tw (this permanent gag order may free these jurors from the re-)Tj 0 -1.401 TD -0.0037 Tc 0.0587 Tw [(lentless media intrusion that often dogs )50.3(American jurors in)]TJ T* 0.0794 Tw (high-profile cases and which often seems designed to pro-)Tj 0 -1.398 TD -0.0034 Tc -0.0625 Tw (voke a media-worthy lurid reaction from jurors.)Tj 1.8 -2.001 TD -0.006 Tc -0.0622 Tw (For example, after the high-profile Rodney King beating)Tj -1.8 -1.401 TD -0.003 Tc 0.0055 Tw (trial, jurors were assailed by the press to the point that local)Tj 0 -1.398 TD -0.0036 Tc -0.003 Tw (police warned them not to remain in their homes because of)Tj 0 -1.401 TD -0.0029 Tc -0.0255 Tw [(all the publicity they were garnering. These jurors felt com-)]TJ 25.5 63.999 TD -0.0032 Tc -0.0099 Tw [(pelled to defend their decision to friends and family and felt)]TJ 0 -1.398 TD -0.0033 Tc 0.0285 Tw (that they were being condemned in the press for the rioting)Tj 0 -1.401 TD -0.0034 Tc -0.0031 Tw (that took place after the verdict. One juror received a bomb)Tj T* -0.0035 Tc -0.0232 Tw [(threat at her workplace. )50.5(Another juror bought a gun for pro-)]TJ 0 -1.398 TD -0.0031 Tc 0.0775 Tw [(tection, while still another slept with an axe. Many jurors)]TJ 0 -1.401 TD -0.0033 Tc 0.0774 Tw [(compared their experience to having been raped; they suf-)]TJ T* -0.003 Tc 0.007 Tw [(fered anxiety)63(, hypervigilance, tearfulness, exhaustion, sleep)]TJ 0 -1.398 TD -0.0032 Tc 0.0773 Tw [(and weight loss, and disruption of family relationships. )50.9(A)]TJ 0 -1.401 TD -0.0036 Tc 0.0825 Tw (few of the jurors sought professional counseling, but most)Tj T* -0.0054 Tc -0.0625 Tw (suffered in silence \(Davis, 1993\).)Tj 1.8 -1.998 TD 0 Tc 0 Tw ( )Tj /TT5 1 Tf 0.186 0 TD -0.0133 Tc -0.0617 Tw (Jury selection process. )Tj /TT2 1 Tf 8.883 0 TD -0.0125 Tc -0.062 Tw [( For many jurors, especially those)]TJ -10.869 -1.401 TD -0.0032 Tc 0.1135 Tw [(that value their privacy)59.8(, filling out detailed questionnaires)]TJ T* -0.0035 Tc 0.0928 Tw [(and answering sometimes very personal questions in front)]TJ 0 -1.398 TD -0.0162 Tc -0.0625 Tw [(of a group of strangers can be extremely uncomfortable. Many)]TJ 0 -1.401 TD -0.003 Tc -0.0196 Tw (jurors have reported feeling as if they were the ones on trial.)Tj T* 0.0328 Tw (For example, in financial fraud cases, lawyers may want to)Tj 0 -1.398 TD -0.0032 Tc -0.0345 Tw [(know what the juror)-39.2()56.8(s)-0.4( salary is or whether he or she has ever)]TJ 0 -1.401 TD -0.0042 Tc -0.0622 Tw [(thought about cheating on their taxes. In sex-related cases,)]TJ T* 0.0121 Tc 0.125 Tw (jurors may be queried about their sexual preferences or)Tj 0 -1.398 TD -0.0036 Tc 0.12 Tw (whether they have ever thought about cheating on their)Tj 0 -1.401 TD -0.0031 Tc 0.0375 Tw [(spouse. Simply refusing to answer could technically result)]TJ T* -0.0034 Tc -0.0332 Tw (in the juror being cited for contempt of court, but few judges)Tj 0 -1.398 TD [(would be willing to subject the juror to further duress. More)]TJ 0 -1.401 TD -0.0189 Tc -0.0621 Tw [(commonly)62.1(, embarrassed jurors will simply lie and tell the ques-)]TJ T* -0.0029 Tc -0.0225 Tw (tioning attorney whatever they believe will make the lawyer)Tj 0 -1.398 TD -0.003 Tc -0.0263 Tw [(move on. The result may be the empanelment of a jury con-)]TJ 0 -1.401 TD -0.0037 Tc 0.0587 Tw (taining several members who have been seated under false)Tj T* -0.0032 Tc -0.0314 Tw (pretenses, thereby compromising the whole rationale of jury)Tj 0 -1.398 TD 0.0023 Tc 0 Tw (selection.)Tj 1.8 -2.001 TD -0.0037 Tc -0.053 Tw [(Perhaps for these kinds of reasons, while )50.4(American law-)]TJ -1.8 -1.401 TD -0.003 Tc 0.1006 Tw (yers can question potential jurors to screen out those they)Tj 0 -1.398 TD -0.0034 Tc -0.0482 Tw (dont like during the voir dire process, in Canada this kind of)Tj 0 -1.401 TD -0.0032 Tc 0.0844 Tw (jury selection process is considered prejudicial and all eli-)Tj T* -0.0019 Tc 0.125 Tw (gible jurors are assigned on a first-come-first-serve basis.)Tj 0 -1.398 TD -0.0036 Tc 0.0367 Tw (The absence of a rigorous juror screening process has been)Tj 0 -1.401 TD -0.0033 Tc -0.0017 Tw (found in surveys to increase stress on those Canadian jurors)Tj T* -0.0035 Tc -0.0435 Tw [(who are seated \(Butler)35.5(, 2007\). It would be an interesting em-)]TJ 0 -1.398 TD 0.0172 Tc 0.125 Tw (pirical question to see which system is associated with)Tj 0 -1.401 TD -0.0027 Tc (the greatest psychological morbidity and satisfaction with)Tj T* -0.0023 Tc -0.04 Tw (jury service.)Tj /TT5 1 Tf 11 0 0 11 321 131.34 Tm 0.0077 Tc 0.1273 Tw [(T)59.3(r)-0.1(ial Factors)]TJ 10 0 0 10 339 111.66 Tm -0.0006 Tc 0.125 Tw (Death penalty cases.)Tj /TT2 1 Tf 8.544 0 TD 0.0001 Tc [( Understandably)60.1(, the decision to)]TJ -10.344 -1.401 TD -0.0032 Tc 0.001 Tw (find a defendant guilty of a crime warranting the death pen-)Tj T* -0.0028 Tc 0.1211 Tw [(alty is one that most )54.2(American jurors take very seriously)60.2(,)]TJ ET endstream endobj 246 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT2 9 0 R /TT3 10 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 248 0 obj << /Length 9111 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 54 59.745 m 546 59.745 l S BT /F1 1 Tf 8 0 0 8 54.99 41.64 Tm 0 0 0 1 k /GS2 gs -0.0052 Tc 0.0896 Tw [(208 )]TJ /TT3 1 Tf 2.745 0 TD -0.005 Tc (Millers Juror Stress)Tj /TT2 1 Tf 10 0 0 10 54 722.64 Tm -0.0035 Tc -0.0544 Tw (reflecting the burden of justice \(Bornstein et al., 2005\) that)Tj 0 -1.398 TD -0.003 Tc 0.1083 Tw [(jurors feel more intensely)60(, the more serious the trial \(e.g.,)]TJ 0 -1.401 TD -0.0031 Tc -0.0239 Tw [(capital murder vs. grand larceny\). In some jurisdictions, the)]TJ T* -0.0155 Tw (jury determines guilt or innocence in a capital crime and the)Tj 0 -1.398 TD -0.0028 Tc -0.0237 Tw [(judge imposes a sentence. In other courts, the jury may first)]TJ 0 -1.401 TD -0.0034 Tc 0.074 Tw (decide on guilt and then deliberate a second time to deter-)Tj T* -0.0032 Tc -0.04 Tw (mine the sentence, usually either death or life imprisonment.)Tj 0 -1.398 TD -0.0035 Tc 0.0188 Tw (Findings from the Capital Jury Project \(Antonio, 2006\) and)Tj 0 -1.401 TD -0.0034 Tc 0.0167 Tw (other studies have shown jurors who render a death penalty)Tj T* -0.0031 Tc -0.0111 Tw (verdict to suffer from a variety of stress reactions, including)Tj /TT5 1 Tf 0 -1.398 TD -0.003 Tc 0.125 Tw (posttraumatic stress disorder)Tj /TT2 1 Tf 11.889 0 TD -0.0023 Tc [( \(PTSD\) at higher rates than)]TJ -11.889 -1.401 TD -0.0035 Tc 0.026 Tw (those who render a life sentence.)Tj 1.8 -2.001 TD -0.0037 Tc 0.0107 Tw (Some jurors describe nightmares that replicate how the)Tj -1.8 -1.398 TD -0.0032 Tc 0.0018 Tw (victim was killed or that relate to details of the crime scene,)Tj 0 -1.401 TD -0.0079 Tc -0.0622 Tw (many of the images coming from photographs viewed at trial.)Tj T* -0.0031 Tc 0.0619 Tw (Some jurors report feeling physically sick during and after)Tj 0 -1.398 TD -0.024 Tw [(the trial. Jurors may express regret at their final punishment)]TJ 0 -1.401 TD -0.0035 Tc -0.0037 Tw (decision, often feeling that the wrong decision was reached.)Tj T* -0.0033 Tc 0.0068 Tw (In some cases, jurors regret the death sentence; but in a few)Tj 0 -1.398 TD -0.0032 Tc 0.111 Tw (others they wish death had been meted out instead of life)Tj 0 -1.401 TD 0.001 Tc 0.125 Tw [(imprisonment. Many jurors who harbor second thoughts)]TJ T* -0.0039 Tc -0.0625 Tw (post-trial feel they were pressured or brainwashed by other)Tj 0 -1.398 TD -0.0035 Tc -0.0255 Tw (jurors to go along with the majority decision: I should have)Tj 0 -1.401 TD -0.0027 Tc 0.0878 Tw (stuck to my guns, but everybody else was so sure of their)Tj T* -0.0032 Tc 0.0125 Tw (side and we all just wanted to get out of there.)Tj 1.8 -1.998 TD -0.0505 Tw (Fear of reprisal by the defendant or his cohorts is a com-)Tj -1.8 -1.401 TD -0.0036 Tc 0.055 Tw (mon theme reported among jurors serving on capital trials.)Tj T* -0.0032 Tc 0.0395 Tw (Many report that the defendant would sit in court and stare)Tj 0 -1.398 TD 0.1013 Tw [(intimidatingly at individual jurors during the trial. Night-)]TJ 0 -1.401 TD -0.0033 Tc 0.0533 Tw (mares of such possible reprisals by the defendant are com-)Tj T* -0.0054 Tc -0.0623 Tw [(monly reported, more frequently by women. Other jurors are)]TJ 0 -1.398 TD -0.0113 Tc -0.0622 Tw [(simply afraid of running into either the victim)48.7(s or defendant)51.7(s)]TJ 0 -1.401 TD -0.0033 Tc -0.0625 Tw [(family in or around the courthouse. Some fear wider censure)]TJ T* -0.0034 Tc 0.0081 Tw (by their own families, friends, and communities for making)Tj 0 -1.398 TD 0.0817 Tw [(the wrong decision in socially sensitive cases. Most ju-)]TJ 0 -1.401 TD -0.0035 Tc 0.008 Tw (rors who have served on capital cases are determined not to)Tj T* -0.0225 Tw (repeat the experience.)Tj 1.8 -1.998 TD -0.0027 Tc 0.0662 Tw [( Interestingly)60.3(, in the Capital Jury Project study \(Anto-)]TJ -1.8 -1.401 TD -0.007 Tc -0.0622 Tw (nio, 2006\), a number of jurors specifically expressed the need)Tj T* -0.002 Tc 0.125 Tw (for some kind of post-trial counseling and half thought it)Tj 0 -1.398 TD -0.0034 Tc -0.0355 Tw [(should be made available by courts themselves. Others took)]TJ 0 -1.401 TD -0.0035 Tc 0.0917 Tw (the initiative and sought counseling on their own after the)Tj T* -0.003 Tc -0.0128 Tw [(trial had ended, either from a family member)39(, cler)15(gyman, or)]TJ 0 -1.398 TD -0.0071 Tc -0.0625 Tw (mental health clinician \(Antonio, 2006\).)Tj /TT5 1 Tf 1.8 -2.001 TD -0.0033 Tc -0.0067 Tw (Grisly evidence. )Tj /TT2 1 Tf 6.921 0 TD -0.0036 Tc -0.0084 Tw (One of the distressing aspects of mur-)Tj 16.779 63.999 TD -0.0032 Tc 0.1084 Tw (der trials or those where there has been significant bodily)Tj 0 -1.398 TD -0.003 Tc 0.0394 Tw (injury is the frequent necessity for juries to view gruesome)Tj 0 -1.401 TD -0.0036 Tc -0.0611 Tw (hospital or crime scene photos depicting death and or mutila-)Tj T* -0.003 Tc 0.0911 Tw (tion, as well as to hear sometimes horrifying testimony of)Tj 0 -1.398 TD -0.0029 Tc 0.1249 Tw [(how victims were assaulted, tortured, raped, and/or killed)]TJ 0 -1.401 TD -0.0092 Tc -0.0625 Tw [(\(Bishop, 1992, Boone, 2008\). Remember that police officers,)]TJ T* -0.0107 Tc -0.0621 Tw (criminal attorneys, judges, and specially trained mental health)Tj 0 -1.398 TD -0.0031 Tc -0.0335 Tw (counselors who work with the court system all have years of)Tj 0 -1.401 TD -0.0145 Tc -0.0625 Tw (experience dealing with disturbing evidence, yet, even in these)Tj T* -0.0082 Tc (hard-boiled veterans, particularly heinous crimes \(often those)Tj 0 -1.398 TD -0.0036 Tc 0.0125 Tw (involving child victims\) may evoke destabilizing emotional)Tj 0 -1.401 TD -0.0033 Tc -0.055 Tw (reactions that require intervention in the form of critical inci-)Tj T* -0.0051 Tc -0.0625 Tw [(dent debriefing or other mental health contact \(Miller)33.9(, 1998c,)]TJ 0 -1.398 TD -0.0273 Tc -0.0621 Tw (1999, 2006a, 2006b, 2007a, 2007b, 2008a, 2008b, 2008c\).)Tj 1.8 -2.001 TD -0.0036 Tc 0.048 Tw (How much greater must the reaction be to this kind of)Tj -1.8 -1.401 TD -0.0034 Tc 0.065 Tw (evidence by untrained, inexperienced jurors who are being)Tj 0 -1.398 TD -0.0028 Tc 0.002 Tw (assailed by grisly evidence throughout the trial. This is fre-)Tj 0 -1.401 TD -0.0013 Tc 0.125 Tw (quently compounded by the fact that prosecution and de-)Tj T* -0.0031 Tc 0.1128 Tw (fense counsel each have their own agendas that they may)Tj 0 -1.398 TD -0.0027 Tc -0.0159 Tw [(play of)18.3(f the jury)63.3(. For example, the prosecution may specifi-)]TJ 0 -1.401 TD -0.0021 Tc 0.061 Tw (cally try to shock the jury by literally throwing the exhibit)Tj T* -0.0087 Tc -0.0625 Tw (\(crime scene photo, bloody clothing, murder weapon\) in front)Tj 0 -1.398 TD -0.0029 Tc 0.038 Tw (of the jury precisely to spur an emotional reaction that will)Tj 0 -1.401 TD -0.0031 Tc -0.0155 Tw (hopefully lead to a conviction \(another variation of this is to)Tj T* -0.05 Tw (abruptly display an image of the disturbing exhibit on a huge)Tj 0 -1.398 TD -0.0073 Tc -0.0625 Tw [(projection screen in the ominously darkened courtroom\). For)]TJ 0 -1.401 TD -0.0056 Tc (its part, the defense team will initially try to exclude evidence)Tj T* -0.0028 Tc 0.0945 Tw [(they consider inflammatory or)36.2(, alternatively)63.2(, if it is pre-)]TJ 0 -1.398 TD -0.0029 Tc -0.061 Tw (sented, may try keep it exposed as long as possible or present)Tj 0 -1.401 TD -0.0025 Tc -0.0295 Tw (it repeatedly in order to try to desensitize the jury to its pres-)Tj T* -0.0035 Tc -0.0582 Tw [(ence. Sometimes this works and jurors get used to seeing the)]TJ 0 -1.398 TD -0.0032 Tc -0.0156 Tw (bloody knife and the photographic stab wounds lying on the)Tj 0 -1.401 TD -0.003 Tc -0.0355 Tw [(evidence table day after day)63(. But sometimes the tactic back-)]TJ T* -0.0032 Tc -0.0087 Tw (fires and the jurors grow increasingly sensitized, rather than)Tj 0 -1.398 TD -0.0089 Tc -0.0617 Tw (immunized, with each exposure.)Tj 1.8 -2.001 TD -0.0037 Tc 0.1129 Tw [(Studies are near-unanimous in reporting high rates of)]TJ -1.8 -1.401 TD -0.0032 Tc -0.0477 Tw [(anxiety)62.8(, depression, and PTSD symptoms in jurors sitting on)]TJ 0 -1.398 TD -0.0004 Tc 0.125 Tw [(capital murder)32.6(, aggravated kidnapping, aggravated sexual)]TJ 0 -1.401 TD -0.0035 Tc 0.0193 Tw (assault, aggravated assault, and child abuse cases \(Antonio,)Tj T* -0.0194 Tc -0.0624 Tw [(2006; Feldman & Bell, 1993; Hafemeister)34.6(, 1993\). Some of this)]TJ 0 -1.398 TD -0.0037 Tc -0.0616 Tw (may relate to the concept of )Tj /TT5 1 Tf 10.911 0 TD -0.0058 Tc -0.06 Tw (vicarious trauma)Tj /TT2 1 Tf 6.714 0 TD -0.0045 Tc -0.0633 Tw (, in which those)Tj -17.625 -1.401 TD -0.0032 Tc 0.0963 Tw (who work frequently and closely with victims of violence)Tj T* -0.0053 Tc -0.0623 Tw (come to empathically absorb and internalize some of the psy-)Tj 0 -1.398 TD -0.0038 Tc 0.1188 Tw (chic pain and begin to show PTSD symptoms themselves)Tj 0 -1.401 TD -0.0034 Tc 0.0457 Tw [(\(Davis & Friedman, 1985; Figley)62.6(, 1983; Fullerton, Carroll,)]TJ T* -0.0092 Tc -0.0624 Tw [(Ursano, & )17.9(W)52.7(right, 1992; Miller)35.8(, 1998a, 1998b, 2008c; Moon,)]TJ ET endstream endobj 249 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT2 9 0 R /TT3 10 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 251 0 obj << /Length 9153 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 66 59.745 m 558 59.745 l S BT /TT3 1 Tf 8 0 0 8 423.24 42.6 Tm 0 0 0 1 k /GS2 gs -0.0051 Tc 0.0326 Tw [(IJEMH Vol. 10, No. 3 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (209)Tj /TT2 1 Tf 10 0 0 10 66 722.64 Tm 0.0128 Tc 0.1253 Tw [(1999; )13.1(T)68.6(albot, Dalton, & Dunn, 1995; )19.1(White, Lawrence,)]TJ 0 -1.398 TD -0.0038 Tc 0.0124 Tw [(Biggerstaf)17.2(f, & Grubb, 1985; )29.4(Y)103.4(assen, 1995\). )14.4(These kinds of)]TJ 0 -1.401 TD -0.0033 Tc -0.0188 Tw (reactions may have implications for adjudication of the case)Tj T* -0.0152 Tc -0.0622 Tw (if jurors make extreme decisions based primarily on their emo-)Tj 0 -1.398 TD -0.003 Tc 0.0105 Tw (tions rather than on a rational analysis of the evidence, or if)Tj 0 -1.401 TD -0.0032 Tc -0.0555 Tw (they become so numbed to the savagery of the crime through)Tj T* -0.035 Tw (repetitive testimony or evidence presentation that they come)Tj 0 -1.398 TD -0.0034 Tc -0.014 Tw (to diminish the seriousness of the criminal act in their delib-)Tj 0 -1.401 TD -0.0108 Tc -0.0625 Tw (erations \(Miller et al., 2007\).)Tj /TT5 1 Tf 1.8 -2.001 TD -0.0041 Tc 0.0375 Tw (Complex Evidence. )Tj /TT2 1 Tf 7.974 0 TD -0.0035 Tc 0.038 Tw (Another feature of murder trials or)Tj -9.774 -1.398 TD -0.0028 Tc 0.1068 Tw (other violent felony trials is that they tend to be long and)Tj 0 -1.401 TD -0.0039 Tc 0.0436 Tw (contain vast amounts of complex and ambiguous evidence.)Tj T* -0.0034 Tc -0.0582 Tw (In most courts, jurors are forbidden to take notes or ask ques-)Tj 0 -1.398 TD -0.0031 Tc 0.0865 Tw [(tions, although some jurisdictions are very recently begin-)]TJ 0 -1.401 TD -0.0074 Tc -0.0622 Tw [(ning to allow limited forms of these activities. Thus, the juror)]TJ T* -0.0037 Tc -0.0625 Tw (is placed in the position of having to process complex techni-)Tj 0 -1.398 TD -0.0027 Tc 0.125 Tw (cal information and conflicting eyewitness narratives pre-)Tj 0 -1.401 TD -0.0029 Tc -0.0182 Tw (sented by two different sides who are each trying to spin the)Tj T* -0.0034 Tc 0.039 Tw [(evidence to the fullest extent that the court will allow)62.6(, with)]TJ 0 -1.398 TD -0.006 Tc -0.0625 Tw (the juror permitted to take no \(or limited\) notes and ask no \(or)Tj 0 -1.401 TD -0.0032 Tc -0.0074 Tw [(limited\) questions. )53.9(Add to this the fact that much testimony)]TJ T* -0.0261 Tw (is just plain boring or literally incomprehensible and there is)Tj 0 -1.398 TD 0.0232 Tw (evidence that jurors forget a great deal of what they hear in)Tj 0 -1.401 TD -0.0033 Tc 0.054 Tw [(court \(Rosehan, 1994\). If this were a college course, what)]TJ T* -0.0111 Tc -0.0624 Tw [(grade do you think the jurors would get? )34(Y)108.1(et, they are char)18.9(ged)]TJ 0 -1.398 TD -0.0034 Tc -0.0405 Tw (with the task of taking this information and using it to render)Tj 0 -1.401 TD -0.003 Tc -0.0373 Tw (what, in some cases, is literally a life or death decision about)Tj T* -0.0044 Tc 0.0614 Tw [(someone)49.6(s fate.)]TJ 1.8 -1.998 TD -0.0032 Tc -0.0419 Tw [(Complicating the process is the fact that, in the case of a)]TJ -1.8 -1.401 TD -0.0033 Tc -0.039 Tw (college course, the students are all more or less equivalent in)Tj T* -0.0035 Tc -0.0175 Tw (background in terms of education, training, and native intel-)Tj 0 -1.398 TD -0.0032 Tc 0.0194 Tw (ligence, and have probably all completed at least some pre-)Tj 0 -1.401 TD -0.0048 Tc -0.0622 Tw [(requisite coursework for the present class. But jury members)]TJ T* -0.0169 Tc (come from all walks of life and will have vastly differing levels)Tj 0 -1.398 TD -0.0035 Tc 0.0363 Tw (of sophistication in handling complex testimony and in un-)Tj 0 -1.401 TD 0.0007 Tc 0.125 Tw (derstanding the legal instructions theyre given \(Antonio,)Tj T* -0.0044 Tc -0.0624 Tw [(2006; Bornstein et al., 2005; Butler)34.6(, 2007; Miller et al., 2007;)]TJ 0 -1.398 TD -0.0163 Tc -0.0625 Tw [(Steele & Thornburg, 1991\). Because most professional people)]TJ 0 -1.401 TD -0.0034 Tc 0.0668 Tw (in their 30s to 50s, as well as most mothers with childcare)Tj T* -0.0032 Tc -0.005 Tw (responsibilities, can probably find some reason to get out of)Tj 0 -1.398 TD -0.0507 Tw [(jury duty)62.9(, most juries will contain a disproportionate number)]TJ 0 -1.401 TD 0.0085 Tc 0.125 Tw (of very young, very old, less educated, and less family-)Tj T* -0.0038 Tc -0.0041 Tw (grounded individuals. In deliberations, less comprehending)Tj 0 -1.398 TD -0.0028 Tc -0.0106 Tw (jurors may feel intimidated by seemingly more savvy mem-)Tj 0 -1.401 TD -0.0031 Tc 0.017 Tw (bers who, for their part, may be frustrated with their slower)Tj 25.5 62.799 TD -0.0035 Tc 0.0931 Tw (compatriots failure to grasp their arguments or see things)Tj 0 -1.398 TD -0.0054 Tc -0.06 Tw [(their way)63.6(.)]TJ 1.8 -2.001 TD -0.0028 Tc -0.031 Tw (Indeed, an entire industry of )Tj /TT5 1 Tf 11.316 0 TD -0.0044 Tc -0.03 Tw (jury persuasion)Tj /TT2 1 Tf 6.159 0 TD -0.0029 Tc -0.0325 Tw (, often traf-)Tj -19.275 -1.401 TD -0.0038 Tc -0.006 Tw [(ficking under the euphemism of )]TJ /TT5 1 Tf 12.879 0 TD -0.004 Tc -0.01 Tw (trial consulting)Tj /TT2 1 Tf 6.072 0 TD -0.0037 Tc -0.0075 Tw (, has sprung)Tj -18.951 -1.398 TD 0.0014 Tc 0.125 Tw (up precisely to capitalize on juries frequent cluelessness)Tj 0 -1.401 TD -0.0046 Tc -0.0625 Tw (and to help attorneys use this to their own advantage \(Kressel)Tj T* -0.0182 Tc -0.0621 Tw [(& Kressel, 2002; Posey & )11.9(W)55.6(rightsman, 2005; )14.9(V)65(inson & Davis,)]TJ 0 -1.398 TD -0.0124 Tc [(1996\). For example, we know from cognitive psychology and)]TJ 0 -1.401 TD -0.003 Tc -0.05 Tw (everyday experience that most people make decisions not by)Tj T* -0.0035 Tc 0.0583 Tw (carefully weighing evidence and using inductive reasoning)Tj 0 -1.398 TD -0.0032 Tc 0.0594 Tw [(to arrive at a conclusion. Rather)35.8(, they make an immediate)]TJ 0 -1.401 TD 0.0273 Tw (judgment which is typically based on emotion and first im-)Tj T* -0.0065 Tc -0.0625 Tw (pressions and lies within their pre-existing frame of reference)Tj 0 -1.398 TD -0.0033 Tc -0.0578 Tw [(and comfortable world-view)62.7(.)-5.1( )18.6(Then, they selectively scan the)]TJ 0 -1.401 TD 0.0154 Tc 0.125 Tw (available data to cherry-pick information that will self-)Tj T* -0.003 Tc -0.0006 Tw (justifyingly support their original position. Hence, most ju-)Tj 0 -1.398 TD -0.0032 Tc 0.0778 Tw (rors strive to reach verdicts which do not conflict strongly)Tj 0 -1.401 TD -0.0268 Tw (with the views theyve held at the beginning of the trial; that)Tj T* -0.0005 Tc 0.125 Tw (is, they strive to reduce cognitive dissonance \(Feigenson,)Tj 0 -1.398 TD -0.0119 Tc -0.0622 Tw [(2000; Nisbett & Ross, 1980; Petty & Ciacioppo, 1986; Singer)36.1(,)]TJ 0 -1.401 TD -0.0183 Tc -0.0624 Tw [(1998; Sunby)62.7(, 1997\).)]TJ 1.8 -2.001 TD -0.0029 Tc -0.035 Tw (Thus, lawyers know that it is good trial strategy to build)Tj -1.8 -1.398 TD -0.0035 Tc 0.0156 Tw (your case around a small number of fundamental principles)Tj 0 -1.401 TD -0.0034 Tc 0.0962 Tw (about which most jurors are surmised to feel strongly and)Tj T* -0.003 Tc 0.0928 Tw (that consequently act as screens or filters to interpret, dis-)Tj 0 -1.398 TD -0.0033 Tc -0.0455 Tw [(tort, or reinforce information presented during the trial. )17.8(T)70.5(ac-)]TJ 0 -1.401 TD -0.0071 Tc -0.0627 Tw [(tically)64.9(, the more an attorney can frame his or her case in terms)]TJ T* -0.0033 Tc -0.04 Tw (of the jurors own personal experience, the greater the likeli-)Tj 0 -1.398 TD -0.0035 Tc -0.05 Tw [(hood of winning the case \(Kressel & Kressel, 2002; Murphy)59.5(,)]TJ 0 -1.401 TD -0.0054 Tc -0.062 Tw [(Loveland, & Munsterman, 1992; )15.8(V)59.8(inson & Davis, 1996\). Fi-)]TJ T* -0.0032 Tc 0.1248 Tw [(nally)56.8(, human beings form impressions about other human)]TJ 0 -1.398 TD -0.0033 Tc -0.0625 Tw [(beings more strongly than they do about abstract data. When)]TJ 0 -1.401 TD 0.0094 Tc 0.125 Tw [(jurors can understand the content of the testimony)60.4(, they)]TJ T* -0.0032 Tc 0.0475 Tw [(usually factor this into their decisions. But when the com-)]TJ 0 -1.398 TD -0.0033 Tc 0.0807 Tw (plexity of the subject matter exceeds their comprehension,)Tj 0 -1.401 TD -0.0028 Tc 0.1013 Tw (they rely on the perceived sincerity and persuasiveness of)Tj T* -0.0037 Tc -0.0624 Tw [(the witness \(Cooper)35.3(, Bennett, & Sukel, 1996\).)]TJ 1.8 -1.998 TD -0.0012 Tc 0.1249 Tw [(T)75.6(oday)52.8(s poor)40.8(, benighted jurors may be for)16.8(given their)]TJ -1.8 -1.401 TD -0.003 Tc 0.0984 Tw (blunders if only because the complexity of the world as a)Tj T* -0.0035 Tc 0.06 Tw (whole has changed much in just a few centuries, while the)Tj 0 -1.398 TD -0.0232 Tw [(human brain and human nature have not. No less an author-)]TJ 0 -1.401 TD -0.0033 Tc -0.055 Tw (ity than retired Supreme Court justice Sandra Day OConnor)Tj T* -0.0036 Tc -0.0378 Tw (\(2003\) has lamented this modern state of affairs:)Tj 2.1 -1.998 TD -0.0051 Tc -0.0625 Tw (The world is a very different place now than it was)Tj 0 -1.401 TD -0.0038 Tc -0.0622 Tw [(in 1220 or in 1789 or fifty years ago. )14.3(W)100(e)0.8( therefore)]TJ ET endstream endobj 252 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT2 9 0 R /TT3 10 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 254 0 obj << /Length 8604 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 54 59.745 m 546 59.745 l S BT /F1 1 Tf 8 0 0 8 54.99 41.64 Tm 0 0 0 1 k /GS2 gs -0.0052 Tc 0.0896 Tw [(210 )]TJ /TT3 1 Tf 2.745 0 TD -0.005 Tc (Millers Juror Stress)Tj /TT5 1 Tf 10 0 0 10 75 722.64 Tm -0.0036 Tc 0 Tw (should)Tj /TT2 1 Tf 2.649 0 TD -0.0008 Tc 0.125 Tw [( not be surprised to learn that aspects of)]TJ -2.649 -1.398 TD -0.003 Tc 0.0938 Tw [(the jury system that worked well in those times)]TJ 0 -1.401 TD -0.0056 Tc -0.0622 Tw [(work less well today and need some repairs. What)]TJ T* -0.003 Tc -0.0161 Tw (should surprise us is that so little of the necessary)Tj 0 -1.398 TD -0.0037 Tc 0.0038 Tw (repair work has been done.)Tj 0 -2.001 TD -0.0025 Tc -0.0004 Tw ( There are three aspects of the jury system that)Tj 0 -1.401 TD -0.0032 Tc 0.028 Tw [(need particular attention. First, )]TJ /TT5 1 Tf 12.834 0 TD -0.0038 Tc 0.03 Tw [(the conditions of)]TJ -12.834 -1.398 TD -0.0047 Tc -0.06 Tw (jury service)Tj /TT2 1 Tf 4.581 0 TD -0.0039 Tc -0.0625 Tw [(. When citizens are called for jury ser-)]TJ -4.581 -1.401 TD -0.0029 Tc 0.04 Tw (vice, they often view it as a burden rather than a)Tj T* -0.0033 Tc -0.0112 Tw [(privilege. )50.7(And for good reason: when they arrive)]TJ 0 -1.398 TD -0.0029 Tc -0.0379 Tw (at the courthouse they frequently are treated more)Tj 0 -1.401 TD -0.0032 Tc 0.0437 Tw (like sheep than people, and the system can seem)Tj T* -0.0036 Tc 0.0356 Tw (designed to disrupt their lives to a maximum de-)Tj 0 -1.398 TD -0.0031 Tc 0.03 Tw [(gree. Second, )]TJ /TT5 1 Tf 5.961 0 TD -0.0039 Tc (jury selection)Tj /TT2 1 Tf 5.394 0 TD -0.0031 Tc 0.031 Tw [(. The process of se-)]TJ -11.355 -1.401 TD -0.0026 Tc 0.1167 Tw (lecting a jury out of the citizens called for jury)Tj T* -0.0023 Tc 0.125 Tw (service on a particular day has changed from a)Tj 0 -1.398 TD 0.0125 Tc (necessary safeguard against potentially biased)Tj 0 -1.401 TD -0.0025 Tc -0.0195 Tw (jurors to a way for highly paid jury consultants to)Tj T* -0.0028 Tc -0.0239 Tw (attempt to ensure a jury favorable to the side pay-)Tj 0 -1.398 TD -0.0031 Tc 0.0276 Tw [(ing their fees. )54(And third, )]TJ /TT5 1 Tf 10.359 0 TD -0.0034 Tc (the conduct of the trial)Tj -10.359 -1.401 TD -0.0032 Tc 0 Tw (itself.)Tj /TT2 1 Tf 2.175 0 TD -0.0035 Tc -0.0168 Tw [( )17.9(T)70.3(oo often, jurors are allowed to do nothing)]TJ -2.175 -1.401 TD -0.0015 Tc 0.125 Tw (but to listen passively to the testimony without)Tj 0 -1.398 TD -0.0029 Tc -0.0095 Tw (any idea what the legal issues are in the case, and)Tj 0 -1.401 TD -0.0035 Tc 0.0764 Tw (without being permitted to take notes or partici-)Tj T* -0.002 Tc 0.0365 Tw [(pate in any way)64(, finally to be read a virtually in-)]TJ 0 -1.398 TD -0.0036 Tc -0.01 Tw (comprehensible set of instructions and sent to the)Tj 0 -1.401 TD -0.0025 Tc -0.0613 Tw (jury room to reach a verdict in a case they may not)Tj T* -0.0033 Tc 0.0743 Tw (understand much better than they did before the)Tj 0 -1.398 TD -0.0051 Tc -0.0619 Tw [(trial began \(OConnor)33.9(, 2003, pp. 217-218; cited in)]TJ 0 -1.401 TD -0.0057 Tc [(Posey & )12.4(W)53.1(rightsman, 2005, pp. 218\).)]TJ /TT5 1 Tf -0.3 -2.001 TD -0.0035 Tc 0.0851 Tw (Jury deliberation. )Tj /TT2 1 Tf 7.521 0 TD 0.0858 Tw [(This is where it all comes together)35.5(,)]TJ -9.321 -1.398 TD -0.001 Tc 0.125 Tw (where the jurors are supposed to put their heads together)Tj 0 -1.401 TD -0.0035 Tc 0.1145 Tw (and come up with a decision that follows the law and re-)Tj T* -0.0002 Tc 0.125 Tw [(spects the evidence in the case. They have already been)]TJ 0 -1.398 TD -0.003 Tc 0.0284 Tw [(instructed that there are specific things they are and are not)]TJ 0 -1.401 TD -0.0335 Tw (allowed to include in their thinking about the case; they may)Tj T* -0.0012 Tc 0.1249 Tw [(or may not understand these rules. )55.7(A)61( number of surveys)]TJ 0 -1.398 TD -0.0034 Tc 0.0656 Tw (have shown that the interactions and dynamics of these 12)Tj 0 -1.401 TD -0.0037 Tc 0.0593 Tw (strangers, thrown together from diverse cultures and walks)Tj T* -0.0056 Tc -0.0625 Tw (of life, with widely varying cognitive skills and personalities,)Tj 0 -1.398 TD -0.0034 Tc -0.0304 Tw (can often be the biggest source of stress for jurors during the)Tj 0 -1.401 TD -0.0066 Tc -0.0622 Tw [(trial. )14.4(While many jury deliberations proceed tolerably)62.4(, and in)]TJ T* -0.0029 Tc 0.0685 Tw (some instances may even be enjoyably challenging, others)Tj 0 -1.398 TD -0.003 Tc -0.0094 Tw (are described by jurors as the worst experience theyve ever)Tj 0 -1.401 TD -0.0107 Tc -0.0625 Tw [(had \(Antonio, 2006; Butler)34.3(, 2007\).)]TJ 27.3 62.799 TD 0.0003 Tc 0.125 Tw (The types of stresses during jury deliberation can be)Tj -1.8 -1.398 TD -0.0035 Tc 0.0656 Tw (multiple and can range from little personal irritations from)Tj 0 -1.401 TD -0.0033 Tc -0.0515 Tw [(another juror)-39.3()53.7(s)-0.1( mannerisms or tone of voice, to a particularly)]TJ T* -0.0035 Tc -0.0107 Tw (obnoxious, ignorant, or intimidating juror who just ticks ev-)Tj 0 -1.398 TD -0.0032 Tc 0.0655 Tw (erybody else off and makes the process so much more un-)Tj 0 -1.401 TD 0.0225 Tw [(pleasant. Not to be overlooked is the physical setting, with)]TJ T* -0.003 Tc 0.1083 Tw (poorly ventilated jury chambers resembling sweaty locker)Tj 0 -1.398 TD -0.0034 Tc -0.006 Tw [(rooms after a few hours. The deliberation process itself can)]TJ 0 -1.401 TD -0.02 Tw (be contentious and the juror who evinces a minority opinion)Tj T* -0.0036 Tc -0.0625 Tw (may find him- or herself reviled and alienated for not letting)Tj 0 -1.398 TD -0.0042 Tc -0.0624 Tw [(us get on with this. Some jury deliberations have reportedly)]TJ 0 -1.401 TD -0.0038 Tc 0.1143 Tw (almost broken into fistfights, and breakdowns in decorum)Tj T* -0.0034 Tc 0.0928 Tw (with inadvertent or intentional spewing of stereotypes and)Tj 0 -1.398 TD -0.0037 Tc -0.0069 Tw (prejudices are not uncommon, as the mounting stress brings)Tj 0 -1.401 TD -0.003 Tc 0.0279 Tw [(out the ugly side of the deliberators \(Bornstein et al., 2005;)]TJ T* -0.0193 Tc -0.0611 Tw [(Butler)34.7(, 2007; Casey)58.7(, 1998\).)]TJ /F1 1 Tf 11 0 0 11 309 480 Tm -0.0052 Tc 0.0375 Tw (Juror Stress: Symptoms and Syndromes)Tj /TT2 1 Tf 10 0 0 10 327 456.66 Tm -0.0127 Tc -0.0623 Tw (Butler \(2007\) points out that if a research committee were)Tj -1.8 -1.401 TD -0.0033 Tc 0.0285 Tw (to propose a study on the human stress response that incor-)Tj T* -0.0034 Tc -0.005 Tw (porated the factors reviewed above, they would no doubt be)Tj 0 -1.398 TD -0.0033 Tc -0.0016 Tw (fired from their university and banned from research for the)Tj 0 -1.401 TD -0.0032 Tc 0.0402 Tw [(rest of their lives. )54(Another)35.8(, perhaps more germane, way to)]TJ T* -0.0033 Tc -0.0018 Tw (look at it is that the kind of working environment that many)Tj 0 -1.398 TD -0.0032 Tc 0.0045 Tw (jurors are subjected to during their service would be strictly)Tj 0 -1.401 TD -0.0036 Tc -0.0555 Tw [(illegal in all regulated )50.5(American public and private or)17.4(ganiza-)]TJ T* -0.0034 Tc 0.1219 Tw (tions, and discovery of such conditions would subject the)Tj 0 -1.398 TD -0.0036 Tc -0.0208 Tw [(organization to civil penalties and criminal prosecution.)]TJ 1.8 -2.001 TD -0.0065 Tc -0.0622 Tw (Juror stress symptoms can be conceptualized along three)Tj -1.8 -1.401 TD -0.008 Tc -0.0625 Tw (dimensions: \(1\) symptom type; \(2\) symptom severity; and \(3\))Tj 0 -1.398 TD -0.0034 Tc -0.0475 Tw (symptom time course.)Tj /TT5 1 Tf 11 0 0 11 309 249.36 Tm 0.0069 Tc 0.1277 Tw [(Symptom T)64.2(ype)]TJ /TT2 1 Tf 10 0 0 10 327 229.65 Tm -0.0034 Tc 0.0793 Tw (Juror stress symptoms tend to replicate those reported)Tj -1.8 -1.401 TD -0.0032 Tc 0.0256 Tw [(more generally in the stress and trauma literature \(Antonio,)]TJ 0 -1.398 TD -0.0036 Tc 0.0095 Tw [(2006; Bell & Feldman, 1992; Bornstein et al., 2004; Butler)35.4(,)]TJ 0 -1.401 TD -0.0105 Tc -0.0624 Tw [(2007; Casey)61.5(, 1998; Costanzo & Costanzo, 1994; Davis, 1993;)]TJ T* -0.0115 Tc [(Feldman & Bell, 1993; Kaplan & )18.4(W)56.4(inget, 1992; Kelley)60.5(, 1994;)]TJ 0 -1.398 TD -0.0042 Tc -0.0622 Tw (Shuman et al., 1994\) and include the following:)Tj /TT5 1 Tf 1.8 -2.001 TD 0.0016 Tc 0.125 Tw (Physical symptoms.)Tj /TT2 1 Tf 8.046 0 TD 0.0026 Tc [( Impaired sleep, headaches, heart)]TJ -9.846 -1.401 TD -0.0036 Tc 0.0325 Tw (palpitation, high blood pressure, cutaneous reactions \(hives)Tj 0 -1.398 TD -0.0514 Tw (and rashes\), ulcers, impaired sexual functioning, muscle ten-)Tj 0 -1.401 TD -0.0033 Tc 0.0413 Tw (sion, tremors, chest pain, faintness.)Tj ET endstream endobj 255 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT2 9 0 R /TT3 10 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 257 0 obj << /Length 8694 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 66 59.745 m 558 59.745 l S BT /TT3 1 Tf 8 0 0 8 423.24 42.6 Tm 0 0 0 1 k /GS2 gs -0.0051 Tc 0.0326 Tw [(IJEMH Vol. 10, No. 3 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (211)Tj /TT5 1 Tf 10 0 0 10 84 722.64 Tm -0.0041 Tc -0.015 Tw (Psychological symptoms. )Tj /TT2 1 Tf 10.236 0 TD -0.0036 Tc (Intrusive recollections, night-)Tj -12.036 -1.398 TD -0.0283 Tw [(mares, emotional numbing and detachment, anxiety)59.4(, depres-)]TJ 0 -1.401 TD -0.0038 Tc 0.06 Tw (sion, increased alcohol consumption.)Tj /TT5 1 Tf 11 0 0 11 66 661.35 Tm 0.0112 Tc 0.1273 Tw (Symptom Severity)Tj /TT2 1 Tf 10 0 0 10 84 641.64 Tm -0.0035 Tc -0.0286 Tw (Juror stress appears to show the standard )Tj /TT5 1 Tf 16.236 0 TD -0.0048 Tc 0 Tw (dose-response)Tj -18.036 -1.398 TD -0.0047 Tc (ratio)Tj /TT2 1 Tf 1.926 0 TD -0.0031 Tc 0.057 Tw [( seen with other stressors, that is, the greater the level)]TJ -1.926 -1.401 TD -0.0033 Tc -0.0094 Tw [(of stress, the more severe the symptoms \(Butler)35.7(, 2007\). For)]TJ T* -0.0036 Tc -0.0579 Tw (example, jurors serving on traumatic trials, including rape,)Tj 0 -1.398 TD -0.0038 Tc 0.0845 Tw [(murder)35.2(, and aggravated kidnapping, were found to experi-)]TJ 0 -1.401 TD 0.0079 Tw (ence more severe symptoms than jurors on non-traumatic)Tj T* -0.0032 Tc 0.12 Tw (trials such as burglary or drug possession \(Shuman et al.,)Tj 0 -1.398 TD -0.056 Tw [(1994\). In particular)38.9(, the jurors on traumatic trials were many)]TJ 0 -1.401 TD -0.0193 Tc -0.0622 Tw (times more likely to experience depression \(Miller et al., 2007\).)Tj /TT5 1 Tf 11 0 0 11 66 496.35 Tm 0.0012 Tc 0.1249 Tw [(Symptom T)53(ime Course)]TJ /TT2 1 Tf 10 0 0 10 84 476.64 Tm -0.0074 Tc -0.0625 Tw (In the Capital Jury Project \(Antonio, 2006\), jurors stress)Tj -1.8 -1.398 TD -0.0035 Tc 0.0733 Tw (reactions were found to occur in three main stages: during)Tj 0 -1.401 TD -0.0034 Tc -0.0622 Tw [(the trial; immediately after the sentence was announced; and)]TJ T* -0.003 Tc 0.0017 Tw (in the days, weeks, or months after the trial ended.)Tj /TT5 1 Tf 1.8 -1.998 TD -0.0034 Tc 0.0416 Tw (During the trial. )Tj /TT2 1 Tf 6.9 0 TD -0.0027 Tc 0.0418 Tw [(Interestingly)60.3(, only a few of the jurors)]TJ -8.7 -1.401 TD -0.0031 Tc -0.0265 Tw (reported that the full impact of their jury experience was felt)Tj T* -0.0037 Tc 0.02 Tw (while the trial was occurring; most jurors seemed to go on)Tj 0 -1.398 TD -0.0034 Tc 0.0325 Tw [(automatic to function while the trial was in progress. The)]TJ 0 -1.401 TD -0.0035 Tc -0.0525 Tw (major source of stress at this time was determining the actual)Tj T* 0.0029 Tc 0.125 Tw [(punishment decision. Other stressors included having to)]TJ 0 -1.398 TD -0.0036 Tc 0.1137 Tw (view disturbing crime scene evidence and the isolation of)Tj 0 -1.401 TD -0.0033 Tc 0.012 Tw (not being able to speak to their families about the case.)Tj /TT5 1 Tf 1.8 -2.001 TD 0 Tc 0.125 Tw (Immediately after the trial. )Tj /TT2 1 Tf 11.526 0 TD 0.0007 Tc 0.1249 Tw (In many cases, the stress)Tj -13.326 -1.398 TD -0.0033 Tc 0.1095 Tw (response came as a delayed reaction right after the trial)Tj 0 -1.401 TD -0.0029 Tc -0.0358 Tw [(was over)54.1(. Most of the jurors in this category reported crying)]TJ T* -0.0032 Tc -0.0082 Tw (at some point, either from the strain of their recent ordeal or)Tj 0 -1.398 TD -0.0033 Tc -0.0213 Tw [(out of sheer relief that it was over)53.7(. )14.9(T)73.5(wo female jurors in this)]TJ 0 -1.401 TD -0.0036 Tc 0.1 Tw (sample were concerned about the effect the verdict would)Tj T* -0.0033 Tc -0.0613 Tw [(have on the victim)50.7(s family)59.7(.)]TJ /TT5 1 Tf 1.8 -1.998 TD 0.055 Tw (Days, weeks, or months after the trial. )Tj /TT2 1 Tf 15.81 0 TD -0.0037 Tc 0.0567 Tw (Most of the ju-)Tj -17.61 -1.401 TD -0.0033 Tc 0.0794 Tw (rors reported that serving in a capital murder trial affected)Tj T* -0.0035 Tc 0.125 Tw [(them long after the trial ended. Some jurors experienced)]TJ 0 -1.398 TD -0.0031 Tc -0.0037 Tw (changes in their relationships and lifestyles. Many reported)Tj 0 -1.401 TD -0.0029 Tc -0.0006 Tw (difficulty forgetting what they heard or saw during the trial,)Tj T* -0.0019 Tc 0.125 Tw (and a few reported classic symptoms of PTSD, including)Tj 0 -1.398 TD -0.0038 Tc 0.1 Tw (nightmares, intrusive recollection, and emotional numbing)Tj 0 -1.401 TD -0.0123 Tc -0.06 Tw (\(Antonio, 2006\).)Tj /F1 1 Tf 11 0 0 11 321 723.99 Tm -0.0043 Tc 0.0614 Tw (Alleviating Juror Stress)Tj /TT2 1 Tf 10 0 0 10 339 700.65 Tm -0.0052 Tc -0.0625 Tw [( Several authorities have proposed recommendations for)]TJ -1.8 -1.401 TD 0.0002 Tc 0.125 Tw (making the juror system less stressful and more humane,)Tj 0 -1.398 TD -0.002 Tc (based on their analyses of juror responses to surveys and)Tj 0 -1.401 TD -0.0035 Tc 0.09 Tw (general experience \(Antonio, 2006; Bornstein et al., 2005;)Tj T* -0.0034 Tc -0.0445 Tw [(Casey)62.6(, 1998; McAree, 2004; Miller et al., 2007; Nordgren &)]TJ 0 -1.398 TD -0.0036 Tc 0.0443 Tw [(Thelen, 1999\). I have divided these recommendations into)]TJ 0 -1.401 TD -0.0037 Tc 0.0262 Tw (procedural measures and clinical approaches.)Tj /TT5 1 Tf 11 0 0 11 321 583.35 Tm 0.0171 Tc 0.1251 Tw [(Court Pr)36.2(ocedural Measur)36.2(es)]TJ /TT2 1 Tf 10 0 0 10 339 563.64 Tm -0.0036 Tc 0.1207 Tw (These issues relate to changing the courtroom setting)Tj -1.8 -1.398 TD -0.0034 Tc -0.0294 Tw (and the conditions of jury service \(Antonio, 2006; Bornstein)Tj 0 -1.401 TD -0.003 Tc -0.027 Tw [(et al., 2005; Casey)63(, 1998; McAree, 2004; Miller et al., 2007;)]TJ T* -0.0038 Tc -0.0543 Tw (Nordgren & Thelen, 1999\) and include the following:)Tj /TT5 1 Tf 1.8 -1.998 TD 0.0112 Tc 0.125 Tw (Improve jury notification and reporting for service.)Tj /TT2 1 Tf -1.8 -1.401 TD -0.0036 Tc 0.0519 Tw (Provide sufficient time for prospective jurors to respond to)Tj T* -0.0032 Tc 0.024 Tw [(jury summons. Many courts now provide the option of de-)]TJ 0 -1.398 TD -0.0205 Tc -0.0623 Tw [(ferring jury service one or more times, as long as the summonee)]TJ 0 -1.401 TD -0.003 Tc 0.125 Tw (reports within a specified period of time \(usually about 6)Tj T* -0.0035 Tc -0.04 Tw [(months\). Giving jurors time to arrange their affairs provides)]TJ 0 -1.398 TD -0.0032 Tc 0.0838 Tw [(a sense of control that may increase juror cooperation and)]TJ 0 -1.401 TD -0.0035 Tc 0.0825 Tw [(motivation to participate. Provide basic information with)]TJ T* 0.046 Tw (regard to how to respond to the summons, where to report,)Tj 0 -1.398 TD -0.0034 Tc -0.0075 Tw [(directions, relevant phone numbers, etc. Provide safe trans-)]TJ 0 -1.401 TD 0.0015 Tc 0.125 Tw (portation and security escort between the courthouse and)Tj T* -0.0034 Tc 0.0228 Tw [(transportation \(parking lot, bus stop\). Remember)35.6(, anything)]TJ 0 -1.398 TD -0.0033 Tc -0.0195 Tw [(the court can do that makes it easier)35.7(, not harder)38.7(, for jurors to)]TJ 0 -1.401 TD -0.003 Tc -0.0555 Tw [(report for jury duty will increase compliance rates. Consider)]TJ T* -0.0034 Tc 0.03 Tw (adjusted compensation rates for self-employed jurors or ju-)Tj 0 -1.398 TD -0.0036 Tc -0.0622 Tw (rors whose employers will not compensate the worker for his)Tj 0 -1.401 TD -0.0034 Tc -0.0516 Tw (or her service time.)Tj /TT5 1 Tf 1.8 -2.001 TD -0.0036 Tc -0.0477 Tw [(Explain the trial pr)29.4(ocess. )]TJ /TT2 1 Tf 10.044 0 TD -0.0032 Tc -0.0483 Tw [( )51.5(All too often, the initial orien-)]TJ -11.844 -1.398 TD 0.0989 Tw (tation to the legal system consists of a short, prepackaged)Tj 0 -1.401 TD -0.0027 Tc -0.0571 Tw (video played on a screen in a busy auditorium that may be all)Tj T* 0.0017 Tc 0.125 Tw (but incomprehensible to most of the stressed and harried)Tj 0 -1.398 TD -0.0036 Tc -0.0511 Tw [(audience in the pre-panel cattle call room. Felons confes-)]TJ 0 -1.401 TD -0.0031 Tc -0.0217 Tw (sions may be thrown out if police cannot affirmatively dem-)Tj T* -0.0129 Tc -0.0622 Tw (onstrate that the suspect made a knowing and informed waiver)Tj 0 -1.398 TD -0.003 Tc 0.0146 Tw [(of his or her Miranda rights at the time of arrest. Similarly)60(,)]TJ 0 -1.401 TD -0.0035 Tc 0.0713 Tw [(considering that people)50.5(s legal fates are at stake, shouldn)17.5(t)]TJ T* -0.0033 Tc 0.0569 Tw (prospective jurors be required to demonstrate that they un-)Tj 0 -1.398 TD 0.002 Tc 0.125 Tw [(derstand the relevant law and legal procedures? Judges)]TJ 0 -1.401 TD -0.0033 Tc 0.0295 Tw (should take the initiative to explain things to the jurors in a)Tj T* -0.0035 Tc -0.0136 Tw [(clear)38.5(, understandable fashion and solicit their feedback with)]TJ 0 -1.398 TD 0.0667 Tw (regard to their understanding.)Tj ET endstream endobj 258 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT2 9 0 R /TT3 10 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 260 0 obj << /Length 9097 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 54 59.745 m 546 59.745 l S BT /F1 1 Tf 8 0 0 8 54.99 41.64 Tm 0 0 0 1 k /GS2 gs -0.0052 Tc 0.0896 Tw [(212 )]TJ /TT3 1 Tf 2.745 0 TD -0.005 Tc (Millers Juror Stress)Tj /TT2 1 Tf 10 0 0 10 72 722.64 Tm -0.0019 Tc 0.1249 Tw [(Also, give jurors a head)49.1(s-up as to what to expect in)]TJ -1.8 -1.398 TD -0.0031 Tc 0.1055 Tw (general from the trial on which they are being selected to)Tj 0 -1.401 TD 0.0811 Tw [(serve. Obviously)62.9(, the nature of the trial, whether criminal)]TJ T* -0.0033 Tc 0.0952 Tw [(\(murder)35.7(, robbery)62.7(, rape, drug possession\) or civil \(personal)]TJ 0 -1.398 TD -0.0029 Tc 0.0025 Tw (injury lawsuit, contract dispute, family law case\), should be)Tj 0 -1.401 TD -0.003 Tc 0.035 Tw [(explained. Many jurors state that they would have liked to)]TJ T* -0.0036 Tc 0.0243 Tw (have been forewarned that the trial could include gruesome)Tj 0 -1.398 TD -0.0037 Tc 0.116 Tw (photographs, foul language, pornographic material, and/or)Tj 0 -1.401 TD -0.0033 Tc -0.0416 Tw [(graphic descriptions of criminal acts. This may be contested)]TJ T* -0.0029 Tc 0.0928 Tw (by some judges and attorneys who are leery of discussing)Tj 0 -1.398 TD -0.0027 Tc 0.0805 Tw (any type of evidence that has not yet been determined ad-)Tj 0 -1.401 TD -0.0138 Tc -0.0623 Tw [(missible. )58.4(Additionally)61.2(, many attorneys may actually be count-)]TJ T* -0.0033 Tc -0.054 Tw (ing on the emotional shock value of certain evidence to sway)Tj 0 -1.398 TD -0.0034 Tc 0.0019 Tw (jurors opinions and dont want them desensitized by previ-)Tj 0 -1.401 TD -0.0032 Tc 0.1139 Tw (ous discussion; other attorneys may not want to tip their)Tj T* -0.0039 Tc -0.0034 Tw (hand about sensitive forthcoming evidence. Courts should)Tj 0 -1.398 TD 0.0038 Tw (strive to work out some compromise solution that preserves)Tj 0 -1.401 TD -0.0033 Tc 0.0445 Tw (the rules of evidence while assuring that jurors will be in a)Tj T* 0.0275 Tw (proper mental state to hear the case.)Tj /TT5 1 Tf 1.8 -1.998 TD -0.0034 Tc 0.036 Tw (Facilitate the jury selection process. )Tj /TT2 1 Tf 14.88 0 TD -0.0037 Tc 0.0367 Tw (One aspect of the)Tj -16.68 -1.401 TD -0.0027 Tc -0.005 Tw (trial system that should be clearly explained is the necessity)Tj T* 0.0056 Tc 0.125 Tw (for attorneys to ask jurors probing questions during voir)Tj 0 -1.398 TD -0.0035 Tc 0.0545 Tw [(dire. This should include an explanation of the purpose of)]TJ 0 -1.401 TD 0.0757 Tw (the voir dire examination, an explanation of the difference)Tj T* -0.0002 Tc 0.125 Tw (between peremptory challenges and challenges for cause,)Tj 0 -1.398 TD -0.0033 Tc 0.0257 Tw (introductory information on the particular case, an estimate)Tj 0 -1.401 TD -0.0031 Tc 0.0154 Tw [(of how long the trial may last, and an indication of whether)]TJ T* -0.0029 Tc -0.0487 Tw [(the jury will be sequestered and, if so, for how long and why)60.1(.)]TJ 1.8 -1.998 TD 0.0039 Tc 0.1249 Tw [(Be sensitive to jurors privacy concerns. Responses)]TJ -1.8 -1.401 TD -0.0073 Tc -0.0622 Tw (from jurors indicate that some judges and attorneys may view)Tj T* -0.0035 Tc -0.0305 Tw (voir dire as a fishing expedition to gain as much information)Tj 0 -1.398 TD -0.0427 Tw (as possible about each juror rather than just enough informa-)Tj 0 -1.401 TD -0.0032 Tc 0.0129 Tw [(tion to determine if a juror can be fair and impartial. Ques-)]TJ T* 0.0091 Tc 0.125 Tw (tions about mental illness, substance abuse, extramarital)Tj 0 -1.398 TD -0.0028 Tc 0.0789 Tw [(af)18.2(fairs, job and salary history)63.2(, or past run-ins with the law)]TJ 0 -1.401 TD -0.0032 Tc 0.0333 Tw (may be shrugged off by some potential jurors but shocking)Tj T* -0.0029 Tc 0.1044 Tw [(to others. Many jurors may be understandably concerned)]TJ 0 -1.398 TD -0.0036 Tc 0.0795 Tw (about who will get their personal information or will have)Tj 0 -1.401 TD -0.0033 Tc 0.0073 Tw [(access to court records. )53.8(Any juror questionnaires should be)]TJ T* -0.0034 Tc 0.0575 Tw (collected at the end of the selection process and the proce-)Tj 0 -1.398 TD -0.0033 Tc 0.0093 Tw (dures for assuring juror privacy should be explained.)Tj 1.8 -2.001 TD -0.0041 Tc 0.0887 Tw (Basic, commonsense recommendations include reduc-)Tj -1.8 -1.401 TD -0.0158 Tc -0.0625 Tw (ing waiting time, providing comfortable accommodations, and)Tj 0 -1.398 TD -0.0035 Tc 0.055 Tw (endeavoring to treat prospective jurors with the kind of re-)Tj 0 -1.401 TD -0.0032 Tc 0.0285 Tw (spect the court pays lip service to when intoning the sacred)Tj T* -0.0028 Tc 0.0229 Tw (civic duty to uphold our system of justice.)Tj /TT5 1 Tf 27.3 64.8 TD -0.0006 Tc 0.125 Tw (Maintain control of the courtroom and trial process.)Tj /TT2 1 Tf -1.8 -1.398 TD -0.0039 Tc 0.0944 Tw (When people are under pressure in an unfamiliar environ-)Tj 0 -1.401 TD -0.0032 Tc -0.0172 Tw [(ment, they want the grownups to be in charge. Jurors report)]TJ T* -0.0033 Tc -0.054 Tw (that much of their stress occurs when they perceive the judge)Tj 0 -1.398 TD -0.0034 Tc 0.0131 Tw [(as losing control of the courtroom. Intimidating, bickering,)]TJ 0 -1.401 TD -0.0478 Tw (or grandstanding attorneys should be reined in, and TV cam-)Tj T* -0.0031 Tc 0.067 Tw (eras should be removed if they interfere with the trial pro-)Tj 0 -1.398 TD -0.0037 Tc 0.1169 Tw [(cess. Loud or obtrusive witnesses or courtroom audience)]TJ 0 -1.401 TD -0.0105 Tc -0.0622 Tw [(members should be quieted or ejected. )13.5(T)69.3(aking control doesn)16.5(t)]TJ T* -0.0008 Tc 0.125 Tw [(mean being a tyrant; judges should always be civil with)]TJ 0 -1.398 TD 0.0051 Tc (attorneys, jurors, and witnesses, but they should make it)Tj 0 -1.401 TD -0.0044 Tc -0.0625 Tw (clear that they will tolerate no breaches of procedure or deco-)Tj T* -0.0035 Tc -0.0445 Tw [(rum in their courtroom. Control also means keeping the trial)]TJ 0 -1.398 TD -0.0004 Tc 0.125 Tw (process humming along so things dont bog down; ironi-)Tj 0 -1.401 TD -0.0032 Tc 0.0263 Tw [(cally)62.8(, boredom is often as much a threat to juror concentra-)]TJ T* -0.0356 Tw [(tion as overstimulation. Finally)59.8(, in high-profile cases, jurors)]TJ 0 -1.398 TD 0.0045 Tc 0.125 Tw (should be given some guidance on how to deal with the)Tj 0 -1.401 TD -0.0287 Tc 0 Tw (media.)Tj /TT5 1 Tf 1.8 -2.001 TD -0.0038 Tc 0.1091 Tw (Modulate the presentation of disturbing evidence and)Tj -1.8 -1.398 TD -0.0047 Tc 0 Tw [(testimony)49.3(.)-5.7( )]TJ /TT2 1 Tf 4.179 0 TD -0.0033 Tc -0.0607 Tw (As noted above, viewing grisly evidence or listen-)Tj -4.179 -1.401 TD -0.0027 Tc -0.0244 Tw (ing to emotionally disturbing testimony is reported by many)Tj T* 0.0029 Tc 0.125 Tw (jurors as being among the most stressful aspects of their)Tj 0 -1.398 TD -0.0021 Tc 0.1249 Tw [(service. )48.8(Although gruesome evidence is typically associ-)]TJ 0 -1.401 TD -0.0062 Tc -0.0622 Tw (ated with criminal trials, civil trials involving claims of negli-)Tj T* -0.0086 Tc -0.0623 Tw (gent injury or medical malpractice often contain their share of)Tj 0 -1.398 TD -0.003 Tc 0.0255 Tw [(hideous material. I recall testifying in one civil case where)]TJ 0 -1.401 TD -0.0036 Tc -0.0528 Tw [(the plaintif)17.4(f)-54.6()53.4(s claim of developing PTSD after seeing a loved)]TJ T* -0.0031 Tc 0.1022 Tw (one killed in a traffic accident was bolstered by full-color)Tj 0 -1.398 TD -0.0037 Tc 0.1186 Tw (accident scene photos detailing what the speeding vehicle)Tj 0 -1.401 TD -0.0034 Tc -0.0009 Tw [(had done to the victim)50.6(s head and body)62.6(. )51.1(Again, the purpose)]TJ T* -0.0033 Tc 0.0225 Tw (of preparing juries for disturbing testimony is not necessar-)Tj 0 -1.398 TD -0.0068 Tc -0.0623 Tw (ily to lessen the import of the criminal or civilly negligent act,)Tj 0 -1.401 TD -0.0032 Tc [(or to bias their view of the evidence in any way)62.8(, but simply to)]TJ T* -0.007 Tc -0.0625 Tw (alert them that such potentially disturbing material is coming.)Tj 0 -1.398 TD -0.0029 Tc 0.125 Tw (Indeed, juries who are shocked and overwhelmed by bla-)Tj 0 -1.401 TD -0.0031 Tc 0.0206 Tw (tantly violent or pornographic material may be less capable)Tj T* -0.0033 Tc -0.0275 Tw (of rendering a fair decision.)Tj /TT5 1 Tf 1.8 -1.998 TD -0.0036 Tc 0.1086 Tw (Allow greater juror participation in the trial process.)Tj /TT2 1 Tf -1.8 -1.401 TD -0.0042 Tc -0.0625 Tw (Under traditional trial procedures, jurors are expected to play)Tj T* -0.0033 Tc 0.005 Tw (a passive role, quietly listening and absorbing the presented)Tj 0 -1.398 TD -0.0049 Tc -0.0622 Tw (evidence and testimony in preparation for their deliberations.)Tj 0 -1.401 TD -0.0061 Tc -0.0623 Tw (Recalling the point made at the beginning of this article, in no)Tj T* -0.0079 Tc -0.0621 Tw (other field medicine, law enforcement, emergency services,)Tj 0 -1.398 TD -0.003 Tc -0.0405 Tw [(business and industry)63(, government, the military are critical)]TJ 0 -1.401 TD -0.0034 Tc -0.0244 Tw (decisions made in the context of deliberate restriction of rel-)Tj T* 0.017 Tw [(evant information. While certain aspects of a legal trial are)]TJ ET endstream endobj 261 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT2 9 0 R /TT3 10 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 263 0 obj << /Length 9057 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 66 59.745 m 558 59.745 l S BT /TT3 1 Tf 8 0 0 8 423.24 42.6 Tm 0 0 0 1 k /GS2 gs -0.0051 Tc 0.0326 Tw [(IJEMH Vol. 10, No. 3 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (213)Tj /TT2 1 Tf 10 0 0 10 66 722.64 Tm -0.0035 Tc 0.0169 Tw (unique, such as the importance of controlling bias, research)Tj 0 -1.398 TD -0.0034 Tc 0.0775 Tw (on juror decision making increasingly shows that this pas-)Tj 0 -1.401 TD -0.0033 Tc 0.105 Tw (sive role no note-taking allowed, no questions asked by)Tj T* -0.0032 Tc 0.0988 Tw (the jury is unnatural and uncomfortable for most jurors,)Tj 0 -1.398 TD -0.0225 Tw (hindering their ability to remain objective, to concentrate on)Tj 0 -1.401 TD -0.0038 Tc -0.0625 Tw [(evidence and testimony)62.2(, and to integrate new)59.2(, unfamiliar ma-)]TJ T* -0.0031 Tc 0.0945 Tw (terial; just imagine trying to pass a high school or college)Tj 0 -1.398 TD 0.0015 Tc 0.125 Tw [(course under these conditions. Conversely)61.5(, studies show)]TJ 0 -1.401 TD -0.0015 Tc [(that juror comprehension and satisfaction are increased if)]TJ T* -0.0032 Tc -0.0009 Tw (jurors are allowed a more active role in trials \(Cooper et al.,)Tj 0 -1.398 TD -0.0098 Tc -0.0625 Tw (1996; Dann, 1993; Heuer & Penrod, 1994; Rosehan, 1994\).)Tj 1.8 -2.001 TD -0.0227 Tc -0.062 Tw [(Accordingly)58.3(, many courts are now permitting limited note-)]TJ -1.8 -1.401 TD -0.0032 Tc 0.1025 Tw [(taking by jurors and the asking of limited questions. The)]TJ 0 -1.398 TD 0.122 Tw (latter usually takes the form of having the juror write the)Tj 0 -1.401 TD 0.0234 Tw (query on a piece of paper which is then passed to the judge)Tj T* -0.0033 Tc 0.0367 Tw [(for review)59.7(. If he or she determines that it is an appropriate)]TJ 0 -1.398 TD -0.0034 Tc -0.0081 Tw (question, the judge will then read it to the witness \(or some-)Tj 0 -1.401 TD -0.0029 Tc -0.0571 Tw [(times have the bailiff or court reporter read it\). In my experi-)]TJ T* -0.0041 Tc -0.0625 Tw (ence, this has almost always occurred in the context of expert)Tj 0 -1.398 TD -0.0032 Tc 0.0388 Tw [(witness testimony)59.8(, where the jury has a legitimate question)]TJ 0 -1.401 TD -0.0002 Tc 0.125 Tw (concerning some technical matter that the expert has just)Tj T* -0.0043 Tc -0.0625 Tw [(expounded upon. Given that jury verdicts may well be deter-)]TJ 0 -1.398 TD -0.0036 Tc (mined by their understanding of such complex material, any-)Tj 0 -1.401 TD -0.0581 Tw (thing that will increase their understanding should well serve)Tj T* -0.0032 Tc 0.0242 Tw (the purposes of a fair and just verdict.)Tj /TT5 1 Tf 1.8 -1.998 TD -0.0035 Tc 0.0715 Tw [(Facilitate jury deliberations. )]TJ /TT2 1 Tf 11.886 0 TD -0.0023 Tc 0.0718 Tw [(A)8.9(r)18.7(guably)60.7(, the jury delib-)]TJ -13.686 -1.401 TD -0.003 Tc -0.0045 Tw (eration process is the most critical aspect of juror activity in)Tj T* -0.0031 Tc 0.0016 Tw (the trial because it is here that the fate of the stakeholders is)Tj 0 -1.398 TD -0.0034 Tc 0.0068 Tw [(decided. Most jurors rank the process of deciding on a ver-)]TJ 0 -1.401 TD -0.0035 Tc -0.0155 Tw (dict and the fear of making a mistake among the top sources)Tj T* -0.0097 Tc -0.0623 Tw [(of stress in their trials. One problem often cited is their lack of)]TJ 0 -1.398 TD -0.0033 Tc 0.115 Tw [(a clear understanding of the judge)50.7(s jury instructions, and)]TJ 0 -1.401 TD -0.0036 Tc 0.0308 Tw (research has demonstrated generally low comprehension of)Tj T* -0.0159 Tc -0.0625 Tw (juror instructions in general \(Greene & Bornstein, 2000; Steele)Tj 0 -1.398 TD -0.0035 Tc -0.0079 Tw [(& )18.1(Thornbur)17.5(g, 1991\). )51.1(Accordingly)62.5(, it is crucial for judges to)]TJ 0 -1.401 TD 0.0014 Tc 0.125 Tw (ascertain that their juries understand the relevant instruc-)Tj T* 0.011 Tc 0 Tw (tions.)Tj 1.8 -1.998 TD -0.0033 Tc 0.0472 Tw (After days of listening to complex, confusing, disturb-)Tj -1.8 -1.401 TD -0.0043 Tc -0.0622 Tw [(ing, and/or boring testimony)61.7(, just throwing a group of strang-)]TJ T* -0.0034 Tc -0.0625 Tw (ers into a room and expecting them to arrive at a just decision)Tj 0 -1.398 TD -0.0032 Tc -0.0575 Tw [(may be more a reflection of naive optimism than reality)59.8(. )18.5(The)]TJ 0 -1.401 TD -0.0033 Tc -0.02 Tw (conduct of jury deliberations can range from polite and civil)Tj T* -0.0035 Tc -0.0335 Tw [(to something resembling a dog fight. Most jurors report that)]TJ 0 -1.398 TD -0.0032 Tc 0.125 Tw (they would have liked some guidelines for their delibera-)Tj 0 -1.401 TD -0.0029 Tc 0.0034 Tw (tions. Especially in tense criminal trials or where jurors are)Tj T* -0.0033 Tc -0.0363 Tw (having difficulty getting along, judges should be prepared to)Tj 25.5 64.8 TD -0.0037 Tc 0.1066 Tw (provide some guidelines for cooperative and collaborative)Tj 0 -1.398 TD -0.0036 Tc 0.0368 Tw [(deliberation, such as listening to one another)-39.6()53.4(s)0.2( points with-)]TJ 0 -1.401 TD -0.0033 Tc 0.01 Tw [(out interruption, disagreeing respectfully)59.7(, and not taking ar)17.7(-)]TJ T* -0.0016 Tc 0.1249 Tw [(guments about the case personally)64.4(. Business people take)]TJ 0 -1.398 TD -0.0038 Tc 0.0478 Tw (hours of courses and training seminars on decision-making)Tj 0 -1.401 TD 0.0034 Tc 0.125 Tw (processes, conflict resolution strategies, and how to con-)Tj T* -0.0038 Tc 0.0286 Tw [(duct productive meetings \(Miller)35.2(, 2008d\) shouldn)17.2(t juries)]TJ 0 -1.398 TD -0.003 Tc 0.0423 Tw [(be given some guidance on this as well? If jury sequestra-)]TJ 0 -1.401 TD -0.001 Tc 0.125 Tw (tion is a possibility in this trial, prepare jurors for this in)Tj T* -0.003 Tc 0.0166 Tw (advance, from the outset of jury selection.)Tj /TT5 1 Tf 11 0 0 11 321 563.34 Tm 0.0156 Tc 0.1276 Tw [(Clinical Measur)34.7(es)]TJ /TT2 1 Tf 10 0 0 10 339 543.66 Tm -0.0038 Tc -0.06 Tw (The following recommendations entail more of an inter-)Tj -1.8 -1.401 TD -0.0111 Tc -0.0625 Tw (face between judicial and mental health professionals in terms)Tj T* -0.0036 Tc 0.045 Tw (of providing specific interventions to help jurors cope with)Tj 0 -1.398 TD -0.0031 Tw (stress. There are some things that judges and court person-)Tj 0 -1.401 TD -0.0034 Tc 0.0427 Tw (nel can do; other approaches require the direct or consulta-)Tj T* -0.0035 Tc 0.0138 Tw (tive role of a qualified mental health professional \(Antonio,)Tj 0 -1.398 TD -0.0157 Tc -0.0622 Tw [(2006; Bienen, 1993; Bornstein et al., 2005; Casey)59.3(, 1998; Dabs,)]TJ 0 -1.401 TD -0.0625 Tw (1992; McAree, 2004; Miller et al., 2007\).)Tj /TT5 1 Tf 1.8 -2.001 TD -0.0036 Tc 0.0925 Tw (Pre-trial interventions. )Tj /TT2 1 Tf 9.57 0 TD -0.0034 Tc 0.093 Tw (This is the proactive aspect of)Tj -11.37 -1.398 TD -0.0035 Tc 0 Tw (juror stress management. The purpose of pre-trial interven-)Tj 0 -1.401 TD -0.003 Tc 0.1032 Tw (tions is to prepare jurors ahead of time for the stress they)Tj T* -0.0032 Tc -0.035 Tw [(may experience during the course of a trial. These measures)]TJ 0 -1.398 TD -0.0038 Tc 0.07 Tw (include informal discussions or prepared educational mod-)Tj 0 -1.401 TD -0.0034 Tc 0.0822 Tw (ules about the potential effects of stress, how to recognize)Tj T* -0.0033 Tc 0.01 Tw (symptoms, and how to utilize a range of coping techniques.)Tj 0 -1.398 TD -0.0037 Tc -0.015 Tw (The techniques themselves are familiar from stress manage-)Tj 0 -1.401 TD -0.0036 Tc 0.0825 Tw (ment applications in other fields, such as law enforcement)Tj T* -0.0094 Tc -0.062 Tw [(and emer)17.6(gency services \(Miller)35.6(, 2008a, 2008b\).)]TJ 1.8 -1.998 TD 0 Tc 0 Tw ( )Tj /TT5 1 Tf 0.255 0 TD -0.0036 Tc 0.01 Tw (Juror stress debriefing. )Tj /TT2 1 Tf 9.555 0 TD -0.0032 Tc 0.009 Tw (Sometimes it may not be clear)Tj -11.61 -1.401 TD -0.0033 Tc -0.0604 Tw (how stressful a trial has been until it has ended, at which time)Tj T* -0.0084 Tc -0.0621 Tw (appropriate follow-up mental health services may be required)Tj 0 -1.398 TD 0.0012 Tc 0.125 Tw [(\(Goleman, 1991\). )52.2(Although court-sponsored services for)]TJ 0 -1.401 TD -0.0114 Tc -0.0625 Tw [(crime victims exist in all 50 states \(Miller)33.6(, 2008c\) and psycho-)]TJ T* -0.0036 Tc 0.1137 Tw (logical services for law enforcement have existed in most)Tj 0 -1.398 TD -0.0262 Tw [(jurisdictions for decades \(Miller)35.5(, 2006b\), prior to 1990 there)]TJ 0 -1.401 TD -0.0037 Tc 0.0793 Tw (were few institutionalized programs through the courts for)Tj T* 0.0162 Tc 0.125 Tw (providing any kind of mental health services for jurors)Tj 0 -1.398 TD -0.0034 Tc -0.0067 Tw [(\(McAree, 2004\). Following several highly-publicized trials)]TJ 0 -1.401 TD 0.0625 Tw (containing horrific evidence, including the Jeffrey Dahmer)Tj T* -0.0038 Tc -0.0623 Tw (serial cannibalism trial, the trial of the Oklahoma City bomb-)Tj 0 -1.398 TD -0.0035 Tc 0.0141 Tw (ers, and the Pam Basu trial, in which a mother was dragged)Tj 0 -1.401 TD 0.0206 Tw [(and mutilated during a carjacking, courts have begun offer-)]TJ T* -0.0034 Tc -0.0088 Tw (ing psychological services to jurors \(Bell & Feldman, 1992;)Tj ET endstream endobj 264 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT2 9 0 R /TT3 10 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 266 0 obj << /Length 8934 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 54 59.745 m 546 59.745 l S BT /F1 1 Tf 8 0 0 8 54.99 41.64 Tm 0 0 0 1 k /GS2 gs -0.0052 Tc 0.0896 Tw [(214 )]TJ /TT3 1 Tf 2.745 0 TD -0.005 Tc (Millers Juror Stress)Tj /TT2 1 Tf 10 0 0 10 54 722.64 Tm -0.0265 Tc -0.0625 Tw [(Feldman & Bell, 1991, 1993; Hafemeister)33.5(, 1993; Hafemeister &)]TJ 0 -1.398 TD -0.0171 Tc -0.0622 Tw [(V)114.1(entis, 1992\), lar)18.9(gely in the form of one or more clinical variet-)]TJ 0 -1.401 TD -0.0031 Tc 0.0025 Tw (ies of )Tj /TT5 1 Tf 2.43 0 TD -0.0036 Tc 0.005 Tw (critical incident stress debriefing)Tj /TT2 1 Tf 13.14 0 TD -0.0037 Tc 0.0047 Tw ( \(CISD\) approaches,)Tj -15.57 -1.401 TD -0.0033 Tc 0 Tw (part of the larger domain of )Tj /TT5 1 Tf 11.181 0 TD -0.0038 Tc (critical incident stress manage-)Tj -11.181 -1.398 TD -0.0047 Tc (ment )Tj /TT2 1 Tf 2.115 0 TD -0.0033 Tc -0.06 Tw (\(CISM\), familiar to most readers of this journal \(Everly)Tj -2.115 -1.401 TD -0.0312 Tc -0.0622 Tw [(& Mitchell, 1997; Miller)37.8(, 1998c, 1999; Mitchell & Everly)64.8(, 2003\).)]TJ 1.8 -2.001 TD -0.0031 Tc 0.0432 Tw (Developed in the field of public safety and emergency)Tj -1.8 -1.398 TD -0.0015 Tc 0.125 Tw (services, the debriefing model has now been applied to a)Tj 0 -1.401 TD -0.0035 Tc 0.0393 Tw (wide range of crises, including crime victimization, natural)Tj T* -0.0062 Tc -0.0622 Tw [(disasters, and victims of terrorism \(Miller)38.8(, 1998c, 2008c\). )50.8(A)10.1(s)]TJ 0 -1.398 TD -0.0034 Tc -0.0058 Tw (developed in the emergency services field, CISD debriefing)Tj 0 -1.401 TD -0.0032 Tc -0.0021 Tw (is a peer-led, clinician-guided process, usually consisting of)Tj T* -0.0037 Tc 0.1222 Tw (one or more mental health professionals and one or more)Tj 0 -1.398 TD -0.0031 Tc -0.0128 Tw (peer debriefers, i.e. fellow police officers, firefighters, para-)Tj 0 -1.401 TD -0.0096 Tc -0.0625 Tw (medics, or crisis clinicians who have been trained in the CISD)Tj T* -0.0034 Tc 0.0912 Tw (process and who may have been through critical incidents)Tj 0 -1.398 TD -0.0032 Tc 0.125 Tw [(and debriefings in their own careers. The purpose of the)]TJ 0 -1.401 TD -0.0033 Tc 0.0293 Tw (debriefing is to normalize and detoxify the immediate trau-)Tj T* -0.0119 Tw (matic stress reactions being experienced by the subjects and)Tj 0 -1.398 TD -0.0031 Tc 0.0892 Tw [(to strengthen resistance to further psychological disability)59.9(.)]TJ 0 -1.401 TD -0.0036 Tc 0.0481 Tw (This is done through a semiformal seven-stage process, in-)Tj T* -0.0032 Tc 0.0883 Tw (cluding the introduction, fact, thought, reaction, symptom,)Tj 0 -1.398 TD 0.0007 Tc 0.125 Tw (education, and reaction phases, designed to ease the pro-)Tj 0 -1.401 TD 0.0028 Tc (cess of ventilating distress, but then reseal psychological)Tj T* -0.0029 Tc 0.04 Tw [(stability and encourage natural healing, aided, if necessary)60.1(,)]TJ 0 -1.398 TD -0.0032 Tc -0.03 Tw (by follow-up referral to additional mental health services.)Tj 1.8 -2.001 TD -0.011 Tc -0.0625 Tw (Recent applications have expanded the use of CISD tech-)Tj -1.8 -1.401 TD -0.0016 Tc 0.125 Tw [(niques with civilian groups. Bell & Feldman \(1992\) and)]TJ 0 -1.398 TD -0.0155 Tc -0.0625 Tw (Feldman & Bell \(1991, 1993\) developed a post-trial debriefing)Tj 0 -1.401 TD -0.0033 Tc 0.0432 Tw (model specifically for jurors and other court personnel that)Tj T* -0.0031 Tc -0.0383 Tw (is essentially similar to the crisis debriefings utilized for vic-)Tj 0 -1.398 TD -0.0033 Tc -0.0175 Tw [(tims of crimes, natural disasters, or similar traumas. In gen-)]TJ 0 -1.401 TD 0.0316 Tc 0.125 Tw (eral, effective debriefing sessions reduce stress, offer)Tj T* -0.0037 Tc 0.0587 Tw (information on mental health services for those who might)Tj 0 -1.398 TD -0.0034 Tc 0.0375 Tw (need it, provide closure, promote confidence in the judicial)Tj 0 -1.401 TD -0.0032 Tc 0.1 Tw (system, and enhance satisfaction.)Tj 1.8 -2.001 TD 0.0537 Tc 0.125 Tw (As with most interventions, controversy exists.)Tj -1.8 -1.398 TD -0.0041 Tc -0.0625 Tw (Bornstein and colleagues \(2005\) conducted a study that mea-)Tj 0 -1.401 TD -0.0034 Tc 0.1069 Tw (sured jurors stress before and after a post-trial debriefing)Tj T* -0.0031 Tc 0.0512 Tw (and found that, while jurors overwhelmingly said that they)Tj 0 -1.398 TD 0.0037 Tc 0.125 Tw (found the debriefing intervention helpful, their measured)Tj 0 -1.401 TD -0.0033 Tc 0.0655 Tw (stress levels and symptom indices were similar at pre- and)Tj T* -0.0035 Tc -0.0278 Tw [(post-debriefing. Juror stress levels were lower at one month)]TJ 0 -1.398 TD -0.0012 Tc 0.125 Tw (post-trial regardless of whether they had received the de-)Tj 0 -1.401 TD -0.0031 Tc -0.0187 Tw [(briefing service or not. This, in fact, is an intriguing finding)]TJ T* 0.0014 Tc 0.125 Tw (that runs through the stress debriefing efficacy literature:)Tj 25.5 64.8 TD -0.005 Tc -0.0622 Tw (participants frequently say it helps, but formal measurements)Tj 0 -1.398 TD -0.0035 Tc -0.0431 Tw (of distress or symptoms remain unchanged \(Arendt & Elklit,)Tj 0 -1.401 TD -0.0516 Tc 0 Tw (2001\).)Tj 1.8 -2.001 TD -0.0034 Tc -0.0139 Tw (As with stress debriefing in other contexts, a major part)Tj -1.8 -1.398 TD -0.0036 Tc -0.0244 Tw (of the problem with using this intervention with jurors prob-)Tj 0 -1.401 TD -0.0032 Tc 0.0087 Tw (ably relates to the appropriateness of its application; mental)Tj T* -0.0036 Tc 0.0931 Tw (health clinicians who advise the courts should guide court)Tj 0 -1.398 TD -0.0029 Tc 0.0761 Tw (officials to use this technique only where it is legitimately)Tj 0 -1.401 TD -0.0031 Tc 0.0626 Tw [(needed \(Casey)62.9(, 1998\). For example, for trials that involve)]TJ T* -0.0027 Tc 0.0039 Tw (relatively low levels of stress, jurors may need only general)Tj 0 -1.398 TD -0.0035 Tc -0.0305 Tw [(discharge instructions from the trial judge prior to being dis-)]TJ 0 -1.401 TD -0.0081 Tc -0.0625 Tw [(missed. In general, informal meetings with the trial judge can)]TJ T* -0.0033 Tc 0.0518 Tw [(provide a sense of closure for the jurors. In more stressful)]TJ 0 -1.398 TD -0.003 Tc 0.0295 Tw (trials, the judge may choose to hold a more lengthy discus-)Tj 0 -1.401 TD -0.0057 Tc -0.0623 Tw (sion with the jurors or bring in a mental health professional to)Tj T* -0.0045 Tc -0.0622 Tw [(conduct a formal debriefing. This may be the case in particu-)]TJ 0 -1.398 TD -0.0031 Tc 0.0835 Tw (larly gruesome trials or those which attract a great deal of)Tj 0 -1.401 TD -0.0053 Tc -0.0624 Tw [(media attention. However)36.7(, surveys indicate that some judges)]TJ T* -0.0029 Tc -0.053 Tw (like to handle these sessions on their own, only rarely calling)Tj 0 -1.398 TD -0.0055 Tc -0.0622 Tw [(in a mental health professional \(Bornstein et al., 2005; Casey)57.5(,)]TJ 0 -1.401 TD -0.0036 Tc 0.0178 Tw [(1998; McAree, 2004\). Other judges seem to recognize that)]TJ T* -0.0027 Tc 0.073 Tw (this is out of their league and are only too happy to find a)Tj 0 -1.398 TD -0.0034 Tc 0.03 Tw (mental health professional who will take over if there are)Tj 0 -1.401 TD -0.0035 Tc -0.0623 Tw (any available who do this kind of work \(Miller et al., 2007\).)Tj 1.8 -2.001 TD -0.0083 Tc -0.0625 Tw (Some recommendations for optimizing the juror debrief-)Tj -1.8 -1.398 TD -0.012 Tc (ing session \(Bornstein et al., 2005; Miller et al., 2007\) include:)Tj 1.2 -2.001 TD -0.0031 Tc -0.0435 Tw [()-1453(Consider the best time of day for the debriefing. The)]TJ 1.8 -1.401 TD 0.0133 Tc 0.125 Tw (afternoon the trial ends may leave jurors feeling)Tj 0 -1.398 TD -0.003 Tc 0.1055 Tw [(drained; all they want to do is go home. Set up a)]TJ 0 -1.401 TD -0.0031 Tc 0.0218 Tw (separate day for the session, perhaps giving jurors a)Tj T* -0.0028 Tc 0.0317 Tw (few days to recoup.)Tj -1.8 -1.998 TD -0.0036 Tc -0.0393 Tw [()-1453.5(Make the jurors feel comfortable. Debriefing should)]TJ 1.8 -1.401 TD -0.0033 Tc -0.0262 Tw (be voluntary and there should be no stigma attached.)Tj T* -0.0036 Tc 0.005 Tw (Nothing that goes on in the session should be on the)Tj 0 -1.398 TD -0.0028 Tc -0.0046 Tw (record the trial is over; this is solely for the jurors)Tj 0 -1.401 TD -0.0176 Tc 0 Tw (well-being.)Tj -1.8 -2.001 TD -0.0004 Tc 0.125 Tw [()-1450.3(Unlike public safety professionals, jurors may not)]TJ 1.8 -1.398 TD -0.0037 Tc 0.0513 Tw (quite know how to proceed, so prime the conversa-)Tj 0 -1.401 TD -0.0036 Tc 0.01 Tw (tional pump to get people talking, but maintain con-)Tj T* -0.0032 Tc 0.1089 Tw [(trol over the discussion, so that it helps, not hurts.)]TJ 0 -1.398 TD -0.0036 Tc 0.042 Tw (Encourage productive venting, not unhealthy spew-)Tj 0 -1.401 TD -0.0033 Tc 0.0294 Tw [(ing or accusing. Keep the focus on the positive.)]TJ -1.8 -2.001 TD -0.0067 Tc -0.0621 Tw [()-1456.6(Positive focus includes normalizing juror stress. This)]TJ 1.8 -1.398 TD 0.0029 Tc 0.125 Tw (should be conceptualized as a normal reaction by)Tj ET endstream endobj 267 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT2 9 0 R /TT3 10 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 269 0 obj << /Length 8947 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 66 59.745 m 558 59.745 l S BT /TT3 1 Tf 8 0 0 8 423.24 42.6 Tm 0 0 0 1 k /GS2 gs -0.0051 Tc 0.0326 Tw [(IJEMH Vol. 10, No. 3 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (215)Tj /TT2 1 Tf 10 0 0 10 96 722.64 Tm -0.0035 Tc 0.1175 Tw [(normal people to an abnormally challenging situa-)]TJ 0 -1.398 TD -0.0028 Tc 0.0027 Tw (tion. Reassure the jurors that they did their best at a)Tj 0 -1.401 TD -0.0041 Tc -0.0625 Tw (difficult job in making a crucial decision.)Tj -1.8 -2.001 TD -0.0029 Tc -0.0144 Tw [()-1452.8(Cover any lingering questions jurors may have. )51.1(A)5.2(d)5.2(-)]TJ 1.8 -1.398 TD -0.0032 Tc 0.0293 Tw (dress concerns about safety and fears of retribution.)Tj 0 -1.401 TD -0.0035 Tc -0.0555 Tw [(Help jurors deal with the media. Seek juror feedback)]TJ T* 0.0325 Tw (as to how things could be improved in the future so)Tj 0 -1.398 TD -0.0028 Tc 0.0242 Tw (that they feel part of the solution.)Tj -1.2 -2.001 TD -0.0034 Tc -0.0228 Tw (In cases where the judge suspects that jurors are experi-)Tj -1.8 -1.401 TD -0.0035 Tc 0.0432 Tw (encing significant stress or showing symptoms of a serious)Tj 0 -1.398 TD -0.0032 Tc -0.0472 Tw [(mental disorder)38.8(, they can refer the juror to a qualified mental)]TJ 0 -1.401 TD 0.0063 Tc 0.125 Tw (health professional for more individualized counseling )Tj T* -0.0032 Tc -0.0088 Tw (again, courts should be proactive in identifying clinicians in)Tj 0 -1.398 TD 0 Tc 0.125 Tw (the community who can serve as resources for these ser-)Tj 0 -1.401 TD 0.0041 Tc 0 Tw (vices.)Tj /TT5 1 Tf 1.8 -2.001 TD 0.0031 Tc 0.125 Tw (Combined interventions. )Tj /TT2 1 Tf 10.416 0 TD 0.0038 Tc (One criticism that has been)Tj -12.216 -1.398 TD -0.0104 Tc -0.0621 Tw (leveled against debriefing-type interventions is that their stan-)Tj 0 -1.401 TD -0.0033 Tc -0.0625 Tw (dard, one-size-fits-all format lacks the flexibility to deal with)Tj T* -0.012 Tc [(diverse types of people and problems. While the CISM model)]TJ 0 -1.398 TD -0.0037 Tc 0.0069 Tw (continues to expand and adapt to new challenges, Nordgren)Tj 0 -1.401 TD -0.0038 Tc -0.0464 Tw (& Thelen \(1999\) have developed a multifaceted intervention)Tj T* 0.0248 Tc 0.125 Tw (program they call )Tj /TT5 1 Tf 8.124 0 TD 0.0236 Tc (Graduated Jury Stress Management)Tj /TT2 1 Tf -8.124 -1.398 TD -0.0036 Tc 0.0243 Tw (\(GJSM\) which contains five intervention levels that are ad-)Tj 0 -1.401 TD -0.0034 Tc 0.0122 Tw (ministered according to the stress level of the individual ju-)Tj T* -0.0143 Tc -0.062 Tw [(ror)48.7(. )58.2(Although GJSM is designed to be a post-trial intervention,)]TJ 0 -1.398 TD -0.0033 Tc 0.1217 Tw (some aspects of it \(i.e. written instructions\) could also be)Tj 0 -1.401 TD -0.0035 Tc 0.0138 Tw (adapted as a pre-trial intervention:)Tj 1.2 -2.001 TD 0 Tc 0 Tw ()Tj /TT5 1 Tf 1.8 0 TD -0.0038 Tc -0.02 Tw (Level 1: Basic Information.)Tj /TT2 1 Tf 10.839 0 TD -0.0028 Tc -0.0209 Tw [( Jurors who have not yet)]TJ -10.839 -1.398 TD -0.0032 Tc -0.0041 Tw (evinced any problems simply receive written educa-)Tj 0 -1.401 TD -0.0035 Tc 0.0741 Tw (tional materials about stress reactions and potential)Tj T* 0.0001 Tc 0.125 Tw (coping strategies.)Tj -1.8 -1.998 TD 0 Tc 0 Tw ()Tj /TT5 1 Tf 1.8 0 TD -0.004 Tc 0.1175 Tw (Level 2: Stress Management Instruction)Tj /TT2 1 Tf 16.32 0 TD -0.003 Tc 0.1184 Tw [(. This ap-)]TJ -16.32 -1.401 TD -0.0046 Tc -0.0625 Tw [(plies to jurors with mild stress levels. The judge indi-)]TJ T* -0.0034 Tc 0.035 Tw (vidually gives these jurors basic stress management)Tj 0 -1.398 TD 0.0002 Tc 0.125 Tw (information along with the standard post-trial dis-)Tj 0 -1.401 TD -0.0003 Tc (charge instructions.)Tj -1.8 -2.001 TD 0 Tc 0 Tw ()Tj /TT5 1 Tf 1.8 0 TD -0.0038 Tc -0.0067 Tw (Level 3: Flexible Defusing.)Tj /TT2 1 Tf 11.871 0 TD -0.0037 Tc -0.0088 Tw [( Jurors with moderate)]TJ -11.871 -1.398 TD -0.0085 Tc -0.0621 Tw (stress receive a 15-20 minute debriefing during which)Tj 0 -1.401 TD -0.0037 Tc 0.0834 Tw (a mental health professional explains normal stress)Tj T* -0.0034 Tc 0.1008 Tw (reactions, offers coping strategies, and assesses in-)Tj 0 -1.398 TD -0.0089 Tc -0.0621 Tw (dividual jurors to determine if further clinical services)Tj 0 -1.401 TD -0.0028 Tc 0.115 Tw [(are necessary)60.2(.)]TJ -1.8 -2.001 TD 0 Tc 0 Tw ()Tj /TT5 1 Tf 1.8 0 TD -0.0037 Tc -0.0463 Tw (Level 4: Jury Stress Debriefing.)Tj /TT2 1 Tf 13.551 0 TD -0.0483 Tw [( This intervention)]TJ -13.551 -1.398 TD -0.0036 Tc 0.0178 Tw (is adapted from the CISD model commonly utilized)Tj 25.5 64.398 TD -0.0034 Tc -0.05 Tw [(with emergency workers and is applied to jurors who)]TJ 0 -1.398 TD -0.0035 Tc 0.034 Tw (are showing significant levels of stress.)Tj -1.8 -2.001 TD 0 Tc 0 Tw ()Tj /TT5 1 Tf 1.8 0 TD -0.0039 Tc 0.0233 Tw [(Level 5: Individual Psychotherapy)53.1(.)]TJ /TT2 1 Tf 13.941 0 TD -0.003 Tc 0.0256 Tw [( )18.6(This may range)]TJ -13.941 -1.401 TD -0.0036 Tc 0.0456 Tw (from a few sessions to ongoing treatment and is in-)Tj 0 -1.398 TD -0.0206 Tw (tended for jurors who are showing extreme stress re-)Tj 0 -1.401 TD -0.01 Tc -0.0622 Tw [(actions and/or clinical symptoms of a mental disorder)50(.)]TJ T* -0.0034 Tc 0.0758 Tw [(Not uncommonly)62.6(, these may have been jurors who)]TJ 0 -1.398 TD -0.0065 Tc -0.0623 Tw [(had difficulties in functioning prior to the trial and the)]TJ 0 -1.401 TD 0.0003 Tc 0.125 Tw (trial stresses have exacerbated their preexisting or)Tj T* 0.0032 Tc [(dormant psychopathology)63.2(.)]TJ -1.2 -1.998 TD -0.0037 Tc 0.0162 Tw [(Clearly)62.3(, Nordgren & )17.1(Thelen)53.3(s GJSM \(1999\) appears to)]TJ -1.8 -1.401 TD -0.0119 Tc -0.0625 Tw (formalize the stages of intervention that most clinicians would)Tj T* 0.0041 Tc 0.125 Tw [(apply to the treatment of traumatic stress cases. But, as)]TJ 0 -1.398 TD -0.0036 Tc -0.0464 Tw (effective as these proactive and responsive clinical measures)Tj 0 -1.401 TD -0.0038 Tc -0.0622 Tw (might be, and as best we may try to make procedural changes)Tj T* -0.0079 Tc [(within the existing )46.4(American jury system, perhaps real ef)16.1(forts)]TJ 0 -1.398 TD -0.003 Tc -0.0069 Tw (to increase accuracy and efficiency and reduce stress within)Tj 0 -1.401 TD 0.0108 Tc 0.125 Tw (the jury system can only come when more fundamental)Tj T* -0.0038 Tc 0.1175 Tw (changes are considered.)Tj /F1 1 Tf 11 0 0 11 321 426 Tm -0.0056 Tc 0.0682 Tw (Conclusions and Recommendations)Tj /TT2 1 Tf 10 0 0 10 339 402.66 Tm -0.0032 Tc -0.0085 Tw (Based on a review of the literature and my own clinical)Tj -1.8 -1.401 TD -0.0038 Tc -0.0358 Tw (and forensic experience, the following recommendations for)Tj T* -0.007 Tc -0.0623 Tw (improving the civil and criminal justice systems in the United)Tj 0 -1.398 TD -0.0034 Tc 0.0075 Tw (States are offered.)Tj /TT5 1 Tf 1.8 -2.001 TD -0.0035 Tc -0.0133 Tw (Let judges judge. )Tj /TT2 1 Tf 7.011 0 TD -0.0142 Tw (Just as we maintain strict training and)Tj -8.811 -1.401 TD -0.0114 Tc -0.0621 Tw (credentialing criteria for authorizing people to call themselves)Tj 0 -1.398 TD -0.0034 Tc 0.0328 Tw [(doctors and attorneys and to practice medicine and law)59.6(, we)]TJ 0 -1.401 TD -0.0037 Tc -0.0366 Tw (should do the same for those who practice jurisprudence; we)Tj T* -0.0029 Tc -0.023 Tw [(should let the judges judge. Many countries already do this.)]TJ 0 -1.398 TD -0.0032 Tc 0.1167 Tw (In some court divisions, such as family court, judges, not)Tj 0 -1.401 TD 0.0372 Tw [(juries, often decide cases. In many other cases, defendants)]TJ T* -0.003 Tc -0.0408 Tw (have the option of waiving a jury trial and opting for a )Tj /TT5 1 Tf 21.336 0 TD -0.0059 Tc 0 Tw (bench)Tj -21.336 -1.398 TD -0.0047 Tc (trial)Tj /TT2 1 Tf 1.704 0 TD -0.0033 Tc 0.0718 Tw (, which is having the judge hear the case and render a)Tj -1.704 -1.401 TD -0.0038 Tc 0 Tw (verdict.)Tj /TT5 1 Tf 1.8 -2.001 TD 0.006 Tc 0.1249 Tw [(Utilize pr)30(ofessional jur)33(ors. )]TJ /TT2 1 Tf 11.55 0 TD 0.0069 Tc 0.1247 Tw [(Okay)60.9(, even doctors have)]TJ -13.35 -1.398 TD -0.0033 Tc 0.0569 Tw (assistants to perform routine clinical tasks and lawyers use)Tj 0 -1.401 TD 0.0104 Tc 0.125 Tw (paralegals for similar purposes because there just arent)Tj T* -0.0031 Tc 0.1156 Tw [(enough physicians and attorneys to go around. But these)]TJ 0 -1.398 TD -0.0035 Tc 0.095 Tw (paraprofessional staff still receive some degree of training)Tj 0 -1.401 TD -0.0028 Tc 0.1021 Tw [(and certification to do what they do. So why not recruit)]TJ T* -0.0031 Tc 0.0593 Tw (reasonably intelligent and educated citizens on a voluntary)Tj 0 -1.398 TD -0.0041 Tc -0.0622 Tw [(basis, provide them with specialized training in the law)61.9(, deci-)]TJ 0 -1.401 TD -0.0036 Tc -0.0471 Tw (sion-making, and interpersonal skills, and credential them as)Tj /TT5 1 Tf T* -0.004 Tc 0.025 Tw (Certified Jurors)Tj /TT2 1 Tf 6.381 0 TD -0.0036 Tc 0.0287 Tw [( or some such appellation.)]TJ ET endstream endobj 270 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT2 9 0 R /TT3 10 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 273 0 obj << /Length 10550 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 54 59.745 m 546 59.745 l S BT /F1 1 Tf 8 0 0 8 54.99 41.64 Tm 0 0 0 1 k /GS2 gs -0.0052 Tc 0.0896 Tw [(216 )]TJ /TT3 1 Tf 2.745 0 TD -0.005 Tc (Millers Juror Stress)Tj /TT2 1 Tf 10 0 0 10 72 722.64 Tm -0.0118 Tc -0.0625 Tw (There could even be board-certified subspecialties within)Tj -1.8 -1.398 TD -0.0165 Tc -0.0621 Tw [(the Certified Juror field, such as certified medical juror)37.5(, cer)19.5(-)]TJ 0 -1.401 TD -0.0038 Tc -0.0549 Tw [(tified mental health juror)35.2(, certified business-economics ju-)]TJ T* 0.0345 Tw [(ror)35.2(, certified industrial-mechanics juror)35.2(, and so on. )18(The)]TJ 0 -1.398 TD -0.0035 Tc -0.047 Tw (next step would be to compensate them for their service \(just)Tj 0 -1.401 TD -0.0034 Tc -0.0525 Tw (as medical assistants and paralegals get paid a fair wage\) and)Tj T* 0.03 Tw (utilize them as part of a rotating pool of professional jurors)Tj 0 -1.398 TD -0.0033 Tc -0.0505 Tw (who can objectively decide cases with a basic prerequisite of)Tj 0 -1.401 TD -0.0036 Tc 0.096 Tw (knowledge and training both in the law and in the subject)Tj T* -0.0033 Tc 0.0017 Tw (matter of the case.)Tj 1.8 -1.998 TD -0.0034 Tc 0.06 Tw (Meanwhile, professionals within the legal system, and)Tj -1.8 -1.401 TD -0.0035 Tc -0.0034 Tw (the mental health clinicians who advise them, must strive to)Tj T* -0.0031 Tc 0.0218 Tw (make jury service as efficient, accurate, and comfortable as)Tj 0 -1.398 TD -0.0035 Tc -0.0317 Tw [(possible. Whether in the emergency room or the courtroom,)]TJ 0 -1.401 TD -0.0031 Tc 0.0232 Tw [(people)50.9(s lives are at stake, in one way or another)53.9(. )18.2(W)94.7(e)1.2( must)]TJ T* -0.0034 Tc 0.107 Tw (assure that those who are called to make the crucial deci-)Tj 0 -1.398 TD -0.0035 Tc -0.0354 Tw (sions are afforded the proper conditions to do so in a manner)Tj 0 -1.401 TD -0.0034 Tc 0.1025 Tw (that serves justice.)Tj /F1 1 Tf 11 0 0 11 133.89 446.01 Tm 0.021 Tc 0 Tw (REFERENCES)Tj /TT2 1 Tf 10 0 0 10 54 428.64 Tm -0.0078 Tc -0.0625 Tw (Antonio, M.E. \(2006\). I didnt know itd be so hard. Jurors)Tj 1.2 -1.398 TD -0.0033 Tc 0.0494 Tw (emotional reactions to serving on a capital trial. )Tj /TT5 1 Tf 19.53 0 TD -0.0048 Tc 0 Tw (Judica-)Tj -19.53 -1.401 TD -0.0145 Tc -0.06 Tw (ture, 89)Tj /TT2 1 Tf 2.94 0 TD -0.0153 Tc (, 282-288.)Tj -4.14 -1.8 TD -0.0133 Tc -0.0624 Tw [(Arendt, M. & Elklit, )49.8(A. \(2001\). Ef)16.7(fectiveness of psychological)]TJ 1.2 -1.401 TD 0.0027 Tc 0 Tw (debriefing. )Tj /TT5 1 Tf 4.776 0 TD 0.0029 Tc 0.125 Tw (Acta Psychiatrica Scandinavica, 104)Tj /TT2 1 Tf 15.249 0 TD 0.0034 Tc (, 423-)Tj -20.025 -1.398 TD -0.0583 Tc 0 Tw (437.)Tj -1.2 -1.8 TD -0.0241 Tc -0.0625 Tw [(Bell, R.A. & Feldman, )20.9(T)76.7(.B. \(1992\). Crisis debriefing of juries: )47.9(A)]TJ 1.2 -1.401 TD 0.0015 Tc 0 Tw (follow-up. )Tj /TT5 1 Tf 4.59 0 TD 0.0021 Tc 0.125 Tw (American Journal of Preventive Psychiatry)Tj -4.59 -1.401 TD -0.0053 Tc -0.0598 Tw [(and Neur)27.7(ology)]TJ /TT2 1 Tf 5.82 0 TD -0.0029 Tc -0.0616 Tw (, Fall, pp. 55-59.)Tj -7.02 -1.8 TD -0.0082 Tc -0.0621 Tw (Bienen, L.B. \(1993\). Helping jurors out: Post-verdict debrief-)Tj 1.2 -1.398 TD -0.0077 Tc -0.0625 Tw (ing for jurors in emotionally disturbing trials.)Tj /TT5 1 Tf 17.394 0 TD -0.0094 Tc [( Indiana Law)]TJ -17.394 -1.401 TD -0.0126 Tc -0.06 Tw (Journal, 68)Tj /TT2 1 Tf 4.416 0 TD (, 1333-1355.)Tj -5.616 -1.8 TD -0.0043 Tc -0.0625 Tw (Bishop, K. \(1992\). When a jury hears details too gruesome to)Tj 1.2 -1.401 TD -0.0056 Tc 0 Tw [(bear)48.4(.)-6.6( )]TJ /TT5 1 Tf 2.106 0 TD -0.0054 Tc -0.0472 Tw [(New Y)87.6(ork T)48.6(imes)]TJ /TT2 1 Tf 6.255 0 TD -0.0023 Tc -0.0487 Tw (, January 31, p. B7.)Tj -9.561 -1.8 TD -0.0032 Tc 0.0111 Tw [(Boone, R. \(2008\). Idaho killer)-39.2()53.8(s)-0.3( jury views letters from tor)17.8(-)]TJ 1.2 -1.398 TD -0.0033 Tc -0.0275 Tw (tured kids. )Tj /TT5 1 Tf 4.38 0 TD -0.004 Tc [(South Florida Sun-Sentinel,)]TJ /TT2 1 Tf 10.98 0 TD -0.0034 Tc [( )54.1(August 15, p. 8A.)]TJ -16.56 -1.8 TD -0.0292 Tc -0.0621 Tw [(Bornstein, B.H., Miller)36.8(, M.K., Nemeth, R.J., Page, G)114.8(.L. & Musil,)]TJ 1.2 -1.401 TD -0.0029 Tc -0.015 Tw (S. \(2005\). Juror reactions to jury duty: Perceptions of the)Tj T* -0.003 Tc 0.0637 Tw (system and potential stressors. )Tj /TT5 1 Tf 12.576 0 TD -0.0042 Tc 0.065 Tw (Behavioral Sciences and)Tj -12.576 -1.398 TD -0.0106 Tc -0.0599 Tw [(the Law)67.4(, 23)]TJ /TT2 1 Tf 4.395 0 TD -0.0098 Tc -0.065 Tw (, 321-346.)Tj -5.595 -1.8 TD -0.0055 Tc -0.0625 Tw (Bornstein, B.H. & Nemeth, R.J. \(1999\). Jurors perception of)Tj 1.2 -1.401 TD -0.0031 Tc 0.06 Tw [(violence: )50.9(A)59.1( framework for inquiry)62.9(. )]TJ /TT5 1 Tf 14.346 0 TD -0.0049 Tc 0.0606 Tw [(Aggr)31.1(ession and V)70.1(io-)]TJ -14.346 -1.401 TD -0.0041 Tc -0.0265 Tw [(lent Behavior)103.9(, 4)]TJ /TT2 1 Tf 6.195 0 TD -0.0033 Tc -0.03 Tw (, 77-92.)Tj -7.395 -1.8 TD -0.0127 Tc -0.062 Tw [(Butler)35.3(, D. \(2007\). )17.6(T)37.1(rial by jury: the hours are long, the benefits)]TJ 26.7 64.8 TD -0.0026 Tc 0.0955 Tw [(are lousy)60.4(, and the work is highly stressful. )]TJ /TT5 1 Tf 17.751 0 TD -0.0051 Tc 0.1 Tw (The Ottowa)Tj -17.751 -1.398 TD -0.0047 Tc 0 Tw (Citizen)Tj /TT2 1 Tf 2.805 0 TD -0.0023 Tc -0.0437 Tw (, January 27, pp. 1-6.)Tj -4.005 -1.8 TD -0.0026 Tc -0.0492 Tw [(Casey)63.4(, P)105.4(.)0( \(1998\). )]TJ /TT5 1 Tf 6.804 0 TD -0.004 Tc -0.049 Tw [(Thr)32(ough the eyes of the jur)32(or: )14.4(A)21.8( manual for)]TJ -5.604 -1.401 TD -0.0049 Tc -0.0442 Tw [(addr)28.1(essing jur)31.1(or str)28.1(ess)]TJ /TT2 1 Tf 8.94 0 TD -0.0042 Tc -0.046 Tw [(.)-6.5( )17(W)54.6(illiamsbur)13.8(g, )17.1(V)133(A: National Cen-)]TJ -8.94 -1.401 TD -0.0034 Tc -0.0066 Tw (ter for State Courts.)Tj -1.2 -1.8 TD -0.0221 Tc -0.0619 Tw [(Cooper)31.9(, J., Bennett, E.A. & Sukel, H.L. \(1996\). Complex scien-)]TJ 1.2 -1.398 TD -0.0031 Tc 0.0014 Tw (tific testimony: How do jurors make decisions? )Tj /TT5 1 Tf 19.056 0 TD -0.0057 Tc 0.005 Tw (Law and)Tj -19.056 -1.401 TD -0.0055 Tc -0.0595 Tw [(Human Behavior)108.5(, 20,)]TJ /TT2 1 Tf 8.28 0 TD -0.006 Tc -0.065 Tw [( 379-394.)]TJ -9.48 -1.8 TD -0.007 Tc -0.0622 Tw [(Costanzo, M. & Costanzo, S. \(1994\). The death penalty: Pub-)]TJ 1.2 -1.401 TD -0.0033 Tc -0.0582 Tw (lic opinions, legal decisions, and juror perspectives. In M.)Tj 0 -1.398 TD -0.0037 Tc -0.003 Tw (Costanzo & S. Oskamp \(Eds.\), )Tj /TT5 1 Tf 12.435 0 TD -0.0039 Tc -0.005 Tw [(V)75.9(iolence and the law)]TJ /TT2 1 Tf 8.25 0 TD -0.0043 Tc -0.004 Tw ( \(pp.)Tj -20.685 -1.401 TD -0.0068 Tc -0.0625 Tw (246-272\). Thousand Oaks, CA: Sage.)Tj -1.2 -1.8 TD -0.0032 Tc -0.062 Tw (Curridan, M. \(1995\). Jury reform. )Tj /TT5 1 Tf 13.386 0 TD -0.005 Tc -0.0625 Tw (American Bar Association)Tj -12.186 -1.401 TD 0 Tw (Journal)Tj /TT2 1 Tf 3.081 0 TD -0.0034 Tc -0.0594 Tw [(, November)38.6(, p. 72.)]TJ -4.281 -1.8 TD -0.0191 Tc -0.0625 Tw (Dabs, M.O. \(1992\). Jury traumatization in high profile criminal)Tj 1.2 -1.398 TD -0.0029 Tc 0.0517 Tw [(trials: )54.1(A)59.3( case for crisis debriefing? )]TJ /TT5 1 Tf 14.139 0 TD -0.0045 Tc 0.0525 Tw (Law and Psychology)Tj -14.139 -1.401 TD -0.0136 Tc -0.0584 Tw [(Review)70.4(, 16)]TJ /TT2 1 Tf 4.125 0 TD -0.06 Tw (, 201-216.)Tj -5.325 -1.8 TD -0.0141 Tc -0.0621 Tw (Dann, B.M. \(1993\). Learning lessons and speaking rights:)Tj 1.2 -1.401 TD 0.0014 Tc 0.125 Tw (Creating educated and democratic juries. )Tj /TT5 1 Tf 17.289 0 TD 0.0002 Tc (Indiana Law)Tj -17.289 -1.398 TD -0.0164 Tc -0.06 Tw (Journal, 68,)Tj /TT2 1 Tf 4.611 0 TD -0.0168 Tc -0.0625 Tw [( 1229, 1238-1247.)]TJ -5.811 -1.8 TD -0.0205 Tc (Davis, R.C. & Friedman, L.N. \(1985\). The emotional aftermath)Tj 1.2 -1.401 TD -0.0104 Tc (of crime and violence. In C.R. Figley \(Ed.\), )Tj /TT5 1 Tf 16.725 0 TD -0.0118 Tc [(T)58.4(rauma and its)]TJ -16.725 -1.401 TD -0.0013 Tc 0.125 Tw (wake: The study and treatment of posttraumatic stress)Tj 0 -1.398 TD -0.0113 Tc 0 Tw [(disor)27.7(der)]TJ /TT2 1 Tf 3.276 0 TD -0.0099 Tc -0.0619 Tw [( \(pp. 90-1)32.1(12\). New )29.2(Y)103.3(ork: Brunner/Mazel.)]TJ -4.476 -1.8 TD -0.0032 Tc 0.0394 Tw (Davis, S.O. \(1993\). The last angry woman: Why King trial)Tj 1.2 -1.401 TD -0.0222 Tw (juror Lindy Miller no longer believes in truth, justice and)Tj T* -0.0041 Tc -0.1159 Tw [(the American )-55.7(way)61.9(.)]TJ /TT5 1 Tf 7.275 0 TD -0.0057 Tc -0.0629 Tw [( Los )15.7(Angeles Magazine)]TJ /TT2 1 Tf 8.985 0 TD -0.0051 Tc -0.062 Tw [(, November)33.9(, pp.)]TJ -16.26 -1.398 TD -0.0516 Tc 0 Tw (58-64.)Tj -1.2 -1.8 TD -0.0039 Tc 0.0322 Tw (Diamond, S.S. \(1993\). 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Ellicott City)62.9(, MD: Chevron.)]TJ -8.346 -1.8 TD -0.0035 Tc 0.095 Tw (Feigenson, N. \(2000\). )Tj /TT5 1 Tf 9.21 0 TD -0.004 Tc 0.096 Tw (Legal blame: How jurors think and)Tj -8.01 -1.398 TD 0.0024 Tc 0.125 Tw (talk about accidents)Tj /TT2 1 Tf 8.355 0 TD 0.0029 Tc 0.1071 Tw [(.)-8.1( W)97.7(ashington, )-17.5(DC: )36(American )-18.3(Psy-)]TJ -8.355 -1.401 TD -0.0039 Tc 0.0749 Tw (chological Association.)Tj -1.2 -1.8 TD -0.0072 Tc -0.0623 Tw [(Feldman, )17(T)78.6(.B. & Bell, R.A. \(1991\). Crisis debriefing of a jury)]TJ 1.2 -1.401 TD -0.003 Tc -0.0138 Tw (after a murder trial. )Tj /TT5 1 Tf 7.905 0 TD -0.0042 Tc -0.0151 Tw [(Hospital and Community Psychiatry)52.6(,)]TJ -7.905 -1.398 TD -0.031 Tc 0 Tw (42)Tj /TT2 1 Tf 0.954 0 TD -0.0217 Tc -0.06 Tw (, 79-81.)Tj -2.154 -1.8 TD -0.011 Tc -0.0622 Tw [(Feldman, )13.3(T)74.8(.B. & Bell, R.A. \(1993\). Juror stress: Identification)]TJ 1.2 -1.401 TD -0.0027 Tc 0.125 Tw (and intervention. )Tj /TT5 1 Tf 7.23 0 TD -0.003 Tc (Bulletin of the American Academy of)Tj -7.23 -1.401 TD -0.004 Tc -0.0298 Tw [(Psychiatry and the Law)71(, 21)]TJ /TT2 1 Tf 10.68 0 TD -0.0037 Tc -0.03 Tw (, 409-417.)Tj ET endstream endobj 274 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT2 9 0 R /TT3 10 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 276 0 obj << /Length 11414 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 66 59.745 m 558 59.745 l S BT /TT3 1 Tf 8 0 0 8 423.24 42.6 Tm 0 0 0 1 k /GS2 gs -0.0051 Tc 0.0326 Tw [(IJEMH Vol. 10, No. 3 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (217)Tj /TT2 1 Tf 10 0 0 10 66 722.64 Tm -0.0061 Tc -0.0623 Tw [(Figley)62.9(, C.R. \(1983\). Catastrophes: )53.8(An overview of family re-)]TJ 1.2 -1.398 TD -0.0114 Tc -0.0619 Tw (actions. In C.R. Figley & H.I. 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Psychological responses of rescue workers:)Tj 0 -1.401 TD -0.0036 Tc 0.0384 Tw (Firefighters and trauma. )Tj /TT5 1 Tf 9.915 0 TD -0.0042 Tc 0.04 Tw (American Journal of Orthopsy-)Tj -9.915 -1.401 TD -0.0111 Tc -0.0589 Tw [(chiatr)-5.1(y)57.7(,)-1.1( 62)]TJ /TT2 1 Tf 4.104 0 TD -0.0113 Tc -0.06 Tw (, 371-378.)Tj -5.304 -1.8 TD -0.0031 Tc 0.04 Tw (Goleman, D. \(1991\). For many jurors, trials begin after the)Tj 1.2 -1.398 TD -0.0033 Tc 0 Tw (verdict. )Tj /TT5 1 Tf 3.21 0 TD -0.0057 Tc -0.0398 Tw [(New Y)84.3(ork T)48.3(imes)]TJ /TT2 1 Tf 6.27 0 TD -0.0022 Tc -0.0425 Tw (, May 14, pp. C1.)Tj -10.68 -1.8 TD -0.0112 Tc -0.0625 Tw (Greene, E. & Bornstein, B.H. \(2000\). Precious little guidance:)Tj 1.2 -1.401 TD -0.0033 Tc 0.095 Tw (Jury instruction on damage awards. )Tj /TT5 1 Tf 14.805 0 TD -0.0042 Tc 0.1007 Tw [(Psychology)52.8(, Public)]TJ -14.805 -1.401 TD -0.0054 Tc -0.0598 Tw [(Policy)54.6(, and Law)69.6(, 6)]TJ /TT2 1 Tf 7.131 0 TD -0.065 Tw (, 743-768.)Tj -8.331 -1.8 TD -0.0033 Tc -0.0147 Tw [(Hafemeister)35.7(, )18(T)76.5(.L. \(1993\). Juror stress. )]TJ /TT5 1 Tf 15.216 0 TD -0.0039 Tc -0.0176 Tw [(V)78.9(iolence and V)71.1(ictims,)]TJ -14.016 -1.398 TD 0 Tc 0 Tw (8)Tj /TT2 1 Tf 0.471 0 TD -0.0327 Tc -0.06 Tw (, 177-186.)Tj -1.671 -1.8 TD -0.0038 Tc -0.0016 Tw [(Hafemeister)35.2(,)-4.2( T)76(.L. )-18.2(& V)115.4(entis, )]TJ 11.181 0 TD -0.003 Tc 0.0156 Tw [(W)106.8(.L. \(1992\). )]TJ 5.3563 0 TD (Juror stress: )Tj 5.0267 0 TD -0.0098 Tc (What)Tj -20.364 -1.401 TD -0.0033 Tc 0.055 Tw (burden have we placed on our juries? )Tj /TT5 1 Tf 15.456 0 TD -0.0041 Tc (State Court Jour-)Tj -15.456 -1.401 TD -0.009 Tc -0.06 Tw (nal, 16)Tj /TT2 1 Tf 2.661 0 TD -0.0084 Tc (, 35-46.)Tj -3.861 -1.8 TD -0.0102 Tc -0.0625 Tw [(Haney)61.8(, C., Sontag, L. & Costanzo, S. \(1994\). Deciding to take)]TJ 1.2 -1.398 TD -0.0062 Tc (a life: Capital juries, sentencing instructions, and the juris-)Tj 0 -1.401 TD -0.0034 Tc -0.0167 Tw [(prudence of death. )]TJ /TT5 1 Tf 7.551 0 TD -0.0036 Tc -0.0163 Tw (Journal of Social Issues, 50)Tj /TT2 1 Tf 10.92 0 TD -0.0038 Tc -0.02 Tw (, 149-176.)Tj -19.671 -1.8 TD -0.0064 Tc -0.0623 Tw [(Heuer)38.6(, L. & Penrod, S. \(1994\). Juror note taking and question)]TJ 1.2 -1.401 TD -0.0033 Tc 0.02 Tw (asking during trials. )Tj /TT5 1 Tf 8.211 0 TD -0.0045 Tc 0.0213 Tw [(Law and Human Behavior)106.5(, 18)]TJ /TT2 1 Tf 11.949 0 TD -0.0036 Tc 0.025 Tw (, 121-)Tj -20.16 -1.398 TD -0.0583 Tc 0 Tw (135.)Tj -1.2 -1.8 TD -0.0056 Tc -0.0625 Tw [(Kaplan, S.M. & )12.4(W)53.2(inget, C. \(1992\). )18.4(The occupational hazards)]TJ 1.2 -1.401 TD -0.0009 Tc 0.0849 Tw [(of jury duty)65.1(. )]TJ /TT5 1 Tf 5.4 0 TD -0.0039 Tc 0.0858 Tw [(Bulletin of the )17.1(American )17.1(Academy of Psy-)]TJ -5.4 -1.401 TD -0.0286 Tw [(chiatry and the Law)71.1(, 20)]TJ /TT2 1 Tf 9.255 0 TD -0.0037 Tc -0.03 Tw (, 325-333.)Tj -10.455 -1.8 TD -0.0032 Tc 0.0705 Tw [(Kelley)62.8(, J.E. \(1994\). )50.7(Addressing juror stress: )50.7(A)59( trial judge)50.8(s)]TJ 1.2 -1.398 TD -0.0037 Tc 0 Tw (perspective. )Tj /TT5 1 Tf 4.989 0 TD -0.0044 Tc -0.0249 Tw [(Drake Law Review)70.6(, 43)]TJ /TT2 1 Tf 8.88 0 TD -0.0034 Tc (, 97-125.)Tj -15.069 -1.8 TD -0.0033 Tc 0.0749 Tw [(Kressel, N.J. & Kressel, D.F)77.7(. \(2002\). )]TJ /TT5 1 Tf 15.336 0 TD -0.004 Tc 0.075 Tw [(S)37(tack and sway: The)]TJ -14.136 -1.401 TD 0.0512 Tc 0.125 Tw (new science of jury consulting)Tj /TT2 1 Tf 14.151 0 TD (. Cambridge, MA:)Tj -14.151 -1.401 TD 0.0034 Tc 0 Tw [(W)92.2(estview)57.4(.)]TJ -1.2 -1.8 TD -0.0032 Tc 0.0983 Tw (McAree, D. \(2004\). Reaching out to juries rocked by evi-)Tj 1.2 -1.398 TD -0.0038 Tc 0 Tw (dence. )Tj /TT5 1 Tf 2.829 0 TD -0.0044 Tc 0.0225 Tw (National Law Journal)Tj /TT2 1 Tf 8.796 0 TD -0.0031 Tc 0.0219 Tw [(, October)38.9(, pp. 1-2.)]TJ -12.825 -1.8 TD -0.0036 Tc -0.0241 Tw [(Miller)35.4(, L. \(1998a\). Our own medicine: )17.6(T)37.2(raumatized psycho-)]TJ 1.2 -1.401 TD 0.0157 Tc 0.1248 Tw [(therapists and the stresses of doing therapy)60.7(. )]TJ /TT5 1 Tf 19.194 0 TD 0.0142 Tc 0 Tw (Psycho-)Tj -19.194 -1.401 TD -0.011 Tc -0.059 Tw [(therapy)55(, 35)]TJ /TT2 1 Tf 4.326 0 TD -0.06 Tw (, 137-146.)Tj -5.526 -1.8 TD -0.0032 Tc -0.0575 Tw [(Miller)35.8(, L. \(1998b\). 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Critical incident stress debriefing: Clinical)]TJ 1.2 -1.401 TD 0.0021 Tc 0.1249 Tw (applications and new directions. )Tj /TT5 1 Tf 13.704 0 TD 0.0016 Tc 0.125 Tw (International Journal)Tj -13.704 -1.401 TD -0.0039 Tc -0.0487 Tw (of Emergency Mental Health, 1)Tj /TT2 1 Tf 12.276 0 TD -0.05 Tw (, 253-265.)Tj -13.476 -1.8 TD -0.0035 Tc -0.0229 Tw [(Miller)35.5(, L. \(2006a\). 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S)17.4(tress and resilience in law enforcement)]TJ 1.2 -1.401 TD -0.0043 Tc -0.0617 Tw (training and practice. )Tj /TT5 1 Tf 8.439 0 TD -0.0051 Tc -0.0616 Tw (International Journal of Emergency)Tj -8.439 -1.401 TD -0.0039 Tc -0.0176 Tw [(Mental Health, 10)]TJ /TT2 1 Tf 7.206 0 TD -0.0032 Tc -0.02 Tw (, 1-16.)Tj -8.406 -1.8 TD -0.0035 Tc -0.0127 Tw [(Miller)35.5(, L. \(2008b\). )]TJ /TT5 1 Tf 7.635 0 TD -0.0043 Tc -0.015 Tw (METTLE: Mental toughness training for)Tj -6.435 -1.398 TD -0.0048 Tc 0.0253 Tw [(law enfor)31.2(cement)]TJ /TT2 1 Tf 6.564 0 TD -0.0039 Tc 0.0279 Tw [(. Flushing, NY)83.1(: Looseleaf Law Publica-)]TJ -6.564 -1.401 TD 0.011 Tc 0 Tw (tions.)Tj -1.2 -1.8 TD -0.0074 Tc -0.0609 Tw [(Miller)31.6(, L. \(2008c\). )]TJ /TT5 1 Tf 7.365 0 TD -0.0625 Tw [(Counseling crime victims: Practical strat-)]TJ -6.165 -1.401 TD -0.0095 Tc -0.061 Tw [(egies for mental health pr)29.5(ofessionals)]TJ /TT2 1 Tf 14.154 0 TD -0.0097 Tc -0.0632 Tw [(. New )29.4(Y)103.5(ork: Springer)50.3(.)]TJ -15.354 -1.8 TD -0.0035 Tc -0.0077 Tw [(Miller)35.5(, L. \(2008d\). )]TJ /TT5 1 Tf 7.65 0 TD -0.0038 Tc -0.01 Tw [(F)6.2(r)32.2(om difficult to disturbed: Understand-)]TJ -6.45 -1.398 TD -0.0041 Tc 0.0888 Tw (ing and managing dysfunctional employees)Tj /TT2 1 Tf 17.526 0 TD 0.0903 Tw [(. New )32.2(Y)103.1(o)0.9(rk:)]TJ -17.526 -1.401 TD -0.0063 Tc 0 Tw (Amacon.)Tj -1.2 -1.8 TD -0.017 Tc -0.062 Tw [(Miller)37(, M.K., Flores, D.M. & Dolezilek, )52.5(A.N. \(2007\). )52.5(Address-)]TJ 1.2 -1.401 TD -0.0035 Tc 0.035 Tw (ing the problem of courtroom stress. )Tj /TT5 1 Tf 14.886 0 TD -0.004 Tc [(Judicature, 91)]TJ /TT2 1 Tf 5.76 0 TD -0.0035 Tc (, 60-)Tj -20.646 -1.398 TD -0.0625 Tc 0 Tw (69.)Tj -1.2 -1.8 TD -0.0029 Tc 0.0051 Tw [(Mitchell, J.T)72.1(. & Everly)63.1(, G)117.1(.S. \(2003\). )]TJ /TT5 1 Tf 14.694 0 TD -0.0041 Tc 0.0079 Tw [(Critical incident str)28.9(ess)]TJ -13.494 -1.401 TD -0.0062 Tc -0.0625 Tw (management \(CISM\): Basic group crisis intervention )Tj /TT2 1 Tf 20.859 0 TD -0.0083 Tc 0 Tw (\(3rd)Tj -20.859 -1.401 TD -0.0175 Tc -0.0617 Tw [(ed.\). Ellicott City: ICISF)75.5(.)]TJ -1.2 -1.8 TD -0.0034 Tc -0.0613 Tw (Moon, E. \(1999\). How to handle the high cost of caring. )Tj /TT5 1 Tf 21.885 0 TD -0.006 Tc 0 Tw (Pro-)Tj -20.685 -1.398 TD -0.0043 Tc -0.045 Tw (fessional Counselor)Tj /TT2 1 Tf 7.851 0 TD -0.0026 Tc -0.0501 Tw [(, February)63.4(, pp. 18-22.)]TJ -9.051 -1.8 TD -0.0031 Tc 0.0179 Tw [(Mott, N.L., Hans, )17.8(V)134.1(.)2(P)107.9(.)0.2( & )]TJ 10.1395 0 TD -0.0043 Tc 0.019 Tw [(Simpson, L. \(2000\). )14.7(What)]TJ 10.6595 0 TD -0.0032 Tc 0.018 Tw (s half a)Tj -19.599 -1.401 TD -0.0034 Tc -0.0582 Tw (lung worth? Civil jurors accounts of their award decision)Tj T* -0.0044 Tc 0 Tw (making. )Tj /TT5 1 Tf 3.414 0 TD -0.0549 Tw [(Law and Human Behavior)103.5(, 24)]TJ /TT2 1 Tf 11.646 0 TD -0.0037 Tc -0.06 Tw (, 401-419.)Tj ET endstream endobj 277 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT2 9 0 R /TT3 10 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 279 0 obj << /Length 7808 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 54 59.745 m 546 59.745 l S BT /F1 1 Tf 8 0 0 8 54.99 41.64 Tm 0 0 0 1 k /GS2 gs -0.0052 Tc 0.0896 Tw [(218 )]TJ /TT3 1 Tf 2.745 0 TD -0.005 Tc (Millers Juror Stress)Tj /TT2 1 Tf 10 0 0 10 54 722.64 Tm -0.0037 Tc 0.0427 Tw [(Murphy)59.3(,)-6.8( )17.1(T)79.1(.R., Loveland, G)113.3(.K. & Munsterman, G)116.3(.)2.1(T)71.3(.)-0.7( \(1992\).)]TJ /TT5 1 Tf 1.2 -1.398 TD -0.0044 Tc 0.0825 Tw (Managing notorious cases)Tj /TT2 1 Tf 10.674 0 TD -0.0039 Tc 0.0709 Tw [(. W)54.9(illiamsbur)17.1(g, V)133.3(A: )-13.6(National)]TJ -10.674 -1.401 TD -0.0036 Tc -0.0133 Tw (Center for State Courts.)Tj -1.2 -1.8 TD -0.0032 Tc 0.0125 Tw (Nisbett, R. & Ross, L. \(1980\). )Tj /TT5 1 Tf 12.285 0 TD -0.0041 Tc (Human inference: Strategies)Tj -11.085 -1.401 TD 0.0113 Tw (and shortcomings of social judgment.)Tj /TT2 1 Tf 14.934 0 TD 0.0125 Tw [( Englewood Cliffs:)]TJ -14.934 -1.398 TD -0.0145 Tc -0.06 Tw (Prentice Hall.)Tj -1.2 -1.8 TD -0.0073 Tc -0.0624 Tw [(Nordgren, C. & )16.8(Thelen, M.W)88.7(. \(1999\). Helping jurors manage)]TJ 1.2 -1.401 TD -0.0036 Tc -0.0312 Tw [(stress: )50.4(A)58.6( multilevel approach. )]TJ /TT5 1 Tf 11.85 0 TD -0.0043 Tc -0.0294 Tw [(Judicatur)31.7(e, 82)]TJ /TT2 1 Tf 5.661 0 TD -0.0038 Tc -0.035 Tw (, 256-263.)Tj -18.711 -1.8 TD -0.0087 Tc -0.0626 Tw [(Petty)63.3(, R.E. & Cacioppo, J.T)69.3(. \(1986\). Communication and per)15.3(-)]TJ 1.2 -1.401 TD -0.0035 Tc -0.01 Tw (suasion: Central and peripheral routes to attitude change.)Tj 0 -1.398 TD -0.0173 Tc -0.0932 Tw [(New Y)104.9(ork: )-31.2(Springer)18.7(-V)108.7(erlag.)]TJ -1.2 -1.8 TD -0.0085 Tc -0.0605 Tw [(OConnor)36.5(, S.D. \(2003\). )]TJ /TT5 1 Tf 9.336 0 TD -0.0625 Tw (The majesty of the law: Reflections of)Tj -8.136 -1.401 TD -0.0037 Tc -0.027 Tw [(a supr)32.3(eme court justice.)]TJ /TT2 1 Tf 9.411 0 TD -0.0044 Tc -0.0289 Tw [( New )31.4(Y)102.8(ork: Random House.)]TJ -10.611 -1.8 TD -0.0111 Tc -0.0618 Tw [(Posey)63.9(,)-7.8( )51.8(A.J. & )18.8(W)59.7(rightsman, L.S. \(2005\). )]TJ /TT5 1 Tf 15.321 0 TD -0.012 Tc -0.06 Tw [(T)61.2(r)0(ial consulting)]TJ /TT2 1 Tf 6.108 0 TD -0.013 Tc -0.065 Tw (. New)Tj -20.229 -1.401 TD -0.0091 Tc -0.0617 Tw [(Y)104.1(ork: Oxford University Press.)]TJ -1.2 -1.8 TD -0.018 Tc -0.0622 Tw [(Rauch, K.D. \(1992\). )51(After the verdict: Healing jurors who have)]TJ 1.2 -1.398 TD -0.0029 Tc -0.0091 Tw [(been traumatized by violent testimony)63.1(. )]TJ /TT5 1 Tf 15.609 0 TD -0.0045 Tc -0.01 Tw [(W)93.5(ashington Post)]TJ /TT2 1 Tf 6.642 0 TD 0 Tc 0 Tw (,)Tj -22.251 -1.401 TD -0.0148 Tc -0.0617 Tw (April 14, p. Z10.)Tj -1.2 -1.8 TD -0.0032 Tc 0.0016 Tw (Rosehan, D.L. \(1994\). Note taking can aid juror recall. )Tj /TT5 1 Tf 21.996 0 TD -0.0096 Tc 0 Tw (Law)Tj -20.796 -1.401 TD -0.0043 Tc -0.0163 Tw [(and Human Behavior)106.7(, 18)]TJ /TT2 1 Tf 9.861 0 TD -0.0034 Tc -0.02 Tw (, 53-61.)Tj -11.061 -1.8 TD -0.0252 Tc -0.0619 Tw [(Shuman, D.W)85.8(., Hamilton, J.A. & Daley)64.8(, C.E. \(1994\). )20.1(The health)]TJ 1.2 -1.398 TD -0.0027 Tc 0.0453 Tw [(ef)18.3(fects of jury service. )]TJ /TT5 1 Tf 9.291 0 TD -0.0042 Tc 0.0451 Tw [(Law and Psychology Review)70.8(, 18)]TJ /TT2 1 Tf 12.96 0 TD 0 Tc 0 Tw (,)Tj -22.251 -1.401 TD -0.0511 Tc (267-307.)Tj -1.2 -1.8 TD -0.0038 Tc 0.0672 Tw [(Singer)38.2(, )50.3(A. \(1998\). Understanding and shaping jurors)71.2( deci-)]TJ 1.2 -1.401 TD -0.003 Tc 0.0836 Tw (sions with litigation psychology research. In E. Pierson)Tj 0 -1.398 TD -0.0028 Tc 0 Tw (\(Ed.\), )Tj /TT5 1 Tf 2.61 0 TD -0.004 Tc 0.104 Tw [(1998 W)50(iley expert witness update: New develop-)]TJ -2.61 -1.401 TD -0.0128 Tc -0.0612 Tw (ments in personal injury litigation )Tj /TT2 1 Tf 13.149 0 TD -0.0136 Tc -0.063 Tw [(\(pp. 73-105\). New )25.7(Y)105.6(ork:)]TJ -13.149 -1.401 TD -0.0178 Tc 0 Tw [(W)62(iley)66.2(.)]TJ -1.2 -1.8 TD -0.0112 Tc -0.0619 Tw [(Slind-Flor)33.8(,)-8.4( )19.1(V)135(.)-0.3( \(1992\). Counties begin to help jurors cope after)18.8(-)]TJ 1.2 -1.398 TD -0.004 Tc 0 Tw (ward. )Tj /TT5 1 Tf 2.469 0 TD -0.0044 Tc -0.015 Tw (National Law Journal)Tj /TT2 1 Tf 8.721 0 TD -0.0022 Tc (, January 20, pp. 3, 28.)Tj 13.11 44.598 TD -0.0032 Tc -0.0221 Tw [(S)22(teele, )18.2(W)106.6(.)14.6(W)86.8(.)-0.9( & )18.2(Thornbur)17.8(g, E.G)116.8(. \(1991\). Jury instructions: )51.2(A)]TJ 1.2 -1.398 TD -0.0037 Tc 0.12 Tw (persistent failure to communicate.)Tj /TT5 1 Tf 13.845 0 TD -0.0036 Tc [( Judicature, 74)]TJ /TT2 1 Tf 6.216 0 TD -0.0038 Tc 0.125 Tw (, 249-)Tj -20.061 -1.401 TD -0.0583 Tc 0 Tw (252.)Tj -1.2 -1.8 TD -0.0029 Tc -0.0203 Tw [(S)22.3(tur)18.1(gess, G)120.1(.)-0.2( \(1990\). Dire days for voir dire: )15.3(T)73.9(oo many trials,)]TJ 1.2 -1.401 TD -0.0031 Tc 0.0605 Tw (too few willing jurors place great strains on justice sys-)Tj 0 -1.398 TD -0.0049 Tc 0 Tw (tem. )Tj /TT5 1 Tf 1.914 0 TD -0.0077 Tc -0.0598 Tw [(Legal T)49.3(imes)]TJ /TT2 1 Tf 4.725 0 TD -0.0058 Tc -0.0625 Tw (, September 10, p. 1.)Tj -7.839 -1.8 TD -0.0185 Tc -0.0624 Tw [(Sunby)65.5(, S.E. \(1997\). )17.4(The jury as critic: )50.4(An empirical look at how)]TJ 1.2 -1.401 TD -0.0028 Tc 0.0184 Tw [(capital juries perceive expert and lay testimony)63.2(. )]TJ /TT5 1 Tf 19.311 0 TD -0.0054 Tc 0 Tw [(V)77.4(i)1.6(r)27.6(ginia)]TJ -19.311 -1.401 TD -0.0099 Tc -0.0594 Tw [(Law Review)68.1(, 83)]TJ /TT2 1 Tf 6.036 0 TD -0.0104 Tc -0.0616 Tw [(, 1)37.6(109-1)28.6(188.)]TJ -7.236 -1.8 TD -0.0034 Tc 0.1216 Tw [(T)73.4(albot, )50.5(A., Dutton, M. & Dunn, P)107.6(.)0( \(1995\). Debriefing the)]TJ 1.2 -1.398 TD -0.0016 Tc 0.1252 Tw [(debriefers: )49.6(An intervention strategy to assist psycholo-)]TJ 0 -1.401 TD -0.0029 Tc 0.07 Tw [(gists after a crisis. In G)117.1(.S. Everly & J.M. Lating \(Eds.\),)]TJ /TT5 1 Tf T* -0.0038 Tc 0.125 Tw (Psychotraumatology: Key papers and core concepts in)Tj 0 -1.398 TD -0.0089 Tc -0.0596 Tw [(posttraumatic str)33.1(ess)]TJ /TT2 1 Tf 7.821 0 TD -0.0087 Tc -0.0618 Tw [( \(pp. 281-298\). New )33.5(Y)101.5(ork: Plenum.)]TJ -9.021 -1.8 TD -0.0079 Tc -0.0625 Tw [(V)63.3(inson, D.E. & Davis, D.S. \(1996\). )]TJ /TT5 1 Tf 13.815 0 TD -0.0091 Tc (Jury persuasion: Psycho-)Tj -12.615 -1.401 TD -0.0036 Tc 0.114 Tw (logical strategies and trial techniques )Tj /TT2 1 Tf 15.846 0 TD -0.0029 Tc 0.115 Tw [(\(3rd ed.\). Little)]TJ -15.846 -1.401 TD -0.0091 Tc -0.0617 Tw [(Falls, NJ: Glasser LegalW)74.9(orks.)]TJ -1.2 -1.8 TD -0.0037 Tc 0.0539 Tw [(White, J.W)86.3(., Lawrence, P)107.3(.S., Biggerstaf)14.3(f, C. & Grubb, J.D.)]TJ 1.2 -1.398 TD -0.0034 Tc -0.0065 Tw (\(1985\). Factors of stress among police officers. )Tj /TT5 1 Tf 18.924 0 TD -0.0051 Tc 0 Tw (Criminal)Tj -18.924 -1.401 TD -0.0039 Tc 0.0002 Tw [(Justice and Behavior)104.1(, 12)]TJ /TT2 1 Tf 9.744 0 TD -0.0041 Tc 0.0021 Tw [(, 1)31.9(1)33.9(1-127.)]TJ -10.944 -1.8 TD -0.0032 Tc -0.0472 Tw [(Y)104(assen, J. \(1995\). Preventing secondary traumatic stress dis-)]TJ 1.2 -1.401 TD -0.0025 Tc 0.0174 Tw [(order)54.5(. In C.R. Figley \(Ed.\), )]TJ /TT5 1 Tf 11.07 0 TD -0.0044 Tc 0.02 Tw (Compassion fatigue: Coping)Tj -11.07 -1.398 TD -0.0037 Tc 0.0561 Tw [(with secondary traumatic stress dis order in those who)]TJ 0 -1.401 TD -0.0042 Tc -0.0047 Tw [(tr)31.8(eat the traumatized)]TJ /TT2 1 Tf 8.265 0 TD -0.0038 Tc -0.0059 Tw [( \(pp. 178-208\). New )32.3(Y)103.4(ork: Brunner/)]TJ -8.265 -1.401 TD -0.0247 Tc 0 Tw (Mazel.)Tj -1.2 -1.8 TD -0.0051 Tc -0.0622 Tw (Zimmerman, I.M. \(2006\). Helping judges in distress. )Tj /TT5 1 Tf 20.739 0 TD -0.0063 Tc 0 Tw (Judica-)Tj -19.539 -1.398 TD -0.0103 Tc -0.06 Tw (ture, 90)Tj /TT2 1 Tf 2.976 0 TD -0.0106 Tc (, 10-15.)Tj /TT5 1 Tf 9 0 0 9 405 294 Tm -0.0048 Tc 0.0022 Tw (Manuscript Received - August 15, 2008)Tj -1.1667 -1.7767 TD -0.0167 Tw [(Manuscript Accepted - )]TJ 9.4284 0 TD -0.0041 Tc -0.0175 Tw (September 2,)Tj 5.1583 0 TD 0.0033 Tc -0.0166 Tw [( 2008)]TJ ET endstream endobj 280 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT2 9 0 R /TT3 10 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 282 0 obj << /Length 6383 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 66 59.745 m 558 59.745 l S BT /TT3 1 Tf 8 0 0 8 423.24 42.6 Tm 0 0 0 1 k /GS2 gs -0.0051 Tc 0.0326 Tw [(IJEMH Vol. 10, No. 3 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (219)Tj /TT3 1 Tf 7 0 0 7 120.66 726.66 Tm -0.0061 Tc 0.021 Tw [(International Journal of Emergency Mental Health, Vol. 10, No. 3, pp. 219-224 2008 Chevron Publishing ISSN 1522-4821)]TJ /TT4 1 Tf 10 0 0 10 102.99 491.34 Tm -0.0042 Tc 0 Tw (Abstract: )Tj /TT5 1 Tf 4.035 0 TD -0.0036 Tc 0.0497 Tw (The behavioral health aspects of disaster have not historically been addressed as a priority in)Tj -4.035 -1.299 TD -0.002 Tc 0.125 Tw [(emergency preparedness planning. The overwhelming evidence of significant to severe psychological)]TJ T* -0.0038 Tc 0.0747 Tw (consequences of disaster has remained in the shadows compared to the more widely televised dramatic)Tj 0 -1.302 TD 0.0607 Tw [(physical destr)-6.9(uction and trauma. However)107.1(, the aftermath of September 1)71.1(1, as well as 2005)125.1(s Hurricane)]TJ 0 -1.299 TD 0.0035 Tc 0.1249 Tw [(Katrina and 2008)123.5(s Hurricane Ike disasters r)33.5(eminded the country that the psychological footprint of)]TJ T* -0.0036 Tc -0.0113 Tw [(disaster easily dwarfs the more visual physical footprint. Disaster behavioral health is now recognized as)]TJ 0 -1.302 TD -0.0243 Tw (a major public health concern and a national issue that deserves a logical, systematic, proactive approach)Tj 0 -1.299 TD -0.004 Tc -0.0435 Tw (within the structure of the National Incident Management System \(NIMS\) and Incident Command Structure)Tj T* 0.0347 Tw [(\(ICS; Fojt, Cohen, W)83(agner)107(, 2008\). W)53(ith incr)29(eased commitment, collaboration, and or)32(ganization we can)]TJ 0 -1.302 TD 0.0049 Tc 0.125 Tw (better utilize our qualified yet limited behavioral health resources, meeting the predictable needs of)Tj 0 -1.299 TD -0.0039 Tc 0.0908 Tw [(future disasters survivors, communities, and responders. [International Journal of Emergency Mental)]TJ T* -0.0032 Tc 0.105 Tw (Health, 2008, 10\(3\), pp. 219-224].)Tj /TT1 1 Tf 9 0 0 9 114 323.01 Tm -0.0056 Tc 0 Tw (Key words: )Tj /TT5 1 Tf 5.11 0 TD -0.0046 Tc -0.0009 Tw (disaster behavioral health, plan, asset typing, all hazards, assessment, triage, Incident Action Plan)Tj -6.2333 -1.3333 TD -0.0053 Tc 0.0116 Tw (\(IAP\), National Incident Management System \(NIMS\), Incident Command System \(ICS\), National Response Framework)Tj 7.2067 -1.3333 TD -0.0055 Tw (\(NRF\), Emergency Support Functions 8 \(ESF 8\), emergency management)Tj ET /GS1 gs 66 173.745 m 299.01 173.745 l S BT 9 0 0 9 66 156 Tm /GS2 gs 0.0176 Tc 0.125 Tw (This article has been adapted from a manuscript previously)Tj 0 -1.2233 TD -0.0051 Tc -0.0131 Tw [(published by SAMSHA)11.6( in )11.8(April 2008.)]TJ /TT2 1 Tf 14.6833 0 TD -0.0046 Tc -0.0145 Tw [( Diane F)72.1(.)0.1( Fojt, MSc, REMT)85.4(-)]TJ -14.6833 -1.22 TD -0.0051 Tc -0.0405 Tw [(P)111.1(,)-0.9( CFT)11.6( is the Operations Director of the Florida Crisis Consortium)]TJ 0 -1.2233 TD -0.0002 Tc 0.1253 Tw (and the CEO of Corporate Crisis Management, Inc. Martin D.)Tj T* -0.006 Tc -0.0622 Tw [(Cohen, Ph.D. is the )47.4(Assistant Clinical Director of the Florida Crisis)]TJ 0 -1.22 TD -0.019 Tc -0.0627 Tw (Consortium and the Director of Behavioral Integration Management,)Tj 0 -1.2233 TD -0.0051 Tc 0.0513 Tw [(Maverick LLC. Janet )11.6(W)88.7(agner)34.9(, CMA)51.6( writes for Corporate Crisis)]TJ T* 0.0044 Tc 0.1276 Tw (Management. Correspondence regarding )Tj 17.0965 0 TD 0.0052 Tc 0.1267 Tw (this article should be)Tj -17.0965 -1.22 TD -0.0048 Tc -0.0028 Tw (directed to )Tj 4.44 0 TD -0.0076 Tc (Dfojt111@gmail.com.)Tj /F1 1 Tf 14 0 0 14 164.4 656.34 Tm 0 Tc 0.1375 Tw (A Systematic, Integrated Behavioral Health)Tj 5.1686 -1.1421 TD 0.0056 Tc (Response to Disaster)Tj 11 0 0 11 66 263.01 Tm -0.0046 Tc 0.0545 Tw (Recent Experiences with Natural Disasters)Tj /TT2 1 Tf 10 0 0 10 84 239.64 Tm -0.0032 Tc 0.016 Tw (The Gulf Coast of the United States, with its history of)Tj -1.8 -1.398 TD -0.0035 Tc 0.0442 Tw (numerous natural disasters, inevitably imparts ample expo-)Tj 0 -1.401 TD -0.0033 Tc -0.0254 Tw (sure to disaster situations and a keen set of first hand experi-)Tj T* 0.028 Tc 0.125 Tw (ences chock-full of disaster management mishaps and)Tj 0 -1.398 TD 0.0298 Tc 0 Tw (successes.)Tj 12 0 0 12 401.91 593.64 Tm -0.0176 Tc -0.0604 Tw (Martin D. Cohen)Tj 10 0 0 10 368.91 581.01 Tm 0.0008 Tc -0.005 Tw [(Florida )51.8(Assistant Crisis Consortium)]TJ -3.3 -1.2 TD -0.0008 Tc -0.0625 Tw [(Behavioral Integration Management, Maverick, LLC)]TJ 12 0 0 12 155.49 593.64 Tm -0.0095 Tc -0.0601 Tw [(Diane F)73(.)-1.7( Fojt)]TJ 10 0 0 10 134.16 581.01 Tm -0.0019 Tc -0.0625 Tw (Florida Crisis Consortium)Tj -1.875 -1.2 TD 0.0011 Tc -0.03 Tw (Corporate Crisis Management, Inc.)Tj 12 0 0 12 281.25 538.14 Tm -0.0175 Tc -0.07 Tw [(Janet W)81.3(agner)]TJ 10 0 0 10 241.89 525.51 Tm 0.0011 Tc -0.03 Tw (Corporate Crisis Management, Inc.)Tj 9.612 -26.286 TD -0.0037 Tc 0.0019 Tw (In 2004, Florida was bombarded with four major hurri-)Tj -1.8 -1.401 TD -0.0031 Tc -0.0456 Tw (canes in a 50-day period: Charlie, Frances, Ivan, and Jeanne.)Tj 0 -1.398 TD -0.0035 Tc 0.085 Tw (The rain, wind, and threats of storm surge found residents)Tj 0 -1.401 TD -0.0038 Tc 0.0514 Tw (caught between removing the shutters from their windows,)Tj T* -0.0034 Tc -0.0445 Tw (and reinstalling them within days for the next storm looming)Tj 0 -1.398 TD -0.0036 Tc -0.0623 Tw [(of)17.4(f Florida coastlines. 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Disaster relief was stymied, moving in to)]TJ T* -0.0035 Tc 0.008 Tw (assist but then evacuating to safer ground in response to the)Tj 0 -1.398 TD 0.007 Tw (threat of the next encroaching storm.)Tj 1.8 -2.001 TD 0.0133 Tc 0.125 Tw [(Quite predictably)64.3(, Hurricanes Katrina, )19.3(W)54.2(ilma, Rita,)]TJ -1.8 -1.401 TD -0.0051 Tc -0.0621 Tw [(Gustav)60.9(, and Ike left in their wake a similar pattern of physical)]TJ ET endstream endobj 283 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT1 8 0 R /TT2 9 0 R /TT3 10 0 R /TT4 20 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 285 0 obj << /Length 8365 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 54 59.745 m 546 59.745 l S BT /F1 1 Tf 8 0 0 8 54.99 41.64 Tm 0 0 0 1 k /GS2 gs -0.0054 Tc 0.0938 Tw [(220 )]TJ /TT3 1 Tf 2.7563 0 TD 0.0953 Tw (Fojt, Cohen and Wagner A Systemic, Integrated Behavioral Health Response to Disaster)Tj /TT2 1 Tf 10 0 0 10 54 722.64 Tm -0.0035 Tc 0.1033 Tw [(and psychological destruction. 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The challenge internationally is to now create a framework)Tj T* -0.0027 Tc 0.0944 Tw (to efficiently and effectively manage the delivery of these)Tj 0 -1.398 TD -0.0005 Tc 0.125 Tw (services. What follows is an example of the creation and)Tj 0 -1.401 TD -0.0037 Tc 0.014 Tw (development of just such a program.)Tj /F1 1 Tf 11 0 0 11 54 398.01 Tm -0.0055 Tc 0.1091 Tw (The Consortium)Tj /TT2 1 Tf 10 0 0 10 72 374.64 Tm -0.0039 Tc -0.0494 Tw (The Florida Crisis Consortium \(FCC\) was formed in the)Tj -1.8 -1.398 TD -0.0036 Tc -0.0583 Tw [(aftermath of the 2004 hurricane season. Comprised of repre-)]TJ 0 -1.401 TD -0.0037 Tc 0.0138 Tw [(sentatives from the state of Florida)50.3(s Department of Health,)]TJ T* -0.0039 Tc -0.0585 Tw [(Department of Children and Families, Department of Educa-)]TJ 0 -1.398 TD -0.0162 Tc -0.0623 Tw [(tion, several universities, faith-based or)19.8(ganizations, the )53(Ameri-)]TJ 0 -1.401 TD -0.0038 Tc -0.01 Tw [(can Red Cross, Florida Crisis Response )14.2(T)73(eam, Green Cross,)]TJ T* -0.011 Tc -0.0621 Tw (Critical Incident Stress Management \(CISM\) of Florida, com-)Tj 0 -1.398 TD -0.0031 Tc 0.0943 Tw (munity based mental health agencies, private industry and)Tj 0 -1.401 TD -0.0035 Tc 0.02 Tw (other interested stakeholders, this group is all-inclusive and)Tj T* -0.0032 Tc 0.0282 Tw (has held an open invitation policy since its inception.)Tj 1.8 -1.998 TD -0.0034 Tc 0.0588 Tw (The goals of the Consortium were to collectively con-)Tj -1.8 -1.401 TD -0.0035 Tc 0.1 Tw (struct a disaster behavioral health plan that would eventu-)Tj T* 0.0651 Tw [(ally become part of the S)17.5(tate)53.5(s Comprehensive Emer)14.5(gency)]TJ 0 -1.398 TD -0.0039 Tc 0.0756 Tw (Management Plan \(CEMP\). The plan needed to be consis-)Tj 0 -1.401 TD -0.0074 Tc -0.0622 Tw (tent with the National Incident Management System \(NIMS\),)Tj T* -0.004 Tc 0.02 Tw (the National Response Framework \(NRF\), and work within)Tj 0 -1.398 TD 0.0004 Tc 0.1248 Tw [(the Incident Command S)18.4(tructure \(ICS\). )51.2(Asset-typing of)]TJ 0 -1.401 TD -0.0148 Tc -0.0625 Tw (teams \(the universal identification of team members skill sets,)Tj T* -0.0035 Tc 0.055 Tw (experience, and training\), credentialing standards, and pro-)Tj 0 -1.398 TD 0.1222 Tw (tocols were developed to support the structural processes.)Tj 0 -1.401 TD -0.0034 Tc 0.0475 Tw [(Obviously)62.6(, the plan needed to be constructed with collabo-)]TJ T* -0.0036 Tc 0.0415 Tw [(ration and input from all interested stakeholders. )50.7(Account-)]TJ 25.5 64.8 TD -0.0032 Tc -0.0323 Tw [(ability)59.8(, backfill plan, clear operational protocols and defined)]TJ 0 -1.398 TD -0.0033 Tc 0.1199 Tw (lines of authority were established. Funding was essential)Tj 0 -1.401 TD -0.0099 Tc -0.0621 Tw [(for sustainability; it was secured through the S)20.1(tate of Florida)50.1(s)]TJ T* -0.0038 Tc 0.105 Tw (Emergency Management Department, Emergency Support)Tj 0 -1.398 TD -0.0202 Tc -0.0622 Tw [(Function 8 \(ESF 8\), Public Health and Medical. It took roughly)]TJ 0 -1.401 TD -0.0033 Tc 0.0411 Tw (two years to complete the first approved plan for statewide)Tj T* -0.0031 Tc 0.0335 Tw (applications. Like any plan, the need to refine and adjust is)Tj 0 -1.398 TD -0.0036 Tc -0.014 Tw (anticipated with utilization and review provisions.)Tj /F1 1 Tf 11 0 0 11 309 591.99 Tm -0.0044 Tc 0.0409 Tw (The Florida Disaster Behaviorial Health)Tj 0 -1.0909 TD -0.0061 Tc 0.0636 Tw (Response Plan)Tj /TT2 1 Tf 10 0 0 10 327 556.65 Tm -0.0033 Tc 0.0315 Tw (The intent of the plan is to mitigate the adverse effects)Tj -1.8 -1.401 TD -0.0031 Tc 0.0749 Tw [(of disaster-related trauma by promoting and restoring psy-)]TJ 0 -1.398 TD -0.0033 Tc 0.0457 Tw (chological well-being and daily life functioning in affected)Tj 0 -1.401 TD -0.0072 Tc -0.0621 Tw [(individuals and communities. )52.8(And like other preventive men-)]TJ T* -0.0035 Tc 0.0619 Tw [(tal health interventions, it is aimed at providing supportive)]TJ 0 -1.398 TD 0.0155 Tw (human contact as close to the time of impact as possible.)Tj 1.8 -2.001 TD 0.0054 Tc 0.125 Tw (The plan encompasses the psychological, social, be-)Tj -1.8 -1.401 TD -0.0035 Tc -0.0175 Tw (havioral, and educational-related supports required to facili-)Tj 0 -1.398 TD 0.0006 Tc 0.1249 Tw [(tate recovery)60.6(. It provides a framework for the following)]TJ 0 -1.401 TD -0.0063 Tc 0 Tw (activities:)Tj 1.2 -2.001 TD -0.0035 Tc 0.032 Tw [()-1453.4(All hazards planning for disaster events,)]TJ 0 -1.998 TD 0.0005 Tc 0.125 Tw [()-1449.4(Responding to the immediate impact of a disaster)]TJ 1.8 -1.401 TD -0.0038 Tc (event, and)Tj -1.8 -2.001 TD -0.0037 Tc 0.12 Tw [()-1453.6(Assisting residents and visitors in recovering from)]TJ 1.8 -1.398 TD -0.0035 Tc -0.0037 Tw [(the impact of a disaster)50.5(.)]TJ -1.2 -2.001 TD -0.0032 Tc -0.0481 Tw (Research shows that the majority of people are resilient,)Tj -1.8 -1.401 TD -0.0034 Tc -0.0622 Tw (and following a disaster they will return to pre-event psycho-)Tj 0 -1.398 TD -0.0032 Tc 0.0135 Tw (logical functioning within a relatively short time. Outreach,)Tj 0 -1.401 TD -0.003 Tc -0.0078 Tw (early psychological support, and referrals can assist disaster)Tj T* -0.0037 Tc 0.0515 Tw (survivors to meet new challenges, offering them assistance)Tj 0 -1.398 TD -0.0033 Tc 0.0294 Tw (in their recovery process and returning them to pre-disaster)Tj 0 -1.401 TD -0.0038 Tc 0.005 Tw (performance and functioning levels.)Tj 1.8 -2.001 TD -0.0037 Tc -0.0562 Tw (The public will require information on how to recognize)Tj -1.8 -1.398 TD -0.0035 Tc 0.085 Tw (and cope with the short and/or long term risk of sustained)Tj 0 -1.401 TD 0.0003 Tc 0.1249 Tw [(stress caused by a disaster or arising from its ef)15.3(fect. )48.2(A)7.5(n)]TJ T* -0.0035 Tc 0.0355 Tw (informed public is better able to respond and cope with the)Tj 0 -1.398 TD 0.1088 Tw [(stresses associated with a disaster)50.4(.)]TJ 1.8 -2.001 TD -0.0086 Tc -0.0622 Tw (Individuals with special needs, especially those with pre-)Tj -1.8 -1.401 TD -0.0036 Tc 0.02 Tw (existing mental illness and substance abuse disorders, older)Tj 0 -1.398 TD 0.0004 Tc 0.125 Tw (individuals, children and adolescents, or people with dis-)Tj 0 -1.401 TD -0.0032 Tc -0.0445 Tw (abilities may be more prone to experience severe stress reac-)Tj T* -0.0037 Tc 0.0941 Tw (tions and adverse outcomes than other populations.)Tj ET endstream endobj 286 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT2 9 0 R /TT3 10 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 288 0 obj << /Length 8017 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 66 59.745 m 558 59.745 l S BT /TT3 1 Tf 8 0 0 8 423.24 42.6 Tm 0 0 0 1 k /GS2 gs -0.0051 Tc 0.0326 Tw [(IJEMH Vol. 10, No. 3 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (221)Tj /TT2 1 Tf 10 0 0 10 84 722.64 Tm -0.0036 Tc 0.0175 Tw (The plan creates regional behavioral health consultants)Tj -1.8 -1.398 TD -0.0034 Tc -0.0588 Tw [(to work with communities to develop local capacity)62.6(, and cre-)]TJ 0 -1.401 TD -0.0035 Tc 0.0138 Tw (ates regional disaster behavioral health teams to respond, at)Tj T* 0.0009 Tc 0.125 Tw (the request of local jurisdictions, by assessing behavioral)Tj 0 -1.398 TD -0.0037 Tc 0.1206 Tw (health needs resulting from an incident and managing the)Tj 0 -1.401 TD -0.0038 Tc 0.105 Tw (behavioral health response.)Tj 1.8 -2.001 TD -0.0033 Tc -0.0565 Tw (At the heart of the plan are the disaster behavioral health)Tj -1.8 -1.398 TD -0.0035 Tc 0.0516 Tw (teams, one located in each of seven regions throughout the)Tj 0 -1.401 TD -0.0033 Tc 0.0256 Tw (state, all overseen and coordinated by an Operations Direc-)Tj T* -0.0035 Tc 0.0155 Tw [(tor and Clinical Director)35.5(, functioning out of the state Emer)17.5(-)]TJ 0 -1.398 TD (gency Operations Center \(EOC; or other remote location as)Tj 0 -1.401 TD 0.0069 Tw [(weather and other conditions dictate\). These teams provide)]TJ T* -0.0008 Tc 0.125 Tw (a multi-tiered response, as they consist of personnel with)Tj 0 -1.398 TD -0.0034 Tc 0.0089 Tw [(escalating levels of experience and training. Each team has)]TJ 0 -1.401 TD -0.0135 Tw (three advanced or specialty responders, two licensed mental)Tj T* -0.0033 Tc -0.0057 Tw [(health professionals, and a primary and backup team leader)50.7(.)]TJ 0 -1.398 TD -0.004 Tc 0.1183 Tw [(T)72.8(eam composition was decided upon after comprehensive)]TJ 0 -1.401 TD -0.0039 Tc 0.1189 Tw [(literature review)59.1(, communication with other governmental)]TJ T* -0.0026 Tc 0.125 Tw (entities and non-governmental organizations \(NGOs\), and)Tj 0 -1.398 TD -0.0037 Tc 0.0061 Tw (much discussion as to just what personnel assets in terms)Tj 0 -1.401 TD -0.0036 Tc 0.0028 Tw (of skills, experience and knowledge were required to get)Tj T* 0.015 Tw [(the job done. )50.4(Another innovative addition to the traditional)]TJ 0 -1.398 TD -0.025 Tw (mental health response model is the adoption of a triage ma-)Tj 0 -1.401 TD -0.0032 Tc 0.0073 Tw (trix for assessment, much like that traditionally used in pre-)Tj T* -0.003 Tc -0.01 Tw (hospital care by emergency medical services.)Tj /TT3 1 Tf 10.089 -3.264 TD -0.0055 Tc -0.05 Tw (Table 1.)Tj -8.925 -1.2 TD -0.0051 Tc -0.0462 Tw (Regional Disaster Behavioral Health Assessment)Tj 1.311 -1.2 TD -0.0053 Tc -0.0287 Tw (Team \(RDBHAT\)Type II team composition:)Tj -0.975 -2.4 TD -0.0051 Tc -0.0571 Tw (2 Team Leader Level \(primary and secondary\))Tj 0 -1.2 TD -0.005 Tc -0.026 Tw (2 Licensed Mental Health Professionals)Tj T* -0.0053 Tc -0.0267 Tw (3 Advanced Providers)Tj /TT2 1 Tf 0.3 -3.936 TD -0.0037 Tc 0.0402 Tw [(Florida)50.3(s statewide disaster behavioral health plan, op-)]TJ -1.8 -1.398 TD -0.0039 Tc 0.0749 Tw [(erational since November)35.1(, 2006, encompasses pre-incident)]TJ 0 -1.401 TD -0.0031 Tw (education and coordination with local EOC and other emer-)Tj T* 0.0013 Tc 0.125 Tw (gency services providers; selection of experienced candi-)Tj 0 -1.398 TD -0.0034 Tc 0.0305 Tw (dates with the right skills; training and preparation of those)Tj 0 -1.401 TD -0.0025 Tc 0.125 Tw (personnel; support of accurate assessment and triage; and)Tj T* -0.0035 Tc -0.015 Tw (provision of effective post-incident support and psychologi-)Tj 0 -1.398 TD -0.0034 Tc -0.055 Tw (cal crisis intervention, to include referral options and follow-)Tj 0 -1.401 TD 0.0125 Tc 0 Tw (up.)Tj /TT5 1 Tf 11 0 0 11 321 723.36 Tm 0.0129 Tc 0.1256 Tw [(Coor)32(dinating the Plan)]TJ /TT2 1 Tf 10 0 0 10 339 703.65 Tm 0.0034 Tc 0.125 Tw (Requesting an assessment team begins at the county)Tj -1.8 -1.401 TD -0.003 Tc -0.027 Tw (level, often referred to as the local level. In emergency man-)Tj 0 -1.398 TD -0.0036 Tc 0.0005 Tw (agement all disasters begin and end at the local level. When)Tj 0 -1.401 TD -0.0034 Tc 0.0794 Tw (a disaster occurs and local mental health resources are ex-)Tj T* -0.0037 Tc -0.0036 Tw (hausted, the Incident Commander can request additional as-)Tj 0 -1.398 TD -0.0036 Tc -0.0188 Tw (sistance through Emergency Support Functions 8 \(ESF 8\) at)Tj 0 -1.401 TD -0.006 Tw (the local EOC. The local ESF 8 representative then makes a)Tj T* 0.0668 Tw [(request to the state EOC through their ESF 8 desk. )50.4(At that)]TJ 0 -1.398 TD 0.0064 Tc 0.1252 Tw [(point a Regional Disaster Behavioral Health )51.6(Assessment)]TJ 0 -1.401 TD -0.0038 Tc -0.0441 Tw [(T)73(eam \(RDBHA)104.2(T\) is mobilized by the Operations Director in)]TJ T* -0.0189 Tc -0.0622 Tw (consultation with the Clinical Director to respond to the staging)Tj 0 -1.398 TD -0.0034 Tc 0.0282 Tw [(area within 24 hours of the request. )17.6(W)55.4(ith the support of the)]TJ 0 -1.401 TD -0.0035 Tc 0.055 Tw (state EOC, supplies and other needed necessities are trans-)Tj T* 0.1125 Tw (ported to the staging area for the teams to become opera-)Tj 0 -1.398 TD -0.003 Tc 0.0318 Tw [(tional as soon as possible. )18(W)55.8(ithin the first full day of being)]TJ 0 -1.401 TD -0.0038 Tc [(onsite, the RDBHA)104.2(T)22( will conduct an assessment of the tar)17.2(-)]TJ T* -0.0034 Tc -0.0189 Tw (geted population, an assessment of the current state of local,)Tj 0 -1.398 TD -0.0036 Tc -0.015 Tw (indigenous mental health facilities and other service provid-)Tj 0 -1.401 TD -0.0093 Tc -0.0625 Tw (ers, brief with local authorities, make recommendations to the)Tj T* -0.0037 Tc 0.0552 Tw [(local ESF 8 representatives, and submit an Incident )50.5(Action)]TJ 0 -1.398 TD -0.0036 Tc -0.0224 Tw (Plan \(IAP\) to the Operations Chief. The IAP will outline the)Tj 0 -1.401 TD -0.0038 Tc 0.0791 Tw (recommendations for behavioral health services with mea-)Tj T* -0.0027 Tc 0.125 Tw (surable objectives and request Disaster Behavioral Health)Tj 0 -1.398 TD -0.0037 Tc 0.0071 Tw [(T)73.1(eams \(DBHT\) as needed to provide the services.)]TJ 1.8 -2.001 TD -0.0073 Tc -0.0623 Tw [(Once the teams are on the ground the RDBHA)106.7(T)24.5( switches)]TJ -1.8 -1.401 TD -0.0038 Tc 0.0068 Tw (roles and becomes an oversight and management team. The)Tj 0 -1.398 TD -0.0063 Tc 0.0769 Tw [(RDBHA)104.7(T)19.5( is res)]TJ 6.395 0 TD -0.0037 Tc 0.0743 Tw (ponsible for briefing all incoming teams)Tj -6.395 -1.401 TD -0.0038 Tc 0.0651 Tw [(whether state-sponsored, NGO)50.2(s such as the Red Cross, or)]TJ T* -0.0003 Tc 0.125 Tw (faith-based volunteersby providing assignments consis-)Tj 0 -1.398 TD -0.0032 Tc (tent with the assessments that they had conducted; assist-)Tj 0 -1.401 TD 0.0342 Tc (ing in the coordination and management of logistics;)Tj T* -0.0036 Tc -0.0325 Tw (conducting end of day briefings; and monitoring team mem-)Tj 0 -1.398 TD -0.0048 Tc -0.0622 Tw [(bers for exposure and compassion fatigue. Prior to demobili-)]TJ 0 -1.401 TD 0.0301 Tc 0.125 Tw [(zation, the RDBHA)105.1(T)19.9( may recommend and/or conduct)]TJ T* -0.0038 Tc 0.0243 Tw (assessments and interventions aimed at health and wellness)Tj 0 -1.398 TD -0.0034 Tc 0.0623 Tw (of all deployed team members. The intention is to monitor)Tj 0 -1.401 TD -0.0031 Tc 0.0166 Tw (and ensure safety of all those who come to help.)Tj 1.8 -2.001 TD -0.0038 Tc 0.1039 Tw [(Post-incident, RDBHA)104.2(T)22( collects all the data from the)]TJ -1.8 -1.398 TD 0.0022 Tc 0.125 Tw (responding teams to compile a report to the State on the)Tj 0 -1.401 TD -0.0037 Tc 0.0471 Tw (number of survivors, number of survivors assisted, worked)Tj T* 0.0007 Tc 0.125 Tw (hours, costs, and other pertinent information that may be)Tj 0 -1.398 TD -0.0035 Tc 0.0639 Tw (useful in the after-action phase. The FCC then reviews the)Tj ET 0.99 w 1000 M /GS1 gs 67.495 365.005 237.01 -98.01 re S endstream endobj 289 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT2 9 0 R /TT3 10 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 291 0 obj << /Length 7782 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 54 59.745 m 546 59.745 l S BT /F1 1 Tf 8 0 0 8 54.99 41.64 Tm 0 0 0 1 k /GS2 gs -0.0054 Tc 0.0938 Tw [(222 )]TJ /TT3 1 Tf 2.7563 0 TD 0.0953 Tw (Fojt, Cohen and Wagner A Systemic, Integrated Behavioral Health Response to Disaster)Tj /TT2 1 Tf 10 0 0 10 54 722.64 Tm -0.0035 Tc 0.125 Tw (reports to develop revisions to the Plan, based on lessons)Tj 0 -1.398 TD -0.004 Tc 0.0237 Tw [(learned. )50.1(A)58.2( Post )53.1(Action S)17(taf)14(f Support \(P)86(ASS\) meeting a)]TJ 0 -1.401 TD -0.0065 Tc -0.0623 Tw (variation on the theme of a debriefing for the debriefers will)Tj T* -0.0035 Tc 0.0305 Tw [(also be scheduled for all team members participating in the)]TJ 0 -1.398 TD -0.0021 Tc 0 Tw (deployment.)Tj /TT5 1 Tf 11 0 0 11 54 633.36 Tm 0.0046 Tc 0.1251 Tw [(Small-scale Initial T)86.4(est)]TJ /TT2 1 Tf 10 0 0 10 72 613.65 Tm -0.0031 Tc 0.085 Tw (The first opportunity to deploy a Plan-coordinated di-)Tj -1.8 -1.401 TD -0.0039 Tc 0.0714 Tw (saster behavioral health assessment team was Ground Hog)Tj 0 -1.398 TD -0.0169 Tc -0.0627 Tw [(Day)64.1(, 2007, when three tornados ripped through central Florida,)]TJ 0 -1.401 TD -0.0157 Tc -0.0622 Tw (claiming 21 lives and creating $10 million in property damage.)Tj T* -0.0025 Tc 0.1249 Tw [(The tornados took many by surprise, striking in the early)]TJ 0 -1.398 TD -0.0069 Tc -0.0622 Tw [(morning hours on Friday)62.1(, February 2, 2007, while many were)]TJ 0 -1.401 TD -0.0034 Tc -0.0209 Tw (still in bed asleep. One tornado reached level EF 3, as winds)Tj T* -0.01 Tc -0.0625 Tw (between 160-165 mph were clocked.)Tj 1.8 -1.998 TD -0.0033 Tc 0.027 Tw (One community in the path of the tornado, made up of)Tj -1.8 -1.401 TD -0.0035 Tc -0.019 Tw (approximately 65,000 residents, suffered extensive damage.)Tj T* 0 Tw (The local fire department made its request through the local)Tj 0 -1.398 TD -0.0034 Tc 0.0468 Tw (ESF 8 representative for a team to respond. In less than 24)Tj 0 -1.401 TD -0.004 Tc 0.06 Tw [(hours, a RDBHA)107(T)21.8( team was on the ground conducting the)]TJ T* -0.0033 Tc 0.0439 Tw (initial assessment. By the next morning it was decided that)Tj 0 -1.398 TD -0.004 Tc 0.0681 Tw [(this RDBHA)104(T)21.8( team could provide the needed services and)]TJ 0 -1.401 TD -0.0029 Tc 0.0765 Tw (that they did not need to request any other disaster behav-)Tj T* -0.0035 Tc -0.0311 Tw [(ioral teams to come in. )17.8(The )17.8(T)70.3(eam worked 12-14 hours a day)62.5(,)]TJ 0 -1.398 TD -0.0038 Tc 0.111 Tw (conducting one-on-ones, crisis management briefings, and)Tj 0 -1.401 TD -0.04 Tw (distributing information on stress management following di-)Tj T* -0.0033 Tc 0.0563 Tw [(sasters. )17.9(The )14.9(T)73.5(eam stayed in constant contact with the local)]TJ 0 -1.398 TD -0.004 Tc -0.0357 Tw [(ESF 8 representatives and their RDBHA)107(T)21.8( Operations Direc-)]TJ 0 -1.401 TD -0.0038 Tc -0.025 Tw [(tor)53.2(. )14.2(This ensured maximum utilization of resources and con-)]TJ T* -0.0138 Tw (tinuous communication between the field and the EOC. The)Tj 0 -1.398 TD -0.0034 Tc 0.1187 Tw (deployment completed operations at the end of the fourth)Tj 0 -1.401 TD 0.0086 Tc 0 Tw [(day)68.6(.)]TJ 1.8 -2.001 TD -0.0043 Tc -0.0468 Tw [(The Post )52.8(Action S)13.7(taf)16.7(f Support \(P)82.7(ASS\) meeting was held)]TJ -1.8 -1.398 TD -0.0034 Tc 0.0317 Tw [(three weeks later)50.6(. )17.6(The )17.6(T)73.4(eam that deployed \(with the excep-)]TJ 0 -1.401 TD -0.0037 Tc 0.0862 Tw (tion of one member\) and the Operations Director attended)Tj T* -0.006 Tc -0.0622 Tw [(the P)84(ASS. One of the S)18(tate)54(s Clinical Directors conducted the)]TJ 0 -1.398 TD -0.0037 Tc 0.1254 Tw [(meeting. )17.7(This same group contributed to the )53.7(After )50.7(Action)]TJ 0 -1.401 TD -0.0078 Tc 0 Tw (Report.)Tj /TT5 1 Tf 11 0 0 11 54 148.35 Tm 0.0162 Tc 0.125 Tw (Observations & Findings)Tj /TT2 1 Tf 10 0 0 10 72 128.64 Tm -0.0085 Tc -0.0621 Tw [(The )51.5(After )54.5(Action Report revealed several important find-)]TJ -1.8 -1.398 TD 0.0013 Tc 0 Tw (ings:)Tj 26.7 60.798 TD -0.0036 Tc 0.0514 Tw [()-1453.5(The time to establish relationships with other agen-)]TJ 1.8 -1.398 TD -0.0034 Tc 0.0493 Tw (cies involved in community mental health is before)Tj 0 -1.401 TD -0.0011 Tc 0.125 Tw [(disasters occur)46.9(.)]TJ -1.8 -2.001 TD -0.0038 Tc -0.0115 Tw [()-1453.7(Mental health professionals must have a good work-)]TJ 1.8 -1.398 TD -0.0607 Tw (ing knowledge of the Incident Command System and)Tj 0 -1.401 TD -0.0037 Tc -0.006 Tw (obtain the FEMA IS 100 and IS 200 courses prior to)Tj T* -0.0021 Tc 0 Tw (deployment.)Tj -1.8 -1.998 TD -0.004 Tc 0.1109 Tw [()-1453.9(Documentation and Incident )50.1(Action Plans are mis-)]TJ 1.8 -1.401 TD -0.0064 Tc -0.06 Tw (sion critical.)Tj -1.8 -2.001 TD -0.0035 Tc -0.02 Tw [()-1453.4(T)0(he need for equipment, such as computers, satellite)]TJ 1.8 -1.398 TD 0.0289 Tc 0.125 Tw (phones, wireless internet connections, and pre-)Tj 0 -1.401 TD -0.0037 Tc 0.0234 Tw (printed materials, should be given equal importance)Tj T* -0.0035 Tc 0.0668 Tw [(regardless of the perceived scope of the event. )49.3(Al-)]TJ 0 -1.398 TD 0.0719 Tw (though all these had been procured in advance, be-)Tj 0 -1.401 TD -0.0033 Tc 0.0405 Tw (cause of the small size of this event, not all support)Tj T* -0.0035 Tc -0.0344 Tw (services were activated and the items were not deliv-)Tj 0 -1.398 TD -0.0034 Tc -0.0189 Tw (ered to the team that needed them. 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It re-)]TJ 0 -1.401 TD -0.0058 Tc -0.0623 Tw (quires a meeting of the minds to plan strategies that will work)Tj T* -0.0005 Tc 0.125 Tw (to preserve the health and well-being of our citizens, our)Tj 0 -1.398 TD -0.0035 Tc 0.0443 Tw (neighbors, and our responders. 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449.818 278.682 449.654 279.67 448.01 279.67 c 446.87 279.67 446.391 278.945 446.391 278.208 c 446.391 277.384 447.086 277.167 447.394 277.094 c 448.357 276.87 l 449.13 276.686 449.359 276.528 449.359 276.033 c 449.359 275.355 448.586 275.236 448.128 275.236 c 447.525 275.236 446.83 275.486 446.83 276.343 c 446.234 276.343 l 446.234 275.902 446.313 275.506 446.712 275.144 c 446.922 274.953 447.263 274.688 448.134 274.688 c 448.94 274.688 449.975 274.999 449.975 276.119 c 449.975 276.87 449.516 277.239 448.907 277.384 c 447.564 277.694 l 447.289 277.76 447.007 277.892 447.007 278.293 c 447.007 279.011 447.682 279.123 448.081 279.123 c 448.612 279.123 449.215 278.893 449.248 278.161 c 449.844 278.161 l f* 450.237 278.978 m 451.829 278.978 l 451.829 274.814 l 452.464 274.814 l 452.464 278.978 l 454.057 278.978 l 454.057 279.545 l 450.237 279.545 l 450.237 278.978 l f* 455.236 276.844 m 456.775 276.844 l 457.535 276.844 457.614 276.389 457.614 276 c 457.614 275.822 457.634 275.105 457.725 274.815 c 458.505 274.815 l 458.505 274.92 l 458.309 275.032 458.275 275.131 458.269 275.394 c 458.23 276.251 l 458.204 276.91 457.935 277.028 457.666 277.14 c 457.968 277.318 458.321 277.575 458.321 278.273 c 458.321 279.275 457.548 279.545 456.775 279.545 c 454.6 279.545 l 454.6 274.815 l 455.236 274.815 l 455.236 276.844 l h 455.236 278.998 m 456.821 278.998 l 457.136 278.998 457.666 278.939 457.666 278.208 c 457.666 277.509 457.175 277.391 456.71 277.391 c 455.236 277.391 l 455.236 278.998 l f* 462.639 275.381 m 459.802 275.381 l 459.802 276.962 l 462.377 276.962 l 462.377 277.529 l 459.802 277.529 l 459.802 278.978 l 462.593 278.978 l 462.593 279.545 l 459.167 279.545 l 459.167 274.815 l 462.639 274.815 l 462.639 275.381 l f* 466.766 278.161 m 466.74 278.682 466.577 279.67 464.932 279.67 c 463.792 279.67 463.314 278.945 463.314 278.208 c 463.314 277.384 464.008 277.167 464.316 277.094 c 465.279 276.87 l 466.052 276.686 466.282 276.528 466.282 276.033 c 466.282 275.355 465.509 275.236 465.05 275.236 c 464.447 275.236 463.753 275.486 463.753 276.343 c 463.157 276.343 l 463.157 275.902 463.235 275.506 463.635 275.144 c 463.844 274.953 464.185 274.688 465.057 274.688 c 465.862 274.688 466.898 274.999 466.898 276.119 c 466.898 276.87 466.439 277.239 465.83 277.384 c 464.487 277.694 l 464.212 277.76 463.93 277.892 463.93 278.293 c 463.93 279.011 464.605 279.123 465.004 279.123 c 465.535 279.123 466.137 278.893 466.17 278.161 c 466.766 278.161 l f* 470.999 278.161 m 470.973 278.682 470.809 279.67 469.164 279.67 c 468.024 279.67 467.546 278.945 467.546 278.208 c 467.546 277.384 468.241 277.167 468.548 277.094 c 469.512 276.87 l 470.285 276.686 470.514 276.528 470.514 276.033 c 470.514 275.355 469.741 275.236 469.282 275.236 c 468.68 275.236 467.985 275.486 467.985 276.343 c 467.389 276.343 l 467.389 275.902 467.468 275.506 467.867 275.144 c 468.077 274.953 468.417 274.688 469.289 274.688 c 470.095 274.688 471.13 274.999 471.13 276.119 c 471.13 276.87 470.671 277.239 470.062 277.384 c 468.719 277.694 l 468.444 277.76 468.162 277.892 468.162 278.293 c 468.162 279.011 468.837 279.123 469.236 279.123 c 469.767 279.123 470.37 278.893 470.403 278.161 c 470.999 278.161 l f* 439.355 269.039 m 441.661 269.039 l 441.661 269.606 l 439.355 269.606 l 439.355 271.055 l 441.976 271.055 l 441.976 271.622 l 438.72 271.622 l 438.72 266.89 l 439.355 266.89 l 439.355 269.039 l f* 446.221 269.257 m 446.221 268.143 445.605 267.332 444.583 267.332 c 443.561 267.332 442.945 268.143 442.945 269.257 c 442.945 270.37 443.561 271.18 444.583 271.18 c 445.605 271.18 446.221 270.37 446.221 269.257 c h 446.876 269.257 m 446.876 270.278 446.339 271.747 444.583 271.747 c 442.827 271.747 442.29 270.278 442.29 269.257 c 442.29 268.235 442.827 266.765 444.583 266.765 c 446.339 266.765 446.876 268.235 446.876 269.257 c f* 450.558 271.622 m 450.558 268.631 l 450.558 267.603 449.903 267.332 449.32 267.332 c 448.75 267.332 448.128 267.616 448.128 268.644 c 448.128 271.622 l 447.492 271.622 l 447.492 268.466 l 447.492 267.583 448.036 266.765 449.3 266.765 c 450.591 266.765 451.194 267.583 451.194 268.551 c 451.194 271.622 l 450.558 271.622 l f* 455.17 267.8 m 455.157 267.8 l 452.805 271.622 l 452.052 271.622 l 452.052 266.891 l 452.668 266.891 l 452.668 270.713 l 452.681 270.713 l 455.072 266.891 l 455.786 266.891 l 455.786 271.622 l 455.17 271.622 l 455.17 267.8 l f* 456.664 266.891 m 458.544 266.891 l 460.091 266.891 460.549 268.262 460.549 269.322 c 460.549 270.686 459.796 271.622 458.57 271.622 c 456.664 271.622 l 456.664 266.891 l h 457.3 271.075 m 458.485 271.075 l 459.35 271.075 459.894 270.475 459.894 269.283 c 459.894 268.09 459.357 267.438 458.531 267.438 c 457.3 267.438 l 457.3 271.075 l f* 463.576 268.268 m 464.041 266.89 l 464.736 266.89 l 463.032 271.622 l 462.312 271.622 l 460.543 266.89 l 461.198 266.89 l 461.689 268.268 l 463.576 268.268 l h 461.886 268.835 m 462.639 270.917 l 462.652 270.917 l 463.347 268.835 l 461.886 268.835 l f* 463.989 271.055 m 465.581 271.055 l 465.581 266.89 l 466.216 266.89 l 466.216 271.055 l 467.808 271.055 l 467.808 271.622 l 463.989 271.622 l 463.989 271.055 l f* 468.371 266.89 0.635 4.732 re f* 473.724 269.257 m 473.724 268.143 473.108 267.332 472.086 267.332 c 471.064 267.332 470.448 268.143 470.448 269.257 c 470.448 270.37 471.064 271.18 472.086 271.18 c 473.108 271.18 473.724 270.37 473.724 269.257 c h 474.379 269.257 m 474.379 270.278 473.842 271.747 472.086 271.747 c 470.33 271.747 469.793 270.278 469.793 269.257 c 469.793 268.235 470.33 266.765 472.086 266.765 c 473.842 266.765 474.379 268.235 474.379 269.257 c f* 478.094 267.8 m 478.081 267.8 l 475.729 271.622 l 474.975 271.622 l 474.975 266.891 l 475.591 266.891 l 475.591 270.713 l 475.604 270.713 l 477.996 266.891 l 478.71 266.891 l 478.71 271.622 l 478.094 271.622 l 478.094 267.8 l f* q 0.9972 0 0 1.0028 0 0 cm 0.333 w 2.613 M 458.221 334.47 m 461.569 334.47 l 461.568 331.037 l 464.338 332.844 l 465.935 330.242 l 462.97 328.516 l 465.957 326.823 l 464.422 324.158 l 461.548 325.824 l 461.548 322.32 l 458.235 322.32 l 458.233 325.746 l 455.301 324.057 l 453.765 326.84 l 456.665 328.492 l 453.711 330.222 l 455.243 332.808 l 458.221 331.036 l 458.221 334.47 l b* Q 0 0 0 0 k 458.976 333.898 m 458.579 334.601 458.235 333.888 y 458.568 324.881 l 458.695 324.629 458.747 324.906 y 458.976 333.898 l f* q 0.9972 0 0 1.0028 0 0 cm 0 0 0 0 K 0.166 w 2.613 M 459.633 330.097 m 459.406 330.239 459.299 330.361 y 458.723 330.978 458.711 331.45 y 458.695 331.865 458.839 332.102 y 458.956 332.358 459.323 332.493 y 459.541 332.578 459.571 332.556 y 459.86 332.551 460.002 332.319 y 460.471 331.982 459.86 331.992 y 459.57 332.035 459.485 332.099 y 459.125 332.003 459.197 331.47 y 459.268 331.155 459.46 330.809 459.611 330.73 c 459.633 330.097 l b* Q q 0.9972 0 0 1.0028 0 0 cm 0 0 0 0 K 0.166 w 2.613 M 459.859 332.296 m 459.812 332.302 459.762 332.281 459.719 332.303 c 459.699 332.313 459.691 332.338 459.698 332.354 c 459.704 332.367 459.736 332.388 459.757 332.381 c 459.801 332.364 459.812 332.309 459.859 332.296 c b* Q q 0.9972 0 0 1.0028 0 0 cm 0 0 0 0 K 0.166 w 2.613 M 459.828 325.776 m 459.857 325.942 459.936 326.068 v 460.005 326.177 460.064 326.234 460.179 326.355 c 460.242 326.422 460.332 326.548 460.397 326.626 c 460.62 326.906 460.434 327.207 v 460.349 327.336 460.12 327.535 v 460.125 326.921 l 460.123 326.776 459.732 326.331 y 459.634 326.207 459.585 326.148 459.538 325.797 c 459.5 325.393 459.83 324.963 v 459.811 325.613 l 459.816 325.722 459.828 325.776 v b* Q q 0.9972 0 0 1.0028 0 0 cm 0 0 0 0 K 0.166 w 2.613 M 460.188 329.709 m 460.223 329.605 459.682 329.039 y 459.634 328.985 459.58 328.924 459.518 328.855 c 459.179 328.488 459.196 328.184 v 459.214 327.76 459.628 327.362 v 459.679 327.32 459.749 327.244 v 459.731 327.825 l 459.686 327.88 459.635 327.964 459.593 328.093 c 459.548 328.185 459.672 328.38 v 459.889 328.579 460.593 329.414 v 460.797 329.763 460.636 329.992 v 460.48 330.222 460.205 330.403 v 460.188 329.709 l b* Q q 0.9972 0 0 1.0028 0 0 cm 0 0 0 0 K 0.166 w 2.613 M 460.052 324.68 m 460.073 324.605 460.063 324.513 459.971 324.409 c 459.775 324.127 l 459.996 324.221 460.1 324.352 v 460.232 324.481 460.2 324.72 v 460.177 324.834 460.064 325.017 v 460.052 324.68 l b* Q q 0.9972 0 0 1.0028 0 0 cm 0 0 0 1 k 1 j 0.333 w 2.613 M 460.365 237.826 m 460.521 237.872 460.638 237.78 460.794 237.872 c 461.107 238.011 461.38 238.104 461.653 238.336 c 461.848 238.474 461.965 238.706 462.161 238.891 c 462.239 238.938 462.365 238.941 462.395 238.799 c 462.434 238.613 462.551 238.567 462.668 238.521 c 463.254 238.289 463.84 238.428 464.425 238.521 c 465.089 238.614 465.557 239.216 466.182 239.494 c 466.494 239.68 466.73 240.035 467.041 240.097 c 467.275 240.143 467.548 240.143 467.743 240.328 c 467.861 240.421 467.822 240.56 v 468.251 240.606 468.563 240.93 468.837 241.301 c 468.915 241.347 469.032 241.44 469.149 241.394 c 469.11 241.394 l 471.999 245.052 l 471.959 245.145 l 471.92 245.284 471.998 245.423 471.92 245.562 c 463.214 243.198 l 463.175 242.874 462.824 242.457 462.629 242.179 c 462.664 242.229 461.969 242.632 462.034 242.761 c 462.45 243.593 462.345 244.36 461.915 245.101 c 461.837 245.287 461.759 245.356 461.642 245.518 c 461.344 245.929 460.861 246.167 460.354 246.074 c 460.236 246.074 l 459.729 246.166 459.377 245.935 459.006 245.611 c 458.837 245.463 458.538 245.148 458.46 244.962 c 458.031 244.221 458.208 243.319 458.54 242.595 c 458.6 242.464 457.897 242.234 457.933 242.184 c 457.738 242.462 457.386 242.879 457.347 243.203 c 448.641 245.564 l 448.562 245.425 448.641 245.287 448.602 245.148 c 448.562 245.055 l 451.452 241.397 l 451.413 241.397 l 451.53 241.443 451.647 241.35 451.725 241.304 c 451.998 240.934 452.311 240.61 452.74 240.563 c 452.701 240.424 452.818 240.332 y 453.013 240.147 453.287 240.147 453.521 240.1 c 453.831 240.039 454.068 239.684 454.38 239.498 c 455.005 239.22 455.473 238.618 456.137 238.526 c 456.723 238.433 457.308 238.294 457.894 238.526 c 458.011 238.572 458.128 238.618 458.167 238.803 c 458.197 238.946 458.323 238.943 458.401 238.896 c 458.597 238.711 458.714 238.48 458.909 238.34 c 459.182 238.109 459.455 238.016 459.768 237.877 c 459.924 237.785 460.041 237.877 460.197 237.831 c 460.365 237.826 l b* Q 451.974 244.466 m 455.848 243.516 l 455.829 243.516 455.829 243.54 455.809 243.54 c 455.906 243.238 456.023 242.936 456.101 242.611 c 456.209 242.159 456.101 241.659 456.081 241.195 c 455.887 241.288 455.867 241.427 v 455.79 241.752 455.79 241.984 455.712 242.309 c 455.692 242.332 455.575 242.449 455.556 242.495 c 455.427 242.801 455.264 242.843 454.991 243.006 c 454.68 243.168 454.368 243.424 454.077 243.563 c 453.454 243.842 452.792 243.888 452.188 244.19 c 452.169 244.213 452.11 244.236 452.091 244.306 c 452.077 244.355 451.916 244.352 451.974 244.466 c f* 452.928 243.679 m 452.967 243.633 453.006 243.54 453.045 243.516 c 453.22 243.424 453.395 243.447 453.57 243.447 c 453.531 243.47 453.492 243.516 453.454 243.516 c 453.239 243.516 453.103 243.586 452.928 243.679 c f* 453.512 243.076 m 453.687 243.076 453.843 243.099 454.018 243.076 c 454.037 243.052 454.018 243.006 453.999 242.983 c 453.843 242.936 453.687 242.843 453.531 242.797 c 453.492 242.773 453.434 242.797 y 453.356 242.727 453.155 242.696 453.181 242.773 c 453.22 242.89 453.356 242.959 453.454 243.029 c 453.512 243.076 l f* 453.531 242.286 m 453.59 242.286 453.648 242.263 453.707 242.309 c 453.823 242.402 454.018 242.541 454.154 242.565 c 453.531 242.286 l f* 453.999 241.938 m 454.174 241.938 454.388 241.891 454.524 241.961 c 454.583 242.007 454.66 242.1 454.699 242.216 c 454.446 242.17 454.291 242.007 454.037 242.007 c 453.999 241.938 l f* 455.206 241.775 m 455.167 241.775 455.128 241.798 455.089 241.775 c 454.952 241.682 454.797 241.659 454.699 241.52 c 454.66 241.45 454.66 241.357 454.66 241.288 c 454.699 241.288 454.738 241.264 454.758 241.288 c 454.855 241.473 455.03 241.52 455.128 241.682 c 455.206 241.775 l f* 454.855 240.916 m 454.855 240.893 454.855 240.846 454.855 240.823 c 455.089 240.754 455.244 240.962 455.42 241.125 c 455.556 241.241 455.42 241.334 455.303 241.241 c 455.244 241.195 455.147 241.125 455.069 241.055 c 455.011 240.986 454.914 241.032 454.836 240.962 c 454.855 240.939 454.855 240.916 v f* 455.595 240.73 m 455.692 240.73 455.712 240.846 455.79 240.893 c 455.595 240.73 l f* 456.023 240.707 m 456.023 240.661 456.023 240.638 456.023 240.591 c 456.062 240.591 l 456.062 240.545 456.062 240.475 456.062 240.428 c 456.023 240.707 l f* 448.197 245.235 m 448.314 245.258 448.412 245.211 448.509 245.165 c 448.529 245.165 448.567 245.118 448.606 245.095 c 448.723 245.049 448.84 245.002 448.957 244.956 c 449.326 244.84 449.716 244.863 450.066 244.654 c 450.203 244.585 450.358 244.515 450.495 244.468 c 450.864 244.376 451.195 244.376 451.565 244.306 c 451.624 244.283 451.682 244.213 451.76 244.213 c 451.37 244.236 450.981 244.167 450.572 244.236 c 450.358 244.283 450.144 244.259 449.93 244.329 c 449.872 244.352 449.852 244.422 449.794 244.445 c 449.58 244.515 449.385 244.422 449.19 244.492 c 449.112 244.515 449.015 244.515 448.937 244.562 c 448.665 244.654 448.489 244.91 448.275 245.142 c 448.256 245.165 448.295 245.211 448.256 245.235 c 448.197 245.235 l f* 448.645 244.422 m 448.723 244.329 448.781 244.213 448.898 244.167 c 449.093 244.12 449.268 243.981 449.463 243.935 c 449.696 243.865 449.911 243.819 450.144 243.795 c 450.436 243.749 450.709 243.749 451.001 243.656 c 451.02 243.656 451.08 243.641 451.098 243.633 c 451.546 243.424 452.013 243.516 452.461 243.516 c 452.48 243.656 452.422 243.842 452.285 243.865 c 452.071 243.911 451.877 243.795 451.663 243.772 c 451.39 243.726 451.137 243.726 450.864 243.772 c 450.767 243.795 450.689 243.819 450.611 243.865 c 450.358 243.981 450.105 243.865 449.852 243.981 c 449.755 244.027 449.677 244.051 449.58 244.097 c 449.307 244.167 449.035 244.213 448.781 244.329 c 448.645 244.422 l f* 449.58 243.284 m 450.008 243.261 450.456 243.377 450.884 243.238 c 450.962 243.215 451.02 243.099 451.118 243.076 c 451.273 243.052 451.429 243.099 451.585 243.122 c 451.916 243.192 452.247 243.099 452.577 243.168 c 451.993 242.704 451.234 242.866 450.572 242.913 c 450.417 242.913 450.3 243.052 450.164 243.076 c 450.047 243.076 449.911 243.076 449.794 243.122 c 449.735 243.145 449.696 243.192 449.638 243.215 c 449.58 243.284 l f* 450.709 242.216 m 450.689 242.24 450.728 242.263 450.728 242.286 c 451.079 242.263 451.429 242.379 451.779 242.449 c 452.169 242.518 452.558 242.356 452.947 242.518 c 452.889 242.495 452.828 242.468 452.772 242.449 c 452.091 242.216 451.487 242.263 450.825 242.24 c 450.709 242.216 l f* 451.468 241.566 m 451.682 241.52 451.955 241.566 452.169 241.566 c 452.441 241.613 452.728 241.546 453.006 241.613 c 453.2 241.659 453.181 241.822 453.415 242.077 c 453.123 242.054 452.986 242.03 452.636 242.054 c 452.414 242.069 452.266 241.914 452.052 241.845 c 451.877 241.798 451.877 241.891 451.74 241.775 c 451.468 241.566 l f* 452.208 241.009 m 452.519 240.986 452.811 241.009 453.123 241.079 c 453.142 241.102 453.181 241.125 453.2 241.148 c 453.317 241.195 453.454 241.148 453.57 241.241 c 453.651 241.306 453.707 241.381 453.804 241.427 c 453.823 241.45 453.862 241.682 453.843 241.682 c 453.765 241.705 453.648 241.566 453.57 241.52 c 453.512 241.52 453.492 241.45 453.434 241.427 c 453.181 241.334 453.162 241.473 452.928 241.311 c 452.792 241.218 452.344 241.241 452.227 241.079 c 452.208 241.009 l f* 453.064 240.498 m 453.278 240.475 453.473 240.568 453.668 240.638 c 453.843 240.707 454.037 240.8 454.193 240.962 c 453.862 241.055 453.57 240.777 453.239 240.684 c 453.2 240.684 453.103 240.614 453.123 240.521 c 453.064 240.498 l f* 453.531 240.219 m 453.57 240.08 453.745 240.103 453.823 240.15 c 453.979 240.266 454.213 240.312 454.252 240.545 c 454.174 240.545 454.115 240.568 454.037 240.521 c 453.979 240.475 453.94 240.428 453.901 240.359 c 453.823 240.243 453.668 240.335 453.59 240.196 c 453.531 240.219 l f* 454.232 239.848 m 454.388 239.848 454.544 239.848 454.699 239.848 c 454.68 240.034 454.738 240.219 454.855 240.359 c 454.855 240.382 454.855 240.428 454.855 240.452 c 454.758 240.498 454.68 240.382 454.602 240.312 c 454.544 240.243 454.544 240.127 454.563 240.034 c 454.466 240.034 454.368 239.987 454.31 239.895 c 454.232 239.848 l f* 455.03 239.732 m 455.206 239.778 455.303 239.964 455.459 240.034 c 455.03 239.732 l f* 455.478 239.755 m 455.595 239.755 455.653 239.941 455.751 240.034 c 455.478 239.755 l f* 455.926 239.732 m 456.068 239.732 456.218 239.662 456.354 239.732 c 456.354 239.802 l 456.257 239.848 456.218 240.034 456.101 239.987 c 456.081 239.987 456.062 239.871 456.023 239.825 c 456.004 239.825 455.984 239.825 455.965 239.825 c 455.926 239.802 455.906 239.732 455.926 239.732 c f* 466 244.462 m 462.127 243.512 l 462.146 243.512 462.146 243.535 462.165 243.535 c 462.068 243.233 461.952 242.931 461.874 242.606 c 461.766 242.155 461.874 241.654 461.894 241.19 c 462.088 241.283 462.107 241.422 v 462.186 241.747 462.185 241.98 462.263 242.304 c 462.282 242.328 462.399 242.444 462.419 242.49 c 462.547 242.797 462.711 242.839 462.983 243.001 c 463.295 243.164 463.606 243.419 463.898 243.559 c 464.521 243.837 465.183 243.884 465.786 244.186 c 465.806 244.209 465.864 244.232 465.884 244.302 c 465.897 244.351 466.059 244.349 466 244.462 c f* 465.047 243.675 m 465.008 243.629 464.969 243.536 464.93 243.513 c 464.755 243.42 464.579 243.443 464.404 243.443 c 464.443 243.466 464.482 243.513 464.521 243.513 c 464.735 243.513 464.871 243.582 465.047 243.675 c f* 464.463 243.071 m 464.287 243.071 464.132 243.094 463.956 243.071 c 463.937 243.048 463.956 243.002 463.976 242.978 c 464.132 242.932 464.287 242.839 464.443 242.793 c 464.482 242.77 464.54 242.793 y 464.619 242.723 464.82 242.692 464.794 242.77 c 464.755 242.886 464.619 242.955 464.521 243.025 c 464.463 243.071 l f* 464.443 242.282 m 464.385 242.282 464.327 242.259 464.268 242.305 c 464.151 242.398 463.957 242.537 463.82 242.56 c 464.443 242.282 l f* 463.976 241.934 m 463.801 241.934 463.587 241.887 463.451 241.956 c 463.392 242.003 463.314 242.096 463.275 242.212 c 463.528 242.166 463.684 242.003 463.937 242.003 c 463.976 241.934 l f* 462.769 241.771 m 462.808 241.771 462.847 241.794 462.886 241.771 c 463.023 241.678 463.178 241.655 463.275 241.516 c 463.315 241.446 463.315 241.353 463.315 241.283 c 463.276 241.283 463.237 241.26 463.217 241.283 c 463.12 241.469 462.944 241.515 462.847 241.678 c 462.769 241.771 l f* 463.12 240.912 m 463.12 240.889 463.12 240.842 463.12 240.819 c 462.886 240.749 462.731 240.958 462.555 241.121 c 462.419 241.237 462.555 241.329 462.672 241.237 c 462.731 241.19 462.828 241.121 462.906 241.051 c 462.964 240.981 463.061 241.028 463.139 240.958 c 463.12 240.935 463.12 240.912 v f* 462.38 240.726 m 462.283 240.726 462.263 240.842 462.186 240.888 c 462.38 240.726 l f* 461.952 240.702 m 461.952 240.656 461.952 240.633 461.952 240.586 c 461.913 240.586 l 461.913 240.54 461.913 240.47 461.913 240.424 c 461.952 240.702 l f* 469.777 245.232 m 469.66 245.255 469.563 245.209 469.465 245.162 c 469.446 245.162 469.407 245.116 469.368 245.092 c 469.251 245.046 469.134 245 469.018 244.953 c 468.648 244.837 468.258 244.86 467.908 244.651 c 467.772 244.581 467.616 244.512 467.48 244.465 c 467.11 244.372 466.779 244.372 466.409 244.302 c 466.351 244.279 466.292 244.209 466.215 244.209 c 466.604 244.233 466.993 244.163 467.402 244.233 c 467.616 244.279 467.83 244.256 468.044 244.326 c 468.103 244.349 468.122 244.419 468.181 244.442 c 468.395 244.512 468.589 244.419 468.784 244.489 c 468.862 244.512 468.959 244.512 469.037 244.558 c 469.31 244.651 469.485 244.907 469.699 245.139 c 469.718 245.162 469.679 245.209 469.718 245.232 c 469.777 245.232 l f* 469.329 244.419 m 469.251 244.326 469.193 244.21 469.076 244.164 c 468.882 244.117 468.706 243.978 468.511 243.931 c 468.278 243.862 468.064 243.815 467.83 243.792 c 467.538 243.745 467.266 243.745 466.974 243.652 c 466.954 243.652 466.894 243.638 466.877 243.629 c 466.429 243.42 465.961 243.513 465.514 243.513 c 465.494 243.652 465.553 243.838 465.689 243.861 c 465.903 243.908 466.098 243.791 466.312 243.768 c 466.584 243.722 466.838 243.722 467.11 243.768 c 467.207 243.792 467.285 243.815 467.363 243.862 c 467.616 243.978 467.869 243.862 468.122 243.978 c 468.22 244.024 468.298 244.047 468.395 244.094 c 468.667 244.164 468.94 244.21 469.193 244.326 c 469.329 244.419 l f* 468.395 243.281 m 467.967 243.258 467.519 243.374 467.091 243.235 c 467.013 243.211 466.954 243.095 466.857 243.072 c 466.701 243.049 466.546 243.095 466.39 243.118 c 466.059 243.188 465.728 243.095 465.397 243.165 c 465.981 242.7 466.74 242.863 467.402 242.91 c 467.558 242.91 467.675 243.049 467.811 243.072 c 467.928 243.072 468.064 243.072 468.181 243.119 c 468.239 243.142 468.278 243.188 468.336 243.211 c 468.395 243.281 l f* 467.266 242.213 m 467.286 242.236 467.247 242.26 467.247 242.283 c 466.896 242.259 466.546 242.375 466.195 242.445 c 465.806 242.514 465.417 242.352 465.027 242.514 c 465.086 242.491 465.146 242.464 465.203 242.445 c 465.884 242.213 466.487 242.259 467.149 242.236 c 467.266 242.213 l f* 466.507 241.562 m 466.293 241.516 466.02 241.562 465.806 241.562 c 465.534 241.609 465.247 241.543 464.969 241.609 c 464.774 241.655 464.794 241.818 464.56 242.073 c 464.852 242.05 464.988 242.026 465.339 242.05 c 465.561 242.065 465.709 241.911 465.923 241.841 c 466.098 241.795 466.098 241.887 466.234 241.771 c 466.507 241.562 l f* 465.767 241.005 m 465.456 240.982 465.164 241.005 464.852 241.075 c 464.833 241.098 464.794 241.121 464.774 241.144 c 464.658 241.191 464.521 241.144 464.405 241.237 c 464.324 241.301 464.268 241.376 464.171 241.423 c 464.152 241.446 464.113 241.678 464.132 241.678 c 464.21 241.701 464.327 241.562 464.405 241.516 c 464.463 241.516 464.482 241.446 464.541 241.423 c 464.794 241.33 464.813 241.469 465.047 241.307 c 465.183 241.214 465.631 241.238 465.748 241.075 c 465.767 241.005 l f* 464.911 240.494 m 464.697 240.471 464.502 240.564 464.307 240.633 c 464.132 240.703 463.937 240.796 463.782 240.958 c 464.113 241.051 464.405 240.772 464.736 240.68 c 464.774 240.68 464.872 240.61 464.853 240.517 c 464.911 240.494 l f* 464.444 240.216 m 464.405 240.076 464.23 240.099 464.152 240.145 c 463.996 240.262 463.762 240.308 463.724 240.54 c 463.801 240.54 463.86 240.564 463.938 240.517 c 463.996 240.471 464.035 240.424 464.074 240.355 c 464.152 240.239 464.307 240.332 464.385 240.192 c 464.444 240.216 l f* 463.743 239.844 m 463.587 239.844 463.432 239.844 463.276 239.844 c 463.295 240.029 463.237 240.215 463.12 240.354 c 463.12 240.378 463.12 240.424 463.12 240.447 c 463.217 240.494 463.295 240.378 463.373 240.308 c 463.432 240.238 463.432 240.122 463.412 240.029 c 463.509 240.029 463.607 239.983 463.665 239.89 c 463.743 239.844 l f* 462.945 239.727 m 462.77 239.774 462.672 239.96 462.517 240.029 c 462.945 239.727 l f* 462.497 239.751 m 462.38 239.751 462.322 239.936 462.225 240.029 c 462.497 239.751 l f* 462.049 239.727 m 461.908 239.727 461.757 239.658 461.621 239.727 c 461.621 239.797 l 461.719 239.843 461.757 240.029 461.874 239.983 c 461.894 239.983 461.913 239.867 461.952 239.82 c 461.972 239.82 461.991 239.82 462.011 239.82 c 462.049 239.797 462.069 239.727 462.049 239.727 c f* 458.409 243.152 m 458.584 243.094 458.772 243.063 458.968 243.063 c 459.926 243.063 460.702 243.813 460.702 244.738 c 460.702 245.662 459.926 246.412 458.968 246.412 c 458.01 246.412 457.234 245.662 457.234 244.738 c 457.234 244.002 457.725 243.377 458.409 243.152 c f* q 0.9972 0 0 1.0028 0 0 cm 1 J 1 j 0.333 w 2.613 M 459.7 242.469 m 459.876 242.411 460.065 242.38 460.261 242.38 c 461.222 242.38 462.001 243.128 462.001 244.05 c 462.001 244.972 461.222 245.72 460.261 245.72 c 459.301 245.72 458.522 244.972 458.522 244.05 c 458.522 243.316 459.015 242.693 459.7 242.469 c S Q q 0.9972 0 0 1.0028 0 0 cm 1 J 1 j 0.166 w 2.613 M 461.618 244.726 m 459.422 242.781 l 459.377 242.764 l 460.256 245.611 l 460.271 245.559 l 461.105 242.711 l 458.972 244.685 l 458.953 244.726 l 461.618 244.726 l S Q 458.475 244.842 m 458.484 244.819 458.522 244.729 458.536 244.709 c 458.575 244.651 458.588 244.653 458.578 244.571 c 458.571 244.513 458.578 244.51 458.62 244.467 c 458.678 244.408 458.676 244.275 458.744 244.217 c 458.774 244.194 458.92 244.373 458.931 244.384 c 459.008 244.456 459.055 244.342 459.211 244.225 c 459.297 244.161 459.304 244.488 459.284 244.634 c 459.28 244.659 459.45 244.819 459.45 244.842 c 459.479 245.086 459.471 245 459.325 245.197 c 459.306 245.209 459.141 245.324 459.131 245.348 c 458.995 245.534 458.993 245.461 458.827 245.426 c 458.818 245.426 458.8 245.365 458.807 245.343 c 458.836 245.235 458.638 245.283 458.599 245.26 c 458.531 245.202 458.5 245.189 458.452 245.108 c 458.423 245.038 458.423 244.957 458.413 244.887 c 458.475 244.842 l f* q 0.9972 0 0 1.0028 0 0 cm 0 0 0 0 K 1 J 1 j 0.166 w 2.613 M 459.767 244.154 m 459.776 244.131 459.814 244.041 459.828 244.021 c 459.867 243.963 459.88 243.965 459.871 243.884 c 459.864 243.826 459.87 243.823 459.912 243.78 c 459.971 243.722 459.969 243.588 460.037 243.531 c 460.066 243.507 460.213 243.687 460.224 243.697 c 460.302 243.769 460.349 243.655 460.505 243.539 c 460.591 243.475 460.599 243.801 460.578 243.946 c 460.574 243.971 460.744 244.131 460.744 244.154 c 460.773 244.398 460.766 244.311 460.619 244.508 c 460.6 244.52 460.435 244.635 460.425 244.658 c 460.288 244.844 460.286 244.772 460.12 244.737 c 460.111 244.737 460.093 244.675 460.099 244.654 c 460.129 244.546 459.93 244.593 459.891 244.57 c 459.823 244.513 459.792 244.5 459.744 244.419 c 459.714 244.349 459.714 244.269 459.704 244.199 c S Q q 0.9972 0 0 1.0028 0 0 cm 0 0 0 1 k 0 0 0 0 K 0.333 w 2.613 M 460.372 241.462 m 460.506 241.462 l 460.539 241.426 460.603 241.438 460.656 241.492 c 460.71 241.546 460.76 241.615 460.771 241.651 c 460.888 241.773 461.079 241.721 461.296 241.566 c 461.359 241.485 461.706 241.206 462.138 241.016 c 462.201 240.941 461.931 241.018 461.88 241.037 c 461.963 240.983 461.87 240.937 461.679 241.027 c 461.732 240.939 461.62 240.963 461.491 241.031 c 461.565 240.942 461.44 240.954 461.334 241.023 c 461.379 240.94 461.262 240.944 461.172 241.03 c 461.217 240.951 461.108 240.951 461.029 241.026 c 461.077 240.943 460.923 240.968 460.87 241.031 c 460.912 240.966 460.727 241.002 460.711 241.069 c 460.684 240.979 460.53 240.962 460.494 241.031 c 460.381 241.031 l 460.289 240.938 460.146 240.992 460.13 241.187 c 459.989 240.961 459.785 240.918 459.849 241.039 c 459.737 240.935 459.676 240.97 459.692 241.031 c 459.527 240.889 459.519 241.01 459.536 241.033 c 459.426 240.946 459.333 240.963 459.363 241.021 c 459.262 240.967 459.14 240.957 459.193 241.034 c 459.074 240.963 458.906 240.966 458.978 241.038 c 458.811 240.97 458.628 240.984 458.785 241.049 c 459.257 241.244 459.409 241.43 459.585 241.569 c 459.861 241.789 460.073 241.737 460.121 241.62 c 460.166 241.512 460.314 241.399 460.367 241.455 c 460.372 241.462 l b* Q q 0.9972 0 0 1.0028 0 0 cm 0 0 0 1 k 0 0 0 0 K 0.333 w 2.613 M 460.372 238.596 m 460.372 238.564 460.385 238.543 460.429 238.543 c 460.472 238.542 460.485 238.569 460.485 238.597 c 460.51 241.547 l 460.366 241.547 l 460.372 238.596 l b* Q q 0.9972 0 0 1.0028 0 0 cm 0 0 0 1 k 0 0 0 0 K 0.333 w 2.613 M 460.429 241.492 m 460.429 241.51 460.488 241.514 460.488 241.495 c 460.467 238.648 l 460.467 238.627 460.456 238.584 460.441 238.584 c 460.431 238.584 460.429 238.624 460.429 238.648 c 460.429 241.492 l b* Q 0 0 0 1 k 459.466 241.97 m 459.431 241.994 459.385 241.987 y 459.441 241.963 459.461 241.941 459.435 241.808 c 459.466 241.97 l f* q 0.9972 0 0 1.0028 0 0 cm 0 0 0 0 K 0.333 w 2.613 M 460.761 241.29 m 460.725 241.314 460.68 241.307 y 460.736 241.283 460.755 241.261 460.729 241.129 c S Q 460.25 242.033 m 460.272 242.015 460.138 242.005 y 460.165 241.983 460.007 241.987 y 460.032 241.958 459.909 241.948 y 459.925 241.925 459.795 241.91 y 459.81 241.889 459.704 241.888 y 459.714 241.866 459.596 241.877 y 459.604 241.849 459.447 241.885 y 460.25 242.033 l f* q 0.9972 0 0 1.0028 0 0 cm 0 0 0 0 K 0.333 w 2.613 M 461.547 241.353 m 461.569 241.335 461.435 241.325 y 461.462 241.303 461.303 241.307 y 461.328 241.278 461.205 241.268 y 461.221 241.245 461.091 241.23 y 461.105 241.209 460.999 241.209 y 461.01 241.186 460.891 241.197 y 460.899 241.17 460.741 241.205 y S Q 460.066 242.189 m 460.064 242.142 459.92 242.181 y 459.917 242.141 459.783 242.166 y 459.791 242.13 459.656 242.135 y 459.665 242.1 459.578 242.11 y 459.605 242.055 459.516 242.031 y 459.536 241.975 459.432 241.984 y 460.066 242.189 l f* q 0.9972 0 0 1.0028 0 0 cm 0 0 0 0 K 0.333 w 2.613 M 461.362 241.509 m 461.361 241.461 461.216 241.5 y 461.213 241.46 461.079 241.486 y 461.087 241.45 460.951 241.454 y 460.961 241.42 460.873 241.429 y 460.9 241.375 460.81 241.351 y 460.831 241.295 460.726 241.304 y S Q 458.823 241.971 m 458.858 241.995 458.903 241.988 y 458.847 241.964 458.828 241.942 458.853 241.81 c 458.823 241.971 l f* q 0.9972 0 0 1.0028 0 0 cm 0 0 0 0 K 0.333 w 2.613 M 460.115 241.291 m 460.151 241.315 460.196 241.308 y 460.14 241.284 460.121 241.262 460.146 241.13 c S Q 458.039 242.037 m 458.016 242.02 458.151 242.009 y 458.123 241.987 458.282 241.99 y 458.256 241.961 458.379 241.951 y 458.363 241.928 458.493 241.912 y 458.478 241.892 458.584 241.891 y 458.574 241.868 458.692 241.879 y 458.683 241.851 458.841 241.886 y 458.039 242.037 l f* q 0.9972 0 0 1.0028 0 0 cm 0 0 0 0 K 0.333 w 2.613 M 459.33 241.356 m 459.307 241.34 459.442 241.329 y 459.414 241.307 459.573 241.31 y 459.548 241.281 459.671 241.271 y 459.655 241.248 459.785 241.233 y 459.77 241.212 459.877 241.211 y 459.866 241.188 459.985 241.199 y 459.976 241.171 460.134 241.207 y S Q 458.224 242.193 m 458.225 242.145 458.369 242.184 y 458.372 242.144 458.507 242.169 y 458.498 242.133 458.634 242.137 y 458.624 242.102 458.712 242.111 y 458.684 242.057 458.773 242.032 y 458.752 241.977 458.857 241.985 y 458.224 242.193 l f* q 0.9972 0 0 1.0028 0 0 cm 0 0 0 0 K 0.333 w 2.613 M 459.516 241.512 m 459.516 241.464 459.661 241.503 y 459.664 241.463 459.799 241.488 y 459.79 241.452 459.926 241.456 y 459.916 241.422 460.005 241.431 y 459.977 241.377 460.066 241.352 y 460.045 241.297 460.15 241.305 y S Q q 0.9972 0 0 1.0028 0 0 cm 0 0 0 0 K 0.333 w 2.613 M 460.437 241.535 m 460.339 241.535 460.26 241.597 460.26 241.674 c 460.26 241.751 460.34 241.813 460.437 241.813 c 460.535 241.813 460.615 241.75 460.614 241.674 c 460.614 241.597 460.534 241.534 460.437 241.535 c b* Q q 0.9972 0 0 1.0028 0 0 cm 0 0 0 0 K 0.333 w 2.613 M 460.42 241.742 m 460.444 241.746 460.429 241.77 460.408 241.77 c 460.345 241.768 460.307 241.719 460.306 241.672 c 460.306 241.649 460.314 241.62 460.329 241.602 c 460.337 241.592 460.36 241.571 460.347 241.576 c 460.304 241.593 460.283 241.634 460.283 241.675 c 460.283 241.743 460.353 241.797 460.438 241.797 c 460.524 241.797 460.594 241.742 460.593 241.674 c 460.593 241.611 460.53 241.556 460.445 241.551 c 460.432 241.55 460.41 241.551 460.404 241.559 c 460.403 241.56 460.432 241.559 460.445 241.56 c 460.511 241.568 460.554 241.611 460.551 241.662 c 460.55 241.675 460.523 241.7 460.526 241.679 c 460.531 241.644 460.488 241.618 460.444 241.617 c 460.409 241.616 460.365 241.645 460.365 241.68 c 460.365 241.714 460.377 241.735 460.42 241.742 c b* Q q 0.9972 0 0 1.0028 0 0 cm 0 0 0 0 K 0.333 w 2.613 M 460.002 240.71 m 459.976 240.373 461.004 240.711 460.977 240.284 c 460.952 239.876 460.179 240.159 460.204 239.935 c 460.216 239.82 460.883 239.897 460.827 239.63 c 460.774 239.381 460.228 239.504 460.249 239.394 c 460.272 239.272 460.806 239.332 460.706 239.109 c 460.625 238.929 460.21 239.054 460.204 238.857 c 460.052 239.034 460.544 239.018 460.575 239.136 c 460.601 239.236 460.134 239.191 460.087 239.384 c 460.03 239.627 460.606 239.517 460.631 239.654 c 460.653 239.771 460.046 239.671 459.983 239.875 c 459.852 240.299 460.654 240.058 460.706 240.284 c 460.753 240.491 459.891 240.246 459.813 240.647 c 459.784 240.799 459.909 240.844 459.986 240.874 c 460.016 240.886 460.009 240.915 460.079 240.927 c 460.141 240.937 460.192 240.919 460.317 240.796 c 460.333 240.779 460.287 240.749 460.249 240.743 c 460.21 240.736 460.115 240.723 460.074 240.753 c 460.039 240.78 460.005 240.748 460.002 240.71 c b* Q q 0.9972 0 0 1.0028 0 0 cm 0 0 0 0 K 0.333 w 2.613 M 460.868 240.708 m 460.893 240.371 459.866 240.713 459.891 240.286 c 459.914 239.878 460.688 240.158 460.662 239.934 c 460.649 239.819 459.983 239.899 460.037 239.632 c 460.088 239.383 460.635 239.503 460.614 239.393 c 460.59 239.271 460.056 239.333 460.154 239.111 c 460.234 238.93 460.651 239.053 460.655 238.856 c 460.808 239.033 460.316 239.019 460.286 239.137 c 460.261 239.237 460.728 239.19 460.775 239.383 c 460.834 239.626 460.257 239.518 460.232 239.655 c 460.212 239.771 460.818 239.67 460.883 239.874 c 461.017 240.297 460.213 240.059 460.162 240.286 c 460.117 240.492 460.977 240.244 461.057 240.644 c 461.087 240.796 460.962 240.842 460.886 240.872 c 460.855 240.884 460.862 240.914 460.792 240.925 c 460.731 240.936 460.68 240.918 460.554 240.796 c 460.537 240.779 460.584 240.749 460.622 240.742 c 460.66 240.735 460.756 240.722 460.796 240.752 c 460.832 240.778 460.865 240.747 460.868 240.708 c b* Q q 0.9972 0 0 1.0028 0 0 cm 0 0 0 0 K 0.333 w 2.613 M 460.705 240.016 m 460.743 240.024 460.845 239.997 460.832 239.93 c 460.789 239.709 460.202 239.815 460.194 239.671 c 460.19 239.586 460.337 239.578 460.27 239.566 c 460.19 239.551 460.074 239.604 460.077 239.669 c 460.084 239.866 460.66 239.811 460.7 239.924 c 460.721 239.984 460.665 240.008 460.705 240.016 c b* Q q 0.9972 0 0 1.0028 0 0 cm 0 0 0 0 K 0.333 w 2.613 M 460.75 240.357 m 460.796 240.366 460.9 240.333 460.888 240.254 c 460.845 239.968 460.149 240.142 460.132 239.963 c 460.122 239.863 460.3 239.853 460.222 239.839 c 460.126 239.822 460.004 239.89 460.012 239.965 c 460.038 240.225 460.705 240.081 460.745 240.249 c 460.762 240.321 460.703 240.347 460.75 240.357 c b* Q q 0.9972 0 0 1.0028 0 0 cm 0 0 0 0 K 0.333 w 2.613 M 460.668 239.7 m 460.7 239.707 460.773 239.688 460.763 239.631 c 460.726 239.443 460.244 239.531 460.221 239.411 c 460.206 239.336 460.333 239.331 460.276 239.321 c 460.207 239.308 460.118 239.359 460.12 239.408 c 460.126 239.576 460.623 239.531 460.657 239.627 c 460.675 239.678 460.633 239.693 460.668 239.7 c b* Q q 0.9972 0 0 1.0028 0 0 cm 0 0 0 0 K 0.333 w 2.613 M 460.643 239.438 m 460.671 239.444 460.73 239.428 460.724 239.379 c 460.707 239.246 460.304 239.26 460.26 239.15 c 460.236 239.089 460.356 239.082 460.307 239.074 c 460.249 239.063 460.18 239.106 460.174 239.148 c 460.155 239.297 460.609 239.273 460.634 239.376 c 460.645 239.42 460.614 239.432 460.643 239.438 c b* Q q 0.9972 0 0 1.0028 0 0 cm 0 0 0 0 K 0.333 w 2.613 M 460.23 238.948 m 460.258 239.038 460.589 239.023 460.598 239.139 c 460.601 239.178 460.581 239.187 460.606 239.192 c 460.63 239.197 460.676 239.184 460.675 239.142 c 460.67 239.014 460.294 239.007 460.23 238.948 c b* Q q 0.9972 0 0 1.0028 0 0 cm 0 0 0 0 K 0.333 w 2.613 M 460.811 240.875 m 460.966 240.828 460.995 240.731 460.983 240.661 c 460.921 240.325 460.099 240.521 460.079 240.31 c 460.067 240.192 460.278 240.181 460.185 240.164 c 460.072 240.143 459.933 240.221 459.94 240.313 c 459.963 240.64 460.776 240.401 460.889 240.642 c 460.914 240.694 460.909 240.833 460.784 240.829 c 460.69 240.825 460.646 240.836 460.699 240.876 c 460.738 240.905 460.794 240.898 460.811 240.875 c b* Q q 0.9972 0 0 1.0028 0 0 cm 0 0 0 0 K 0.333 w 2.613 M 459.888 240.663 m 459.938 240.509 460.142 240.543 460.112 240.553 c 460.042 240.576 459.998 240.601 459.968 240.65 c 459.901 240.76 459.954 240.859 460.081 240.835 c 460.172 240.818 460.226 240.836 460.173 240.876 c 460.134 240.906 460.077 240.899 460.06 240.877 c 459.905 240.83 459.858 240.754 459.888 240.663 c b* Q 459.435 241.808 m 459.42 241.732 459.377 241.668 459.29 241.667 c 459.224 241.667 459.209 241.704 y 459.435 241.808 l f* q 0.9972 0 0 1.0028 0 0 cm 0 0 0 0 K 0.333 w 2.613 M 460.729 241.129 m 460.714 241.053 460.672 240.989 460.585 240.988 c 460.518 240.988 460.503 241.025 y S Q 459.881 241.709 m 459.911 241.691 459.866 241.629 459.809 241.662 c 459.629 241.768 459.596 241.877 y 459.5 241.933 459.466 241.97 y 459.881 241.709 l f* q 0.9972 0 0 1.0028 0 0 cm 0 0 0 0 K 0.333 w 2.613 M 461.177 241.03 m 461.207 241.011 461.162 240.95 461.105 240.983 c 460.925 241.089 460.891 241.197 y 460.795 241.253 460.761 241.29 y S Q 459.729 241.716 m 459.772 241.689 459.73 241.626 459.648 241.669 c 459.528 241.733 459.447 241.885 y 459.729 241.716 l f* q 0.9972 0 0 1.0028 0 0 cm 0 0 0 0 K 0.333 w 2.613 M 461.024 241.037 m 461.068 241.009 461.025 240.947 460.943 240.99 c 460.823 241.054 460.741 241.205 y S Q 459.211 242.147 m 459.283 242.069 459.423 242.219 459.466 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The IES is a fifteen item)Tj T* -0.0037 Tc 0.016 Tw (self-rating questionnaire comprising two subscales \(In-)Tj 0 -1.398 TD -0.004 Tc 0.0902 Tw [(trusion and )50.2(A)79.2(voidance\).)]TJ ET endstream endobj 322 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /F9 57 0 R /F61 323 0 R /TT1 8 0 R /TT2 9 0 R /TT3 10 0 R /TT4 20 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> /ColorSpace << /Cs20 324 0 R >> >> endobj 326 0 obj << /FunctionType 0 /Domain [0 1] /Range [0 1 0 1 0 1 0 1] /BitsPerSample 8 /Size [255] /Length 1035 /Filter /FlateDecode >> stream H    ! !"!!"#"!#$#"$%$#%&%$&'&%'('&()(')*)(*+*)+,+*,-,+-.-,./.-/0/.010/121023213432454356546765787689879:97:;:8;<;9<=<:=>=;>?>=@A?>AB@?BCA@CDBADECBEFDCFGEDGHFEHIGFIJHGJKIHKLJILMKJMNLKNOMLOPNMPQOMQRPNRSQOSTRPTUSQUVTRVWUSWXVTXYWUYZXVZ[YW[\ZX\][Y]^\Z^_][_`^\`a_]ab`^bca_cdb`decaefdbfgecghfchigdijgejkhfkliglmjhmnkinoljopmkpqnlqromrspnstqoturpuvsqvwtrwxusxyvtyzwuz{xv{|yw|}zx}~{y~|y}z~{|}~½þĿ¾ÿ 0 endstream endobj 324 0 obj [/Separation /Auto /DeviceCMYK 326 0 R] endobj 328 0 obj << /Length 10410 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 54 59.745 m 546 59.745 l S BT /F1 1 Tf 8 0 0 8 54.99 41.64 Tm 0 0 0 1 k /GS2 gs -0.0052 Tc 0.1209 Tw [(226 )]TJ /TT3 1 Tf 2.8388 0 TD -0.0058 Tc (Selected Annotated Journal Resources)Tj /F9 1 Tf 10 0 0 10 54 721.65 Tm 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc 0.0149 Tw [(Additionally)59.4(, the Symptom Checlist-90-Revised \(SCL-)]TJ 0 -1.401 TD -0.0034 Tc 0.055 Tw (90-R\) was used to assess a broad spectrum of psycho-)Tj 0 -1.398 TD -0.0069 Tc -0.06 Tw (logical complaints.)Tj /F9 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0035 Tc -0.0356 Tw (Patients social networks and recent life events were as-)Tj 0 -1.398 TD -0.0037 Tc 0.1128 Tw (sessed using a questionnaire complied from a revised)Tj 0 -1.401 TD -0.0036 Tc -0.0532 Tw (version of the Social Network Index, an adapted version)Tj T* -0.0033 Tc 0.0514 Tw (of the Social Support Questionairre, and the Inventory)Tj 0 -1.398 TD -0.0075 Tc -0.0616 Tw (for Determining Life-Changing Events.)Tj /F9 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc -0.0521 Tw (Biographical protective and risk factors for the develop-)Tj 0 -1.398 TD -0.0115 Tc -0.0625 Tw (ment of psychological and psychosomatic disorders were)Tj 0 -1.401 TD -0.0032 Tc 0.125 Tw (determined in a semi-structured interview based on a)Tj T* -0.0069 Tc -0.0621 Tw (compilation of established factors. Each item was scored)Tj 0 -1.398 TD -0.0035 Tc -0.0017 Tw (as present \(1\) or not present \(0\). The most predominant)Tj 0 -1.401 TD -0.0034 Tc -0.035 Tw (factors were low-SES of parents \(51%\), severe physical)Tj T* -0.0035 Tc -0.005 Tw (disease of one parent \(37%\), contact wit social services)Tj 0 -1.398 TD 0.0084 Tc 0.125 Tw (\(29%\), age difference between siblings less than 18)Tj 0 -1.401 TD -0.0038 Tc -0.0092 Tw (months \(21%\), and chronic marital problems of parents)Tj T* -0.0398 Tc 0 Tw (\(19%\).)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0039 Tc -0.0583 Tw [( )52.8(Antonovsky)50.1(s Sense of Coherence questionnaire \(SOC\))]TJ 0 -1.401 TD -0.002 Tc 0.125 Tw (was used to measure participants resiliency to stress)Tj 0 -1.398 TD 0.0009 Tc (and capacity to cope with stressful events. The SOC)Tj 0 -1.401 TD -0.0061 Tc -0.0625 Tw (used was the 29-item full version. Higher scores indicate)Tj T* -0.0031 Tc -0.055 Tw (that participants have a greater capacity to handle stress,)Tj 0 -1.398 TD 0.11 Tw (find it worthwhile to rise to meet the challenges they)Tj 0 -1.401 TD 0.0986 Tw (may face, and perceive stressful events as predictable)Tj T* -0.0102 Tc -0.06 Tw (and explicable.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD 0.037 Tc 0.125 Tw [(The active, problem-oriented coping scale of the)]TJ 0 -1.401 TD -0.0039 Tc -0.01 Tw (Freidburg Questionnaire of Coping with Illness \(FQIC\))Tj 0 -1.398 TD -0.003 Tc 0.0625 Tw [(was used in this study)60(.)]TJ /F9 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0066 Tc -0.0621 Tw [(The 14-item self rating Hospital )53.4(Anxiety and Depression)]TJ 0 -1.398 TD -0.0035 Tc 0.0932 Tw (scale \(HADS\) was used to assess anxiety and depres-)Tj 0 -1.401 TD -0.0116 Tw (sion in medical patients.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0032 Tc 0.0313 Tw (The subjective appraisal of the severity of the accident)Tj 0 -1.401 TD -0.0195 Tw (was rated by the patients on a Likert scale ranging from)Tj T* -0.0024 Tc -0.0224 Tw (1 \(very slight\) to 5 \(very severe\).)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0034 Tc 0.0383 Tw (For the assessment of the life threatening nature of the)Tj 0 -1.401 TD -0.0033 Tc -0.0586 Tw (accident, patients were asked whether they thought their)Tj 0 -1.398 TD -0.0032 Tc -0.0212 Tw (life was at risk during or after the accident.)Tj /TT1 1 Tf 11 0 0 11 54 157.65 Tm 0.0154 Tc 0 Tw [(RESUL)83.6(TS)]TJ /F9 1 Tf 10 0 0 10 54 141.66 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0037 Tc 0.0971 Tw (There was no significant correlation between ISS and)Tj 0 -1.401 TD -0.0034 Tc 0.0607 Tw (the patients subjective appraisal of the event \(threat to)Tj T* -0.0166 Tc -0.0625 Tw (life: Pearson )Tj /TT5 1 Tf 4.926 0 TD 0 Tc 0 Tw (r)Tj /TT2 1 Tf 0.369 0 TD -0.0159 Tc -0.0625 Tw [( = 0.07; accident severity: Pearson )]TJ /TT5 1 Tf 13.089 0 TD 0 Tc 0 Tw (r)Tj /TT2 1 Tf 0.372 0 TD -0.016 Tc -0.0625 Tw [( = 0.06\).)]TJ -18.756 -1.398 TD 0.002 Tc 0.125 Tw (Experiencing the accident as life-threatening was re-)Tj 0 -1.401 TD -0.0031 Tc -0.02 Tw (ported by 21 patients \(23%\).)Tj /F9 1 Tf 23.7 63.699 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0035 Tc -0.0595 Tw (At baseline 5 participants \(6%\) met all criteria for PTSD)Tj 0 -1.398 TD -0.0151 Tc -0.0622 Tw (\(except the duration criteria\) and 19 \(21%\) met criteria for)Tj 0 -1.401 TD -0.0038 Tc -0.0171 Tw [(sub-threshold disorder)53.2(. )50.2(At 6 months 3 participants \(3%\))]TJ T* 0.0872 Tw (were diagnosed with full PTSD and 8 \(9%\) with sub-)Tj 0 -1.398 TD -0.0032 Tc 0.0756 Tw [(threshold disorder)50.8(. )53.8(At 1 year 2 participants \(2%\) were)]TJ 0 -1.401 TD -0.0041 Tc -0.0625 Tw (diagnosed with full PTSD and 10 \(11%\) were diagnosed)Tj T* -0.0032 Tc 0.0308 Tw [(with sub-threshold disorder)53.8(. )17.9(Three years after the acci-)]TJ 0 -1.398 TD -0.0035 Tc -0.0565 Tw (dent 4 participants \(4%\) met criteria for full PTSD and 9)Tj 0 -1.401 TD -0.0038 Tc 0.0489 Tw [(participants \(10%\) for sub-threshold disorder)53.2(. )49.9(At some)]TJ T* -0.0109 Tc -0.0625 Tw (point during follow-up, 32 patients \(36%\) met the criteria)Tj 0 -1.398 TD -0.0036 Tc -0.029 Tw (for either full or sub-threshold PTSD.)Tj /F9 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0019 Tc 0.125 Tw (Mean CAPS scores were used to indicate severity of)Tj 0 -1.398 TD -0.0038 Tc 0.0825 Tw (PTSD symptoms over time. The mean CAPS score at)Tj 0 -1.401 TD -0.0239 Tc -0.0616 Tw (baseline was 18.9 \()Tj /TT5 1 Tf 7.029 0 TD -0.0312 Tc 0 Tw (SD)Tj /TT2 1 Tf 1.17 0 TD -0.0235 Tc -0.0625 Tw [( = 15.0, range 0-79\), 10.9 \()]TJ /TT5 1 Tf 9.756 0 TD -0.0312 Tc 0 Tw (SD)Tj /TT2 1 Tf 1.17 0 TD -0.0234 Tc -0.0625 Tw [( = 13.4,)]TJ -19.125 -1.401 TD -0.0111 Tc (range 0-57\) at 6 months, 13.4 \()Tj /TT5 1 Tf 11.67 0 TD -0.0222 Tc 0 Tw (SD)Tj /TT2 1 Tf 1.194 0 TD -0.0109 Tc -0.0625 Tw [( = 15.6, range 0-64\) at 1)]TJ -12.864 -1.398 TD -0.0024 Tc 0.0244 Tw [(year)36.6(, and 10.6 \()]TJ /TT5 1 Tf 6.249 0 TD -0.0132 Tc 0 Tw (SD)Tj /TT2 1 Tf 1.212 0 TD -0.0028 Tc 0.025 Tw [( =15.2, range 0-60\) at the three year)]TJ -7.461 -1.401 TD -0.0187 Tc -0.0622 Tw (follow-up, indicating a relatively low overall PTSD symp-)Tj T* -0.0035 Tc -0.0488 Tw (tom level in this sample.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0073 Tc -0.0622 Tw (Predictors of PTSD at three years were examined using a)Tj 0 -1.401 TD -0.0036 Tc 0.0332 Tw (prediction model the authors had established for the 1-)Tj 0 -1.398 TD -0.016 Tc -0.0621 Tw (year follow-up. For the multiple regression analysis, com-)Tj 0 -1.401 TD -0.006 Tc -0.0625 Tw (plete data for 89 participants were available. The authors)Tj T* -0.0066 Tc -0.0622 Tw (model remained largely stable over time explaining 32%)Tj 0 -1.398 TD -0.0033 Tc -0.0564 Tw (of the variance of PTSD symptoms 1-year post-accident)Tj 0 -1.401 TD 0 Tc 0 Tw (\()Tj /TT5 1 Tf 0.315 0 TD (n)Tj /TT2 1 Tf 0.48 0 TD -0.018 Tc -0.0617 Tw [( = 89, )]TJ /TT5 1 Tf 2.256 0 TD 0 Tc 0 Tw (r)Tj /TT2 1 Tf 0.369 0 TD -0.0187 Tc -0.0617 Tw [( = 0.63, )]TJ /TT5 1 Tf 2.964 0 TD 0 Tc 0 Tw (r)Tj /TT2 1 Tf 5.8 0 0 5.8 394.56 386.01 Tm (2)Tj 10 0 0 10 397.35 382.65 Tm -0.0187 Tc -0.0617 Tw [( = 0.32, )]TJ /TT5 1 Tf 2.964 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.48 0 TD -0.0188 Tc -0.0622 Tw [( = < 0.001\) and 23% at 3-years)]TJ -10.479 -1.401 TD -0.0037 Tc 0.0175 Tw (post accident \()Tj /TT5 1 Tf 5.814 0 TD 0 Tc 0 Tw (n)Tj /TT2 1 Tf 0.495 0 TD -0.0022 Tc 0.0167 Tw [( = 89, )]TJ /TT5 1 Tf 2.601 0 TD 0 Tc 0 Tw (r)Tj /TT2 1 Tf 0.384 0 TD -0.0022 Tc 0.0183 Tw [( = 0.57, )]TJ /TT5 1 Tf 3.351 0 TD 0 Tc 0 Tw (r)Tj /TT2 1 Tf 5.8 0 0 5.8 457.29 372 Tm (2)Tj 10 0 0 10 460.2 368.64 Tm -0.0022 Tc 0.0183 Tw [( = 0.23, )]TJ /TT5 1 Tf 3.351 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.495 0 TD -0.0029 Tc 0.0183 Tw [( = < 0.001\).)]TJ -17.166 -1.398 TD -0.0036 Tc -0.0286 Tw (Biographical risk factors and the IES Intrusion subscale)Tj 0 -1.401 TD 0.0093 Tc 0.125 Tw [(contributed significantly to the prediction; however)33.3(,)]TJ T* -0.0034 Tc 0.0469 Tw [(patient)50.6(s sense of threat to life and active problem-ori-)]TJ 0 -1.398 TD -0.0033 Tc 0.015 Tw [(ented coping \(FQCI\), significant at one year)35.7(, no longer)]TJ 0 -1.401 TD -0.0038 Tc -0.0125 Tw [(was a predictor)50.2(.)]TJ /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0035 Tc 0.0522 Tw [(T)73.3(o)0( search for variations in the natural course of PTSD)]TJ 0 -1.401 TD 0.0872 Tw (symptoms the authors concentrated on patients with a)Tj T* -0.0188 Tc -0.0625 Tw (CAPS score of 30 or more at any measurement time \(28%,)Tj /TT5 1 Tf 0 -1.398 TD -0.015 Tc 0 Tw (n )Tj /TT2 1 Tf 0.66 0 TD -0.0168 Tc -0.0622 Tw (= 25\). The authors identified three types of PTSD course)Tj -0.66 -1.401 TD -0.0034 Tc -0.05 Tw [(using the following procedure. First, there was a separa-)]TJ T* -0.0167 Tc -0.0622 Tw (tion of patients showing an initial increase in PTSD symp-)Tj 0 -1.398 TD -0.0058 Tc -0.06 Tw (toms \(increasing group)Tj /TT5 1 Tf 8.979 0 TD -0.0025 Tc -0.0625 Tw [( n )]TJ /TT2 1 Tf 0.867 0 TD -0.0057 Tc -0.063 Tw (= 10\) from patients showing an)Tj -9.846 -1.401 TD -0.0046 Tc -0.0621 Tw (initial decrease in PTSD symptoms \(decreasing group; )Tj /TT5 1 Tf 21.405 0 TD 0 Tc 0 Tw (n)Tj /TT2 1 Tf -21.405 -1.401 TD -0.0065 Tc -0.0625 Tw (= 15\) in the first 6 months post-trauma. Next, they subdi-)Tj 0 -1.398 TD -0.0015 Tc 0.125 Tw (vided the group with an initial decrease into a group)Tj 0 -1.401 TD -0.0034 Tc 0.0235 Tw (scoring above 30 on the CAPS at 2 weeks only \()Tj /TT5 1 Tf 19.47 0 TD 0 Tc 0 Tw (n)Tj /TT2 1 Tf 0.495 0 TD -0.003 Tc 0.025 Tw [( = 8\))]TJ -19.965 -1.401 TD -0.0004 Tc 0.1249 Tw [(and a group of patients with a secondary increase of)]TJ 0 -1.398 TD -0.0034 Tc -0.0032 Tw (CAPS score above 30 later on \(delayed increase group;)Tj /TT5 1 Tf 0 -1.401 TD 0 Tc 0 Tw (n)Tj /TT2 1 Tf 0.495 0 TD -0.0034 Tc 0.0773 Tw [( = 7\). The three groups of PTSD courses and the re-)]TJ ET endstream endobj 329 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /F9 57 0 R /TT1 8 0 R /TT2 9 0 R /TT3 10 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 331 0 obj << /Length 10084 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 66 59.745 m 558 59.745 l S BT /TT3 1 Tf 8 0 0 8 423.24 42.6 Tm 0 0 0 1 k /GS2 gs -0.0051 Tc 0.0326 Tw [(IJEMH Vol. 10, No. 3 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (227)Tj /TT2 1 Tf 10 0 0 10 84 722.64 Tm -0.0034 Tc 0.0175 Tw (maining less symptomatic group did not differ with re-)Tj 0 -1.398 TD -0.0104 Tc -0.0616 Tw (gard to age \()Tj /TT5 1 Tf 4.71 0 TD 0 Tc 0 Tw (F)Tj /TT2 1 Tf 0.6 0 TD -0.0094 Tc -0.0616 Tw [( = 0.49, )]TJ /TT5 1 Tf 3.045 0 TD -0.0188 Tc 0 Tw (df)Tj /TT2 1 Tf 0.756 0 TD -0.0089 Tc -0.0625 Tw [( = 3, 86, )]TJ /TT5 1 Tf 3.225 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.489 0 TD -0.0105 Tc -0.0625 Tw (< .056\) and gender \()Tj /F9 1 Tf 7.689 0 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 5.8 0 0 5.8 294.51 711.99 Tm (2)Tj 10 0 0 10 297.39 708.66 Tm (=)Tj -21.339 -1.401 TD -0.0168 Tc (2.08, )Tj /TT5 1 Tf 2.094 0 TD -0.0189 Tc (df )Tj /TT2 1 Tf 0.921 0 TD -0.0157 Tc -0.0625 Tw (= 3, )Tj /TT5 1 Tf 1.614 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.48 0 TD -0.0164 Tc -0.0625 Tw [( < 0.56\).)]TJ /F9 1 Tf -6.909 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD 0.0033 Tc 0.125 Tw (Post hoc analyses revealed that the increasing group)Tj 0 -1.401 TD -0.0035 Tc -0.0071 Tw (and the delayed increasing group represented a homog-)Tj T* -0.0033 Tc 0.125 Tw (enous subset of means compared with the decreasing)Tj 0 -1.398 TD -0.0037 Tc 0.0872 Tw (group and patients who never scored above 30 on the)Tj 0 -1.401 TD -0.0033 Tc -0.0289 Tw [(CAPS. )54(Accordingly the increasing and delayed increas-)]TJ T* -0.0032 Tc 0.0656 Tw (ing group reported significantly more stress due to re-)Tj 0 -1.398 TD -0.0034 Tc 0.0075 Tw (cent life events assessed \()Tj /TT5 1 Tf 10.215 0 TD 0 Tc 0 Tw (t)Tj /TT2 1 Tf 0.276 0 TD -0.0027 Tc 0.0075 Tw (-tests, all )Tj /TT5 1 Tf 3.843 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.495 0 TD -0.0032 Tc 0.0088 Tw [( < 0.001\) than the)]TJ -14.829 -1.401 TD -0.0038 Tc 0.0028 Tw (decreasing group combined with the group scoring less)Tj T* -0.0175 Tw (than 30 on the CAPS.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0032 Tc 0.0765 Tw (At the 1 year assessment, 84 of the 90 patients \(93%\))Tj 0 -1.401 TD -0.0064 Tc -0.0621 Tw (completed the HADS. Seven patients \(8%\) scored above)Tj 0 -1.398 TD -0.0034 Tc -0.0139 Tw (the cut-off level of 7 points for possible depression. Pa-)Tj 0 -1.401 TD -0.0038 Tc 0.0421 Tw (tients diagnosed with full or sub-threshold PTSD were)Tj T* -0.0031 Tc -0.003 Tw (more likely to have scores above the cut off for depres-)Tj 0 -1.398 TD -0.0035 Tc 0.0652 Tw [(sion \(Fisher)-39.5()56.5(s)-0.7( exact test, )]TJ /TT5 1 Tf 10.125 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.495 0 TD -0.0033 Tc 0.067 Tw [( < 0.01\). Fifiteen \(18%\) pa-)]TJ -10.62 -1.401 TD 0.0145 Tc 0.125 Tw (tients scored above the cut off for possible anxiety)Tj T* -0.0037 Tc 0.0768 Tw [(disorder)53.3(. Patients diagnosed with full or sub-threshold)]TJ 0 -1.398 TD -0.0033 Tc -0.0305 Tw (PTSD were more likely to have scores above the cut off)Tj 0 -1.401 TD -0.0029 Tc -0.045 Tw [(for anxiety \(Fisher)-38.9()54.1(s)-0.1( exact test, )]TJ /TT5 1 Tf 12.324 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.495 0 TD -0.0026 Tc -0.046 Tw [( < 0.001\). )51.4(At 1-year the)]TJ -12.819 -1.401 TD -0.0037 Tc 0.07 Tw [(CAPS correlated significantly with the HADS depres-)]TJ 0 -1.398 TD -0.005 Tc -0.06 Tw (sion \(Pearson )Tj /TT5 1 Tf 5.475 0 TD 0 Tc 0 Tw (r)Tj /TT2 1 Tf 0.381 0 TD -0.0035 Tc -0.0633 Tw [( = 0.61, )]TJ /TT5 1 Tf 3.09 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.495 0 TD -0.005 Tc -0.0625 Tw [( < 0.001\) and the HADS anxiety)]TJ -9.441 -1.401 TD -0.0044 Tc 0 Tw (\(Pearson )Tj /TT5 1 Tf 3.684 0 TD 0 Tc (r)Tj /TT2 1 Tf 0.387 0 TD -0.0025 Tc -0.035 Tw [( = 0.71, )]TJ /TT5 1 Tf 3.189 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.495 0 TD -0.0034 Tc -0.035 Tw [( < 0.001\) at the same assessment.)]TJ /F9 1 Tf -9.555 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.013 Tc -0.0625 Tw (At the 3 year follow-up, HADS data were available for 87)Tj 0 -1.401 TD -0.0037 Tc 0.1007 Tw (patients \(97%\). Nine patients \(10%\) scored above the)Tj T* -0.0036 Tc 0.0078 Tw [(cut-of)14.4(f level of 7 points for possible depression. )53.7(Again,)]TJ 0 -1.398 TD -0.0087 Tc -0.0621 Tw (Patients diagnosed with full or sub-threshold PTSD were)Tj 0 -1.401 TD -0.0031 Tc -0.003 Tw (more likely to have scores above the cut off for depres-)Tj T* -0.0036 Tc 0.0778 Tw [(sion \(Fisher)-39.6()53.4(s)-0.9( exact test, )]TJ /TT5 1 Tf 10.176 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.495 0 TD -0.0037 Tc 0.0788 Tw [( < 0.001\). Seventeen \(19%\))]TJ -10.671 -1.398 TD -0.0032 Tc 0.1206 Tw (patients scored above the cut off for possible anxiety)Tj 0 -1.401 TD -0.0037 Tc 0.0768 Tw [(disorder)53.3(. Patients diagnosed with full or sub-threshold)]TJ T* -0.0033 Tc -0.0305 Tw (PTSD were more likely to have scores above the cut off)Tj 0 -1.398 TD -0.0029 Tc 0.068 Tw [(for anxiety \(Fisher)-38.9()54.1(s)-0.1( exact test, )]TJ /TT5 1 Tf 12.891 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.495 0 TD -0.0027 Tc 0.0699 Tw [( < 0.001\). )51.2(At 3-years)]TJ -13.386 -1.401 TD -0.0036 Tc -0.0386 Tw (again the CAPS correlated significantly with the HADS)Tj T* -0.0039 Tc -0.0175 Tw (depression \(Pearson )Tj /TT5 1 Tf 8.166 0 TD 0 Tc 0 Tw (r)Tj /TT2 1 Tf 0.384 0 TD -0.0024 Tc -0.0183 Tw [( = 0.77, )]TJ /TT5 1 Tf 3.24 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.495 0 TD -0.0038 Tc -0.018 Tw [( < 0.001\) and the HADS)]TJ -12.285 -1.398 TD -0.0092 Tc -0.06 Tw (anxiety \(Pearson )Tj /TT5 1 Tf 6.669 0 TD 0 Tc 0 Tw (r)Tj /TT2 1 Tf 0.375 0 TD -0.0087 Tc -0.0634 Tw [( = 0.80, )]TJ /TT5 1 Tf 3.051 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.489 0 TD -0.0101 Tc -0.0625 Tw [( < 0.001\))]TJ /F9 1 Tf -12.384 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0034 Tc 0.0608 Tw [(At 3-years six patients \(7%\) reported pharmacological)]TJ 0 -1.398 TD -0.0033 Tc 0.0517 Tw (and/or psychotherapeutic treatment related to the acci-)Tj 0 -1.401 TD -0.0036 Tc 0.0072 Tw (dent. Of these, four were diagnosed with PTSD or sub-)Tj T* 0.065 Tw (threshold PTSD at any assessment.)Tj /TT1 1 Tf 11 0 0 11 321 722.64 Tm 0.0217 Tc 0 Tw [(CONCLUSIONS/SUMMAR)32.6(Y)]TJ /F9 1 Tf 10 0 0 10 321 706.65 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0089 Tc -0.0625 Tw (The relatively low incidence of PTSD is remarkable con-)Tj 0 -1.401 TD 0.0055 Tc 0.125 Tw (sidering the severity of the injuries sustained by the)Tj 0 -1.398 TD 0.0029 Tc 0 Tw (participants.)Tj /F9 1 Tf -1.8 -1.602 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc 0.0057 Tw (This finding is congruent with several other studies ex-)Tj 0 -1.398 TD -0.0034 Tc -0.049 Tw [(amining PTSD rates after severe injury)59.6(.)]TJ /F9 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0114 Tc -0.0621 Tw (PTSD becomes less predictive at 3-year follow-up. How-)Tj 0 -1.398 TD -0.0105 Tc [(ever)40.5(, the author)-40.5()52.5(s)0( model explained 32% of the variance at)]TJ 0 -1.401 TD -0.003 Tc 0.1043 Tw (1-year compared with 23% at 3-years, illustrating the)Tj T* -0.0029 Tc -0.0125 Tw [(relative stability of the disorder)51.1(.)]TJ /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD 0.0031 Tc 0.125 Tw (The findings underscore the importance of assessing)Tj 0 -1.401 TD -0.0198 Tc -0.0624 Tw [(prevalence rates, as well as the individual)52.2(s)0( clinical course.)]TJ /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc 0.0884 Tw (Co-morbid anxiety and depression scores suggest that)Tj 0 -1.401 TD -0.0032 Tc -0.0466 Tw (it is important not to only focus on PTSD, and be sure to)Tj 0 -1.398 TD -0.0034 Tc -0.04 Tw (examine non-specific psychiatric conditions related to a)Tj 0 -1.401 TD -0.0037 Tc 0.12 Tw [(severe accident.)]TJ /TT1 1 Tf 11 0 0 11 321 470.64 Tm 0.0267 Tc 0 Tw [(LIMIT)62.2(A)72.5(TIONS)]TJ /F9 1 Tf 10 0 0 10 321 454.65 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0033 Tc 0.1068 Tw (The restriction of the sample to include only German)Tj 0 -1.401 TD -0.044 Tw [(speaking participants limits the external validity)59.7(.)]TJ /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0095 Tc -0.0622 Tw (The decrease of the variance explained from 32% to 23%)Tj 0 -1.401 TD -0.003 Tc -0.0462 Tw (at 3-year follow-up may reduce the clinical relevance of)Tj 0 -1.398 TD -0.004 Tc -0.06 Tw (the model.)Tj /F9 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc 0.0305 Tw (The low level of PTSD symptoms in the sample might)Tj 0 -1.398 TD -0.0037 Tc -0.0129 Tw (limit the prediction model with populations with higher)Tj 0 -1.401 TD -0.0048 Tc -0.06 Tw (PTSD rates.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc -0.0081 Tw (The grouping of biographical risk factors form 0-17 as-)Tj 0 -1.401 TD 0.1145 Tw (sumes that the higher the number the higher the risk.)Tj T* 0.0014 Tc 0.125 Tw (This does not take into consideration the full impact)Tj 0 -1.398 TD -0.0032 Tc 0.0278 Tw (these different factors may have. The biographical risk)Tj 0 -1.401 TD 0.1243 Tw (factors assessed in this study were general psychoso-)Tj T* -0.0033 Tc 0.0883 Tw (cial risk factors in childhood predicting psychological)Tj 0 -1.398 TD -0.0032 Tc -0.0619 Tw (health in the long term, not specifically the development)Tj 0 -1.401 TD -0.0169 Tc -0.06 Tw (of PTSD.)Tj ET 3.99 w /GS1 gs 321 214.005 m 558 214.005 l S BT /TT1 1 Tf 11 0 0 11 321 195 Tm /GS2 gs -0.0033 Tc 0.0344 Tw (Goldman, R. L., Radnitz, C. L., & McGrath, R. E.)Tj 0 -1.1809 TD 0.0104 Tc 0.1254 Tw (\(2008\). Posttraumatic stress disorder and major)Tj 0 -1.1836 TD 0.0228 Tc 0.1253 Tw [(depr)14.6(ession in veterans with spinal cord injur)-7.2(y)56.4(.)]TJ ET 0.99 w /GS1 gs 321 147.495 m 558 147.495 l S BT /TT4 1 Tf 11 0 0 11 321 156 Tm /GS2 gs 0.0077 Tc 0.1259 Tw [(Rehabilit)7.7(ation Psychology)37.7(, 53)]TJ /TT1 1 Tf 12.7309 0 TD 0.008 Tc 0 Tw (\(2\),)Tj /TT4 1 Tf 1.4509 0 TD 0 Tc ( )Tj /TT1 1 Tf 0.39 0 TD 0.0071 Tc (162-170.)Tj -14.5718 -2.9782 TD -0.008 Tc 0.1236 Tw [(TYPE OF)27.4( )46.5(A)10(R)27.5(TICLE)]TJ /F9 1 Tf 10 0 0 10 321 107.25 Tm 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0031 Tc -0.0501 Tw [(Exploratory Factor )50.8(Analysis)]TJ ET endstream endobj 332 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /F9 57 0 R /TT1 8 0 R /TT2 9 0 R /TT3 10 0 R /TT4 20 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 334 0 obj << /Length 9071 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 54 59.745 m 546 59.745 l S BT /F1 1 Tf 8 0 0 8 54.99 41.64 Tm 0 0 0 1 k /GS2 gs -0.0052 Tc 0.1209 Tw [(228 )]TJ /TT3 1 Tf 2.8388 0 TD -0.0058 Tc (Selected Annotated Journal Resources)Tj /TT1 1 Tf 11 0 0 11 54 722.64 Tm 0.0066 Tc 0.126 Tw [(OBJECTIVE/PURPOSE OF)31.1( )14.4(THE )47.8(A)13.7(R)28.4(TICLE)]TJ /F9 1 Tf 10 0 0 10 54 706.65 Tm 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0035 Tc 0.015 Tw (This study explored the relation between posttraumatic)Tj 0 -1.401 TD -0.0038 Tc 0.1183 Tw (stress disorder \(PTSD\) and major depressive disorder)Tj 0 -1.398 TD -0.0034 Tc 0.0122 Tw (\(MDD\) in veterans with spinal cord injury and to com-)Tj 0 -1.401 TD -0.0018 Tc 0.125 Tw (pare those results with results found in veterans who)Tj T* -0.0033 Tc 0.0237 Tw [(had sustained other traumatic injury)59.7(.)]TJ /TT1 1 Tf 11 0 0 11 54 618.66 Tm 0.0265 Tc 0 Tw (PROCEDURE)Tj 0 -1.4564 TD 0.0026 Tc (Participants)Tj /F9 1 Tf 10 0 0 10 54 586.65 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0035 Tc -0.007 Tw (A total of 173 male veterans and 1 female veteran were)Tj 0 -1.401 TD -0.0046 Tc -0.0621 Tw [(recruited from services at )13.4(V)117.6(eterans )52.4(A)6.6(f)19.4(fairs Medical Cen-)]TJ 0 -1.398 TD -0.0109 Tc [(ters in the New )34.2(Y)105.3(ork metropolitan area between 1993 and)]TJ 0 -1.401 TD -0.0563 Tc 0 Tw (1995.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0101 Tc -0.0621 Tw (124 participants had traumatic spinal cord injuries \(SCIs\))Tj 0 -1.401 TD -0.0021 Tc 0.125 Tw (and were recruited from inpatient and outpatient SCI)Tj T* 0.0068 Tc 0 Tw (services.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc -0.06 Tw (An additional 50 participants were recruited from ortho-)Tj 0 -1.401 TD 0.0143 Tc 0.125 Tw (pedic services and rehabilitation medicine services.)Tj 0 -1.398 TD -0.0013 Tc (These individuals had sustained other traumatic inju-)Tj 0 -1.401 TD -0.0034 Tc 0.0194 Tw (ries, comparable to those of the veterans with SCI, and)Tj T* -0.0038 Tc 0.028 Tw [(were used as a comparison group.)]TJ /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0041 Tc -0.0625 Tw (Mean age of the participants was 49.3 years \()Tj /TT5 1 Tf 17.451 0 TD -0.0132 Tc 0 Tw (SD)Tj /TT2 1 Tf 1.209 0 TD -0.004 Tc -0.0625 Tw [( = 14.3\).)]TJ /F9 1 Tf -20.46 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0034 Tc 0.035 Tw (Fifty-four percent of participants identified themselves)Tj 0 -1.401 TD -0.0038 Tc 0.0664 Tw [(as )17.1(White, 33.9 % as )50.1(African )53.1(American, and 12.1 % as)]TJ T* -0.0142 Tc 0 Tw (Latino.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0069 Tc -0.0625 Tw (Of the 174 participants, 69 had a history of combat expo-)Tj 0 -1.401 TD -0.0034 Tc 0.1022 Tw (sure, 51 served in combat theaters but were never di-)Tj 0 -1.398 TD -0.0138 Tc -0.0625 Tw (rectly involved in combat, 53 had military experience that)Tj 0 -1.401 TD 0.0541 Tc 0.1249 Tw [(did not include serving in a war theater)39.1(, and 1)]TJ T* -0.0038 Tc -0.0333 Tw [(participant)53.2(s information was unavailable.)]TJ /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0143 Tc -0.0625 Tw (38.5 % of the sample were married, 30.5 % were divorced)Tj 0 -1.401 TD -0.0035 Tc -0.0325 Tw (or separated, 27 % were single, and 4 % were widowed.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0039 Tc 0.0991 Tw (Among those participants diagnosed with SCI, 57.3%)Tj 0 -1.401 TD -0.062 Tw (were tetraplegic and 42.7% were paraplegic.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0035 Tc 0.0611 Tw (The most common source of the injury was motor ve-)Tj 0 -1.401 TD -0.0059 Tc -0.0621 Tw (hicle accidents \(37.0%\), followed by falling \(27%\), non-)Tj 0 -1.398 TD -0.0079 Tc -0.0625 Tw (military violence \(12.1%\), sports accidents \(7.5%\), other)Tj 0 -1.401 TD -0.005 Tc (traumatic injuries \(5.7%\), combat violence \(5.6%\), mili-)Tj T* -0.0033 Tc -0.0236 Tw (tary non-combat violence \(4.0%\), and medical or surgi-)Tj 0 -1.398 TD -0.0139 Tc -0.0625 Tw (cal injuries \(1.1%\).)Tj /F9 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0097 Tc -0.0622 Tw (Participants injuries had occurred on average 18.46 years)Tj 0 -1.398 TD 0 Tc 0 Tw (\()Tj /TT5 1 Tf 0.33 0 TD -0.0132 Tc (SD)Tj /TT2 1 Tf 1.209 0 TD -0.0029 Tc -0.0445 Tw [( = 19.8\) prior to their recruitment for the study)60.1(.)]TJ /F9 1 Tf -3.339 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD 0.0021 Tc 0.125 Tw (For those diagnosed with both MDD and PTSD, the)Tj 0 -1.398 TD -0.0068 Tc -0.0621 Tw (mean time since injury was 15.13 years \()Tj /TT5 1 Tf 15.681 0 TD -0.0162 Tc 0 Tw (SD)Tj /TT2 1 Tf 1.203 0 TD -0.007 Tc -0.0625 Tw [( = 18.3\).)]TJ /TT1 1 Tf 11 0 0 11 309 722.64 Tm 0.0242 Tc 0 Tw (Procedure)Tj /F9 1 Tf 10 0 0 10 309 706.65 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0033 Tc (Analyses were based on data that were collected over a)Tj 0 -1.401 TD -0.0038 Tc -0.0284 Tw (period of 18 months.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD 0.0089 Tc 0.125 Tw (Before participants were recruited, researchers were)Tj 0 -1.401 TD -0.0036 Tc 0.0725 Tw (trained to administer the Structured Clinical Interview)Tj 0 -1.398 TD -0.0192 Tc -0.062 Tw (for DSM-III-R \(SCID\) and Clinician-Administered PTSD)Tj 0 -1.401 TD -0.0186 Tc -0.06 Tw (Scale \(CAPS\).)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0033 Tc 0.0791 Tw (Interrater reliability estimates obtained after 13 CAPS)Tj 0 -1.401 TD -0.0034 Tc 0.01 Tw (interviews, yielded 100% agreement between raters di-)Tj T* -0.0149 Tc -0.0625 Tw (agnosing current PTSD, and 92% for lifetime PTSD diag-)Tj 0 -1.398 TD 0.0188 Tc 0 Tw (nosis.)Tj /F9 1 Tf -1.8 -1.602 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc 0.0794 Tw (Diagnoses of PTSD were assigned only in cases were)Tj 0 -1.398 TD -0.0039 Tc 0.0595 Tw [(there was consensus on both the CAPS and the SCID.)]TJ 0 -1.401 TD -0.004 Tc -0.0285 Tw (Agreement between instruments was reached in 93% of)Tj T* -0.0037 Tc -0.0533 Tw (the cases for current PTSD and 89% for lifetime PTSD.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0035 Tc 0.112 Tw [(T)73.3(o)0( recruit participants, research assistants approached)]TJ 0 -1.401 TD 0.0011 Tc 0.125 Tw (persons with SCI and/or other traumatic injuries and)Tj 0 -1.398 TD -0.0032 Tc -0.016 Tw [(asked if the would participate in the study)62.8(. )50.8(After a com-)]TJ 0 -1.401 TD 0.004 Tc 0.125 Tw [(plete description of the study)64(, informed consent was)]TJ T* -0.0037 Tc -0.025 Tw [(gathered. )17.3(T)70.1(welve volunteers were excluded due to scor)17.3(-)]TJ 0 -1.398 TD -0.0056 Tc -0.0622 Tw (ing below cut-off on the Mini-Mental State Examination)Tj 0 -1.401 TD -0.0038 Tc -0.0238 Tw [(\(MMSE\) and 1 was excluded due to incomplete data.)]TJ /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.004 Tc 0.1119 Tw (Those not excluded were given the SCID and CAPS.)Tj 0 -1.401 TD -0.0036 Tc -0.0543 Tw (The Beck Depression Inventory \(BDI\) and personal his-)Tj T* -0.0033 Tc -0.0625 Tw [(tory form were administered in writing or by interview)59.7(.)]TJ /TT1 1 Tf 11 0 0 11 309 342.66 Tm 0.0557 Tc 0 Tw (Measures)Tj /F9 1 Tf 10 0 0 10 309 326.64 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD 0.0343 Tc 0.125 Tw (Authors used the personal history form to gather)Tj 0 -1.398 TD -0.0167 Tc -0.0621 Tw (demographical information and data related to the trauma.)Tj /F9 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0038 Tc 0.0656 Tw (The BDI was used to assess depression. The BDI was)Tj 0 -1.398 TD -0.0034 Tc 0.1116 Tw (used because of its wide acceptance as a reliable and)Tj 0 -1.401 TD -0.0035 Tc -0.045 Tw (valid tool.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0037 Tc 0.0971 Tw (Posttraumatic stress was assessed using the Impact of)Tj 0 -1.401 TD -0.0038 Tc -0.0219 Tw (Events Scale- Revised two months and six months after)Tj T* -0.0036 Tc 0.12 Tw (the event.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0055 Tc -0.0622 Tw (The CAPS was used to assess current and lifetime PTSD)Tj 0 -1.401 TD -0.0077 Tc -0.0623 Tw [(prevalence. )10.5(T)75.1(est-retest reliability estimates for the CAPS)]TJ 0 -1.398 TD -0.0041 Tc -0.0617 Tw [(range from .77 to .96 and a coefficient )-82.3(=)-0.1( .94.)]TJ /F9 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0039 Tc 0.0881 Tw (The MMSE was used to screen for possible cognitive)Tj 0 -1.398 TD -0.003 Tc -0.0119 Tw (impairment that may interfere with the ability to under-)Tj 0 -1.401 TD -0.0033 Tc 0.1062 Tw (stand and accurately answer questions.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0034 Tc 0.0306 Tw (The SCID was used to assess current and lifetime psy-)Tj 0 -1.401 TD -0.0011 Tc 0.125 Tw (chiatric diagnoses. The authors used the SCID, Non-)Tj T* 0.0102 Tc 0.1249 Tw [(patient )22.1(V)60.4(ietnam )22.1(V)111.4(ersion to measure the presence or)]TJ 0 -1.398 TD -0.0041 Tc -0.0621 Tw (absence of PTSD symptoms. Reliability estimates of the)Tj ET endstream endobj 335 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /F9 57 0 R /TT1 8 0 R /TT2 9 0 R /TT3 10 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 337 0 obj << /Length 8674 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 66 59.745 m 558 59.745 l S BT /TT3 1 Tf 8 0 0 8 423.24 42.6 Tm 0 0 0 1 k /GS2 gs -0.0051 Tc 0.0326 Tw [(IJEMH Vol. 10, No. 3 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (229)Tj /TT2 1 Tf 10 0 0 10 84 722.64 Tm -0.0038 Tc 0.1178 Tw (SCID have been shown to be comparable to those of)Tj 0 -1.398 TD -0.0075 Tc -0.0625 Tw (other diagnostic interviews, with overall weighted kappa)Tj 0 -1.401 TD -0.0033 Tc 0.0622 Tw (values of .61 for current disorders and .68 for lifetime)Tj T* 0.0174 Tc 0 Tw (diagnoses.)Tj /TT1 1 Tf 11 0 0 11 66 648.66 Tm 0.0154 Tc [(RESUL)83.6(TS)]TJ /F9 1 Tf 10 0 0 10 66 632.64 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.006 Tc -0.0625 Tw [(T)70.8(o)0( examine the relationship between PTSD and MDD in)]TJ 0 -1.398 TD -0.0036 Tc -0.0014 Tw (persons with SCI, the authors conducted three different)Tj 0 -1.401 TD 0.014 Tc 0 Tw (analyses.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0075 Tc -0.0622 Tw (Pearson correlations were computed to examine the rela-)Tj 0 -1.401 TD -0.0035 Tc 0.0433 Tw (tion between corresponding items \(i.e., anhedonia, im-)Tj T* -0.0142 Tc -0.0622 Tw [(paired sleep, and concentration problems\) from the PTSD)]TJ 0 -1.398 TD -0.004 Tc 0.0405 Tw (and MDD modules of the SCID, BDI, and CAPS. The)Tj 0 -1.401 TD -0.0035 Tc -0.0229 Tw (mean correlation value for those symptoms endorsed as)Tj T* -0.0033 Tc -0.002 Tw (part of a current diagnosis in the total sample was 0.35,)Tj 0 -1.398 TD -0.0085 Tc -0.0625 Tw (0.33 for those with SCI, and 0.49 for person without SCI.)Tj /F9 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0032 Tc -0.0425 Tw (The authors implemented an exploratory factor analysis)Tj 0 -1.398 TD -0.0046 Tc -0.0623 Tw (of the items from the CAPS and BDI. The authors used a)Tj 0 -1.401 TD -0.0056 Tc -0.0625 Tw (parallel analysis to determine how many factors to retain)Tj T* -0.0031 Tc -0.0408 Tw (on the basis of preliminary principal components analy-)Tj 0 -1.398 TD -0.0034 Tc 0.0289 Tw (sis. This resulted in retaining two factors for both non-)Tj 0 -1.401 TD -0.0037 Tc 0.0568 Tw (SCI and SCI samples. The authors then used principal)Tj T* -0.0034 Tc -0.0385 Tw (axis factor analysis with varimax rotation to determine)Tj 0 -1.398 TD -0.0037 Tc 0.06 Tw (factor loadings.)Tj /F9 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0057 Tc -0.0625 Tw (The authors selected a cut-off of .40 for loadings to iden-)Tj 0 -1.398 TD -0.0015 Tc 0.125 Tw (tify the items that best characterized each of the two)Tj 0 -1.401 TD 0.0042 Tc 0 Tw (factors.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0033 Tc -0.0106 Tw (For the SCI group, the first factor loaded )Tj /F9 1 Tf 16.356 0 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 0.543 0 TD -0.0031 Tc -0.0112 Tw [( .40 on 19 of)]TJ -16.899 -1.401 TD -0.0089 Tc -0.0619 Tw (the 21 BDI items. The second factor loaded )Tj /F9 1 Tf 16.815 0 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 0.54 0 TD -0.0089 Tc -0.0633 Tw (.40 on 14 of)Tj -17.355 -1.401 TD -0.0038 Tc 0.0595 Tw (the 17 CAPS items. 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Specifically some items did not load on the)Tj T* -0.0165 Tc -0.0623 Tw (same factor as did other items from their respective scales,)Tj 0 -1.398 TD -0.0034 Tc -0.0369 Tw [(some did not load on either of the two factors, and some)]TJ 0 -1.401 TD -0.0036 Tc 0.0717 Tw (loaded on both factors.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0087 Tc -0.0622 Tw (Five of the CAPS items loaded on the first factor with the)Tj 0 -1.401 TD -0.008 Tc -0.0625 Tw (majority of the BDI items, whereas four of the BDI items)Tj T* 0.0017 Tc 0.125 Tw (loaded on the second factor with the majority of the)Tj 25.5 64.8 TD -0.0076 Tc -0.0621 Tw (CAPS items. Therefore, in participants who have experi-)Tj 0 -1.398 TD -0.014 Tc -0.0625 Tw [(enced a non-SCI traumatic injury)61(, MDD and PTSD repre-)]TJ 0 -1.401 TD -0.0034 Tc 0.0843 Tw (sent two independent reactions, but are not as distinct)Tj T* -0.0036 Tc -0.0488 Tw (as in individuals with SCI.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0038 Tc 0.1 Tw (Pearson correlations were computed between the four)Tj 0 -1.401 TD -0.0034 Tc 0.0675 Tw (factors to determine if the factor structure was consis-)Tj 0 -1.398 TD -0.0036 Tc -0.0119 Tw (tent across the two samples. 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Thus, a portion of the)Tj 0 -1.398 TD -0.0034 Tc 0.0043 Tw (sample may have been subjected to additional traumas.)Tj 0 -1.401 TD -0.0032 Tc 0.1016 Tw (Also, there is possibility that participants experienced)Tj T* -0.04 Tw (other types of traumatic events before their SCI, such as)Tj 0 -1.398 TD -0.007 Tc -0.0626 Tw (crime victimization or child abuse.)Tj /F9 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0034 Tc 0.0333 Tw (Participants may have experienced earlier traumas dis-)Tj 0 -1.398 TD -0.0115 Tc -0.0617 Tw [(tinct form SCI injury)63.5(.)]TJ /F9 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0033 Tc 0.0792 Tw (Participants were largely male veterans receiving care)Tj 0 -1.398 TD -0.0038 Tc 0.0333 Tw [(form Northeastern )17.2(V)112.4(eterans )50.2(A)7.4(f)17.2(fairs Medical Centers in)]TJ 0 -1.401 TD -0.0034 Tc -0.04 Tw (urban, suburban, and rural settings. This calls into ques-)Tj T* -0.0129 Tc -0.0625 Tw (tion if these finding can be generalized to other SCI popu-)Tj 0 -1.398 TD 0.0012 Tc 0 Tw (lations.)Tj ET endstream endobj 338 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /F9 57 0 R /TT1 8 0 R /TT2 9 0 R /TT3 10 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 340 0 obj << /Length 8745 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 54 59.745 m 546 59.745 l S BT /F1 1 Tf 8 0 0 8 54.99 41.64 Tm 0 0 0 1 k /GS2 gs -0.0052 Tc 0.1209 Tw [(230 )]TJ /TT3 1 Tf 2.8388 0 TD -0.0058 Tc (Selected Annotated Journal Resources)Tj ET 3.99 w /GS1 gs 54 728.985 m 291 728.985 l S BT /TT1 1 Tf 11 0 0 11 54 710.01 Tm /GS2 gs 0.0164 Tc 0.1251 Tw [(Neuner)90(, F)90(., Onyut, P)81.9(.)-0.3( L., & Er)-5.4(tl, )13.8(V)133.1(., Odenwald,)]TJ 0 -1.1836 TD 0.0144 Tc 0.1249 Tw [(M., Schauer)88(, E., & Elbert, )14(T)75.9(.)-0.4( \(2008\). )14(T)81.4(r)19.2(eatment)]TJ 0 -1.1809 TD 0.0222 Tc 0.125 Tw (of posttraumatic stress disorder by trained lay)Tj T* 0.0255 Tc 0.1249 Tw [(counselors in an )52.7(African r)17.3(efugee settlement: )47.2(A)]TJ 0 -1.1836 TD -0.0033 Tc 0.0523 Tw (randomized controlled trial.)Tj /TT4 1 Tf 12.0409 0 TD -0.0036 Tc 0.0531 Tw [( Journal of Consulting)]TJ ET 0.99 w /GS1 gs 54 635.535 m 291 635.535 l S BT 11 0 0 11 54 644.04 Tm /GS2 gs 0.0077 Tc 0.1262 Tw [(and Clinical Psychology)35(, 76)]TJ /TT1 1 Tf 12.0491 0 TD 0.008 Tc 0 Tw (\(4\),)Tj /TT4 1 Tf 1.4509 0 TD 0 Tc ( )Tj /TT1 1 Tf 0.39 0 TD 0.0071 Tc (686-694.)Tj -13.89 -3.1227 TD -0.008 Tc 0.1236 Tw [(TYPE OF)27.5( )46.5(A)10(R)27.5(TICLE)]TJ /F9 1 Tf 10 0 0 10 54 593.7 Tm 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0084 Tc -0.0625 Tw (Randomized controlled trial)Tj /TT1 1 Tf 11 0 0 11 54 561.69 Tm 0.0066 Tc 0.126 Tw [(OBJECTIVE/PURPOSE OF)31.1( )14.4(THE )47.8(A)13.7(R)28.4(TICLE)]TJ /F9 1 Tf 10 0 0 10 54 545.7 Tm 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0032 Tc -0.0564 Tw (This study examined whether trained lay counselors can)Tj 0 -1.401 TD -0.0386 Tw (carry out effective treatment of posttraumatic stress dis-)Tj 0 -1.398 TD -0.0036 Tc -0.044 Tw (order \(PTSD\) in a refugee settlement.)Tj /TT1 1 Tf 11 0 0 11 54 485.7 Tm 0.0265 Tc 0 Tw (PROCEDURE)Tj 0 -1.4536 TD 0.0026 Tc (Participants)Tj /F9 1 Tf 10 0 0 10 54 453.69 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0035 Tc -0.0472 Tw (A team of 12 research assistants were recruited from the)Tj 0 -1.398 TD 0.0252 Tc 0.1248 Tw [(refugee community)64.2(, 50% were Somalian and 50%)]TJ 0 -1.401 TD -0.0137 Tc -0.0622 Tw (Rwandan. They were trained in a six-week course in prin-)Tj T* -0.0036 Tc 0.1 Tw (ciples of quantitative data collection and interviewing)Tj 0 -1.398 TD 0.0124 Tc 0 Tw (techniques.)Tj /F9 1 Tf -1.8 -1.602 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0035 Tc 0.02 Tw (The sample consisted of 1,442 refugees randomly cho-)Tj 0 -1.398 TD -0.0032 Tc 0.0046 Tw (sen using cluster sampling. Of this group, 884 refugees)Tj 0 -1.401 TD -0.0129 Tc -0.062 Tw [(fulfilled DSM-IV)17.1( criteria of PTSD. Finally)62.1(, 277 individu-)]TJ T* -0.0031 Tc 0.0575 Tw (als were chosen due to their close proximity to the re-)Tj 0 -1.398 TD -0.0034 Tc 0.0462 Tw (search base in the settlement.)Tj /TT1 1 Tf 11 0 0 11 54 293.7 Tm 0.0242 Tc 0 Tw (Procedure)Tj /F9 1 Tf 10 0 0 10 54 277.71 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0033 Tc 0.0862 Tw (Analyses were based on data that were collected over)Tj 0 -1.401 TD -0.0044 Tc -0.0625 Tw (the years 2003 and 2004.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0033 Tc 0.0478 Tw (Participants were randomly assigned to a narrative ex-)Tj 0 -1.401 TD -0.0036 Tc 0.1109 Tw (posure therapy \(NET\) group, trauma counseling \(TC\))Tj T* -0.0038 Tc -0.0291 Tw (group, or a no-treatment monitoring group \(MG\).)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0063 Tc -0.0621 Tw (Participants were approached by their counselors at their)Tj 0 -1.401 TD -0.0205 Tc (home and informed of the protocol with all refugees agree-)Tj 0 -1.398 TD -0.0034 Tc 0.005 Tw (ing to participate.)Tj /F9 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0037 Tc 0.0633 Tw (Participants who received treatment were reassessed 3)Tj 0 -1.398 TD -0.0032 Tc -0.0184 Tw (and 6 months later by the same local research assistants)Tj 0 -1.401 TD -0.0033 Tc 0.0977 Tw [(who had done the interviews for the survey and were)]TJ T* -0.0035 Tc 0.0065 Tw (blind with respect to the particular treatment condition.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc 0.092 Tw [(Individuals in the MG group were retested at 6 and 9)]TJ 0 -1.401 TD 0.005 Tc 0 Tw (months.)Tj /F9 1 Tf 23.7 63.495 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0035 Tc 0.0715 Tw (At 9 months the baseline psychopathological status of)Tj 0 -1.398 TD -0.0032 Tc 0.1162 Tw [(the participants in all three groups was assessed by a)]TJ 0 -1.401 TD -0.0036 Tc 0.0744 Tw (group of five expert interviewers who were not previ-)Tj T* -0.0026 Tc 0.015 Tw (ously involved in any aspect of the trial.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc 0.055 Tw (Nine refugees from the community \(5 women, 4 men\))Tj 0 -1.401 TD -0.0032 Tc -0.0225 Tw (with a mean age of 27 years were trained as counselors.)Tj 0 -1.398 TD -0.0034 Tc -0.0072 Tw (Eduacation level of the counselors varied from primary)Tj 0 -1.401 TD -0.0035 Tc 0.125 Tw (school \()Tj /TT5 1 Tf 3.294 0 TD 0 Tc 0 Tw (n)Tj /TT2 1 Tf 0.495 0 TD -0.0022 Tc 0.125 Tw [( =1\), secondary school \()]TJ /TT5 1 Tf 10.095 0 TD 0 Tc 0 Tw (n)Tj /TT2 1 Tf 0.495 0 TD -0.0016 Tc 0.125 Tw [( =7\), to university)]TJ -14.379 -1.401 TD -0.0106 Tc -0.06 Tw (educated \()Tj /TT5 1 Tf 3.975 0 TD 0 Tc 0 Tw (n)Tj /TT2 1 Tf 0.489 0 TD -0.0101 Tc -0.0625 Tw [( =1\). Three of the trainees had lifetime PTSD,)]TJ -4.464 -1.398 TD -0.0036 Tc -0.0325 Tw (and two had current PTSD. These five trainees received)Tj 0 -1.401 TD -0.0031 Tc -0.0339 Tw (NET treatment by the trainers as part of their education.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc 0.0537 Tw (Trainees were educated in a 6-week course on general)Tj 0 -1.401 TD -0.005 Tw (counseling skills. The trainees were educated on all ap-)Tj T* 0.0349 Tc 0.125 Tw [(proaches used in the study)61.9(.)-6.1( )19.9(The trainers were all)]TJ 0 -1.398 TD -0.0037 Tc -0.0375 Tw (postdoctoral and doctoral-level personnel from the Uni-)Tj 0 -1.401 TD -0.0138 Tc -0.062 Tw [(versity of Konstantz, Germany)61.2(, the aid or)19.2(ganization )13.3(V)69.4(ivo,)]TJ T* 0.007 Tc 0.1249 Tw [(and Mbarara University of Science and )15.9(T)71.8(echnology)61(,)]TJ 0 -1.398 TD 0.0025 Tc 0 Tw (Uganda.)Tj /F9 1 Tf -1.8 -1.602 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0033 Tc 0.125 Tw (The head of the Ugandan Counseling Institute devel-)Tj 0 -1.398 TD -0.0038 Tc 0.0034 Tw (oped the TC treatment.)Tj /F9 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0015 Tc 0.125 Tw (Trainee counselors received intensive supervision for)Tj 0 -1.398 TD -0.0037 Tc 0.015 Tw (both approaches before allowed to work autonomously)Tj 0 -1.401 TD 0.02 Tw (with participants.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0034 Tc 0.0519 Tw (Both treatment types were conducted for 6 sessions \(2)Tj 0 -1.401 TD -0.0036 Tc 0.037 Tw (sessions per week\) that were between 1 and 2 hours in)Tj T* 0.0042 Tc 0 Tw (length.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD 0.0217 Tc 0.125 Tw (In each protocol, the first session always included)Tj 0 -1.401 TD 0.0078 Tc (psychoeducation about the nature and prevalence of)Tj 0 -1.398 TD -0.0037 Tc -0.025 Tw (PTSD symptoms and what treatment would entail.)Tj /F9 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0037 Tc -0.0355 Tw (NET was carried out as outlined in the NET manual.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc 0.1087 Tw (The TC condition was applied as a flexible treatment)Tj 0 -1.401 TD -0.0033 Tc 0.0931 Tw (approach that combines a combination of a variety of)Tj 0 -1.398 TD -0.0118 Tc -0.0625 Tw (counseling methods that can be implemented at the thera-)Tj 0 -1.401 TD -0.0035 Tc 0.0822 Tw [(pists)71.5( discretion. )53.5(A)58.7( main principle of )17.5(TC was to relate)]TJ T* -0.0038 Tc 0.1044 Tw [(current problems to past traumatic experiences. )50.4(Addi-)]TJ 0 -1.398 TD -0.0148 Tc -0.0625 Tw (tional skills included, non-directive active listening, prob-)Tj 0 -1.401 TD -0.0034 Tc 0.0462 Tw (lem solving, the exploration of coping skills, and grief)Tj T* 0.0061 Tc 0 Tw (interventions.)Tj /TT1 1 Tf 11 0 0 11 309 156.66 Tm 0.0557 Tc (Measures)Tj /F9 1 Tf 10 0 0 10 309 140.64 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD 0.059 Tc 0.66 Tw (The authors used a previously developed)Tj 0 -1.398 TD -0.0021 Tc 0.125 Tw (sociodemographical survey to assess nutritional, edu-)Tj 0 -1.401 TD -0.0037 Tc -0.035 Tw (cational, and socioeconomic, displacement, and general)Tj T* -0.0079 Tc -0.06 Tw (demographic information.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0038 Tc 0.0358 Tw (Traumatic experiences were assessed through a check-)Tj ET endstream endobj 341 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /F9 57 0 R /TT1 8 0 R /TT2 9 0 R /TT3 10 0 R /TT4 20 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 343 0 obj << /Length 12582 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 66 59.745 m 558 59.745 l S BT /TT3 1 Tf 8 0 0 8 423.24 42.6 Tm 0 0 0 1 k /GS2 gs -0.0051 Tc 0.0326 Tw [(IJEMH Vol. 10, No. 3 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (231)Tj /TT2 1 Tf 10 0 0 10 84 722.64 Tm -0.0074 Tc -0.0622 Tw (list of 31 different types of traumatic events. 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In the author)-33()54(s)0( translation, the sum score reached)]TJ 0 -1.398 TD -0.0035 Tc (a retest reliability of 0.87 over a 2-week period.)Tj /F9 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc -0.0621 Tw (Physical symptoms were assessed using a checklist with)Tj 0 -1.398 TD 0.0244 Tw (six illnesses and symptoms that had been present more)Tj 0 -1.401 TD -0.0032 Tc 0.013 Tw [(that 25% in a previous survey)59.8(.)]TJ /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0041 Tc -0.0012 Tw (The DSM-IV diagnosis of PTSD was assessed with the)Tj 0 -1.401 TD -0.0036 Tc 0.0088 Tw (PTSD section of the CIDI. Trained local translators as-)Tj T* -0.0032 Tc -0.0193 Tw (sisted in linguistically adapting this measure. The inter-)Tj 0 -1.398 TD 0.0043 Tc 0.125 Tw (view was conducted by Ph.D.-level psychologists or)Tj 0 -1.401 TD -0.0034 Tc 0.0636 Tw (graduate students who had been extensively trained in)Tj T* -0.0039 Tc -0.0014 Tw (PTSD assessment with the CIDI and other instruments.)Tj /TT1 1 Tf 11 0 0 11 66 434.25 Tm 0.0154 Tc 0 Tw [(RESUL)83.6(TS)]TJ /F9 1 Tf 10 0 0 10 66 418.26 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc -0.005 Tw (In the NET group, 4 participants \(3.6%\) dropped out or)Tj 0 -1.401 TD 0.0145 Tc 0.125 Tw (refused treatment. In the TC group, 22 participants)Tj T* -0.0037 Tc 0.0777 Tw [(\(19.8%\) did not complete therapy)59.3(.)-4.8( )17.1(The dif)14.3(ference was)]TJ 0 -1.398 TD -0.0222 Tc 0 Tw (significant, )Tj /F9 1 Tf 4.374 0 TD 0 Tc ()Tj /TT2 1 Tf 5.8 0 0 5.8 132.99 379.59 Tm (2)Tj 10 0 0 10 135.84 376.26 Tm -0.0223 Tc (\(1, )Tj /TT5 1 Tf 1.191 0 TD 0 Tc (N)Tj /TT2 1 Tf 0.639 0 TD -0.0217 Tc -0.062 Tw [( = 222\) = 14.12, )]TJ /TT5 1 Tf 6.036 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.474 0 TD -0.0222 Tc -0.0625 Tw [( = < .001. Drop out did)]TJ -13.524 -1.401 TD -0.0083 Tc -0.0621 Tw (not differ significantly from treatment completers on any)Tj T* -0.0107 Tc -0.06 Tw (variable \(all )Tj /TT5 1 Tf 4.785 0 TD -0.0192 Tc 0 Tw (ps)Tj /TT2 1 Tf 0.864 0 TD -0.0105 Tc -0.0634 Tw [( = > .20\).)]TJ /F9 1 Tf -7.449 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.013 Tc -0.0622 Tw (For the PDS sum score, a mixed-effects model was calcu-)Tj 0 -1.401 TD -0.0036 Tc 0.0444 Tw (lated with the PDS sum score as a dependent variable;)Tj 0 -1.398 TD -0.0034 Tc 0.12 Tw (participant as random effect; and treatment, time, na-)Tj 0 -1.401 TD -0.0055 Tc -0.0625 Tw [(tionality)63.5(, )15.1(T)35.3(ime x )15.1(T)35.3(reatment, and Nationality x )12.1(T)35.3(reatment)]TJ T* -0.0033 Tc 0.0411 Tw (as fixed effects. 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The Time x Treat-)]TJ -12.339 -1.401 TD -0.008 Tc (ment effect was significant )Tj /TT5 1 Tf 10.581 0 TD 0 Tc 0 Tw (F)Tj /TT2 1 Tf 0.6 0 TD -0.0072 Tc -0.0625 Tw [(\(2, 112\) = 6.03, )]TJ /TT5 1 Tf 6.108 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.492 0 TD -0.0075 Tc -0.0625 Tw [( < .01.)]TJ /F9 1 Tf -19.581 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0032 Tc (A contrast analysis of the Time x treatment interaction,)Tj 0 -1.401 TD -0.0038 Tc -0.0322 Tw (each treatment was compared to the MG group. Using a)Tj T* -0.0176 Tc -0.0625 Tw (Bonferroni-Holm correction of significance level, TC was)Tj 0 -1.398 TD -0.0094 Tc -0.061 Tw (superior to the MG group )Tj /TT5 1 Tf 9.936 0 TD 0 Tc 0 Tw (F)Tj /TT2 1 Tf 0.6 0 TD -0.0086 Tc -0.0617 Tw (\(1,112\) = 8.2, )Tj /TT5 1 Tf 5.418 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.492 0 TD -0.0095 Tc -0.0633 Tw [( = .0008. NET)]TJ -16.446 -1.401 TD -0.0037 Tc 0.0258 Tw (was also superior to the MG group )Tj /TT5 1 Tf 14.196 0 TD 0 Tc 0 Tw (F)Tj /TT2 1 Tf 0.603 0 TD -0.0028 Tc 0.025 Tw (\(1,112\) = 8.2, )Tj /TT5 1 Tf 5.766 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.495 0 TD 0.026 Tc ( =)Tj -21.06 -1.401 TD -0.05 Tc (.005.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0035 Tc 0.0633 Tw (Estimation of clinical significance of treatment effects)Tj 0 -1.401 TD -0.0037 Tc 0.0242 Tw (was examined by inspecting the PTSD diagnosis made)Tj 0 -1.398 TD -0.007 Tc -0.0625 Tw (by experts at follow-up. In the NET group, 69.8% of par-)Tj 0 -1.401 TD -0.0126 Tc (ticipants no longer met criteria for PTSD, in the TC group)Tj T* -0.0038 Tc 0.0094 Tw [(65.2% no longer had PTSD;however)35.2(, only 35.8% were)]TJ 0 -1.398 TD -0.0037 Tc -0.0324 Tw [(free of diagnosis in the MG group. Differences between)]TJ 0 -1.401 TD -0.0039 Tc -0.0617 Tw (the three group were generally significant )Tj /F9 1 Tf 16.404 0 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 5.8 0 0 5.8 508.44 428.01 Tm (2)Tj 10 0 0 10 511.41 424.65 Tm -0.0027 Tc (\(2, )Tj /TT5 1 Tf 1.26 0 TD 0 Tc (N)Tj /TT2 1 Tf 0.654 0 TD -0.0045 Tc -0.0625 Tw [( = 108\))]TJ -19.155 -1.401 TD -0.0022 Tc -0.0125 Tw (= 6.3, )Tj /TT5 1 Tf 2.526 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.495 0 TD -0.0033 Tc -0.0134 Tw [( < .042. )53.9(Additionally the dif)14.7(ference between the)]TJ -3.021 -1.398 TD -0.0039 Tc -0.0231 Tw (NET group and the MG group was significant )Tj /F9 1 Tf 18.315 0 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 5.8 0 0 5.8 527.61 399.99 Tm (2)Tj 10 0 0 10 530.55 396.66 Tm -0.003 Tc (\(1, )Tj /TT5 1 Tf 1.299 0 TD 0 Tc (N)Tj /TT2 1 Tf 0.66 0 TD -0.028 Tc ( =)Tj -21.114 -1.401 TD -0.0086 Tc -0.0617 Tw (53\) = 5.7, )Tj /TT5 1 Tf 3.87 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.486 0 TD -0.0097 Tc -0.0622 Tw [( < .017, as was the difference between TC and)]TJ -4.356 -1.401 TD -0.0273 Tc -0.0432 Tw [(MG)101.7(,)-16.8( )]TJ /F9 1 Tf 2.049 0 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 5.8 0 0 5.8 364.8 372 Tm (2)Tj 10 0 0 10 367.71 368.64 Tm -0.0147 Tc (\(1, )Tj /TT5 1 Tf 1.209 0 TD 0 Tc (N)Tj /TT2 1 Tf 0.651 0 TD -0.014 Tc -0.062 Tw [( = 65\) = 4.4, )]TJ /TT5 1 Tf 4.704 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.48 0 TD -0.0149 Tc -0.0625 Tw [( < .036.)]TJ /F9 1 Tf -11.715 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0031 Tc 0.0829 Tw [(T)73.7(o)0( estimate the changes in physical health symptoms,)]TJ 0 -1.401 TD 0.0029 Tc 0.125 Tw (the authors calculated a sum score of the number of)Tj 0 -1.398 TD -0.0028 Tc 0.0671 Tw (physical health symptoms experienced in the last year)Tj 0 -1.401 TD -0.0047 Tc -0.0622 Tw (for baseline and the follow-up time point. Using a mixed)Tj T* -0.0036 Tc -0.0443 Tw (model including the factors participant as random effect)Tj 0 -1.398 TD -0.0034 Tc 0.0443 Tw [(and treatment, time, nationality)59.6(, )17.6(T)37.4(ime x )17.6(T)37.4(reatment and)]TJ 0 -1.401 TD -0.0032 Tc -0.0343 Tw [(Nationality x Treatment as fixed effects, there were sig-)]TJ T* -0.0169 Tc -0.0615 Tw [(nificant ef)19.1(fects of nationality)58.1(, )]TJ /TT5 1 Tf 11.196 0 TD 0 Tc 0 Tw (F)Tj /TT2 1 Tf 0.588 0 TD -0.0172 Tc -0.0615 Tw [(\(1,1)30.8(16\) = 6.60, )]TJ /TT5 1 Tf 5.742 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.48 0 TD -0.0174 Tc -0.0633 Tw [( = .01, and)]TJ -18.006 -1.398 TD -0.0078 Tc -0.0614 Tw (a significant interaction of Time x Treatment, )Tj /TT5 1 Tf 17.7 0 TD 0 Tc 0 Tw (F)Tj /TT2 1 Tf 0.6 0 TD -0.0081 Tc -0.065 Tw (\(2,116\) =)Tj -18.3 -1.401 TD -0.0192 Tc 0 Tw (4.60, )Tj /TT5 1 Tf 2.076 0 TD 0 Tc (p)Tj /TT2 1 Tf 0.48 0 TD -0.02 Tc -0.0625 Tw [( = .01.)]TJ /F9 1 Tf -4.356 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0032 Tc 0.0367 Tw (In a contrast analysis of the Time x Treatment interac-)Tj 0 -1.401 TD -0.0154 Tc -0.0619 Tw [(tion, )14.4(TC was superior to MG)113.6(,)-6.1( )]TJ /TT5 1 Tf 11.115 0 TD 0 Tc 0 Tw (F)Tj /TT2 1 Tf 0.594 0 TD -0.0147 Tc -0.0612 Tw [(\(1,1)30.3(12\) = 5.56, )]TJ /TT5 1 Tf 5.787 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.48 0 TD -0.0144 Tc -0.0633 Tw [( = .02, and)]TJ -17.976 -1.401 TD -0.0113 Tc -0.062 Tw [(N)5.1(E)5.1(T)15.7( was superior to MG)111.7(,)-8.3( )]TJ /TT5 1 Tf 9.954 0 TD 0 Tc 0 Tw (F)Tj /TT2 1 Tf 0.6 0 TD -0.0099 Tc -0.0614 Tw [(\(1,1)35.1(16\) = 9.17, )]TJ /TT5 1 Tf 5.85 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.492 0 TD -0.01 Tc -0.0625 Tw [( < .01.)]TJ /F9 1 Tf -18.696 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0034 Tc -0.0013 Tw (Chi-square tests were calculated for the pretest and fol-)Tj 0 -1.401 TD -0.0031 Tc 0.0415 Tw [(low-up prevalence rates for each physical symptom. )51(A)]TJ 0 -1.398 TD -0.0035 Tc 0.0614 Tw (significant treatment effect was found for cough, diar-)Tj 0 -1.401 TD -0.0058 Tc -0.0623 Tw [(rhea, and fever)54.2(. )15.4(The ef)12.2(fect of flu, pain, and headache was)]TJ T* -0.0036 Tc 0.055 Tw (not significant.)Tj ET endstream endobj 344 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /F9 57 0 R /TT1 8 0 R /TT2 9 0 R /TT3 10 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 346 0 obj << /Length 8941 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 54 59.745 m 546 59.745 l S BT /F1 1 Tf 8 0 0 8 54.99 41.64 Tm 0 0 0 1 k /GS2 gs -0.0052 Tc 0.1209 Tw [(232 )]TJ /TT3 1 Tf 2.8388 0 TD -0.0058 Tc (Selected Annotated Journal Resources)Tj /TT1 1 Tf 11 0 0 11 54 722.64 Tm 0.0217 Tc 0 Tw [(CONCLUSIONS/SUMMAR)32.6(Y)]TJ /F9 1 Tf 10 0 0 10 54 706.65 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0035 Tc 0.1144 Tw (Results suggest that over a period of 6-9 months, the)Tj 0 -1.401 TD 0.0542 Tw (groups that received active treatment developed statis-)Tj 0 -1.398 TD -0.0029 Tc 0.0228 Tw (tically and clinically better on scales of PTSD than did)Tj 0 -1.401 TD -0.0039 Tc 0.0525 Tw [(non-treated monitoring group.)]TJ /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0033 Tc 0.1087 Tw (Results indicate that it is possible to treat war-related)Tj 0 -1.401 TD -0.0035 Tc -0.0228 Tw (PTSD in refugee populations and that effective psycho-)Tj T* 0.0047 Tc 0.125 Tw (therapy can be carried out by trained lay counselors)Tj 0 -1.398 TD -0.0029 Tc -0.038 Tw (after only 6 weeks of training.)Tj /F9 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD 0.0071 Tc 0.125 Tw (Physical health improved through psychotherapeutic)Tj 0 -1.398 TD -0.0033 Tc -0.0072 Tw (intervention at a refugee camp under deficient hygienic)Tj 0 -1.401 TD -0.0037 Tc 0.085 Tw (and health-care conditions.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0037 Tc -0.06 Tw (Given the high-need for treatment in war-affected popu-)Tj 0 -1.401 TD -0.0036 Tc -0.0325 Tw (lation, this approach might provide a possible answer to)Tj T* -0.0067 Tc -0.0622 Tw (the urgent mental health problems of war-afflicted areas.)Tj /TT1 1 Tf 11 0 0 11 54 486.66 Tm 0.0267 Tc 0 Tw [(LIMIT)62.2(A)72.5(TIONS)]TJ /F9 1 Tf 10 0 0 10 54 470.64 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc 0.0322 Tw (A high number of participants could not be located for)Tj 0 -1.398 TD -0.0121 Tc -0.06 Tw (follow-up examinations.)Tj /F9 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0089 Tc -0.0625 Tw (Randomization resulted in a significantly different group)Tj 0 -1.398 TD -0.0034 Tc -0.01 Tw [(comparison with regard to nationality)59.6(.)]TJ /F9 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0034 Tc 0.0444 Tw (Due to the laborious nature of the translation and vali-)Tj 0 -1.398 TD -0.003 Tc 0.0885 Tw (dation of useful instruments, only physical health and)Tj 0 -1.401 TD -0.0039 Tc 0.0858 Tw (PTSD were examined. Future research should include)Tj T* 0.09 Tw (measures of depression.)Tj ET 3.99 w /GS1 gs 54 343.995 m 291 343.995 l S BT /TT1 1 Tf 11 0 0 11 54 324.99 Tm /GS2 gs 0.0289 Tc 0.1249 Tw [(B)7.9(r)-3.8(yant, R. )53.3(A., Moulds, M. L., Guthrie, R. M.,)]TJ 0 -1.1809 TD 0.0234 Tc 0.1254 Tw [(Dang, S. )15.3(T)79.5(., Mastr)15.2(odomenico, J., Nixon, R. D.,)]TJ T* 0.0128 Tc 0.1252 Tw [(Felmingham, K. L., Hopwood, S. \(2008\). )53.6(A)61.3( ran-)]TJ 0 -1.1836 TD -0.002 Tc 0.125 Tw [(domized controlled trial of exposure therapy and)]TJ 0 -1.1809 TD 0.0176 Tc (cognitive restructuring for posttraumatic stress)Tj T* 0.0043 Tc 0 Tw [(disorder)91.6(.)-5.7( )]TJ /TT4 1 Tf 4.1945 0 TD 0.0049 Tc 0.1264 Tw (Journal of Consulting and Clinical Psy-)Tj ET 0.99 w /GS1 gs 54 238.515 m 291 238.515 l S BT 11 0 0 11 54 246.99 Tm /GS2 gs 0.0128 Tc 0.1284 Tw [(chology)34.6(, 76)]TJ /TT1 1 Tf 4.9582 0 TD 0.0125 Tc 0 Tw (\(4\),)Tj /TT4 1 Tf 1.4727 0 TD 0 Tc ( )Tj /TT1 1 Tf 0.3955 0 TD 0.0129 Tc (695-703.)Tj -6.8264 -3.1227 TD -0.008 Tc 0.1236 Tw [(TYPE OF)27.5( )46.5(A)10(R)27.5(TICLE)]TJ /F9 1 Tf 10 0 0 10 54 196.65 Tm 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0084 Tc -0.0625 Tw (Randomized controlled trial)Tj /TT1 1 Tf 11 0 0 11 54 166.26 Tm 0.0066 Tc 0.126 Tw [(OBJECTIVE/PURPOSE OF)31.1( )14.4(THE )47.8(A)13.7(R)28.4(TICLE)]TJ /F9 1 Tf 10 0 0 10 54 150.24 Tm 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0034 Tc 0.0313 Tw (This study sought to understand the effects of combin-)Tj 0 -1.398 TD -0.0036 Tc 0.0028 Tw (ing imaginal or in-vivo exposure and cognitive restruc-)Tj 0 -1.401 TD 0.0063 Tw (turing to decrease PTSD symptoms.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0024 Tc 0.1249 Tw [(Supportive counseling was added to treatment condi-)]TJ 0 -1.401 TD -0.0035 Tc 0.0627 Tw (tions that did not have a full complement of treatment)Tj T* 0.0023 Tc 0.125 Tw (components so that therapy time and specified treat-)Tj 25.5 64.341 TD -0.004 Tc 0.051 Tw (ment components were matched across conditions.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc 0.0425 Tw (The authors hypothesized that combining imaginal ex-)Tj 0 -1.401 TD 0.0066 Tc 0.125 Tw (posure, in-vivo exposure and cognitive restructuring)Tj T* -0.0037 Tc 0.0421 Tw (would be the most effective treatment combination for)Tj 0 -1.398 TD -0.0363 Tc 0 Tw (PTSD.)Tj /F9 1 Tf -1.8 -1.602 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc -0.0125 Tw (The authors also hypothesized that combining imaginal)Tj 0 -1.398 TD -0.0038 Tc -0.0286 Tw (exposure and in-vivo exposure would be more effective)Tj 0 -1.401 TD -0.0033 Tc -0.0009 Tw [(than either of the exposure treatments individually)59.7(.)]TJ /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0032 Tc -0.0276 Tw [(Finally)62.8(,)0.1( that authors hypothesized that in-vivo exposure)]TJ 0 -1.401 TD -0.0037 Tc -0.0467 Tw (would be more effective than imaginal exposure.)Tj /TT1 1 Tf 11 0 0 11 309 557.64 Tm 0.0265 Tc 0 Tw (PROCEDURE)Tj 0 -1.4536 TD 0.0026 Tc (Participants)Tj /F9 1 Tf 10 0 0 10 309 525.66 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0042 Tc -0.06 Tw (Participants \()Tj /TT5 1 Tf 5.19 0 TD 0 Tc 0 Tw (n)Tj /TT2 1 Tf 0.495 0 TD -0.004 Tc -0.0621 Tw [( = 90\) were civilian trauma survivors who)]TJ -5.685 -1.401 TD -0.0083 Tc -0.0619 Tw [(were referred to the )18.9(W)95.5(estmead Hospital )15.9(T)38.5(raumatic S)9.7(t)1.5(ress)]TJ T* -0.0032 Tc 0.0184 Tw [(Clinic over a 4-year period after a nonsexual assault or)]TJ 0 -1.398 TD -0.0035 Tc -0.0031 Tw (motor vehicle accident and displayed PTSD for a mini-)Tj 0 -1.401 TD -0.0041 Tc -0.0433 Tw (mum of three months.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD 0.0072 Tc 0.125 Tw (Individuals with psychosis, organic brain syndrome,)Tj 0 -1.401 TD -0.0035 Tc -0.0017 Tw (substance dependence, current suicidal risk, and inabil-)Tj T* -0.0031 Tc -0.0175 Tw [(ity to speak English were excluded from the study)59.9(.)]TJ /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0035 Tc 0.0941 Tw [(Additionally)59.5(, individuals were required to be between)]TJ 0 -1.401 TD -0.0028 Tc -0.0058 Tw (the ages of 18 and 59 years.)Tj /TT1 1 Tf 11 0 0 11 309 363.66 Tm 0.0242 Tc 0 Tw (Procedure)Tj /F9 1 Tf 10 0 0 10 309 347.64 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0086 Tc -0.0625 Tw (Participants were assigned to one of the treatment groups)Tj 0 -1.398 TD 0.0046 Tc 0.125 Tw [(using a stratified sampling process based on gender)34.6(,)]TJ 0 -1.401 TD -0.0032 Tc -0.015 Tw (trauma type, and PTSD score.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD 0.0348 Tc 0.125 Tw (Every three months the allocation procedure was)Tj 0 -1.401 TD -0.0035 Tc 0.0013 Tw [(amended to ensure that gender)35.5(, trauma type, and PTSD)]TJ T* -0.0034 Tc 0.0612 Tw (severity remained balanced across conditions.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0125 Tc -0.0621 Tw (Participants were assigned to an imaginal exposure group)Tj 0 -1.401 TD 0 Tc 0 Tw (\()Tj /TT5 1 Tf 0.33 0 TD (n)Tj /TT2 1 Tf 0.489 0 TD -0.006 Tc -0.0622 Tw [( = 31\), an in-vivo exposure group \()]TJ /TT5 1 Tf 13.362 0 TD 0 Tc 0 Tw (n)Tj /TT2 1 Tf 0.489 0 TD -0.0061 Tc -0.0625 Tw [( = 28\), an imaginal)]TJ -14.67 -1.398 TD -0.0177 Tc -0.062 Tw (exposure and in-vivo exposure group \()Tj /TT5 1 Tf 14.505 0 TD 0 Tc 0 Tw (n)Tj /TT2 1 Tf 0.486 0 TD -0.0175 Tc -0.062 Tw [( = 31\) or an imagi-)]TJ -14.991 -1.401 TD -0.0036 Tc -0.0517 Tw (nal exposure, in-vivo exposure and cognitive restructur-)Tj T* -0.004 Tc -0.045 Tw (ing group \()Tj /TT5 1 Tf 4.314 0 TD 0 Tc 0 Tw (n)Tj /TT2 1 Tf 0.495 0 TD -0.0027 Tc -0.045 Tw [( = 28\).)]TJ /F9 1 Tf -6.609 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0034 Tc -0.0125 Tw (Ninety participants completed treatment and 84 partici-)Tj 0 -1.401 TD -0.0039 Tc 0.0225 Tw (pants completed the six-month follow up assessment.)Tj /TT1 1 Tf 11 0 0 11 309 141.66 Tm 0.0557 Tc 0 Tw (Measures)Tj /F9 1 Tf 10 0 0 10 309 125.64 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0041 Tc -0.0519 Tw [(PTSD diagnosis was made using the Clinician )53.1(Adminis-)]TJ 0 -1.398 TD -0.0037 Tc 0.0743 Tw (tered PTSD Scale \(CAPS\) which is a structured inter-)Tj 0 -1.401 TD -0.0054 Tc -0.0622 Tw (view encompassing the DSM-IV criteria. The CAPS has)Tj T* -0.0034 Tc 0.04 Tw (been determined to have good sensitivity and specific-)Tj 0 -1.398 TD -0.0026 Tc -0.0075 Tw [(ity as well as good test-retest reliability)60.4(.)]TJ ET endstream endobj 347 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /F9 57 0 R /TT1 8 0 R /TT2 9 0 R /TT3 10 0 R /TT4 20 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 349 0 obj << /Length 10949 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 66 59.745 m 558 59.745 l S BT /TT3 1 Tf 8 0 0 8 423.24 42.6 Tm 0 0 0 1 k /GS2 gs -0.0051 Tc 0.0326 Tw [(IJEMH Vol. 10, No. 3 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (233)Tj /F9 1 Tf 10 0 0 10 66 722.64 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0032 Tc -0.0017 Tw (Additionally the Beck Depression Inventory \(BDI\), the)Tj 0 -1.398 TD -0.0124 Tc -0.0621 Tw [(Impact of the Event Scale \(IES\), and the S)17.6(tate-T)32.6(rait )53.7(Anxi-)]TJ 0 -1.401 TD -0.0026 Tc 0.1247 Tw [(ety Inventory-S)15.4(tate Scale \(ST)72.4(AI\) were used to assess)]TJ T* 0.0038 Tc 0.125 Tw [(further psychopathology)63.8(.)]TJ /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0103 Tc -0.0625 Tw (The Catastrophic Cognitive Questionnaire \(CCQ\) is self-)Tj 0 -1.401 TD -0.0037 Tc -0.0466 Tw (report measure that assesses catastrophic thinking about)Tj 0 -1.398 TD -0.007 Tc -0.0625 Tw (emotional reactions, somatic sensations, and mental pro-)Tj 0 -1.401 TD 0.0293 Tc 0 Tw (cesses.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0031 Tc 0.1118 Tw (Individual therapy was conducted by one of six mas-)Tj 0 -1.401 TD -0.0035 Tc 0.0657 Tw (ters-level clinicians who were trained to use treatment)Tj T* 0.0154 Tc 0.125 Tw (manuals and weekly supervision. Eight-100 minute)Tj 0 -1.398 TD -0.0036 Tc -0.0125 Tw (therapy sessions were conducted with structured home-)Tj 0 -1.401 TD -0.0043 Tc 0.05 Tw (work assignments.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0035 Tc 0.0775 Tw [( In the imaginal exposure group, participants were in-)]TJ 0 -1.401 TD -0.0034 Tc 0.0383 Tw (structed to provide a narrative of their trauma that was)Tj T* -0.0032 Tc -0.0061 Tw (written in present tense that focused on the sensory and)Tj 0 -1.398 TD -0.0035 Tc 0.0772 Tw (affective response to the trauma. Participants were in-)Tj 0 -1.401 TD 0.014 Tc 0.125 Tw (structed to rehearse the procedure on a daily basis.)Tj T* 0.03 Tc (Monitoring forms were used to ensure homework)Tj 0 -1.398 TD -0.0035 Tc 0.0558 Tw (completion. Each therapy session included 40 minutes)Tj 0 -1.401 TD -0.004 Tc -0.0621 Tw (of imaginal exposure, 50 minutes of supportive counsel-)Tj T* -0.0039 Tc -0.02 Tw (ing, and 10 minutes of homework assignments.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD 0.0063 Tc 0.125 Tw (In the in-vivo group, sessions focused on creating a)Tj 0 -1.401 TD -0.0097 Tc -0.0625 Tw (hierarchy of feared situations and establishing prescribed)Tj 0 -1.398 TD -0.0038 Tc 0.0422 Tw (homework to approach and remain in feared situations)Tj 0 -1.401 TD -0.0029 Tc 0.0728 Tw (until the participants anxiety decreased by 50 percent.)Tj T* -0.0138 Tc -0.0622 Tw [(Participants were instructed to rehearse the exercise daily)61.2(.)]TJ 0 -1.398 TD -0.0034 Tc -0.0306 Tw (Each therapy session consisted of 25 minutes of in-vivo)Tj 0 -1.401 TD -0.0037 Tc 0.0336 Tw (exposure, 65 minutes of supportive counseling, and 10)Tj T* -0.0042 Tc -0.0033 Tw (minutes of homework assignments.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0038 Tc 0.0457 Tw (In the combined imaginal and in-vivo exposure group,)Tj 0 -1.401 TD -0.0042 Tc -0.0625 Tw (both a narrative of the traumatic event and a hierarchy of)Tj 0 -1.398 TD -0.0031 Tc 0.125 Tw [(feared situations was used. In each therapy 100 ses-)]TJ 0 -1.401 TD -0.0037 Tc -0.0293 Tw (sion, 40 minutes were devoted to imaginal exposure, 25)Tj T* 0.0693 Tw (minutes to in-vivo exposure, 25 minutes to supportive)Tj 0 -1.398 TD -0.004 Tc 0.0033 Tw (counseling and 10 minute to homework assignments.)Tj /F9 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0037 Tc 0.01 Tw (In the combined imaginal, in-vivo exposure group, and)Tj 0 -1.398 TD 0.115 Tw (cognitive restructuring group participants were taught)Tj 0 -1.401 TD -0.0029 Tc 0.108 Tw (to identify dysfunctional, unrealistic, and catastrophic)Tj T* -0.0037 Tc -0.018 Tw (thoughts about their traumatic experiences, themselves,)Tj 0 -1.398 TD -0.0035 Tc 0.0693 Tw (and their future. Participants were required to monitor)Tj 0 -1.401 TD -0.003 Tc 0.0638 Tw (their thoughts and affective states daily and to modify)Tj T* -0.0037 Tc 0.12 Tw (those thoughts using Socratic questioning, probabilis-)Tj 0 -1.398 TD -0.0035 Tc 0.065 Tw [(tic reasoning, and evidence-based thinking. Each ses-)]TJ 0 -1.401 TD 0.053 Tc 0.125 Tw (sion was comprised of 25 minutes of cognitive)Tj T* -0.0036 Tc -0.0372 Tw (restructuring, 40 minutes of imaginal exposure, 25 min-)Tj 25.5 64.2 TD -0.0038 Tc 0.0225 Tw (utes of in-vivo exposure, and 10 minutes of homework)Tj 0 -1.398 TD 0.0101 Tc 0 Tw (assignments.)Tj /F9 1 Tf -1.8 -1.602 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0032 Tc 0.1007 Tw (Audiotapes of 70 therapy sessions were randomly se-)Tj 0 -1.398 TD -0.0036 Tc 0.05 Tw (lected to ensure treatment adherence.)Tj /TT1 1 Tf 11 0 0 11 321 646.65 Tm 0.0154 Tc 0 Tw [(RESUL)83.6(TS)]TJ /F9 1 Tf 10 0 0 10 321 630.66 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0031 Tc 0.0583 Tw (One-way analysis of variance indicated no differences)Tj 0 -1.401 TD -0.0039 Tc 0.0825 Tw (between treatment groups.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0022 Tc 0.125 Tw (Individuals who dropped out of treatment had higher)Tj 0 -1.401 TD -0.0047 Tc 0.025 Tw (CAPS scores )Tj /TT5 1 Tf 5.499 0 TD 0 Tc 0 Tw (t)Tj /TT2 1 Tf 0.276 0 TD -0.0029 Tc 0.025 Tw (\(1, 116\) = 4.02, )Tj /TT5 1 Tf 6.534 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.495 0 TD -0.0033 Tc 0.026 Tw [( < .01, and higher BDI)]TJ -12.804 -1.401 TD -0.0038 Tc 0 Tw (scores )Tj /TT5 1 Tf 2.706 0 TD 0 Tc (t)Tj /TT2 1 Tf 0.273 0 TD -0.0028 Tc -0.0212 Tw [(\(1, 116\) = 2.50, )]TJ /TT5 1 Tf 6.351 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.495 0 TD -0.0036 Tc -0.0225 Tw [( < .05 when compared to those)]TJ -9.825 -1.398 TD -0.004 Tc (who completed treatment.)Tj /F9 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0063 Tc -0.0085 Tw [(The ANCOV)122.7(A)55.9( )-50.3(on )]TJ 7.3895 0 TD -0.0037 Tc 0.0391 Tw (post-treatment responses indicated a)Tj -7.3895 -1.398 TD -0.013 Tc -0.0612 Tw (main effects for CAPS, )Tj /TT5 1 Tf 9.039 0 TD 0 Tc 0 Tw (F)Tj /TT2 1 Tf 0.597 0 TD -0.0124 Tc -0.0617 Tw (\(3,113\) = 4.20, )Tj /TT5 1 Tf 5.85 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.483 0 TD -0.0129 Tc -0.0633 Tw [( < .01. Post-hoc)]TJ -15.969 -1.401 TD -0.0024 Tc 0.125 Tw (Tukey comparisons indicated that the imaginal expo-)Tj T* -0.0045 Tc -0.0625 Tw (sure, in-vivo exposure and cognitive restructuring group)Tj 0 -1.398 TD -0.0037 Tc -0.0406 Tw (scored lower than the other groups on CAPS scores \()Tj /TT5 1 Tf 20.64 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.495 0 TD -0.049 Tc ( <)Tj -21.135 -1.401 TD -0.0458 Tc (.05\).)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.003 Tc 0.0814 Tw [(W)55.8(ith regard to follow-up )]TJ 10.4691 0 TD (analyses the )Tj 5.1819 0 TD -0.0067 Tc 0.0839 Tw [(ANCOV)122.3(A)55.5( indi-)]TJ -15.651 -1.401 TD -0.0035 Tc -0.0066 Tw (cated a main effect for CAPS, )Tj /TT5 1 Tf 12.105 0 TD 0 Tc 0 Tw (F)Tj /TT2 1 Tf 0.606 0 TD -0.0031 Tc -0.0083 Tw (\(3,113\) = 4.43, )Tj /TT5 1 Tf 6.159 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.495 0 TD -0.0023 Tc -0.0075 Tw [( < .01.)]TJ -19.365 -1.401 TD -0.0035 Tc -0.0464 Tw (Post hoc Tukey comparisons indicated that the imaginal)Tj 0 -1.398 TD -0.0037 Tc 0.043 Tw (exposure, in-vivo exposure and cognitive restructuring)Tj 0 -1.401 TD 0.0098 Tc 0.125 Tw (group scored lower than the other groups on CAPS)Tj T* -0.0039 Tc -0.04 Tw (scores \()Tj /TT5 1 Tf 3.015 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.495 0 TD -0.0024 Tc -0.045 Tw [( < .05\).)]TJ /F9 1 Tf -5.31 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc 0.0422 Tw (At post treatment there were no significant differences)Tj 0 -1.401 TD -0.0375 Tw (in rates of PTSD in the imaginal exposure group, the in-)Tj 0 -1.398 TD -0.0039 Tc 0.0216 Tw (vivo exposure group, combined imaginal exposure and)Tj 0 -1.401 TD 0.015 Tw (in-vivo exposure group.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0123 Tc -0.0625 Tw (At follow-up, there were fewer participants with PTSD in)Tj 0 -1.401 TD -0.0037 Tc 0.0583 Tw (the imaginal exposure, in-vivo exposure and cognitive)Tj T* -0.0038 Tc -0.0521 Tw (restructuring groups when compared to the imaginal ex-)Tj 0 -1.398 TD 0.0038 Tc 0.125 Tw (posure group, in-vivo exposure group and combined)Tj 0 -1.401 TD -0.0038 Tc -0.0567 Tw (imaginal exposure and in-vivo exposure group )Tj /F9 1 Tf 18.375 0 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 5.8 0 0 5.8 528.24 260.01 Tm (2)Tj 10 0 0 10 531.21 256.65 Tm -0.003 Tc (\(1, )Tj /TT5 1 Tf 1.269 0 TD 0 Tc (N)Tj /TT2 1 Tf 0.66 0 TD -0.064 Tc ( =)Tj -21.15 -1.401 TD -0.0216 Tc -0.0617 Tw (103\) = 12.42, )Tj /TT5 1 Tf 5.166 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.48 0 TD -0.022 Tc -0.0625 Tw [( < .01)]TJ /F9 1 Tf -7.446 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.006 Tc -0.0618 Tw [(W)52.8(ith regard to secondary measures, separate )48.7(ANCOV)132(As)]TJ 0 -1.401 TD -0.0035 Tc 0.0108 Tw [(indicated no significant main effects at post treatment.)]TJ /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0053 Tc -0.0378 Tw [(At follow-up, )50.1(ANCOV)]TJ 8.901 0 TD -0.0035 Tc -0.0391 Tw [(A)115.7()53.5(s indicated significant main ef-)]TJ -8.901 -1.401 TD 0.0184 Tw (fects for IES-Intrusions, )Tj /TT5 1 Tf 9.855 0 TD 0 Tc 0 Tw (F)Tj /TT2 1 Tf 0.606 0 TD -0.0029 Tc 0.02 Tw (\(3,113\) = 4.19, )Tj /TT5 1 Tf 6.243 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.495 0 TD -0.0031 Tc 0.02 Tw [( < .05; IES-)]TJ -17.199 -1.398 TD -0.0216 Tc 0 Tw [(A)79.6(voidance, )]TJ /TT5 1 Tf 4.461 0 TD 0 Tc (F)Tj /TT2 1 Tf 0.588 0 TD -0.0215 Tc -0.0613 Tw [(\(3,1)26.5(13\) = 3.45, )]TJ /TT5 1 Tf 5.682 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.474 0 TD -0.0207 Tc -0.0625 Tw [( < .05; BDI, )]TJ /TT5 1 Tf 4.551 0 TD 0 Tc 0 Tw (F)Tj /TT2 1 Tf 0.585 0 TD -0.0211 Tc -0.0625 Tw (\(3,107\) = 2.83,)Tj /TT5 1 Tf -16.341 -1.401 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.495 0 TD -0.0034 Tc 0.0199 Tw [( < .05; CCQ )]TJ /TT5 1 Tf 5.19 0 TD 0 Tc 0 Tw (F)Tj /TT2 1 Tf 0.606 0 TD -0.0029 Tc 0.02 Tw (\(3,107\) = 2.83, )Tj /TT5 1 Tf 6.243 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.495 0 TD -0.0029 Tc 0.02 Tw [( <.05. Post-hoc Tukey)]TJ -13.029 -1.401 TD -0.0073 Tc -0.0625 Tw (comparisons indicated that the combined imaginal expo-)Tj 0 -1.398 TD -0.0035 Tc 0.092 Tw (sure, in-vivo exposure, cognitive restructuring partici-)Tj 0 -1.401 TD -0.007 Tw (pants scored lower than did each of the other groups on)Tj T* -0.0164 Tc -0.0625 Tw (IES- Intrusions \()Tj /TT5 1 Tf 6.27 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.48 0 TD -0.0162 Tc -0.0625 Tw [( < .05\), IES-A)73.8(voidance \()]TJ /TT5 1 Tf 9.186 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.483 0 TD -0.0155 Tc -0.0625 Tw [( < .05\), BDI \()]TJ /TT5 1 Tf 4.986 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf -21.405 -1.398 TD -0.0144 Tc -0.0625 Tw (< .05\), and CCQ \()Tj /TT5 1 Tf 6.741 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.483 0 TD -0.0137 Tc -0.0625 Tw [( < .05\).)]TJ ET endstream endobj 350 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /F9 57 0 R /TT1 8 0 R /TT2 9 0 R /TT3 10 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 352 0 obj << /Length 8188 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 54 59.745 m 546 59.745 l S BT /F1 1 Tf 8 0 0 8 54.99 41.64 Tm 0 0 0 1 k /GS2 gs -0.0052 Tc 0.1209 Tw [(234 )]TJ /TT3 1 Tf 2.8388 0 TD -0.0058 Tc (Selected Annotated Journal Resources)Tj /F9 1 Tf 10 0 0 10 54 722.64 Tm 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0037 Tc -0.0517 Tw (Participants in the combined imaginal exposure, in-vivo)Tj 0 -1.398 TD -0.0034 Tc -0.004 Tw (exposure, cognitive restructuring group displayed large)Tj 0 -1.401 TD -0.0061 Tc -0.0625 Tw (to moderate effect sizes on most measures, while partici-)Tj T* -0.0088 Tc (pants in the imaginal exposure or in-vivo exposure group)Tj 0 -1.398 TD -0.0036 Tc -0.016 Tw (showed small to moderate effect sizes.)Tj /TT1 1 Tf 11 0 0 11 54 634.65 Tm 0.0217 Tc 0 Tw [(CONCLUSIONS/SUMMAR)32.6(Y)]TJ /F9 1 Tf 10 0 0 10 54 618.66 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0039 Tc -0.062 Tw (Combining imaginal exposure, in-vivo exposure, cogni-)Tj 0 -1.401 TD -0.0034 Tc 0.0736 Tw (tive restructuring resulted in a greater treatment effect)Tj T* -0.0106 Tc -0.0621 Tw (for PTSD and depressive symptoms than exposure alone.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc 0.0542 Tw (This finding contradicts earlier studies discounting the)Tj 0 -1.401 TD 0.0375 Tw (additive effects of cognitive restructuring.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0192 Tc -0.0621 Tw (Imaginal exposure, in-vivo, and the combination of imagi-)Tj 0 -1.401 TD 0.0026 Tc 0.125 Tw (nal exposure and in-vivo exposure were found to be)Tj 0 -1.398 TD -0.0033 Tc -0.029 Tw (equally effective when treating PTSD symptoms.)Tj /TT1 1 Tf 11 0 0 11 54 484.65 Tm 0.0267 Tc 0 Tw [(LIMIT)62.2(A)72.5(TIONS)]TJ /F9 1 Tf 10 0 0 10 54 468.66 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc 0.0383 Tw (The sample size was modest for a design that incorpo-)Tj 0 -1.401 TD -0.0031 Tc 0.0916 Tw (rated four types of treatment and a larger sample size)Tj T* -0.0034 Tc 0.0243 Tw [(may have revealed more differences between the treat-)]TJ 0 -1.398 TD -0.0042 Tc 0.075 Tw (ment groups.)Tj /F9 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc 0.1055 Tw (There was no assessments of the degree to which the)Tj 0 -1.398 TD 0.0744 Tw (assessors were blind to the treatment group of partici-)Tj 0 -1.401 TD 0.0228 Tc 0 Tw (pants.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0038 Tc -0.0192 Tw (The delineation between exposure treatment and cogni-)Tj 0 -1.401 TD -0.0029 Tc 0.125 Tw (tive treatment may be somewhat artificial and not an)Tj T* -0.008 Tc -0.0622 Tw (accurate reflection of common clinical practice as practi-)Tj 0 -1.398 TD -0.0037 Tc 0.0125 Tw (tioners use the two methods in combination rather than)Tj 0 -1.401 TD -0.0035 Tc 0.0266 Tw [(one or the other)50.5(.)]TJ /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0039 Tc 0.0241 Tw (No assessment for comorbid disorders was completed.)Tj ET 3.99 w /GS1 gs 54 270.015 m 291 270.015 l S BT /TT1 1 Tf 11 0 0 11 54 251.01 Tm /GS2 gs 0.0089 Tc 0.1255 Tw [(Seery)53.4(,)-0.9( M. 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/TT1 1 Tf 11 0 0 11 66 722.64 Tm 0.0557 Tc (Measures)Tj /F9 1 Tf 10 0 0 10 66 706.65 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0038 Tc 0.0475 Tw [(T)73(wo variables were created from the above-mentioned)]TJ 0 -1.401 TD 0.0469 Tw [(response: 1\) a dichotomous measure of whether or not)]TJ 0 -1.398 TD -0.0034 Tc -0.0445 Tw (participants responded, 2\) a measure of the length of the)Tj 0 -1.401 TD -0.0038 Tc 0.0559 Tw (response based on the number of words.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0033 Tc -0.0242 Tw (Participants completed the Brief Symptom Inventory in)Tj 0 -1.401 TD -0.0032 Tc 0.0825 Tw (order to assess for generalized anxiety six months, 12)Tj T* -0.0038 Tc 0.0256 Tw (months, 18 months and 24 months after September 11,)Tj 0 -1.398 TD -0.0562 Tc 0 Tw (2001.)Tj /F9 1 Tf -1.8 -1.602 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0037 Tc 0.0971 Tw (Posttraumatic stress was assessed using the Impact of)Tj 0 -1.398 TD -0.0038 Tc -0.0219 Tw (Events Scale- Revised two months and six months after)Tj 0 -1.401 TD -0.0036 Tc 0.12 Tw (the event.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0083 Tc -0.0625 Tw (The Posttrauma Stress Disorder checklist was completed)Tj 0 -1.401 TD -0.0045 Tc -0.0622 Tw (at 12 months, 18 months, and 24 months post September)Tj T* -0.0394 Tc -0.06 Tw (11, 2001.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0033 Tc -0.0333 Tw (Physician diagnosed physical and mental ailments were)Tj 0 -1.401 TD -0.0076 Tc -0.0622 Tw (assessed 12 and 24 months using the same measure com-)Tj 0 -1.398 TD -0.0036 Tc 0.0288 Tw (pleted upon joining the panel.)Tj /F9 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc 0.1 Tw (Participants were also assessed regarding their degree)Tj 0 -1.398 TD 0.0017 Tc 0.125 Tw (of exposure to the terrorist attacks and placed in the)Tj 0 -1.401 TD -0.0033 Tc 0.04 Tw (direct exposure category \(seeing or hearing the attacks)Tj T* -0.0037 Tc 0.0675 Tw (in person or having a close relationship with someone)Tj 0 -1.398 TD -0.0033 Tc 0.0925 Tw (targeted\), live media exposure category \(watching the)Tj 0 -1.401 TD -0.003 Tc 0.0761 Tw (attacks on television live as they occurred\), or no live)Tj T* 0.1007 Tw (exposure category \(seeing video replay or learning of)Tj 0 -1.398 TD -0.0029 Tc 0.0338 Tw (the attacks after they occurred\).)Tj /F9 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0035 Tc 0.1186 Tw (An index of physician diagnosed mental health prob-)Tj 0 -1.398 TD -0.0033 Tc -0.0183 Tw (lems was created as was an index of physical ailments.)Tj /F9 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD 0.0116 Tc 0.1253 Tw [(Acute stress was assessed using the S)17.6(tanford )50.9(Acute)]TJ 0 -1.398 TD -0.0039 Tc -0.0191 Tw (Stress Reaction Questionnaire two weeks after Septem-)Tj 0 -1.401 TD -0.0231 Tc -0.0625 Tw (ber 11, 2001.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD 0.0034 Tc 0.125 Tw (Coping strategies were assessed two weeks after the)Tj 0 -1.401 TD -0.0038 Tc -0.0538 Tw (event using the Brief COPE.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0008 Tc 0.125 Tw [(W)94(orld beliefs about benevolence and meaningfulness)]TJ 0 -1.401 TD -0.0036 Tc 0.0139 Tw (of the world were assessed using a modified version of)Tj T* -0.0037 Tc 0.0008 Tw [(the )17.4(W)94.1(orld )53.4(Assumptions Scale between two and twenty-)]TJ 0 -1.398 TD -0.0038 Tc 0.0083 Tw (four months post 9/11.)Tj /F9 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0034 Tc 0.095 Tw (Lifetime exposure to stressful events was assessed by)Tj 0 -1.398 TD -0.003 Tc 0.0156 Tw (asking participants if they experienced any of 37 nega-)Tj 0 -1.401 TD -0.0033 Tc -0.0625 Tw (tive events \(e.g. child abuse, divorce\) and if so, what age)Tj T* -0.0036 Tc 0.08 Tw (the event\(s\) occurred.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc -0.0019 Tw [(Participants completed the )17.5(T)70.2(en-Item Personality Inven-)]TJ 0 -1.401 TD -0.003 Tc -0.0478 Tw (tory in order to assess the Big Five personality domains.)Tj /TT1 1 Tf 11 0 0 11 321 722.64 Tm 0.0154 Tc 0 Tw [(RESUL)83.6(TS)]TJ /F9 1 Tf 10 0 0 10 321 706.65 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD 0.0263 Tc 0.125 Tw [(All analyses controlled for demographics \(gender)35.3(,)]TJ 0 -1.401 TD -0.0026 Tc 0.1248 Tw [(ethnicity)63.4(, age, income, marital status, and education\),)]TJ 0 -1.398 TD -0.0035 Tc -0.0322 Tw (degree of exposure to the attacks and pre September 11,)Tj 0 -1.401 TD -0.003 Tc -0.028 Tw [(2001 mental and physical health history)60(.)]TJ /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0033 Tc 0.0244 Tw (A logistic regression was used to identify predictors of)Tj 0 -1.401 TD 0.0055 Tc 0.125 Tw (reading the open-ended prompt which indicated that)Tj T* -0.0038 Tc 0.0688 Tw (older respondents \(odds ratio [)Tj /TT5 1 Tf 12.381 0 TD -0.013 Tc 0 Tw (OR)Tj /TT2 1 Tf 1.32 0 TD -0.0038 Tc 0.07 Tw (] = 1.32; confidence)Tj -13.701 -1.398 TD -0.0101 Tc -0.06 Tw (interval [)Tj /TT5 1 Tf 3.48 0 TD -0.019 Tc 0 Tw (CI)Tj /TT2 1 Tf 0.975 0 TD -0.01 Tc -0.0622 Tw (] = 1.18, 1.46\), widowed respondents as com-)Tj -4.455 -1.401 TD -0.0098 Tc -0.0625 Tw (pared to married respondents \()Tj /TT5 1 Tf 11.679 0 TD -0.019 Tc 0 Tw (OR)Tj /TT2 1 Tf 1.311 0 TD -0.0095 Tc -0.0625 Tw [( = 1.46; 95% )]TJ /TT5 1 Tf 5.055 0 TD -0.016 Tc 0 Tw (CI)Tj /TT2 1 Tf 0.981 0 TD -0.0093 Tc -0.0625 Tw [( = 1.01,)]TJ -19.026 -1.401 TD -0.0037 Tc -0.011 Tw [(2.13\), respondents who lived 100 500 from the )14.4(W)97.1(o)1.3(rld)]TJ 0 -1.398 TD -0.0181 Tc -0.06 Tw (Trade Center \()Tj /TT5 1 Tf 5.46 0 TD -0.028 Tc 0 Tw (OR)Tj /TT2 1 Tf 1.29 0 TD -0.0175 Tc -0.0625 Tw [( = 1.88; 95% )]TJ /TT5 1 Tf 4.95 0 TD -0.025 Tc 0 Tw (CI)Tj /TT2 1 Tf 0.96 0 TD -0.0179 Tc -0.0633 Tw [( 1.26, 2.82\), respondents)]TJ -12.66 -1.401 TD -0.0039 Tc -0.0531 Tw [(who lived 500-1,000 miles from the )17.1(W)93.9(orld )14.1(T)36.9(rade Center)]TJ T* 0 Tc 0 Tw (\()Tj /TT5 1 Tf 0.33 0 TD -0.013 Tc (OR)Tj /TT2 1 Tf 1.32 0 TD -0.0034 Tc -0.0237 Tw [( = 1.48; 95% )]TJ /TT5 1 Tf 5.289 0 TD -0.01 Tc 0 Tw (CI)Tj /TT2 1 Tf 0.99 0 TD -0.0033 Tc -0.0242 Tw [( = 1.00, 2.18\), compared with those)]TJ -7.929 -1.398 TD -0.0087 Tc -0.0623 Tw (who lived within 25 miles, and respondents with a higher)Tj 0 -1.401 TD -0.0035 Tc -0.0126 Tw [(number of pre-9/1)32.5(1 physical dif)14.5(ficulties. )17.4(W)94.4(omen \()]TJ /TT5 1 Tf 19.785 0 TD -0.013 Tc 0 Tw (OR)Tj /TT2 1 Tf 1.32 0 TD -0.019 Tc ( =)Tj -21.105 -1.401 TD -0.008 Tc -0.0625 Tw (0.82; 95% )Tj /TT5 1 Tf 4.164 0 TD -0.016 Tc 0 Tw (CI)Tj /TT2 1 Tf 0.987 0 TD -0.0073 Tc -0.0625 Tw [( = 0.69, 0.99\) and high-income respondents)]TJ -5.151 -1.398 TD 0 Tc 0 Tw (\()Tj /TT5 1 Tf 0.33 0 TD -0.013 Tc (OR)Tj /TT2 1 Tf 1.32 0 TD -0.0034 Tc -0.0237 Tw [( = 0.87; 95% )]TJ /TT5 1 Tf 5.289 0 TD -0.01 Tc 0 Tw (CI)Tj /TT2 1 Tf 0.99 0 TD -0.0025 Tc -0.0238 Tw [( = 0.78, 0.96\) were less likely to re-)]TJ -7.929 -1.401 TD 0.0272 Tc 0 Tw (spond.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0037 Tc 0.1128 Tw (A generalized estimating equation was used to assess)Tj 0 -1.401 TD -0.0031 Tc 0.0587 Tw [(predictors of attrition over the two-year period of data)]TJ T* 0.0963 Tw [(collection. Participants who were least likely to miss)]TJ 0 -1.398 TD -0.0069 Tc -0.062 Tw [(assessments were older participants \()]TJ /TT5 1 Tf 14.511 0 TD -0.019 Tc 0 Tw (OR)Tj /TT2 1 Tf 1.314 0 TD -0.007 Tc -0.0625 Tw [( = 0.83; 95% )]TJ /TT5 1 Tf 5.091 0 TD -0.016 Tc 0 Tw (CI)Tj /TT2 1 Tf -20.916 -1.401 TD -0.0104 Tc -0.0625 Tw [(= 0.78, 0.88\), respondents with a high school degree \()]TJ /TT5 1 Tf 20.589 0 TD -0.022 Tc 0 Tw (OR)Tj /TT2 1 Tf -20.589 -1.401 TD -0.0036 Tc -0.0417 Tw (= 0.73; 95% )Tj /TT5 1 Tf 5.01 0 TD -0.01 Tc 0 Tw (CI)Tj /TT2 1 Tf 0.99 0 TD -0.0029 Tc -0.0422 Tw [( = 0.61, 0.88\), some college \()]TJ /TT5 1 Tf 11.595 0 TD -0.013 Tc 0 Tw (OR)Tj /TT2 1 Tf 1.32 0 TD -0.0031 Tc -0.0425 Tw [( = 0.82;)]TJ -18.915 -1.398 TD -0.0073 Tc 0 Tw (95% )Tj /TT5 1 Tf 1.995 0 TD -0.016 Tc (CI)Tj /TT2 1 Tf 0.981 0 TD -0.0067 Tc -0.0625 Tw [( = 0.67, 0.99\), and a college degree or higher \()]TJ /TT5 1 Tf 17.61 0 TD -0.019 Tc 0 Tw (OR)Tj /TT2 1 Tf -20.586 -1.401 TD -0.0208 Tc -0.0617 Tw (= 0.76; 95% )Tj /TT5 1 Tf 4.74 0 TD -0.031 Tc 0 Tw (CI)Tj /TT2 1 Tf 0.954 0 TD -0.0201 Tc -0.0616 Tw [( = 0.63, 0.93\).)]TJ /F9 1 Tf -7.494 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0032 Tc 0.055 Tw (A logistic regression analysis was used in order to de-)Tj 0 -1.401 TD -0.001 Tc 0.1252 Tw [(termine who would respond to the prompt. )32.2(Y)103.2(ounger)]TJ T* -0.0042 Tc -0.03 Tw (respondents \()Tj /TT5 1 Tf 5.28 0 TD -0.013 Tc 0 Tw (OR)Tj /TT2 1 Tf 1.32 0 TD -0.0032 Tc -0.0325 Tw [( = 1.23; 95% )]TJ /TT5 1 Tf 5.256 0 TD -0.01 Tc 0 Tw (CI)Tj /TT2 1 Tf 0.99 0 TD -0.0031 Tc -0.032 Tw (= 1.08, 1.39\) as well as)Tj -12.846 -1.398 TD -0.0035 Tc -0.0034 Tw (respondents with higher 9/11 physical health diagnoses)Tj 0 -1.401 TD 0 Tc 0 Tw (\()Tj /TT5 1 Tf 0.33 0 TD -0.013 Tc (OR)Tj /TT2 1 Tf 1.32 0 TD -0.0033 Tc -0.0275 Tw [( = 1.2; 95% )]TJ /TT5 1 Tf 4.779 0 TD -0.01 Tc 0 Tw (CI)Tj /TT2 1 Tf 0.99 0 TD -0.0027 Tc -0.0287 Tw [( = 1.06, 1.35\) were more likely to re-)]TJ -7.419 -1.401 TD -0.0038 Tc 0.065 Tw (spond to the prompt.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0035 Tc -0.0469 Tw [(W)55.3(i)0.1(th regard to length of response, women wrote signifi-)]TJ 0 -1.401 TD -0.0033 Tc 0.0873 Tw (cantly longer responses than did men \( = 0.258\) and)Tj 0 -1.398 TD -0.0034 Tc -0.0319 Tw (respondents with more pre 9/11 physical diagnoses \( =)Tj 0 -1.401 TD -0.0516 Tc 0 Tw (0.069\))Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0038 Tc -0.005 Tw (Compared with participants who elected not to respond)Tj 0 -1.401 TD -0.0037 Tc -0.0256 Tw (to the open ended prompt, participants who did respond)Tj T* -0.0034 Tc -0.0072 Tw [(reported a higher number of posttraumatic stress symp-)]TJ 0 -1.398 TD -0.0063 Tc -0.0617 Tw (toms from two to six months \()Tj /TT5 1 Tf 11.559 0 TD 0 Tc 0 Tw (Z)Tj /TT2 1 Tf 0.552 0 TD -0.0056 Tc -0.0617 Tw [( = 3.20, )]TJ /TT5 1 Tf 3.084 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.495 0 TD -0.0059 Tc -0.063 Tw [( < .01\) and 12 to)]TJ -15.69 -1.401 TD -0.0042 Tc -0.0325 Tw (24 months \()Tj /TT5 1 Tf 4.671 0 TD 0 Tc 0 Tw (Z)Tj /TT2 1 Tf 0.549 0 TD -0.0024 Tc -0.0333 Tw [( = 3.81, )]TJ /TT5 1 Tf 3.195 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.495 0 TD -0.0033 Tc -0.0343 Tw [( < .001\) post 9/11 even after con-)]TJ -8.91 -1.401 TD -0.0035 Tc -0.0337 Tw (trolling for degree of exposure.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.004 Tc 0.0725 Tw (Among participants who responded to the open-ended)Tj 0 -1.401 TD -0.0037 Tc -0.015 Tw (prompt, longer responses were associated with general-)Tj 0 -1.398 TD -0.0228 Tw (ized distress from six to 24 months and more diagnosed)Tj ET endstream endobj 356 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /F9 57 0 R /TT1 8 0 R /TT2 9 0 R /TT3 10 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 359 0 obj << /Length 9311 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 54 59.745 m 546 59.745 l S BT /F1 1 Tf 8 0 0 8 54.99 41.64 Tm 0 0 0 1 k /GS2 gs -0.0052 Tc 0.1209 Tw [(236 )]TJ /TT3 1 Tf 2.8388 0 TD -0.0058 Tc (Selected Annotated Journal Resources)Tj /TT2 1 Tf 10 0 0 10 72 722.64 Tm -0.0034 Tc -0.0306 Tw (physical disorders at 12 to 24 months \(Generalized Dis-)Tj 0 -1.398 TD -0.0074 Tc 0 Tw (tress )Tj /TT5 1 Tf 1.986 0 TD 0 Tc (Z)Tj /TT2 1 Tf 0.543 0 TD -0.006 Tc -0.0617 Tw [( = 2.01, )]TJ /TT5 1 Tf 3.075 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.492 0 TD -0.0069 Tc -0.0617 Tw [( < .05; Diagnosed Physical Disorders )]TJ /TT5 1 Tf 14.52 0 TD -0.0122 Tc 0 Tw (Z )Tj /TT2 1 Tf 0.723 0 TD 0 Tc (=)Tj -21.339 -1.401 TD -0.0032 Tc (3.93, )Tj /TT5 1 Tf 2.199 0 TD 0 Tc (p)Tj /TT2 1 Tf 0.495 0 TD -0.0032 Tc -0.0363 Tw [( < .01\) regardless of the degree of exposure.)]TJ /F9 1 Tf -4.494 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0018 Tc 0.125 Tw (Significant interactions emerged between participants)Tj 0 -1.401 TD -0.0038 Tc 0.0811 Tw (who were within 25 miles of exposure and those who)Tj T* 0.0021 Tc 0.125 Tw (were further away and responded with posttraumatic)Tj 0 -1.398 TD -0.0155 Tc -0.0622 Tw (stress symptoms 12 to 24 months posttrauma \( = -0.570\).)Tj /F9 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0039 Tc -0.0491 Tw [(Among participants who lived closer to the )17.4(W)93.9(orld )14.4(T)36.9(rade)]TJ 0 -1.398 TD 0.0012 Tc 0.1252 Tw [(Center)34.2(, those that responded to the prompt exhibited)]TJ 0 -1.401 TD -0.0036 Tc -0.0411 Tw (poorer mental health over time that did those who chose)Tj T* -0.005 Tc -0.0625 Tw (not to respond \(from two to six months: = 0.67 from 12)Tj 0 -1.398 TD -0.0032 Tc -0.0608 Tw (to 24 months; = 0.72, )Tj /TT5 1 Tf 9.126 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.495 0 TD -0.0026 Tc -0.0625 Tw [( < .01\).)]TJ /F9 1 Tf -11.421 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0034 Tc 0.05 Tw (In linear regressions, participants who chose not to re-)Tj 0 -1.398 TD -0.0037 Tc 0.1055 Tw (spond to the prompt were compared to those who re-)Tj 0 -1.401 TD 0.059 Tc 0.1307 Tw [(sponded to the prompt. Results indicated that)]TJ T* 0.0009 Tc 0.125 Tw (participants who did respond indicated seeking more)Tj 0 -1.398 TD -0.0127 Tc -0.0625 Tw (emotional support \( = 0.17, )Tj /TT5 1 Tf 11.145 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.486 0 TD -0.0128 Tc -0.0625 Tw [( < .01\) and venting more \()]TJ -11.631 -1.401 TD -0.0026 Tc -0.0425 Tw (= 0.19, )Tj /TT5 1 Tf 2.961 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.495 0 TD -0.0034 Tc -0.0445 Tw [( < .01\) than participants who did not respond to)]TJ -3.456 -1.401 TD -0.004 Tc 0.005 Tw (the prompt.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0038 Tc -0.0622 Tw (Responding to the prompt \( = 0.16, )Tj /TT5 1 Tf 14.244 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.495 0 TD -0.0038 Tc -0.0625 Tw [( < .01\) and writing)]TJ -14.739 -1.401 TD -0.0072 Tc -0.062 Tw (longer responses \( = 0.089, )Tj /TT5 1 Tf 11.076 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.489 0 TD -0.0075 Tc -0.062 Tw [( < .01\) was associated with)]TJ -11.565 -1.398 TD -0.0035 Tc 0.01 Tw (higher levels of distress two weeks post 9/11.)Tj /TT1 1 Tf 11 0 0 11 54 388.65 Tm 0.0217 Tc 0 Tw [(CONCLUSIONS/SUMMAR)32.6(Y)]TJ /F9 1 Tf 10 0 0 10 54 372.66 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0034 Tc 0.0636 Tw (This study highlights the importance of allowing indi-)Tj 0 -1.401 TD -0.0032 Tc 0.0367 Tw (viduals to choose if they want to express their feelings)Tj T* -0.0033 Tc 0.0656 Tw (and the degree that they choose to express themselves)Tj 0 -1.398 TD -0.0036 Tc 0.0017 Tw (rather than compelling them to do so.)Tj /F9 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc -0.0307 Tw (Results from this study contradict the common assump-)Tj 0 -1.398 TD 0.0035 Tc 0.125 Tw [(tion that choosing not to express one)51.5(s thoughts and)]TJ 0 -1.401 TD -0.0133 Tc -0.0625 Tw (feelings in the immediate aftermath of a collective trauma)Tj T* -0.0031 Tc -0.0375 Tw (is harmful and indicative of vulnerability to future diffi-)Tj 0 -1.398 TD -0.0015 Tc 0 Tw (culties.)Tj /F9 1 Tf -1.8 -1.602 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0037 Tc 0.0029 Tw [(Reluctance to express one)50.3(s feelings appears to suggest)]TJ 0 -1.398 TD -0.0032 Tc 0.035 Tw [(resilience rather than pathology)59.8(.)]TJ /F9 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0037 Tc 0.1092 Tw [(Greater expression suggested higher levels of distress)]TJ 0 -1.398 TD 0.002 Tc 0.125 Tw (and predicted subsequent mental and physical health)Tj 0 -1.401 TD -0.0056 Tc -0.0625 Tw (problems over time.)Tj /F9 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0034 Tc -0.0125 Tw (Identifying individual willingness to express feelings is)Tj 0 -1.401 TD -0.0032 Tc -0.0275 Tw (a key component after a collective trauma.)Tj /TT1 1 Tf 11 0 0 11 54 122.64 Tm 0.0267 Tc 0 Tw [(LIMIT)62.2(A)72.5(TIONS)]TJ /F9 1 Tf 10 0 0 10 54 106.65 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc 0.05 Tw (The criteria used for assessing mental health problems)Tj 0 -1.401 TD -0.0038 Tc 0.03 Tw (pre 9/11 was dichotomous \(diagnosis vs. no diagnosis\))Tj 0 -1.398 TD -0.0031 Tc [(and therefore lacks sensitivity)59.9(.)]TJ /F9 1 Tf 23.7 64.398 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0046 Tc -0.0621 Tw (Only the physical health measure was administered both)Tj 0 -1.398 TD -0.0036 Tc 0.0067 Tw (pre and post 9/11.)Tj /F9 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0034 Tc 0.0086 Tw (Measures used were self-report thus relying on respon-)Tj 0 -1.398 TD -0.0041 Tc -0.062 Tw [(dents. 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L., & Schumm, J. )49.4(A. \(2008\).)]TJ 0 -1.1836 TD 0.0215 Tc 0.1255 Tw (Change in posttraumatic stress disorder symp-)Tj 0 -1.1809 TD 0.0125 Tc 0.125 Tw (toms: Do clinicians and patients agree? )Tj /TT4 1 Tf 18.1991 0 TD 0.0116 Tc 0 Tw (Psycho-)Tj ET 0.99 w /GS1 gs 309 560.505 m 546 560.505 l S BT 11 0 0 11 309 569.01 Tm /GS2 gs 0.0101 Tc 0.0954 Tw (logical Assessment)Tj /TT1 1 Tf 8.0318 0 TD 0 Tc 0 Tw (,)Tj /TT4 1 Tf 0.2645 0 TD 0.0118 Tc 0.1273 Tw [( 2,)]TJ /TT1 1 Tf 1.1618 0 TD 0.0102 Tc [( 131-138.)]TJ -9.4582 -3.1227 TD -0.008 Tc 0.1236 Tw [(TYPE OF)27.5( )46.5(A)10(R)27.4(TICLE)]TJ /F9 1 Tf 10 0 0 10 309 518.64 Tm 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.006 Tc (Longitudinal)Tj /TT1 1 Tf 11 0 0 11 309 502.65 Tm 0.0066 Tc 0.126 Tw [(OBJECTIVE/PURPOSE OF)31.1( )14.4(THE )47.8(A)13.7(R)28.4(TICLE)]TJ /F9 1 Tf 10 0 0 10 309 486.66 Tm 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD 0.0019 Tc 0.125 Tw (This study measured the longitudinal association be-)Tj 0 -1.401 TD -0.0109 Tc -0.0621 Tw (tween clinician and patient ratings of posttraumatic stress)Tj T* -0.0036 Tc 0.0881 Tw (disorder \(PTSD\) over the course of two different ran-)Tj 0 -1.398 TD -0.0135 Tc -0.0625 Tw (domized clinical trials.)Tj /F9 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0035 Tc -0.0033 Tw (The authors hypothesized an association between clini-)Tj 0 -1.398 TD 0.0778 Tw [(cian and patient measures over time. 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Most)Tj 0 -1.398 TD -0.0031 Tc -0.0358 Tw (participants were approximately 50 years old, Cau-)Tj 0 -1.401 TD 0 Tc 0.125 Tw [(casian and have post-high school education. )51(A)5.1(p)5.1(-)]TJ T* -0.0243 Tc -0.0625 Tw (proximately half were married and approximately half)Tj 0 -1.398 TD -0.0036 Tc 0.109 Tw (were unemployed. Trauma has occurred approxi-)Tj ET endstream endobj 360 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /F9 57 0 R /TT1 8 0 R /TT2 9 0 R /TT3 10 0 R /TT4 20 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 362 0 obj << /Length 8834 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 66 59.745 m 558 59.745 l S BT /TT3 1 Tf 8 0 0 8 423.24 42.6 Tm 0 0 0 1 k /GS2 gs -0.0051 Tc 0.0326 Tw [(IJEMH Vol. 10, No. 3 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (237)Tj /TT2 1 Tf 10 0 0 10 102 722.64 Tm -0.0022 Tc -0.0092 Tw [(mately 25 years prior to the study)60.8(.)]TJ -1.2 -1.599 TD 0.028 Tc 0.125 Tw [(o)-672(Participants were randomly assigned to either)]TJ 1.2 -1.401 TD -0.0035 Tc 0.0687 Tw (trauma-focused group therapy or present-centered)Tj 0 -1.398 TD -0.0031 Tc 0.12 Tw [(group therapy)59.9(.)]TJ -1.2 -1.602 TD 0.0513 Tc 0.125 Tw [(o)-648.7(The trauma-focused group therapy included)]TJ 1.2 -1.398 TD 0.0371 Tc (psychoeducation, identification of coping re-)Tj 0 -1.401 TD -0.0004 Tc (sources, exposure and cognitive restructuring re-)Tj T* 0.0052 Tc (lated to members war zone scenes, and relapse)Tj 0 -1.398 TD -0.0037 Tc 0.005 Tw (prevention for gains made during treatment.)Tj -1.2 -1.602 TD 0.046 Tc 0.125 Tw [(o)-654(The present-centered trauma group included)]TJ 1.2 -1.398 TD -0.005 Tc -0.062 Tw (psychoeducation, the impact of posttraumatic stress)Tj 0 -1.401 TD -0.0056 Tc -0.0625 Tw (on relationships and problem solving as well as pro-)Tj T* -0.0037 Tc 0.07 Tw (cessing current experiences within sessions.)Tj -1.2 -1.599 TD 0.0004 Tc 0.125 Tw [(o)-699.6(Both treatments consisted of 30 weekly sessions)]TJ 1.2 -1.401 TD -0.003 Tc 0.0419 Tw [(followed by five monthly booster sessions.)]TJ -1.2 -1.599 TD -0.0036 Tc 0.075 Tw [(o)-703.6(All participants were assessed using the Clinician)]TJ 1.2 -1.401 TD -0.004 Tc 0.0725 Tw (Administered Posttraumatic Stress Disorder Scale)Tj 0 -1.398 TD -0.0039 Tc 0.0241 Tw (\(CAPS\) and the PTSD Checklist before treatment,)Tj 0 -1.401 TD 0.09 Tw (following treatment, and following completion of)Tj T* 0.0127 Tc 0.125 Tw (booster sessions.)Tj -1.2 -1.599 TD 0.0082 Tc [(o)-691.8(A)0( portion of participants were also tested at 18)]TJ 1.2 -1.401 TD -0.0036 Tc 0.046 Tw [(months and 24 months post therapy)59.4(.)]TJ /F9 1 Tf -3.6 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0135 Tc -0.06 Tw (Trial two)Tj 0.6 -1.599 TD -0.0127 Tc -0.0625 Tw [(o)-712.7(Sixty veterans \(54 men, six women\) with military re-)]TJ 1.2 -1.401 TD -0.0104 Tc -0.06 Tw (lated PTSD.)Tj -1.2 -1.599 TD -0.0033 Tc -0.05 Tw [(o)-703.3(Seventy eight percent had served in )17.7(V)61.9(ietnam. 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Mitchell, PhD)Tj /F63 1 Tf 10 0 0 10 240 253.5 Tm -0.0017 Tc 0.1099 Tw [(Group Crisis Support )]TJ /F64 1 Tf 7.41 0 TD 0.095 Tw (is a straightforward, practical guidebook for anyone providing either)Tj -7.41 -1.2 TD -0.0035 Tc 0.0167 Tw [(crucial information or crisis support services to distressed groups. More than a hundred years)]TJ T* -0.0034 Tc -0.0046 Tw (of sound crisis intervention theory and positive-outcome research back up the guidelines in the)Tj T* -0.0048 Tc 0 Tw (book. )Tj /F63 1 Tf 2.109 0 TD -0.0036 Tc (Group Crisis Support)Tj /F64 1 Tf 6.822 0 TD -0.0034 Tc -0.0004 Tw ( provides valuable information for those recently trained as well as)Tj -8.931 -1.2 TD 0.0225 Tw [(the more experienced peer support personnel and crisis intervention professionals. It contains)]TJ T* -0.0033 Tc 0.0228 Tw (thoughtful crisis management strategies and well-referenced crisis intervention procedures for)Tj T* -0.0036 Tc 0.0631 Tw (both large and small groups that will undoubtedly enhance the group management skills of)Tj T* -0.0034 Tc 0.008 Tw (trained crisis support personnel. )Tj /F63 1 Tf 10.476 0 TD -0.0035 Tc 0.0117 Tw (Group Crisis Support )Tj /F64 1 Tf 7.074 0 TD -0.0033 Tc 0.0091 Tw [(is an invaluable tool for crisis response)]TJ -17.55 -1.2 TD 0.0011 Tc 0.095 Tw (teams in schools, businesses, church groups, emergency medical services, fire services, law)Tj T* -0.0035 Tc 0.0362 Tw [(enforcement organizations, and the military)71.5(.)]TJ ET q 382.45 150.6 9.05 -6.7 re W n /GS1 gs /Fm10 Do Q BT /TT13 1 Tf 30 0 0 30 146.49 428.49 Tm /GS1 gs -0.0054 Tc 0.0425 Tw (Exclusively from Chevron!)Tj 24 0 5.04 24 140.49 398.49 Tm -0.0042 Tc 0.0232 Tw [(A New Book by Jeffrey T. Mitchell)]TJ ET q 151.75 0 0 232 72.05 141.5 cm /Im21 Do Q 0 0 0 0.2 k 0.99 w 1000 M 71.495 128.505 468.01 -49.01 re B* BT /TT3 1 Tf 11 0 0 11 148.41 113.01 Tm 0 0 0 1 k /GS2 gs -0.004 Tc 0.0359 Tw (Get your copy of this important new resource by ordering NOW!)Tj 2.4164 -1.0909 TD -0.0047 Tc 0.0197 Tw (Order by calling Chevron Publishing at 410-418-8002)Tj 3.2045 -1.0909 TD 0.0303 Tw (Order online at chevronpublishing.com)Tj ET /GS1 gs 55.495 458.005 491.51 -386.01 re S endstream endobj 366 0 obj << /ProcSet [/PDF /Text /ImageC ] /Font << /F1 4 0 R /F8 36 0 R /F9 57 0 R /F62 367 0 R /F63 368 0 R /F64 369 0 R /TT1 8 0 R /TT2 9 0 R /TT3 10 0 R /TT12 370 0 R /TT13 371 0 R >> /XObject << /Im21 372 0 R /Fm10 373 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 375 0 obj << /Length 7312 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 66 59.745 m 558 59.745 l S BT /TT3 1 Tf 8 0 0 8 423.24 42.6 Tm 0 0 0 1 k /GS2 gs -0.0051 Tc 0.0326 Tw [(IJEMH Vol. 10, No. 3 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (239)Tj /TT2 1 Tf 10 0 0 10 84 530.64 Tm -0.0036 Tc -0.0354 Tw (When I was in high school, a friend and I decided it was)Tj -1.8 -1.398 TD 0.0015 Tc 0.125 Tw (time we toughened up, so we purchased a thin drugstore)Tj 0 -1.401 TD -0.0037 Tc -0.06 Tw (paperback called )Tj /TT5 1 Tf 6.816 0 TD -0.0042 Tc -0.0629 Tw [(T)93(each Y)85.8(ourself Karate.)]TJ /TT2 1 Tf 8.913 0 TD -0.0034 Tc -0.063 Tw [( I was skeptical: can)]TJ -15.729 -1.401 TD -0.0073 Tc -0.0625 Tw (you really learn a complex martial arts technique by reading a)Tj 0 -1.398 TD -0.0031 Tc 0.081 Tw [(book? But my friend was determined and we spent many)]TJ 0 -1.401 TD -0.0035 Tc -0.035 Tw (hours emulating and practicing the kicks, chops, thrusts, and)Tj T* -0.0034 Tc -0.006 Tw [(blocks described and illustrated in that slim tome. I eventu-)]TJ 0 -1.398 TD -0.003 Tc 0.0182 Tw (ally lost interest but he went on to take real-life martial arts)Tj 0 -1.401 TD -0.0032 Tc 0.0011 Tw (training, ultimately earning a black belt and becoming a ka-)Tj T* -0.0033 Tc 0.07 Tw [(rate instructor himself. )32.7(Y)103.9(ears later)35.7(, he told me that he had)]TJ 0 -1.398 TD -0.0042 Tc -0.0623 Tw (really learned only the rudimentary basics of karate from that)Tj 0 -1.401 TD -0.0037 Tc 0.036 Tw (book, but that it gave me the foundation, the knowledge )Tj T* -0.0036 Tc 0.0214 Tw (and that was something I could build on.)Tj 1.8 -1.998 TD -0.0034 Tc 0.0422 Tw [(So, as a law enforcement instructor)38.6(, Im often asked if)]TJ -1.8 -1.401 TD -0.003 Tc -0.04 Tw (practical police skills especially ones that may have poten-)Tj T* -0.0089 Tc -0.0622 Tw (tial life-and-death consequences can be learned from a book)Tj 0 -1.398 TD -0.0031 Tc 0.0575 Tw [(or a course. 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Here is a volume so richly packed with)]TJ 0 -1.398 TD -0.0028 Tc 0.0062 Tw [(practical, useful information, that you could literally rip out)]TJ 0 -1.401 TD -0.0029 Tc 0.0023 Tw (any page at random and teach a class from it. )Tj /TT5 1 Tf 18.441 0 TD -0.0042 Tc 0.005 Tw (Surviving the)Tj -18.441 -1.401 TD -0.0036 Tc 0 Tw (Street )Tj /TT2 1 Tf 2.511 0 TD -0.0027 Tc -0.0513 Tw (is informed by an easygoing, confident style and read-)Tj -2.511 -1.398 TD -0.0032 Tc 0.0706 Tw (ability that reflects the consummate career experience of a)Tj 0 -1.401 TD -0.0036 Tc -0.0413 Tw (seasoned, senior law enforcement trainer who has earned his)Tj T* -0.0031 Tc 0.0884 Tw (chops and street cred the old-fashioned way: by being out)Tj 0 -1.398 TD 0.0323 Tw [(there and living it. )29.6(Y)104(et, the author doesn)17.8(t talk down to his)]TJ ET 0.99 w 1000 M /GS1 gs 67.495 731.305 490.51 -28.81 re S BT /TT4 1 Tf 14 0 0 14 197.25 713.34 Tm /GS2 gs 0.0031 Tc 0.1236 Tw (Media Reviews Daniel Clark, Editor)Tj /F1 1 Tf 4.4743 -5.6421 TD 0.0084 Tc 0.1393 Tw (BOOK REVIEW)Tj /TT2 1 Tf 12 0 0 12 255.75 619.65 Tm -0.0261 Tc -0.0613 Tw [(By Laurence Miller)31.4(, PhD)]TJ 10 0 0 10 190.5 591 Tm 0.0013 Tc -0.0091 Tw [(Surviving the S)16.3(treet: Of)16.3(ficer Safety and Survival )16.5(T)72.1(echniques)]TJ 6.6 -1.2 TD -0.0092 Tc -0.0621 Tw [(By Gerald )14.7(W)109.6(.)0.3( Garner \(2005\))]TJ -1.2 -1.2 TD -0.0051 Tc -0.0625 Tw (Springfield, IL: Charles C Thomas)Tj 7.65 -3.636 TD -0.0035 Tc 0.0855 Tw (readers and suffused though the text is a palpable concern)Tj 0 -1.398 TD -0.0143 Tc -0.0622 Tw [(for of)15.7(ficer safety and welfare. Gerald Garner)33.7(, Chief of the Fort)]TJ 0 -1.401 TD -0.0037 Tc 0.0707 Tw (Lupton, Colorado Police Department, is a real-world com-)Tj T* -0.0033 Tc 0.0023 Tw [(mander)35.7(, responsible for the lives and safety of real men and)]TJ 0 -1.398 TD 0.0223 Tw [(women, and he takes this char)17.7(ge seriously)59.7(.)]TJ 1.8 -2.001 TD 0.0073 Tc 0.125 Tw (Introductory chapters describe the different types of)Tj -1.8 -1.401 TD -0.0037 Tc 0.1199 Tw [(dangers inherent in police work, including not-so-obvious)]TJ 0 -1.398 TD -0.0034 Tc 0.0756 Tw (threats that the rookie officer might overlook or disregard.)Tj 0 -1.401 TD -0.0031 Tc -0.0099 Tw (The basic principles of police officer safety on the street are)Tj T* -0.0037 Tc 0.0825 Tw [(then outlined and expanded in subsequent chapters. From)]TJ 0 -1.398 TD -0.0025 Tc 0.125 Tw (the perspective of a police psychologist, I was pleased to)Tj 0 -1.401 TD -0.0035 Tc -0.0018 Tw [(note the careful attention to behavioral indicators of danger)35.5(,)]TJ T* -0.0053 Tc -0.0625 Tw (verbal and nonverbal, and the guidelines offered for respond-)Tj 0 -1.398 TD -0.0033 Tc 0.0566 Tw (ing to these clues.)Tj 1.8 -2.001 TD -0.0038 Tc -0.01 Tw (Individual chapters discuss how to approach suspicious)Tj -1.8 -1.401 TD 0.0037 Tc 0.125 Tw (persons and situations; carrying out safe and proper per-)Tj 0 -1.398 TD -0.0002 Tc 0.1251 Tw [(sonal, car)32.8(, and building searches; vehicle contacts, traf)14.8(fic)]TJ 0 -1.401 TD -0.0036 Tc 0.02 Tw (stops, and high-speed pursuits; proper handling of arrestees)Tj T* -0.0034 Tc -0.0616 Tw (and prisoners; dealing with intoxicated, mentally disordered,)Tj 0 -1.398 TD 0 Tc 0.125 Tw (and other out-of-control subjects; crime-in-progress calls;)Tj 0 -1.401 TD -0.0046 Tc -0.0621 Tw (crowd control and civil disturbances; domestic violence inci-)Tj T* -0.0035 Tc 0.1058 Tw [(dents; drowning, fire, hazmat, and other rescue situations;)]TJ 0 -1.398 TD -0.0037 Tc 0.0244 Tw (and what to do when confronted with criminal action while)Tj 0 -1.401 TD -0.0033 Tc -0.0503 Tw [(o)4.7(f)17.7(f-duty)62.7(. )51(An important closing chapter deals with the crucial)]TJ T* -0.0036 Tc -0.0306 Tw (role of law enforcement administration in fostering a culture)Tj 0 -1.398 TD -0.003 Tc 0.0025 Tw (of safety within police agencies.)Tj 1.8 -2.001 TD 0.0056 Tc 0.125 Tw (As is probably unavoidable in a book of this scope,)Tj -1.8 -1.401 TD -0.003 Tc 0.0387 Tw [(certain topics are covered more spottily and cursorily)63(, such)]TJ 0 -1.398 TD 0.0025 Tc 0.125 Tw [(as hostage negotiation and terrorism. )47.5(Also, although the)]TJ 0 -1.401 TD -0.0036 Tc 0.0032 Tw (author does provide a section on Additional Officer Safety)Tj T* -0.0033 Tc -0.0295 Tw (Reading, the nerdy professor in me would have liked to see)Tj 0 -1.398 TD -0.0031 Tc -0.0445 Tw (a more academic reference section, if only to be able to track)Tj ET endstream endobj 376 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT2 9 0 R /TT3 10 0 R /TT4 20 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 378 0 obj << /Length 7125 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 54 59.745 m 546 59.745 l S BT /F1 1 Tf 8 0 0 8 54.99 41.64 Tm 0 0 0 1 k /GS2 gs -0.0052 Tc 0.0771 Tw [(240 )]TJ /TT3 1 Tf 2.7075 0 TD -0.006 Tc 0.0791 Tw (Clark Media Reviews)Tj /TT2 1 Tf 10 0 0 10 54 722.64 Tm -0.0036 Tc 0.0534 Tw [(down the sources of many of this book)50.4(s outstanding ideas)]TJ 0 -1.398 TD -0.0033 Tc 0.094 Tw [(and applications. Obviously)59.7(, however)38.7(, a lar)14.7(ge part of this)]TJ 0 -1.401 TD -0.0041 Tc 0.0745 Tw [(volume)49.9(s content comes from the author)-37.1()52.9(s)0( own experience)]TJ T* 0.0019 Tc 0.1251 Tw [(and encyclopedic practical knowledge base as an of)10.9(ficer)37.9(,)]TJ 0 -1.398 TD -0.0038 Tc -0.0352 Tw [(commander)35.2(, and trainer)35.2(, so it)]TJ 11.67 0 TD -0.0031 Tc -0.0361 Tw (s probably an unfair quibble to)Tj -11.67 -1.401 TD -0.0037 Tc 0.0557 Tw (expect the kind of owlish documentation that characterizes)Tj T* -0.023 Tw (the writings of the desk-and-armchair crowd.)Tj 1.8 -1.998 TD -0.003 Tc -0.0013 Tw (So can you learn street survival skills from a book? Or)Tj -1.8 -1.401 TD -0.0052 Tc -0.0619 Tw [(law)60.8(, medicine, psychology)63.8(, aircraft piloting, sports, music, or)]TJ T* -0.0028 Tc -0.0505 Tw [(any other complex field of knowledge? No, not entirely)63.2(, and)]TJ 0 -1.398 TD -0.0035 Tc -0.0122 Tw (the author makes a clear disclaimer that the lessons outlined)Tj 0 -1.401 TD 0.0363 Tw (in this volume must be supplemented by continuing educa-)Tj T* -0.0032 Tc -0.0455 Tw [(tion, training, and experience. But good manuals, written by)]TJ 0 -1.398 TD 0.0053 Tc 0.125 Tw (knowledgeable and experienced practitioners in all these)Tj 25.5 18.699 TD -0.0029 Tc 0.0306 Tw (fields, enable you to assimilate the necessary practical wis-)Tj 0 -1.401 TD -0.0032 Tc 0.0754 Tw (dom so that when you go on to the training exercises, and)Tj 0 -1.398 TD 0.0066 Tc 0.125 Tw (ultimately to actual life-and-death street encounters, you)Tj 0 -1.401 TD -0.0029 Tc -0.0482 Tw (wont feel like you have to follow a script; your law enforce-)Tj T* -0.0057 Tc -0.0622 Tw (ment style and technique will seem natural and unforced, like)Tj 0 -1.398 TD [(an accomplished musician playing a well-mastered piece and)]TJ 0 -1.401 TD -0.0069 Tc -0.06 Tw [(improvising creatively)62.1(.)]TJ /TT5 1 Tf 1.8 -2.001 TD -0.0035 Tc 0.0933 Tw (Surviving the Street )Tj /TT2 1 Tf 8.346 0 TD (is the best source in one package)Tj -10.146 -1.398 TD -0.0105 Tc -0.0621 Tw (for valid, practical, and immediately applicable street survival)Tj 0 -1.401 TD -0.0044 Tc -0.0625 Tw [(skills and safe patrol policing tactics to date. It can be readily)]TJ T* -0.0108 Tc -0.0622 Tw (adapted for police academy courses on this subject and should)Tj 0 -1.398 TD -0.0034 Tc 0.0261 Tw [(be on the bookshelf of every law enforcement of)14.6(ficer)38.6(, from)]TJ 0 -1.401 TD -0.0035 Tc 0.0325 Tw (rookie to brass.)Tj /F1 1 Tf 14 0 0 14 227.01 435.36 Tm -0.0006 Tc 0.1374 Tw [(T)83.3(alk,)33.7( Listen,)35.8( Connect:)]TJ -4.3114 -1.1443 TD 0.0108 Tc 0.1375 Tw (Deployments, Homecomings, Changes)Tj /TT2 1 Tf 12 0 0 12 257.4 390.66 Tm -0.0095 Tc -0.068 Tw [(Sesame W)81.8(orkshop)]TJ 10 0 0 10 193.26 378 Tm 0.0009 Tc 0.09 Tw (Download at: )Tj ET 500 w 407.76 -622 m 251.85 -622 l S BT 10 0 0 10 251.85 378 Tm 0.0011 Tc 0 Tw (http://archive.sesameworkshop.org/tlc/)Tj -17.886 -3.534 TD -0.004 Tc -0.0037 Tw [(Sesame )14.3(W)96.8(orkshop, the nonprofit educational or)14(ganiza-)]TJ -1.8 -1.401 TD -0.0038 Tc 0.0049 Tw [(tion behind the popular children)50.2(s show Sesame S)17.2(treet, and)]TJ T* -0.0035 Tc -0.0371 Tw [(W)94.3(al-Mart S)17.5(tores, Inc., have produced a bilingual, multi-me-)]TJ 0 -1.398 TD -0.0068 Tc -0.0625 Tw (dia kit for military families with children between the ages of)Tj 0 -1.401 TD -0.0024 Tc -0.0163 Tw (2 and 5 years old.)Tj 1.8 -2.001 TD -0.0032 Tc 0.03 Tw (According to recent news articles, the military has de-)Tj -1.8 -1.398 TD -0.0034 Tc 0.0177 Tw [(ployed approximately 33,000 service members to )50.8(Afghani-)]TJ 0 -1.401 TD 0.0204 Tc 0.125 Tw (stan and 155,000 to Iraq \(unclassified estimates\), plus)Tj T* (thousands of additional service members are deployed)Tj 0 -1.398 TD -0.0033 Tc 0.0522 Tw (throughout the world, including within the US at duty sta-)Tj 0 -1.401 TD -0.0058 Tc -0.0622 Tw [(tions far from their homes and families. Consequently)60.2(, thou-)]TJ T* 0.0276 Tc 0.125 Tw (sands of families are dealing with issues surrounding)Tj 0 -1.398 TD -0.0034 Tc -0.0458 Tw [(deployments, homecomings, and changes within the family)62.6(.)]TJ 1.8 -2.001 TD -0.0033 Tc 0.0206 Tw (The videos in this kit employ the celebrated and loved)Tj -1.8 -1.401 TD -0.0035 Tc -0.0243 Tw (Sesame Street characters to address these significant issues.)Tj 0 -1.398 TD -0.0212 Tc -0.0625 Tw (Interspersed with the memorable cast are military family mem-)Tj 0 -1.401 TD -0.0069 Tc -0.0622 Tw [(bers sharing their experiences. Filled with the familiar sights)]TJ T* -0.0032 Tc 0.011 Tw (and sounds of Sesame Street, the videos are likely to capti-)Tj 0 -1.398 TD -0.0033 Tc 0.061 Tw [(vate young children and other family members. )51.1(Although)]TJ 25.401 26.349 TD -0.0032 Tc 0.0317 Tw (the focus is on younger children, there are valuable lessons)Tj 0 -1.401 TD -0.0033 Tc 0.002 Tw (for teens and caretakers as well.)Tj 1.8 -1.998 TD 0.0025 Tc 0.125 Tw (The videos and songs focus on three topics: deploy-)Tj -1.8 -1.401 TD -0.0134 Tc -0.0625 Tw (ments, homecomings, and the changes which may occur when)Tj T* -0.0027 Tc 0.125 Tw [(a military parent returns from deployment with an injury)60.3(,)]TJ 0 -1.398 TD -0.003 Tc -0.0066 Tw [(whether the injury is visible or not. )51.1(A)59.2( separate set of videos)]TJ 0 -1.401 TD -0.0035 Tc 0.0041 Tw (reaches out to caretakers. Labeled For Grown-Ups, these)Tj T* 0.0275 Tw (videos offer practical suggestions, such as helping the fam-)Tj 0 -1.398 TD 0.0629 Tw (ily remain connected via long-distance hugs through let-)Tj 0 -1.401 TD -0.0032 Tc -0.0525 Tw (ters, email, and video links.)Tj 1.8 -2.001 TD 0.0003 Tc 0.125 Tw [(The kit is available through two sources. If you are)]TJ -1.8 -1.398 TD -0.0028 Tc -0.056 Tw [(associated with the military)63.2(, you may obtain the complete kit)]TJ 0 -1.401 TD -0.0101 Tc -0.062 Tw (through Military One Source at )Tj ET 451.41 -837.85 m 430.8 -837.85 l S BT 10 0 0 10 430.8 162.15 Tm -0.0183 Tc 0 Tw (www)Tj ET 543.51 -837.85 m 451.41 -837.85 l S BT 10 0 0 10 451.41 162.15 Tm -0.0105 Tc (.militaryonesource.com,)Tj -14.241 -1.401 TD -0.0033 Tc 0.0141 Tw [(after registering on the site. The kit contains two DVDs, in)]TJ 0 -1.398 TD -0.0035 Tc 0.0772 Tw [(English and Spanish, plus a poster)38.5(, and four colorful post-)]TJ 0 -1.401 TD -0.0029 Tc -0.0505 Tw (cards to send to the deployed military parent. In addition, the)Tj T* -0.0036 Tc -0.0618 Tw (kit contains a 20 page, bilingual magazine containing helpful)Tj 0 -1.398 TD -0.0037 Tc -0.015 Tw (information and recommendations to assist children in deal-)Tj 0 -1.401 TD -0.0038 Tc 0.0038 Tw (ing with deployments and homecomings.)Tj ET endstream endobj 379 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT2 9 0 R /TT3 10 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 380 0 obj << /Length 725 >> stream Sidran Ad.indd endstream endobj 383 0 obj << /Length 26364 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 66 59.745 m 558 59.745 l S BT /TT3 1 Tf 8 0 0 8 423.24 42.6 Tm 0 0 0 1 k /GS2 gs -0.0051 Tc 0.0326 Tw [(IJEMH Vol. 10, No. 3 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (241)Tj /TT2 1 Tf 10 0 0 10 84 722.64 Tm -0.0029 Tc -0.0396 Tw [(If you are not associated with the military)60.1(, the same ma-)]TJ -1.8 -1.398 TD 0.0006 Tc 0.125 Tw [(terials are available from the Sesame )15.6(W)95.4(orkshop at )]TJ ET 500 w 303 -291.34 m 279.06 -291.34 l S BT 10 0 0 10 279.06 708.66 Tm 0.0008 Tc 0 Tw (http://)Tj ET 196.29 -305.35 m 66 -305.35 l S BT 10 0 0 10 66 694.65 Tm -0.004 Tc -0.0621 Tw [(archive.sesameworkshop.org/tlc/. The videos may be down-)]TJ 0 -1.401 TD -0.0034 Tc 0.005 Tw (loaded or streamed from the site, and the magazine is avail-)Tj 0 -1.398 TD -0.06 Tw (able in pdf format.)Tj 1.8 -2.001 TD -0.0058 Tc -0.062 Tw [(Also available for download from the Sesame )15.3(W)98(orkshop)]TJ -1.8 -1.401 TD -0.0034 Tc -0.0154 Tw (website are a 12 page facilitators guide and a 5 page supple-)Tj 0 -1.398 TD -0.0031 Tc 0.0805 Tw [(ment to the facilitators guide. These tools can be used by)]TJ 0 -1.401 TD -0.01 Tw (family readiness groups, child care facilities, medical facili-)Tj 25.5 11.7 TD -0.0035 Tc 0.0783 Tw (ties \(including rehabilitation\), schools, and other programs)Tj 0 -1.401 TD -0.0033 Tc -0.0225 Tw [(providing support to military families. The guides highlight)]TJ 0 -1.398 TD -0.0093 Tc -0.0625 Tw (important messages, story summaries, family activities, ques-)Tj 0 -1.401 TD -0.0036 Tc 0.0708 Tw (tions to promote discussion, and additional resources.)Tj 1.8 -2.001 TD -0.02 Tw (This is a fun-filled, well-produced, and well-researched)Tj -1.8 -1.398 TD -0.0625 Tw (set of materials designed for a target population under a great)Tj 0 -1.401 TD -0.0123 Tc -0.0622 Tw [(deal of stress. 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