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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. 4 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (245)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. 4, pp. 245-252 2008 Chevron Publishing ISSN 1522-4821)]TJ /TT4 1 Tf 10 0 0 10 102 461.34 Tm -0.0082 Tc 0 Tw (Abstract: )Tj /TT5 1 Tf 3.891 0 TD -0.0623 Tw (The field of Critical Incident Stress Management \(CISM\), a comprehensive, integrated, systematic,)Tj -3.891 -1.299 TD -0.0037 Tc 0.0842 Tw (and multi-component staff support program, developed, expanded in its scope, and spread rapidly with)Tj T* -0.0035 Tc 0.0564 Tw [(little criticism for over a decade. The next ten years \(1996-2006\) could be characterized as a period of)]TJ 0 -1.302 TD -0.0037 Tc 0.0097 Tw [(intense scrutiny and opposition. CISM has recently emerged from the hostile inspection process stronger)]TJ 0 -1.299 TD -0.0038 Tc 0.0612 Tw [(and mor)32.2(e or)29.2(ganized, in many ways, than earlier in its history)53(.)-0.3( Numer)32.2(ous positive outcome studies wer)32.2(e)]TJ T* -0.0036 Tc 0.0599 Tw [(completed during the period of evaluation; these support the principles of CISM. Most importantly)53.4(, the)]TJ 0 -1.302 TD -0.0037 Tc 0.1121 Tw [(United Nations has recently adopted the concepts of CISM for support of its personnel. [International)]TJ 0 -1.299 TD -0.0035 Tc 0.0762 Tw (Journal of Emergency Mental Health, 2008, 10\(4\), pp. 245-252].)Tj /TT1 1 Tf 9 0 0 9 121.14 332.01 Tm -0.0055 Tc -0.0055 Tw (Key words: )Tj /TT5 1 Tf 5.1 0 TD -0.0048 Tc -0.0071 Tw (Critical Incident Stress Management, CISM, crisis intervention, staff support, psychological first aid,)Tj -10.6833 -1.3333 TD -0.0047 Tc -0.0191 Tw (emotional first aid, early psychological intervention, Critical Incident Stress Debriefing, United Nations, Staff Outreach Supp)Tj 49.5139 0 TD 0 Tw (ort,)Tj -32.4306 -1.3333 TD -0.0051 Tc -0.018 Tw (Critical Incident Stress Management Unit.)Tj ET /GS1 gs 66.99 156.765 m 300 156.765 l S BT /TT2 1 Tf 9 0 0 9 66.99 138.99 Tm /GS2 gs 0.0022 Tc 0.125 Tw [(J)5.2(e)5.2(f)12.2(frey )11.9(T)69.7(.)0.3( Mitchell, PhD is a Clinical Professor of Emer)5.5(gency)]TJ 0 -1.22 TD -0.01 Tc -0.0623 Tw [(Health Services at the University of Maryland in Baltimore County)60(,)]TJ 0 -1.2233 TD -0.0051 Tc -0.0136 Tw (and is the President Emeritus of the International Critical Incident)Tj T* -0.0048 Tc 0.0494 Tw [(Stress Foundation. The United Nations has appointed him as an)]TJ 0 -1.22 TD -0.005 Tc -0.0043 Tw (expert consultant to the United Nations Department of Safety and)Tj 0 -1.2233 TD -0.0048 Tc -0.0128 Tw [(Security )11.8(W)89(orking Group on S)11.9(tress. Correspondence regarding the)]TJ T* -0.0055 Tc 0 Tw (article should be directed to jmitch@umbc.edu.)Tj /F1 1 Tf 14 0 0 14 192.99 629.34 Tm 0.0002 Tc 0.1381 Tw (From Controversy to Confirmation:)Tj -4.1486 -1.1421 TD -0.0039 Tc 0.1374 Tw [(Crisis Suppor)-23.2(t Ser)-18.9(vices f)13.2(or the )92.4(T)65(wenty-Fir)9(st Centur)-16.8(y)]TJ /TT2 1 Tf 10 0 0 10 84.99 276.66 Tm -0.0035 Tc -0.0589 Tw (The rudimentary elements of what came to be known as)Tj /TT5 1 Tf -1.8 -1.401 TD -0.0038 Tc 0.07 Tw (crisis intervention)Tj /TT2 1 Tf 7.251 0 TD -0.0027 Tc 0.0714 Tw [( slowly crept into the then newly devel-)]TJ -7.251 -1.401 TD -0.003 Tc -0.0475 Tw (oping fields of neurology and psychology during the Franco)Tj 0 -1.398 TD -0.0037 Tc -0.0326 Tw [(Prussian )14.5(W)97.1(ar of 1870-1871 \(Howard, 1991\). Ef)14.3(forts to deal)]TJ 0 -1.401 TD -0.0033 Tc -0.0243 Tw (with huge numbers of psychologically traumatized war vet-)Tj T* 0.0041 Tc 0.125 Tw [(erans and the psychological ef)13.1(fects of France)55.1(s crushing)]TJ 0 -1.398 TD -0.0035 Tc 0.045 Tw (defeat led to advances in both the recognition of traumatic)Tj 0 -1.401 TD -0.0034 Tc 0.06 Tw (stress reactions and in the value of simple, supportive ser-)Tj 12 0 0 12 273 563.64 Tm -0.0309 Tc -0.0695 Tw [(Jef)11.6(frey T)79.9(.)-0.9( )-10(Mitchell)]TJ 10 0 0 10 207 551.01 Tm 0.0022 Tc -0.054 Tw [(University of Maryland, Baltimore County)62.2(, Maryland)]TJ 11.4 -27.435 TD -0.0042 Tc -0.0622 Tw (vices such as rest, nourishment, and verbalization of the trau-)Tj 0 -1.401 TD -0.0034 Tc -0.0212 Tw [(matic events. Crisis intervention)50.6(s roots, therefore, grew in-)]TJ T* -0.003 Tc -0.05 Tw [(terwoven within the very roots of the fields of neurology and)]TJ 0 -1.398 TD -0.0176 Tc -0.0621 Tw (psychology \(Janet, 1889; Richet, 1891; Boadella, 1997; Crocq,)Tj 0 -1.401 TD -0.0516 Tc 0 Tw (1999\).)Tj 1.8 -2.001 TD -0.0032 Tc 0.055 Tw (More than a hundred years ago, crisis intervention be-)Tj -1.8 -1.398 TD -0.0283 Tw [(gan its evolution into a distinct field of its own. Great disas-)]TJ 0 -1.401 TD 0.01 Tc 0.125 Tw [(ters and a series of horrific wars set the stage for crisis)]TJ T* -0.003 Tc -0.0189 Tw (intervention to maintain its links to psychology while, at the)Tj 0 -1.398 TD -0.0057 Tc -0.0622 Tw [(same time, developing a wide range of temporary)60.3(, active, and)]TJ 0 -1.401 TD -0.0036 Tc 0.0175 Tw (supportive services to mitigate the impact of emotional dis-)Tj T* -0.0034 Tc 0.0578 Tw (tress and to restore people to adaptive functions. There are)Tj 0 -1.398 TD -0.0031 Tc 0.0756 Tw (many luminaries who established the theory base that cur-)Tj 0 -1.401 TD -0.003 Tc 0.0894 Tw (rently supports the practice of modern day crisis interven-)Tj T* -0.0176 Tc -0.0622 Tw (tion \(Charcot, 1890; Stierlin, 1909; Salmon, 1919; Lindemann,)Tj ET endstream endobj 44 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT1 8 0 R /TT2 9 0 R /TT3 10 0 R /TT4 20 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 46 0 obj << /Length 9316 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 54 59.745 m 546 59.745 l S BT /F1 1 Tf 8 0 0 8 54.99 41.01 Tm 0 0 0 1 k /GS2 gs -0.0054 Tc 0.0938 Tw [(246 )]TJ /TT3 1 Tf 2.7563 0 TD -0.005 Tc 0.0937 Tw (Mitchell )Tj 4.4325 0 TD 0.0047 Tc (Crisis Support Services for the 21)Tj 4.7 0 0 4.7 236.76 43.65 Tm 0.0073 Tc 0 Tw (st)Tj 8 0 0 8 240.51 41.01 Tm 0.004 Tc 0.1 Tw [( Century)]TJ /TT2 1 Tf 10 0 0 10 54 722.64 Tm -0.0037 Tc -0.0112 Tw (1944; Kardiner & Spiegel, 1947; Caplan, 1961, 1964, 1969;)Tj 0 -1.398 TD -0.0562 Tw [(Artiss, 1963; Parad & Parad, 1968; Solomon & Benbenishty)59.3(,)]TJ 0 -1.401 TD -0.0516 Tc 0 Tw (1986\).)Tj 1.8 -2.001 TD -0.0035 Tc -0.0105 Tw (Over time various labels have been applied to efforts to)Tj -1.8 -1.398 TD -0.0034 Tc 0.0945 Tw (stabilize and to guide people in emotional turmoil. )Tj /TT5 1 Tf 21.336 0 TD -0.0052 Tc 0 Tw (Crisis)Tj -21.336 -1.401 TD 0.0092 Tc 0.125 Tw (intervention, psychological first aid, emotional first aid,)Tj T* -0.0039 Tc 0.0833 Tw (critical incident stress management)Tj /TT2 1 Tf 14.364 0 TD -0.0026 Tc 0.0825 Tw (, and )Tj /TT5 1 Tf 2.346 0 TD -0.0041 Tc 0.085 Tw (early psychologi-)Tj -16.71 -1.398 TD 0.0034 Tc 0.125 Tw (cal intervention)Tj /TT2 1 Tf 6.486 0 TD 0.0045 Tc [( are a few of the terms currently used to)]TJ -6.486 -1.401 TD -0.0013 Tc (describe the organized, supportive assistance provided by)Tj T* -0.0033 Tc -0.0624 Tw [(trained people in times of acute distress. )50.8(Although there may)]TJ 0 -1.398 TD -0.0036 Tc -0.0625 Tw (be subtle differences, the terms are often used synonymously)Tj 0 -1.401 TD -0.0037 Tc 0.0793 Tw (and each represents a multi-component approach to assist-)Tj T* -0.0033 Tc -0.0261 Tw [(ing people in pain \(Thorne, 1952; Caplan, 1964; Neil, Oney)59.7(,)]TJ 0 -1.398 TD -0.0173 Tc -0.0621 Tw [(DiFonso, )19.1(Thacker)36.7(, & Reichart, 1974; Everly & Mitchell, 1997;)]TJ 0 -1.401 TD -0.0158 Tc -0.0623 Tw [(Everly)59.2(, 1999; Mitchell, 2004a; Everly & Mitchell, 2008\).)]TJ 1.8 -2.001 TD -0.0034 Tc -0.015 Tw (This article explores a transition of the Critical Incident)Tj -1.8 -1.398 TD -0.0036 Tc 0.085 Tw (Stress Management program from a period of surprisingly)Tj 0 -1.401 TD -0.0037 Tw (rapid, widespread, and peaceful growth through a decade of)Tj T* -0.0031 Tc 0.0505 Tw (controversy to a final acceptance of its principles as a sup-)Tj 0 -1.398 TD -0.0033 Tc -0.005 Tw (port system for staff members of the United Nations.)Tj /F1 1 Tf 11 0 0 11 54 411.99 Tm -0.0052 Tc 0.0659 Tw (Controversy in Psychology)Tj /TT2 1 Tf 10 0 0 10 72 388.65 Tm -0.0035 Tc -0.0137 Tw [(As is the case with most human endeavors, controversy)]TJ -1.8 -1.401 TD -0.0023 Tc 0.125 Tw [(accompanied the growth and development of psychology)60.7(.)]TJ 0 -1.398 TD -0.0028 Tc -0.013 Tw [(Experiences, opinions, personality styles, history)63.2(, emotions,)]TJ 0 -1.401 TD -0.0035 Tc 0.031 Tw (misinterpretations, misapplication of procedures, and many)Tj T* -0.0033 Tc 0.0025 Tw (other factors all contribute to differing views of the best ap-)Tj 0 -1.398 TD -0.0027 Tc 0.0115 Tw [(proaches to do practically anything in the field. During my)]TJ 0 -1.401 TD -0.0036 Tc 0.0287 Tw (research for this article I Google-searched the words, con-)Tj T* -0.0027 Tc 0.0617 Tw [(troversy in psychology)60.3(. In a matter of seconds the report)]TJ 0 -1.398 TD -0.0034 Tc -0.0189 Tw (came back that there were a staggering 3,810,000 entries re-)Tj 0 -1.401 TD -0.0031 Tc -0.0518 Tw [(garding the topic! Im sure youll appreciate that I am resist-)]TJ T* -0.0035 Tc -0.0331 Tw (ing the temptation to discuss all of them, but a few examples)Tj 0 -1.398 TD -0.0027 Tc 0.0141 Tw [(of controversies in psychology may be helpful. )18.4(W)95.1(e)-0.1( are, for)]TJ 0 -1.401 TD -0.0033 Tc 0.0179 Tw (example, all familiar with the nurture-nature controversy in)Tj T* -0.0028 Tc 0.0918 Tw [(psychology)63.2(.)-4.4( )54.6(Another area of psychological controversy is)]TJ 0 -1.398 TD -0.0033 Tc -0.0317 Tw (the argument between behaviorists and psychoanalysts. One)Tj 0 -1.401 TD -0.0063 Tc -0.0621 Tw [(final example of controversy is that of Mesmer)-39.3()56.7(s)-0.2( theories, the)]TJ T* -0.0027 Tc -0.0084 Tw (very ones that eventually evolved into the field of hypnosis.)Tj 0 -1.398 TD -0.0032 Tc 0.0593 Tw (Those theories were hotly contested by his contemporaries)Tj 0 -1.401 TD -0.0035 Tc -0.0009 Tw (in the late 1800s. Some of the arguments were not so much)Tj T* -0.0013 Tc 0.125 Tw (against his theories as they were vigorous attacks against)Tj 0 -1.398 TD -0.0034 Tc 0.055 Tw [(him as a person. Be that as it was, Mesmer)-39.4()53.6(s)0.2( theories sur)17.6(-)]TJ 0 -1.401 TD -0.0051 Tc -0.0625 Tw (vived beyond the controversy and became a foundation stone)Tj T* -0.0031 Tc -0.0528 Tw (for therapeutic hypnosis as we know it today \(Boring, 1929\).)Tj /F1 1 Tf 11 0 0 11 309 723.99 Tm -0.0044 Tc 0.0348 Tw (Critical Incident Stress Management)Tj /TT2 1 Tf 10 0 0 10 327 700.65 Tm -0.0047 Tc -0.0625 Tw (Critical Incident Stress Management \(CISM\), a compre-)Tj -1.8 -1.401 TD -0.0034 Tc 0.014 Tw (hensive, integrated, systematic, and multi-component pack-)Tj 0 -1.398 TD -0.0559 Tw [(age of crisis support services, was initiated in 1974. CISM is)]TJ 0 -1.401 TD -0.003 Tc 0.0463 Tw [(a subset of crisis intervention and it shares in its theory)60(, its)]TJ T* -0.0031 Tc 0.0085 Tw [(history)62.9(, and in the main guiding principles of )]TJ /TT5 1 Tf 18.165 0 TD -0.0041 Tc 0.0108 Tw [(p)6.1(r)28.9(oximity)52.9(, im-)]TJ -18.165 -1.398 TD 0.0054 Tc 0.1254 Tw [(mediacy)50.4(, expectancy)47.4(, br)38.4(evity)50.4(,)-0.2( simplicity)50.4(, practicality)50.4(, and)]TJ 0 -1.401 TD 0.0024 Tc 0 Tw (innovation)Tj /TT2 1 Tf 4.311 0 TD 0.004 Tc 0.125 Tw (. This sensible approach to assisting people in)Tj -4.311 -1.401 TD -0.0034 Tc 0.1119 Tw (times of crisis became extremely popular within a decade)Tj 0 -1.398 TD -0.0068 Tc -0.0622 Tw [(\(Mitchell, 1983; Mitchell, 2004a\). CISM has expanded to in-)]TJ 0 -1.401 TD -0.0033 Tc 0.0778 Tw (corporate so many crisis support services for such a broad)Tj T* -0.0032 Tc -0.0368 Tw (segment of the population that today CISM is a field in itself)Tj 0 -1.398 TD -0.0134 Tc -0.0621 Tw (\(Mitchell & Mitchell, 2006; Everly & Mitchell, 2008\).)Tj /F1 1 Tf 11 0 0 11 309 513.99 Tm -0.005 Tc 0.0705 Tw (Controversy in CISM)Tj /TT2 1 Tf 10 0 0 10 327 490.65 Tm -0.004 Tc 0.0107 Tw (The rapid and widespread dissemination of CISM does)Tj -1.8 -1.401 TD -0.0032 Tc 0.109 Tw [(not mean that the field escaped controversy)62.8(. On the con-)]TJ 0 -1.398 TD -0.003 Tc 0.0198 Tw [(trary)60(, it too has been scrutinized, criticized, and debated for)]TJ 0 -1.401 TD -0.0034 Tc -0.0005 Tw (two of the three decades of its existence \(Mc Farlane, 1988;)Tj T* -0.0031 Tc 0.1114 Tw [(W)94.7(essely)62.9(, Rose, & Bisson 1998; Rose, Bisson, & )17.4(W)94.8(essely)62.9(,)]TJ 0 -1.398 TD -0.0042 Tc -0.0417 Tw (2002; van Emmerik, Kamphuis, Hulsbosch, & Emmelkamp,)Tj 0 -1.401 TD -0.0034 Tc 0.0755 Tw [(2002\). Despite the criticisms, CISM continues to exist, to)]TJ T* -0.0035 Tc 0.0776 Tw [(grow)59.5(, and to expand its services. It is the most discussed,)]TJ 0 -1.398 TD -0.0032 Tc -0.0587 Tw (most recognized, and most widely applied crisis support sys-)Tj 0 -1.401 TD -0.0034 Tc 0.0433 Tw (tem in the world today \(Bisson, McFarlane, & Rose, 2000;)Tj T* -0.0133 Tc -0.0625 Tw [(Helmus & Glenn, 2005; Meichenbaum, 1994; Raphael & )16.7(W)57.6(il-)]TJ 0 -1.398 TD -0.0043 Tc -0.0624 Tw [(son, 2000\). )16.8(W)54.5(ithout question, CISM services are delivered to)]TJ 0 -1.401 TD -0.0036 Tc -0.0367 Tw (vast populations through the efforts of more than 1500 Criti-)Tj T* 0.0018 Tc 0.125 Tw (cal Incident Stress Management teams that operate in 30)Tj 0 -1.398 TD -0.0035 Tc -0.0225 Tw [(countries around the globe. Those efforts do not include the)]TJ 0 -1.401 TD -0.0047 Tc -0.0622 Tw [(activities of the United Nations, which will be described later)]TJ T* -0.003 Tc -0.05 Tw (in this article.)Tj 1.8 -1.998 TD -0.0029 Tc 0.1071 Tw [( It is not my intention to delve into the details of the)]TJ -1.8 -1.401 TD -0.0035 Tc 0.023 Tw [(CISM controversy)62.5(. )17.7(The issues within the debate have been)]TJ T* 0.0056 Tc 0.125 Tw (thoroughly explored and appropriately responded to in a)Tj 0 -1.398 TD -0.0031 Tc 0.023 Tw (variety of articles and book chapters spanning at least a de-)Tj 0 -1.401 TD -0.003 Tc 0.0521 Tw [(cade \(Dyregrov)63(, 1998; Everly)63(, Flannery)60(, & Mitchell, 2000;)]TJ T* -0.0095 Tc -0.0625 Tw [(Everly)59.5(, Flannery)59.5(, Eyler)38.5(, & Mitchell, 2001; Mitchell, 2003a, b;)]TJ 0 -1.398 TD -0.0048 Tc [(2004b; 2007; Everly & Mitchell, 2008\). There are some cau-)]TJ 0 -1.401 TD -0.0036 Tc 0.0445 Tw [(tions, however)35.4(, that should be heeded when one sets out to)]TJ T* -0.0042 Tc -0.0625 Tw [(read the research in the CISM field. First, it is always recom-)]TJ 0 -1.398 TD -0.0036 Tc 0.0061 Tw (mended that people read the original documents in their en-)Tj 0 -1.401 TD 0.0227 Tc 0.125 Tw (tirety or they risk the strong probability that they will)Tj T* -0.0055 Tc -0.0622 Tw (misunderstand or misinterpret the studies. Second, look care-)Tj 0 -1.398 TD -0.0028 Tc 0.0075 Tw [(fully for clear descriptions of what was actually studied. In)]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 8331 >> 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. 4 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (247)Tj /TT2 1 Tf 10 0 0 10 66 722.64 Tm -0.0034 Tc 0.0435 Tw (most cases related to the CISM field, the researchers so al-)Tj 0 -1.398 TD -0.0033 Tc -0.0188 Tw (tered the various processes they studied that those processes)Tj 0 -1.401 TD -0.0032 Tc 0.0533 Tw (bear no resemblance to the techniques that are actually ap-)Tj T* -0.0067 Tc -0.0625 Tw (plied within the CISM field.)Tj /F1 1 Tf 11 0 0 11 66 648 Tm -0.0049 Tc 0.0557 Tw (The Lawsuit Behind the Controversy)Tj /TT2 1 Tf 10 0 0 10 84 624.66 Tm -0.0035 Tc 0.0856 Tw (The backdrop for the main body of the CISM contro-)Tj -1.8 -1.401 TD -0.0028 Tc 0.0145 Tw (versy is a lawsuit brought by the Royal Marines against the)Tj T* -0.0039 Tc 0.0893 Tw (government of the United Kingdom in 1996. The Marines)Tj 0 -1.398 TD -0.003 Tc 0.0756 Tw (instituted the lawsuit because they believed that they were)Tj 0 -1.401 TD -0.0033 Tc 0.055 Tw (denied support services by the Ministry of Defense \(MoD\))Tj T* -0.0035 Tc -0.0285 Tw [(after both the Falkland Islands )14.6(W)97.3(ar in 1982 and the first Per)14.5(-)]TJ 0 -1.398 TD -0.0038 Tc 0.0128 Tw [(sian Gulf )17.5(W)94(ar with Iraq in 1990-91. )17.5(The marines contested)]TJ 0 -1.401 TD 0.0087 Tc 0.125 Tw (that support services might have prevented the develop-)Tj T* -0.0036 Tc -0.0155 Tw [(ment of posttraumatic stress disorder \(PTSD\). The soldiers)]TJ 0 -1.398 TD 0.0021 Tc 0.125 Tw (asserted that:)Tj 1.2 -2.001 TD -0.0034 Tc -0.0223 Tw [( They didnt look after me when I got back)]TJ T* -0.0033 Tc 0.0021 Tw ( They didnt pick up all the signs)Tj 0 -1.998 TD -0.0039 Tc -0.0312 Tw ( They didnt listen to)Tj 0 -2.001 TD -0.0341 Tw ( I didnt get a debrief )Tj 0.6 -2.001 TD -0.0033 Tc 0.0306 Tw (The primary claim in the lawsuit was that there should)Tj -1.8 -1.398 TD -0.0008 Tc 0.125 Tw (have been a crisis support system in place to protect and)Tj 0 -1.401 TD -0.0035 Tc 0.0787 Tw [(benefit the mental health of the combatants. Furthermore,)]TJ T* -0.0037 Tc 0.0932 Tw (the lawsuit claimed that all combat personnel should have)Tj 0 -1.398 TD -0.0072 Tc -0.0625 Tw (had a debrief \(McGhee, 2008\).)Tj 1.8 -2.001 TD -0.004 Tc 0.0263 Tw (The government of the United Kingdom sensed an im-)Tj -1.8 -1.401 TD -0.0036 Tc 0.1 Tw (mediate need to protect itself from a significant economic)Tj 0 -1.398 TD -0.0032 Tc -0.0433 Tw [(threat embodied in the Royal Marines lawsuit. The Ministry)]TJ 0 -1.401 TD -0.0035 Tc 0.0317 Tw [(of Defense engaged Dr)53.5(. Simon )14.5(W)94.3(essely to lead a concerted)]TJ T* -0.0034 Tc -0.04 Tw (effort to disprove the value of debriefing. The first Cochrane)Tj 0 -1.398 TD -0.0047 Tc -0.0627 Tw [(Review on debriefing was published in 1998 \(W)76.3(essely)58.3(, Rose,)]TJ 0 -1.401 TD -0.0034 Tc 0.0454 Tw [(& Bisson\). It contained reports on six studies. )17.6(T)70.4(wo of the)]TJ T* -0.0037 Tc 0.095 Tw (studies reported positive outcomes; two were described as)Tj 0 -1.398 TD -0.0031 Tc 0.0475 Tw [(neutral. Only two of the six studies contained negative re-)]TJ 0 -1.401 TD -0.003 Tc 0.0035 Tw (sults. It should be noted that )Tj /TT1 1 Tf 11.706 0 TD -0.0074 Tc 0 Tw (none)Tj /TT2 1 Tf 2.034 0 TD -0.0032 Tc 0.0038 Tw ( of the studies were actu-)Tj -13.74 -1.401 TD -0.0258 Tc -0.0625 Tw (ally performed on the Critical Incident Stress Debriefing \(CISD\))Tj 0 -1.398 TD -0.004 Tc -0.0621 Tw [(small group process. )53.1(All were performed on individual crisis)]TJ 0 -1.401 TD -0.0036 Tc -0.0128 Tw [(victims, not homogeneous groups. Despite the fact that two)]TJ T* -0.0034 Tc 0.07 Tw (studies were positive in their results and two were neutral,)Tj 0 -1.398 TD -0.0058 Tc -0.0622 Tw (and none were actually about the CISD process, the research-)Tj 0 -1.401 TD -0.0035 Tc -0.0583 Tw [(ers concluded that debriefings did not work. These research-)]TJ T* -0.0031 Tc -0.0138 Tw (ers furthermore suggested that the Royal Marines really had)Tj 25.5 62.4 TD -0.0035 Tc 0.0288 Tw [(no claim against the UK)50.5(s Ministry of Defense because de-)]TJ 0 -1.398 TD -0.0033 Tc 0.0044 Tw (briefing \(a\) would probably have caused harm; and/or \(b\) if)Tj 0 -1.401 TD -0.0154 Tc -0.0623 Tw (not harmful, then it would not have been efficacious \(McGhee,)Tj T* -0.0516 Tc 0 Tw (2008\).)Tj 1.8 -1.998 TD -0.0034 Tc 0.1107 Tw (The first Cochrane Review was so severely criticized)Tj -1.8 -1.401 TD -0.0032 Tc 0.045 Tw (that it caused the Cochrane Library to update its review on)Tj T* -0.0043 Tc -0.0624 Tw [(the issue of debriefing \(Rose, Bisson, & )16.8(W)93.6(essely)64.7(, 2002\). )16.8(The)]TJ 0 -1.398 TD -0.0036 Tc -0.0275 Tw (Cochrane Review is touted as a non-biased, objective evalu-)Tj 0 -1.401 TD -0.0034 Tc 0.1122 Tw [(ation of medical and psychiatric procedures. Recognition)]TJ T* -0.0048 Tc -0.0625 Tw (that in both the 1998 and the 2002 reviews, two of its primary)Tj 0 -1.398 TD -0.0034 Tc -0.0189 Tw (authors were, in fact, authors of studies within the Cochrane)Tj 0 -1.401 TD -0.0038 Tc 0.1078 Tw (Review on debriefing, raises serious concerns about the)Tj T* -0.0037 Tc 0.0651 Tw [(review)50.3(s non-biased, objective evaluation of the debriefing)]TJ 0 -1.398 TD -0.0033 Tc 0.0573 Tw [(issue. Coincidentally)62.7(, the second Cochrane review was is-)]TJ 0 -1.401 TD -0.0034 Tc 0.0245 Tw (sued before the court came to its final judgment in the law-)Tj T* -0.0033 Tc 0.0036 Tw [(suit. )50.7(At least one study)62.7(, which had not even been published)]TJ 0 -1.398 TD -0.0146 Tw (at the time, was rushed into the review so that it might serve)Tj 0 -1.401 TD -0.0036 Tc 0.028 Tw [(as evidence in the court)53.4(s judgment.)]TJ 1.8 -2.001 TD 0.002 Tc 0.125 Tw (Again, this second review did not address the actual)Tj -1.8 -1.398 TD -0.0035 Tc 0.0825 Tw [(Critical Incident Stress Debriefing. Not a single reviewed)]TJ 0 -1.401 TD -0.002 Tc 0.125 Tw (study actually researched the CISD process; all of the 11)Tj T* -0.0013 Tc (studies in the review were performed on individuals who)Tj 0 -1.398 TD -0.0039 Tc 0.0089 Tw [(were wounded victims. )50.1(A)58.3( full 25% of the Cochrane Review)]TJ 0 -1.401 TD -0.0037 Tc -0.0035 Tw (studies were performed on individual auto accident victims.)Tj T* -0.036 Tw (Another 25% of the studies in the review were performed on)Tj 0 -1.398 TD -0.0033 Tc 0.0293 Tw (individual emergency room patients from house fires, falls,)Tj 0 -1.401 TD -0.0125 Tc -0.0625 Tw [(and other physical traumas. )53.5(A)58.7( surprising 25% of the Cochrane)]TJ T* -0.0079 Tc -0.0621 Tw (studies were performed on individual women with pregnancy)Tj 0 -1.398 TD -0.0036 Tc -0.045 Tw (problems including birth mothers after difficult pregnancies,)Tj 0 -1.401 TD 0.0256 Tw (women who miscarried, and mothers who delivered by Ce-)Tj T* -0.006 Tw [(sarean section. The remaining 25% of the studies were per-)]TJ 0 -1.398 TD -0.0189 Tw (formed on burn victims, sexual assault victims, and dog bite)Tj 0 -1.401 TD 0.0356 Tw [(victims. No homogeneous groups, such as emergency per-)]TJ T* -0.0131 Tc -0.0622 Tw (sonnel, military personnel, or aviation employees, were evalu-)Tj 0 -1.398 TD -0.0036 Tc 0.082 Tw [(ated in either of the Cochrane Reviews \(W)77.4(essely)62.4(, Rose, &)]TJ 0 -1.401 TD -0.0032 Tc 0.0779 Tw [(Bisson 1998; Rose, Bisson, & )14.7(W)97.6(essely)62.8(, 2002\). In fact the)]TJ T* -0.0035 Tc -0.0129 Tw [(authors admit that )]TJ /TT5 1 Tf 8.031 0 TD -0.0037 Tc -0.015 Tw [(W)94.3(e)1( ar)32.3(e unable to comment on the use of)]TJ -8.031 -1.398 TD -0.0036 Tc 0.0211 Tw (group debriefing, nor the use of debriefing after mass trau-)Tj 0 -1.401 TD -0.0075 Tc 0 Tw (mas)Tj /TT2 1 Tf 2.145 0 TD -0.003 Tc -0.0602 Tw [( \(Rose, Bisson, & )17.8(W)94.9(essely)63(, 2002, p.10\).)]TJ /F1 1 Tf 11 0 0 11 321 146.01 Tm -0.005 Tc 0.0363 Tw [(The )97(T)76.9(rial and the J)14.1(u)1.9(dgment)]TJ /TT2 1 Tf 10 0 0 10 339 122.64 Tm 0.0154 Tc 0.125 Tw (The Royal Marines versus the Ministry of Defense)Tj -1.8 -1.398 TD -0.0061 Tc -0.0621 Tw [(\(United Kingdom\) came to trial in 2001. The claimants alle-)]TJ 0 -1.401 TD -0.0036 Tc 0.0083 Tw (gation was that the MoD failed to:)Tj ET endstream endobj 50 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 52 0 obj << /Length 9122 >> 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 41.01 Tm 0 0 0 1 k /GS2 gs -0.0054 Tc 0.0938 Tw [(248 )]TJ /TT3 1 Tf 2.7563 0 TD -0.005 Tc 0.0937 Tw (Mitchell )Tj 4.4325 0 TD 0.0047 Tc (Crisis Support Services for the 21)Tj 4.7 0 0 4.7 236.76 43.65 Tm 0.0073 Tc 0 Tw (st)Tj 8 0 0 8 240.51 41.01 Tm 0.004 Tc 0.1 Tw [( Century)]TJ /TT2 1 Tf 10 0 0 10 54 722.64 Tm -0.0061 Tc 0 Tw ( )Tj /TT5 1 Tf 0.684 0 TD -0.0035 Tc 0.0916 Tw ( devise, operate or implement a suitable system for the)Tj 0.516 -1.398 TD -0.0038 Tc 0.0372 Tw (handling of personnel following combat, as a generality)Tj 0 -1.401 TD -0.0037 Tc 0.0414 Tw (involving operational debriefing in a group or individu-)Tj T* -0.0038 Tc 0.0859 Tw [(ally)50.2(, or similar technique appr)32.2(opriate for date,allowing)]TJ 0 -1.398 TD -0.0036 Tc 0.0729 Tw (for psychological first aid and the voluntary ventilation)Tj 0 -1.401 TD -0.0037 Tc 0.0011 Tw (and defusing of past experience in an atmosphere of mu-)Tj T* 0 Tc 0.125 Tw (tual support for those with mild tomoderate ASR; and)Tj 0 -1.398 TD -0.0037 Tc 0.0767 Tw (with briefings at the conclusions of deployment.)Tj /TT2 1 Tf -1.2 -2.001 TD -0.0061 Tc 0 Tw ( )Tj /TT5 1 Tf 0.684 0 TD -0.0035 Tc 0.0905 Tw [( Devise, operate or implement a suitable system for the)]TJ 0.516 -1.401 TD -0.0038 Tc 0.1122 Tw (monitoring and vigilant surveillance of those known to)Tj 0 -1.398 TD -0.0035 Tc 0.0227 Tw (be, or suspected to be suffering from PTSD or in a class)Tj 0 -1.401 TD -0.0155 Tc -0.061 Tw (objectively at risk from PTSD. )Tj /TT2 1 Tf 12.141 0 TD -0.0161 Tc -0.0633 Tw [(\(Generic statement of case\))]TJ -11.541 -2.001 TD -0.0002 Tc 0.125 Tw (The Judgment in the case was issued in favor of the)Tj -1.8 -1.398 TD -0.0031 Tc 0.0028 Tw [(U)5.1(K)5.1()53.9(s Ministry of Defense and against the Royal Marines in)]TJ 0 -1.401 TD -0.0036 Tc 0.0539 Tw [(2002. Dr)50.4(. Simon )17.4(W)94.2(essely claimed that his defense drew a)]TJ T* 0.0325 Tw [(line in the sand against the claimants. The judgment does)]TJ 0 -1.398 TD -0.003 Tc 0.03 Tw (not state that there was no system. It states that there was a)Tj 0 -1.401 TD 0.0441 Tw (system and it was fine. The judgment does not say that the)Tj T* -0.0037 Tc 0.015 Tw (MoD should not now take on board the Mitchell principles.)Tj 0 -1.398 TD -0.0032 Tc 0.0162 Tw (It just states that it did not have to over the time frame cov-)Tj 0 -1.401 TD -0.0048 Tc -0.062 Tw (ered by the litigation \(McGhee, 2008\).)Tj 1.8 -2.001 TD -0.0018 Tc 0.125 Tw (An interesting effect of the Royal Marines lawsuit is)Tj -1.8 -1.398 TD -0.0102 Tc -0.062 Tw [(that the British military are now utilising their version / inter-)]TJ 0 -1.401 TD -0.0035 Tc -0.0066 Tw [(pretation of the Mitchell principles \(McGhee, 2008\). )50.9(A)58.7( re-)]TJ T* -0.0033 Tc 0.03 Tw [(cent randomized controlled trial by the United S)17.7(tates )50.7(Army)]TJ 0 -1.398 TD -0.0064 Tc -0.0622 Tw (concluded that the Critical Incident Stress Debriefing \(CISD\))Tj 0 -1.401 TD -0.0032 Tc 0.111 Tw (does not cause harm and is preferred by soldiers over the)Tj T* -0.0033 Tc -0.0193 Tw [(S)21.9(tress Management Class that has been of)17.7(fered by the army)59.7(.)]TJ 0 -1.398 TD 0.0062 Tc 0.125 Tw (Furthermore, the study concluded that the CISD process)Tj 0 -1.401 TD -0.0037 Tc 0.0871 Tw (enhanced the perception that the command structure cared)Tj T* 0.0057 Tc 0.125 Tw (for and supported the operations personnel \(Adler et al.,)Tj 0 -1.398 TD -0.0516 Tc 0 Tw (2008\).)Tj /F1 1 Tf 11 0 0 11 54 237.99 Tm -0.0049 Tc 0.0398 Tw (The United Nations and CISM)Tj /TT2 1 Tf 10 0 0 10 72 214.65 Tm -0.0034 Tc 0.0039 Tw (While the controversy was at its height, the United Na-)Tj -1.8 -1.401 TD -0.0038 Tc 0.0381 Tw (tions was engaged in an independant world-wide review of)Tj 0 -1.398 TD -0.0035 Tc -0.0193 Tw (crisis intervention programs, with the objective of establish-)Tj 0 -1.401 TD -0.0025 Tc -0.0367 Tw [(ing an internal staff support system. In the early years of the)]TJ T* -0.0033 Tc -0.0555 Tw (United Nations, it was quite rare for in-service staff deaths to)Tj 0 -1.398 TD -0.003 Tc -0.0537 Tw [(occur as a result of warfare or terrorist activity)63(. Most deaths-)]TJ 0 -1.401 TD -0.0033 Tc 0.0105 Tw [(in-service were the result of accidents or disease. That dra-)]TJ T* -0.0018 Tc 0.125 Tw (matically changed in 1985 when deaths-in-service caused)Tj 0 -1.398 TD -0.003 Tc 0.0659 Tw [(by warfare and terrorists events rose sharply)63(. )15.4(The overall)]TJ 0 -1.401 TD -0.0035 Tc -0.025 Tw (staff death rate remained higher during the 1990s than it had)Tj T* -0.0037 Tc 0.0825 Tw [(been in previous decades. )50.3(Accidents and disease continue)]TJ 25.5 64.8 TD -0.0032 Tc 0.0365 Tw (to take UN lives, but violence against UN staff is currently)Tj 0 -1.398 TD -0.0054 Tc -0.0625 Tw (elevated. The years 2003 and 2007 were among the most vio-)Tj 0 -1.401 TD -0.003 Tc -0.0149 Tw [(lent and lethal for UN staf)18(f in its history)60(.)]TJ 1.8 -2.001 TD -0.0032 Tc -0.0015 Tw (Many dedicated and caring UN personnel regularly en-)Tj -1.8 -1.398 TD -0.0036 Tc 0.0061 Tw (counter a wide range of painful and disturbing personal and)Tj 0 -1.401 TD -0.0032 Tc -0.0123 Tw [(occupational tragedies each year)50.8(. )18.4(They experience personal)]TJ T* -0.0033 Tc 0.1095 Tw (illness as well as illness and deaths in their own families.)Tj 0 -1.398 TD -0.0457 Tw (They witness horrific disease, starvation, crowding, and vio-)Tj 0 -1.401 TD 0.0462 Tw [(lence against refugee populations. They are sometimes re-)]TJ T* -0.0078 Tc -0.0625 Tw (quired to perform the difficult task of making announcements)Tj 0 -1.398 TD -0.0088 Tc -0.0622 Tw (of deaths or injuries regarding fellow staff members or people)Tj 0 -1.401 TD -0.0051 Tc -0.0623 Tw [(in the communities they serve. In many ways, UN staff func-)]TJ T* -0.0033 Tc -0.0625 Tw (tion at levels well beyond the call of duty and their efforts are)Tj 0 -1.398 TD -0.0028 Tc 0.0075 Tw (rarely acknowledged or thanked by the world they serve.)Tj 1.8 -2.001 TD -0.0063 Tc -0.0623 Tw [(The emotional toll on UN staff is high. The long deploy-)]TJ -1.8 -1.401 TD -0.0034 Tc 0.052 Tw (ments to various nations are disruptive to social life and to)Tj 0 -1.398 TD -0.0028 Tc 0.0178 Tw [(marital and family life. Political instability in the countries)]TJ 0 -1.401 TD -0.0032 Tc -0.05 Tw (serviced by the UN can add elements of threat and fear to the)Tj T* -0.0036 Tc -0.0431 Tw [(already numerous demands on staff members. Some experi-)]TJ 0 -1.398 TD -0.0034 Tc -0.0115 Tw [(ence so much stress that their health is threatened. Unfortu-)]TJ 0 -1.401 TD -0.0031 Tc -0.0495 Tw [(nately some resort to taking their own lives. The suicide rate)]TJ T* 0.01 Tw (among UN staff has been on the rise in recent years.)Tj 1.8 -1.998 TD 0.039 Tc 0.125 Tw (In 2004, Ruth Sembajwe, the leader of the Staff)Tj -1.8 -1.401 TD -0.0038 Tc -0.0204 Tw [(Counselor)-36.8()53.2(s)1.1( Of)14.2(fice in the UN headquarters in New )32.4(Y)103.4(o)-0.8(rk, re-)]TJ T* -0.0037 Tc 0.1094 Tw [(quested this author)-39.7()53.3(s)-0.1( assistance in the establishment of an)]TJ 0 -1.398 TD -0.0035 Tc 0.0211 Tw [(internal crisis support team for the UN headquarters. Their)]TJ 0 -1.401 TD -0.0038 Tc 0.0794 Tw (crisis support team was named the Staff Outreach Support)Tj T* -0.0036 Tc 0.0211 Tw [(\(SOS\) team. The mental health professionals and the peers)]TJ 0 -1.398 TD -0.0065 Tc -0.0625 Tw (serving on the team were trained in both individual and group)Tj 0 -1.401 TD -0.0034 Tc -0.02 Tw (crisis intervention skills.)Tj 1.8 -2.001 TD -0.0041 Tc -0.0623 Tw [(Ruth Sembajwe joined Dr)49.9(. Moussa Ba, the lead psychia-)]TJ -1.8 -1.398 TD -0.0031 Tc 0.1228 Tw [(trist with the UN Department of Safety and Security)62.9(, and)]TJ 0 -1.401 TD -0.0033 Tc 0.0571 Tw (performed a meticulous, objective three-year review of the)Tj T* -0.006 Tc -0.0625 Tw [(literature for and against the CISM concepts. They were well)]TJ 0 -1.398 TD 0.0155 Tc 0.125 Tw (aware of the negative outcome studies described in the)Tj 0 -1.401 TD -0.0036 Tc 0.0733 Tw (Cochrane Review as well as almost all other negative out-)Tj T* -0.0033 Tc -0.0173 Tw [(come studies. They were also aware that the preponderance)]TJ 0 -1.398 TD 0.0005 Tw (of studies actually performed on CISM as a whole, or on its)Tj 0 -1.401 TD -0.0038 Tc -0.0619 Tw (components such as the CISD group process, described posi-)Tj T* -0.0023 Tc 0.125 Tw (tive outcomes in their results sections \(Bohl, 1991, 1995;)Tj 0 -1.398 TD -0.0072 Tc -0.0623 Tw [(Boscarino, )53(Adams, & Figley)58.8(, 2005; Campfield & Hills, 2001;)]TJ 0 -1.401 TD -0.0076 Tc -0.062 Tw [(Chemtob, )19.6(T)72.2(omas, Law)61.4(, & Cremniter)37.4(, 1997; Deahl et al. 2000;)]TJ T* -0.0032 Tc 0.055 Tw [(Dyregrove, 1998; Eid, Johnson, & )14.8(W)97.6(eisaeth, 2001; Everly)59.8(,)]TJ 0 -1.398 TD -0.0107 Tc -0.0625 Tw [(Flannery)58.3(, &Mitchell 2000; Everly et al. 2001; Flannery)64.3(, 2005;)]TJ 0 -1.401 TD -0.0039 Tc 0.1136 Tw (Jenkins, 1996; Nurmi, 1999; Richards, 2001; Robinson &)Tj ET endstream endobj 53 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT2 9 0 R /TT3 10 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 55 0 obj << /Length 9318 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 66 59.745 m 558 59.745 l S BT /TT3 1 Tf 8 0 0 8 423.24 42.6 Tm 0 0 0 1 k /GS2 gs -0.0051 Tc 0.0326 Tw [(IJEMH Vol. 10, No. 4 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (249)Tj /TT2 1 Tf 10 0 0 10 66 722.64 Tm -0.014 Tc -0.0623 Tw [(Mitchell, 1993; )19.2(V)135.2(ogt, Leonhardt, Koper)34(, & Pennig, 2004; )16.2(V)132.2(ogt)]TJ 0 -1.398 TD -0.0215 Tc -0.0622 Tw [(& Pennig, 2006; )20.5(V)130.7(ogt, Pennig, & Leonhardt, 2007; )17.5(W)97.3(ee, Miller)38.5(,)]TJ 0 -1.401 TD -0.004 Tc -0.0366 Tw [(& Koelher)38(, 1999; )17.1(W)93.8(estern Management Consultants, 1996\).)]TJ 1.8 -2.001 TD -0.0037 Tc -0.0285 Tw (The UN representatives concluded that there were three)Tj -1.8 -1.398 TD -0.0015 Tc 0.125 Tw (crisis intervention systems that could be considered best)Tj 0 -1.401 TD 0 Tc (practices and thus eligible to be incorporated into a UN)Tj T* -0.0015 Tc [(staff support program. The three programs included the)]TJ 0 -1.398 TD 0.0005 Tc (French Research Institute for Education and Research on)Tj 0 -1.401 TD -0.0033 Tc 0.0434 Tw [(T)37.5(raumatic S)17.7(tress, based in Paris, France and headed by Dr)50.7(.)]TJ T* -0.0035 Tc -0.0461 Tw [(Louis Crocq. The second was the International Critical Inci-)]TJ 0 -1.398 TD 0.0415 Tw (dent Stress Foundation, based in Maryland and co-founded)Tj 0 -1.401 TD 0.0646 Tw [(by this author)50.4(. )17.6(The third program was the )50.6(American )53.6(Acad-)]TJ T* -0.0033 Tc 0.0466 Tw (emy of Experts in Traumatic Stress, based on Long Island,)Tj 0 -1.398 TD -0.0127 Tc -0.062 Tw [(New )32.6(Y)100.5(ork and headed, at that time, by Dr)47.3(. Mark Lerner)53.3(. It was)]TJ 0 -1.401 TD -0.0034 Tc 0.096 Tw (decided that a composite of the best elements of the three)Tj T* -0.0038 Tc 0.0228 Tw (programs would constitute the UN staff support program.)Tj 1.8 -1.998 TD -0.0055 Tc -0.0626 Tw [(Representatives of the UN)48.5(s )15.4(W)98.3(orld Health Or)12.5(ganization,)]TJ -1.8 -1.401 TD -0.0039 Tc 0.0581 Tw [(the UN headquarters S)17.1(taf)14.1(f Counselor)-36.9()53.1(s)0.5( Of)17.1(fice, and the De-)]TJ T* -0.0166 Tc -0.0622 Tw (partment of Safety and Security met with Drs. Crocq, Mitchell,)Tj 0 -1.398 TD -0.0172 Tc [(and Lerner in Paris in )51.9(April, 2006 and again in December)33.8(, 2006)]TJ 0 -1.401 TD -0.0034 Tc -0.003 Tw (to plan the training course for the best practices approach to)Tj T* -0.0035 Tc -0.0038 Tw [(crisis intervention for UN staf)14.5(f. )53.7(A)58.7( training manual was pro-)]TJ 0 -1.398 TD -0.0037 Tc 0.1031 Tw (duced and two trainings were provided for UN personnel.)Tj 0 -1.401 TD -0.0538 Tw [(One was held in Glen Cove, New )32.3(Y)103.5(ork in March of 2007; the)]TJ T* -0.0031 Tc 0.0045 Tw (second was held in Paris, France in June of that year)Tj 1.8 -1.998 TD -0.0034 Tc 0.0065 Tw (At the training in Paris, it was announced that the Gen-)Tj -1.8 -1.401 TD -0.0046 Tc -0.0623 Tw [(eral )52.3(Assembly of the United Nations had confirmed the name)]TJ T* -0.009 Tc -0.0625 Tw (of the UN staff support program as the Critical Incident Stress)Tj 0 -1.398 TD -0.0037 Tc -0.035 Tw [(Management Unit \(CISMU\). In a challenging, exciting, and)]TJ 0 -1.401 TD 0.0344 Tw (interesting decade, CISM concepts passed from a period of)Tj T* -0.0032 Tc 0.0828 Tw (intense controversy to confirmation by the United Nations)Tj 0 -1.398 TD -0.0056 Tc -0.0625 Tw (\(United Nations, 2007a, b, c\).)Tj 1.8 -2.001 TD -0.0035 Tc -0.0624 Tw [(It is, indeed, a marvelous testimony to the wisdom of the)]TJ -1.8 -1.401 TD -0.0024 Tc 0.125 Tw [(United Nations that the General )51.6(Assembly decided that it)]TJ 0 -1.398 TD -0.0033 Tc -0.0505 Tw (was extremely important to support its personnel in their dif-)Tj 0 -1.401 TD -0.0035 Tc 0.0488 Tw [(ficult and stressful missions. )17.5(The General )50.6(Assembly heard)]TJ T* -0.0034 Tc 0.0516 Tw [(the intensive requests for adequate staff support. Its mem-)]TJ 0 -1.398 TD -0.0036 Tc -0.0305 Tw (bers were convinced of the common sense belief that a com-)Tj 0 -1.401 TD 0.0154 Tc 0.125 Tw (prehensive, integrated, systematic and multi-component)Tj T* -0.0064 Tc -0.0622 Tw (\(CISM\) program of support services was required to meet the)Tj 0 -1.398 TD -0.0037 Tc -0.0625 Tw [(various needs of UN personnel in the worldwide community)59.3(.)]TJ 0 -1.401 TD -0.0035 Tc -0.06 Tw (The UN decision to accept a composite CISM system, devel-)Tj T* -0.0555 Tw (oped from the three best practices crisis systems will make)Tj 0 -1.398 TD -0.003 Tc 0.0665 Tw (a difference, not only for their own staff, but for countless)Tj 0 -1.401 TD -0.0031 Tc 0.0133 Tw (people in many nations.)Tj /F1 1 Tf 11 0 0 11 321 723.99 Tm 0.0011 Tc 0 Tw (Conclusion)Tj /TT2 1 Tf 10 0 0 10 339 700.65 Tm -0.0037 Tc 0.0971 Tw (The field of Critical Incident Stress Management was)Tj -1.8 -1.401 TD -0.0031 Tc 0.11 Tw (born of necessity for emergency services personnel in the)Tj 0 -1.398 TD -0.0034 Tc -0.0463 Tw (turbulent years of warfare and increasing exposure to human)Tj 0 -1.401 TD -0.0032 Tc -0.0056 Tw (misery due to accidents, illness, and natural and technologi-)Tj T* 0.105 Tw [(cal disasters. Necessity was the driving force that caused)]TJ 0 -1.398 TD -0.0033 Tc -0.0275 Tw (CISM to expand well beyond its originally perceived sphere)Tj 0 -1.401 TD 0.0316 Tw [(of influence in emergency services. The program has been)]TJ T* -0.0032 Tc 0.09 Tw (tested in the adversity of a prolonged and divisive contro-)Tj 0 -1.398 TD -0.0067 Tw [(versy)62.8(, which often appeared to be based more in the politics)]TJ 0 -1.401 TD -0.0364 Tw [(of power and influence than in the realm of science. Finally)59.9(,)]TJ T* -0.0036 Tc -0.0128 Tw [(CISM has emer)17.4(ged with the recognition of a world body)59.4(.)]TJ 1.8 -1.998 TD -0.0037 Tc -0.0494 Tw (Recognition and confirmation does not mean that all the)Tj -1.8 -1.401 TD -0.0038 Tc 0.0363 Tw (misunderstandings, misinterpretations, and controversies in)Tj T* -0.0032 Tc 0.0115 Tw [(the CISM field have suddenly ended. In all likelihood, dis-)]TJ 0 -1.398 TD -0.0035 Tc 0.0756 Tw [(agreements will continue for the foreseeable future. More)]TJ 0 -1.401 TD -0.0034 Tc -0.0118 Tw (carefully designed research will be required to answer some)Tj T* -0.028 Tw [(of the pressing questions. But research alone will not define)]TJ 0 -1.398 TD -0.0036 Tc 0.015 Tw (the future of staff support services within a CISM program.)Tj 0 -1.401 TD -0.0037 Tc 0.009 Tw (What will direct the future most will be an open-minded at-)Tj T* -0.0001 Tc 0.125 Tw (mosphere that allows the right questions to be asked and)Tj 0 -1.398 TD 0.0065 Tc (encourages researchers to listen carefully to the answers)Tj 0 -1.401 TD -0.004 Tc -0.024 Tw (from people who receive CISM support.)Tj /F1 1 Tf 11 0 0 11 400.89 368.01 Tm 0.021 Tc 0 Tw (REFERENCES)Tj /TT2 1 Tf 10 0 0 10 321 350.64 Tm -0.0285 Tc -0.062 Tw [(Adler)34.5(, )52.7(A, Litz,, B, Castro,C.A., Suvak, M., )19.7(Thomas, J.L., Burrell,)]TJ 1.2 -1.398 TD -0.0031 Tc -0.0454 Tw [(L., et al. \(2008\). )51(A)59.1( group randomized trial of critical inci-)]TJ 0 -1.401 TD -0.0123 Tc -0.0621 Tw (dent stress debriefing provided to U.S. peacekeepers. )Tj /TT5 1 Tf 20.394 0 TD -0.015 Tc 0 Tw (Jour-)Tj -20.394 -1.401 TD -0.0054 Tc -0.0624 Tw [(nal of T)48.6(raumatic S)30.6(t)1.6(r)27.6(ess, 21)]TJ /TT2 1 Tf 10.359 0 TD -0.0053 Tc 0 Tw (\(3\),253-263.)Tj -11.559 -1.8 TD -0.0113 Tc -0.0625 Tw (Artiss, K. \(1963\). 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Reese and J. Horn, and C. Dunning \(Eds.\). )]TJ /TT5 1 Tf 19.419 0 TD -0.0043 Tc 0 Tw (Critical)Tj -19.419 -1.398 TD 0.0022 Tc 0.1251 Tw (incidents in policing, Revised \(pp.31-38\). )Tj /TT2 1 Tf 17.496 0 TD 0.0018 Tc 0 Tw [(W)96.6(ashington,)]TJ -17.496 -1.401 TD -0.0043 Tc -0.0616 Tw (DC: Department of Justice.)Tj -1.2 -1.8 TD -0.0034 Tc -0.0256 Tw (Bohl, N. \(1995\). Measuring the effectiveness of CISD. )Tj /TT5 1 Tf 21.996 0 TD -0.0059 Tc 0 Tw (Fire)Tj -20.796 -1.401 TD -0.0079 Tc (Engineering,)Tj /TT2 1 Tf 5.1 0 TD 0 Tc ( )Tj /TT5 1 Tf 0.186 0 TD -0.012 Tc (148)Tj /TT2 1 Tf 1.47 0 TD -0.0079 Tc -0.06 Tw (\(8\), 125-126.)Tj -7.956 -1.8 TD -0.0101 Tc -0.0625 Tw [(Boadella, D. \(1997\). )49.9(A)91.1(wakening sensibility)61.9(, recovering motil-)]TJ 1.2 -1.398 TD -0.0024 Tc -0.0585 Tw [(ity)60.6(. Psycho-physical synthesis at the foundations of body-)]TJ ET endstream endobj 56 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 58 0 obj << /Length 12010 >> 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 41.01 Tm 0 0 0 1 k /GS2 gs -0.0054 Tc 0.0938 Tw [(250 )]TJ /TT3 1 Tf 2.7563 0 TD -0.005 Tc 0.0937 Tw (Mitchell )Tj 4.4325 0 TD 0.0047 Tc (Crisis Support Services for the 21)Tj 4.7 0 0 4.7 236.76 43.65 Tm 0.0073 Tc 0 Tw (st)Tj 8 0 0 8 240.51 41.01 Tm 0.004 Tc 0.1 Tw [( Century)]TJ /TT2 1 Tf 10 0 0 10 66 722.64 Tm -0.0025 Tc -0.0469 Tw (psychotherapy: The100-year legacy ofPierre Janet. )Tj /TT5 1 Tf 20.244 0 TD -0.0042 Tc 0 Tw (Inter-)Tj -20.244 -1.398 TD -0.0039 Tc 0.0281 Tw [(national Journal of Psychotherapy)53.1(, 2)]TJ /TT2 1 Tf 14.835 0 TD -0.0033 Tc 0.03 Tw (, 45-56.)Tj -16.035 -1.8 TD -0.0032 Tc 0.0676 Tw [(Boring, E.G)116.8(. \(1929\). )15.5(The Psychology of Controversy)62.8(. )51.5(Ad-)]TJ 1.2 -1.401 TD -0.0036 Tc -0.0226 Tw [(dress of the President before the )52.8(American Psychological)]TJ T* -0.0038 Tc 0.0242 Tw [(Association at New )29.2(Y)103.4(ork, December 28, 1928.First pub-)]TJ 0 -1.398 TD -0.0034 Tc -0.03 Tw (lished in )Tj /TT5 1 Tf 3.576 0 TD -0.0043 Tc (Psychological Review)Tj /TT2 1 Tf 8.688 0 TD 0.001 Tc 0 Tw (, )Tj /TT5 1 Tf 0.471 0 TD -0.01 Tc (36)Tj /TT2 1 Tf 0.99 0 TD -0.0035 Tc -0.03 Tw (, 97-121.)Tj -14.925 -1.8 TD -0.003 Tc -0.0536 Tw [(Boscarino, J. )51(A., )54(Adams, R.E., & Figley)63(, C.R. \(2005\). )51(A)59.2( pro-)]TJ 1.2 -1.401 TD -0.0001 Tc 0.1251 Tw (spective cohort study of the effectiveness of employer)Tj T* -0.0035 Tc -0.0112 Tw [(sponsored crisis )-4.7(intervention after a major disaster)35.5(, 7 \(1\),)]TJ /TT5 1 Tf 0 -1.398 TD -0.0041 Tc 0.0139 Tw (International Journal of Emergency Mental Health, 7\(1\))Tj /TT2 1 Tf 0 -1.401 TD -0.0516 Tc 0 Tw (31-44.)Tj -1.2 -1.8 TD -0.0033 Tc -0.0575 Tw [(Campfield, K., & Hills, )50.7(A. \(2001\). Ef)17.7(fect of timing of critical)]TJ 1.2 -1.401 TD -0.0036 Tc -0.0401 Tw (incident stress debriefing \(CISD\) on posttraumatic symp-)Tj 0 -1.398 TD -0.0042 Tc 0 Tw (toms. )Tj /TT5 1 Tf 2.394 0 TD -0.0045 Tc -0.0283 Tw [(Journal of T)56.7(raumatic S)28.5(t)2.5(r)31.5(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 -0.0599 Tw [(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 -0.0041 Tc -0.0585 Tw [(New )33.4(Y)103.1(ork: Grune and S)21.1(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 -1.401 TD -0.0122 Tc -0.0625 Tw [(Y)104(ork: Basic Books.)]TJ -1.2 -1.8 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 -0.001 Tc 0.125 Tw (Charcot, J.-M. \(1890\).)Tj /TT5 1 Tf 9.174 0 TD -0.0009 Tc [( Lecons du Mardi a la Salpetriere.)]TJ -7.974 -1.398 TD -0.0039 Tc -0.0375 Tw (Policlinque 1887-1888. )Tj /TT2 1 Tf 9.531 0 TD -0.004 Tc -0.04 Tw (Notes de cours)Tj /TT5 1 Tf 5.808 0 TD 0 Tc 0 Tw (.)Tj /TT2 1 Tf 0.252 0 TD -0.0052 Tc -0.0558 Tw [( T)71.6(ome )-15.8(I)]TJ /TT5 1 Tf 2.97 0 TD -0.004 Tc -0.04 Tw [( et Lecons)]TJ -18.561 -1.401 TD -0.0039 Tc -0.0049 Tw (du Mardi a la Salpetriere. Policlinque 1888-1889.)Tj /TT2 1 Tf 19.95 0 TD -0.0046 Tc -0.01 Tw [( Notes)]TJ -19.95 -1.401 TD -0.0034 Tc -0.0079 Tw [(de cours. )18(T)73.4(ome II. Paris )-7.8(: Bureaux du Progres Medical, 2)]TJ 0 -1.398 TD -0.0093 Tc 0 Tw (vol.)Tj -1.2 -1.8 TD -0.0189 Tc -0.0625 Tw [(Chemtob, C., )17.1(T)72.9(omas, S., Law)59.1(, )17.1(W)108.9(., & Cremniter)38.1(, D. \(1997\). Post)]TJ 1.2 -1.401 TD -0.0031 Tc 0.0175 Tw (disaster psychosocial intervention. )Tj /TT5 1 Tf 14.259 0 TD -0.0042 Tc 0.02 Tw (American Journal of)Tj -14.259 -1.401 TD -0.0115 Tc 0 Tw (Psychiatry)Tj /TT2 1 Tf 4.164 0 TD -0.005 Tc (, )Tj /TT5 1 Tf 0.426 0 TD -0.015 Tc (134)Tj /TT2 1 Tf 1.464 0 TD -0.0113 Tc -0.06 Tw (, 415-417.)Tj -7.254 -1.8 TD -0.0033 Tc 0.0667 Tw (Crocq, L. \(1999\). )Tj /TT5 1 Tf 7.365 0 TD -0.0041 Tc 0.0671 Tw [(Les T)52.9(raumatismes psychiques de guerr)34.1(e)-0.3(.)]TJ /TT2 1 Tf -6.165 -1.398 TD -0.007 Tc -0.0625 Tw (Paris: Odile Jacob.)Tj -1.2 -1.8 TD -0.0048 Tc -0.0622 Tw (Deahl, M., Srinivasan, M., Jones, N., Thomas, J., Neblett, C.,)Tj 1.2 -1.401 TD -0.0121 Tc -0.0618 Tw [(& Jolly)56.9(, )53.8(A. )-9.2(\(2000\). Preventing psychological trauma in sol-)]TJ T* -0.0032 Tc 0.0134 Tw (diers. 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H., & )17.9(W)94.7(eisaeth, L. \(2001\). )17.9(The ef)14.9(fects of)]TJ 1.2 -1.398 TD -0.0035 Tc 0.0422 Tw (group psychological debriefing on acute stress reactions)Tj 0 -1.401 TD -0.0201 Tc -0.0617 Tw [(following a traf)12.9(fic accident: )54.2(A)57.1( quasi-experimental approach.)]TJ /TT5 1 Tf T* 0.0004 Tc 0.125 Tw (International Journal of Emergency Mental Health)Tj /TT2 1 Tf 21.114 0 TD 0.005 Tc 0 Tw (, )Tj /TT5 1 Tf 0.636 0 TD 0 Tc (3)Tj /TT2 1 Tf 0.501 0 TD (,)Tj -22.251 -1.398 TD -0.0511 Tc (145-154.)Tj 24.3 64.998 TD -0.0031 Tc 0.0053 Tw [(Everly)62.9(, G)116.9(.S., Jr)53.9(. \(1999\). 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Caplan, community and)]TJ 1.2 -1.401 TD -0.0038 Tc -0.0251 Tw [(Critical )-8.9(Incident Stress Management. )]TJ /TT5 1 Tf 14.904 0 TD -0.004 Tc (International Jour-)Tj -14.904 -1.401 TD -0.0043 Tc -0.0238 Tw (nal of Emergency Mental Health)Tj /TT2 1 Tf 12.891 0 TD -0.001 Tc 0 Tw (, )Tj /TT5 1 Tf 0.474 0 TD 0 Tc (8)Tj /TT2 1 Tf 0.495 0 TD -0.0032 Tc -0.03 Tw (\(1\), 1-10.)Tj -15.06 -1.8 TD -0.0028 Tc 0.0209 Tw [(Neil, )18.6(T)77(., Oney)63.2(, J., DiFonso, L., )18.6(Thacker)36.2(, B., & Reichart, )18.6(W)104(.)]TJ 1.2 -1.398 TD -0.017 Tc 0 Tw (\(1974\).)Tj /TT5 1 Tf 2.805 0 TD -0.0162 Tc -0.0589 Tw [( Emotional first aid. )]TJ /TT2 1 Tf 7.716 0 TD -0.0171 Tc -0.065 Tw (Louisville: Kemper-Behavioral)Tj -10.521 -1.401 TD -0.0006 Tc 0.0746 Tw (Science Associates.)Tj -1.2 -1.8 TD -0.0034 Tc -0.012 Tw (Nurmi, L. \(1999\). 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Paris )-61.6(: Flix )47.8(Alcan.)]TJ -2.604 -1.8 TD -0.0135 Tc -0.0625 Tw [(Robinson, R.C., & Mitchell, J.T)70.5(. \(1993\) Evaluation of psycho-)]TJ 1.2 -1.401 TD -0.0102 Tc -0.0558 Tw (logical debriefings. )Tj /TT5 1 Tf 7.641 0 TD -0.0111 Tc -0.0612 Tw [(Journal of T)51.9(raumatic S)27.9(t)1.9(r)30.9(ess, 6)]TJ /TT2 1 Tf 11.508 0 TD -0.0104 Tc -0.065 Tw (\(3\), 367-)Tj -19.149 -1.401 TD -0.0583 Tc 0 Tw (382.)Tj -1.2 -1.8 TD -0.0028 Tc -0.0445 Tw [(Rose, S., Bisson, J., & )18.1(W)95(essely)63.2(, S. \(2002\). Psychological de-)]TJ 1.2 -1.398 TD 0.013 Tc 0.125 Tw [(briefing for )-8(preventing post traumatic stress disorder)]TJ 0 -1.401 TD -0.0068 Tc 0 Tw (\(PTSD\). )Tj /TT5 1 Tf 3.501 0 TD -0.007 Tc -0.0626 Tw (The Cochrane Library)Tj /TT2 1 Tf 8.739 0 TD -0.0063 Tc -0.0619 Tw [(,)-7.3( Issue 1. 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Cost-Benefit-Analyses of Criti-)]TJ 1.2 -1.398 TD -0.0038 Tc -0.0506 Tw (cal Incident Stress Management CISM. In J. Leonhardt &)Tj 0 -1.401 TD 0.0052 Tc 0.1078 Tw [(J. V)130.4(ogt )-17.1(\(Editors\) )]TJ /TT5 1 Tf 7.269 0 TD 0.005 Tc 0.125 Tw [(Critical Incident S)29(t)3(r)29(ess Management)]TJ -7.269 -1.401 TD -0.004 Tc -0.01 Tw (CISM in aviation )Tj /TT2 1 Tf 7.044 0 TD -0.0042 Tc -0.0598 Tw [(\(pp )-50.2(153-170\). 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Dr)87.3(. Mitchell)32.3(s ar)-5.2(ticle appears on pages 197 201 of that)]TJ T* 0.0138 Tc 0 Tw (issue.)Tj 0 -2.3625 TD -0.0064 Tc -0.052 Tw [(Corr)11.1(ection: )8.5(The corr)11.1(ect page numbers for)8.6( Dr)86.1(. Laur)8.6(ence Miller)-21.4()34.1(s)-0.2( ar)-6.4(ticle on jur)11.1(or)8.6( str)11.1(ess in)]TJ 0 -1.165 TD -0.0051 Tc 0.0215 Tw (that same issue are 203 218)Tj /TT2 1 Tf 12.315 0 TD 0 Tc 0 Tw (.)Tj ET 2.01 w 1000 M /GS1 gs 55.005 248.995 489.99 -157.49 re S endstream endobj 67 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 69 0 obj << /Length 6183 >> 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. 4 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (253)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. 4, pp. 253-260 2008 Chevron Publishing ISSN 1522-4821)]TJ /TT4 1 Tf 10 0 0 10 102 550.35 Tm -0.0042 Tc 0 Tw (Abstract: )Tj /TT5 1 Tf 4.035 0 TD -0.0037 Tc 0.0457 Tw (This article examines the debate on debriefing that has persisted for two decades and remains)Tj -4.035 -1.299 TD 0.0091 Tc 0.1254 Tw [(lar)27.1(gely unr)30.1(esolved to this day)54.1(. )15.5(A)19.9( brief histor)-5.9(y of Critical Incident S)33.1(t)1.1(r)27.1(ess Management \(CISM\) and)]TJ 0 -1.302 TD -0.0035 Tc 0.0721 Tw (Critical Incident Stress Debriefing \(CISD\) is given, these being the subject of the debate, followed by a)Tj 0 -1.299 TD -0.0037 Tc 0.0545 Tw [(summary of the development and current status of the debate. Discussion follows on why the opposing)]TJ T* -0.0038 Tc 0.0593 Tw (positions appear to be at a stalemate. [International Journal of Emergency Mental Health, 2008, 10\(4\),)Tj 0 -1.302 TD 0.0023 Tc 0.125 Tw (pp. 253-260].)Tj /TT1 1 Tf 9 0 0 9 125.01 459.99 Tm -0.0055 Tc -0.0139 Tw (Key words: )Tj /TT5 1 Tf 5.0833 0 TD -0.0048 Tc -0.0144 Tw (Critical Incident Stress Management, CISM, Critical Incident Stress Debriefing, CISD, debriefing,)Tj 6.3767 -1.3333 TD -0.0047 Tc -0.0204 Tw (evaluation, debriefing debate, research.)Tj ET /GS1 gs 66 143.745 m 299.01 143.745 l S BT /TT2 1 Tf 9 0 0 9 66 126 Tm /GS2 gs -0.0088 Tc -0.0622 Tw [(Robyn Robinson, )48(AM, Ph.D., F)64.5(APS, is Director of )8(T)35.4(rauma Support)]TJ 0 -1.2233 TD -0.0043 Tc 0.0593 Tw [(Consultants Pty)62.4(. Ltd., a Clinical Psychologist, and Fellow of the)]TJ 0 -1.22 TD -0.013 Tc -0.0624 Tw [(Australian Psychological Society)63.7(. She is the Co-Founder)30.3(, Founding)]TJ 0 -1.2233 TD -0.0053 Tc 0.102 Tw (President, and Immediate Past President of the Critical Incident)Tj T* 0.0156 Tc 0.1251 Tw [(S)15.1(tress Management Foundation, )52.4(Australia. Correspondence)]TJ 0 -1.22 TD -0.0093 Tc -0.0627 Tw (regarding this article should be directed to: robynr@bigpond.net.au)Tj /F1 1 Tf 14 0 0 14 186.66 629.34 Tm 0 Tc 0.1375 Tw (Reflections on the Debriefing Debate)Tj /TT2 1 Tf 10 0 0 10 83.01 405.66 Tm -0.0003 Tc 0.125 Tw (The debate on whether debriefing has positive ef-)Tj -1.8 -1.401 TD -0.0033 Tc 0.0268 Tw [(fects continues for two decades. It has been prolonged. It)]TJ T* 0.1188 Tw [(has included personal attacks and vitriol. The debate, in)]TJ 0 -1.398 TD 0.0014 Tc 0.125 Tw (many respects, remains unresolved today despite sizable)Tj 0 -1.401 TD -0.0039 Tc -0.0623 Tw [(and growing research literature. One may well ask, Why?)]TJ 1.8 -2.001 TD -0.0057 Tc -0.0622 Tw (In circumstances like these there are likely to be factors,)Tj -1.8 -1.398 TD -0.0001 Tc 0.125 Tw (separate from the research literature, causing the lack of)Tj 0 -1.401 TD -0.0031 Tc -0.0485 Tw [(resolution; these ought to be explored. This is a particularly)]TJ T* -0.0445 Tw (difficult task because, to a large extent, it relies on informed)Tj 0 -1.398 TD -0.0099 Tc -0.0625 Tw (speculation and opinion rather than on description and analy-)Tj 0 -1.401 TD 0.0029 Tc 0.125 Tw [(sis of research studies. Nevertheless, it is a task that is)]TJ T* -0.0038 Tc 0.0125 Tw (important to undertake.)Tj /F1 1 Tf 11 0 0 11 65.01 213 Tm 0.0421 Tw (History of Critical Incident Stress)Tj 0 -1.0909 TD -0.0049 Tc 0 Tw (Management)Tj /TT2 1 Tf 10 0 0 10 83.01 177.66 Tm -0.0032 Tc 0.0213 Tw [(In the late 1970s, Jef)17.8(frey )14.4(T)76.6(.)0.5( Mitchell proposed an idea)]TJ -1.8 -1.401 TD -0.0038 Tc -0.0625 Tw [(whose time had come. This was, in essence, that emergency)]TJ 12 0 0 12 274.65 593.64 Tm -0.0289 Tc (Robyn Robinson)Tj 10 0 0 10 321 405.66 Tm -0.0038 Tc -0.0622 Tw (service personnel basically cope well with their job but, from)Tj T* -0.0032 Tc -0.0615 Tw [(time to time, some may become overwhelmed. This may oc-)]TJ T* -0.0033 Tc -0.0384 Tw [(cur through exposure to especially awful events or through a)]TJ 0 -1.398 TD -0.0031 Tc 0.036 Tw [(culmination of events. He argued that, at such times, early)]TJ 0 -1.401 TD -0.0037 Tc 0.0061 Tw (and appropriate support would assist most to return to work)Tj T* -0.0036 Tc -0.0367 Tw (and could also enable identification of those who might ben-)Tj 0 -1.398 TD 0.0138 Tw [(efit from further ongoing professional assistance. From the)]TJ 0 -1.401 TD 0.0238 Tc 0.125 Tw (outset, Mitchell emphasized that staff support systems)Tj T* -0.0078 Tc -0.0625 Tw [(should be multi-component \(Mitchell, 1983\). While he intro-)]TJ 0 -1.398 TD -0.0038 Tc 0.015 Tw (duced group discussion formats \(including Critical Incident)Tj 0 -1.401 TD -0.0037 Tc -0.0125 Tw (Stress debriefing [ CISD]\), his Critical Incident Stress Man-)Tj T* -0.0036 Tc -0.028 Tw [(agement \(CISM\) model was not limited to this. Mitchell as-)]TJ 0 -1.398 TD 0.1161 Tw (serted that those who provide support services need to be)Tj 0 -1.401 TD -0.0032 Tc 0.0284 Tw (appropriately and properly trained \(including mental health)Tj T* -0.0036 Tc -0.0228 Tw [(professionals\). )53.4(Also, he saw these staf)14.4(f support programs as)]TJ 0 -1.398 TD -0.01 Tc -0.0622 Tw [(being in the time frame of early intervention, with links to, but)]TJ 0 -1.401 TD -0.0111 Tc -0.0619 Tw [(distinguished from, longer)12.9(-term counseling or psychotherapy)63.9(.)]TJ 1.8 -2.001 TD -0.0064 Tc -0.0625 Tw [(The Mitchell model evolved and changed over the years.)]TJ -1.8 -1.398 TD -0.0032 Tc -0.02 Tw (Many contributed to this development, especially George S.)Tj 0 -1.401 TD -0.0617 Tw [(Everly)62.9(, Jr)56.9(. who worked closely with Mitchell. )15.4(T)73.7(ogether)35.9(,)-3.2( they)]TJ T* -0.0065 Tc -0.0619 Tw [(and others expanded Mitchell)53.5(s early work. )20.8(The most current)]TJ 0 -1.398 TD -0.0076 Tc -0.0625 Tw (form of CISM is best described in Mitchell \(2007\) and Everly)Tj 0 -1.401 TD -0.0195 Tc (& Mitchell \(2008\).)Tj ET endstream endobj 70 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 72 0 obj << /Length 8272 >> 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 /TT3 1 Tf 8 0 0 8 54.99 41.64 Tm 0 0 0 1 k /GS2 gs -0.006 Tc 0.075 Tw [(254 Robinson)]TJ /F1 1 Tf 6.8775 0 TD -0.0067 Tc [(  )]TJ /TT3 1 Tf 1.0425 0 TD -0.0054 Tc (Reflections on the Debriefing Debate)Tj /TT2 1 Tf 10 0 0 10 72 722.64 Tm -0.0036 Tc -0.0622 Tw (The CISM field encompasses several key innovations in)Tj -1.8 -1.398 TD -0.025 Tw (crisis intervention, including the following:)Tj 1.2 -2.001 TD -0.0031 Tc 0.089 Tw [()-1453(Recognizing the potential for psychologically trau-)]TJ 1.8 -1.401 TD -0.0034 Tc -0.0529 Tw (matic events to impact on emergency service person-)Tj 0 -1.398 TD -0.0035 Tc -0.0071 Tw (nel \(as well as those from allied professions\);)Tj -1.8 -2.001 TD -0.0038 Tc -0.0542 Tw [()-1453.7(Articulating how to support staff through multi-com-)]TJ 1.8 -1.401 TD -0.0032 Tc -0.0125 Tw (ponent programs, delivered by appropriately-trained)Tj 0 -1.398 TD -0.0027 Tc -0.0133 Tw (personnel in timely ways;)Tj -1.8 -2.001 TD 0.0201 Tc 0.125 Tw [()-1429.8(Recognizing the role which workers themselves)]TJ 1.8 -1.401 TD -0.0032 Tc -0.0257 Tw (\(peers\) could play in supporting staff, in conjunction)Tj 0 -1.398 TD -0.0038 Tc 0.025 Tw (with mental health professionals;)Tj -1.8 -2.001 TD -0.004 Tc 0.0742 Tw [()-1453.9(Developing group interventions \(such as CISD and)]TJ 1.8 -1.401 TD -0.0035 Tc -0.0344 Tw [(defusing\) wherein staff who had experienced a criti-)]TJ 0 -1.398 TD -0.0583 Tw (cal event could come together to talk about that event)Tj 0 -1.401 TD -0.0039 Tc 0.125 Tw (and support one another;)Tj -1.8 -2.001 TD -0.0034 Tc 0.0729 Tw [()-1453.3(Articulating the many and varied possible needs of)]TJ 1.8 -1.398 TD -0.0035 Tc 0.058 Tw (workers, immediately post-exposure to trauma, and)Tj 0 -1.401 TD -0.0032 Tc 0.0875 Tw (educating helpers to be flexible in their support by)Tj T* -0.0036 Tc 0.12 Tw (providing practical assistance and a good listening)Tj 0 -1.398 TD 0.0005 Tc 0 Tw (ear;)Tj -1.8 -2.001 TD -0.0039 Tc 0.0279 Tw [()-1453.8(Recognizing the kinds of thoughts that are common)]TJ 1.8 -1.401 TD -0.0036 Tc 0.0943 Tw (in workers post-exposure to trauma, and those that)Tj 0 -1.398 TD -0.0034 Tc 0.025 Tw (are not.)Tj -1.2 -2.001 TD -0.005 Tc -0.0622 Tw [(Mitchell)49(s training and early career as an emer)19(gency ser)16(-)]TJ -1.8 -1.401 TD -0.0036 Tc 0.0457 Tw (vice worker undoubtedly gave him experience and insights)Tj 0 -1.398 TD 0.0034 Tc 0.125 Tw [(into this field. He began educating on stress response)]TJ 0 -1.401 TD -0.0029 Tc 0.0103 Tw (and, in the space of a few years, it was evident that what he)Tj T* -0.0034 Tc 0.1022 Tw (was saying was striking a chord with \(and helping\) emer-)Tj 0 -1.398 TD -0.0031 Tc 0.0125 Tw (gency service workers.)Tj 1.8 -2.001 TD -0.0037 Tc 0.0287 Tw [(W)55.1(ithin a decade, the CISM model had spread through-)]TJ -1.8 -1.401 TD -0.0039 Tc 0.01 Tw [(out the USA)50.1( and other countries, including Canada, )50.1(Austra-)]TJ 0 -1.398 TD -0.0028 Tc 0.0049 Tw [(lia, Germany)63.2(, and Britain. )51.1(At the same time, the essentially)]TJ 0 -1.401 TD -0.009 Tc -0.0625 Tw (emergency service model was adopted and adapted to simi-)Tj T* -0.0015 Tc 0.125 Tw (lar workplaces and other occupational groups where staff)Tj 0 -1.398 TD 0.0005 Tc [(were exposed to loss and trauma. These included health)]TJ 0 -1.401 TD -0.0033 Tc 0 Tw (agencies, corrective services, defense forces, protective ser-)Tj T* -0.0031 Tc -0.0129 Tw [(vices, airlines, industry counselors, the education sector)35.9(, the)]TJ 0 -1.398 TD -0.0033 Tc 0.0894 Tw [(private sector)35.7(, mining, welfare agencies, and many others.)]TJ 0 -1.401 TD -0.0036 Tc 0.0062 Tw [(Concurrently)62.4(, the Mitchell or CISM model continued to ex-)]TJ T* 0.0245 Tw (pand and to develop as it was field-tested and was found to)Tj 0 -1.398 TD -0.003 Tc 0.0821 Tw (apply to events from everyday critical incidents through)Tj 0 -1.401 TD -0.0037 Tc 0.006 Tw [(to lar)17.3(ge-scale disasters. V)104.3(ariations on a theme evolved as)]TJ T* -0.0039 Tc -0.0307 Tw (CISM programs were honed to meet particular requirements)Tj 25.5 63.6 TD -0.0034 Tc 0.0062 Tw [(of agencies, situations, and culture. Such widespread adap-)]TJ 0 -1.398 TD -0.0037 Tc 0.0244 Tw (tation and adoption of the model showed its robustness and)Tj 0 -1.401 TD -0.0028 Tc 0.0512 Tw (also its suitability as a crisis intervention model, flexibility)Tj T* -0.0003 Tc 0.125 Tw [(being essential in the field of crisis intervention. On the)]TJ 0 -1.398 TD -0.0049 Tc -0.0623 Tw (other hand, there were instances where the model was misap-)Tj 0 -1.401 TD -0.0033 Tc 0.05 Tw (plied , used with primary victims and also in organizations)Tj T* -0.0034 Tc -0.0555 Tw (where it was not suited to the needs of particular workplaces.)Tj 0 -1.398 TD -0.0033 Tc 0.0065 Tw (Already a picture is painted of how difficult this model was)Tj 0 -1.401 TD -0.0034 Tc 0.0425 Tw (going to be to evaluate.)Tj /F1 1 Tf 11 0 0 11 309 578.01 Tm -0.005 Tc 0.0614 Tw (The Debriefing Debate)Tj /TT2 1 Tf 10 0 0 10 327 554.64 Tm -0.0037 Tc 0.0186 Tw (There has been prolonged debate concerning the effec-)Tj -1.8 -1.398 TD -0.0022 Tc 0.125 Tw (tiveness and efficacy of debriefing; a debate that remains)Tj 0 -1.401 TD -0.0034 Tc -0.0462 Tw [(unresolved at this time. People have taken particular stances)]TJ T* -0.0036 Tc 0.0778 Tw [(and each side has its proponents. The format of the de-)]TJ 0 -1.398 TD -0.0068 Tc -0.0622 Tw (bate appears to have followed a pattern wherein specific criti-)Tj 0 -1.401 TD -0.003 Tc 0.1249 Tw [(cism is raised then rebutted. Soon after)36(, new criticism is)]TJ T* -0.0034 Tc 0.0335 Tw [(raised then rebutted. This pattern of criticism then rebut-)]TJ 0 -1.398 TD -0.0031 Tc -0.0387 Tw [(tal has been cyclic. There have also been those who are not)]TJ 0 -1.401 TD 0.045 Tw (closely involved in the field but who seek resolution to the)Tj T* -0.0038 Tc -0.0073 Tw [(debate and guidance on whether or not to use CISM. While)]TJ 0 -1.398 TD -0.0032 Tc 0.0778 Tw (they have been urged to better understand the research lit-)Tj 0 -1.401 TD -0.0033 Tc -0.0051 Tw [(erature and make up their own minds \(T)32.7(uckey)59.7(, 2007\), many)]TJ T* 0.0127 Tw (have not had the time or inclination to do so.)Tj 1.8 -1.998 TD -0.0035 Tc 0.0017 Tw (One unfortunate aspect of the debate has been the level)Tj -1.8 -1.401 TD -0.0038 Tc -0.0305 Tw (of personal attack on the proponents of CISD and CISM and)Tj T* -0.0037 Tc -0.0381 Tw (those who practice and support the model \(Levenson, 2004\).)Tj 0 -1.398 TD -0.0035 Tc 0.0167 Tw (This has predominantly occurred in speaking presentations,)Tj 0 -1.401 TD -0.0033 Tc 0.035 Tw (popular publications, and in the print media, but it can also)Tj T* -0.0036 Tc 0.0436 Tw (be found in peer-review research literature \(Bledsoe, 2003;)Tj 0 -1.398 TD -0.0124 Tc -0.0623 Tw [(Devilly & Cotton, 2003\). For example, accusations have been)]TJ 0 -1.401 TD -0.0035 Tc -0.0017 Tw (made that CISM is a money-making business and its practi-)Tj T* -0.0033 Tc 0.0458 Tw [(tioners exploit people financially; that proponents are scar-)]TJ 0 -1.398 TD -0.0027 Tc 0.125 Tw (ing organizations into adopting debriefing using litigation)Tj 0 -1.401 TD 0.0102 Tc (arguments; that debriefers are uncontrolled at disaster)Tj T* -0.0034 Tc 0.0095 Tw (scenes and go there to tout for business; and that the propo-)Tj 0 -1.398 TD -0.0114 Tc -0.0625 Tw [(nents of CISM are just clever marketers and charlatans. There)]TJ 0 -1.401 TD -0.0003 Tc 0.125 Tw (have been aspersions cast on the professional and ethical)Tj T* -0.0038 Tc 0.1108 Tw (standards of CISM practitioners, sometimes with negative)Tj 0 -1.398 TD -0.002 Tc 0.125 Tw (personal comments being made about well-known propo-)Tj 0 -1.401 TD 0.0228 Tc 0 Tw (nents.)Tj 1.8 -2.001 TD -0.0035 Tc 0.004 Tw [(The debate in peer)14.5(-reviewed literature began, ar)17.5(guably)59.5(,)]TJ -1.8 -1.398 TD -0.0071 Tc -0.0623 Tw [(from a publication in the British Medical Journal which ques-)]TJ 0 -1.401 TD -0.0036 Tc -0.0315 Tw (tioned the evidence basis for debriefing \(Raphael, Meldrum,)Tj T* -0.0032 Tc 0.0115 Tw [(& McFarlane, 1995\). This paper cites a study that assessed)]TJ ET endstream endobj 73 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 75 0 obj << /Length 8523 >> 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. 4 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (255)Tj /TT2 1 Tf 10 0 0 10 66 722.64 Tm -0.018 Tc -0.0621 Tw (debriefing of workers following an earthquake in Newcastle,)Tj 0 -1.398 TD -0.0033 Tc 0.08 Tw (Australia \(Kenardy et al., 1996\). Rescue workers who had)Tj 0 -1.401 TD -0.0042 Tc -0.0625 Tw (been involved in the incident were asked, 12 months after the)Tj T* -0.0012 Tc 0.125 Tw [(earthquake, if they had received debriefing. The study)]TJ 0 -1.398 TD -0.0036 Tc 0.0344 Tw (reported that, on measures of the General Health Question-)Tj 0 -1.401 TD -0.0033 Tc 0.0585 Tw (naire and Impact of Events Scale, those who said they had)Tj T* -0.0035 Tc -0.0035 Tw (been debriefed did no better than those who said they had)Tj 0 -1.398 TD 0.0145 Tw [(not been debriefed. There were many problems with this)]TJ 0 -1.401 TD -0.003 Tc -0.0608 Tw [(study)63(. Debriefing was not defined by the researchers. )15.1(There)]TJ T* -0.0035 Tc 0.0594 Tw (was no baseline measure between those who said they had)Tj 0 -1.398 TD -0.0042 Tc -0.0625 Tw (been debriefed and those who said that they had not, which)Tj 0 -1.401 TD -0.0037 Tc 0.0207 Tw [(could have been used to interpret the assessment outcomes.)]TJ T* 0.0064 Tc 0.125 Tw (As the researchers themselves stated, they did not know)Tj 0 -1.398 TD -0.0038 Tc 0.0462 Tw (how participants defined debriefing or even if those who)Tj 0 -1.401 TD -0.0033 Tc -0.0119 Tw (stated that they had received debriefing had indeed received)Tj T* -0.0417 Tw [(any form of intervention. Notwithstanding all of these prob-)]TJ 0 -1.398 TD -0.0038 Tc 0.0764 Tw (lems, the researchers concluded that debriefing made no)Tj 0 -1.401 TD 0.0026 Tc 0.125 Tw (difference. Whatever this study assessed, it is highly un-)Tj T* -0.0034 Tc -0.0225 Tw (likely to have been CISD, because formal training programs)Tj 0 -1.398 TD -0.0038 Tc 0.0793 Tw [(for CISM practitioners had not commenced in )50.1(Australia at)]TJ 0 -1.401 TD -0.0047 Tc -0.06 Tw [(that time.)]TJ 1.8 -2.001 TD -0.0061 Tc -0.0625 Tw (A wave of negative outcome studies came from attempts)Tj -1.8 -1.398 TD -0.0033 Tc -0.0506 Tw (to apply debriefing to primary victims, using an individual)Tj 0 -1.401 TD -0.0035 Tc 0.0122 Tw (rather than group format and using a particular research de-)Tj T* -0.0141 Tc -0.0622 Tw [(sign known as randomized controlled trial \(RCT\). These stud-)]TJ 0 -1.398 TD -0.0032 Tc -0.0206 Tw (ies were reported separately and they were also summarized)Tj 0 -1.401 TD -0.0037 Tc 0.0012 Tw [(\(Rose, Bisson & )17.1(W)94.1(essely)62.3(, 2002; )17.1(V)112.5(an Emmerick, Kamphuis,)]TJ T* -0.0121 Tc -0.0625 Tw [(Hulsbosch, & Emmelkamp, 2002\). The summaries have been)]TJ 0 -1.398 TD -0.003 Tc 0.065 Tw (particularly widely quoted, and have been used to criticize)Tj 0 -1.401 TD -0.0038 Tc 0.01 Tw (debriefing in general and to caution organizations against)Tj T* -0.0036 Tc -0.0481 Tw [(adopting debriefing practices. There are problems with such)]TJ 0 -1.398 TD -0.0101 Tc -0.0625 Tw (conclusions as identified by several authors \(see, for example,)Tj 0 -1.401 TD -0.0326 Tc (Everly & Mitchell, 2008; Mitchell, 2003; Regal, 2007; Robinson,)Tj T* -0.0152 Tc -0.0621 Tw (2003; Robinson, 2004; Robinson, 2007; Robinson & Mitchell,)Tj 0 -1.398 TD -0.0035 Tc -0.0403 Tw [(1995; and )14.7(T)37.3(uckey)62.5(, 2007\). )14.7(The problems include the follow-)]TJ 0 -1.401 TD -0.0093 Tc 0 Tw (ing.)Tj 1.2 -2.001 TD -0.0036 Tc -0.0519 Tw [()-1453.5(Individual intervention is not CISD, which is a group)]TJ 1.8 -1.398 TD -0.0032 Tc 0.06 Tw (process delivered by trained personnel.)Tj -1.8 -2.001 TD 0.0101 Tc 0.125 Tw [()-1439.8(These studies inappropriately assess debriefing)]TJ 1.8 -1.401 TD 0.0306 Tc (outcomes using therapy-outcome variables, yet)Tj 0 -1.398 TD -0.0033 Tc 0.0021 Tw (therapy outcomes are not expected from crisis inter-)Tj 0 -1.401 TD 0.06 Tw (vention and they are not the expected outcomes set)Tj T* -0.0034 Tc -0.0036 Tw (out by the authors of CISD and CISM.)Tj -1.8 -1.998 TD -0.0036 Tc 0.121 Tw [()-1453.5(Administration of debriefing to primary victims,)]TJ 1.8 -1.401 TD -0.003 Tc -0.0281 Tw (especially within a day or two of hospital admission,)Tj 25.5 63.999 TD -0.0036 Tc 0.065 Tw [(and without assessment of the client)50.4(s needs, is not)]TJ 0 -1.398 TD -0.0062 Tc -0.0625 Tw (within CISM guidelines.)Tj -1.2 -2.001 TD -0.0035 Tc -0.0268 Tw (In short, what was studied was not CISD as it is defined)Tj -1.8 -1.401 TD -0.0077 Tc -0.0617 Tw (within the CISM model.)Tj 1.8 -1.998 TD -0.0034 Tc -0.0016 Tw (As a generalization, the studies cited above find no dif-)Tj -1.8 -1.401 TD -0.0041 Tc 0.099 Tw (ference between debriefed and non-debriefed persons.)Tj T* 0.0034 Tc 0.125 Tw [(Nevertheless, two of these studies are used to argue that)]TJ 0 -1.398 TD -0.0076 Tc -0.062 Tw [(debriefing harms people \(Bisson, Jenkins, )46.5(Alexander)37.4(, & Ban-)]TJ 0 -1.401 TD -0.0129 Tc -0.0621 Tw [(nister)35.1(, 1997; Hobbs, Mayou, Harrison, & )20.5(W)93.9(orlock, 1996\). )14.5(The)]TJ T* -0.0031 Tc -0.0036 Tw (conclusion drawn by these researchers is particularly unfor-)Tj 0 -1.398 TD -0.0057 Tc -0.0622 Tw (tunate because both of these studies have severe flaws, which)Tj 0 -1.401 TD -0.0175 Tc -0.0625 Tw [(include research design problems. While RCT is itself a highly)]TJ T* -0.0034 Tc 0.1067 Tw (respected research design, it appears not to have been ad-)Tj 0 -1.398 TD -0.0035 Tc 0.0142 Tw (equately applied on these occasions and randomization was)Tj 0 -1.401 TD -0.0031 Tc 0.0425 Tw [(not achieved in either study)59.9(.)]TJ 1.8 -2.001 TD -0.0039 Tc 0.115 Tw (Bisson and colleagues \(1997\) administered individual)Tj -1.8 -1.398 TD -0.0037 Tc 0.1016 Tw [(debriefings to burns victims following hospital admission.)]TJ 0 -1.401 TD -0.0032 Tc 0.0995 Tw (They found that, at 13 months, 16 \(26%\) of the debriefed)Tj T* -0.0037 Tc 0.049 Tw (group had PTSD compared to 4 \(9%\) of the control group.)Tj 0 -1.398 TD -0.0039 Tc 0.0259 Tw [(However)35.1(, the debriefed group also had more severe dimen-)]TJ 0 -1.401 TD -0.0029 Tc 0.0141 Tw [(sions of burn trauma. Severity of injury can be expected to)]TJ T* -0.003 Tc -0.0461 Tw (influence recovery and to be a stronger predictor of recovery)Tj 0 -1.398 TD -0.0034 Tc 0.105 Tw (than a one-hour discussion within days of hospital admis-)Tj 0 -1.401 TD -0.0031 Tc 0.0118 Tw [(sion. Nevertheless, the researchers seriously question the)]TJ T* -0.0038 Tc 0.038 Tw (wisdom of advocating once-off interventions post-trauma.)Tj 1.8 -1.998 TD -0.004 Tc 0.0009 Tw (Hobbs and colleagues \(1996\) instigated debriefing to)Tj -1.8 -1.401 TD -0.0081 Tc -0.0624 Tw [(victims of motor vehicle accidents 24-48 hours after the acci-)]TJ T* -0.0032 Tc -0.0484 Tw (dent. They found that, at four months, the intervention group)Tj 0 -1.398 TD -0.0036 Tc -0.0595 Tw (had a worse outcome on two subscales of the Brief Symptom)Tj 0 -1.401 TD -0.0034 Tc 0.0718 Tw [(Inventory)59.6(. )17.7(The intervention group also had a higher mean)]TJ T* 0.0027 Tc 0.125 Tw (injury severity score and longer hospital stay \(more than)Tj 0 -1.398 TD -0.0031 Tc 0.0749 Tw [(double that of the control group\). )53.8(A)59.1( three-year follow-up)]TJ 0 -1.401 TD -0.0036 Tc 0.0456 Tw (\(Mayou, Ehlers, & Hobbs, 2000\) showed a worse outcome)Tj T* 0.124 Tw (for those who had been debriefed \(i.e. for the more se-)Tj 0 -1.398 TD -0.0032 Tc 0.0832 Tw [(verely injured group\). )50.7(Again, the authors fail to acknowl-)]TJ 0 -1.401 TD -0.0099 Tc -0.0623 Tw (edge the role of severity of injury and other factors that cannot)Tj T* -0.0029 Tc 0.0972 Tw [(be controlled over a three-year period. They instead con-)]TJ 0 -1.398 TD -0.0036 Tc -0.0461 Tw (cluded that a one-hour debriefing session, within 48 hours of)Tj 0 -1.401 TD -0.0033 Tc -0.0018 Tw (hospital admission, is responsible for poor recovery at three)Tj T* 0.008 Tc 0 Tw (years.)Tj 1.8 -1.998 TD -0.0101 Tc -0.0625 Tw [(There are many positive outcome studies. Mitchell listed)]TJ -1.8 -1.401 TD -0.0194 Tc -0.0623 Tw (65 of these in 2003 \(Mitchell, 2003\); this was updated in Everly)Tj T* -0.0036 Tc 0.06 Tw [(& Mitchell \(2008\). For example, )14.4(W)97.2(ee, Mills, and Koehler)]TJ 0 -1.398 TD -0.0564 Tw (\(1999\) followed emergency medical technicians who had re-)Tj ET endstream endobj 76 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 78 0 obj << /Length 8278 >> 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 /TT3 1 Tf 8 0 0 8 54.99 41.64 Tm 0 0 0 1 k /GS2 gs -0.006 Tc 0.075 Tw [(256 Robinson)]TJ /F1 1 Tf 6.8775 0 TD -0.0067 Tc [(  )]TJ /TT3 1 Tf 1.0425 0 TD -0.0054 Tc (Reflections on the Debriefing Debate)Tj /TT2 1 Tf 10 0 0 10 54 722.64 Tm -0.0035 Tc 0.1009 Tw [(sponded to the 1992 Los )50.3(Angeles civil disturbance. )17.3(They)]TJ 0 -1.398 TD -0.061 Tw (found that those who participated in a CISD, relative to those)Tj 0 -1.401 TD -0.0033 Tc 0.0632 Tw (who did not, had significantly lower arousal and intrusion,)Tj T* -0.0036 Tc 0.0016 Tw [(and fewer stress-related symptoms. Boscarino, )50.6(Adams, and)]TJ 0 -1.398 TD -0.0599 Tw [(Figley \(2005\) studied 1681 adults in New )29.5(Y)103.6(ork following the)]TJ 0 -1.401 TD -0.0046 Tc -0.062 Tw [(2001 )16.6(W)93.2(orld )16.6(T)36.2(rade Center terrorist attacks. )16.6(These adults were)]TJ T* -0.003 Tc 0.0994 Tw [(offered crisis intervention by their workplace. They were)]TJ 0 -1.398 TD -0.0037 Tc -0.0623 Tw [(interviewed at 12 months and 2 years. The results were com-)]TJ 0 -1.401 TD -0.0036 Tc 0.0318 Tw [(pared to a group formed from census data. The group who)]TJ T* 0.11 Tw (had received assistance had less alcohol use, fewer PTSD)Tj 0 -1.398 TD -0.0032 Tc 0.1167 Tw [(symptoms, less depression, and less anxiety)59.8(. )18.3(The authors)]TJ 0 -1.401 TD -0.0036 Tc 0.0243 Tw (concluded that post-disaster crisis intervention in the work-)Tj T* -0.0092 Tc -0.0621 Tw (place significantly reduces mental health disorders and symp-)Tj 0 -1.398 TD -0.003 Tc 0.0013 Tw (toms up to 2 years after the initial interventions.)Tj 1.8 -2.001 TD -0.0037 Tc -0.0417 Tw [(CISM programs have also been studied. For example, a)]TJ -1.8 -1.401 TD -0.0039 Tc 0.0175 Tw (CISM program was introduced for 1500 nurses across rural)Tj 0 -1.398 TD 0.0279 Tw [(Canada in the mid-1990s. Independent evaluators assessed)]TJ 0 -1.401 TD -0.0031 Tc 0.0255 Tw [(the costs of staf)17.9(f turnover)35.9(, disability claims, and sick leave.)]TJ T* -0.0037 Tc 0.0519 Tw (The assessment occurred before and after the program was)Tj 0 -1.398 TD -0.0034 Tc -0.0294 Tw [(implemented. It was found that every Canadian dollar spent)]TJ 0 -1.401 TD -0.0035 Tc 0.047 Tw [(on the program resulted in $7.06 being saved. Further)35.5(, the)]TJ T* -0.0425 Tw (researchers concluded that CISM significantly reduced turn-)Tj 0 -1.398 TD -0.0151 Tc -0.0626 Tw [(over among nurses \(W)74.9(estern Management Consultants, 1996\).)]TJ 0 -1.401 TD -0.0098 Tc -0.062 Tw (Flannery introduced a multi-component CISM-type program,)Tj T* -0.0041 Tc 0.0255 Tw [(known as the )52.8(Assaulted S)16.9(taf)13.9(f )49.8(Action Program \(ASAP\), into)]TJ 0 -1.398 TD -0.0013 Tc 0.125 Tw [(health settings, including hospitals and schools. Over 15)]TJ 0 -1.401 TD -0.0031 Tc 0.0466 Tw [(years, through a series of studies, he has demonstrated that)]TJ T* -0.0035 Tc 0.0571 Tw (CISM programs provide psychological support to staff, re-)Tj 0 -1.398 TD 0.0055 Tc 0.125 Tw (duce assaults on staff, and reduce the harmful effects of)Tj 0 -1.401 TD -0.0034 Tc 0.0925 Tw (workplace violence, as well as reduce sick leave, accident)Tj T* -0.004 Tc -0.062 Tw [(claims, and staf)20(f turnover \(Flannery)62(, 2001\).)]TJ 1.8 -1.998 TD -0.0073 Tc -0.0625 Tw (Some of the positive outcome studies have flaws, similar)Tj -1.8 -1.401 TD -0.0036 Tc -0.0144 Tw [(to the negative outcome studies. However)38.4(, the total number)]TJ T* 0.0037 Tc 0.125 Tw (of basically sound positive outcome studies gives a con-)Tj 0 -1.398 TD -0.0037 Tc 0.0413 Tw (vincing picture of beneficial effects from CISD and CISM.)Tj 0 -1.401 TD -0.0036 Tc -0.0583 Tw (Notwithstanding the above, there is a prevalent view in some)Tj T* -0.0518 Tw (sections of the professional and general community that de-)Tj 0 -1.398 TD -0.0034 Tc -0.047 Tw (briefing does not work and that the research indicates that it)Tj 0 -1.401 TD -0.0032 Tc 0.0844 Tw (is either ineffective or possibly harmful [see, for example,)Tj T* 0.0591 Tc 0.2994 Tw [(how the current topic is presented in )20.2(W)57.9(ikipedia)]TJ 0 -1.398 TD -0.0039 Tc -0.036 Tw [(\(www)62.1(.)13.9(W)35.1(ikipedia.com\)]. Understanding is needed as to why)]TJ 0 -1.401 TD -0.0034 Tc 0.041 Tw (there is a dominant response to the negative or neutral out-)Tj T* -0.0043 Tc -0.0625 Tw (come studies, and a lack of impact from the positive outcome)Tj 0 -1.398 TD 0.0175 Tc 0 Tw (studies.)Tj /F1 1 Tf 11 0 0 11 309 723.99 Tm -0.0047 Tc 0.0355 Tw (The Apparent Failure of the Research)Tj 0 -1.0909 TD 0.04 Tw (Literature to Resolve the Opposing Stances)Tj /TT2 1 Tf 10 0 0 10 327 688.65 Tm -0.0036 Tc (There are examples in other areas where research over)Tj -1.8 -1.401 TD 0.0481 Tw [(time has answered questions and clarified differences. For)]TJ 0 -1.398 TD -0.0033 Tc -0.0079 Tw (example, the therapy of Eye Movement Desensitization Re-)Tj 0 -1.401 TD -0.0083 Tc -0.0625 Tw (processing \(EMDR\), which was soundly criticized in its early)Tj T* -0.0031 Tc 0.0525 Tw (days, has, through studies, been found to be a credible and)Tj 0 -1.398 TD -0.0036 Tc 0.0591 Tw [(useful treatment model \(American Psychiatric )53.5(Association,)]TJ 0 -1.401 TD -0.0132 Tc -0.0625 Tw [(2004; Foa, Keane, & Friedman, 2000\). In contrast, research to)]TJ T* 0.0002 Tc 0.125 Tw (date has failed to answer key questions about debriefing.)Tj 0 -1.398 TD -0.0036 Tc 0.0483 Tw (Some possible reasons for this are postulated.)Tj /TT5 1 Tf 11 0 0 11 309 543.36 Tm 0.0028 Tc 0.1254 Tw [(Failur)35.5(e to assess the theor)-8.1(y as it is expounded by)]TJ 0 -1.1836 TD 0.0097 Tc 0.125 Tw (the author\(s\) of the theory)Tj /TT2 1 Tf 10 0 0 10 327 510.66 Tm -0.0029 Tc -0.0059 Tw (It is usual, when elements of a theory are tested, to first)Tj -1.8 -1.401 TD -0.0034 Tc 0.0951 Tw [(describe the author)-36.4()53.6(s)-0.2( model \(or aspects of it\), then for the)]TJ T* 0.0032 Tc 0.125 Tw (experimenter to explain how they propose to assess this.)Tj 0 -1.398 TD -0.0035 Tc -0.0017 Tw (There are many examples where this has not happened with)Tj 0 -1.401 TD -0.0037 Tc 0.0106 Tw (studies purported to examine the effectiveness of CISD and)Tj T* -0.0363 Tc 0 Tw (CISM.)Tj 1.2 -1.998 TD -0.0035 Tc -0.0161 Tw [()-1453.4(The term debriefing has been used to study a wide)]TJ 1.8 -1.401 TD -0.0031 Tc 0.0528 Tw (variety of practices, some but not all of which con-)Tj T* -0.0036 Tc -0.0244 Tw [(form to CISD principles. Indeed some practices that)]TJ 0 -1.398 TD -0.0005 Tc 0.1249 Tw [(have been studied would, within CISM theory)62.5(, be)]TJ 0 -1.401 TD -0.0035 Tc -0.0279 Tw [(regarded as bad practices. Conclusions, within stud-)]TJ T* -0.0034 Tc 0.055 Tw (ies, have failed sometimes to limit their generaliza-)Tj 0 -1.398 TD -0.0035 Tc 0.1221 Tw (tions to the particular intervention which has been)Tj 0 -1.401 TD 0.0123 Tc 0 Tw (studied.)Tj -1.8 -2.001 TD -0.0099 Tc -0.0621 Tw [()-1459.8(CISD has been studied independently of CISM. Some)]TJ 1.8 -1.398 TD -0.0035 Tc 0.0964 Tw (have confused an entire system of support \(CISM\))Tj 0 -1.401 TD 0.0115 Tw [(with a small group support process \(CISD\). )53.2(A)58.6( good)]TJ T* -0.0034 Tc 0.0875 Tw (example of the dangers of this can be found in the)Tj 0 -1.398 TD -0.0008 Tc 0.1249 Tw [(study of )50.1(Alder and colleagues \(2008\). )11.1(This study)]TJ 0 -1.401 TD -0.0147 Tc -0.0625 Tw (implemented the RCT research design well, but it does)Tj T* -0.0033 Tc 0.0129 Tw [(not test the appropriate application of a CISD. The)]TJ 0 -1.398 TD -0.0035 Tc 0.0283 Tw (researchers administered a debriefing for soldiers at)Tj 0 -1.401 TD -0.011 Tc -0.0624 Tw [(the end of a 6-month tour of duty)58(. Such circumstances)]TJ T* 0.004 Tc 0.125 Tw (should call for pre-deployment briefing, on-going)Tj 0 -1.398 TD -0.0025 Tc 0.1249 Tw [(support while away)63.5(, and appropriate and on-going)]TJ 0 -1.401 TD -0.0033 Tc -0.0021 Tw (support for staff and families post-deployment. No-)Tj T* -0.0075 Tc -0.0623 Tw (where in the literature is a once-off CISD at the end of)Tj 0 -1.398 TD -0.0037 Tc 0.0533 Tw (prolonged duty recommended as the support model)Tj 0 -1.401 TD -0.0625 Tw [(of choice. One would expect a brief once-off discus-)]TJ ET endstream endobj 79 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 81 0 obj << /Length 8626 >> 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. 4 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (257)Tj /TT2 1 Tf 10 0 0 10 96 722.64 Tm -0.0025 Tc 0.116 Tw (sion at the end of lengthy duty to be a reasonably)Tj 0 -1.398 TD -0.0012 Tc 0.125 Tw (ineffectual support response over time, and this is)Tj 0 -1.401 TD -0.0029 Tc -0.0233 Tw (exactly what is found.)Tj -1.8 -2.001 TD -0.0036 Tc -0.0428 Tw [()-1453.5(There is confusion over the difference between crisis)]TJ 1.8 -1.398 TD -0.0526 Tw [(intervention and therapy)59.4(. CISD and CISM are some-)]TJ 0 -1.401 TD -0.0032 Tc 0.0134 Tw (times being studied as if they are therapies and with)Tj T* -0.0033 Tc -0.0371 Tw (the expectations that they will achieve outcomes that)Tj 0 -1.398 TD -0.0034 Tc 0.0043 Tw (are therapeutic \(such as reduction in clinical depres-)Tj 0 -1.401 TD -0.0036 Tc -0.0042 Tw (sion and reduction in posttraumatic stress response\).)Tj T* -0.0175 Tw (Thus, outcomes of debriefing are being set up which)Tj 0 -1.398 TD -0.0038 Tc -0.0321 Tw (would not be expected or predicted from CISM.)Tj -1.8 -2.001 TD -0.0035 Tc -0.0175 Tw [()-1453.4(On occasion, there has been a direct misstatement of)]TJ 1.8 -1.401 TD -0.0033 Tc -0.0451 Tw [(theory)59.7(, with claims that an author)-39.3()56.7(s)0.2( position is dif)14.7(fer)17.7(-)]TJ 0 -1.398 TD -0.0034 Tc 0.0789 Tw (ent to that which the author has expressed in print.)Tj 0 -1.401 TD 0.0764 Tw (For example, Devilly and Cotton \(2003\) argue that)Tj T* -0.0104 Tc -0.0625 Tw (CISD and CISM are equivalent and that Mitchell does)Tj 0 -1.398 TD -0.0037 Tc 0.0675 Tw (not distinguish between the two.)Tj /TT5 1 Tf 11 0 0 11 66 453.36 Tm 0.0125 Tc 0.1254 Tw [(V)77.9(iews on evaluation, including study design)]TJ /TT2 1 Tf 10 0 0 10 84 433.65 Tm -0.0033 Tc -0.0071 Tw (The field of evaluation is multi-disciplinary and consti-)Tj -1.8 -1.401 TD -0.003 Tc 0.0275 Tw [(tutes a field of enquiry in its own right. For some decades,)]TJ 0 -1.398 TD -0.0036 Tc 0.0932 Tw (the argument has been put that particular research designs)Tj 0 -1.401 TD -0.0037 Tc -0.0169 Tw (each have their advantages and disadvantages and that com-)Tj T* -0.0035 Tc -0.047 Tw (plex research issues are often best suited to using a combina-)Tj 0 -1.398 TD 0.0633 Tw (tion of research designs.)Tj 1.8 -2.001 TD 0.015 Tw (RCT is often argued as the design of choice for assess-)Tj -1.8 -1.401 TD -0.0029 Tc -0.0062 Tw [(ing CISD. )18.3(While it is rightly praised by many)63.1(, pre-occupa-)]TJ 0 -1.398 TD -0.0033 Tc 0.0505 Tw (tion with this design can hamper the way forward to better)Tj 0 -1.401 TD -0.0037 Tc 0.082 Tw [(assess CISD and CISM. The effectiveness of RCT lies in)]TJ T* -0.0035 Tc 0.0056 Tw [(controlling variables. )5.6( This is difficult to do with CISM and)]TJ 0 -1.398 TD -0.0032 Tc 0.0091 Tw [(also, in most cases, undesirable. )9.2( )50.7(At the heart of crisis inter)17.8(-)]TJ 0 -1.401 TD 0.0315 Tw [(vention and its ef)17.8(fectiveness is flexibility)62.8(. )31.7( How can this be)]TJ T* -0.0034 Tc 0.0844 Tw (assessed by utilizing a research design that imposes maxi-)Tj 0 -1.398 TD -0.0031 Tc 0.0455 Tw [(mum rigidity in controlling what helpers do? )45.5( In fact, RCT)]TJ 0 -1.401 TD -0.0034 Tc 0.0432 Tw (may not be the design of choice to assess CISM \(or CISD\))Tj T* -0.0598 Tw [(ef)17.6(fectiveness. Rather)38.6(, a combination of approaches may bet-)]TJ 0 -1.398 TD -0.026 Tw [(ter build a picture and assist us in assessing CISM. )-26(Modern)]TJ 0 -1.401 TD -0.0033 Tc -0.0607 Tw (evaluation literature provides many creative options \(see, for)Tj T* -0.0236 Tc -0.0617 Tw [(example, Brinkerhoff , 2003\). )-61.7( )-61.7( )-61.7( )]TJ 1.8 -1.998 TD -0.0029 Tc 0.1109 Tw [(If the method of studying CISD is defined by the re-)]TJ -1.8 -1.401 TD -0.0033 Tc 0.0875 Tw (search design, that design will determine test study condi-)Tj T* -0.0028 Tc 0.0079 Tw [(tions. )7.8( If these conditions do not apply in reality)63.2(, the danger)]TJ 0 -1.398 TD -0.0029 Tc -0.0159 Tw [(is that neither the practice nor the theory will be tested. The)]TJ 0 -1.401 TD -0.0031 Tc -0.0555 Tw (author reviewed a study that looked at the efficacy of EMDR)Tj T* -0.0035 Tc 0.0083 Tw [(where EMDR was delivered to several clients. )5.8( In one case,)]TJ 25.5 65.1 TD -0.0033 Tc -0.0569 Tw (when the therapist reached the eye-movement part, the client)Tj 0 -1.398 TD 0.005 Tc 0.125 Tw [(\(in a state of distress\) requested the therapist to stop. )125( )53(A)]TJ 0 -1.401 TD -0.0032 Tc -0.0068 Tw (trained therapist would normally be very responsive to such)Tj T* 0.0731 Tw [(a request and stop. )73.1( Nevertheless, because the therapy was)]TJ 0 -1.398 TD -0.0038 Tc -0.0074 Tw [(being assessed and it had to be completed \(to meet design)]TJ 0 -1.401 TD -0.0031 Tc -0.0575 Tw [(requirements\), the therapist continued. )-57.5( The client had a very)]TJ T* -0.0035 Tc 0.0986 Tw (bad dissociative reaction and reported a negative reaction.)Tj 0 -1.398 TD -0.0039 Tc 0.0983 Tw [(The conclusion then was that EMDR does not work. )98.3( If)]TJ 0 -1.401 TD -0.0036 Tc 0.0794 Tw (there is rigorous implementation of an intervention so that)Tj T* 0.015 Tw (the requirements of a design are met, spurious and negative)Tj 0 -1.398 TD -0.0033 Tc 0.016 Tw [(results can be obtained not due to the intervention )16(but aris-)]TJ 0 -1.401 TD -0.0035 Tc -0.035 Tw (ing from the manner in which it was applied in order to meet)Tj T* -0.004 Tc (scientific rigors.)Tj 1.8 -1.998 TD -0.0035 Tc 0.0872 Tw (Another issue relates to opinions held on the value or)Tj -1.8 -1.401 TD -0.0034 Tc 0.0042 Tw (otherwise of self-report. Notwithstanding that self-report is)Tj T* -0.0063 Tc -0.0625 Tw (a commonly accepted research tool in many areas, self-report)Tj 0 -1.398 TD -0.0033 Tc 0.0594 Tw [(of positive experiences in CISD is often discounted by de-)]TJ 0 -1.401 TD -0.0032 Tc 0.004 Tw [(tractors \(see, for example, Raphael et al., 1995\). )53.8(Almost all)]TJ T* -0.0105 Tc -0.0625 Tw (CISD outcome studies report that participants rate CISD posi-)Tj 0 -1.398 TD -0.0034 Tc 0.0348 Tw [(tively)62.6(. However in studies where quantitative measures fail)]TJ 0 -1.401 TD -0.0036 Tc -0.0412 Tw (to show a positive result in favor of CISD, it is not uncom-)Tj T* -0.0034 Tc -0.0085 Tw (mon for researchers to conclude that there are no clear posi-)Tj 0 -1.398 TD -0.0128 Tc -0.0625 Tw [(tive effects. Self-report is therefore given severely diminished)]TJ 0 -1.401 TD -0.0033 Tc -0.028 Tw [(credence. It is quite possible that researchers are not admin-)]TJ T* -0.0032 Tc 0.0733 Tw (istering tests that capture the positive effects that are actu-)Tj 0 -1.398 TD -0.003 Tc -0.035 Tw [(ally occurring. )-35( This possibility needs to be considered more)]TJ 0 -1.401 TD 0.0031 Tc 0 Tw [(seriously)63.1(.)]TJ /TT5 1 Tf 11 0 0 11 321 319.35 Tm 0.0112 Tc 0.1252 Tw [(Generally negative attitudes towar)33(ds CISD and)]TJ 0 -1.1809 TD 0.0405 Tc 0 Tw (CISM)Tj /TT2 1 Tf 10 0 0 10 339 286.65 Tm -0.0047 Tc -0.0623 Tw (It may be the case that a generally negative view is being)Tj -1.8 -1.401 TD -0.0038 Tc 0.0367 Tw [(held regarding CISD and CISM and that this is influencing)]TJ 0 -1.398 TD 0.0049 Tc 0.125 Tw (the ways that study results are being interpreted and de-)Tj 0 -1.401 TD -0.0001 Tc [(scribed. If this is so, it is desirable to try to reach some)]TJ T* 0.002 Tc (understanding of how the general negativity came about.)Tj 0 -1.398 TD -0.0036 Tc -0.0288 Tw (Some possibilities are as follows.)Tj 1.2 -2.001 TD 0 Tc 0 Tw ()Tj /TT5 1 Tf 1.8 0 TD 0.0048 Tc 0.125 Tw [(Perceptions of the field being practice-based and)]TJ 0 -1.401 TD -0.0038 Tc 0.025 Tw (unscientifically tested)Tj /TT2 1 Tf 8.634 0 TD -0.0028 Tc 0.0292 Tw [(. CISM is based in the theory)]TJ -8.634 -1.398 TD -0.0033 Tc -0.0593 Tw [(of crisis intervention. Nevertheless, its practices also)]TJ 0 -1.401 TD -0.0041 Tc -0.0492 Tw (evolved from observation and that which was found)Tj T* -0.0033 Tc -0.0585 Tw [(to work. This was later subject to theoretical devel-)]TJ 0 -1.398 TD -0.0034 Tc 0.062 Tw [(opment and scientific scrutiny)62.6(. Some would prefer)]TJ 0 -1.401 TD -0.0033 Tc 0.0442 Tw (interventions to be theoretically developed first and)Tj T* 0.0575 Tw [(scientifically tested prior to implementation. How-)]TJ 0 -1.398 TD -0.0268 Tw [(ever)35.7(, this is not the first time that useful assistance to)]TJ 0 -1.401 TD 0.0023 Tc 0.125 Tw [(others has been based on what has been found to)]TJ ET endstream endobj 82 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 84 0 obj << /Length 8861 >> 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 /TT3 1 Tf 8 0 0 8 54.99 41.64 Tm 0 0 0 1 k /GS2 gs -0.006 Tc 0.075 Tw [(258 Robinson)]TJ /F1 1 Tf 6.8775 0 TD -0.0067 Tc [(  )]TJ /TT3 1 Tf 1.0425 0 TD -0.0054 Tc (Reflections on the Debriefing Debate)Tj /TT2 1 Tf 10 0 0 10 84 722.64 Tm 0.0055 Tc 0.125 Tw (work, with assessment and theory development)Tj 0 -1.398 TD -0.0137 Tc -0.0617 Tw (following \(e.g., Shapiro, 1995\).)Tj -1.8 -2.001 TD 0 Tc 0 Tw ()Tj /TT5 1 Tf 1.8 0 TD 0.0371 Tc 0.125 Tw (Perceptions of psychological knowledge being)Tj 0 -1.401 TD 0.0005 Tc (implemented by people who are untrained in psy-)Tj 0 -1.398 TD 0.0073 Tc (chological practice)Tj /TT2 1 Tf 8.016 0 TD 0.0089 Tc 0.1255 Tw [(. )21.4(W)58.7(ithin the field of physical)]TJ -8.016 -1.401 TD -0.0008 Tc 0.125 Tw (health and ill health, turf battles have been wit-)Tj T* -0.0034 Tc -0.0557 Tw (nessed as nurses, paramedics, first aid personnel, and)Tj 0 -1.398 TD -0.0037 Tc 0.1221 Tw (others formed a tiered response between what had)Tj 0 -1.401 TD -0.0035 Tc -0.0625 Tw (otherwise been a direct link between patient and phy-)Tj T* 0.0016 Tc 0.125 Tw [(sician. It is possible that a parallel shake-up is)]TJ 0 -1.398 TD -0.0034 Tc 0.035 Tw (occurring in the psychological sphere with interme-)Tj 0 -1.401 TD -0.0036 Tc 0.0742 Tw (diaries being introduced between the client /patient)Tj T* -0.0028 Tc 0.0337 Tw [(and the psychologist or psychiatrist. It is important)]TJ 0 -1.398 TD -0.0037 Tc -0.045 Tw (to remember that CISM, while advocating the role of)Tj 0 -1.401 TD -0.0034 Tc 0.0169 Tw (peer support, articulates how peers fit within the es-)Tj T* -0.0035 Tc 0.0964 Tw (tablished system and how peer support and mental)Tj 0 -1.398 TD -0.0038 Tc 0.0008 Tw (health professionals should work in cooperation and)Tj 0 -1.401 TD -0.0034 Tc 0.0729 Tw [(collaboration with one another)53.6(. )15(There may also be)]TJ T* 0.0014 Tc 0.125 Tw (concerns that the educational programs that equip)Tj 0 -1.398 TD -0.0033 Tc -0.0495 Tw [(people to help others are inadequate. It is recognized)]TJ 0 -1.401 TD -0.0037 Tc 0.0069 Tw (within the CISM field that more training should and)Tj T* 0.0318 Tw [(can be done to best equip practitioners. )50.7(Appropriate)]TJ 0 -1.398 TD -0.0034 Tc -0.0225 Tw (organizations, such as the International Critical Inci-)Tj 0 -1.401 TD 0.0393 Tc 0.125 Tw (dent Stress Foundation, have been developing)Tj T* 0.0076 Tc (courses and standards of training on an on-going)Tj 0 -1.398 TD 0.015 Tc 0 Tw (basis.)Tj -1.8 -2.001 TD 0 Tc ()Tj /TT5 1 Tf 1.8 0 TD -0.0037 Tc (Perceptions of blind acceptance of the CISM model)Tj 0 -1.401 TD 0.0118 Tc 0.125 Tw (by the field.)Tj /TT2 1 Tf 5.1 0 TD 0.0112 Tc [( Considerable passion was generated)]TJ -5.1 -1.398 TD -0.0035 Tc -0.0341 Tw (amongst emergency service workers and others, par-)Tj 0 -1.401 TD -0.0041 Tc -0.0624 Tw [(ticularly in the early days of CISM, probably because)]TJ T* -0.0033 Tc 0.105 Tw [(this was an idea whose time had come. This may)]TJ 0 -1.398 TD -0.0034 Tc -0.023 Tw (have led Raphael, for example, to refer to CISM as a)Tj 0 -1.401 TD -0.0036 Tc 0.0231 Tw [(social movement \(Raphael et al., 1995\). CISM was)]TJ T* 0.12 Tw (never a social movement, but these words give an)Tj 0 -1.398 TD 0.0756 Tw (indication of some of the concerns that might have)Tj 0 -1.401 TD -0.003 Tc 0.082 Tw [(been held. It is the author)-36()54(s)-0.2( view that workers, by)]TJ T* -0.0031 Tc -0.0125 Tw (and large, have a capacity to articulate those support)Tj 0 -1.398 TD -0.0033 Tc 0.0456 Tw (activities that are helpful to them and those that are)Tj 0 -1.401 TD -0.0034 Tc 0.1057 Tw [(not. 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It is hoped that)]TJ -1.8 -1.401 TD -0.0036 Tc 0.0465 Tw (this can occur while embracing a broader view of what the)Tj T* 0.053 Tw [(field of evaluation can of)17.4(fer)53.4(.)-6.1( )-6.1( )17.4(This will enable research de-)]TJ 0 -1.398 TD -0.0034 Tc 0.0646 Tw (signs to be selected on the basis of the questions that need)Tj 0 -1.401 TD -0.0032 Tc 0.0725 Tw [(to be answered. 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90.372 650.175 l 90.625 650.067 l 90.843 649.972 l 91.033 649.896 l 91.197 649.83 l 91.345 649.778 l 91.478 649.738 l 91.598 649.702 l 91.717 649.673 l 91.835 649.649 l 91.958 649.626 l 92.092 649.607 l 92.237 649.583 l 92.207 649.433 l 92.171 649.288 l 92.126 649.147 l 92.072 649.012 l 92.01 648.88 l 91.945 648.753 l 91.871 648.631 l 91.79 648.512 l 91.708 648.398 l 91.616 648.287 l 91.519 648.177 l 91.421 648.072 l 91.315 647.97 l 91.208 647.872 l 91.096 647.774 l 90.978 647.678 l 90.859 647.586 l 90.616 647.403 l 90.487 647.317 l 90.23 647.143 l 89.971 646.972 l 89.704 646.801 l 89.445 646.63 l 89.314 646.545 l 89.185 646.459 l 89.056 646.37 l 88.932 646.282 l 88.932 645.881 l 88.771 645.809 l 88.613 645.737 l 88.456 645.661 l 88.3 645.583 l 88.149 645.504 l 87.998 645.425 l 87.847 645.342 l 87.695 645.264 l 87.695 644.86 l 87.294 644.86 l 87.294 644.43 l 87.205 644.393 l 87.113 644.354 l 87.025 644.311 l 86.936 644.265 l 86.851 644.215 l 86.762 644.166 l 86.676 644.111 l 86.591 644.054 l 86.505 643.996 l 86.42 643.933 l 86.337 643.87 l 86.256 643.804 l 86.177 643.736 l 86.098 643.667 l 85.946 643.522 l 85.869 643.447 l 85.802 643.368 l 85.728 643.292 l 85.662 643.211 l 85.532 643.046 l 85.469 642.964 l 85.414 642.879 l 85.354 642.793 l 85.301 642.708 l 85.248 642.619 l 85.204 642.53 l 85.157 642.441 l 85.114 642.353 l 85.075 642.264 l 85.039 642.176 l 84.203 642.176 l f* 114.488 644.86 m 114.251 645.053 l 114.005 645.247 l 113.748 645.437 l 113.479 645.628 l 113.199 645.816 l 112.91 646.003 l 112.613 646.187 l 112.311 646.367 l 111.999 646.545 l 111.683 646.722 l 111.361 646.896 l 111.032 647.067 l 110.7 647.235 l 110.365 647.399 l 110.026 647.559 l 109.687 647.718 l 109.346 647.868 l 109.003 648.017 l 108.658 648.161 l 108.32 648.302 l 107.977 648.437 l 107.638 648.569 l 107.306 648.693 l 106.975 648.812 l 106.646 648.927 l 106.324 649.035 l 106.008 649.137 l 105.698 649.233 l 105.396 649.325 l 105.1 649.406 l 104.814 649.485 l 104.539 649.555 l 104.479 649.673 l 104.433 649.778 l 104.394 649.866 l 104.367 649.945 l 104.347 650.015 l 104.337 650.073 l 104.337 650.155 l 104.341 650.179 l 104.35 650.227 l 104.367 650.277 l 104.386 650.326 l 104.41 650.379 l 104.439 650.438 l 104.468 650.504 l 104.501 650.579 l 104.539 650.664 l 104.751 650.75 l 104.968 650.839 l 105.192 650.934 l 105.422 651.036 l 105.653 651.141 l 105.884 651.253 l 106.12 651.371 l 106.356 651.492 l 106.594 651.618 l 106.83 651.752 l 107.064 651.887 l 107.3 652.031 l 107.533 652.176 l 107.764 652.328 l 107.99 652.485 l 108.214 652.646 l 108.435 652.81 l 108.648 652.981 l 108.855 653.152 l 109.059 653.333 l 109.256 653.514 l 109.444 653.698 l 109.625 653.888 l 109.796 654.082 l 109.957 654.279 l 110.109 654.479 l 110.25 654.686 l 110.381 654.894 l 110.5 655.107 l 110.605 655.32 l 110.7 655.537 l 110.779 655.76 l 110.884 655.747 l 110.99 655.732 l 111.096 655.715 l 111.2 655.695 l 111.308 655.672 l 111.417 655.652 l 111.528 655.629 l 111.643 655.606 l 111.884 655.021 l 112.131 654.411 l 112.391 653.779 l 112.653 653.132 l 112.92 652.468 l 113.189 651.792 l 113.32 651.447 l 113.453 651.102 l 113.584 650.757 l 113.715 650.405 l 113.843 650.057 l 113.969 649.706 l 114.212 649.003 l 114.33 648.648 l 114.442 648.296 l 114.554 647.944 l 114.659 647.597 l 114.762 647.245 l 114.86 646.896 l 114.952 646.551 l 115.037 646.206 l 115.116 645.867 l 115.191 645.527 l 115.261 645.191 l 115.32 644.86 l 114.488 644.86 l f* 74.717 651.22 m 74.717 652.455 l 74.993 652.63 l 75.257 652.824 l 75.506 653.043 l 75.749 653.283 l 75.982 653.542 l 76.205 653.819 l 76.421 654.111 l 76.63 654.42 l 76.835 654.738 l 77.032 655.071 l 77.222 655.413 l 77.41 655.76 l 77.597 656.119 l 77.778 656.477 l 77.959 656.841 l 78.139 657.206 l 78.318 657.571 l 78.499 657.936 l 78.679 658.297 l 78.863 658.652 l 79.052 659 l 79.241 659.338 l 79.436 659.67 l 79.636 659.989 l 79.843 660.295 l 80.054 660.587 l 80.273 660.863 l 80.504 661.119 l 80.74 661.356 l 80.988 661.573 l 81.247 661.767 l 81.514 661.935 l 81.603 661.543 l 81.701 661.116 l 81.754 660.889 l 81.81 660.656 l 81.872 660.419 l 81.938 660.176 l 82.007 659.926 l 82.079 659.677 l 82.155 659.424 l 82.237 659.17 l 82.325 658.917 l 82.418 658.661 l 82.513 658.412 l 82.616 658.158 l 82.723 657.912 l 82.838 657.67 l 82.957 657.433 l 83.082 657.2 l 83.213 656.973 l 83.352 656.752 l 83.496 656.542 l 83.647 656.342 l 83.808 656.151 l 83.974 655.971 l 84.147 655.803 l 84.328 655.649 l 84.516 655.507 l 84.713 655.38 l 84.917 655.268 l 85.13 655.173 l 85.193 654.959 l 85.236 654.788 l 85.266 654.65 l 85.275 654.588 l 85.282 654.529 l 85.285 654.469 l 85.282 654.406 l 85.278 654.345 l 85.275 654.275 l 85.252 654.111 l 85.222 653.907 l 83.845 653.563 l 82.629 653.254 l 81.563 652.981 l 80.633 652.741 l 79.82 652.528 l 79.117 652.339 l 78.501 652.176 l 77.966 652.031 l 77.492 651.904 l 77.065 651.788 l 76.673 651.684 l 76.302 651.588 l 75.933 651.496 l 75.558 651.407 l 75.157 651.315 l 74.717 651.22 l f* 96.163 651.838 m 95.907 651.907 l 95.652 651.976 l 95.397 652.044 l 95.144 652.11 l 94.889 652.179 l 94.634 652.246 l 94.381 652.311 l 94.127 652.377 l 93.875 652.439 l 93.621 652.505 l 93.367 652.57 l 93.118 652.633 l 92.865 652.698 l 92.616 652.761 l 92.365 652.824 l 92.115 652.89 l 91.527 653.263 l 90.968 653.642 l 90.435 654.022 l 89.928 654.404 l 89.452 654.788 l 89.001 655.176 l 88.574 655.567 l 88.175 655.965 l 87.8 656.365 l 87.453 656.772 l 87.131 657.186 l 86.827 657.607 l 86.555 658.034 l 86.301 658.471 l 86.071 658.914 l 85.864 659.368 l 85.68 659.831 l 85.519 660.305 l 85.376 660.787 l 85.255 661.283 l 85.157 661.792 l 85.078 662.312 l 85.018 662.844 l 84.979 663.392 l 84.96 663.95 l 84.956 664.529 l 84.974 665.117 l 85.006 665.725 l 85.059 666.349 l 85.128 666.99 l 85.213 667.651 l 85.314 668.328 l 85.535 668.761 l 85.745 669.181 l 85.949 669.583 l 86.15 669.97 l 86.345 670.338 l 86.535 670.692 l 86.723 671.035 l 86.906 671.36 l 87.094 671.672 l 87.279 671.974 l 87.465 672.263 l 87.656 672.542 l 87.847 672.812 l 88.045 673.072 l 88.249 673.321 l 88.456 673.564 l 88.672 673.797 l 88.896 674.024 l 89.13 674.248 l 89.376 674.461 l 89.629 674.674 l 89.898 674.881 l 90.179 675.085 l 90.475 675.286 l 90.786 675.486 l 91.112 675.684 l 91.457 675.88 l 91.819 676.078 l 92.201 676.275 l 92.605 676.471 l 93.03 676.675 l 93.473 676.879 l 94.006 676.971 l 94.523 677.053 l 95.018 677.123 l 95.502 677.185 l 95.969 677.23 l 96.42 677.267 l 96.86 677.293 l 97.29 677.306 l 97.709 677.306 l 98.12 677.297 l 98.52 677.274 l 98.912 677.237 l 99.3 677.191 l 99.681 677.129 l 100.06 677.058 l 100.435 676.971 l 100.808 676.873 l 101.181 676.758 l 101.552 676.633 l 101.923 676.495 l 102.301 676.34 l 102.68 676.176 l 103.061 675.995 l 103.453 675.802 l 103.847 675.595 l 104.249 675.371 l 104.659 675.135 l 105.084 674.881 l 105.514 674.616 l 105.958 674.337 l 106.416 674.041 l 106.886 673.728 l 106.931 673.614 l 106.978 673.499 l 107.024 673.38 l 107.07 673.266 l 107.471 673.266 l 107.895 672.418 l 108.099 672.004 l 108.303 671.597 l 108.504 671.192 l 108.701 670.789 l 108.894 670.381 l 109.086 669.97 l 109.277 669.553 l 109.467 669.125 l 109.651 668.689 l 109.835 668.239 l 109.928 668.006 l 110.02 667.772 l 110.111 667.532 l 110.201 667.289 l 110.292 667.039 l 110.381 666.783 l 110.473 666.524 l 110.562 666.257 l 110.608 666.244 l 110.655 666.229 l 110.7 666.212 l 110.749 666.192 l 110.841 666.149 l 110.933 666.102 l 110.875 665.331 l 110.812 664.582 l 110.779 664.218 l 110.742 663.853 l 110.703 663.494 l 110.664 663.143 l 110.615 662.795 l 110.565 662.449 l 110.509 662.108 l 110.447 661.773 l 110.378 661.438 l 110.306 661.109 l 110.224 660.784 l 110.135 660.463 l 110.035 660.141 l 109.931 659.824 l 109.816 659.509 l 109.687 659.197 l 109.553 658.888 l 109.405 658.582 l 109.246 658.277 l 109.079 657.976 l 108.894 657.672 l 108.701 657.374 l 108.491 657.079 l 108.267 656.782 l 108.03 656.487 l 107.777 656.191 l 107.51 655.899 l 107.224 655.606 l 107.182 655.475 l 107.103 655.34 l 106.994 655.202 l 106.856 655.064 l 106.688 654.923 l 106.494 654.778 l 106.277 654.637 l 106.041 654.492 l 105.784 654.351 l 105.509 654.207 l 105.219 654.066 l 104.916 653.925 l 104.601 653.783 l 104.275 653.645 l 103.947 653.51 l 103.611 653.378 l 103.271 653.25 l 102.933 653.122 l 102.594 653.001 l 102.259 652.886 l 101.931 652.771 l 101.609 652.665 l 101.296 652.56 l 100.993 652.466 l 100.707 652.377 l 100.435 652.294 l 100.181 652.219 l 99.948 652.149 l 99.737 652.091 l 99.546 652.038 l 99.385 651.995 l 99.253 651.963 l 98.86 651.95 l 98.665 651.946 l 98.471 651.94 l 98.277 651.933 l 98.083 651.927 l 97.89 651.92 l 97.695 651.914 l 97.505 651.904 l 97.31 651.897 l 97.119 651.887 l 96.929 651.88 l 96.734 651.871 l 96.545 651.861 l 96.353 651.851 l 96.163 651.838 l f* 112.85 659.062 m 112.837 659.318 l 112.831 659.568 l 112.831 659.822 l 112.837 660.067 l 112.85 660.317 l 112.867 660.564 l 112.89 660.807 l 112.92 661.053 l 112.949 661.297 l 112.986 661.54 l 113.021 661.779 l 113.065 662.02 l 113.15 662.502 l 113.239 662.982 l 113.331 663.458 l 113.459 664.178 l 113.498 664.421 l 113.535 664.661 l 113.568 664.904 l 113.594 665.147 l 113.619 665.39 l 113.639 665.633 l 113.656 665.88 l 113.662 666.126 l 113.665 666.376 l 113.662 666.622 l 113.653 666.875 l 113.736 666.898 l 113.814 666.922 l 113.896 666.945 l 113.978 666.967 l 114.058 666.99 l 114.14 667.013 l 114.221 667.036 l 114.3 667.06 l 114.347 666.967 l 114.396 666.872 l 114.442 666.77 l 114.488 666.658 l 114.764 666.596 l 115.044 666.526 l 115.323 666.455 l 115.602 666.379 l 115.883 666.297 l 116.166 666.212 l 116.445 666.123 l 116.728 666.035 l 117.011 665.939 l 117.292 665.84 l 117.576 665.742 l 117.862 665.64 l 118.43 665.433 l 119.006 665.219 l 119.584 665.003 l 120.166 664.785 l 120.751 664.565 l 121.344 664.352 l 121.64 664.247 l 121.94 664.145 l 122.239 664.043 l 122.541 663.945 l 122.844 663.846 l 123.146 663.751 l 123.452 663.659 l 123.757 663.57 l 123.757 662.552 l 123.584 662.532 l 123.402 662.513 l 123.215 662.487 l 123.021 662.456 l 122.823 662.424 l 122.623 662.387 l 122.416 662.351 l 122.209 662.308 l 121.999 662.262 l 121.785 662.217 l 121.571 662.167 l 121.358 662.112 l 121.143 662.055 l 120.932 661.999 l 120.723 661.938 l 120.512 661.872 l 120.308 661.806 l 120.104 661.737 l 119.907 661.668 l 119.713 661.591 l 119.525 661.517 l 119.345 661.438 l 119.17 661.359 l 119.002 661.277 l 118.844 661.192 l 118.694 661.106 l 118.552 661.017 l 118.42 660.925 l 118.301 660.834 l 118.191 660.738 l 118.094 660.643 l 118.009 660.544 l 117.963 660.547 l 117.911 660.547 l 117.846 660.541 l 117.772 660.528 l 117.691 660.512 l 117.602 660.491 l 117.503 660.469 l 117.395 660.438 l 117.158 660.374 l 116.888 660.292 l 116.59 660.199 l 116.264 660.094 l 115.912 659.982 l 115.537 659.86 l 115.136 659.733 l 114.715 659.604 l 114.274 659.47 l 113.817 659.336 l 113.34 659.197 l 112.85 659.062 l f* 80.899 663.57 m 80.754 663.738 l 80.58 663.908 l 80.383 664.083 l 80.162 664.26 l 79.919 664.437 l 79.656 664.618 l 79.374 664.802 l 79.074 664.987 l 78.758 665.17 l 78.429 665.354 l 78.091 665.538 l 77.739 665.722 l 77.381 665.906 l 77.015 666.089 l 76.643 666.27 l 76.269 666.451 l 75.519 666.8 l 75.144 666.971 l 74.773 667.139 l 74.049 667.463 l 72.721 668.048 l 72.142 668.305 l 71.879 668.42 l 71.64 668.531 l 71.419 668.633 l 71.224 668.729 l 71.185 668.902 l 71.159 669.044 l 71.149 669.106 l 71.146 669.165 l 71.146 669.224 l 71.152 669.283 l 71.162 669.346 l 71.175 669.412 l 71.195 669.487 l 71.221 669.569 l 71.288 669.769 l 71.38 670.022 l 72.037 670.177 l 72.704 670.331 l 73.376 670.485 l 74.056 670.64 l 74.737 670.792 l 75.425 670.936 l 75.77 671.005 l 76.117 671.074 l 76.462 671.14 l 76.812 671.202 l 77.157 671.261 l 77.505 671.318 l 77.854 671.373 l 78.206 671.422 l 78.554 671.468 l 78.903 671.511 l 79.25 671.55 l 79.599 671.583 l 79.948 671.612 l 80.3 671.636 l 80.646 671.656 l 80.994 671.669 l 81.343 671.675 l 81.688 671.675 l 82.035 671.672 l 82.382 671.662 l 82.379 671.55 l 82.375 671.438 l 82.371 671.33 l 82.362 671.218 l 82.343 670.992 l 82.316 670.768 l 82.283 670.542 l 82.242 670.312 l 82.203 670.079 l 82.162 669.845 l 82.115 669.613 l 82.07 669.372 l 82.02 669.132 l 81.977 668.889 l 81.931 668.646 l 81.892 668.396 l 81.855 668.147 l 81.823 667.894 l 81.826 667.776 l 81.832 667.647 l 81.842 667.512 l 81.855 667.375 l 81.888 667.079 l 81.929 666.768 l 81.964 666.446 l 81.994 666.113 l 82.007 665.948 l 82.017 665.781 l 82.02 665.617 l 82.02 665.456 l 82.017 665.294 l 82.007 665.134 l 81.987 664.979 l 81.964 664.832 l 81.931 664.683 l 81.892 664.542 l 81.842 664.409 l 81.787 664.28 l 81.718 664.162 l 81.635 664.047 l 81.547 663.945 l 81.441 663.849 l 81.325 663.765 l 81.198 663.688 l 81.054 663.623 l 80.899 663.57 l f* 112.85 668.729 m 112.828 668.761 l 112.805 668.801 l 112.785 668.846 l 112.762 668.898 l 112.742 668.955 l 112.722 669.021 l 112.705 669.09 l 112.686 669.165 l 112.65 669.332 l 112.611 669.513 l 112.574 669.714 l 112.535 669.924 l 112.453 670.378 l 112.406 670.613 l 112.358 670.854 l 112.305 671.097 l 112.246 671.34 l 112.213 671.462 l 112.179 671.58 l 112.143 671.698 l 112.107 671.813 l 112.042 671.919 l 111.972 672.026 l 111.894 672.142 l 111.811 672.26 l 111.627 672.517 l 111.433 672.791 l 111.226 673.078 l 111.016 673.37 l 110.801 673.673 l 110.598 673.971 l 110.5 674.123 l 110.401 674.27 l 110.309 674.416 l 110.224 674.56 l 110.141 674.701 l 110.062 674.839 l 109.994 674.97 l 109.931 675.101 l 109.875 675.227 l 109.828 675.345 l 109.789 675.46 l 109.763 675.565 l 109.743 675.667 l 109.736 675.759 l 109.743 675.844 l 109.76 675.92 l 110.046 675.95 l 110.334 675.982 l 110.624 676.019 l 110.914 676.061 l 111.203 676.108 l 111.496 676.157 l 111.788 676.209 l 112.081 676.264 l 112.374 676.324 l 112.666 676.387 l 112.962 676.452 l 113.255 676.521 l 113.55 676.594 l 113.846 676.666 l 114.142 676.741 l 114.442 676.82 l 115.034 676.981 l 115.632 677.149 l 116.227 677.323 l 116.826 677.497 l 117.421 677.674 l 118.02 677.852 l 118.618 678.029 l 119.217 678.207 l 119.217 678.338 l 119.22 678.437 l 119.223 678.476 l 119.227 678.509 l 119.233 678.535 l 119.243 678.558 l 119.253 678.574 l 119.269 678.588 l 119.285 678.595 l 119.306 678.601 l 119.362 678.608 l 119.43 678.608 l 119.46 678.531 l 119.496 678.45 l 119.539 678.362 l 119.584 678.269 l 120.296 678.269 l 120.285 678.147 l 120.252 678.01 l 120.196 677.852 l 120.121 677.678 l 120.029 677.487 l 119.92 677.287 l 119.795 677.07 l 119.654 676.843 l 119.502 676.603 l 119.338 676.357 l 119.164 676.1 l 118.981 675.84 l 118.79 675.575 l 118.591 675.302 l 118.389 675.03 l 118.181 674.757 l 117.759 674.208 l 117.34 673.666 l 116.931 673.148 l 116.544 672.657 l 116.185 672.208 l 115.873 671.806 l 115.734 671.629 l 115.613 671.468 l 115.504 671.323 l 115.415 671.199 l 115.129 670.943 l 114.854 670.703 l 114.718 670.585 l 114.591 670.466 l 114.465 670.344 l 114.347 670.219 l 114.29 670.158 l 114.235 670.091 l 114.182 670.026 l 114.129 669.957 l 114.076 669.888 l 114.027 669.816 l 113.982 669.74 l 113.935 669.664 l 113.893 669.586 l 113.854 669.503 l 113.814 669.418 l 113.778 669.33 l 113.742 669.237 l 113.709 669.145 l 113.679 669.047 l 113.653 668.945 l 113.547 668.919 l 113.446 668.896 l 113.34 668.872 l 113.239 668.846 l 113.14 668.819 l 113.041 668.791 l 112.943 668.761 l 112.85 668.729 l f* 83.986 674.501 m 83.877 674.546 l 83.776 674.593 l 83.677 674.638 l 83.585 674.685 l 83.507 674.97 l 83.424 675.26 l 83.338 675.555 l 83.247 675.858 l 83.055 676.476 l 82.851 677.106 l 82.644 677.75 l 82.431 678.404 l 82.217 679.06 l 82.01 679.718 l 81.908 680.046 l 81.81 680.375 l 81.71 680.7 l 81.527 681.344 l 81.441 681.659 l 81.359 681.975 l 81.283 682.284 l 80.647 683.717 l 80.581 684.018 l 80.522 684.314 l 80.469 684.604 l 80.424 684.887 l 80.384 685.162 l 80.354 685.432 l 80.336 685.695 l 80.578 685.721 l 80.831 685.718 l 81.095 685.679 l 81.368 685.612 l 81.643 685.52 l 81.929 685.402 l 82.222 685.26 l 82.517 685.099 l 82.82 684.919 l 83.13 684.721 l 84.006 683.388 l 84.321 683.168 l 84.638 682.938 l 84.96 682.701 l 85.609 682.215 l 85.936 681.972 l 86.262 681.732 l 86.591 681.495 l 86.916 681.262 l 87.242 681.042 l 87.564 680.832 l 87.886 680.634 l 88.205 680.454 l 88.521 680.293 l 88.834 680.148 l 89.143 680.027 l 89.445 679.931 l 89.744 679.863 l 90.037 679.823 l 90.322 679.817 l 90.599 679.842 l 90.629 679.678 l 90.649 679.544 l 90.652 679.484 l 90.655 679.428 l 90.652 679.373 l 90.642 679.317 l 90.629 679.258 l 90.611 679.192 l 90.59 679.122 l 90.487 678.853 l 90.386 678.608 l 90.257 678.582 l 90.123 678.542 l 89.978 678.492 l 89.822 678.433 l 89.662 678.365 l 89.497 678.285 l 89.327 678.197 l 89.149 678.102 l 88.971 678 l 88.787 677.888 l 88.603 677.773 l 88.415 677.651 l 88.228 677.527 l 88.041 677.398 l 87.856 677.264 l 87.673 677.129 l 87.492 676.991 l 87.314 676.853 l 87.14 676.713 l 86.972 676.573 l 86.811 676.432 l 86.656 676.294 l 86.508 676.157 l 86.367 676.025 l 86.239 675.893 l 86.117 675.765 l 86.009 675.644 l 85.913 675.525 l 85.828 675.414 l 85.755 675.309 l 85.699 675.21 l 85.657 675.118 l 85.222 675.118 l 85.177 675.003 l 85.133 674.889 l 85.114 674.829 l 85.098 674.77 l 85.081 674.714 l 85.068 674.655 l 84.93 674.642 l 84.793 674.625 l 84.654 674.609 l 84.516 674.589 l 84.38 674.57 l 84.246 674.546 l 84.114 674.523 l 83.986 674.501 l f* q 67.176 690.337 62.226 -80.704 re W n 107.471 676.354 m 107.386 676.554 l 107.283 676.75 l 107.17 676.938 l 107.037 677.123 l 106.892 677.297 l 106.738 677.468 l 106.57 677.632 l 106.393 677.786 l 106.201 677.941 l 106.004 678.085 l 105.801 678.223 l 105.59 678.358 l 105.369 678.486 l 105.148 678.61 l 104.916 678.728 l 104.683 678.843 l 104.449 678.953 l 104.209 679.055 l 103.969 679.152 l 103.729 679.249 l 103.49 679.337 l 103.249 679.422 l 103.012 679.501 l 102.779 679.58 l 102.549 679.652 l 102.322 679.721 l 102.102 679.788 l 101.887 679.846 l 101.48 679.957 l 101.109 680.059 l 101.181 680.391 l 101.266 680.713 l 101.365 681.029 l 101.476 681.331 l 101.598 681.626 l 101.729 681.916 l 101.871 682.195 l 102.019 682.471 l 102.177 682.737 l 102.345 682.997 l 102.516 683.256 l 102.877 683.755 l 103.258 684.243 l 103.456 684.482 l 103.853 684.954 l 104.255 685.428 l 104.456 685.668 l 104.656 685.904 l 104.857 686.145 l 105.051 686.387 l 105.245 686.634 l 105.435 686.884 l 105.62 687.136 l 105.801 687.396 l 105.975 687.659 l 106.139 687.928 l 106.301 688.204 l 106.452 688.487 l 106.587 688.526 l 106.691 688.555 l 106.742 688.569 l 106.783 688.575 l 106.827 688.582 l 106.869 688.586 l 106.916 688.586 l 106.961 688.582 l 107.014 688.575 l 107.07 688.569 l 107.205 688.549 l 107.379 688.52 l 107.487 687.853 l 107.596 687.159 l 107.704 686.44 l 107.814 685.7 l 107.866 685.323 l 107.919 684.941 l 108.017 684.167 l 108.109 683.384 l 108.155 682.991 l 108.193 682.593 l 108.234 682.198 l 108.271 681.801 l 108.303 681.406 l 108.329 681.009 l 108.356 680.619 l 108.378 680.224 l 108.395 679.836 l 108.409 679.449 l 108.418 679.064 l 108.425 678.683 l 108.421 678.309 l 108.418 677.937 l 108.405 677.57 l 108.388 677.212 l 108.365 676.856 l 108.338 676.507 l 108.224 676.495 l 108.113 676.479 l 108 676.462 l 107.892 676.442 l 107.786 676.422 l 107.681 676.4 l 107.471 676.354 l f* 91.835 679.626 m 91.816 679.964 l 91.803 680.306 l 91.803 680.651 l 91.809 680.995 l 91.823 681.341 l 91.849 681.686 l 91.879 682.034 l 91.915 682.383 l 91.96 682.731 l 92.012 683.079 l 92.069 683.424 l 92.131 683.772 l 92.198 684.12 l 92.269 684.465 l 92.348 684.814 l 92.427 685.156 l 92.51 685.501 l 92.598 685.842 l 92.687 686.181 l 92.775 686.518 l 92.964 687.185 l 93.154 687.846 l 93.341 688.489 l 93.529 689.124 l 93.707 689.739 l 93.877 690.34 l 94.045 690.252 l 94.206 690.132 l 94.368 689.981 l 94.523 689.804 l 94.673 689.604 l 94.822 689.377 l 94.966 689.13 l 95.11 688.864 l 95.255 688.578 l 95.397 688.28 l 95.537 687.964 l 95.962 686.952 l 96.252 686.245 l 96.4 685.885 l 96.551 685.527 l 96.705 685.169 l 96.863 684.81 l 97.027 684.462 l 97.195 684.117 l 97.37 683.782 l 97.547 683.456 l 97.734 683.147 l 97.925 682.85 l 98.126 682.569 l 98.333 682.307 l 98.55 682.063 l 98.774 681.844 l 99.007 681.65 l 99.253 681.479 l 99.224 681.275 l 99.201 681.084 l 99.188 680.993 l 99.172 680.903 l 99.152 680.818 l 99.129 680.734 l 99.116 680.694 l 99.099 680.651 l 99.083 680.611 l 99.063 680.572 l 99.044 680.536 l 99.02 680.496 l 98.994 680.461 l 98.965 680.425 l 98.934 680.388 l 98.902 680.352 l 98.865 680.316 l 98.826 680.283 l 98.784 680.249 l 98.738 680.217 l 98.688 680.185 l 98.635 680.152 l 98.204 680.121 l 97.777 680.092 l 97.349 680.059 l 96.926 680.03 l 96.498 679.997 l 96.075 679.964 l 95.65 679.935 l 95.223 679.898 l 94.798 679.865 l 94.377 679.833 l 93.953 679.801 l 93.529 679.764 l 93.104 679.731 l 92.684 679.695 l 92.26 679.662 l 91.835 679.626 l f* Q q 447.158 519.381 77.819 -59.83 re W n 1 1 1 rg 486.446 519.241 m 471.528 501.626 l 447.612 489.907 l 447.252 489.79 l 471.671 477.854 l 486.607 459.84 l 502.438 478.711 l 502.438 478.769 l 524.971 489.455 l 525.28 489.681 l 502.209 501.112 l 486.446 519.241 l f 0 0.286 0.388 RG 0.427 w 2.613 M /GS3 gs 486.446 519.241 m 471.528 501.626 l 447.612 489.907 l 447.252 489.79 l 471.671 477.854 l 486.607 459.84 l 502.438 478.711 l 502.438 478.769 l 524.971 489.455 l 525.28 489.681 l 502.209 501.112 l 486.446 519.241 l S Q 0 0.286 0.388 RG 1.282 w 2.613 M /GS3 gs 486.607 472.562 m 497.966 472.562 507.173 480.277 507.173 489.795 c 507.173 499.311 497.966 507.026 486.607 507.026 c 475.249 507.026 466.042 499.311 466.042 489.795 c 466.042 480.277 475.249 472.562 486.607 472.562 c S 0.427 w 486.77 474.056 m 498.127 474.056 505.675 481.864 505.675 489.795 c 505.675 497.725 497.804 505.533 486.446 505.533 c 475.088 505.533 467.541 497.725 467.541 489.795 c 467.541 481.864 475.411 474.056 486.77 474.056 c S 0.137 0.122 0.125 RG 486.77 474.056 m 486.77 474.056 l S 0 0.286 0.388 rg 474.157 498.825 0.329 -2.43 re f 476.629 496.862 m 476.623 496.862 l 475.407 498.825 l 475.017 498.825 l 475.017 496.395 l 475.335 496.395 l 475.335 498.358 l 475.343 498.358 l 476.578 496.395 l 476.948 496.395 l 476.948 498.825 l 476.629 498.825 l 476.629 496.862 l f* 477.174 498.534 m 477.998 498.534 l 477.998 496.395 l 478.326 496.395 l 478.326 498.534 l 479.15 498.534 l 479.15 498.825 l 477.174 498.825 l 477.174 498.534 l f* 481.219 496.686 m 479.752 496.686 l 479.752 497.498 l 481.084 497.498 l 481.084 497.79 l 479.752 497.79 l 479.752 498.534 l 481.196 498.534 l 481.196 498.825 l 479.424 498.825 l 479.424 496.395 l 481.219 496.395 l 481.219 496.686 l f* 481.947 498.544 m 482.768 498.544 l 482.93 498.544 483.204 498.513 483.204 498.138 c 483.204 497.78 482.951 497.718 482.71 497.718 c 481.947 497.718 l 481.947 498.544 l h 481.947 497.437 m 482.743 497.437 l 483.136 497.437 483.177 497.203 483.177 497.004 c 483.177 496.913 483.187 496.544 483.235 496.395 c 483.638 496.395 l 483.638 496.449 l 483.536 496.507 483.52 496.558 483.516 496.692 c 483.495 497.133 l 483.482 497.472 483.343 497.532 483.204 497.59 c 483.36 497.681 483.543 497.813 483.543 498.172 c 483.543 498.687 483.144 498.825 482.743 498.825 c 481.619 498.825 l 481.619 496.395 l 481.947 496.395 l 481.947 497.437 l f* 485.558 496.862 m 485.552 496.862 l 484.336 498.825 l 483.946 498.825 l 483.946 496.395 l 484.264 496.395 l 484.264 498.358 l 484.271 498.358 l 485.507 496.395 l 485.877 496.395 l 485.877 498.825 l 485.558 498.825 l 485.558 496.862 l f* 486.798 497.394 m 487.188 498.463 l 487.194 498.463 l 487.553 497.394 l 486.798 497.394 l h 487.672 497.102 m 487.913 496.395 l 488.272 496.395 l 487.391 498.825 l 487.019 498.825 l 486.103 496.395 l 486.442 496.395 l 486.696 497.102 l 487.672 497.102 l f* 487.886 498.534 m 488.708 498.534 l 488.708 496.395 l 489.037 496.395 l 489.037 498.534 l 489.86 498.534 l 489.86 498.825 l 487.886 498.825 l 487.886 498.534 l f* 490.152 498.825 0.328 -2.43 re f 493.258 497.61 m 493.258 498.135 492.979 498.89 492.073 498.89 c 491.165 498.89 490.887 498.135 490.887 497.61 c 490.887 497.086 491.165 496.331 492.073 496.331 c 492.979 496.331 493.258 497.086 493.258 497.61 c h 492.919 497.61 m 492.919 497.038 492.601 496.622 492.073 496.622 c 491.543 496.622 491.225 497.038 491.225 497.61 c 491.225 498.182 491.543 498.599 492.073 498.599 c 492.601 498.599 492.919 498.182 492.919 497.61 c f* 495.179 496.862 m 495.171 496.862 l 493.955 498.825 l 493.565 498.825 l 493.565 496.395 l 493.885 496.395 l 493.885 498.358 l 493.891 498.358 l 495.128 496.395 l 495.496 496.395 l 495.496 498.825 l 495.179 498.825 l 495.179 496.862 l f* 496.418 497.394 m 496.807 498.463 l 496.815 498.463 l 497.174 497.394 l 496.418 497.394 l h 497.292 497.102 m 497.532 496.395 l 497.891 496.395 l 497.01 498.825 l 496.638 498.825 l 495.724 496.395 l 496.063 496.395 l 496.316 497.102 l 497.292 497.102 l f* 498.45 498.825 m 498.122 498.825 l 498.122 496.395 l 499.683 496.395 l 499.683 496.686 l 498.45 496.686 l 498.45 498.825 l f* 481.58 494.024 m 481.533 494.43 481.207 494.819 480.58 494.819 c 479.873 494.819 479.446 494.301 479.446 493.553 c 479.446 492.619 479.988 492.259 480.541 492.259 c 480.723 492.259 481.468 492.3 481.603 493.218 c 481.285 493.218 l 481.174 492.653 480.804 492.551 480.591 492.551 c 479.988 492.551 479.785 492.991 479.785 493.564 c 479.785 494.203 480.14 494.528 480.58 494.528 c 480.814 494.528 481.17 494.45 481.262 494.024 c 481.58 494.024 l f* 482.291 494.473 m 483.111 494.473 l 483.274 494.473 483.548 494.443 483.548 494.068 c 483.548 493.709 483.294 493.648 483.054 493.648 c 482.291 493.648 l 482.291 494.473 l h 482.291 493.367 m 483.087 493.367 l 483.481 493.367 483.521 493.133 483.521 492.934 c 483.521 492.842 483.531 492.474 483.578 492.325 c 483.982 492.325 l 483.982 492.379 l 483.88 492.436 483.863 492.487 483.859 492.622 c 483.839 493.063 l 483.826 493.401 483.687 493.461 483.548 493.519 c 483.704 493.611 483.887 493.743 483.887 494.102 c 483.887 494.615 483.487 494.755 483.087 494.755 c 481.963 494.755 l 481.963 492.325 l 482.291 492.325 l 482.291 493.367 l f* 484.34 494.755 0.329 -2.43 re f 484.991 494.463 m 485.815 494.463 l 485.815 492.324 l 486.143 492.324 l 486.143 494.463 l 486.966 494.463 l 486.966 494.755 l 484.991 494.755 l 484.991 494.463 l f* 487.257 494.755 0.329 -2.43 re f 490.142 494.024 m 490.096 494.43 489.77 494.819 489.144 494.819 c 488.436 494.819 488.009 494.301 488.009 493.553 c 488.009 492.619 488.551 492.259 489.103 492.259 c 489.286 492.259 490.031 492.3 490.167 493.218 c 489.848 493.218 l 489.737 492.653 489.367 492.551 489.154 492.551 c 488.551 492.551 488.348 492.991 488.348 493.564 c 488.348 494.203 488.704 494.528 489.144 494.528 c 489.377 494.528 489.733 494.45 489.825 494.024 c 490.142 494.024 l f* 490.97 493.323 m 491.359 494.393 l 491.366 494.393 l 491.724 493.323 l 490.97 493.323 l h 491.843 493.032 m 492.084 492.324 l 492.443 492.324 l 491.563 494.755 l 491.19 494.755 l 490.275 492.324 l 490.613 492.324 l 490.867 493.032 l 491.843 493.032 l f* 493.002 494.755 m 492.673 494.755 l 492.673 492.325 l 494.235 492.325 l 494.235 492.615 l 493.002 492.615 l 493.002 494.755 l f* 479.335 490.685 0.329 -2.431 re f 481.807 488.721 m 481.8 488.721 l 480.584 490.684 l 480.194 490.684 l 480.194 488.255 l 480.513 488.255 l 480.513 490.218 l 480.52 490.218 l 481.756 488.255 l 482.125 488.255 l 482.125 490.684 l 481.807 490.684 l 481.807 488.721 l f* 484.588 489.953 m 484.541 490.36 484.215 490.749 483.588 490.749 c 482.881 490.749 482.454 490.231 482.454 489.483 c 482.454 488.549 482.996 488.189 483.548 488.189 c 483.731 488.189 484.476 488.23 484.611 489.148 c 484.293 489.148 l 484.182 488.582 483.812 488.481 483.599 488.481 c 482.996 488.481 482.793 488.921 482.793 489.493 c 482.793 490.132 483.148 490.458 483.588 490.458 c 483.822 490.458 484.178 490.38 484.27 489.953 c 484.588 489.953 l f* 484.981 490.685 0.329 -2.431 re f 486.187 490.403 m 486.799 490.403 l 487.247 490.403 487.528 490.095 487.528 489.483 c 487.528 488.871 487.251 488.535 486.824 488.535 c 486.187 488.535 l 486.187 490.403 l h 485.858 488.255 m 486.83 488.255 l 487.629 488.255 487.866 488.958 487.866 489.503 c 487.866 490.204 487.477 490.684 486.844 490.684 c 485.858 490.684 l 485.858 488.255 l f* 490.038 488.545 m 488.572 488.545 l 488.572 489.358 l 489.903 489.358 l 489.903 489.649 l 488.572 489.649 l 488.572 490.393 l 490.014 490.393 l 490.014 490.684 l 488.243 490.684 l 488.243 488.255 l 490.038 488.255 l 490.038 488.545 l f* 492.009 488.721 m 492.003 488.721 l 490.787 490.684 l 490.397 490.684 l 490.397 488.255 l 490.715 488.255 l 490.715 490.218 l 490.723 490.218 l 491.959 488.255 l 492.328 488.255 l 492.328 490.684 l 492.009 490.684 l 492.009 488.721 l f* 492.555 490.393 m 493.378 490.393 l 493.378 488.254 l 493.706 488.254 l 493.706 490.393 l 494.53 490.393 l 494.53 490.684 l 492.555 490.684 l 492.555 490.393 l f* 482.238 485.903 m 482.225 486.17 482.141 486.679 481.291 486.679 c 480.701 486.679 480.454 486.306 480.454 485.926 c 480.454 485.503 480.813 485.392 480.972 485.355 c 481.47 485.24 l 481.87 485.145 481.988 485.064 481.988 484.81 c 481.988 484.462 481.589 484.401 481.352 484.401 c 481.04 484.401 480.681 484.529 480.681 484.969 c 480.372 484.969 l 480.372 484.743 480.413 484.54 480.619 484.353 c 480.728 484.255 480.904 484.119 481.355 484.119 c 481.771 484.119 482.306 484.279 482.306 484.854 c 482.306 485.24 482.069 485.429 481.755 485.503 c 481.06 485.663 l 480.917 485.696 480.772 485.764 480.772 485.971 c 480.772 486.34 481.121 486.398 481.328 486.398 c 481.602 486.398 481.914 486.279 481.93 485.903 c 482.238 485.903 l f* 482.442 486.323 m 483.265 486.323 l 483.265 484.184 l 483.594 484.184 l 483.594 486.323 l 484.417 486.323 l 484.417 486.614 l 482.442 486.614 l 482.442 486.323 l f* 485.026 486.333 m 485.846 486.333 l 486.008 486.333 486.283 486.302 486.283 485.926 c 486.283 485.568 486.029 485.507 485.788 485.507 c 485.026 485.507 l 485.026 486.333 l h 485.026 485.226 m 485.823 485.226 l 486.216 485.226 486.256 484.992 486.256 484.793 c 486.256 484.701 486.266 484.333 486.314 484.184 c 486.717 484.184 l 486.717 484.238 l 486.615 484.296 486.598 484.347 486.594 484.481 c 486.575 484.922 l 486.561 485.26 486.422 485.321 486.283 485.378 c 486.439 485.47 486.622 485.602 486.622 485.961 c 486.622 486.475 486.222 486.614 485.823 486.614 c 484.698 486.614 l 484.698 484.184 l 485.026 484.184 l 485.026 485.226 l f* 488.854 484.475 m 487.387 484.475 l 487.387 485.287 l 488.718 485.287 l 488.718 485.579 l 487.387 485.579 l 487.387 486.323 l 488.831 486.323 l 488.831 486.614 l 487.058 486.614 l 487.058 484.184 l 488.854 484.184 l 488.854 484.475 l f* 490.988 485.903 m 490.974 486.17 490.89 486.679 490.039 486.679 c 489.45 486.679 489.203 486.306 489.203 485.926 c 489.203 485.503 489.562 485.392 489.722 485.355 c 490.219 485.24 l 490.619 485.145 490.738 485.064 490.738 484.81 c 490.738 484.462 490.338 484.401 490.101 484.401 c 489.789 484.401 489.429 484.529 489.429 484.969 c 489.122 484.969 l 489.122 484.743 489.162 484.54 489.369 484.353 c 489.478 484.255 489.653 484.119 490.103 484.119 c 490.521 484.119 491.056 484.279 491.056 484.854 c 491.056 485.24 490.818 485.429 490.504 485.503 c 489.809 485.663 l 489.667 485.696 489.521 485.764 489.521 485.971 c 489.521 486.34 489.87 486.398 490.077 486.398 c 490.351 486.398 490.663 486.279 490.68 485.903 c 490.988 485.903 l f* 493.176 485.903 m 493.162 486.17 493.078 486.679 492.228 486.679 c 491.638 486.679 491.391 486.306 491.391 485.926 c 491.391 485.503 491.75 485.392 491.909 485.355 c 492.408 485.24 l 492.808 485.145 492.926 485.064 492.926 484.81 c 492.926 484.462 492.526 484.401 492.289 484.401 c 491.977 484.401 491.619 484.529 491.619 484.969 c 491.31 484.969 l 491.31 484.743 491.35 484.54 491.557 484.353 c 491.665 484.255 491.842 484.119 492.293 484.119 c 492.709 484.119 493.244 484.279 493.244 484.854 c 493.244 485.24 493.006 485.429 492.692 485.503 c 491.997 485.663 l 491.855 485.696 491.71 485.764 491.71 485.971 c 491.71 486.34 492.059 486.398 492.266 486.398 c 492.539 486.398 492.851 486.279 492.868 485.903 c 493.176 485.903 l f* 476.816 481.217 m 478.008 481.217 l 478.008 481.508 l 476.816 481.508 l 476.816 482.252 l 478.17 482.252 l 478.17 482.543 l 476.487 482.543 l 476.487 480.113 l 476.816 480.113 l 476.816 481.217 l f* 480.704 481.328 m 480.704 481.853 480.426 482.608 479.519 482.608 c 478.611 482.608 478.334 481.853 478.334 481.328 c 478.334 480.804 478.611 480.048 479.519 480.048 c 480.426 480.048 480.704 480.804 480.704 481.328 c h 480.366 481.328 m 480.366 480.757 480.048 480.34 479.519 480.34 c 478.99 480.34 478.672 480.757 478.672 481.328 c 478.672 481.901 478.99 482.317 479.519 482.317 c 480.048 482.317 480.366 481.901 480.366 481.328 c f* 482.608 482.543 m 482.608 481.007 l 482.608 480.479 482.269 480.34 481.968 480.34 c 481.673 480.34 481.352 480.486 481.352 481.014 c 481.352 482.543 l 481.022 482.543 l 481.022 480.923 l 481.022 480.468 481.304 480.048 481.958 480.048 c 482.625 480.048 482.937 480.468 482.937 480.967 c 482.937 482.543 l 482.608 482.543 l f* 484.993 480.581 m 484.985 480.581 l 483.77 482.543 l 483.38 482.543 l 483.38 480.114 l 483.699 480.114 l 483.699 482.077 l 483.705 482.077 l 484.942 480.114 l 485.311 480.114 l 485.311 482.543 l 484.993 482.543 l 484.993 480.581 l f* 486.093 482.262 m 486.707 482.262 l 487.153 482.262 487.434 481.954 487.434 481.342 c 487.434 480.73 487.157 480.394 486.73 480.394 c 486.093 480.394 l 486.093 482.262 l h 485.765 480.114 m 486.737 480.114 l 487.537 480.114 487.773 480.817 487.773 481.363 c 487.773 482.063 487.384 482.543 486.75 482.543 c 485.765 482.543 l 485.765 480.114 l f* 488.465 481.112 m 488.854 482.182 l 488.86 482.182 l 489.22 481.112 l 488.465 481.112 l h 489.339 480.821 m 489.579 480.113 l 489.938 480.113 l 489.057 482.543 l 488.685 482.543 l 487.77 480.113 l 488.109 480.113 l 488.363 480.821 l 489.339 480.821 l f* 489.552 482.252 m 490.375 482.252 l 490.375 480.113 l 490.704 480.113 l 490.704 482.252 l 491.527 482.252 l 491.527 482.543 l 489.552 482.543 l 489.552 482.252 l f* 491.818 482.543 0.329 -2.43 re f 494.924 481.328 m 494.924 481.853 494.647 482.608 493.738 482.608 c 492.831 482.608 492.552 481.853 492.552 481.328 c 492.552 480.804 492.831 480.048 493.738 480.048 c 494.647 480.048 494.924 480.804 494.924 481.328 c h 494.586 481.328 m 494.586 480.757 494.267 480.34 493.738 480.34 c 493.211 480.34 492.891 480.757 492.891 481.328 c 492.891 481.901 493.211 482.317 493.738 482.317 c 494.267 482.317 494.586 481.901 494.586 481.328 c f* 496.844 480.581 m 496.838 480.581 l 495.622 482.543 l 495.233 482.543 l 495.233 480.114 l 495.551 480.114 l 495.551 482.077 l 495.558 482.077 l 496.794 480.114 l 497.163 480.114 l 497.163 482.543 l 496.844 482.543 l 496.844 480.581 l f* 485.905 515.314 m 487.63 515.314 l 487.629 513.545 l 489.058 514.476 l 489.882 513.136 l 488.353 512.247 l 489.893 511.375 l 489.101 510.002 l 487.619 510.86 l 487.619 509.055 l 485.911 509.055 l 485.91 510.82 l 484.399 509.949 l 483.607 511.383 l 485.102 512.234 l 483.579 513.125 l 484.369 514.457 l 485.905 513.545 l 485.905 515.314 l f* 0 0.286 0.388 RG 485.905 515.314 m 487.63 515.314 l 487.629 513.545 l 489.058 514.476 l 489.882 513.136 l 488.353 512.247 l 489.893 511.375 l 489.101 510.002 l 487.619 510.86 l 487.619 509.055 l 485.911 509.055 l 485.91 510.82 l 484.399 509.949 l 483.607 511.383 l 485.102 512.234 l 483.579 513.125 l 484.369 514.457 l 485.905 513.545 l 485.905 515.314 l s 1 1 1 rg 486.96 514.536 m 486.755 514.897 486.577 514.53 y 486.749 509.903 l 486.814 509.774 486.842 509.916 y 486.96 514.536 l f* 486.632 513.061 m 486.514 513.134 486.461 513.197 y 486.163 513.515 486.157 513.759 y 486.149 513.972 486.223 514.094 y 486.283 514.226 486.473 514.296 y 486.585 514.339 486.6 514.328 y 486.749 514.325 486.822 514.206 y 487.064 514.032 486.749 514.037 y 486.6 514.059 486.555 514.093 y 486.37 514.042 486.408 513.769 y 486.444 513.605 486.542 513.427 486.621 513.387 c 486.632 513.061 l f* 1 1 1 RG 0.213 w 486.632 513.061 m 486.514 513.134 486.461 513.197 y 486.163 513.515 486.157 513.759 y 486.149 513.972 486.223 514.094 y 486.283 514.226 486.473 514.296 y 486.585 514.339 486.6 514.328 y 486.749 514.325 486.822 514.206 y 487.064 514.032 486.749 514.037 y 486.6 514.059 486.555 514.093 y 486.37 514.042 486.408 513.769 y 486.444 513.605 486.542 513.427 486.621 513.387 c 486.632 513.061 l s 486.748 514.194 m 486.724 514.196 486.698 514.186 486.677 514.197 c 486.666 514.202 486.662 514.215 486.666 514.224 c 486.669 514.231 486.685 514.242 486.696 514.237 c 486.719 514.229 486.724 514.201 486.748 514.194 c f* 486.748 514.194 m 486.724 514.196 486.698 514.186 486.677 514.197 c 486.666 514.202 486.662 514.215 486.666 514.224 c 486.669 514.231 486.685 514.242 486.696 514.237 c 486.719 514.229 486.724 514.201 486.748 514.194 c s 486.733 510.835 m 486.747 510.92 486.788 510.985 v 486.825 511.042 486.854 511.071 486.914 511.133 c 486.946 511.168 486.993 511.233 487.026 511.273 c 487.141 511.417 487.045 511.572 v 487.002 511.638 486.883 511.741 v 486.886 511.425 l 486.885 511.35 486.683 511.121 y 486.632 511.057 486.607 511.027 486.583 510.846 c 486.564 510.638 486.734 510.416 v 486.724 510.751 l 486.727 510.807 486.733 510.835 v f* 486.733 510.835 m 486.747 510.92 486.788 510.985 v 486.825 511.042 486.854 511.071 486.914 511.133 c 486.946 511.168 486.993 511.233 487.026 511.273 c 487.141 511.417 487.045 511.572 v 487.002 511.638 486.883 511.741 v 486.886 511.425 l 486.885 511.35 486.683 511.121 y 486.632 511.057 486.607 511.027 486.583 510.846 c 486.564 510.638 486.734 510.416 v 486.724 510.751 l 486.727 510.807 486.733 510.835 v s 486.918 512.861 m 486.936 512.808 486.657 512.516 y 486.633 512.488 486.605 512.456 486.573 512.421 c 486.398 512.232 486.407 512.075 v 486.416 511.857 486.63 511.652 v 486.656 511.631 486.692 511.592 v 486.682 511.89 l 486.659 511.919 486.633 511.963 486.611 512.029 c 486.588 512.076 486.652 512.177 v 486.764 512.279 487.127 512.709 v 487.233 512.888 487.149 513.007 v 487.069 513.125 486.928 513.219 v 486.918 512.861 l f* 486.918 512.861 m 486.936 512.808 486.657 512.516 y 486.633 512.488 486.605 512.456 486.573 512.421 c 486.398 512.232 486.407 512.075 v 486.416 511.857 486.63 511.652 v 486.656 511.631 486.692 511.592 v 486.682 511.89 l 486.659 511.919 486.633 511.963 486.611 512.029 c 486.588 512.076 486.652 512.177 v 486.764 512.279 487.127 512.709 v 487.233 512.888 487.149 513.007 v 487.069 513.125 486.928 513.219 v 486.918 512.861 l s 486.849 510.27 m 486.859 510.232 486.853 510.185 486.807 510.131 c 486.706 509.985 l 486.819 510.033 486.873 510.101 v 486.941 510.168 486.925 510.291 v 486.913 510.35 486.854 510.444 v 486.849 510.27 l f* 486.849 510.27 m 486.859 510.232 486.853 510.185 486.807 510.131 c 486.706 509.985 l 486.819 510.033 486.873 510.101 v 486.941 510.168 486.925 510.291 v 486.913 510.35 486.854 510.444 v 486.849 510.27 l s 0 0.286 0.388 rg 509.933 492.026 m 510.069 492.108 510.484 492.734 510.499 492.708 c 510.747 492.315 511.087 491.918 511.811 491.918 c 512.536 491.918 513.124 492.272 513.124 492.708 c 513.124 492.272 513.689 491.939 514.414 491.939 c 515.138 491.939 515.5 492.274 515.726 492.73 c 515.735 492.769 l 515.869 492.683 516.517 492.256 516.497 492.232 c 514.46 490.783 518.669 487.761 513.739 486.016 c 513.487 485.945 513.373 485.773 v 513.327 485.857 512.965 486.022 y 507.646 487.182 512.128 490.577 509.933 492.026 c f* 0 0.286 0.388 RG 1 J 1 j 0.427 w 509.933 492.026 m 510.069 492.108 510.484 492.734 510.499 492.708 c 510.747 492.315 511.087 491.918 511.811 491.918 c 512.536 491.918 513.124 492.272 513.124 492.708 c S 0.137 0.122 0.125 RG 513.124 492.708 m 513.124 492.708 l S 0 0.286 0.388 RG 513.124 492.708 m 513.124 492.272 513.689 491.939 514.414 491.939 c 515.138 491.939 515.5 492.274 515.726 492.73 c S 0.137 0.122 0.125 RG 515.726 492.73 m 515.735 492.769 l S 0 0.286 0.388 RG 515.735 492.769 m 515.869 492.683 516.517 492.256 516.497 492.232 c 514.46 490.783 518.669 487.761 513.739 486.016 c 513.487 485.945 513.373 485.773 v S 0.137 0.122 0.125 RG 513.373 485.773 m 513.373 485.773 l S 0 0.286 0.388 RG 513.373 485.773 m 513.327 485.857 512.965 486.022 y 507.646 487.182 512.128 490.577 509.933 492.026 c S 1 1 1 rg 511.841 487.115 m 512.318 489.04 l 511.109 490.108 l 512.625 490.11 l 513.104 491.884 l 513.659 490.103 l 515.292 490.106 l 513.976 488.955 l 514.548 487.115 l 513.219 488.297 l 511.841 487.115 l f* 0.137 0.122 0.125 rg 457.244 490.697 m 457.074 490.662 456.983 490.651 456.877 490.436 c 456.839 490.36 456.799 490.271 456.746 490.201 c 456.536 489.893 456.576 489.527 456.602 489.196 c 456.628 489.149 456.655 489.083 456.655 489.03 c 456.655 488.96 456.727 488.914 456.746 488.841 c 456.786 488.687 456.917 488.629 456.995 488.511 c 457.048 488.463 457.231 488.333 457.231 488.357 c 457.231 488.664 457.14 488.99 457.074 489.244 c 456.982 489.598 457.1 489.94 457.179 490.319 c 457.231 490.461 457.218 490.555 457.244 490.697 c f* 0.137 0.122 0.125 RG 0 J 457.244 490.697 m 457.074 490.662 456.983 490.651 456.877 490.436 c 456.839 490.36 456.799 490.271 456.746 490.201 c 456.536 489.893 456.576 489.527 456.602 489.196 c 456.628 489.149 456.655 489.083 456.655 489.03 c 456.655 488.96 456.727 488.914 456.746 488.841 c 456.786 488.687 456.917 488.629 456.995 488.511 c 457.048 488.463 457.231 488.333 457.231 488.357 c 457.231 488.664 457.14 488.99 457.074 489.244 c 456.982 489.598 457.1 489.94 457.179 490.319 c 457.231 490.461 457.218 490.555 457.244 490.697 c s 458.724 487.128 m 458.772 486.976 458.779 486.841 459.02 486.756 c 459.109 486.724 459.208 486.693 459.289 486.648 c 459.639 486.474 460.043 486.527 460.407 486.566 c 460.458 486.592 460.53 486.618 460.588 486.62 c 460.666 486.624 460.714 486.692 460.794 486.712 c 460.962 486.755 461.021 486.875 461.148 486.951 c 461.197 487.001 461.334 487.172 461.307 487.171 c 460.967 487.157 460.611 487.059 460.333 486.989 c 459.945 486.889 459.56 486.979 459.137 487.033 c 458.978 487.073 458.882 487.11 458.724 487.128 c f* 458.724 487.128 m 458.772 486.976 458.779 486.841 459.02 486.756 c 459.109 486.724 459.208 486.693 459.289 486.648 c 459.639 486.474 460.043 486.527 460.407 486.566 c 460.458 486.592 460.53 486.618 460.588 486.62 c 460.666 486.624 460.714 486.692 460.794 486.712 c 460.962 486.755 461.021 486.875 461.148 486.951 c 461.197 487.001 461.334 487.172 461.307 487.171 c 460.967 487.157 460.611 487.059 460.333 486.989 c 459.945 486.889 459.56 486.979 459.137 487.033 c 458.978 487.073 458.882 487.11 458.724 487.128 c s 462.733 488.475 m 462.9 488.52 462.989 488.536 463.08 488.756 c 463.113 488.835 463.147 488.925 463.194 488.999 c 463.382 489.318 463.372 489.689 463.322 490.017 c 463.293 490.063 463.267 490.142 463.263 490.194 c 463.25 490.377 463.108 490.515 463.126 490.461 c 463.075 490.612 462.997 490.578 462.909 490.692 c 462.854 490.735 462.731 490.821 462.733 490.797 c 462.754 490.491 462.787 490.213 462.87 489.964 c 462.987 489.616 462.823 489.238 462.771 488.856 c 462.729 488.711 462.749 488.617 462.733 488.475 c f* 462.733 488.475 m 462.9 488.52 462.989 488.536 463.08 488.756 c 463.113 488.835 463.147 488.925 463.194 488.999 c 463.382 489.318 463.372 489.689 463.322 490.017 c 463.293 490.063 463.267 490.142 463.263 490.194 c 463.25 490.377 463.108 490.515 463.126 490.461 c 463.075 490.612 462.997 490.578 462.909 490.692 c 462.854 490.735 462.731 490.821 462.733 490.797 c 462.754 490.491 462.787 490.213 462.87 489.964 c 462.987 489.616 462.823 489.238 462.771 488.856 c 462.729 488.711 462.749 488.617 462.733 488.475 c s 461.321 491.955 m 461.282 492.109 461.27 492.191 461.033 492.286 c 460.947 492.321 460.849 492.358 460.771 492.405 c 460.431 492.595 460.025 492.56 459.657 492.536 c 459.605 492.513 459.533 492.489 459.474 492.489 c 459.395 492.489 459.345 492.423 459.265 492.407 c 459.095 492.372 459.029 492.253 458.898 492.182 c 458.845 492.135 458.701 491.97 458.727 491.97 c 459.068 491.969 459.429 492.051 459.709 492.111 c 460.103 492.192 460.483 492.086 460.901 492.014 c 461.059 491.967 461.164 491.979 461.321 491.955 c f* 461.321 491.955 m 461.282 492.109 461.27 492.191 461.033 492.286 c 460.947 492.321 460.849 492.358 460.771 492.405 c 460.431 492.595 460.025 492.56 459.657 492.536 c 459.605 492.513 459.533 492.489 459.474 492.489 c 459.395 492.489 459.345 492.423 459.265 492.407 c 459.095 492.372 459.029 492.253 458.898 492.182 c 458.845 492.135 458.701 491.97 458.727 491.97 c 459.068 491.969 459.429 492.051 459.709 492.111 c 460.103 492.192 460.483 492.086 460.901 492.014 c 461.059 491.967 461.164 491.979 461.321 491.955 c s 0 0.286 0.388 rg 459.942 487.292 m 461.369 487.292 462.527 488.341 462.527 489.636 c 462.527 490.931 461.369 491.981 459.942 491.981 c 458.515 491.981 457.359 490.931 457.359 489.636 c 457.359 488.341 458.515 487.292 459.942 487.292 c f* 0 0.286 0.388 RG 1.708 w 459.942 487.292 m 461.369 487.292 462.527 488.341 462.527 489.636 c 462.527 490.931 461.369 491.981 459.942 491.981 c 458.515 491.981 457.359 490.931 457.359 489.636 c 457.359 488.341 458.515 487.292 459.942 487.292 c s 457.839 491.005 m 456.503 492.034 l 456.385 491.927 456.518 491.791 456.298 491.349 c 456.214 491.181 456.208 490.774 456.13 490.579 c 456.13 490.544 456.149 490.616 456.13 490.579 c 456.11 490.491 455.933 490.101 455.953 490.013 c 455.933 490.013 455.953 490.013 y 455.894 489.764 455.894 489.534 455.913 489.285 c 455.922 489.1 455.964 489.058 456.115 488.434 c 456.155 488.274 456.305 487.859 456.344 487.681 c 456.383 487.522 456.464 487.194 456.522 487.052 c 456.542 487.016 456.444 487.034 456.522 487.052 c 457.956 488.097 l 457.924 488.16 458.003 488.029 457.956 488.097 c 457.842 488.348 457.604 488.73 457.557 489.002 c 457.489 489.299 457.489 489.617 457.512 489.914 c 457.512 489.937 457.644 490.347 457.649 490.37 c 457.727 490.658 457.696 490.666 457.839 491.005 c f* 0.427 w 457.839 491.005 m 456.503 492.034 l 456.385 491.927 456.518 491.791 456.298 491.349 c 456.214 491.181 456.208 490.774 456.13 490.579 c 456.13 490.544 456.149 490.616 456.13 490.579 c 456.11 490.491 455.933 490.101 455.953 490.013 c 455.933 490.013 455.953 490.013 y 455.894 489.764 455.894 489.534 455.913 489.285 c 455.922 489.1 455.964 489.058 456.115 488.434 c 456.155 488.274 456.305 487.859 456.344 487.681 c 456.383 487.522 456.464 487.194 456.522 487.052 c 456.542 487.016 456.444 487.034 456.522 487.052 c 457.956 488.097 l 457.924 488.16 458.003 488.029 457.956 488.097 c 457.842 488.348 457.604 488.73 457.557 489.002 c 457.489 489.299 457.489 489.617 457.512 489.914 c 457.512 489.937 457.644 490.347 457.649 490.37 c 457.727 490.658 457.696 490.666 457.839 491.005 c s 461.359 491.542 m 462.447 492.828 l 462.345 492.949 462.202 492.821 461.767 493.059 c 461.602 493.149 461.194 493.172 461.001 493.258 c 460.965 493.259 461.036 493.237 461.001 493.258 c 460.912 493.282 460.528 493.473 460.438 493.457 c 460.439 493.476 460.438 493.457 y 460.191 493.525 459.96 493.535 459.709 493.525 c 459.523 493.525 459.48 493.485 458.845 493.36 c 458.683 493.328 458.26 493.195 458.081 493.163 c 457.918 493.13 457.585 493.064 457.44 493.012 c 457.403 492.993 457.425 493.09 457.44 493.012 c 458.433 491.543 l 458.497 491.574 458.362 491.5 458.433 491.543 c 458.689 491.647 459.082 491.869 459.358 491.903 c 459.659 491.96 459.979 491.947 460.276 491.911 c 460.299 491.91 460.76 491.834 460.781 491.827 c 461.063 491.741 461.011 491.714 461.359 491.542 c f* 461.359 491.542 m 462.447 492.828 l 462.345 492.949 462.202 492.821 461.767 493.059 c 461.602 493.149 461.194 493.172 461.001 493.258 c 460.965 493.259 461.036 493.237 461.001 493.258 c 460.912 493.282 460.528 493.473 460.438 493.457 c 460.439 493.476 460.438 493.457 y 460.191 493.525 459.96 493.535 459.709 493.525 c 459.523 493.525 459.48 493.485 458.845 493.36 c 458.683 493.328 458.26 493.195 458.081 493.163 c 457.918 493.13 457.585 493.064 457.44 493.012 c 457.403 492.993 457.425 493.09 457.44 493.012 c 458.433 491.543 l 458.497 491.574 458.362 491.5 458.433 491.543 c 458.689 491.647 459.082 491.869 459.358 491.903 c 459.659 491.96 459.979 491.947 460.276 491.911 c 460.299 491.91 460.76 491.834 460.781 491.827 c 461.063 491.741 461.011 491.714 461.359 491.542 c s 458.568 487.62 m 457.546 486.284 l 457.654 486.167 457.789 486.301 458.236 486.085 c 458.405 486.003 458.814 486.002 459.011 485.925 c 459.046 485.925 458.975 485.944 459.011 485.925 c 459.1 485.906 459.494 485.734 459.583 485.754 c 459.583 485.734 459.583 485.754 y 459.833 485.697 460.065 485.699 460.315 485.721 c 460.501 485.732 460.542 485.773 461.169 485.928 c 461.329 485.968 461.745 486.122 461.922 486.162 c 462.083 486.203 462.414 486.285 462.556 486.346 c 462.591 486.365 462.574 486.268 462.556 486.346 c 461.491 487.763 l 461.429 487.73 461.559 487.81 461.491 487.763 c 461.24 487.647 460.859 487.406 460.584 487.359 c 460.287 487.287 459.966 487.284 459.668 487.305 c 459.645 487.305 459.231 487.432 459.209 487.438 c 458.864 487.526 458.919 487.527 458.568 487.62 c f* 458.568 487.62 m 457.546 486.284 l 457.654 486.167 457.789 486.301 458.236 486.085 c 458.405 486.003 458.814 486.002 459.011 485.925 c 459.046 485.925 458.975 485.944 459.011 485.925 c 459.1 485.906 459.494 485.734 459.583 485.754 c 459.583 485.734 459.583 485.754 y 459.833 485.697 460.065 485.699 460.315 485.721 c 460.501 485.732 460.542 485.773 461.169 485.928 c 461.329 485.968 461.745 486.122 461.922 486.162 c 462.083 486.203 462.414 486.285 462.556 486.346 c 462.591 486.365 462.574 486.268 462.556 486.346 c 461.491 487.763 l 461.429 487.73 461.559 487.81 461.491 487.763 c 461.24 487.647 460.859 487.406 460.584 487.359 c 460.287 487.287 459.966 487.284 459.668 487.305 c 459.645 487.305 459.231 487.432 459.209 487.438 c 458.864 487.526 458.919 487.527 458.568 487.62 c s 462.041 488.388 m 463.784 487.329 l 463.891 487.447 463.745 487.569 463.92 488.03 c 463.987 488.206 463.954 488.611 464.012 488.812 c 464.008 488.848 463.996 488.775 464.012 488.812 c 464.023 488.902 464.161 489.308 464.133 489.394 c 464.152 489.397 464.133 489.394 y 464.166 489.647 464.144 489.876 464.1 490.121 c 464.072 490.306 464.027 490.342 463.815 490.949 c 463.761 491.105 463.57 491.503 463.514 491.676 c 463.459 491.831 463.346 492.15 463.274 492.286 c 463.251 492.319 463.35 492.311 463.274 492.286 c 461.949 491.105 l 461.988 491.046 461.897 491.168 461.949 491.105 c 462.088 490.867 462.363 490.511 462.436 490.243 c 462.533 489.955 462.448 489.642 462.453 489.345 c 462.456 489.322 462.388 488.911 462.385 488.889 c 462.327 488.54 462.247 488.684 462.064 488.388 c 462.041 488.388 l f* 462.041 488.388 m 463.784 487.329 l 463.891 487.447 463.745 487.569 463.92 488.03 c 463.987 488.206 463.954 488.611 464.012 488.812 c 464.008 488.848 463.996 488.775 464.012 488.812 c 464.023 488.902 464.161 489.308 464.133 489.394 c 464.152 489.397 464.133 489.394 y 464.166 489.647 464.144 489.876 464.1 490.121 c 464.072 490.306 464.027 490.342 463.815 490.949 c 463.761 491.105 463.57 491.503 463.514 491.676 c 463.459 491.831 463.346 492.15 463.274 492.286 c 463.251 492.319 463.35 492.311 463.274 492.286 c 461.949 491.105 l 461.988 491.046 461.897 491.168 461.949 491.105 c 462.088 490.867 462.363 490.511 462.436 490.243 c 462.533 489.955 462.448 489.642 462.453 489.345 c 462.456 489.322 462.388 488.911 462.385 488.889 c 462.327 488.54 462.247 488.684 462.064 488.388 c 462.041 488.388 l s 1 1 1 rg 458.499 488.749 m 458.475 488.932 458.59 489.205 458.59 489.387 c 458.567 489.364 458.819 489.159 458.796 489.137 c 458.864 489.137 458.956 489.114 458.956 489.137 c 459.139 489.501 459.048 489.319 459.186 489.752 c 459.207 489.821 459.162 490.389 459.208 490.48 c 459.231 490.503 459.506 490.077 459.506 490.025 c 459.506 489.843 459.712 490.503 459.781 490.321 c 459.849 490.184 459.621 489.706 459.735 489.615 c 459.918 489.478 460.033 489.82 460.01 490.002 c 460.102 489.638 459.987 489.364 459.896 489.182 c 459.799 488.99 459.46 489.059 459.3 488.795 c 459.231 488.681 459.231 488.522 459.162 488.408 c 459.117 488.362 459.048 488.385 459.025 488.317 c 458.499 488.749 l f* 1 1 1 RG 1 J 458.499 488.749 m 458.475 488.932 458.59 489.205 458.59 489.387 c 458.567 489.364 458.819 489.159 458.796 489.137 c 458.864 489.137 458.956 489.114 458.956 489.137 c 459.139 489.501 459.048 489.319 459.186 489.752 c 459.207 489.821 459.162 490.389 459.208 490.48 c 459.231 490.503 459.506 490.077 459.506 490.025 c 459.506 489.843 459.712 490.503 459.781 490.321 c 459.849 490.184 459.621 489.706 459.735 489.615 c 459.918 489.478 460.033 489.82 460.01 490.002 c 460.102 489.638 459.987 489.364 459.896 489.182 c 459.799 488.99 459.46 489.059 459.3 488.795 c 459.231 488.681 459.231 488.522 459.162 488.408 c 459.117 488.362 459.048 488.385 459.025 488.317 c S 459.498 488.069 m 459.498 488.137 459.568 488.137 459.59 488.182 c 459.865 488.365 460.21 488.411 460.346 488.707 c 460.438 488.911 460.416 489.117 460.369 489.322 c 460.369 489.412 460.232 489.481 460.255 489.595 c 460.324 489.572 460.553 489.459 460.599 489.527 c 460.736 489.709 460.805 490.142 460.736 490.37 c 460.942 490.005 460.988 489.459 460.85 489.002 c 460.896 489.002 461.171 489.345 461.217 489.322 c 461.24 489.299 461.148 488.821 461.125 488.775 c 460.965 488.57 460.805 488.342 460.53 488.228 c 459.498 488.069 l f* 459.498 488.069 m 459.498 488.137 459.568 488.137 459.59 488.182 c 459.865 488.365 460.21 488.411 460.346 488.707 c 460.438 488.911 460.416 489.117 460.369 489.322 c 460.369 489.412 460.232 489.481 460.255 489.595 c 460.324 489.572 460.553 489.459 460.599 489.527 c 460.736 489.709 460.805 490.142 460.736 490.37 c 460.942 490.005 460.988 489.459 460.85 489.002 c 460.896 489.002 461.171 489.345 461.217 489.322 c 461.24 489.299 461.148 488.821 461.125 488.775 c 460.965 488.57 460.805 488.342 460.53 488.228 c S 0 0.286 0.388 rg 486.631 465.705 m 486.717 465.73 486.782 465.679 486.867 465.73 c 487.039 465.807 487.189 465.858 487.34 465.985 c 487.447 466.062 487.511 466.189 487.619 466.291 c 487.662 466.317 487.732 466.318 487.748 466.24 c 487.77 466.138 487.835 466.113 487.899 466.087 c 488.221 465.96 488.543 466.037 488.865 466.087 c 489.231 466.138 489.488 466.469 489.832 466.622 c 490.004 466.724 490.134 466.92 490.305 466.954 c 490.434 466.979 490.584 466.979 490.692 467.08 c 490.756 467.132 490.735 467.208 v 490.971 467.234 491.142 467.412 491.294 467.615 c 491.336 467.641 491.4 467.691 491.464 467.666 c 491.443 467.666 l 493.033 469.678 l 493.011 469.728 l 492.99 469.805 493.032 469.882 492.99 469.958 c 488.199 468.659 l 488.177 468.48 487.984 468.252 487.876 468.098 c 487.897 468.126 487.514 468.347 487.55 468.419 c 487.778 468.875 487.72 469.298 487.485 469.705 c 487.441 469.807 487.398 469.845 487.334 469.934 c 487.17 470.161 486.904 470.291 486.625 470.24 c 486.561 470.24 l 486.281 470.291 486.087 470.164 485.883 469.984 c 485.79 469.904 485.626 469.73 485.583 469.628 c 485.347 469.221 485.444 468.724 485.627 468.327 c 485.659 468.254 485.273 468.128 485.293 468.101 c 485.186 468.254 484.992 468.483 484.971 468.662 c 480.179 469.96 l 480.137 469.883 480.179 469.807 480.158 469.73 c 480.137 469.679 l 481.727 467.668 l 481.705 467.668 l 481.77 467.694 481.834 467.642 481.877 467.617 c 482.028 467.414 482.199 467.235 482.435 467.21 c 482.414 467.133 482.479 467.083 y 482.586 466.981 482.736 466.981 482.865 466.955 c 483.036 466.922 483.166 466.726 483.338 466.625 c 483.681 466.472 483.939 466.14 484.305 466.089 c 484.627 466.038 484.949 465.962 485.271 466.089 c 485.335 466.114 485.4 466.14 485.422 466.242 c 485.438 466.32 485.507 466.319 485.551 466.294 c 485.658 466.191 485.723 466.064 485.83 465.987 c 485.981 465.86 486.13 465.809 486.303 465.733 c 486.389 465.682 486.453 465.733 486.54 465.707 c 486.631 465.705 l f 0 0.286 0.388 RG 4 M 486.631 465.705 m 486.717 465.73 486.782 465.679 486.867 465.73 c 487.039 465.807 487.189 465.858 487.34 465.985 c 487.447 466.062 487.511 466.189 487.619 466.291 c 487.662 466.317 487.732 466.318 487.748 466.24 c 487.77 466.138 487.835 466.113 487.899 466.087 c 488.221 465.96 488.543 466.037 488.865 466.087 c 489.231 466.138 489.488 466.469 489.832 466.622 c 490.004 466.724 490.134 466.92 490.305 466.954 c 490.434 466.979 490.584 466.979 490.692 467.08 c 490.756 467.132 490.735 467.208 v 490.971 467.234 491.142 467.412 491.294 467.615 c 491.336 467.641 491.4 467.691 491.464 467.666 c 491.443 467.666 l 493.033 469.678 l 493.011 469.728 l 492.99 469.805 493.032 469.882 492.99 469.958 c 488.199 468.659 l 488.177 468.48 487.984 468.252 487.876 468.098 c 487.897 468.126 487.514 468.347 487.55 468.419 c 487.778 468.875 487.72 469.298 487.485 469.705 c 487.441 469.807 487.398 469.845 487.334 469.934 c 487.17 470.161 486.904 470.291 486.625 470.24 c 486.561 470.24 l 486.281 470.291 486.087 470.164 485.883 469.984 c 485.79 469.904 485.626 469.73 485.583 469.628 c 485.347 469.221 485.444 468.724 485.627 468.327 c 485.659 468.254 485.273 468.128 485.293 468.101 c 485.186 468.254 484.992 468.483 484.971 468.662 c 480.179 469.96 l 480.137 469.883 480.179 469.807 480.158 469.73 c 480.137 469.679 l 481.727 467.668 l 481.705 467.668 l 481.77 467.694 481.834 467.642 481.877 467.617 c 482.028 467.414 482.199 467.235 482.435 467.21 c 482.414 467.133 482.479 467.083 y 482.586 466.981 482.736 466.981 482.865 466.955 c 483.036 466.922 483.166 466.726 483.338 466.625 c 483.681 466.472 483.939 466.14 484.305 466.089 c 484.627 466.038 484.949 465.962 485.271 466.089 c 485.335 466.114 485.4 466.14 485.422 466.242 c 485.438 466.32 485.507 466.319 485.551 466.294 c 485.658 466.191 485.723 466.064 485.83 465.987 c 485.981 465.86 486.13 465.809 486.303 465.733 c 486.389 465.682 486.453 465.733 486.54 465.707 c 486.631 465.705 l s 1 1 1 rg 482.715 468.978 m 484.853 468.458 l 484.842 468.458 484.842 468.471 484.83 468.471 c 484.885 468.305 484.949 468.139 484.992 467.961 c 485.051 467.713 484.992 467.439 484.982 467.185 c 484.874 467.235 484.863 467.312 v 484.82 467.49 484.82 467.617 484.777 467.795 c 484.766 467.808 484.702 467.871 484.691 467.897 c 484.621 468.065 484.531 468.088 484.38 468.177 c 484.207 468.267 484.036 468.407 483.875 468.483 c 483.532 468.636 483.166 468.662 482.833 468.826 c 482.822 468.84 482.79 468.852 482.78 468.891 c 482.771 468.918 482.682 468.916 482.715 468.978 c f 483.241 468.547 m 483.262 468.521 483.284 468.471 483.305 468.458 c 483.403 468.407 483.499 468.419 483.596 468.419 c 483.574 468.432 483.553 468.458 483.532 468.458 c 483.413 468.458 483.338 468.496 483.241 468.547 c f 483.563 468.216 m 483.661 468.216 483.746 468.229 483.843 468.216 c 483.854 468.203 483.843 468.177 483.832 468.164 c 483.746 468.139 483.661 468.088 483.574 468.062 c 483.553 468.049 483.521 468.062 y 483.477 468.024 483.366 468.008 483.381 468.049 c 483.403 468.113 483.477 468.152 483.532 468.19 c f 483.574 467.782 m 483.607 467.782 483.638 467.77 483.671 467.795 c 483.735 467.846 483.843 467.922 483.918 467.935 c f 483.832 467.592 m 483.928 467.592 484.047 467.566 484.122 467.604 c 484.155 467.63 484.197 467.68 484.219 467.744 c 484.079 467.719 483.993 467.63 483.854 467.63 c f 484.498 467.502 m 484.477 467.502 484.455 467.515 484.434 467.502 c 484.358 467.452 484.272 467.439 484.219 467.363 c 484.197 467.325 484.197 467.274 484.197 467.235 c 484.219 467.235 484.24 467.223 484.251 467.235 c 484.305 467.337 484.402 467.363 484.455 467.452 c f 484.305 467.032 m 484.305 467.019 484.305 466.993 484.305 466.981 c 484.434 466.943 484.519 467.057 484.616 467.146 c 484.691 467.21 484.616 467.261 484.552 467.21 c 484.519 467.185 484.466 467.146 484.423 467.108 c 484.39 467.07 484.337 467.095 484.294 467.057 c 484.305 467.044 484.305 467.032 v f 484.713 466.93 m 484.766 466.93 484.777 466.993 484.82 467.019 c f 484.949 466.917 m 484.949 466.892 484.949 466.879 484.949 466.853 c 484.971 466.853 l 484.971 466.828 484.971 466.79 484.971 466.764 c f 480.631 469.4 m 480.696 469.412 480.749 469.387 480.802 469.361 c 480.813 469.361 480.835 469.336 480.856 469.323 c 480.921 469.298 480.985 469.272 481.049 469.247 c 481.254 469.183 481.469 469.196 481.662 469.082 c 481.737 469.043 481.823 469.005 481.898 468.98 c 482.102 468.928 482.285 468.928 482.489 468.891 c 482.522 468.878 482.553 468.84 482.597 468.84 c 482.381 468.852 482.167 468.814 481.941 468.852 c 481.823 468.878 481.705 468.865 481.587 468.903 c 481.554 468.916 481.544 468.954 481.512 468.967 c 481.394 469.005 481.286 468.954 481.178 468.992 c 481.136 469.005 481.082 469.005 481.039 469.03 c 480.889 469.082 480.792 469.221 480.673 469.349 c 480.663 469.361 480.684 469.387 480.663 469.4 c f 480.878 468.954 m 480.921 468.903 480.953 468.84 481.018 468.814 c 481.124 468.789 481.222 468.712 481.329 468.687 c 481.458 468.649 481.577 468.623 481.705 468.611 c 481.866 468.585 482.017 468.585 482.178 468.534 c 482.188 468.534 482.222 468.526 482.231 468.521 c 482.479 468.407 482.736 468.458 482.984 468.458 c 482.994 468.534 482.962 468.636 482.886 468.649 c 482.769 468.674 482.661 468.611 482.543 468.598 c 482.393 468.573 482.252 468.573 482.102 468.598 c 482.049 468.611 482.005 468.623 481.963 468.649 c 481.823 468.712 481.683 468.649 481.544 468.712 c 481.49 468.738 481.448 468.751 481.394 468.776 c 481.243 468.814 481.093 468.84 480.953 468.903 c f 481.394 468.331 m 481.63 468.318 481.877 468.381 482.113 468.305 c 482.156 468.292 482.188 468.229 482.242 468.216 c 482.328 468.203 482.414 468.229 482.5 468.241 c 482.682 468.28 482.865 468.229 483.048 468.267 c 482.726 468.011 482.306 468.101 481.941 468.126 c 481.855 468.126 481.791 468.203 481.716 468.216 c 481.651 468.216 481.577 468.216 481.512 468.241 c 481.479 468.254 481.458 468.28 481.426 468.292 c f 482.017 467.744 m 482.005 467.757 482.028 467.77 482.028 467.782 c 482.221 467.77 482.414 467.834 482.607 467.871 c 482.822 467.909 483.037 467.821 483.252 467.909 c 483.22 467.897 483.186 467.883 483.156 467.871 c 482.78 467.744 482.446 467.77 482.081 467.757 c f 482.435 467.388 m 482.553 467.363 482.704 467.388 482.822 467.388 c 482.973 467.414 483.131 467.377 483.284 467.414 c 483.391 467.439 483.381 467.528 483.509 467.668 c 483.349 467.656 483.274 467.642 483.08 467.656 c 482.958 467.663 482.876 467.579 482.757 467.541 c 482.661 467.515 482.661 467.566 482.586 467.502 c f 482.844 467.083 m 483.016 467.07 483.177 467.083 483.349 467.121 c 483.359 467.133 483.381 467.146 483.391 467.159 c 483.456 467.185 483.532 467.159 483.596 467.21 c 483.64 467.245 483.671 467.286 483.725 467.312 c 483.735 467.325 483.757 467.452 483.746 467.452 c 483.703 467.464 483.638 467.388 483.596 467.363 c 483.563 467.363 483.553 467.325 483.521 467.312 c 483.381 467.261 483.37 467.337 483.241 467.248 c 483.166 467.197 482.919 467.21 482.854 467.121 c f 483.316 466.803 m 483.434 466.79 483.542 466.841 483.65 466.879 c 483.746 466.917 483.854 466.968 483.939 467.057 c 483.757 467.108 483.596 466.955 483.413 466.904 c 483.391 466.904 483.338 466.866 483.349 466.816 c f 483.574 466.65 m 483.596 466.574 483.692 466.586 483.735 466.612 c 483.821 466.676 483.95 466.701 483.972 466.828 c 483.928 466.828 483.896 466.841 483.854 466.816 c 483.821 466.79 483.8 466.764 483.779 466.726 c 483.735 466.663 483.65 466.714 483.607 466.637 c f 483.961 466.446 m 484.047 466.446 484.132 466.446 484.219 466.446 c 484.207 466.548 484.24 466.65 484.305 466.726 c 484.305 466.74 484.305 466.764 484.305 466.778 c 484.251 466.803 484.207 466.74 484.165 466.701 c 484.132 466.663 484.132 466.599 484.143 466.548 c 484.09 466.548 484.036 466.523 484.004 466.472 c f 484.402 466.383 m 484.498 466.408 484.552 466.51 484.637 466.548 c f 484.648 466.395 m 484.713 466.395 484.745 466.497 484.799 466.548 c f 484.895 466.383 m 484.973 466.383 485.057 466.344 485.132 466.383 c 485.132 466.421 l 485.078 466.446 485.057 466.548 484.992 466.523 c 484.982 466.523 484.971 466.459 484.949 466.434 c 484.938 466.434 484.928 466.434 484.917 466.434 c 484.895 466.421 484.885 466.383 484.895 466.383 c f 490.454 468.976 m 488.317 468.455 l 488.328 468.455 488.328 468.467 488.339 468.467 c 488.285 468.302 488.221 468.137 488.178 467.959 c 488.118 467.711 488.178 467.436 488.188 467.182 c 488.296 467.233 488.307 467.309 v 488.35 467.487 488.35 467.614 488.393 467.793 c 488.404 467.806 488.468 467.87 488.478 467.895 c 488.549 468.062 488.639 468.086 488.79 468.175 c 488.962 468.264 489.133 468.404 489.295 468.481 c 489.638 468.633 490.004 468.659 490.336 468.824 c 490.348 468.837 490.379 468.85 490.39 468.888 c 490.398 468.915 490.487 468.914 490.454 468.976 c f 489.929 468.545 m 489.907 468.519 489.885 468.468 489.864 468.456 c 489.767 468.404 489.671 468.417 489.574 468.417 c 489.596 468.43 489.617 468.456 489.638 468.456 c 489.756 468.456 489.831 468.494 489.929 468.545 c f 489.607 468.214 m 489.509 468.214 489.424 468.226 489.327 468.214 c 489.316 468.201 489.327 468.175 489.338 468.162 c 489.424 468.137 489.509 468.087 489.596 468.061 c 489.617 468.049 489.649 468.061 y 489.692 468.023 489.804 468.006 489.789 468.049 c 489.767 468.112 489.692 468.15 489.638 468.188 c f 489.596 467.78 m 489.564 467.78 489.532 467.767 489.499 467.793 c 489.434 467.844 489.327 467.921 489.252 467.934 c f 489.338 467.589 m 489.241 467.589 489.123 467.564 489.048 467.602 c 489.015 467.627 488.973 467.678 488.951 467.742 c 489.091 467.716 489.177 467.627 489.316 467.627 c f 488.672 467.5 m 488.693 467.5 488.715 467.513 488.736 467.5 c 488.811 467.449 488.898 467.436 488.951 467.36 c 488.973 467.322 488.973 467.271 488.973 467.233 c 488.951 467.233 488.93 467.22 488.919 467.233 c 488.865 467.335 488.768 467.36 488.715 467.449 c f 488.865 467.029 m 488.865 467.016 488.865 466.991 488.865 466.978 c 488.736 466.94 488.651 467.055 488.554 467.143 c 488.478 467.207 488.554 467.258 488.618 467.207 c 488.651 467.182 488.704 467.143 488.747 467.105 c 488.78 467.067 488.833 467.093 488.876 467.055 c 488.865 467.042 488.865 467.029 v f 488.457 466.927 m 488.404 466.927 488.393 466.991 488.35 467.016 c f 488.221 466.914 m 488.221 466.889 488.221 466.876 488.221 466.851 c 488.199 466.851 l 488.199 466.826 488.199 466.787 488.199 466.762 c f 492.539 469.398 m 492.474 469.41 492.421 469.385 492.367 469.36 c 492.356 469.36 492.335 469.334 492.313 469.321 c 492.249 469.296 492.185 469.271 492.12 469.245 c 491.916 469.181 491.7 469.194 491.508 469.079 c 491.432 469.041 491.346 469.003 491.271 468.978 c 491.067 468.927 490.885 468.927 490.681 468.888 c 490.648 468.875 490.616 468.837 490.573 468.837 c 490.788 468.85 491.003 468.812 491.228 468.85 c 491.346 468.875 491.464 468.863 491.582 468.901 c 491.615 468.914 491.626 468.952 491.658 468.965 c 491.776 469.003 491.883 468.952 491.991 468.991 c 492.034 469.003 492.087 469.003 492.131 469.029 c 492.28 469.079 492.378 469.219 492.496 469.346 c 492.507 469.36 492.486 469.385 492.507 469.398 c f 492.292 468.952 m 492.249 468.901 492.216 468.837 492.152 468.812 c 492.045 468.787 491.948 468.711 491.84 468.685 c 491.712 468.647 491.594 468.622 491.464 468.608 c 491.304 468.583 491.153 468.583 490.992 468.532 c 490.982 468.532 490.948 468.523 490.938 468.52 c 490.691 468.405 490.433 468.456 490.187 468.456 c 490.176 468.532 490.207 468.634 490.284 468.646 c 490.401 468.672 490.509 468.608 490.627 468.596 c 490.777 468.57 490.917 468.57 491.067 468.596 c 491.121 468.608 491.165 468.622 491.207 468.646 c 491.346 468.71 491.486 468.647 491.626 468.71 c 491.68 468.735 491.723 468.749 491.776 468.774 c 491.927 468.812 492.077 468.837 492.216 468.901 c f 491.776 468.329 m 491.54 468.316 491.293 468.379 491.057 468.303 c 491.013 468.29 490.982 468.226 490.928 468.214 c 490.841 468.201 490.756 468.226 490.67 468.239 c 490.487 468.278 490.305 468.226 490.122 468.264 c 490.444 468.01 490.863 468.099 491.228 468.125 c 491.315 468.125 491.379 468.201 491.454 468.214 c 491.518 468.214 491.594 468.214 491.658 468.239 c 491.691 468.253 491.712 468.278 491.744 468.29 c f 491.153 467.743 m 491.165 467.755 491.142 467.768 491.142 467.78 c 490.949 467.768 490.756 467.832 490.562 467.87 c 490.348 467.908 490.133 467.818 489.918 467.908 c 489.95 467.895 489.984 467.881 490.014 467.87 c 490.39 467.742 490.724 467.768 491.088 467.755 c f 490.735 467.386 m 490.617 467.361 490.466 467.386 490.348 467.386 c 490.197 467.411 490.039 467.375 489.885 467.411 c 489.779 467.437 489.79 467.525 489.66 467.665 c 489.821 467.653 489.896 467.64 490.09 467.653 c 490.212 467.662 490.294 467.576 490.413 467.539 c 490.509 467.513 490.509 467.564 490.583 467.501 c f 490.326 467.08 m 490.155 467.067 489.993 467.08 489.821 467.119 c 489.811 467.131 489.79 467.144 489.779 467.157 c 489.714 467.182 489.638 467.157 489.574 467.207 c 489.53 467.243 489.499 467.283 489.445 467.309 c 489.435 467.322 489.413 467.449 489.424 467.449 c 489.467 467.462 489.532 467.386 489.574 467.36 c 489.607 467.36 489.617 467.322 489.649 467.309 c 489.79 467.258 489.8 467.335 489.929 467.246 c 490.004 467.195 490.251 467.207 490.316 467.119 c f 489.854 466.8 m 489.736 466.788 489.628 466.839 489.52 466.877 c 489.424 466.915 489.316 466.965 489.231 467.055 c 489.413 467.105 489.574 466.953 489.757 466.902 c 489.779 466.902 489.832 466.864 489.821 466.813 c f 489.596 466.647 m 489.574 466.571 489.478 466.584 489.435 466.609 c 489.349 466.673 489.22 466.698 489.198 466.826 c 489.241 466.826 489.273 466.839 489.316 466.813 c 489.349 466.788 489.37 466.762 489.391 466.724 c 489.435 466.66 489.52 466.711 489.564 466.635 c f 489.209 466.444 m 489.123 466.444 489.037 466.444 488.951 466.444 c 488.962 466.546 488.93 466.647 488.865 466.724 c 488.865 466.736 488.865 466.762 488.865 466.775 c 488.919 466.8 488.962 466.736 489.004 466.698 c 489.037 466.66 489.037 466.597 489.027 466.546 c 489.08 466.546 489.134 466.52 489.167 466.469 c f 488.768 466.38 m 488.672 466.406 488.618 466.508 488.532 466.545 c f 488.522 466.393 m 488.457 466.393 488.425 466.494 488.371 466.545 c f 488.275 466.38 m 488.197 466.38 488.113 466.342 488.038 466.38 c 488.038 466.418 l 488.092 466.443 488.113 466.545 488.178 466.52 c 488.188 466.52 488.199 466.456 488.221 466.431 c 488.232 466.431 488.242 466.431 488.253 466.431 c 488.275 466.418 488.286 466.38 488.275 466.38 c f 486.266 468.258 m 486.362 468.226 486.466 468.209 486.575 468.209 c 487.103 468.209 487.531 468.62 487.531 469.126 c 487.531 469.634 487.103 470.045 486.575 470.045 c 486.046 470.045 485.617 469.634 485.617 469.126 c 485.617 468.724 485.889 468.381 486.266 468.258 c f 486.266 468.258 m 486.362 468.226 486.466 468.209 486.575 468.209 c 487.103 468.209 487.531 468.62 487.531 469.126 c 487.531 469.634 487.103 470.045 486.575 470.045 c 486.046 470.045 485.617 469.634 485.617 469.126 c 485.617 468.724 485.889 468.381 486.266 468.258 c S 0.263 0.263 0.267 rg 486.625 467.727 m 486.708 467.727 l 486.728 467.703 486.767 467.711 486.8 467.744 c 486.832 467.778 486.864 467.82 486.87 467.842 c 486.942 467.918 487.059 467.885 487.193 467.791 c 487.232 467.74 487.446 467.569 487.711 467.452 c 487.749 467.406 487.583 467.453 487.551 467.465 c 487.603 467.432 487.546 467.404 487.429 467.459 c 487.461 467.405 487.393 467.419 487.313 467.461 c 487.358 467.406 487.281 467.415 487.216 467.457 c 487.244 467.406 487.172 467.408 487.117 467.46 c 487.145 467.412 487.078 467.412 487.029 467.459 c 487.058 467.407 486.964 467.422 486.931 467.461 c 486.957 467.422 486.843 467.443 486.833 467.485 c 486.817 467.429 486.722 467.419 486.699 467.461 c 486.63 467.461 l 486.574 467.405 486.486 467.437 486.476 467.557 c 486.389 467.419 486.264 467.392 486.304 467.466 c 486.234 467.402 486.197 467.423 486.207 467.461 c 486.105 467.374 486.1 467.448 486.111 467.462 c 486.044 467.409 485.986 467.42 486.005 467.455 c 485.943 467.422 485.867 467.416 485.9 467.463 c 485.827 467.42 485.724 467.422 485.768 467.466 c 485.665 467.423 485.553 467.433 485.648 467.473 c 485.94 467.592 486.033 467.706 486.14 467.792 c 486.31 467.926 486.441 467.895 486.471 467.823 c 486.498 467.756 486.589 467.688 486.622 467.722 c 486.625 467.727 l f 1 1 1 RG 0 J 0 j 0.213 w 486.625 467.727 m 486.708 467.727 l 486.728 467.703 486.767 467.711 486.8 467.744 c 486.832 467.778 486.864 467.82 486.87 467.842 c 486.942 467.918 487.059 467.885 487.193 467.791 c 487.232 467.74 487.446 467.569 487.711 467.452 c 487.749 467.406 487.583 467.453 487.551 467.465 c 487.603 467.432 487.546 467.404 487.429 467.459 c 487.461 467.405 487.393 467.419 487.313 467.461 c 487.358 467.406 487.281 467.415 487.216 467.457 c 487.244 467.406 487.172 467.408 487.117 467.46 c 487.145 467.412 487.078 467.412 487.029 467.459 c 487.058 467.407 486.964 467.422 486.931 467.461 c 486.957 467.422 486.843 467.443 486.833 467.485 c 486.817 467.429 486.722 467.419 486.699 467.461 c 486.63 467.461 l 486.574 467.405 486.486 467.437 486.476 467.557 c 486.389 467.419 486.264 467.392 486.304 467.466 c 486.234 467.402 486.197 467.423 486.207 467.461 c 486.105 467.374 486.1 467.448 486.111 467.462 c 486.044 467.409 485.986 467.42 486.005 467.455 c 485.943 467.422 485.867 467.416 485.9 467.463 c 485.827 467.42 485.724 467.422 485.768 467.466 c 485.665 467.423 485.553 467.433 485.648 467.473 c 485.94 467.592 486.033 467.706 486.14 467.792 c 486.31 467.926 486.441 467.895 486.471 467.823 c 486.498 467.756 486.589 467.688 486.622 467.722 c 486.625 467.727 l s 486.625 465.965 m 486.625 465.946 486.633 465.932 486.66 465.932 c 486.686 465.932 486.695 465.949 486.695 465.966 c 486.709 467.779 l 486.621 467.779 l 486.625 465.965 l f 486.625 465.965 m 486.625 465.946 486.633 465.932 486.66 465.932 c 486.686 465.932 486.695 465.949 486.695 465.966 c 486.709 467.779 l 486.621 467.779 l 486.625 465.965 l s 0.306 0.306 0.314 rg 486.66 467.744 m 486.66 467.755 486.696 467.758 486.696 467.746 c 486.683 465.997 l 486.683 465.985 486.677 465.958 486.668 465.958 c 486.661 465.958 486.66 465.983 486.66 465.997 c 486.66 467.744 l f 486.66 467.744 m 486.66 467.755 486.696 467.758 486.696 467.746 c 486.683 465.997 l 486.683 465.985 486.677 465.958 486.668 465.958 c 486.661 465.958 486.66 465.983 486.66 465.997 c 486.66 467.744 l s 0.263 0.263 0.267 rg 486.864 467.62 m 486.842 467.636 486.814 467.63 y 486.849 467.616 486.861 467.602 486.844 467.522 c f 486.864 467.62 m 486.842 467.636 486.814 467.63 y 486.849 467.616 486.861 467.602 486.844 467.522 c S 487.347 467.659 m 487.361 467.648 487.279 467.642 y 487.295 467.628 487.198 467.63 y 487.213 467.613 487.137 467.607 y 487.147 467.593 487.067 467.584 y 487.076 467.571 487.01 467.571 y 487.017 467.557 486.944 467.563 y 486.949 467.546 486.852 467.568 y f 487.347 467.659 m 487.361 467.648 487.279 467.642 y 487.295 467.628 487.198 467.63 y 487.213 467.613 487.137 467.607 y 487.147 467.593 487.067 467.584 y 487.076 467.571 487.01 467.571 y 487.017 467.557 486.944 467.563 y 486.949 467.546 486.852 467.568 y S 487.233 467.754 m 487.233 467.726 487.144 467.75 y 487.142 467.725 487.059 467.741 y 487.064 467.718 486.98 467.722 y 486.987 467.7 486.932 467.706 y 486.949 467.673 486.895 467.658 y 486.907 467.624 486.843 467.629 y f 487.233 467.754 m 487.233 467.726 487.144 467.75 y 487.142 467.725 487.059 467.741 y 487.064 467.718 486.98 467.722 y 486.987 467.7 486.932 467.706 y 486.949 467.673 486.895 467.658 y 486.907 467.624 486.843 467.629 y S 486.467 467.621 m 486.489 467.636 486.516 467.631 y 486.482 467.616 486.471 467.603 486.486 467.523 c f 486.467 467.621 m 486.489 467.636 486.516 467.631 y 486.482 467.616 486.471 467.603 486.486 467.523 c S 485.984 467.662 m 485.97 467.651 486.053 467.644 y 486.035 467.63 486.134 467.633 y 486.118 467.614 486.194 467.609 y 486.184 467.595 486.264 467.586 y 486.255 467.573 486.32 467.572 y 486.314 467.558 486.386 467.564 y 486.382 467.548 486.479 467.569 y f 485.984 467.662 m 485.97 467.651 486.053 467.644 y 486.035 467.63 486.134 467.633 y 486.118 467.614 486.194 467.609 y 486.184 467.595 486.264 467.586 y 486.255 467.573 486.32 467.572 y 486.314 467.558 486.386 467.564 y 486.382 467.548 486.479 467.569 y S 486.099 467.757 m 486.099 467.728 486.188 467.752 y 486.19 467.727 486.272 467.742 y 486.267 467.72 486.351 467.722 y 486.345 467.701 486.399 467.707 y 486.382 467.674 486.436 467.659 y 486.423 467.625 486.488 467.63 y f 486.099 467.757 m 486.099 467.728 486.188 467.752 y 486.19 467.727 486.272 467.742 y 486.267 467.72 486.351 467.722 y 486.345 467.701 486.399 467.707 y 486.382 467.674 486.436 467.659 y 486.423 467.625 486.488 467.63 y S 486.665 467.77 m 486.604 467.771 486.556 467.809 486.556 467.857 c 486.556 467.904 486.604 467.942 486.665 467.942 c 486.725 467.942 486.774 467.904 486.773 467.856 c 486.773 467.808 486.725 467.77 486.665 467.77 c f 486.665 467.77 m 486.604 467.771 486.556 467.809 486.556 467.857 c 486.556 467.904 486.604 467.942 486.665 467.942 c 486.725 467.942 486.774 467.904 486.773 467.856 c 486.773 467.808 486.725 467.77 486.665 467.77 c s 486.655 467.898 m 486.669 467.901 486.66 467.916 486.646 467.915 c 486.608 467.914 486.585 467.883 486.585 467.855 c 486.585 467.841 486.589 467.823 486.598 467.812 c 486.604 467.806 486.617 467.793 486.609 467.796 c 486.583 467.806 486.57 467.832 486.57 467.857 c 486.57 467.898 486.613 467.932 486.666 467.932 c 486.719 467.932 486.761 467.898 486.76 467.857 c 486.76 467.818 486.722 467.784 486.669 467.78 c 486.661 467.78 486.648 467.78 486.644 467.786 c 486.643 467.786 486.661 467.785 486.669 467.786 c 486.71 467.792 486.737 467.818 486.734 467.849 c 486.734 467.857 486.718 467.872 486.72 467.859 c 486.722 467.838 486.696 467.822 486.669 467.821 c 486.648 467.821 486.62 467.839 486.62 467.86 c 486.621 467.881 486.628 467.893 486.655 467.898 c f 486.655 467.898 m 486.669 467.901 486.66 467.916 486.646 467.915 c 486.608 467.914 486.585 467.883 486.585 467.855 c 486.585 467.841 486.589 467.823 486.598 467.812 c 486.604 467.806 486.617 467.793 486.609 467.796 c 486.583 467.806 486.57 467.832 486.57 467.857 c 486.57 467.898 486.613 467.932 486.666 467.932 c 486.719 467.932 486.761 467.898 486.76 467.857 c 486.76 467.818 486.722 467.784 486.669 467.78 c 486.661 467.78 486.648 467.78 486.644 467.786 c 486.643 467.786 486.661 467.785 486.669 467.786 c 486.71 467.792 486.737 467.818 486.734 467.849 c 486.734 467.857 486.718 467.872 486.72 467.859 c 486.722 467.838 486.696 467.822 486.669 467.821 c 486.648 467.821 486.62 467.839 486.62 467.86 c 486.621 467.881 486.628 467.893 486.655 467.898 c s 486.397 467.264 m 486.382 467.057 487.013 467.265 486.997 467.002 c 486.981 466.752 486.506 466.925 486.521 466.788 c 486.529 466.717 486.939 466.765 486.904 466.601 c 486.873 466.447 486.536 466.524 486.549 466.456 c 486.564 466.381 486.892 466.417 486.83 466.281 c 486.78 466.17 486.525 466.246 486.522 466.126 c 486.428 466.234 486.731 466.225 486.749 466.297 c 486.765 466.359 486.478 466.331 486.45 466.449 c 486.414 466.599 486.769 466.531 486.785 466.615 c 486.798 466.687 486.424 466.626 486.385 466.751 c 486.305 467.011 486.799 466.864 486.83 467.003 c 486.859 467.129 486.329 466.979 486.281 467.225 c 486.263 467.319 486.34 467.346 486.387 467.364 c 486.406 467.372 486.402 467.39 486.445 467.397 c 486.483 467.404 486.514 467.393 486.591 467.317 c 486.601 467.306 486.572 467.288 486.549 467.284 c 486.526 467.28 486.467 467.272 486.442 467.291 c 486.42 467.307 486.399 467.287 486.397 467.264 c f 486.397 467.264 m 486.382 467.057 487.013 467.265 486.997 467.002 c 486.981 466.752 486.506 466.925 486.521 466.788 c 486.529 466.717 486.939 466.765 486.904 466.601 c 486.873 466.447 486.536 466.524 486.549 466.456 c 486.564 466.381 486.892 466.417 486.83 466.281 c 486.78 466.17 486.525 466.246 486.522 466.126 c 486.428 466.234 486.731 466.225 486.749 466.297 c 486.765 466.359 486.478 466.331 486.45 466.449 c 486.414 466.599 486.769 466.531 486.785 466.615 c 486.798 466.687 486.424 466.626 486.385 466.751 c 486.305 467.011 486.799 466.864 486.83 467.003 c 486.859 467.129 486.329 466.979 486.281 467.225 c 486.263 467.319 486.34 467.346 486.387 467.364 c 486.406 467.372 486.402 467.39 486.445 467.397 c 486.483 467.404 486.514 467.393 486.591 467.317 c 486.601 467.306 486.572 467.288 486.549 467.284 c 486.526 467.28 486.467 467.272 486.442 467.291 c 486.42 467.307 486.399 467.287 486.397 467.264 c s 486.93 467.263 m 486.945 467.056 486.314 467.266 486.329 467.003 c 486.343 466.753 486.819 466.924 486.803 466.787 c 486.795 466.717 486.385 466.766 486.419 466.601 c 486.45 466.448 486.786 466.523 486.773 466.455 c 486.759 466.38 486.43 466.418 486.491 466.281 c 486.54 466.171 486.797 466.246 486.799 466.125 c 486.893 466.233 486.59 466.225 486.572 466.297 c 486.556 466.359 486.843 466.33 486.873 466.448 c 486.909 466.598 486.554 466.531 486.54 466.616 c 486.526 466.687 486.9 466.626 486.939 466.75 c 487.021 467.011 486.527 466.864 486.496 467.003 c 486.468 467.13 486.997 466.978 487.045 467.224 c 487.065 467.318 486.988 467.345 486.941 467.363 c 486.922 467.37 486.927 467.389 486.883 467.396 c 486.846 467.402 486.814 467.392 486.737 467.317 c 486.726 467.306 486.755 467.288 486.779 467.283 c 486.802 467.28 486.861 467.271 486.886 467.29 c 486.908 467.306 486.928 467.287 486.93 467.263 c f 486.93 467.263 m 486.945 467.056 486.314 467.266 486.329 467.003 c 486.343 466.753 486.819 466.924 486.803 466.787 c 486.795 466.717 486.385 466.766 486.419 466.601 c 486.45 466.448 486.786 466.523 486.773 466.455 c 486.759 466.38 486.43 466.418 486.491 466.281 c 486.54 466.171 486.797 466.246 486.799 466.125 c 486.893 466.233 486.59 466.225 486.572 466.297 c 486.556 466.359 486.843 466.33 486.873 466.448 c 486.909 466.598 486.554 466.531 486.54 466.616 c 486.526 466.687 486.9 466.626 486.939 466.75 c 487.021 467.011 486.527 466.864 486.496 467.003 c 486.468 467.13 486.997 466.978 487.045 467.224 c 487.065 467.318 486.988 467.345 486.941 467.363 c 486.922 467.37 486.927 467.389 486.883 467.396 c 486.846 467.402 486.814 467.392 486.737 467.317 c 486.726 467.306 486.755 467.288 486.779 467.283 c 486.802 467.28 486.861 467.271 486.886 467.29 c 486.908 467.306 486.928 467.287 486.93 467.263 c s 486.829 466.838 m 486.853 466.843 486.915 466.826 486.908 466.785 c 486.881 466.649 486.52 466.714 486.515 466.626 c 486.513 466.574 486.604 466.569 486.563 466.562 c 486.513 466.552 486.441 466.585 486.443 466.625 c 486.448 466.745 486.802 466.712 486.826 466.781 c 486.839 466.819 486.804 466.832 486.829 466.838 c f 486.829 466.838 m 486.853 466.843 486.915 466.826 486.908 466.785 c 486.881 466.649 486.52 466.714 486.515 466.626 c 486.513 466.574 486.604 466.569 486.563 466.562 c 486.513 466.552 486.441 466.585 486.443 466.625 c 486.448 466.745 486.802 466.712 486.826 466.781 c 486.839 466.819 486.804 466.832 486.829 466.838 c s 486.858 467.047 m 486.885 467.052 486.949 467.033 486.942 466.984 c 486.915 466.808 486.488 466.915 486.476 466.806 c 486.471 466.743 486.58 466.738 486.533 466.729 c 486.474 466.718 486.398 466.76 486.403 466.806 c 486.42 466.966 486.829 466.878 486.854 466.981 c 486.864 467.024 486.828 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Direct correspondence regarding this article)]TJ T* -0.0046 Tc 0.1167 Tw (to geverly@jhsph.edu.)Tj /F1 1 Tf 14 0 0 14 217.26 656.34 Tm 0.009 Tc 0.1375 Tw (Resistance and Resilience:)Tj -5.8393 -1.1421 TD -0.0058 Tc 0.138 Tw [( )97.3(The Final Fr)15.6(ontier in )95.2(T)80.2(raumatic Stress Manag)-7.7(e)2.9(ment)]TJ /TT2 1 Tf 10 0 0 10 84 259.14 Tm -0.0123 Tc -0.06 Tw (The term )Tj /TT5 1 Tf 3.666 0 TD -0.0139 Tc 0 Tw [(str)31.1(ess)]TJ /TT2 1 Tf 2.175 0 TD -0.011 Tc -0.0627 Tw [( was first coined in the 1930s by Dr)55(. Hans)]TJ -7.641 -1.398 TD -0.0029 Tc 0.115 Tw (Selye \(1956\), considered by some to be the father of the)Tj 0 -1.401 TD 0.004 Tc 0.125 Tw (stress concept. Selye defined stress as the sum total of)Tj T* -0.003 Tc 0.0101 Tw [(wear and tear on the body)63(. )51.1(According to Selye, stress has)]TJ 0 -1.398 TD -0.0032 Tc 0.0106 Tw [(two primary variants: eustress and distress. Eustress is de-)]TJ 12 0 0 12 138.66 593.64 Tm -0.0138 Tc -0.0605 Tw [(Geor)8.7(ge S. Everly)56.2(, Jr)48.7(.)-14531.3(V)]TJ 22.965 0 TD -0.0275 Tc -0.07 Tw [(ictor W)83.8(elzant)]TJ -11.8125 -4.665 TD -0.0068 Tc -0.0604 Tw (Jodi M. Jacobson)Tj 10 0 0 10 246.66 525 Tm -0.003 Tc -0.0616 Tw (Univerity of Maryland, Baltimore)Tj 7.434 -26.634 TD -0.0032 Tc -0.0225 Tw (fined as positively motivating stress, while distress is exces-)Tj 0 -1.401 TD 0.001 Tc 0.125 Tw (sive stress that may lead to dysfunction and even mental)Tj T* -0.0029 Tc 0.0075 Tw [(and/or physical illness. Selye noted that stress could not be)]TJ 0 -1.398 TD 0.006 Tc 0.1251 Tw [(avoided altogether)39(, and the absence of stress, he said, is)]TJ 0 -1.401 TD -0.0033 Tc 0.0625 Tw [(death. Therefore, the goal in managing stress is to experi-)]TJ T* 0.0042 Tc 0.125 Tw (ence more eustress than distress, and when distress does)Tj 0 -1.398 TD -0.0034 Tc -0.0486 Tw [(occur)35.6(, to resume adaptive functioning as quickly as possible.)]TJ 0 -1.401 TD -0.0035 Tc 0.1178 Tw (Thus, there emerge three potential intervention epochs, in)Tj T* -0.0032 Tc -0.0119 Tw (the trajectory of the human stress response: protective resis-)Tj 0 -1.398 TD 0.0616 Tw [(tance or immunity)59.9(, resilience in the wake of acute psycho-)]TJ 0 -1.401 TD -0.0061 Tc -0.0625 Tw (logical or behavioral perturbations and the ability to rebound,)Tj T* -0.0032 Tc 0.0325 Tw (and therapeutic recovery and rehabilitation.)Tj -23.961 47.535 TD 0.001 Tc -0.0243 Tw [(Johns Hopkins Bloomberg School of Public Health)]TJ 0.975 -1.2 TD 0.0013 Tc 0.019 Tw (Johns Hopkins University School of Medicine)Tj 3.711 -1.2 TD 0.0021 Tc -0.0534 Tw (Loyola College in Maryland)Tj 21.414 2.7 TD 0.0013 Tc 0.0087 Tw (International Critical Incident Stress Foundation)Tj ET endstream endobj 134 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 137 0 obj << /Length 9324 >> 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 /TT3 1 Tf 8 0 0 8 54.99 41.64 Tm 0 0 0 1 k /GS2 gs -0.0057 Tc 0.1094 Tw [(262 Everly, Welzant & Jacobson)]TJ /F1 1 Tf 15.4313 0 TD -0.0055 Tc [(  )]TJ /TT3 1 Tf 1.1138 0 TD -0.0059 Tc (Resistance and Resilience)Tj /TT2 1 Tf 10 0 0 10 72 722.64 Tm -0.0033 Tc 0.0635 Tw (Given the recent advances in the generally recognized)Tj -1.8 -1.398 TD -0.0012 Tc 0.125 Tw (therapeutic standard of care in the treatment of excessive)Tj 0 -1.401 TD -0.0031 Tc 0.0377 Tw [(and especially traumatic stress, this paper will focus on the)]TJ T* -0.0033 Tc 0.0536 Tw (emergent constructs of protective resistance and the ability)Tj 0 -1.398 TD -0.0031 Tc -0.04 Tw (to rebound resiliently in the wake of adversity and otherwise)Tj 0 -1.401 TD -0.0029 Tc -0.0585 Tw [(potentially disruptive life events. It may be argued that these)]TJ T* -0.0031 Tc 0.125 Tw (constructs or domains represent the final frontier in the)Tj 0 -1.398 TD -0.0035 Tc 0.045 Tw (attendance to traumatic and other forms of debilitating dis-)Tj 0 -1.401 TD 0.0184 Tc 0 Tw (tress.)Tj /F1 1 Tf 11 0 0 11 54 578.01 Tm -0.005 Tc 0.0568 Tw (Defining Human Resilience)Tj /TT2 1 Tf 10 0 0 10 72 554.64 Tm -0.0027 Tc -0.0278 Tw (Resilience may be thought of as the ability to positively)Tj -1.8 -1.398 TD -0.0034 Tc 0.0775 Tw [(adapt to and/or rebound from significant adversity and the)]TJ 0 -1.401 TD -0.0031 Tc 0.115 Tw [(distress it often creates. Psychologists have studied resil-)]TJ T* -0.003 Tc 0.0906 Tw [(ience for years; however)39(, their primary research focus has)]TJ 0 -1.398 TD -0.0008 Tc 0.125 Tw (been on recovery from traumatic events, which has often)Tj 0 -1.401 TD -0.0036 Tc 0.0517 Tw [(been combined or confused with resilience. There is how-)]TJ T* -0.0034 Tc 0.0079 Tw [(ever)35.6(, an emer)17.6(ging field of research that focuses on studying)]TJ 0 -1.398 TD -0.003 Tc 0.0628 Tw (resiliency from the true perspective of primary prevention,)Tj 0 -1.401 TD -0.0035 Tc 0.0587 Tw (with the goal of determining characteristics that support or)Tj T* -0.0034 Tc 0.0978 Tw (improve resilience prior to exposure to a stressful or trau-)Tj 0 -1.398 TD -0.0031 Tc -0.0075 Tw [(matic event. Given the relative paucity of research on resil-)]TJ 0 -1.401 TD 0.0067 Tc 0.125 Tw (ience and primary prevention, there has yet to emerge a)Tj T* -0.0033 Tc -0.032 Tw (complete consensus as to the nature of resiliency and how to)Tj 0 -1.398 TD -0.003 Tc -0.04 Tw (create it.)Tj 1.8 -2.001 TD -0.0045 Tc -0.0625 Tw [(Reivich and Shatte \(2002\) define resilience as the ability)]TJ -1.8 -1.401 TD -0.0031 Tc 0.0173 Tw [(to persevere and adapt when things go awry \(p. 1\). They)]TJ 0 -1.398 TD -0.0034 Tc 0.055 Tw (argue that resilience resides in the domain of cognitive ap-)Tj 0 -1.401 TD -0.0032 Tc 0.0317 Tw [(praisal. Bonnano \(2004\) defines resilience as the ability of)]TJ T* -0.0027 Tc -0.0478 Tw (adults to maintain relatively stable and healthy levels of psy-)Tj 0 -1.398 TD -0.0034 Tc 0.1243 Tw (chological and physical functioning after having been ex-)Tj 0 -1.401 TD 0.0818 Tw [(posed to potentially disruptive or traumatic events. While)]TJ T* -0.0098 Tc -0.0625 Tw (the majority of adults will face a traumatic experience at some)Tj 0 -1.398 TD -0.0035 Tc 0.0985 Tw (point in their lives, Bonnano argues that most do not suc-)Tj 0 -1.401 TD -0.0037 Tc -0.0095 Tw [(cumb to a traumatic stress disorder)50.3(.)-5.7( )-5.7( )17.3(This suggests the exist-)]TJ T* 0.0414 Tc 0.125 Tw (ence of a functional resiliency that may not be well)Tj 0 -1.398 TD -0.0029 Tc (understood. Bonnano asserts, theorists working in this)Tj 0 -1.401 TD -0.0037 Tc -0.0175 Tw (area have often underestimated or misunderstood resilience,)Tj T* -0.0034 Tc -0.0305 Tw [(viewing it either as a pathological state or as something seen)]TJ 0 -1.398 TD -0.0027 Tc 0.0525 Tw (only in rare and exceptionally healthy individuals \(p. 20\).)Tj 0 -1.401 TD -0.0035 Tc 0.0799 Tw [(Three key points support and further define Bonnano)50.5(s ar)17.5(-)]TJ T* -0.0087 Tc 0 Tw (gument:)Tj /TT5 1 Tf 1.2 -1.998 TD -0.0034 Tc -0.0126 Tw [(1.)-1053.4(Resilience is differ)32.6(ent than r)32.6(ecovery)]TJ /TT2 1 Tf 15.99 0 TD -0.0033 Tc -0.0132 Tw [(. )18.2(The former re-)]TJ -14.19 -1.401 TD -0.0099 Tc -0.0625 Tw (fers to the ability to maintain equilibrium, whereas the)Tj T* -0.0031 Tc -0.0225 Tw (latter refers to a return to functionality subsequent to)Tj 25.5 64.2 TD -0.0038 Tc -0.0267 Tw (the development of threshold or sub-threshold mani-)Tj 0 -1.398 TD -0.0033 Tc -0.0585 Tw [(festations of psychopathology)59.7(. Bonnano notes, how-)]TJ 0 -1.401 TD 0.0061 Tc 0.1251 Tw [(ever)36.1(, that even resilient individuals may manifest)]TJ T* -0.0031 Tc 0.078 Tw (transient perturbations in psychological or physical)Tj 0 -1.398 TD 0.0013 Tc 0 Tw (functioning.)Tj /TT5 1 Tf -1.8 -2.001 TD -0.0038 Tc 0.0096 Tw [(2.)-1053.8(Resilience is common)]TJ /TT2 1 Tf 10.404 0 TD -0.0031 Tc 0.0121 Tw [(. Bonnano cites a series of in-)]TJ -8.604 -1.401 TD -0.0035 Tc -0.0012 Tw (vestigations that argue psychopathological reactions)Tj 0 -1.398 TD -0.0033 Tc 0.038 Tw (in the wake of loss or exposure to a life threatening)Tj 0 -1.401 TD -0.0027 Tc 0.1245 Tw (event are rare, with typically less than 30% of af-)Tj T* -0.0038 Tc 0.106 Tw (fected populations showing evidence of significant)Tj 0 -1.398 TD -0.0037 Tc -0.0583 Tw [(maladjustment or posttraumatic morbidity)59.3(.)]TJ /TT5 1 Tf -1.8 -2.001 TD -0.0036 Tc -0.0237 Tw [(3.)-1053.6(There are many different pathways to, or constituent)]TJ 1.8 -1.401 TD 0.0056 Tc 0.125 Tw (factors within, resilience)Tj /TT2 1 Tf 10.314 0 TD 0.0059 Tc [(. Bonnano suggests that)]TJ -10.314 -1.398 TD -0.0036 Tc 0.028 Tw (factors such as hardiness, self-enhancement, repres-)Tj 0 -1.401 TD 0.0039 Tc 0.125 Tw (sive coping \(emotional dissociation\), and positive)Tj T* -0.0033 Tc -0.04 Tw [(emotions may undergird effective resilience.)]TJ -1.2 -1.998 TD -0.0037 Tc 0.0068 Tw [(Haglund, Cooper)38.3(, Southwick, and Charney \(2007\) pro-)]TJ -1.8 -1.401 TD -0.0033 Tc 0.0505 Tw (vide one of the most succinct analyses of the various com-)Tj T* -0.0027 Tc -0.0144 Tw [(ponents of resilience. They identify six primary factors that)]TJ 0 -1.398 TD -0.0055 Tc -0.0625 Tw (may protect against and aid in recovery from extreme or trau-)Tj 0 -1.401 TD -0.0035 Tc (matic stress: 1\) actively facing fears and trying to solve prob-)Tj T* -0.0123 Tc -0.0622 Tw (lems; 2\) regular physical exercise; 3\) optimism; 4\) following a)Tj 0 -1.398 TD -0.0116 Tc (moral compass; 5\) promoting social support, nurturing friend-)Tj 0 -1.401 TD -0.0037 Tc 0.0761 Tw (ships, and seeking role models; and 6\) being open minded)Tj T* -0.0033 Tc -0.024 Tw (and flexible in the way one thinks about problems, or avoid-)Tj 0 -1.398 TD -0.0037 Tc -0.0313 Tw (ing rigid and dogmatic thinking.)Tj 1.8 -2.001 TD 0.0029 Tw (One model contributing heuristic value to the construct)Tj -1.8 -1.401 TD -0.0036 Tc -0.0305 Tw (of resilience is the Johns Hopkins Tripartite Model of Resis-)Tj 0 -1.398 TD -0.0013 Tc 0.125 Tw (tance, Resilience, and Recovery \(henceforth, the Hopkins)Tj 0 -1.401 TD -0.0038 Tc 0.0375 Tw (Model\), which embraces the distinction between protective)Tj T* 0.0194 Tc 0.1249 Tw [(factors and rebound capability \(Kaminsky et al., 2007;)]TJ 0 -1.398 TD -0.0034 Tc 0.0205 Tw [(Nucifora et al., 2007\). The Hopkins model describes )]TJ /TT5 1 Tf 21.501 0 TD -0.0046 Tc 0 Tw (resis-)Tj -21.501 -1.401 TD -0.0051 Tc (tance)Tj /TT2 1 Tf 2.145 0 TD -0.0045 Tc 0.03 Tw [( as)]TJ /TT5 1 Tf 1.104 0 TD 0 Tc 0 Tw ( )Tj /TT2 1 Tf 0.285 0 TD -0.0032 Tc 0.035 Tw (the ability of an individual, a group, an organiza-)Tj -3.534 -1.401 TD -0.0053 Tc -0.0625 Tw (tion, or even an entire population to withstand manifestations)Tj 0 -1.398 TD -0.0017 Tc 0.125 Tw (of clinical distress, impairment, or dysfunction associated)Tj 0 -1.401 TD -0.0034 Tc 0.0507 Tw (with critical incidents, terrorism, and even mass disasters.)Tj T* -0.0035 Tc 0.0972 Tw (One could think of resistance as a form of psychological)Tj 0 -1.398 TD -0.0027 Tc 0.125 Tw (immunity to distress and dysfunction \(Nucifora et al., p.)Tj 0 -1.401 TD -0.0032 Tc 0.055 Tw (S34\). )Tj /TT5 1 Tf 2.73 0 TD -0.0042 Tc 0 Tw (Resilience)Tj /TT2 1 Tf 4.071 0 TD -0.0029 Tc 0.0561 Tw (, in this model, refers to the ability of an)Tj -6.801 -1.401 TD -0.0034 Tc -0.0161 Tw (individual, a group, an organization, or even an entire popu-)Tj 0 -1.398 TD -0.003 Tc 0.055 Tw (lation, to )Tj /TT5 1 Tf 3.885 0 TD -0.0036 Tc 0.0575 Tw (rapidly and effectively)Tj /TT2 1 Tf 8.976 0 TD 0 Tc 0 Tw ( )Tj /TT5 1 Tf 0.309 0 TD -0.0055 Tc (rebound)Tj /TT2 1 Tf 3.3 0 TD -0.0032 Tc 0.0575 Tw [( from psychologi-)]TJ -16.47 -1.401 TD -0.0036 Tc 0.0884 Tw (cal and/or behavioral perturbations associated with critical)Tj T* -0.0032 Tc 0.125 Tw [(incidents, terrorism, and even mass disasters \(Kaminsky)59.8(,)]TJ 0 -1.398 TD -0.0038 Tc -0.0613 Tw [(McCabe, Langlieb, & Everly)59.2(, 2007\). Finally)62.2(,)-6.2( )]TJ /TT5 1 Tf 17.841 0 TD -0.0061 Tc 0 Tw [(r)35.1(ecover)-9.1(y)]TJ /TT2 1 Tf 3.423 0 TD -0.0041 Tc -0.065 Tw [( refers)]TJ -21.264 -1.401 TD -0.0037 Tc -0.0071 Tw (to observed improvement following the application of treat-)Tj ET endstream endobj 138 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 140 0 obj << /Length 8167 >> 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. 4 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (263)Tj /TT2 1 Tf 10 0 0 10 66 722.64 Tm 0.0035 Tc 0.125 Tw (ment and rehabilitation subsequent to threshold and sub-)Tj 0 -1.398 TD -0.0001 Tc (threshold manifestations of psychological and/or physical)Tj 0 -1.401 TD -0.0013 Tc 0.1252 Tw [(morbidity)61.7(. )13.9(The Hopkins Model views the notion of self-)]TJ T* -0.0032 Tc 0.0771 Tw (efficacy and self-confidence as essential elements in resis-)Tj 0 -1.398 TD -0.0034 Tc 0.0211 Tw [(tance and resilience. These elements are supported in prior)]TJ 0 -1.401 TD -0.0035 Tc 0.1069 Tw (research as being central features of resilience \(Connor &)Tj T* -0.0613 Tw [(Davidson, 2003; Kobasa, 1979; Nucifora et al.; Rutter)35.4(, 1985;)]TJ 0 -1.398 TD -0.0066 Tc -0.0618 Tw [(W)91.2(agnild & )29.3(Y)100.6(oung, 1993\).)]TJ /F1 1 Tf 11 0 0 11 66 591.99 Tm -0.0046 Tc 0.0466 Tw (Learning From Resilient Children and)Tj 0 -1.0909 TD -0.0068 Tc 0 Tw (Families)Tj /TT2 1 Tf 10 0 0 10 84 556.65 Tm -0.0029 Tc -0.0187 Tw (The study of resilience was largely initiated via investi-)Tj -1.8 -1.401 TD 0.0097 Tc 0.125 Tw (gations of child development under challenging circum-)Tj 0 -1.398 TD -0.0033 Tc -0.0576 Tw [(stances. )17.9(W)94.5(erner)-39.3()53.7(s)-0.1( longitudinal study of children in Hawaii is)]TJ 0 -1.401 TD -0.0034 Tc -0.017 Tw (often considered a seminal work, helping to set the stage for)Tj T* -0.0037 Tc 0.0437 Tw [(resiliency research \(W)77.3(erner)35.3(, 1984; )17.4(W)94.1(erner & Smith, 1982\).)]TJ 0 -1.398 TD -0.0084 Tc -0.0625 Tw (After following 505 men and women from childhood through)Tj 0 -1.401 TD -0.0004 Tc 0.1252 Tw [(adulthood, )14.8(W)91.4(erner concluded that resilient children were:)]TJ T* -0.0037 Tc -0.0621 Tw [(proactive, optimistic, found meaning in life \(especially when)]TJ 0 -1.398 TD -0.0033 Tc 0.04 Tw (faced with adversity\), and acquired interpersonal support.)Tj 1.8 -2.001 TD -0.0082 Tc -0.0625 Tw (In a review of runaway children who showed remarkable)Tj -1.8 -1.401 TD -0.0035 Tc 0.0986 Tw (resilience, four factors emerged as protective according to)Tj 0 -1.398 TD -0.0045 Tc -0.0623 Tw [(W)54.3(illiam, Lindsey)61.5(, Kurtz, and Jarvis \(2001\). )16.7(These protective)]TJ 0 -1.401 TD -0.0042 Tc -0.0625 Tw (factors include determination and persistence, optimism, ori-)Tj T* -0.0032 Tc 0.07 Tw (entation to problem-solving, ability to find purpose in life,)Tj 0 -1.398 TD -0.0003 Tc 0.125 Tw [(and caring for oneself. )50.7(According to )17.7(The Northwest Re-)]TJ 0 -1.401 TD -0.0036 Tc 0.0283 Tw [(gional Educational Laboratory)59.4(,)-6.3( )]TJ /TT5 1 Tf 12.639 0 TD -0.0041 Tc 0.03 Tw (Fostering Resiliency)Tj /TT2 1 Tf 8.202 0 TD -0.0043 Tc [( [avail-)]TJ -20.841 -1.401 TD -0.0039 Tc 0.1049 Tw [(able online: http://www)62.1(.nwrel.or)14.1(g/pirc/hot9.html], children)]TJ 0 -1.398 TD 0.0069 Tc 0.125 Tw (who develop competence, despite adversity and difficult)Tj 0 -1.401 TD -0.0037 Tc 0.0344 Tw (conditions while growing up, appear to share the following)Tj T* -0.0073 Tc 0 Tw (qualities:)Tj 1.2 -1.998 TD -0.0032 Tc 0.0047 Tw [(1)71.8(.)-1128.2(A)59( sense of self-esteem and self-ef)14.8(ficacy)62.8(,)]TJ 0 -2.001 TD 0.004 Tc 0.125 Tw [(2)79(.)-1121(An action oriented approach to obstacles or chal-)]TJ 1.8 -1.401 TD 0.0076 Tc 0 Tw (lenges,)Tj -1.8 -1.998 TD -0.0031 Tc 0.0475 Tw [(3)71.9(.)-1128.1(The ability to see an obstacle as a problem that can)]TJ 1.8 -1.401 TD -0.0034 Tc -0.005 Tw (be engaged, changed, overcome, or at least endured,)Tj -1.8 -2.001 TD -0.0071 Tc -0.0621 Tw [(4)67.9(.)-1132.1(Reasonable persistence, with an ability to know when)]TJ 1.8 -1.398 TD -0.0044 Tc 0.1117 Tw (enough is enough, and)Tj -1.8 -2.001 TD -0.008 Tc -0.062 Tw [(5)67(.)-1133(Flexible problem-solving and stress management tac-)]TJ 1.8 -1.401 TD 0.0028 Tc 0 Tw (tics.)Tj -1.2 -1.998 TD -0.0029 Tc 0.0472 Tw (The study of resistance and resiliency is not limited to)Tj -1.8 -1.401 TD -0.0027 Tc 0.0311 Tw [(individuals; it also extends to systems. The family system,)]TJ T* -0.0034 Tc 0.0996 Tw [(an important system to consider)35.6(, can serve as an ef)14.6(fective)]TJ 25.5 64.2 TD -0.0031 Tc -0.0254 Tw [(proxy for the study of organizations of all kinds. McCubbin)]TJ 0 -1.398 TD -0.0053 Tc -0.0622 Tw [(and McCubbin \(1988\) argued that there are three things resil-)]TJ 0 -1.401 TD -0.0032 Tc -0.0495 Tw (ient families do that less resilient families fail to do:)Tj 1.2 -2.001 TD -0.0024 Tc 0.0029 Tw [(1)72.6(.)-1127.4(They believe in the family unit. They believe in the)]TJ 1.8 -1.398 TD -0.0029 Tc -0.0557 Tw [(importance of family cohesion. They believe in their)]TJ 0 -1.401 TD 0.0594 Tw [(ability to support and protect one another)36.1(, and they)]TJ T* 0.1179 Tw (are optimistic about their ability to achieve family)Tj 0 -1.398 TD 0.0078 Tc 0 Tw (goals.)Tj -1.8 -2.001 TD -0.0024 Tc 0.0229 Tw [(2)72.6(.)-1127.4(They celebrate key family events, such as birthdays)]TJ 1.8 -1.401 TD -0.0038 Tc 0.12 Tw (and anniversaries.)Tj -1.8 -1.998 TD -0.0032 Tc 0.0433 Tw [(3)71.8(.)-1128.2(They create and uphold rituals and routines.)]TJ 0.6 -2.001 TD -0.003 Tc 0.0011 Tw [(Finally)63(, the critical factors that appear to assist families)]TJ -1.8 -1.401 TD -0.0028 Tc -0.0111 Tw (to rebound from adversity include a sense of family identity)Tj 0 -1.398 TD -0.0019 Tc 0.125 Tw (and cohesion, good family communications, adherence to)Tj 0 -1.401 TD -0.0036 Tc -0.0621 Tw (family routines and traditions, optimism, and self-efficacy of)Tj T* -0.0026 Tc 0.0005 Tw (the family unit and the ability for the family to advocate for)Tj 0 -1.398 TD -0.0087 Tc -0.0625 Tw (itself \(McCubbin et al., 1997\).)Tj /F1 1 Tf 11 0 0 11 321 441.99 Tm -0.0048 Tc 0.0218 Tw [(The Psychology of Stress and Resilience)]TJ /TT2 1 Tf 10 0 0 10 339 418.65 Tm -0.0034 Tc 0.0883 Tw [(The previous discussions have offered varying defini-)]TJ -1.8 -1.401 TD -0.0025 Tc 0.125 Tw (tions of human resilience as well as provided a list of its)Tj 0 -1.398 TD -0.0034 Tc 0.1031 Tw [(functional constituents or undergirding factors. But if the)]TJ 0 -1.401 TD -0.0032 Tc 0.125 Tw [(goal is to develop interventions which foster resilience in)]TJ T* -0.0029 Tc 0.035 Tw (those who do not innately possess the trait, a deeper analy-)Tj 0 -1.398 TD -0.0032 Tc 0.03 Tw (sis is requisite.)Tj 1.8 -2.001 TD 0.1139 Tw [(W)94.6(e)0( return to Hans Selye to help us better understand)]TJ -1.8 -1.401 TD -0.0028 Tc 0.0873 Tw (the psychology of stress and resilience. Selye noted, It is)Tj 0 -1.398 TD -0.0029 Tc 0.0213 Tw (not what happens to you that matters, but how you take it.)Tj 0 -1.401 TD -0.0037 Tc 0.0175 Tw (The philosopher Epictetus once wrote that man is disturbed)Tj T* 0.0045 Tc 0.125 Tw (not by things, but by the views which he takes of them.)Tj 0 -1.398 TD -0.0037 Tc 0.0022 Tw (Moving from philosophy to empiricism, Reivich and Shatte)Tj 0 -1.401 TD 0 Tc 0.125 Tw (\(2002\) conclude, our research has demonstrated that the)Tj T* -0.0053 Tc -0.0624 Tw [(number-one roadblock to resilience is not genetics, not child-)]TJ 0 -1.398 TD -0.0032 Tc 0.0225 Tw [(hood experiences, not a lack of opportunity or wealth. The)]TJ 0 -1.401 TD -0.0034 Tc 0.0794 Tw (principle obstacle to tapping into our inner strength lies in)Tj T* -0.0031 Tc -0.055 Tw (our cognitive style \(p.11\).)Tj 1.8 -1.998 TD -0.0034 Tc -0.0583 Tw (Theory and controlled empirical investigations alike ap-)Tj -1.8 -1.401 TD -0.0033 Tc 0.023 Tw (pear to converge on the conclusion that the response to any)Tj T* -0.0029 Tc -0.0034 Tw (stressful event will be greatly influenced by the appraisal of)Tj 0 -1.398 TD -0.0031 Tc 0.0255 Tw (the situation, the ability to attach a constructive meaning to)Tj 0 -1.401 TD 0.0622 Tw (the experience, the ability to foresee an effective means of)Tj T* -0.0034 Tc -0.0225 Tw (coping with the challenges of a given situation, and the abil-)Tj 0 -1.398 TD 0.0267 Tc 0.125 Tw (ity to ultimately incorporate the experience into some)Tj ET endstream endobj 141 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 143 0 obj << /Length 9628 >> 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 /TT3 1 Tf 8 0 0 8 54.99 41.64 Tm 0 0 0 1 k /GS2 gs -0.0057 Tc 0.1094 Tw [(264 Everly, Welzant & Jacobson)]TJ /F1 1 Tf 15.4313 0 TD -0.0055 Tc [(  )]TJ /TT3 1 Tf 1.1138 0 TD -0.0059 Tc (Resistance and Resilience)Tj /TT2 1 Tf 10 0 0 10 54 722.64 Tm -0.0064 Tc -0.0624 Tw [(overarching belief system or schema \(Everly)62.6(, 1980; Everly &)]TJ 0 -1.398 TD -0.0094 Tc -0.062 Tw [(Lating, 2002; 2004; Reivich & Shatte, 2002; Smith, Davey)59.6(,)-1.6( &)]TJ 0 -1.401 TD -0.0032 Tc -0.0316 Tw [(Everly)62.8(, 2007\). )50.7(A)59( series of research studies was conducted to)]TJ T* -0.0098 Tc -0.0621 Tw (empirically examine the viability of the putative deterministic)Tj 0 -1.398 TD -0.0063 Tc -0.0625 Tw (role of appraisal in health and work-related outcomes \(Smith,)Tj 0 -1.401 TD -0.003 Tc 0.0065 Tw [(Davey)63(, & Everly)63(, 1995; 2006; 2007; Smith & Everly)63(, 1990;)]TJ T* -0.0192 Tc -0.0622 Tw [(Smith, Everly)67.8(, & Johns, 1993; Smith, Davey)58.8(, & S)16.8(tewart, 1998\).)]TJ 0 -1.398 TD -0.0035 Tc 0.0963 Tw (In a number of investigations, acute cognitive or affective)Tj 0 -1.401 TD -0.0015 Tc 0.125 Tw (indicators were predictive of physical health outcomes as)Tj T* -0.0035 Tc -0.0344 Tw (well as work-related outcomes such as job satisfaction, turn-)Tj 0 -1.398 TD -0.0037 Tw (over intention, and burnout. Replicated results indicate that)Tj 0 -1.401 TD -0.0034 Tc -0.036 Tw (adverse life events are not as important in the ultimate deter-)Tj T* -0.003 Tc 0.0114 Tw (mination of physical health, psychological health, job satis-)Tj 0 -1.398 TD -0.0034 Tc -0.0585 Tw (faction, job performance, and the desire to change jobs as are)Tj 0 -1.401 TD -0.0095 Tc -0.0625 Tw (the cognitive or affective indicia associated with those events.)Tj 1.8 -2.001 TD -0.0036 Tc 0.0934 Tw (Perhaps the most operative uses of the notion of con-)Tj -1.8 -1.398 TD 0.0068 Tc 0.125 Tw (structive cognitions are the constructions of )Tj /TT5 1 Tf 18.786 0 TD 0.007 Tc 0 Tw (self-efficacy)Tj /TT2 1 Tf -18.786 -1.401 TD -0.0038 Tc -0.031 Tw (\(Bandura, 1977; 1982; 1997\) and )Tj /TT5 1 Tf 13.281 0 TD -0.005 Tc 0 Tw (hardiness)Tj /TT2 1 Tf 3.849 0 TD -0.0041 Tc -0.0325 Tw [( \(Kobasa, Maddi)]TJ -17.13 -1.401 TD -0.0054 Tc -0.0625 Tw [(& Kahn, 1983\). 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First is )]TJ /TT5 1 Tf 19.59 0 TD 0.0061 Tc 0 Tw (successful)Tj -19.59 -1.401 TD -0.0049 Tc (performance)Tj /TT2 1 Tf 5.061 0 TD -0.0033 Tc 0.0064 Tw [( which can contribute to improved efficacy ap-)]TJ -5.061 -1.401 TD -0.0035 Tc -0.0237 Tw (praisals and vice versa; failed performance can contribute to)Tj 0 -1.398 TD -0.0037 Tc 0.0393 Tw [(worsened appraisals \(Bandura, 1982\). Though enactive at-)]TJ 0 -1.401 TD -0.0305 Tw (tainment has been considered to be the single most powerful)Tj T* -0.003 Tc 0.0367 Tw [(way of influencing perceptions of self-ef)18(ficacy)63(, it is impor)18(-)]TJ 0 -1.398 TD -0.0031 Tc -0.0422 Tw [(tant to note that success is subjective. 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Bandura)]TJ -19.581 -1.401 TD -0.0077 Tc -0.0621 Tw (writes, Seeing or visualizing similar others perform success-)Tj 0 -1.398 TD -0.0026 Tc -0.06 Tw (fully can raise self-percepts of efficacy in observers that they)Tj 0 -1.401 TD -0.0061 Tc -0.0622 Tw (too possess the capabilities to master comparable activities....)Tj T* -0.0033 Tc -0.024 Tw (By the same token, observing others to be of similar compe-)Tj 0 -1.398 TD -0.0036 Tc -0.0306 Tw (tence fail despite high efforts lowers observers judgments of)Tj 0 -1.401 TD -0.0113 Tc -0.0621 Tw (their own capabilities and undermines their efforts \(Bandura,)Tj T* -0.0257 Tc -0.0625 Tw (1982, p. 27\).)Tj 1.8 -1.998 TD 0.0026 Tc 0.125 Tw (The third predictor is )Tj /TT5 1 Tf 9.279 0 TD 0.0016 Tc (verbal persuasion)Tj /TT2 1 Tf 7.35 0 TD 0.0013 Tc [( and )]TJ /TT5 1 Tf 2.205 0 TD 0.0016 Tc 0 Tw (support)Tj /TT2 1 Tf -20.634 -1.401 TD -0.0038 Tc 0.0375 Tw (which comprises such constructs as suggestion, encourage-)Tj T* -0.0037 Tc 0.0829 Tw (ment, and education as intervention for improving percep-)Tj 0 -1.398 TD -0.003 Tc 0.0066 Tw [(tions of self-ef)18(ficacy)63(. Cognitive alterations may be brought)]TJ 0 -1.401 TD -0.0029 Tc 0.0868 Tw (about by oneself or by another person such as a trainer or)Tj T* -0.0034 Tc -0.0311 Tw (coach, supervisor or other person in a leadership position, or)Tj 0 -1.398 TD -0.0035 Tc 0.05 Tw (a counselor or therapist.)Tj 1.8 -2.001 TD -0.0034 Tc 0.005 Tw (The fourth and final predictor is )Tj /TT5 1 Tf 12.969 0 TD -0.0045 Tc 0 Tw (physiological)Tj /TT2 1 Tf 5.337 0 TD -0.0023 Tc 0.0075 Tw [( or )]TJ /TT5 1 Tf 1.338 0 TD -0.0041 Tc 0 Tw (affec-)Tj -21.444 -1.401 TD -0.0021 Tc 0.125 Tw (tive arousal)Tj /TT2 1 Tf 4.851 0 TD 0 Tc 0 Tw (.)Tj /TT5 1 Tf -2.751 -1.998 TD -0.0036 Tc 0.0843 Tw (People rely partly on their state of physiologi-)Tj 0 -1.401 TD 0.0293 Tw (cal arousal in judging their capabilities and vul-)Tj T* 0.024 Tc 0.125 Tw [(nerability to stress. Because unusually high)]TJ 0 -1.398 TD 0.0142 Tc (arousal usually debilitates performance, indi-)Tj 0 -1.401 TD -0.0002 Tc (viduals are more likely to expect success when)Tj T* -0.0034 Tc 0.0433 Tw [(they are not beset by aversive arousal. Fear re-)]TJ 0 -1.398 TD 0.0016 Tc 0.125 Tw (actions generate further fear through anticipa-)Tj 0 -1.401 TD -0.0034 Tc 0.0008 Tw (tory self-arousal.... People can rouse themselves)Tj T* -0.04 Tw (to elevated levels of distress that produce the very)Tj 0 -1.398 TD -0.0038 Tc 0.0131 Tw [(dysfunctions they fear)107.2(. T)53.2(r)34.4(eatments that eliminate)]TJ 0 -1.401 TD 0.0115 Tc 0.125 Tw (emotional arousal heighten perceived efficacy)Tj T* 0.0298 Tc (with corresponding improvements in perfor-)Tj 0 -1.398 TD -0.0118 Tc 0 Tw (mance )Tj /TT2 1 Tf 3.276 0 TD -0.0111 Tc -0.0617 Tw (\(Bandura, 1982, p. 28\).)Tj -1.776 -2.001 TD -0.0037 Tc -0.0344 Tw (Kobasa, Maddi, and Kahn \(1982\) focus on the con-)Tj -3.6 -1.401 TD -0.0035 Tc 0.1225 Tw (cept of )Tj /TT5 1 Tf 3.219 0 TD -0.005 Tc 0 Tw (hardiness)Tj /TT2 1 Tf 3.852 0 TD -0.0033 Tc 0.1241 Tw (, described as a protective factor against)Tj -7.071 -1.398 TD 0.0019 Tc 0.125 Tw (stressors and therefore a potential predictor of resilience.)Tj 0 -1.401 TD -0.0031 Tc 0.117 Tw (Hardiness is characterized by: 1\) )Tj /TT5 1 Tf 13.839 0 TD -0.0045 Tc 0 Tw (Control,)Tj /TT2 1 Tf 3.33 0 TD -0.003 Tc 0.1175 Tw [( or the belief in)]TJ -17.169 -1.401 TD -0.0029 Tc -0.0513 Tw (oneself and ability to control life events; 2\) )Tj /TT5 1 Tf 16.95 0 TD -0.0045 Tc 0 Tw (Challenge,)Tj /TT2 1 Tf 4.32 0 TD -0.0033 Tc -0.0525 Tw [( or the)]TJ -21.27 -1.398 TD 0.0004 Tc 0.125 Tw (propensity to view stressful events in life as a challenge,)Tj 0 -1.401 TD -0.0034 Tc -0.005 Tw (thereby allowing oneself to overcome the challenge and po-)Tj T* -0.0032 Tc -0.0139 Tw (tentially grow from the resolution of the stressful event; and)Tj 0 -1.398 TD -0.0045 Tc 0 Tw (3\) )Tj /TT5 1 Tf 1.134 0 TD -0.0051 Tc (Commitment,)Tj /TT2 1 Tf 5.31 0 TD -0.003 Tc 0.06 Tw [( or the tendency to see important activities)]TJ -6.444 -1.401 TD -0.0035 Tc 0.0655 Tw (not just as tasks to be performed, but as commitments that)Tj T* 0.0822 Tw [(have meaning in and of themselves. Rutter \(1985\) agreed)]TJ 0 -1.398 TD -0.0037 Tc 0.12 Tw (with Kobasa and colleaguesdescription of hardiness, not-)Tj ET endstream endobj 144 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 146 0 obj << /Length 8881 >> 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. 4 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (265)Tj /TT2 1 Tf 10 0 0 10 66 722.64 Tm -0.0033 Tc 0.0168 Tw (ing that a sense of self-esteem and self-efficacy increases)Tj 0 -1.398 TD -0.0036 Tc 0.0344 Tw (the likelihood of successful coping, while a sense of help-)Tj 0 -1.401 TD 0.0795 Tw (lessness increases the chances of failed coping as well as)Tj T* 0.0008 Tc 0.1249 Tw [(repeated adversity)60.8(. More importantly)66.8(, Rutter pointed out)]TJ 0 -1.398 TD -0.0029 Tc 0.0984 Tw [(that this belief system is not a static personality)63.1(, therefore)]TJ 0 -1.401 TD -0.0032 Tc -0.0063 Tw (lending itself to be altered.)Tj 1.8 -2.001 TD -0.0026 Tc 0.125 Tw (In a further refinement of the theme of cognitive ap-)Tj -1.8 -1.398 TD 0.0007 Tc (praisal, researchers investigating resilience to stressors in)Tj 0 -1.401 TD -0.0061 Tc -0.0625 Tw (daily life, as well as the stress associated with grieving, found)Tj T* -0.0036 Tc 0.0871 Tw (that positive emotions served to predict successful adapta-)Tj 0 -1.398 TD -0.0134 Tc -0.0624 Tw [(tion to adversity \(Ong, Ber)16.6(geman, Bisconti, & )16.7(W)96.4(allace, 2006\).)]TJ 0 -1.401 TD -0.007 Tc -0.0622 Tw [(Similarly)62(, Everly)65(, Smith, and )16.9(W)96.8(elzant, \(2008\) discovered that)]TJ T* -0.0025 Tc 0.125 Tw (positive states were associated with positive outcomes on)Tj 0 -1.398 TD -0.0033 Tc 0.0414 Tw (the job and inversely correlated with work-related burnout.)Tj 0 -1.401 TD -0.0038 Tc 0.0792 Tw (Fredrickson \(2000\) underscores the importance of positive)Tj T* -0.0033 Tc -0.0243 Tw (states, specifically positive emotions, and argues that inter-)Tj 0 -1.398 TD -0.0035 Tc 0.1107 Tw (vention strategies that cultivate positive emotions are par-)Tj 0 -1.401 TD -0.0033 Tc 0.03 Tw (ticularly suited for preventing and treating problems rooted)Tj T* 0.1129 Tw [(in negative emotions, such as anxiety)62.7(, depression, aggres-)]TJ 0 -1.398 TD -0.0034 Tc -0.035 Tw [(sion, and stress-related health problems \(p. 1\). Fredrickson)]TJ 0 -1.401 TD -0.0039 Tc -0.0025 Tw (developed the )Tj /TT5 1 Tf 6.105 0 TD -0.0049 Tc 0 Tw (broadenandbuild)Tj /TT2 1 Tf 8.139 0 TD -0.0041 Tc -0.0025 Tw ( model of positive emo-)Tj -14.244 -1.401 TD -0.0035 Tc 0.1231 Tw [(tions asserting that negative emotions such as fear)38.5(, anger)35.5(,)]TJ 0 -1.398 TD -0.0042 Tc -0.0465 Tw [(and sadness limit an individual)49.8(s immediate thoughtaction)]TJ 0 -1.401 TD -0.0034 Tc 0.0879 Tw [(repertoire. Positive emotions, on the other hand, such as)]TJ T* 0.0078 Tc 0.1254 Tw [(joy and contentment, broaden an individual)46.8(s immediate)]TJ 0 -1.398 TD 0.0131 Tc 0.125 Tw (thoughtaction repertoire, which in turn can build that)Tj 0 -1.401 TD -0.004 Tc -0.0619 Tw [(individual)53(s enduring personal resources \(Fredrickson, p.)]TJ T* -0.054 Tc 0 Tw (1\).)Tj /F1 1 Tf 11 0 0 11 66 306 Tm -0.005 Tc 0.0386 Tw (Applying Concepts of Resistance and)Tj 0 -1.0909 TD -0.0051 Tc 0.0267 Tw [(Resilience to a )74.9(W)60.7(orkplace Evidence-Based)]TJ T* 0.0025 Tc 0 Tw [(T)76.2(raining)]TJ /TT2 1 Tf 10 0 0 10 84 258.66 Tm 0.002 Tc 0.125 Tw (Depression, a common response to traumatic events,)Tj -1.8 -1.401 TD -0.0035 Tc -0.0565 Tw (provides a good example of applying cognitive interventions)Tj T* -0.0034 Tc 0.122 Tw [(designed to prevent the onset of mental illness. )17.6(W)55.4(ith the)]TJ 0 -1.398 TD -0.0033 Tc -0.0119 Tw (increased attention to the costs employers experience due to)Tj 0 -1.401 TD -0.009 Tc -0.0621 Tw (depression among their employees, researchers are now seek-)Tj T* -0.0018 Tc 0.125 Tw (ing to develop evidence-based interventions and trainings)Tj 0 -1.398 TD -0.0092 Tc -0.0622 Tw [(designed to prevent depression within the workplace \(Couser)35.8(,)]TJ 0 -1.401 TD 0.0155 Tc 0.125 Tw (2008; Dunnagan, Peterson, & Haynes, 2001; Hurrell &)Tj T* -0.0035 Tc -0.0394 Tw [(Murphy)59.5(, 1006; Kagen, Kagan, & )17.5(W)94.3(atson, 1995\). Based par)17.5(-)]TJ 0 -1.398 TD -0.0031 Tc 0.1144 Tw (tially on the constructs described earlier in this paper and)Tj 0 -1.401 TD -0.0034 Tc -0.003 Tw (placed within the context of a public health approach to pri-)Tj T* 0.0034 Tc 0.125 Tw (mary intervention, depression prevention strategies focus)Tj 0 -1.398 TD -0.0039 Tc 0.0336 Tw (on reducing modifiable risk factors and improving protec-)Tj 0 -1.401 TD -0.0035 Tc -0.0271 Tw [(tive factors \(Couser)35.5(, 2008, p. 412\), which sounds similar to)]TJ 25.5 64.599 TD 0.07 Tw (theorists perspectives on resistance and resilience.)Tj 1.8 -1.998 TD -0.0594 Tw (Recent advances in the mental health field allow for bet-)Tj -1.8 -1.401 TD -0.0033 Tc 0.0594 Tw (ter detection of targeted populations who may be at higher)Tj T* 0.0029 Tc 0.125 Tw (risk for developing depression or other mental disorders.)Tj 0 -1.398 TD -0.0037 Tc 0.0328 Tw [(However)35.3(, when these identified risk factors are not modifi-)]TJ 0 -1.401 TD -0.003 Tc 0.1236 Tw [(able, such as genetics, family history)63(, gender)36(, upbringing,)]TJ T* -0.0028 Tc -0.0055 Tw (personality traits, etc., there is little one can do to intervene,)Tj 0 -1.398 TD -0.0035 Tc -0.0621 Tw [(not to mention build resistance or resiliency)62.5(. On a more opti-)]TJ 0 -1.401 TD -0.0032 Tc 0.0072 Tw (mistic note, many risk factors related to the development of)Tj T* 0.008 Tc 0.125 Tw (depression and other mental disorders, such as posttrau-)Tj 0 -1.398 TD -0.0032 Tc 0.1232 Tw [(matic stress disorder)38.8(, are indeed modifiable, either by the)]TJ 0 -1.401 TD -0.0035 Tc 0.055 Tw (affected individual, their environment, or a combination of)Tj T* -0.0034 Tc -0.005 Tw (both. Some risk factors that may lend themselves to modifi-)Tj 0 -1.398 TD 0.0614 Tw (cation by an individual through education and intervention)Tj 0 -1.401 TD -0.009 Tc -0.0619 Tw [(include chronic health conditions \(Bilsker)36(, Gilbert, Myette, &)]TJ T* -0.0181 Tc [(S)22.1(tewart-Patterson, 2004\), substance misuse \(Kendler)32.9(, Gardner)35.9(,)]TJ 0 -1.398 TD -0.0082 Tc -0.0622 Tw (& Prescott, 2006\), self-esteem and self-efficacy \(Beardslee &)Tj 0 -1.401 TD -0.0029 Tc 0.125 Tw (Gladstone, 2001; Bilsker et al., 2004; Munoz, Mrazek, &)Tj T* -0.0031 Tc -0.06 Tw [(Haggerty)59.9(, 1996\), social support \(Bilsker et al.; Kendler et al.,)]TJ 0 -1.398 TD 0.0248 Tc 0.125 Tw (2006\) and perceptions of helplessness or hopelessness)Tj 0 -1.401 TD -0.0034 Tc 0.0417 Tw (\(Beardslee & Gladstone, 2001; Bilsker et al.; Munoz et al.,)Tj T* -0.0516 Tc 0 Tw (1996\).)Tj 1.8 -1.998 TD -0.0038 Tc 0.02 Tw (While depression and other negative reactions to stress)Tj -1.8 -1.401 TD -0.0034 Tc 0.0572 Tw (are not always preventable, research suggests that working)Tj T* -0.0033 Tc 0.1118 Tw (with individuals at risk to improve protective factors may)Tj 0 -1.398 TD -0.0037 Tc -0.015 Tw (minimize negative reactions and contribute to more positive)Tj 0 -1.401 TD -0.0038 Tc -0.0398 Tw [(outcomes \(W)74.2(orld Health Or)17.2(ganization, 2004a\). In one study)]TJ T* -0.0035 Tc -0.0238 Tw (utilizing group training as an intervention for preventing de-)Tj 0 -1.398 TD -0.0032 Tc 0.111 Tw [(pression, researchers reported significantly reduced symp-)]TJ 0 -1.401 TD -0.0037 Tc -0.0328 Tw (toms of depression among emergency personnel following a)Tj T* -0.0038 Tc -0.04 Tw (stress management program that included interpersonal con-)Tj 0 -1.398 TD -0.0045 Tc -0.0621 Tw (flict resolution, communication, and relaxation \(Kagan et al.,)Tj 0 -1.401 TD -0.003 Tc -0.0143 Tw [(1995\). In a recent study conducted by )18.2(W)94.9(ang and colleagues)]TJ T* -0.0036 Tc 0.0767 Tw (\(2007\) employees reported significant improvement of de-)Tj 0 -1.398 TD -0.0016 Tc 0.125 Tw (pressive symptoms in addition to positive workplace out-)Tj 0 -1.401 TD -0.0038 Tc 0.1225 Tw (comes among employees who received enhanced services)Tj T* -0.0032 Tc 0.015 Tw [(for identification and treatment of depression. Specifically)59.8(,)]TJ 0 -1.398 TD -0.0036 Tc 0.0793 Tw (the intervention utilized telephone outreach and case man-)Tj 0 -1.401 TD 0.0026 Tc 0.125 Tw (agement services to encourage and support employees at)Tj T* -0.0036 Tc -0.0138 Tw [(the beginning and through completion of treatment. In addi-)]TJ 0 -1.398 TD 0.12 Tw (tion to reduction in depression symptoms, workplace out-)Tj 0 -1.401 TD 0.0352 Tc 0.125 Tw (comes included higher work hours and improved job)Tj T* 0.0023 Tc 0 Tw (retention.)Tj 1.8 -1.998 TD -0.0037 Tc -0.0092 Tw [(Thus, integrating Bandura)53.3(s \(1977; 1997\) work on self-)]TJ -1.8 -1.401 TD -0.0036 Tc -0.0141 Tw [(ef)17.4(ficacy and Fredrickson)53.4(s \(2000\) model and constituent as-)]TJ T* 0.0343 Tw (sertions, the construction of a training program designed to)Tj ET endstream endobj 147 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 149 0 obj << /Length 9721 >> 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 /TT3 1 Tf 8 0 0 8 54.99 41.64 Tm 0 0 0 1 k /GS2 gs -0.0057 Tc 0.1094 Tw [(266 Everly, Welzant & Jacobson)]TJ /F1 1 Tf 15.4313 0 TD -0.0055 Tc [(  )]TJ /TT3 1 Tf 1.1138 0 TD -0.0059 Tc (Resistance and Resilience)Tj /TT2 1 Tf 10 0 0 10 54 722.64 Tm -0.0034 Tc -0.0382 Tw (build resistance, which will in turn enhance resilience, could)Tj 0 -1.398 TD -0.0038 Tc 0.0619 Tw [(be developed. Such a program would provide information)]TJ 0 -1.401 TD -0.0035 Tc -0.0217 Tw (and education, in addition to assisting in the development of)Tj T* -0.0131 Tc -0.062 Tw (basic stress-management, self-enhancement, and related skills)Tj 0 -1.398 TD -0.0036 Tc -0.0481 Tw [(designed to improve self-confidence. Similar to benefits ob-)]TJ 0 -1.401 TD -0.0032 Tc 0.0043 Tw (served following use of exposure therapy \(behavior therapy)Tj T* -0.0035 Tc 0.1161 Tw (in which a person confronts reactions and feeling about a)Tj 0 -1.398 TD -0.003 Tc 0.008 Tw [(traumatic event in a therapy setting; Cahill et al., 2006; )15(V)116.2(a)4.8(n)]TJ 0 -1.401 TD -0.0032 Tc 0.0027 Tw (Minnen & Foa, 2006\)], resilience may be enhanced by con-)Tj T* -0.0021 Tc 0.125 Tw (fronting stressors at a time \(pre-incident\) that allows for)Tj 0 -1.398 TD -0.0034 Tc 0.0766 Tw [(self-confidence and social competence to increase mastery)]TJ 0 -1.401 TD -0.0032 Tc -0.0123 Tw [(and appropriate responsibility \(Couser)35.8(, 2008, p. 416\). Per)17.8(-)]TJ T* -0.0035 Tc 0.0978 Tw (haps one of the most important protective factors is stress)Tj 0 -1.398 TD 0.0024 Tc 0.1249 Tw [(management \(W)77.4(orld Health Or)17.4(ganization, 2004b, Jensen,)]TJ 0 -1.401 TD -0.0035 Tc -0.0591 Tw [(Decker)35.5(, & )53.8(Andersen, 2006; Everly & Lating, 2002\), which is)]TJ T* -0.0085 Tc -0.0622 Tw [(paramount in the field of primary prevention. 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Practice application of such a)]TJ 0 -1.398 TD -0.0062 Tc -0.0622 Tw (training program would be appropriate for a business or other)Tj 0 -1.401 TD -0.0036 Tc 0.0859 Tw (work organization where employee populations are identi-)Tj T* 0.0931 Tw (fied as being at high-risk for experiencing predictable and)Tj 0 -1.398 TD -0.0034 Tc -0.0425 Tw (potentially traumatic events while working.)Tj /F1 1 Tf 11 0 0 11 54 297.99 Tm -0.0043 Tc 0.0279 Tw [(A Pilot In)36.6(vestigation)]TJ /TT2 1 Tf 10 0 0 10 72 274.65 Tm -0.0039 Tc -0.0622 Tw (In order to facilitate the progression from theory to prac-)Tj -1.8 -1.401 TD -0.0035 Tc -0.0155 Tw (tice, a training program based on the constructs described in)Tj 0 -1.398 TD -0.0032 Tc 0.1144 Tw (this article was developed by the current authors with the)Tj 0 -1.401 TD -0.008 Tc -0.0625 Tw (intention to increase the protective factors of resilience herein)Tj T* -0.0032 Tc 0.0266 Tw (referred to as )Tj /TT5 1 Tf 5.559 0 TD -0.0039 Tc 0 Tw (resistance.)Tj /F1 1 Tf 11 0 0 11 148.14 186 Tm 0.0198 Tc (METHOD)Tj /TT2 1 Tf 10 0 0 10 72 162.66 Tm -0.006 Tc -0.0628 Tw [(Initially)63(, a six hour training program was developed with)]TJ -1.8 -1.401 TD -0.0066 Tc -0.0622 Tw (the desired outcome being improvement in self-reported con-)Tj T* -0.0036 Tc 0.0106 Tw (fidence and preparedness in the context of workplace crises)Tj 0 -1.398 TD 0.0065 Tc 0.125 Tw [(and disasters. These outcomes were consonant with the)]TJ 0 -1.401 TD -0.0031 Tc -0.0258 Tw (authors beliefs, supported by prior research, that self-confi-)Tj T* 0.0844 Tw (dence and perceived self-efficacy are the core elements of)Tj 0 -1.398 TD -0.0089 Tc -0.0625 Tw [(resistance. The curriculum for the training program consisted)]TJ 25.5 64.398 TD -0.0033 Tc 0.0135 Tw (of a basic introduction to topics relevant to crisis and disas-)Tj 0 -1.398 TD -0.0032 Tc 0.1245 Tw (ter mental health, a review of the signs and symptoms of)Tj 0 -1.401 TD -0.0138 Tc -0.0622 Tw [(excessive stress, an introduction to crisis communication tech-)]TJ T* 0.0134 Tc 0.125 Tw (niques, and selected stress management techniques pre-)Tj 0 -1.398 TD -0.0033 Tc -0.0111 Tw [(sented in primarily an educational format. The training was)]TJ 0 -1.401 TD -0.0034 Tc -0.0138 Tw (not advertised as a resistance or resilience training program,)Tj T* -0.0031 Tc 0.0282 Tw (so as to avoid face validity bias in the assessment aspect of)Tj 0 -1.398 TD -0.0028 Tc 0.0675 Tw [(this pilot study)60.2(.)]TJ 1.8 -2.001 TD -0.0036 Tc 0.0186 Tw (A within-subjects pre-test and post-test design was uti-)Tj -1.8 -1.401 TD -0.0045 Tc -0.0622 Tw [(lized with 180 participants in four separate trainings. Partici-)]TJ 0 -1.398 TD -0.0156 Tc -0.0623 Tw (pants were employees in the fields of public health, emergency)Tj 0 -1.401 TD -0.0032 Tc 0.1112 Tw [(services, and education. Primary outcomes of interest in-)]TJ T* 0.0229 Tw [(cluded perceived confidence in one)50.8(s ability to be stress re-)]TJ 0 -1.398 TD 0.0365 Tc 0.125 Tw [(sistant and resilient. This was measured using three)]TJ 0 -1.401 TD -0.0036 Tc 0.0687 Tw (self-report items with a Cronbach alpha of .90 \(Spearman-)Tj T* -0.0033 Tc -0.0005 Tw (Brown = .94\). The second primary outcome of interest was)Tj 0 -1.398 TD -0.0036 Tc 0.1001 Tw [(one)53.4(s perception of preparedness to be stress resistant and)]TJ 0 -1.401 TD -0.0029 Tc 0.125 Tw (resilient, which was also measured using three self-report)Tj T* -0.0038 Tc 0.0078 Tw (items and had a Cronbach alpha of .94 \(Spearman-Brown =)Tj 0 -1.398 TD -0.0458 Tc 0 Tw (.93\).)Tj /F1 1 Tf 11 0 0 11 401.64 417.99 Tm 0.0198 Tc [(RESUL)82.5(TS)]TJ /TT2 1 Tf 10 0 0 10 327 394.65 Tm -0.0072 Tc -0.0625 Tw (Regarding the outcome variable of perceived confidence)Tj -1.8 -1.401 TD -0.0031 Tc -0.035 Tw [(in one)50.9(s ability to be stress resistant and resilient, the within-)]TJ 0 -1.398 TD 0.1007 Tw (subjects paired t-test revealed a statistically significant in-)Tj 0 -1.401 TD -0.0058 Tc -0.0625 Tw (crease in average scores from pre-test to post-test \()Tj /TT5 1 Tf 19.515 0 TD 0 Tc 0 Tw (t)Tj /TT2 1 Tf 0.276 0 TD -0.0049 Tc -0.0625 Tw [( = 8.98, )]TJ /TT5 1 Tf 3.144 0 TD -0.0128 Tc 0 Tw (df)Tj /TT2 1 Tf -22.935 -1.401 TD -0.0033 Tc -0.0425 Tw (= 179, )Tj /TT5 1 Tf 2.709 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.495 0 TD -0.0042 Tc -0.0427 Tw [(<.0001; Cohen)49.8(s )]TJ /TT5 1 Tf 6.726 0 TD 0 Tc 0 Tw (d)Tj /TT2 1 Tf 0.495 0 TD -0.0022 Tc -0.0425 Tw [( =.61, )]TJ /TT5 1 Tf 2.466 0 TD 0 Tc 0 Tw (r)Tj /TT2 1 Tf 0.384 0 TD -0.003 Tc -0.0436 Tw [( = .29\). Means for the pre-)]TJ -13.275 -1.398 TD -0.0032 Tc 0.0133 Tw (test were 8.40 \()Tj /TT5 1 Tf 6.156 0 TD -0.0132 Tc 0 Tw (SD)Tj /TT2 1 Tf 1.209 0 TD -0.0034 Tc 0.015 Tw [( = )15(2.27\) and means for the post-test were)]TJ -7.365 -1.401 TD -0.0038 Tc 0.065 Tw (9.75 \()Tj /TT5 1 Tf 2.379 0 TD -0.0132 Tc 0 Tw (SD)Tj /TT2 1 Tf 1.212 0 TD -0.0034 Tc 0.07 Tw [( = 2.14\). Regarding the outcome variable of per-)]TJ -3.591 -1.401 TD 0.0825 Tw (ceived preparedness to be stress resistant and resilient, the)Tj 0 -1.398 TD -0.0032 Tc 0.0065 Tw (within-subjects paired t-test also revealed a statistically sig-)Tj 0 -1.401 TD -0.0035 Tc -0.055 Tw (nificant increase in mean scores \()Tj /TT5 1 Tf 12.966 0 TD -0.0028 Tc 0 Tw (t )Tj /TT2 1 Tf 0.465 0 TD -0.0031 Tc -0.055 Tw (= 10.94, )Tj /TT5 1 Tf 3.429 0 TD -0.0068 Tc 0 Tw (df)Tj /TT2 1 Tf 0.771 0 TD -0.0032 Tc [( )55(179 )]TJ /TT5 1 Tf 2.124 0 TD 0 Tc (p)Tj /TT2 1 Tf 0.495 0 TD -0.0033 Tc -0.0576 Tw [( < .0001;)]TJ -20.25 -1.401 TD -0.0179 Tc 0 Tw [(Cohen)48.1(s )]TJ /TT5 1 Tf 3.336 0 TD 0 Tc (d)Tj /TT2 1 Tf 0.48 0 TD -0.0156 Tc -0.0616 Tw [( = .73, )]TJ /TT5 1 Tf 2.508 0 TD 0 Tc 0 Tw (r)Tj /TT2 1 Tf 0.375 0 TD -0.0163 Tc -0.0625 Tw [( = .34\) with pre-test means equaling 8.15 \()]TJ /TT5 1 Tf 15.807 0 TD -0.0282 Tc 0 Tw (SD)Tj /TT2 1 Tf -22.506 -1.398 TD -0.0081 Tc -0.0621 Tw (= 2.33\) and post-test means equaling 9.8 \()Tj /TT5 1 Tf 16.041 0 TD -0.0162 Tc 0 Tw (SD)Tj /TT2 1 Tf 1.2 0 TD -0.0082 Tc -0.0608 Tw [( = 2.15\). Results)]TJ -17.241 -1.401 TD -0.0033 Tc -0.0171 Tw (suggest statistically significant changes emerging as a result)Tj T* 0.0256 Tw (of completing the training program, in the hypothesized di-)Tj 0 -1.398 TD -0.0036 Tc -0.0621 Tw (rection of increased perceived confidence and perceived pre-)Tj 0 -1.401 TD -0.0034 Tc 0.0867 Tw [(paredness to be stress resistant and resilient.)]TJ /F1 1 Tf 11 0 0 11 309 152.01 Tm -0.0045 Tc 0.0568 Tw (Strengths and Limitations)Tj /TT2 1 Tf 10 0 0 10 327 128.64 Tm -0.0029 Tc -0.01 Tw [(Given the exploratory nature of this pilot study)60.1(, the pri-)]TJ -1.8 -1.398 TD -0.0031 Tc 0.071 Tw (mary focus was on the ability to develop and implement a)Tj 0 -1.401 TD -0.0036 Tc 0.0656 Tw [(training program that would be applicable to various high-)]TJ T* -0.0033 Tc 0.0394 Tw [(risk employee populations. The researchers plan to further)]TJ 0 -1.398 TD -0.0029 Tc 0.1124 Tw [(refine and test the training in the future. )51(As with any re-)]TJ ET endstream endobj 150 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 152 0 obj << /Length 9199 >> 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. 4 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (267)Tj /TT2 1 Tf 10 0 0 10 66 722.64 Tm -0.003 Tc 0.0339 Tw [(search study)60(, especially pilot studies, there are a number of)]TJ 0 -1.398 TD -0.0036 Tc 0.1186 Tw (limitations that must be considered before interpreting re-)Tj 0 -1.401 TD -0.0032 Tc 0.0845 Tw [(sults. First, the use of a within-subjects pre- and post-test)]TJ T* -0.0029 Tc -0.0555 Tw (design is limited in its ability to predict causality of observed)Tj 0 -1.398 TD -0.0033 Tc -0.0537 Tw [(changes. Therefore, results should be considered cautiously)]TJ 0 -1.401 TD -0.0035 Tc -0.014 Tw (as there is a high likelihood that the observed changes could)Tj T* -0.0028 Tc -0.0349 Tw [(be due to a threat to internal validity such as history)63.2(, matura-)]TJ 0 -1.398 TD -0.0018 Tc 0.125 Tw [(tion, and Hawthorne effects. Second, all employees who)]TJ 0 -1.401 TD (participated were exposed to the training, resulting in the)Tj T* -0.0035 Tc -0.0031 Tw (lack of a control or comparison group. Given the initial po-)Tj 0 -1.398 TD -0.0034 Tc 0.0894 Tw (tential for success of the training program, future research)Tj 0 -1.401 TD -0.0038 Tc -0.0625 Tw (will utilize a control condition to generate greater confidence)Tj T* -0.0002 Tc 0.125 Tw [(in findings. Finally)59.8(, the researchers developed their own)]TJ 0 -1.398 TD -0.0038 Tc -0.0481 Tw (assessment items to measure outcomes and, while the 3-item)Tj 0 -1.401 TD -0.0048 Tc -0.0625 Tw (scales that were utilized demonstrated some validity and reli-)Tj T* -0.0032 Tc 0.0348 Tw [(ability)59.8(, future studies will utilize standardized measures for)]TJ 0 -1.398 TD -0.0094 Tw [(concepts of self-confidence and self-ef)17.8(ficacy)62.8(. Utilization of)]TJ 0 -1.401 TD -0.0034 Tc -0.0014 Tw (outcome variables shown to correlate with self-efficacy and)Tj T* 0.1081 Tw [(behavioral outcomes would be similarly desired. Using a)]TJ 0 -1.398 TD -0.0035 Tc 0.0856 Tw (pre- and post-test design to measure the effectiveness of a)Tj 0 -1.401 TD -0.0032 Tc 0.125 Tw (training program lends itself nicely for conducting a con-)Tj T* -0.0029 Tc -0.04 Tw (trolled, randomized study as employees can be randomly as-)Tj 0 -1.398 TD 0.0115 Tc 0.125 Tw (signed to one of two groups \(i.e. training group and no)Tj 0 -1.401 TD -0.0035 Tc -0.0431 Tw [(training group\). Outcomes could be measured after employ-)]TJ T* 0.0367 Tw (ees are exposed \(both groups\) to the same traumatic events)Tj 0 -1.398 TD -0.0034 Tc -0.0581 Tw [(within a particular course of time. Using a control group that)]TJ 0 -1.401 TD -0.0036 Tc 0.0061 Tw (is exposed to the same traumatic events as the experimental)Tj T* -0.0034 Tc -0.036 Tw (group would lend itself to results that would be reliable indi-)Tj 0 -1.398 TD -0.0035 Tc 0.1161 Tw (cators of outcomes for a training program to teach at-risk)Tj 0 -1.401 TD 0.0044 Tc 0.125 Tw (work groups resistance and resilience strategies to better)Tj T* -0.0037 Tc 0.0312 Tw (manage workplace crises and disasters.)Tj /F1 1 Tf 11 0 0 11 146.25 270 Tm 0.0258 Tc 0 Tw (CONCLUSION)Tj /TT2 1 Tf 10 0 0 10 84 246.66 Tm -0.0035 Tc 0.0812 Tw [( The development and initial indicators of success for)]TJ -1.8 -1.401 TD -0.0038 Tw [(the training program used in this study)59.5(, which was designed)]TJ T* 0.1185 Tw (to increase perceptions of confidence in and preparedness)Tj 0 -1.398 TD -0.0093 Tc -0.0622 Tw (for resistance and resilience among high-risk employee popu-)Tj 0 -1.401 TD -0.0028 Tc 0.0239 Tw (lations, has particular applicability to a variety of work set-)Tj T* -0.0031 Tc 0.0731 Tw [(tings. For an employer)38.9(, preparing employees for probable)]TJ 0 -1.398 TD -0.0035 Tc -0.0156 Tw (exposure to traumatic events, training such as this should be)Tj 0 -1.401 TD -0.0032 Tc -0.0035 Tw (a critical element of any comprehensive business continuity)Tj T* -0.0042 Tc -0.0619 Tw [(plan. The Institute of Medicine \(IOM\) Report, )]TJ /TT5 1 Tf 18.306 0 TD -0.0057 Tc -0.065 Tw (Preparing for)Tj -18.306 -1.398 TD 0.0118 Tc 0.125 Tw [(the Psychological Consequences of T)86.8(e)4.8(rr)32(orism: )11.8(A)22.6( Public)]TJ 0 -1.401 TD -0.0061 Tc -0.06 Tw [(Health S)26.9(trategy)]TJ /TT2 1 Tf 6.129 0 TD -0.0046 Tc -0.0621 Tw (, identifies the workplace as a primary setting)Tj -6.129 -1.401 TD -0.0036 Tc 0.0986 Tw (for addressing the negative consequences of terrorism, for)Tj 0 -1.398 TD -0.0137 Tc -0.0625 Tw [(which the workplace is a primary target \(IOM, 2003\). Specifi-)]TJ 0 -1.401 TD -0.0036 Tc -0.0628 Tw [(cally)62.4(, the IOM recommends that workplaces employ a public)]TJ 25.5 65.799 TD -0.0038 Tc 0.0925 Tw (health approach to preparedness, which would incorporate)Tj 0 -1.398 TD -0.0033 Tc 0.0807 Tw (primary prevention interventions, such as the training pro-)Tj 0 -1.401 TD -0.0034 Tc -0.0325 Tw (gram described in this article.)Tj 1.8 -2.001 TD -0.0032 Tc 0.0366 Tw [(Historically)59.8(, workplaces have focused on continuity of)]TJ -1.8 -1.398 TD 0.0074 Tc 0.125 Tw (operations post-disaster as they relate to technology and)Tj 0 -1.401 TD -0.0035 Tc 0.0893 Tw (infrastructure, rather than focusing on the human needs of)Tj T* -0.003 Tc -0.0065 Tw (employees and what has been recently termed )Tj /TT5 1 Tf 18.456 0 TD -0.0046 Tc -0.01 Tw (human conti-)Tj -18.456 -1.398 TD -0.0071 Tc 0 Tw (nuity)Tj /TT2 1 Tf 1.965 0 TD -0.0061 Tc -0.0623 Tw [( \(Cavanagh, 2003; Mankin & Perry)56.9(, 2004; )17.8(T)40.7(ierney et al.,)]TJ -1.965 -1.401 TD -0.0032 Tc -0.0196 Tw [(2001\). This failure to attend to the human needs of employ-)]TJ T* -0.0035 Tc 0.0378 Tw (ees during and immediately following traumatic events has)Tj 0 -1.398 TD -0.0034 Tc 0.0156 Tw (led to employers having to contend with increased negative)Tj 0 -1.401 TD -0.0035 Tc 0.0572 Tw (reactions and responses from employees including, but not)Tj T* -0.0037 Tw (limited to, higher levels of work disruption, increased nega-)Tj 0 -1.398 TD -0.0037 Tc 0.0985 Tw [(tive and sometimes dangerous health behaviors, and onset)]TJ 0 -1.401 TD -0.0197 Tc -0.0625 Tw (or recurrence of mental illness \(Grieger et al., 2003; 2005; Stein)Tj T* -0.0024 Tc 0.125 Tw [(et al., 2003\). These negative reactions contribute to eco-)]TJ 0 -1.398 TD -0.0049 Tc -0.0622 Tw (nomic impacts due to lost work time / absenteeism, increased)Tj 0 -1.401 TD -0.0034 Tc [(disability and healthcare claims, and turnover)38.6(, among others.)]TJ 1.8 -2.001 TD -0.0037 Tc 0.0812 Tw (More recent studies on the human aspects of business)Tj -1.8 -1.398 TD -0.0035 Tc 0.0378 Tw (continuity and preparedness have focused on assessing and)Tj 0 -1.401 TD -0.0033 Tc 0.0279 Tw (preventing risk by modifying and whenever possible elimi-)Tj T* -0.0035 Tc 0.0946 Tw [(nating physical risks within the work environment. )50.7(Addi-)]TJ 0 -1.398 TD 0.0397 Tc 0.1249 Tw [(tionally)57.7(,)0.1( workplaces have been providing timely and)]TJ 0 -1.401 TD -0.0035 Tc 0.055 Tw (appropriate responses to a traumatic event with the goal of)Tj T* -0.0107 Tc -0.0622 Tw (mitigating psychological distress that may contribute to short-)Tj 0 -1.398 TD -0.0036 Tc -0.0345 Tw [(term and long-term problems. What businesses have not yet)]TJ 0 -1.401 TD -0.0032 Tc 0.035 Tw (fully embraced is their potential role in preparing their em-)Tj T* -0.0028 Tc 0.0881 Tw [(ployees, psychologically and emotionally)60.2(, to minimize the)]TJ 0 -1.398 TD -0.0036 Tc 0.0559 Tw (negative effects of predictable traumatic workplace events.)Tj 0 -1.401 TD -0.0031 Tc 0.0344 Tw (Resistance, as described in this article, not only enhances a)Tj T* -0.0078 Tc -0.0621 Tw (business risk management plan in surveying and minimizing)Tj 0 -1.398 TD -0.0033 Tc -0.0156 Tw (environmental and physical risks, but also contributes to the)Tj 0 -1.401 TD -0.0034 Tc -0.0462 Tw (preparation of employees to react and recover from probable)Tj T* -0.0472 Tw (traumatic events, often referred to as occupational hazards.)Tj 0 -1.398 TD -0.0036 Tc -0.0407 Tw (Examples of high-risk employee populations that could ben-)Tj 0 -1.401 TD -0.0034 Tc 0.0028 Tw (efit from such training include police, fire and rescue work-)Tj T* -0.0061 Tc -0.0619 Tw [(ers, nurses, physicians, the military)65.9(, air)17.9(-traf)14.9(fic controllers and)]TJ 0 -1.398 TD -0.0033 Tc 0.0875 Tw (other airline employees, and railroad and mass transit em-)Tj 0 -1.401 TD -0.0017 Tw (ployees; and given the recent reshaping of the world econo-)Tj T* 0.0464 Tc 0.125 Tw (mies, those employees working in the financial and)Tj 0 -1.398 TD -0.0041 Tc -0.0625 Tw (international trade professions could potentially benefit from)Tj 0 -1.401 TD -0.0037 Tc 0.08 Tw (such training.)Tj 1.8 -2.001 TD 0.0028 Tw (One workplace model for disaster preparedness and re-)Tj -1.8 -1.398 TD -0.0033 Tc -0.0016 Tw (sponse that already supports the use of hardiness training or)Tj 0 -1.401 TD -0.0007 Tc 0.1252 Tw [(stress-hardening in the workplace is the Employee )50.5(Assis-)]TJ T* -0.0117 Tc -0.0621 Tw (tance Program \(EAP\) Critical Incident Response - Continuum)Tj ET endstream endobj 153 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 155 0 obj << /Length 10171 >> 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 /TT3 1 Tf 8 0 0 8 54.99 41.64 Tm 0 0 0 1 k /GS2 gs -0.0057 Tc 0.1094 Tw [(268 Everly, Welzant & Jacobson)]TJ /F1 1 Tf 15.4313 0 TD -0.0055 Tc [(  )]TJ /TT3 1 Tf 1.1138 0 TD -0.0059 Tc (Resistance and Resilience)Tj /TT2 1 Tf 10 0 0 10 54 722.64 Tm -0.0039 Tc -0.0075 Tw (of Services \(The EAP Continuum; Jacobson, Paul, & Blum,)Tj 0 -1.398 TD -0.0077 Tc -0.0622 Tw [(2005; Paul & Blum, 2006\). The EAP Continuum specifically)]TJ 0 -1.401 TD -0.0038 Tc 0.0243 Tw [(describes an EAP)53.2(s role in workplace disaster preparedness)]TJ T* -0.0035 Tc 0.0705 Tw [(and response. While the majority of EAPs continue to re-)]TJ 0 -1.398 TD 0 Tc 0.125 Tw (ceive initial calls for assistance after the incident has oc-)Tj 0 -1.401 TD -0.0035 Tc 0.0765 Tw (curred, the ideal situation would be one in which the EAP)Tj T* -0.0525 Tw (would work as a strategic partner with the workplace prior to)Tj 0 -1.398 TD -0.0034 Tc -0.04 Tw [(an incident occurring. Specifically)62.6(, EAPs would collaborate)]TJ 0 -1.401 TD -0.0036 Tc 0.125 Tw (with other workplace leaders to develop a comprehensive)Tj T* 0.0217 Tw [(business continuity plan which would incorporate interven-)]TJ 0 -1.398 TD -0.0031 Tc 0.0582 Tw (tions such as the one described in this study to build resis-)Tj 0 -1.401 TD -0.0034 Tc 0.02 Tw (tance among employees.)Tj 1.8 -2.001 TD -0.0035 Tc -0.0464 Tw (Preparedness has always been the most challenging part)Tj -1.8 -1.398 TD -0.0038 Tc 0.0306 Tw (of the EAP Continuum and other disaster response plans to)Tj 0 -1.401 TD -0.0028 Tc 0.0425 Tw (implement, partially due to false beliefs held by employers)Tj T* -0.0217 Tc -0.0622 Tw (that preparing for a traumatic event will increase anxiety among)Tj 0 -1.398 TD -0.0145 Tc [(employees \(Ursano & )15.8(V)62.7(inebur)15.5(gh, 2003\), denial that their busi-)]TJ 0 -1.401 TD -0.0032 Tc -0.0265 Tw (ness or work organization will be affected by such a disaster)Tj T* -0.0033 Tc 0.0143 Tw [(\(Comp Psych Survey)62.7(, 2004\), and perceived expense of pre-)]TJ 0 -1.398 TD -0.003 Tc 0.0032 Tw (paring \(Ursano, n.d.\). The promising possibility of the pro-)Tj 0 -1.401 TD 0.0038 Tc 0.125 Tw (posed training program described in this article is that it)Tj T* -0.0042 Tc -0.062 Tw (complements existing workplace disaster response programs)Tj 0 -1.398 TD -0.0034 Tc -0.0462 Tw (and interventions without taking away the importance of cri-)Tj 0 -1.401 TD -0.0031 Tc 0.06 Tw (sis response and other security priorities.)Tj 1.8 -2.001 TD -0.0124 Tc -0.0625 Tw (Next steps for this training program include further modi-)Tj -1.8 -1.398 TD -0.0028 Tc 0.0737 Tw (fying the learning modules to more accurately identify the)Tj 0 -1.401 TD -0.0063 Tc -0.0621 Tw (latent mechanisms that undergird all resistance and resilience)Tj T* -0.0032 Tc -0.0236 Tw [(among high-risk employee populations. If successfully rep-)]TJ 0 -1.398 TD 0.0056 Tc 0.125 Tw (licated with future controlled studies, using standardized)Tj 0 -1.401 TD -0.008 Tc -0.0621 Tw (measures for assessing outcomes, this training program could)Tj T* -0.0027 Tc -0.024 Tw (be very applicable to a variety of workplaces with very little)Tj 0 -1.398 TD -0.0034 Tc -0.0278 Tw [(alteration. Implications for the workforce from such a train-)]TJ 0 -1.401 TD -0.0036 Tc 0.0734 Tw (ing program will be evaluated in terms of cost-benefit and)Tj T* -0.0032 Tc 0.0807 Tw [(cost-effectiveness. Considering the relatively low cost as-)]TJ 0 -1.398 TD 0.0157 Tw (sociated with providing the training, employers may expect)Tj 0 -1.401 TD -0.0036 Tc -0.0032 Tw (to see a significant return-on-investment, not to mention an)Tj T* -0.003 Tc -0.0585 Tw (improved quality of life for the high-risk employee.)Tj /F1 1 Tf 11 0 0 11 133.89 174 Tm 0.021 Tc 0 Tw (REFERENCES)Tj /TT2 1 Tf 10 0 0 10 54 156.66 Tm -0.0029 Tc -0.0265 Tw [(Bandura, )54(A. \(1977\). Self-ef)18.1(ficacy: )15(T)73.9(oward a unifying theory)]TJ 1.2 -1.401 TD -0.0036 Tc -0.0133 Tw (of behavior change. )Tj /TT5 1 Tf 8.055 0 TD -0.0044 Tc -0.01 Tw (Psychological Review)Tj /TT2 1 Tf 8.709 0 TD 0.001 Tc 0 Tw (, )Tj /TT5 1 Tf 0.486 0 TD -0.01 Tc (84)Tj /TT2 1 Tf 0.99 0 TD -0.0037 Tc -0.015 Tw (, 191-215.)Tj -19.44 -1.8 TD -0.0059 Tc -0.0622 Tw [(Bandura, )54.4(A. \(1982\). )12.4(The self and mechanisms of agency)60.1(. 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Loss, trauma, and human resilience:)]TJ 1.2 -1.401 TD 0.0021 Tc 0.1249 Tw [(Have we underestimated the human capacity to thrive)]TJ 0 -1.398 TD -0.0028 Tc 0.0038 Tw (after extremely aversive events? )Tj /TT5 1 Tf 13.086 0 TD -0.0042 Tc 0.005 Tw (American Psychologist,)Tj -13.086 -1.401 TD -0.034 Tc 0 Tw (59)Tj /TT2 1 Tf 0.945 0 TD -0.0259 Tc -0.06 Tw (\(1\), 20-28.)Tj -2.145 -1.8 TD -0.0029 Tc -0.0016 Tw [(Cahill, S. P)108.1(., Foa, E. B., Hembree, E. )51.2(A., Marshall, R. D., &)]TJ 1.2 -1.401 TD -0.0034 Tc -0.0207 Tw (Nacash, N. \(2006\). Dissemination of exposure therapy in)Tj 0 -1.398 TD -0.0037 Tc 0.075 Tw (the treatment of PTSD. )Tj /TT5 1 Tf 9.744 0 TD -0.0046 Tc 0.0753 Tw [(Journal of T)49.4(raumatic S)28.4(t)2.4(r)31.4(ess)]TJ /TT2 1 Tf 11.19 0 TD 0.001 Tc 0 Tw (, )Tj /TT5 1 Tf 0.576 0 TD -0.01 Tc (19)Tj /TT2 1 Tf -21.51 -1.401 TD -0.0387 Tc -0.06 Tw (\(5\), 597-610.)Tj -1.2 -1.8 TD -0.0059 Tc -0.0619 Tw [(Cavanagh, )12.3(T)76.9(.)-0.2( E. \(2003\). Corporate security management: Or)12.1(-)]TJ 1.2 -1.401 TD 0.0172 Tc 0.125 Tw (ganization and spending since 9/11, )Tj /TT5 1 Tf 15.801 0 TD 0.0159 Tc 0.1331 Tw (The Conference)Tj -15.801 -1.398 TD -0.0048 Tc 0.0754 Tw [(Boar)31.2(d Executive Summar)-4.8(y)52.1(.)]TJ /TT2 1 Tf -1.2 -1.8 TD -0.0029 Tc 0.0233 Tw (CompPsyc Survey \(2004\). )Tj /TT5 1 Tf 10.836 0 TD -0.0038 Tc 0.0237 Tw (Employees Feel Sense of Inertia)Tj -9.636 -1.401 TD -0.0055 Tc 0.0826 Tw [(Ar)30.5(ound T)81.5(e)2.5(r)-5.5(r)35.7(or W)84.5(arnings.)]TJ /TT2 1 Tf -1.2 -1.8 TD -0.0038 Tc -0.0253 Tw [(Connor)35.2(, K.M. & Davidson, J.R.T)74.2(. \(2003\). Development of a)]TJ 1.2 -1.401 TD -0.0007 Tc 0.125 Tw (new resilience scale: The Connor-Davidson Resilience)Tj 0 -1.398 TD -0.0079 Tc -0.06 Tw (Scale \(DC-RISC\). )Tj /TT5 1 Tf 7.281 0 TD -0.0081 Tc -0.0607 Tw [(Depr)33.9(ession & )16.9(Anxiety)51.9(, 18)]TJ /TT2 1 Tf 9.855 0 TD -0.0077 Tc -0.065 Tw (, 76-82.)Tj -18.336 -1.8 TD -0.0131 Tc -0.0619 Tw [(Couser)37.9(, G)115.9(.)4.1(P)100.9(.)-0.2( \(2008\). 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Mental)]TJ 1.2 -1.401 TD -0.0035 Tc -0.013 Tw [(health issues in the workplace: )53.5(A)58.7( case for a new manage-)]TJ 0 -1.398 TD -0.0034 Tc -0.015 Tw (rial approach. )Tj /TT5 1 Tf 5.67 0 TD -0.0042 Tc -0.0162 Tw (Journal of Occupational and Environmen-)Tj -5.67 -1.401 TD -0.0111 Tc -0.06 Tw (tal Medicine, 43)Tj /TT2 1 Tf 6.234 0 TD -0.0118 Tc -0.0646 Tw [(\(12\), 1073-)-8.8(1080.)]TJ -7.434 -1.8 TD -0.0026 Tc -0.015 Tw [(Everly)63.4(, G)117.4(.)-0.6( S., Jr)51.4(. \(1980\). )]TJ /TT5 1 Tf 9.711 0 TD -0.004 Tc [(The natur)32(e and tr)29(eatment of the hu-)]TJ -8.511 -1.401 TD -0.0058 Tc -0.0621 Tw [(man str)30.2(ess r)27.2(esponse)]TJ /TT2 1 Tf 7.77 0 TD -0.0054 Tc -0.063 Tw [(. NY)84.6(: Plenum.)]TJ -8.97 -1.8 TD -0.0085 Tc -0.0621 Tw [(Everly)60.5(, G)117.5(.)-0.2( S., Jr)54.5(. & Lating, J. M. \(2002\). )]TJ /TT5 1 Tf 15.345 0 TD -0.0092 Tc -0.0625 Tw [(A)22.6( clinical guide to the)]TJ -14.145 -1.398 TD -0.0043 Tc -0.0145 Tw [(tr)31.7(eatment of the human str)28.7(ess r)31.7(esponse)]TJ /TT2 1 Tf 15.315 0 TD -0.0152 Tw [(. NY)85.6(: Plenum.)]TJ -16.515 -1.8 TD -0.0025 Tc 0.0031 Tw [(Everly)63.5(, G)117.5(.)-0.4( S., Jr)51.5(. & Lating, J. M. \(2004\). )]TJ /TT5 1 Tf 16.185 0 TD -0.0042 Tc 0.005 Tw (Personality guided)Tj -14.985 -1.401 TD 0.0939 Tw [(therapy of posttraumatic str)31.9(ess disor)31.9(der)103.9(.)]TJ /TT2 1 Tf 16.8 0 TD 0.0711 Tc 0 Tw [(W)93.9(a)0(shington,)]TJ -16.8 -1.401 TD -0.004 Tc -0.0898 Tw [(DC: American )-52(Psychological Association.)]TJ ET endstream endobj 156 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 158 0 obj << /Length 11442 >> 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. 4 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (269)Tj /TT2 1 Tf 10 0 0 10 66 722.64 Tm -0.0164 Tc -0.0622 Tw [(Everly)61.6(, G)115.6(.)-0.9( S., Jr)52.6(., Smith, K. J., & )13.7(W)99.4(elzant, )10.7(V)135.8(.)0.7( \(2008\). Cognitive-)]TJ 1.2 -1.398 TD -0.0035 Tc 0.0965 Tw (affective resilience indicia as predictors of burnout and)Tj 0 -1.401 TD -0.0037 Tc -0.045 Tw (job-related outcome. )Tj /TT5 1 Tf 8.361 0 TD -0.0041 Tc -0.0466 Tw (International Journal of Emergency)Tj -8.361 -1.401 TD -0.0082 Tc -0.06 Tw (Mental Health)Tj /TT2 1 Tf 5.64 0 TD 0.001 Tc 0 Tw (, )Tj /TT5 1 Tf 0.435 0 TD -0.016 Tc (10)Tj /TT2 1 Tf 0.981 0 TD -0.0079 Tc -0.06 Tw (\(3\), 185-189.)Tj -8.256 -1.8 TD -0.0036 Tc 0.0465 Tw (Fredrickson, B. L. \(2000\). Cultivating positive emotions to)Tj 1.2 -1.398 TD -0.0037 Tc -0.0175 Tw (optimize health and well-being. )Tj /TT5 1 Tf 12.729 0 TD -0.0045 Tc -0.0196 Tw [(P)5.5(r)28.5(evention & T)52.5(r)33.7(eatment)]TJ /TT2 1 Tf 9.522 0 TD 0 Tc 0 Tw (,)Tj /TT5 1 Tf -22.251 -1.401 TD (3)Tj /TT2 1 Tf 0.486 0 TD -0.0168 Tc -0.06 Tw [( \(1\).)]TJ -1.686 -1.8 TD -0.0032 Tc -0.0358 Tw [(Grieger)35.8(, )17.9(T)76.6(.)-4.1( )50.9(A., Fullerton, C. S., & Ursano, R. J. \(2003\). Post-)]TJ 1.2 -1.401 TD 0.0172 Tc 0.1258 Tw [(traumatic stress disorder)32.2(, alcohol use, and perceived)]TJ 0 -1.398 TD -0.0094 Tc -0.0622 Tw (safety after the terrorist attack of September 11, 2001. )Tj /TT5 1 Tf 20.76 0 TD -0.0123 Tc 0 Tw (Psy-)Tj -20.76 -1.401 TD -0.0098 Tc -0.06 Tw (chiatric Services, 54)Tj /TT2 1 Tf 7.869 0 TD -0.0102 Tc -0.065 Tw (\(10\), 1380-1382.)Tj -9.069 -1.8 TD -0.0622 Tw [(Grieger)40.8(, )14.1(T)75.6(.)-1.7( )50.1(A., )14.1(W)99.6(aldrep, D. )53.1(A., Lovasz, M. M., & Ursano, R. J.)]TJ 1.2 -1.401 TD -0.0033 Tc -0.0609 Tw (\(2005\). Follow-up of Pentagon employees two years after)Tj 0 -1.398 TD -0.0101 Tc -0.0614 Tw (the terrorist attack of September 11, 2001. )Tj /TT5 1 Tf 16.26 0 TD -0.011 Tc -0.065 Tw (Psychiatric Ser-)Tj -16.26 -1.401 TD -0.0218 Tc -0.06 Tw (vices, 56)Tj /TT2 1 Tf 3.246 0 TD -0.0223 Tc (\(11\), 1374-1378.)Tj -4.446 -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 -1.401 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 -1.398 TD -0.0148 Tc (Psychiatry)Tj /TT2 1 Tf 4.131 0 TD -0.0139 Tc -0.0625 Tw (, 6, 23-30.)Tj -5.331 -1.8 TD 0.0143 Tc 0.1251 Tw [(Institute of Medicine of the National )53.4(Academies \(IOM;)]TJ 1.2 -1.401 TD -0.0048 Tc 0 Tw (2003\).)Tj /TT5 1 Tf 2.559 0 TD -0.0035 Tc -0.0414 Tw [(The futur)32.5(e of the public)125.5(s health in the 2)6.5(1)]TJ 5.8 0 0 5.8 263.25 440.01 Tm -0.0049 Tc 0 Tw (st)Tj 10 0 0 10 267.09 436.65 Tm -0.0038 Tc -0.0458 Tw [( Century)53(.)]TJ /TT2 1 Tf -18.909 -1.401 TD -0.0041 Tc 0.008 Tw [(W)93.7(ashington, DC: )16.9(The National )49.9(Academies Press.)]TJ -1.2 -1.8 TD -0.0065 Tc -0.0625 Tw [(Jacobson, J. M., Paul, J., & Blum, D. \(2005\). The EAP work-)]TJ 1.2 -1.398 TD -0.0135 Tc -0.0612 Tw (place critical incident continuum. )Tj /TT5 1 Tf 12.921 0 TD -0.0143 Tc -0.0625 Tw (The Journal of Employee)Tj -12.921 -1.401 TD -0.0109 Tc -0.06 Tw (Assistance, 32)Tj /TT2 1 Tf 5.514 0 TD -0.0103 Tc (\(2\), 28-30.)Tj -6.714 -1.8 TD -0.0111 Tc -0.0623 Tw [(Jensen, L. )16.1(W)107.7(., Decker)33.9(, L., & )49.1(Andersen, M. M. \(2006\). Depres-)]TJ 1.2 -1.401 TD -0.0036 Tc -0.0621 Tw (sion and health-promoting lifestyles of persons with men-)Tj 0 -1.398 TD -0.0032 Tc 0.09 Tw (tal illnesses. )Tj /TT5 1 Tf 5.274 0 TD -0.0036 Tc (Issues of Mental Health Nursing, 27, )Tj /TT2 1 Tf 15.411 0 TD -0.006 Tc 0 Tw (617-)Tj -20.685 -1.401 TD -0.0583 Tc (634.)Tj -1.2 -1.8 TD -0.0152 Tc -0.0622 Tw [(Kagen, N. I., Kagan, H., & )14.9(W)94.6(atson, M. G)113.8(.)0.1( \(1995\). 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Proceedings of)]TJ 1.2 -1.398 TD -0.0039 Tc -0.0287 Tw (the 2004 Conference on )Tj /TT5 1 Tf 9.63 0 TD -0.004 Tc -0.03 Tw (Prevention of Mental Disorders:)Tj -9.63 -1.401 TD 0.0237 Tc 0.1249 Tw (Effective Interventions and Options. )Tj /TT2 1 Tf 16.074 0 TD 0.0233 Tc 0.1077 Tw [(Geneva: W)97.1(orld)]TJ -16.074 -1.401 TD -0.0079 Tc -0.06 Tw (Health Organization.)Tj /TT5 1 Tf 9 0 0 9 351 248.01 Tm -0.0049 Tc -0.0009 Tw (Manuscript submitted and accepted December 3, 2008)Tj ET endstream endobj 162 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 164 0 obj << /Length 6178 >> 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. 4 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (271)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. 4, pp. 271-274 2008 Chevron Publishing ISSN 1522-4821)]TJ /TT4 1 Tf 10 0 0 10 104.01 510.36 Tm -0.0041 Tc 0 Tw (Abstract: )Tj /TT5 1 Tf 3.993 0 TD 0.0074 Tw [(Nationally)50(, health car)29(e is moving towar)32(d standar)32(ds of evidence-based tr)32(eatments and practices.)]TJ -3.993 -1.302 TD -0.0036 Tc 0.0314 Tw (Evidence-based care is rooted in empirical data that demonstrate safety and efficacy for the intervention)Tj 0 -1.299 TD 0.0521 Tw [(in question. In time, all medicines, surgical interventions, rehabilitation approaches, and psychological)]TJ T* 0.0577 Tw [(treatments will be expected to be rooted in data. Crisis intervention services will not be exempted from)]TJ 0 -1.302 TD -0.0037 Tc 0.0473 Tw [(this national standard. This paper reviews the lessons learned from the Assaulted Staff Action Program)]TJ 0 -1.299 TD -0.0038 Tc 0.0133 Tw (\(ASAP\) data base to illustrate how empirical data can meet the national standard of evidence-based care)Tj T* -0.0036 Tc -0.02 Tw [(and improve the quality of services provided. The ASAP data have demonstrated the safety and efficacy of)]TJ 0 -1.302 TD -0.0366 Tw (ASAP as well as providing insights for risk management strategies in the changing face of patient violence.)Tj 0 -1.299 TD 0.0922 Tw ([International Journal of Emergency Mental Health, 2008, 10\(4\), pp. 271-274].)Tj /TT1 1 Tf -0.201 -2.7 TD -0.0057 Tc -0.0375 Tw (Key words: )Tj /TT5 1 Tf 5.034 0 TD -0.0038 Tc -0.0383 Tw (Assaulted Staff Action Program \(ASAP\), crisis intervention, evidence-based practices, lessons)Tj -5.034 -1.299 TD -0.0012 Tc 0.125 Tw (learned, patient assaults.)Tj ET /GS1 gs 66 166.755 m 299.01 166.755 l S BT /TT2 1 Tf 9 0 0 9 66 149.01 Tm /GS2 gs 0.054 Tc 0.1254 Tw [(Raymond B. Flannery)57.3(, Jr)47.3(., PhD, is Senior Psychologist,)]TJ 0 -1.2233 TD 0.0096 Tc 0.126 Tw [(Massachusetts Department of )-7(Mental Health, )9.7(W)86.8(orcester S)9.6(tate)]TJ T* -0.0048 Tc -0.019 Tw [(Hospital and )51.9(Associate Clinical Professor of Psychology)61.9(, Harvard)]TJ 0 -1.22 TD -0.0046 Tc -0.0371 Tw [(Medical School. Dr)52.1(. Flannery created and has been Director of the)]TJ 0 -1.2233 TD -0.0052 Tc 0.075 Tw [(Assaulted S)11.5(t)5.5(a)5.5(f)11.5(f )51.5(Action Program \(ASAP\) for its seventeen years.)]TJ T* -0.0069 Tc -0.0625 Tw (Correspondence regarding this article may be directed to Raymond)Tj 0 -1.22 TD -0.0042 Tc 0.1244 Tw [(B. Flannery)62.5(, Jr)52.5(., Ph.D., Department of Psychology)62.5(,)-5.1( )-4.8( )12.8(W)89.6(orcester)]TJ 0 -1.2233 TD -0.0054 Tc 0.076 Tw [(S)17.4(tate Hospital, 305 Belmont S)11.3(treet, )7.7(W)88.4(orcester)34.6(, MA)51.3( 01604)]TJ /F1 1 Tf 14 0 0 14 147.15 656.34 Tm -0.0014 Tc 0.1379 Tw (Crisis Intervention Services and Empirical Data:)Tj -4.5536 -1.1421 TD -0.0023 Tc 0.1375 Tw [(Lessons Learned from the Assaulted Staff Action Program \(ASAP\))]TJ /TT2 1 Tf 10 0 0 10 84.99 314.64 Tm 0.0017 Tc 0.125 Tw (After thirty years of intensive crisis intervention re-)Tj -1.8 -1.398 TD -0.0033 Tc 0.1019 Tw [(search and ten years of this Journal)50.7(s important contribu-)]TJ 0 -1.401 TD -0.0036 Tc 0.0007 Tw [(tions toward the field)50.4(s development, this short perspective)]TJ T* -0.0037 Tc -0.0107 Tw (focuses on the continuing importance of empirical research)Tj 0 -1.398 TD -0.0052 Tc -0.0621 Tw (in improving the quality of clinically efficacious, cost-effec-)Tj 0 -1.401 TD -0.004 Tc 0.0018 Tw [(tive crisis intervention procedures. )14.4(The )53.4(Assaulted S)14(taf)17(f )50.4(Ac-)]TJ T* 0.0164 Tc 0.125 Tw [(tion Program \(ASAP; Flannery)58.4(, 1998\), online 24/7 for)]TJ 0 -1.398 TD -0.0032 Tc -0.043 Tw (seventeen years with 34 teams in )Tj 13.0779 0 TD -0.0042 Tc -0.042 Tw [(six states and 1,400 )50.8(ASAP)]TJ -13.0779 -1.401 TD -0.0037 Tc -0.0375 Tw (team members, provides the focus for lessons learned about)Tj T* -0.0034 Tc -0.058 Tw (the important role of empirical data.)Tj 12 0 0 12 254.16 593.64 Tm -0.0173 Tc -0.0614 Tw [( Raymond B. Flannery)57.7(, Jr)50.2(.)]TJ 10 0 0 10 212.91 581.01 Tm 0.001 Tc 0.07 Tw (The Massachusetts Department of Mental Health)Tj 9.258 -1.2 TD 0.0281 Tc 0 Tw (and)Tj -4.125 -1.2 TD 0.0007 Tc -0.0475 Tw (Harvard Medical School)Tj 7.476 -24.237 TD -0.0032 Tc 0.0744 Tw (It is true, as both historians \(Razario, 2007\) and clini-)Tj -1.8 -1.398 TD -0.0066 Tc -0.0625 Tw [(cians \(Raphael & )14.4(W)58.2(i)-0.3(lson, 2000\) have indicated, that opportu-)]TJ 0 -1.401 TD -0.0033 Tc 0.1234 Tw [(nities for personal and societal growth are present in the)]TJ T* -0.0096 Tc -0.0624 Tw [(aftermath of critical incidents. However)38.4(,)-0.1( in the immediate im-)]TJ 0 -1.398 TD -0.0035 Tc 0.0862 Tw (pact of these critical events lives and communities experi-)Tj 0 -1.401 TD 0.0162 Tc 0.125 Tw (ence great disruptions and sound, empirically validated)Tj T* -0.0031 Tc -0.0155 Tw [(methods of clinical intervention need be at the ready for uti-)]TJ 0 -1.398 TD -0.003 Tc 0.005 Tw (lization by emergency services and health care providers.)Tj 1.8 -2.001 TD -0.0032 Tc 0.0381 Tw (If emergency service and health care providers are do-)Tj -1.8 -1.401 TD -0.0034 Tc 0.1012 Tw (ing good work, why is empirical validation important and)Tj 0 -1.398 TD 0.0188 Tc 0 Tw (necessary?)Tj 1.8 -2.001 TD -0.0085 Tc -0.0625 Tw [( The first principle in medicine and all health care is to do)]TJ -1.8 -1.401 TD -0.0033 Tc 0.1241 Tw [(no harm. Human nature being what it is, self-reports of)]TJ 0 -1.398 TD -0.0035 Tc -0.0485 Tw [(perceived beneficial outcomes by victims and care providers)]TJ 0 -1.401 TD -0.0031 Tc -0.0019 Tw (are not necessarily accurate. Even if an intervention is ben-)Tj T* 0.1218 Tw (eficial in one case, the field cannot infer that it would be)Tj 0 -1.398 TD -0.0183 Tc -0.0625 Tw [(necessarily beneficial to others in similar circumstances. Some)]TJ ET endstream endobj 165 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 168 0 obj << /Length 9858 >> 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 /TT3 1 Tf 8 0 0 8 54.99 41.64 Tm 0 0 0 1 k /GS2 gs -0.0051 Tc 0.1 Tw [(272 Flannery )]TJ 7.7213 0 TD 0.0036 Tc (Lessons Learned from ASAP)Tj /TT2 1 Tf 10 0 0 10 54 722.64 Tm -0.0025 Tc 0.125 Tw (objective process is needed in which perceived beneficial)Tj 0 -1.398 TD -0.0036 Tc 0.0412 Tw (outcomes are based in behavior that is observable, measur-)Tj 0 -1.401 TD -0.0033 Tc 0.0165 Tw [(able, and attainable and which results in empirical data. )14.7(T)73.5(o)]TJ T* -0.0031 Tc 0.0011 Tw (obtain this goal, society has created the scientific method to)Tj 0 -1.398 TD -0.0033 Tc 0.0395 Tw (evaluate these processes in health care so as to be sure that)Tj 0 -1.401 TD -0.0069 Tc -0.062 Tw (medicines, surgical interventions, rehabilitation services, and)Tj T* 0.0053 Tc 0.125 Tw (counseling interventions, including crisis counseling ser-)Tj 0 -1.398 TD -0.0033 Tc 0.038 Tw (vices, are both safe and helpful in resolving the health care)Tj 0 -1.401 TD -0.0035 Tc 0.09 Tw (issue at hand.)Tj 1.8 -2.001 TD 0.056 Tw [(There are two main methods of attaining data. 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The second form of)]TJ 0 -1.401 TD -0.0037 Tc 0.0237 Tw (evidence is known as )Tj /TT5 1 Tf 8.796 0 TD -0.0041 Tc 0 Tw (evidence-based )Tj /TT4 1 Tf 6.378 0 TD -0.0043 Tc (practice)Tj /TT1 1 Tf 3.246 0 TD 0 Tc ( )Tj /TT2 1 Tf 0.276 0 TD -0.0036 Tc 0.025 Tw (and refers to)Tj -18.696 -1.401 TD -0.0022 Tc 0.125 Tw (clinical care that is informed by evidence about interven-)Tj 0 -1.398 TD -0.0033 Tc 0.0211 Tw [(tions, clinical expertise, and patient needs and values. [See)]TJ 0 -1.401 TD -0.0035 Tc 0.0794 Tw (Kazdin \(2008\) for a detailed review of these two differing)Tj T* -0.0034 Tc -0.0292 Tw [(approaches.] Both approaches yield behavioral, observable,)]TJ 0 -1.398 TD -0.0035 Tc 0.1108 Tw (measurable, and attainable data regarding beneficial inter-)Tj 0 -1.401 TD -0.0031 Tc 0.125 Tw (ventions and outcomes.)Tj 1.8 -2.001 TD 0.005 Tc (Evidence-based treatments and evidence-based prac-)Tj -1.8 -1.398 TD -0.0017 Tc (tices are rapidly becoming the national standards of care.)Tj 0 -1.401 TD -0.0035 Tc -0.0566 Tw (Health care providers, including emergency services person-)Tj T* -0.003 Tc 0.0043 Tw (nel, are expected by licensure, federal and state regulations,)Tj 0 -1.398 TD -0.0036 Tc 0.035 Tw (insurance companies, and informed employers and patients)Tj 0 -1.401 TD -0.0037 Tc 0.0827 Tw [(to practice with evidence-informed interventions. )50.1(As time)]TJ T* 0.0088 Tc 0.125 Tw (passes, interventions that appear efficacious but that are)Tj 0 -1.398 TD -0.0031 Tc -0.0033 Tw (without empirical data will likely no longer be permitted by)Tj 0 -1.401 TD 0.0141 Tw (regulatory statutes nor reimbursed by insurance companies.)Tj T* -0.0029 Tc -0.039 Tw (This is why data collection on the efficacy of crisis interven-)Tj 0 -1.398 TD -0.0034 Tc 0.0082 Tw (tion procedures has become so critical to the field.)Tj 1.8 -2.001 TD -0.0035 Tc 0.0606 Tw (This paper illustrates how empirical data can meet the)Tj -1.8 -1.401 TD -0.0033 Tc 0.0929 Tw (standard of evidence-based care for efficacy and addition-)Tj 0 -1.398 TD -0.0028 Tc 0.0241 Tw [(ally improve the quality of that care. The paper focuses on)]TJ 0 -1.401 TD 0.0227 Tc 0.1254 Tw [(some of the important lessons learned from the )47.1(ASAP)]TJ T* -0.0036 Tc 0.0382 Tw [(program)50.4(s empirical data \(Flannery 1998\) during its seven-)]TJ 0 -1.398 TD -0.0028 Tc 0.09 Tw [(teen years of service. These lessons include the ability to)]TJ 0 -1.401 TD -0.0034 Tc -0.0475 Tw (continuously provide crisis intervention services, to enhance)Tj T* 0.0021 Tw (quality management procedures, to adapt to societal change)Tj 0 -1.398 TD -0.0033 Tc -0.061 Tw (with a flexible research design, to publish findings for a criti-)Tj 0 -1.401 TD -0.0034 Tc 0.0578 Tw (cal audience, and to address the cultural resistance and de-)Tj T* -0.0033 Tc 0.0112 Tw (nial associated with psychological trauma.)Tj /F1 1 Tf 11 0 0 11 309 723.99 Tm -0.0057 Tc 0.0182 Tw [( Lessons Learned)]TJ /TT2 1 Tf 10 0 0 10 327 700.65 Tm -0.0042 Tc 0.0369 Tw [(The )50(Assaulted S)16.8(taf)13.8(f )53(Action Program \(ASAP; Flannery)58.8(,)]TJ -1.8 -1.401 TD -0.0031 Tc -0.0513 Tw [(1998\) is a voluntary)62.9(, system-wide, peer)17.9(-help, crisis interven-)]TJ 0 -1.398 TD -0.0035 Tc 0.0673 Tw (tion program to assist staff victims of patient assaults with)Tj 0 -1.401 TD -0.0031 Tc -0.0181 Tw (psychological aftermath of these critical )Tj 16.0796 0 TD -0.0046 Tc -0.017 Tw [(incidents. )50.5(ASAP)31.4( is)]TJ -16.0796 -1.401 TD 0.0026 Tc 0.125 Tw (a critical incident stress management program \(Everly &)Tj 0 -1.398 TD -0.0032 Tc -0.0599 Tw [(Mitchell, 1999\) in that it contains differing types of interven-)]TJ 0 -1.401 TD -0.0034 Tc 0.0585 Tw (tion services, including individual, group, staff victim sup-)Tj T* -0.0033 Tc -0.0178 Tw (port groups, family victim outreach, and individual referrals)Tj 0 -1.398 TD -0.0034 Tc 0.0263 Tw (to trauma specialists, as indicated.)Tj 1.8 -2.001 TD -0.0038 Tc 0.0331 Tw (ASAP has firm empirical support and has been associ-)Tj -1.8 -1.401 TD -0.0032 Tc 0.0268 Tw [(ated with resolving intense fear in staff victims. It has also)]TJ 0 -1.398 TD -0.0181 Tc -0.0625 Tw (been associated with facility-wide declines in violence in many)Tj 0 -1.401 TD -0.0042 Tc 0.0735 Tw [(facilities after an )50.8(ASAP)]TJ 9.564 0 TD -0.0033 Tc 0.0725 Tw [( team was fielded \(Flannery)59.7(, 1998;)]TJ -9.564 -1.401 TD -0.0069 Tc -0.0623 Tw [(Flannery)62.1(, Farley)62.1(, Rego & )17(W)]TJ 10.776 0 TD -0.0077 Tc -0.0609 Tw [(alker)37.3(, 2006\). )]TJ 5.193 0 TD -0.0098 Tc [(Although the )48.6(ASAP)]TJ -15.969 -1.398 TD -0.003 Tc -0.0409 Tw [(declines in violence do not occur in every facility)60(, it happens)]TJ 0 -1.401 TD -0.0031 Tc 0.0155 Tw (frequently enough so that )Tj 10.4231 0 TD -0.0047 Tc -0.0368 Tw [(the ASAP)28.3( )-53.8(program )]TJ 7.8071 0 TD -0.0032 Tc 0.0155 Tw (has felt that it)Tj -18.2302 -1.401 TD -0.0082 Tc -0.0625 Tw [(would be unethical to wi)]TJ 9.4387 0 TD -0.0624 Tw [(thhold an )]TJ 3.7403 0 TD -0.0103 Tc -0.0594 Tw [(ASAP)28.7( team )]TJ 4.75 0 TD -0.0072 Tc -0.0625 Tw (from any facil-)Tj -17.929 -1.398 TD -0.003 Tc -0.0154 Tw [(ity that wanted its own team. )]TJ 11.8537 0 TD -0.0042 Tc -0.0142 Tw [(For this reason, )51(ASAP)]TJ 8.7923 0 TD -0.0037 Tc -0.0154 Tw [( has not)]TJ -20.646 -1.401 TD 0.0018 Tc 0.125 Tw (conducted a randomized controlled study to date and the)Tj T* -0.0042 Tc -0.0625 Tw (lessons learned research reported below are evidenced-based)Tj 0 -1.398 TD -0.0034 Tc 0.04 Tw (practice data.)Tj 11 0 0 11 309 381.36 Tm 0 Tc 0 Tw ( )Tj /TT5 1 Tf 0.3873 0 TD 0.0116 Tc 0.1274 Tw [(Continuous Pr)33.4(ovision of Services)]TJ /TT2 1 Tf 10 0 0 10 327 361.65 Tm -0.007 Tc -0.0623 Tw (The first lesson is the importance and power of empirical)Tj -1.8 -1.401 TD -0.0036 Tc -0.0266 Tw (data in permitting the ongoing functioning )Tj 16.906 0 TD -0.0051 Tc -0.0251 Tw [(of the )53.5(ASAP)27.9( pro-)]TJ -16.906 -1.398 TD -0.0033 Tc -0.0446 Tw [(gram. This has been true in three sets of circumstances. The)]TJ 0 -1.401 TD 0.0277 Tw [(first was, and is, the co)]TJ 9.2475 0 TD (ntinued functioni)Tj 6.8307 0 TD -0.005 Tc 0.0292 Tw [(ng of )50.4(ASAP)31( within)]TJ -16.0782 -1.401 TD -0.0069 Tc -0.0625 Tw [(the MA Department of Mental Health. Consecutive commis-)]TJ 0 -1.398 TD 0.006 Tc 0.125 Tw (sioners have cited the need for )Tj 13.329 0 TD 0.0047 Tc 0.1261 Tw [(ASAP)28.7( to demonstrate its)]TJ -13.329 -1.401 TD -0.0035 Tc 0 Tw (clinical effectiveness on an ongoing basis and such data has)Tj T* -0.0038 Tc -0.0413 Tw [(been available for each commissioner)50.2(.)]TJ 1.8 -1.998 TD -0.0037 Tc -0.01 Tw (The second circumstance involved the international de-)Tj -1.8 -1.401 TD -0.0086 Tc -0.0625 Tw (bate on Critical Incident Stress Debriefing \(CISD; Mitchell &)Tj T* -0.0031 Tc -0.0167 Tw [(Everly)62.9(, 2001\). )14.9(This debate focused lar)17.9(gely on the perceived)]TJ 0 -1.398 TD -0.0036 Tc -0.0583 Tw [(lack of empirical evidence to support CISD interventions. In)]TJ 0 -1.401 TD -0.0044 Tc 0.072 Tw [(this debate )53.5(ASAP)28.6( was cited )]TJ 11.5206 0 TD -0.0033 Tc 0.0711 Tw (as a similar crisis intervention)Tj -11.5206 -1.401 TD -0.0041 Tc 0.0529 Tw (program. While helpful suggestions were made to improve)Tj 0 -1.398 TD -0.0046 Tc 0.0003 Tw [(ASAP)103.4(, its empirical )]TJ 8.0829 0 TD -0.0035 Tc -0.0008 Tw (foundation was not challenged.)Tj -6.2829 -2.001 TD -0.0037 Tc 0.05 Tw (The third set of circumstances involves the emergence)Tj -1.8 -1.401 TD -0.0038 Tc 0.0486 Tw [(of Psychological First )50.2(Aid \(PF)74.2(A; National Child )14.2(T)37(raumatic)]TJ 0 -1.398 TD 0.0273 Tw (Stress Network and National Center for PTSD, 2005\) as an)Tj 0 -1.401 TD 0.0027 Tc 0.125 Tw (acceptable form for national crisis intervention purposes.)Tj T* 0.1259 Tw [(ASAP)26.8( has met and surpassed )]TJ 12.6507 0 TD 0.0039 Tc 0.125 Tw [(all PF)69.9(A)60.1( standards and, be-)]TJ ET endstream endobj 169 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 171 0 obj << /Length 9211 >> 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. 4 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (273)Tj /TT2 1 Tf 10 0 0 10 66 722.64 Tm -0.003 Tc 0.086 Tw (cause of this ability to meet the )Tj 13.2457 0 TD -0.0045 Tc 0.0868 Tw [(PF)70.5(A)57.7( standards, )50.3(ASAP)31.5( has)]TJ -13.2457 -1.398 TD -0.0032 Tc -0.0155 Tw (been accepted for use by some state regulators as an empiri-)Tj 0 -1.401 TD -0.0033 Tc 0.0134 Tw (cally-validated crisis intervention procedure.)Tj 11 0 0 11 66 661.35 Tm 0 Tc 0 Tw ( )Tj /TT5 1 Tf 0.39 0 TD 0.0157 Tc 0.1273 Tw (Enhanced Quality Management)Tj /TT2 1 Tf 10 0 0 10 84 641.64 Tm -0.0036 Tc 0.0537 Tw (ASAP gathers data on both patient assailants and staff)Tj -1.8 -1.398 TD -0.0032 Tc 0.0161 Tw [(victims in very incident. 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In)]TJ T* -0.0031 Tc 0.0649 Tw [(today)50.9(s age, it appears perilous not to empirically examine)]TJ 0 -1.398 TD 0.0005 Tc 0.1249 Tw [(the care that is being provided by any given set of crisis)]TJ 0 -1.401 TD -0.0008 Tc 0.125 Tw (intervention procedures.)Tj /F1 1 Tf 11 0 0 11 133.89 311.19 Tm 0.021 Tc 0 Tw (REFERENCES)Tj /TT2 1 Tf 10 0 0 10 54 293.85 Tm -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 -0.0042 Tc 0.0271 Tw (Management \(CISM\):A new era and standard of care in)Tj 0 -1.398 TD -0.0208 Tc -0.0597 Tw [(crisis inter)-5.8(vention.)]TJ /TT2 1 Tf 7.035 0 TD -0.0204 Tc -0.0621 Tw [( Second Edition. EllicottCity)66.6(, MD: Chev-)]TJ -7.035 -1.401 TD -0.0041 Tc 0.02 Tw (ron Publishing.)Tj -1.2 -1.8 TD -0.0027 Tc 0.0461 Tw [(Flannery)60.3(, R.B., Jr)51.3(. \(1998\). )]TJ /TT5 1 Tf 11.07 0 TD -0.0047 Tc 0.0342 Tw [(The Assaulted )-13.8(S)31.3(taff Action )-14(Pr)31.3(o-)]TJ -9.87 -1.401 TD -0.0017 Tc 0.125 Tw [(gram \(ASAP\): Coping with the )-4.7(aftermath of violence.)]TJ /TT2 1 Tf 0 -1.398 TD -0.0071 Tc -0.0625 Tw [(Ellicott City)58.9(, MD.: Chevron Publishing.)]TJ 24.3 51.678 TD -0.0293 Tc -0.0619 Tw [(Flannery)66.7(, R.B., Jr)54.7(., Farley)66.7(, E.M., Rego, S., & )22.3(W)95.5(alker)33.7(, )52.3(A.P)102.7(. \(2006\).)]TJ 1.2 -1.398 TD -0.0032 Tc 0.0476 Tw (Characteristics of staff victims of psychiatric patient as-)Tj 0 -1.401 TD -0.0033 Tc 0.0891 Tw [(saults: Fifteen-year analysis of the )51(Assaulted S)17.7(taf)14.7(f )51(Ac-)]TJ T* -0.0042 Tc -0.0533 Tw (tion Program \(ASAP\). )Tj /TT5 1 Tf 8.979 0 TD -0.0039 Tc -0.0544 Tw [(Psychiatric Quarterly)50.1(, 78,)]TJ /TT2 1 Tf 10.242 0 TD -0.004 Tc -0.055 Tw [( 25-37.)]TJ -20.421 -1.8 TD -0.0269 Tc -0.0624 Tw [(Flannery)60.1(, R.B., Jr)51.1(., Juliano, J., Cronin, S., & )18(W)94.9(alker)39.1(, )45(A. 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Past violence, substance use, and precipi-)]TJ 0 -1.401 TD -0.0028 Tc -0.0091 Tw (tants to psychiatric patient assaults: Eleven-year analysis)Tj T* -0.0041 Tc -0.0004 Tw [(of the )50.1(Assaulted S)16.9(taf)13.9(f )53.1(Action Program \(ASAP\). )]TJ /TT5 1 Tf 19.254 0 TD -0.0044 Tc 0 Tw (Interna-)Tj -19.254 -1.398 TD -0.004 Tc 0.0887 Tw (tional Journal of Emergency Mental)Tj 16.8 0 TD -0.0163 Tc -0.06 Tw (Health, 8,)Tj /TT2 1 Tf 3.75 0 TD -0.0183 Tc [( 157-)]TJ -20.55 -1.401 TD -0.0583 Tc 0 Tw (163.)Tj -1.2 -1.8 TD -0.0071 Tc -0.0621 Tw [(Flannery)61.9(, R.B., Jr)52.9(., )17.3(White, D. L., Flannery)58.9(, G)115.9(.)-2.5( J., )17.3(W)96.8(alker)37.9(, )53.3(A. P)106.9(.)]TJ 1.2 -1.401 TD -0.0064 Tc [(\(2008\). Time of psychiatric patient assaults: Eleven-year)]TJ 0 -1.398 TD -0.0041 Tc 0.0029 Tw [(Analysis of the )52(Assaulted S)16.9(taf)13.9(f )52(Action Program \(ASAP\).)]TJ /TT5 1 Tf 0 -1.401 TD -0.0063 Tc -0.0625 Tw (International Journal of Emergency Mental Health, 2007,)Tj T* -0.03 Tc 0 Tw (9,)Tj /TT2 1 Tf 0.699 0 TD -0.0287 Tc -0.06 Tw [( 89-96.)]TJ -1.899 -1.8 TD -0.0043 Tc -0.0624 Tw [(Kazdin, )52.8(A.E. \(2008\). Evidence-based treatment and practice:)]TJ 1.2 -1.398 TD -0.0037 Tc 0.0969 Tw (New opportunities to bridge clinical research and prac-)Tj 0 -1.401 TD -0.0036 Tc 0.1193 Tw (tice, enhance the knowledge base, and improve patient)Tj T* -0.0029 Tc 0 Tw (care. )Tj /TT5 1 Tf 2.1 0 TD -0.0037 Tc -0.05 Tw (American Psychologist, 63, )Tj /TT2 1 Tf 11.001 0 TD -0.0049 Tc 0 Tw (146-159.)Tj -14.301 -1.8 TD -0.021 Tc -0.0623 Tw [(Mitchell, J.T)69(., & Everly)60(, G)114(.S., Jr)54(. \(2001\). )]TJ /TT5 1 Tf 15.255 0 TD -0.0221 Tc [(Critical incident str)34.9(ess)]TJ -14.055 -1.398 TD -0.0038 Tc 0.1198 Tw [(debriefing: An operations manual for CISD, defusing,)]TJ 0 -1.401 TD -0.0492 Tw [(and other gr)29.2(oup crisis intervention services.)]TJ /TT2 1 Tf 17.28 0 TD -0.0025 Tc -0.05 Tw [( Ellicott City)60.5(,)]TJ -17.28 -1.401 TD -0.0043 Tc -0.04 Tw (MD: Chevron Publishing Corp.)Tj -1.2 -1.8 TD -0.0039 Tc -0.0464 Tw (National Child Traumatic Stress Network and National Cen-)Tj 1.2 -1.398 TD -0.0034 Tc 0.01 Tw (ter for PTSD \(2005\). )Tj /TT5 1 Tf 8.811 0 TD -0.0038 Tc (Psychological First Aid: Field op-)Tj -8.811 -1.401 TD 0.06 Tw (erations guide.)Tj /TT2 1 Tf 6.006 0 TD -0.004 Tc 0.045 Tw [( )-21( W)93.8(ashington, )-17.1(DC: The )-16.9(authors.)]TJ -7.206 -1.8 TD -0.0031 Tc -0.0124 Tw [(Raphael, B., & )18(W)55.7(ilson, J.P)104.9(. \(Eds.; 2000\). )]TJ /TT5 1 Tf 16.59 0 TD -0.0042 Tc -0.015 Tw (Psychological de-)Tj -15.39 -1.401 TD -0.0038 Tc 0.0597 Tw [(briefing: Theory)56(,)-0.5( )]TJ 7.0784 0 TD -0.0033 Tc 0.06 Tw (practice, and)Tj 6.1216 0 TD 0.0049 Tc (evidence.)Tj /TT2 1 Tf 3.795 0 TD 0.0056 Tc 0.125 Tw [( Cambridge,)]TJ -16.995 -1.398 TD -0.0063 Tc -0.0616 Tw (UK: Cambridge University Press.)Tj -1.2 -1.8 TD -0.0047 Tc -0.0617 Tw (Rozario, K. \(2007\). )Tj /TT5 1 Tf 7.779 0 TD -0.005 Tc -0.0625 Tw (The culture of calamity: Disaster and the)Tj -6.579 -1.401 TD -0.004 Tc 0.0925 Tw (making of modern America. )Tj /TT2 1 Tf 11.685 0 TD -0.0032 Tc 0.095 Tw [(Chicago, IL: University of)]TJ -11.685 -1.401 TD -0.0041 Tc 0.035 Tw (Chicago Press.)Tj /TT5 1 Tf 9 0 0 9 364.5 164.01 Tm -0.005 Tc -0.0028 Tw (Manuscript submitted and accepted: May 28, 2008)Tj ET endstream endobj 175 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 177 0 obj << /Length 7315 >> 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. 4 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (275)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. 4, pp. 275-290 2008 Chevron Publishing ISSN 1522-4821)]TJ /TT4 1 Tf 10 0 0 10 103.5 539.34 Tm -0.0042 Tc 0 Tw (Abstract: )Tj /TT5 1 Tf 3.945 0 TD -0.0043 Tc -0.0491 Tw [(In this article we r)28.7(eview findings fr)28.7(om the W)85.7(orld T)52.7(rade Center Disaster \(WTCD\) Outcomes S)28.7(tudy)49.7(,)]TJ -3.945 -1.299 TD 0.0009 Tc 0.125 Tw [(a pr)30.9(ospective cohor)-5.1(t study of 2,368 New Y)87.9(ork City \(NYC\) adults funded by the National Institutes of)]TJ T* -0.0038 Tc 0.0424 Tw [(Health after the September 1)71.2(1)-0.3( attacks. The findings r)29.2(eported wer)32.2(e based on a baseline survey conducted)]TJ 0 -1.302 TD -0.0035 Tc 0.0997 Tw [(one year after the disaster and a follow-up conducted two years post-disaster)107.5(. One of the goals of this)]TJ 0 -1.299 TD -0.0037 Tc 0.0573 Tw (research was to assess the effectiveness of post-disaster treatments received by NYC residents following)Tj T* -0.0035 Tc 0.0975 Tw (the attacks. Among the major findings of this study were the relatively small increase in mental health)Tj 0 -1.302 TD 0.0049 Tc 0.1249 Tw (service utilization and the fact that only brief worksite interventions seemed to be an effective post-)Tj 0 -1.299 TD 0.0232 Tc 0.1251 Tw [(disaster tr)32.2(eatment intervention. Specifically)50.2(, those who r)32.2(eceived mor)35.2(e conventional post-disaster)]TJ T* 0.0022 Tc 0.125 Tw (interventions, such as formal psychotherapy sessions and/or psychotropic medicines, seemed to have)Tj 0 -1.302 TD -0.0038 Tc -0.0065 Tw (poorer outcomes. Since this study was designed to assess treatment outcomes, use advanced measurement)Tj 0 -1.299 TD -0.0037 Tc 0.0358 Tw (techniques, and incorporate propensity score matching to control for bias, these treatment findings were)Tj T* 0.0009 Tc 0.125 Tw (unexpected and raised clinical questions. Additional findings were also discussed related to minority)Tj 0 -1.302 TD -0.0038 Tc 0.0839 Tw [(g)6.4(r)29.2(oup members, alcohol abuse, the onset and course of posttraumatic str)32.2(ess disor)32.2(der post-disaster)107.2(, and)]TJ 0 -1.299 TD 0.004 Tc 0.1252 Tw [(other findings. Futur)34(e r)28(esear)28(ch is r)37(e)0.5(commended to r)28(esolve the issues raised by this important study)46(,)]TJ T* -0.0037 Tc 0.121 Tw [(especially as this relates to treatment outcomes. [International Journal of Emergency Mental Health,)]TJ 0 -1.302 TD -0.0025 Tc 0.125 Tw (2008, 10\(4\), pp. 275-290].)Tj /TT1 1 Tf 9 0 0 9 121.14 324 Tm -0.0056 Tc 0.0167 Tw (Key words: )Tj /TT5 1 Tf 5.1467 0 TD -0.0049 Tc [(Posttraumatic str)35.1(ess disor)35.1(der)105.1(, PTSD, disaster)108.4(, mental health, alcohol abuse, tr)31.8(eatment, effectiveness,)]TJ -3.3567 -1.3333 TD 0.0237 Tw [(outcomes, bar)-5(riers to car)31.7(e, brief inter)-5(ventions, W)85(orld T)51.7(rade Center Disaster)108.3(, September 1)65(1)]TJ ET /GS1 gs 66 194.745 m 299.01 194.745 l S BT /TT2 1 Tf 9 0 0 9 66 177 Tm /GS2 gs 0.0695 Tw (This research was supported in part by grants from the National)Tj 0 -1.2233 TD 0.0122 Tc 0.1253 Tw (Institute of Mental Health \(Grant # R01 MH-66403\) and the)Tj 0 -1.22 TD -0.0066 Tc -0.0624 Tw [(Pennsylvania Department of Health \(Grant # 4100042573\). )-6.3(Joseph)]TJ 0 -1.2233 TD -0.0045 Tc -0.0451 Tw (A. Boscarino, PhD, MPH serves as the Senior Investigator, Center)Tj T* -0.0063 Tc -0.0624 Tw [(for Health Research at the Geisinger Clinic. He is also an )50.6(Asscoiate)]TJ 0 -1.22 TD -0.0049 Tc -0.0095 Tw (Professor in the Depts. of Medicine and Pediatrics at Mount Sinai)Tj 0 -1.2233 TD -0.0477 Tw [(School of Medicine. Richard E. )51.8(Adams, PhD serves with the Dept.)]TJ T* -0.0056 Tc -0.0623 Tw [(of Sociology at Kent S)11.1(tate University)57.7(. )11(The authors have no conflict)]TJ 0 -1.22 TD -0.015 Tc [(of interest related to the current research. Correspondence regarding)]TJ 0 -1.2233 TD -0.0048 Tc -0.03 Tw [(the article should be directed to jaboscarino@geisinger)51.9(.edu )]TJ /F1 1 Tf 14 0 0 14 111.15 656.34 Tm -0.006 Tc 0.1297 Tw [(Over)-16.7(vie)9(w of Findings fr)15.4(om the )73.5(W)65.9(orld )95(T)80(rade Center Disaster)]TJ -0.885 -1.1421 TD -0.0018 Tc 0.1378 Tw [(Outcome Study: )-7.3(Recommendations for Future Research after)]TJ 6.6171 -1.1421 TD 0.0057 Tc 0.1384 Tw [(Exposure to Psychological )93.9(T)81(rauma)]TJ /TT2 1 Tf 10 0 0 10 84 280.14 Tm -0.0185 Tc -0.0622 Tw [(Following the September 1)29.5(1)-0.6( terrorist attacks in New )26.8(Y)103.7(ork)]TJ -1.8 -1.398 TD -0.0035 Tc -0.0425 Tw (City \(NYC\), several large-scale epidemiologic studies were)Tj 0 -1.401 TD -0.0033 Tc 0.0383 Tw (funded by the National Institutes of Health to examine the)Tj T* -0.003 Tc 0.0004 Tw [(impact of this event on area residents. )17.8(The study)63(, )]TJ /TT5 1 Tf 19.626 0 TD -0.0045 Tc 0.005 Tw (Impact of)Tj -19.626 -1.398 TD -0.0058 Tc -0.0614 Tw (Mental Health Services in NY after WTC Disaster)Tj /TT2 1 Tf 19.275 0 TD -0.0064 Tc -0.065 Tw [( \(Research)]TJ -19.275 -1.401 TD -0.0038 Tc -0.0339 Tw (Grant R01# MH-66403, Boscarino PI\), was one of these in-)Tj 12 0 0 12 399.24 593.64 Tm -0.0215 Tc -0.0587 Tw [(Richard E. )45.2(Adams)]TJ 10 0 0 10 375.99 581.01 Tm 0.0016 Tc -0.0303 Tw [(Kent S)16.6(tate University)61.6(, Kent, OH)]TJ 12 0 0 12 138.66 593.64 Tm -0.0149 Tc -0.108 Tw [(Joseph A. )-47.8(Boscarino)]TJ 10 0 0 10 126.66 581.01 Tm -0.0087 Tc -0.0616 Tw [(Geisinger Clinic, Danville, P)87.3(A)]TJ -3.717 -1.2 TD 0.0005 Tc -0.062 Tw [(Mount Sinai School of Medicine, New )30.6(Y)101.7(ork, NY)]TJ 23.151 -28.887 TD -0.0033 Tc 0.0668 Tw [(vestigations. It)53.7(s primary purpose was to assess the impact)]TJ 0 -1.398 TD -0.0035 Tc -0.0014 Tw (of post-event treatments received by NYC residents follow-)Tj 0 -1.401 TD -0.0041 Tc 0.0311 Tw [(ing the )16.7(W)93.8(orld )16.8(T)36.7(rade Center Disaster \(WTCD\). )16.7(The second-)]TJ T* -0.0011 Tc 0.125 Tw (ary purpose was to describe the prevalence of PTSD and)Tj 0 -1.398 TD -0.0033 Tc -0.06 Tw (related mental disorders among area residents and to identify)Tj 0 -1.401 TD -0.0039 Tc 0.0837 Tw (risk and protective factors for such outcomes. The WTCD)Tj T* -0.0033 Tc -0.0265 Tw (was a unique event in US history and represented the largest)Tj 0 -1.398 TD -0.0036 Tc 0.0268 Tw [(war)17.4(-related loss of life on US soil since the )50.7(American Civil)]TJ 0 -1.401 TD -0.0034 Tc -0.0089 Tw [(W)94.5(ar \(Centers for Disease Control, 2002\). In response to this)]TJ T* -0.0035 Tc 0.0467 Tw [(disaster)35.5(, NYC agencies and institutions, as well as those in)]TJ 0 -1.398 TD 0.0007 Tc 0.125 Tw (surrounding communities, provided an extensive array of)Tj 0 -1.401 TD -0.0035 Tc -0.0106 Tw (mental health treatment services for area residents. In NYC,)Tj T* -0.0184 Tw (these services were made available to the public through the)Tj 0 -1.398 TD -0.0034 Tc 0.069 Tw (federally-funded Project Liberty program, which offered)Tj 0 -1.401 TD -0.0033 Tc -0.0604 Tw (mental health services to the general public at no or little cost)Tj ET endstream endobj 178 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 180 0 obj << /Length 8878 >> 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 -0.009 Tc 0 Tw (276)Tj /TT3 1 Tf 1.65 0 TD -0.0058 Tc 0.115 Tw [( Boscarino and Adams)]TJ /F1 1 Tf 11.07 0 TD -0.0061 Tc 0.1156 Tw [(  )]TJ /TT3 1 Tf 1.125 0 TD -0.0056 Tc 0.1163 Tw (World Trade Center Disaster Outcomes Study)Tj /TT2 1 Tf 10 0 0 10 54 722.64 Tm -0.0032 Tc 0.0906 Tw [(\(Felton, 2002\). Our study offered a unique health services)]TJ 0 -1.398 TD -0.0005 Tc 0.125 Tw (research opportunity and was specifically designed to as-)Tj 0 -1.401 TD 0.0055 Tc (sess mental health outcomes associated with this service)Tj T* -0.007 Tc -0.0624 Tw [(delivery ef)20(fort \(Boscarino, )50.1(Adams, & Figley)65(,)-0.6( 2004\).)]TJ /F1 1 Tf 11 0 0 11 82.89 648 Tm -0.0038 Tc 0.1409 Tw [(STUD)64.4(Y O)42.6(VER)39.8(VIEW AND METHOD)]TJ /TT2 1 Tf 10 0 0 10 72 624.66 Tm -0.0033 Tc 0.0122 Tw (The data for this study come from a prospective cohort)Tj -1.8 -1.401 TD -0.003 Tc 0.0725 Tw (study of adults who were living in NYC on the day of the)Tj T* -0.0034 Tc 0.0189 Tw [(disaster)50.6(. Detailed information on the basic study design has)]TJ 0 -1.398 TD -0.0205 Tc -0.0618 Tw [(been published elsewhere \(Adams & Boscarino, 2005a; )48.8(Adams)]TJ 0 -1.401 TD 0.0008 Tc 0.1251 Tw [(& Boscarino, 2005b; )51.9(Adams & Boscarino, 2006; )51.9(Adams,)]TJ T* -0.0309 Tc -0.0622 Tw [(Boscarino, & Galea, 2006a; )47.1(Adams, Boscarino, & Galea, 2006b;)]TJ 0 -1.398 TD 0.0133 Tc 0.1249 Tw [(Boscarino, Figley)61.3(, )49.2(Adams, Galea, Resnick, et al., 2004;)]TJ 0 -1.401 TD -0.0156 Tc -0.0618 Tw [(Boscarino, Galea, )47.7(Ahern, Resnick, & )14.7(Vlahov)62.4(, 2002; Boscarino)]TJ T* -0.0119 Tc -0.062 Tw [(& )51.2(Adams, 2008; Boscarino, Galea, )54.2(Ahern, Resnick, &Vlahov)63.1(,)]TJ 0 -1.398 TD -0.0036 Tc 0.0499 Tw [(2003; Boscarino, Galea, et al., 2004; Boscarino, )50.3(Adams, &)]TJ 0 -1.401 TD -0.0034 Tc -0.0458 Tw [(Figley)59.6(, 2004; Boscarino, )53.5(Adams, & Figley)59.6(, 2005; Boscarino,)]TJ T* -0.0111 Tc -0.0622 Tw [(Adams, Foa, et. al., 2006; Boscarino, )54.9(Adams, Figley)57.9(, Galea, et)]TJ 0 -1.398 TD -0.0226 Tc -0.0624 Tw [(al., 2006; Boscarino, )52.5(Adams, S)19.4(tuber)37.4(, & Galea, 2005; Boscarino,)]TJ 0 -1.401 TD -0.0136 Tc -0.0622 Tw [(Adams, & Galea, 2006; Galea, Boscarino, Resnick, & )16.7(Vlahov)61.4(,)]TJ T* -0.004 Tc [(2003; )17.3(Vlahov et al., 2004; )17.3(Vlahov et al., 2002\). Briefly)62(, using)]TJ 0 -1.398 TD -0.0034 Tc 0.0414 Tw (random-digit dialing, a baseline telephone survey was con-)Tj 0 -1.401 TD 0.0234 Tw [(ducted a year after the )14.8(WTCD attack. )53.8(As part of the overall)]TJ T* -0.0529 Tw (study design, residents who reported receiving mental health)Tj 0 -1.398 TD -0.0032 Tc -0.0389 Tw (treatment a year after the attack were over-sampled by use)Tj 0 -1.401 TD -0.0001 Tc 0.1251 Tw [(of screener questions at the beginning of the survey)65.9(. )15(The)]TJ T* -0.0034 Tc 0.0962 Tw (baseline population was also stratified by the 5 NYC bor-)Tj 0 -1.398 TD -0.0037 Tc 0.0443 Tw [(oughs and gender)35.3(, and was sampled proportionately)62.3(. Ques-)]TJ 0 -1.401 TD 0.0589 Tc 0.295 Tw (tionnaires were translated into Spanish and then)Tj T* -0.0035 Tc 0.0582 Tw [(back-translated by bilingual )50.4(Americans to ensure linguistic)]TJ 0 -1.398 TD -0.0292 Tw [(and cultural appropriateness. )50.6(Approximately 7% of these in-)]TJ 0 -1.401 TD -0.0011 Tc 0.125 Tw (terviews were conducted in Spanish. The baseline survey)Tj T* -0.0042 Tc -0.0625 Tw (occurred between October and December 2002 and a follow-)Tj 0 -1.398 TD -0.0024 Tc 0.1249 Tw [(up survey occurred one-year later)36.6(, between October 2003)]TJ 0 -1.401 TD -0.0034 Tc -0.0156 Tw (and February 2004. The data collection procedures were the)Tj T* -0.0043 Tc -0.0621 Tw (same for both surveys. Trained interviewers using computer-)Tj 0 -1.398 TD -0.0038 Tc 0.0367 Tw [(assisted telephone interviewing \(CA)104.2(TI\) conducted all inter)17.2(-)]TJ 0 -1.401 TD -0.0035 Tc 0.0885 Tw [(views. )53.4(All interviewers were supervised and monitored by)]TJ T* -0.0033 Tc 0.0064 Tw (the survey contractor in collaboration with the investigative)Tj 0 -1.398 TD -0.0035 Tc -0.039 Tw (staff. The mean duration of the interview was 45 minutes for)Tj 0 -1.401 TD 0.0901 Tw [(the baseline and 35 minutes for the follow-up survey)59.5(. )17.6(The)]TJ T* -0.0077 Tc -0.0626 Tw [(Institutional Review Board \(IRB\) of )16.2(The New )34.2(Y)99.5(ork )52.2(Academy)]TJ 0 -1.398 TD -0.0007 Tc 0.125 Tw [(of Medicine \(NY)107.3(AM\) reviewed and approved the study)50.3(s)]TJ 0 -1.401 TD -0.0036 Tc 0.01 Tw (original protocol. The Geisinger Health System \(GHS\) IRB)Tj T* -0.0005 Tc 0.125 Tw (subsequently approved the analyses related to the current)Tj 0 -1.398 TD 0.0245 Tc 0 Tw [(study)63.5(.)]TJ 27.3 64.398 TD -0.0034 Tc 0.0015 Tw [(For the baseline study)62.6(, 2,368 individuals completed the)]TJ -1.8 -1.398 TD -0.0032 Tc -0.0148 Tw [(survey)62.8(. )15(W)97.6(e)0.2( were able to re-interview 1,681 of these respon-)]TJ 0 -1.401 TD -0.0033 Tc 0.0436 Tw [(dents in the follow-up survey)62.7(. Using industry-standard sur)14.7(-)]TJ T* 0.0462 Tw (vey definitions, the baseline cooperation rate was 63% and)Tj 0 -1.398 TD -0.015 Tc -0.0622 Tw (the re-interview rate for the follow-up study was 71% \(Adams,)Tj 0 -1.401 TD -0.0037 Tc -0.0435 Tw (Boscarino, & Galea, 2006b\), consistent with previous epide-)Tj T* -0.0251 Tc -0.0622 Tw (miological investigations \(Galea et al., 2002\). Sampling weights)Tj 0 -1.398 TD -0.0035 Tc -0.0061 Tw (were developed for each wave to correct for potential selec-)Tj 0 -1.401 TD 0.1222 Tw (tion bias related to the number of telephone numbers and)Tj T* 0.1137 Tw (persons per household and for the over-sampling of treat-)Tj 0 -1.398 TD 0.0091 Tc 0.125 Tw [(ment-seeking respondents \(Boscarino, )54.1(Adams, & Figley)60.1(,)]TJ 0 -1.401 TD -0.0047 Tc -0.0625 Tw (2004\). Demographic weights also were used with the follow-)Tj T* -0.0031 Tc 0.031 Tw (up data, to adjust for slight differences in response rates by)Tj 0 -1.398 TD -0.0037 Tc 0.0671 Tw (different demographic groups, a common practice in panel)Tj 0 -1.401 TD -0.0046 Tc -0.0624 Tw [(surveys \(Groves et al., 2004\). )13.5(W)60.2(ith these survey adjustments,)]TJ T* 0.0074 Tc 0.125 Tw (the study database is considered representative of adults)Tj 0 -1.398 TD -0.0037 Tc 0.1091 Tw (who were living in NYC on the day of the WTCD attack)Tj 0 -1.401 TD -0.0102 Tc -0.0621 Tw [(\(Boscarino, )50.2(Adams, & Figley)64.8(, 2004\).)]TJ 1.8 -2.001 TD 0.004 Tc 0.125 Tw (The basic data analyses in our study focused on an-)Tj -1.8 -1.398 TD -0.0037 Tc 0.027 Tw (swering the following specific research questions.)Tj 1.2 -2.001 TD -0.0428 Tw [()-1453.6(Who sought mental health treatment after this event?)]TJ T* -0.0038 Tc -0.01 Tw [()-1453.7(What were the barriers encountered to seeking treat-)]TJ 1.8 -1.398 TD -0.0031 Tc 0.0183 Tw (ment after this event?)Tj -1.8 -2.001 TD -0.0041 Tc -0.0022 Tw [()-1454(What were the mental health outcomes among those)]TJ 1.8 -1.401 TD -0.0036 Tc 0.0001 Tw (who received treatment?)Tj -1.8 -1.998 TD -0.002 Tc 0.125 Tw [()-1451.9(What types of post-disaster interventions were the)]TJ 1.8 -1.401 TD -0.0033 Tc -0.015 Tw (most effective?)Tj -1.8 -2.001 TD -0.0037 Tc -0.0125 Tw [()-1453.6(What were the risk and protective factors for experi-)]TJ 1.8 -1.398 TD 0.0097 Tc 0.125 Tw (encing adverse mental health outcomes after this)Tj 0 -1.401 TD 0.0181 Tc 0 Tw (event?)Tj -1.2 -2.001 TD -0.0036 Tc 0.1183 Tw (Earlier research regarding the health consequences of)Tj -1.8 -1.398 TD 0.0116 Tc 0.125 Tw (disasters and other traumatic events guided our original)Tj 0 -1.401 TD -0.0038 Tc 0.0603 Tw [(study)62.2(.)-4.2( )16.9(The post-disaster literature relevant to the )13.9(WTCD at)]TJ T* -0.0034 Tc -0.0595 Tw (the time related to the survivors of the Oklahoma City bomb-)Tj 0 -1.398 TD -0.0035 Tc -0.0144 Tw [(ing. )53.6(Among direct survivors of that incident, 45% had post-)]TJ 0 -1.401 TD 0.0294 Tw (disaster psychiatric disorders and 34% had PTSD \(North et)Tj T* -0.0057 Tc -0.0621 Tw [(al., 1999\). )48.5(Another study of the same event found that 62% of)]TJ 0 -1.398 TD -0.0122 Tc [(residents of the Oklahoma City metropolitan area experienced)]TJ 0 -1.401 TD -0.0035 Tc -0.0367 Tw (at least one direct stress-related outcome due to the bombing)Tj T* -0.0291 Tw [(\(Smith, Christiansen, )17.8(V)64.7(incent, & Hann, 1999\). In addition, a)]TJ 0 -1.398 TD -0.025 Tw [(comparison of Oklahoma City area residents to Indianapolis)]TJ 0 -1.401 TD -0.0034 Tc -0.0067 Tw (area residents, used as a control group, suggested that Okla-)Tj T* 0.0535 Tw (homa residents reported about twice the psychological dis-)Tj 0 -1.398 TD -0.0036 Tc 0.0585 Tw (tress, PTSD, increased alcohol use, and increased smoking)Tj ET endstream endobj 181 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 183 0 obj << /Length 8848 >> 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. 4 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (277)Tj /TT2 1 Tf 10 0 0 10 66 722.64 Tm -0.0102 Tc -0.0624 Tw [(behavior)40.8(, compared to persons in the Indianapolis area \(Smith)]TJ 0 -1.398 TD -0.0037 Tc 0.0979 Tw [(et al., 1999\). )50.3(Although some investigators have contended)]TJ 0 -1.401 TD -0.0032 Tc 0.1193 Tw (that persons recover quickly from these experiences \(e.g.,)Tj T* -0.0037 Tc 0.0825 Tw [(McFarlane, 1988; McFarlane, 1989\), others suggested that)]TJ 0 -1.398 TD -0.0034 Tc 0.1042 Tw (large-scale community disasters could result in significant)Tj 0 -1.401 TD -0.0029 Tc 0.125 Tw (psychological problems and poorer health outcomes post-)Tj T* -0.0191 Tc -0.0625 Tw [(disaster \(Brewin, )52.9(Andrews, & )16.9(V)112.1(alentine, 2000; Bromet & Dew)58.9(,)]TJ 0 -1.398 TD -0.0036 Tc -0.0144 Tw (1995: Rubonis & Bickman, 1991\). Thus, the research litera-)Tj 0 -1.401 TD -0.0033 Tc 0.0656 Tw (ture at the time suggested that the psychological impact of)Tj T* -0.0039 Tc -0.0162 Tw (the WTCD event would be significant. In addition, previous)Tj 0 -1.398 TD 0.008 Tc 0.125 Tw [(studies of the consequences of PTSD suggested that the)]TJ 0 -1.401 TD -0.0036 Tc 0.0462 Tw [(impact of this disorder could be substantial \(Kessler)35.4(, 2000;)]TJ T* 0.0205 Tw (Kulka et al., 1990\). Other research suggests that PTSD was)Tj 0 -1.398 TD -0.0003 Tc 0.125 Tw (not only associated with mental health problems but also)Tj 0 -1.401 TD -0.0033 Tc 0.065 Tw (with alterations in physical health status \(Boscarino, 1996;)Tj T* -0.004 Tc 0.0472 Tw (Boscarino, 1997; Boscarino & Chang, 1999a; Boscarino &)Tj 0 -1.398 TD -0.0094 Tc -0.0625 Tw (Chang, 1999b; Boscarino, 2004; Boscarino, 2006; Boscarino,)Tj 0 -1.401 TD 0.0055 Tc 0.125 Tw [(2008; McFarlane, )50.5(Atchison, Rafalowicz, & Papay)59.5(, 1994;)]TJ T* -0.012 Tc -0.0625 Tw (Schnurr & Green, 2004\). Furthermore, other research has sug-)Tj 0 -1.398 TD 0.0017 Tc 0.125 Tw (gested that survivors of these events have increased psy-)Tj 0 -1.401 TD 0.0214 Tc (chological difficulties, chronic problems in living, and)Tj T* -0.0033 Tc 0.0607 Tw (significant psychosocial resource loss \(Adams et al., 2002;)Tj 0 -1.398 TD -0.0155 Tc -0.0622 Tw [(Bromet & Dew)59.5(, 1995; Norris et al., 2002\), possibly amplifying)]TJ 0 -1.401 TD 0.0332 Tc 0.125 Tw (adverse health outcomes \(Adams & Boscarino, 2006;)Tj T* -0.0158 Tc -0.06 Tw (Boscarino, 1995\).)Tj /F1 1 Tf 11 0 0 11 131.25 354 Tm 0.0117 Tc 0.1409 Tw (RESEARCH FOCUS)Tj -5.9318 -1.4536 TD -0.0049 Tc 0.1137 Tw (Psychobiological-Stressor Model)Tj /TT2 1 Tf 10 0 0 10 84 314.64 Tm -0.0036 Tc -0.0207 Tw (Although level of exposure and disaster-related loss are)Tj -1.8 -1.398 TD 0.0028 Tc 0.125 Tw (commonly associated with the impact of these events on)Tj 0 -1.401 TD -0.0124 Tc -0.0621 Tw (well-being \(Caldera, Palma, Penayo, & Kullgren, 2001; Galea)Tj T* -0.0069 Tc (et al., 2002; Geonjian et al., 2001; Mecocci et al., 2000\), there)Tj 0 -1.398 TD -0.0034 Tc 0.1237 Tw (are other risk factors involved. Research suggests that in-)Tj 0 -1.401 TD -0.0035 Tc -0.0463 Tw (creased PTSD vulnerability often occurs among those with a)Tj T* -0.0029 Tc 0.0389 Tw (history of mental health disorders, child abuse, or a history)Tj 0 -1.398 TD 0.003 Tc 0.125 Tw [(of previous traumas \(Boscarino, )48(Adams, & Figley)63(, 2004;)]TJ 0 -1.401 TD -0.0098 Tc -0.0625 Tw [(Breslau, Chilcoat, Kessler)35.2(, & Davis, 1999; Shalev)59.2(, 1996\). De-)]TJ T* -0.0038 Tc 0.0038 Tw (mographic and socioeconomic factors also are known to af-)Tj 0 -1.398 TD 0.0133 Tc 0.125 Tw [(fect these experiences \(Adams & Boscarino, 2005a\). In)]TJ 0 -1.401 TD -0.0034 Tc 0.1169 Tw (addition, research has identified the role of social support)Tj T* -0.0036 Tc 0.1006 Tw (among those exposed to traumatic stress, both in terms of)Tj 0 -1.398 TD -0.0151 Tc -0.0622 Tw (protecting individuals from PTSD onset \(Adams & Boscarino,)Tj 0 -1.401 TD 0.0185 Tc 0.125 Tw (2006\), and in terms of influencing effective treatments)Tj T* -0.0036 Tc -0.0377 Tw (\(Boscarino, 1995; van der Kolk, McFarlane, & van der Hart,)Tj 0 -1.398 TD -0.0033 Tc 0.0813 Tw [(1996\). In summary)59.7(, the degree of exposure, social/cultural)]TJ 0 -1.401 TD -0.0034 Tc 0.1063 Tw (variables, and other factors, such as self-esteem and other)Tj 25.5 64.599 TD 0.0333 Tw (character traits, are known to enhance or reduce the impact)Tj 0 -1.398 TD -0.0036 Tc 0.075 Tw (of traumatic stress exposures on mental health \(Boscarino,)Tj 0 -1.401 TD -0.0029 Tc -0.0225 Tw [(Adams, & Figley)63.1(, 2004\). In addition, while many psychoso-)]TJ T* -0.0036 Tc 0.0381 Tw (cial components of traumatic stress exposures are now rec-)Tj 0 -1.398 TD -0.0032 Tc -0.0585 Tw [(ognized \(Adams, Figley)62.8(, & Boscarino. 2008\), the underlying)]TJ 0 -1.401 TD -0.0035 Tc 0.0775 Tw (biological bases of these syndromes have also become ap-)Tj T* 0.0331 Tc 0.125 Tw (parent \(Boscarino, 1996; Boscarino & Chang, 1999a;)Tj 0 -1.398 TD -0.0176 Tc -0.0621 Tw (Boscarino & Chang 1999b; Boscarino, 2004; Boscarino, 2008;)Tj 0 -1.401 TD -0.0066 Tc (van der Kolk, 1996; Chrousos, 1995\). Thus, we would expect)Tj T* -0.0088 Tc (long-term health issues to emerge in traumatized populations,)Tj 0 -1.398 TD -0.0036 Tc 0.0436 Tw (including increases in substance use, changes in help-seek-)Tj 0 -1.401 TD 0.0012 Tc 0.125 Tw (ing behaviors, and the onset of chronic health conditions)Tj T* -0.0035 Tc -0.019 Tw (\(Boscarino, 2004; Boscarino, 2008\). This psychobiological-)Tj 0 -1.398 TD -0.0033 Tc 0.0491 Tw (stressor model guided the original study design.)Tj /F1 1 Tf 11 0 0 11 321 507.99 Tm -0.0055 Tc 0.0704 Tw (Outcomes Research Design)Tj /TT2 1 Tf 10 0 0 10 339 484.65 Tm -0.0042 Tc -0.0216 Tw [(As we note below)61.8(, our )13.9(WTCD sample represents one of)]TJ -1.8 -1.401 TD -0.0037 Tc -0.0543 Tw (the limited number of population-based studies that prospec-)Tj 0 -1.398 TD 0.0073 Tc 0.125 Tw (tively examined post-disaster mental health services and)Tj 0 -1.401 TD -0.0037 Tc 0.1107 Tw (health outcomes for these interventions following a major)Tj T* -0.013 Tc -0.0622 Tw (traumatic event \(Boscarino et al., 2002; Boscarino et al., 2003;)Tj 0 -1.398 TD -0.0034 Tc -0.0092 Tw [(Boscarino, Galea, et al., 2004; Boscarino, )50.8(Adams, & Figley)59.6(,)]TJ 0 -1.401 TD 0.0034 Tc 0.1249 Tw [(2004; Boscarino, Figley)63.4(, )48.3(Adams, et al., 2004; Boscarino,)]TJ T* -0.0072 Tc -0.0622 Tw [(Adams, & Figley)61.8(, 2005; Boscarino, )55.8(Adams, Foa, et. al., 2005;)]TJ 0 -1.398 TD -0.0034 Tc 0.063 Tw [(Boscarino, )53.8(Adams, S)14.6(tuber)35.6(, et. al., 2005\). In addition to de-)]TJ 0 -1.401 TD -0.003 Tc 0.1111 Tw [(scriptive research, our data enabled us to test specific hy-)]TJ T* -0.0085 Tc -0.0625 Tw (potheses about the relationships between trauma experiences,)Tj 0 -1.398 TD -0.0034 Tc -0.0344 Tw (the impact of different interventions, risk and protective fac-)Tj 0 -1.401 TD -0.0033 Tc 0.125 Tw [(tors, and long-term mental health outcomes. )14.7(W)97.5(e)-0.4( note that)]TJ T* -0.0029 Tc 0.1081 Tw (our study was specifically designed as an outcomes study)Tj 0 -1.398 TD -0.0064 Tc -0.0622 Tw (and was implemented to answer these kinds of research ques-)Tj 0 -1.401 TD 0.007 Tc 0.125 Tw (tions using a cohort study design \(Boscarino and Chang)Tj T* -0.0069 Tc -0.0622 Tw [(1999c; Figley)62.1(, Carbonell, Boscarino, & Chang, 1999; Hulley)62.1(,)]TJ 0 -1.398 TD -0.0052 Tc [(Cummings, Browner)33.8(, Grady)60.8(, & Newman, 2007; Rogers et al.)]TJ 0 -1.401 TD -0.0081 Tc -0.0616 Tw [(2000; Rosenheck, S)9.9(tolar)36.9(, & Fontana, 2000\).)]TJ 1.8 -2.001 TD -0.0034 Tc 0.0871 Tw (The survey instruments used in this research included)Tj -1.8 -1.398 TD 0.0005 Tc 0.125 Tw (reliable scales and health services research measures that)Tj 0 -1.401 TD -0.0034 Tc 0.0956 Tw [(had been used and validated in previous research \(Freedy)59.6(,)]TJ T* -0.0071 Tc -0.0621 Tw [(Kilpatrick & Resnick., 1993; Kilpatrick, )52.9(Acierno, Resnick, &)]TJ 0 -1.398 TD -0.0034 Tc 0.0579 Tw (Sanders, 1997; Kilpatrick et al., 2000; Resnick, Kilpatrick,)Tj 0 -1.401 TD -0.0288 Tw [(Dansky)59.6(, Saunders, & Best, 1993\) and recent traumatic stres-)]TJ T* 0.0433 Tc 0.1249 Tw [(sor research \(Adams & Boscarino, 2005a; )49.2(Adams &)]TJ 0 -1.398 TD 0.0248 Tc 0.1251 Tw [(Boscarino, 2005b; )48.9(Adams & Boscarino, 2006; )51.9(Adams,)]TJ 0 -1.401 TD -0.0309 Tc -0.0622 Tw [(Boscarino, & Galea, 2006a; )47.1(Adams, Boscarino, & Galea, 2006b;)]TJ T* -0.0034 Tc 0.0599 Tw [(Boscarino et al., 2002; Boscarino, )53.5(Adams, & Figley)59.6(, 2004;)]TJ 0 -1.398 TD -0.0033 Tc -0.0622 Tw (Boscarino, Galea, et al., 2003; Boscarino, Galea, et al., 2004;)Tj ET endstream endobj 184 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /TT2 9 0 R /TT3 10 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 186 0 obj << /Length 7918 >> stream 0 0 0 1 K 0 J 0 j 0.51 w 10 M []0 d /GS1 gs 1 i 54 59.745 m 546 59.745 l S BT /F1 1 Tf 8 0 0 8 54.99 41.64 Tm 0 0 0 1 k /GS2 gs -0.009 Tc 0 Tw (278)Tj /TT3 1 Tf 1.65 0 TD -0.0058 Tc 0.115 Tw [( Boscarino and Adams)]TJ /F1 1 Tf 11.07 0 TD -0.0061 Tc 0.1156 Tw [(  )]TJ /TT3 1 Tf 1.125 0 TD -0.0056 Tc 0.1163 Tw (World Trade Center Disaster Outcomes Study)Tj /TT2 1 Tf 10 0 0 10 54 722.64 Tm -0.0039 Tc -0.0625 Tw [(Boscarino, Figley)62.1(,)-7.4( )50.1(Adams, et al., 2004; Boscarino, )50.1(Adams, &)]TJ 0 -1.398 TD -0.0072 Tc [(Figley)64.8(, 2005; Boscarino, )52.8(Adams, Foa, et al., 2006; Boscarino,)]TJ 0 -1.401 TD -0.0217 Tc -0.0621 Tw [(Adams, S)17.3(tuber)38.3(, et. al., 2005; Boscarino, )53.4(Adams, & Galea, 2006;)]TJ T* -0.0036 Tc [(Boscarino & )50.5(Adams, 2008; Galea, Boscarino, et al., 2003\). )50.5(A)]TJ 0 -1.398 TD -0.0261 Tw (summary of these scales and measures is presented below in)Tj 0 -1.401 TD -0.0029 Tc 0.0294 Tw [(T)73.9(able 1. Briefly)60.1(, most of these data were prospectively col-)]TJ T* -0.0037 Tc 0.0106 Tw (lected and included the following core measures: \(1\) demo-)Tj 0 -1.398 TD -0.0039 Tc 0.1083 Tw (graphic characteristics; \(2\) WTCD exposure variables; \(3\))Tj 0 -1.401 TD 0.0943 Tw [(exposure to other traumatic events; \(4\) WTCD rescue and)]TJ T* -0.0072 Tc -0.0621 Tw (recovery involvement; \(5\) stressful life experiences; \(6\) men-)Tj 25.5 12.6 TD -0.0041 Tc -0.0623 Tw [(tal health, medical, and other services received pre- and post-)]TJ 0 -1.398 TD -0.0036 Tc -0.0385 Tw (disaster; \(7\) prescription medication use pre- and post-disas-)Tj 0 -1.401 TD 0.0593 Tc 0.1343 Tw (ter; \(8\) use of alternative health services pre- and)Tj T* -0.0035 Tc 0.0557 Tw (post-disaster; \(9\) substance use pre- and post-disaster; \(10\))Tj 0 -1.398 TD -0.0034 Tc 0.0393 Tw (barriers to care; \(11\) self-esteem, social support, functional)Tj 0 -1.401 TD 0.0113 Tc 0.125 Tw (health status and work productivity; \(12\) post-traumatic)Tj T* -0.0034 Tc -0.0328 Tw (stress disorder; \(13\) major depressive disorder; \(14\) psycho-)Tj 0 -1.398 TD -0.0031 Tc -0.0499 Tw (logical symptoms in past 30 days; and \(15\) community-level)Tj 0 -1.401 TD -0.0033 Tc -0.0137 Tw [(indicator data \(see )17.8(T)73.5(able 1\).)]TJ /TT3 1 Tf -15.375 -3.864 TD -0.0053 Tc -0.0443 Tw (Table1. Core Measurement Instruments in WTCD Outcome Study*)Tj /TT6 1 Tf -9.525 -3.942 TD 0 Tc -0.0325 Tw (1. Mental health)Tj 1.2 -1.2 TD 0.0064 Tc 0 Tw (status)Tj -1.2 -4.8 TD -0.0005 Tc 0.0025 Tw (2. Substance use)Tj 0 -3.6 TD 0.0006 Tc -0.0325 Tw (3. Care visits,)Tj 1.2 -1.2 TD -0.0004 Tc 0.035 Tw (treatments &)Tj T* -0.0162 Tc 0 Tw (interventions)Tj -1.2 -3.6 TD -0.0005 Tc 0.0746 Tw [(4. S)41.5(tress)]TJ 1.2 -1.2 TD -0.0048 Tc 0 Tw (exposures)Tj 9.5 0 0 9.5 60 317.61 Tm 0.019 Tc 0.1368 Tw (5. Social/)Tj 1.2632 -1.2 TD 0.0371 Tc 0 Tw (community)Tj 10 0 0 10 72 294.39 Tm -0.0051 Tc (resources)Tj -1.2 -2.4 TD -0.0001 Tc 0.05 Tw (6. Psychological)Tj 1.2 -1.2 TD -0.0051 Tc 0 Tw (resources)Tj -1.2 -2.4 TD 0 Tc -0.0251 Tw (7. Functional)Tj 1.2 -1.2 TD 0.0064 Tc 0 Tw (status)Tj -1.2 -4.8 TD -0.0069 Tc -0.07 Tw (8. Demographic)Tj 1.2 -1.2 TD -0.0165 Tc 0 Tw (measures)Tj -1.2 -3.6 TD -0.0004 Tc -0.05 Tw (9. 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Mental health service use 1-year after the World Trade Center disaster: implications for medical)]TJ T* -0.0071 Tc 0 Tw (care. )Tj /F32 1 Tf 9 0 1.913 9 78.21 62.01 Tm -0.0059 Tc 0.1168 Tw [(General Hospital Psychiatr)-32.6(y)97.4(,)1.4( 26,)]TJ /TT3 1 Tf 9 0 0 9 207.66 62.01 Tm -0.0065 Tc 0.1166 Tw [( 346-358.)]TJ ET /GS1 gs 55.5 549 m 545.01 549.99 l S endstream endobj 187 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /F32 188 0 R /TT2 9 0 R /TT3 10 0 R /TT6 22 0 R /TT7 30 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> /ColorSpace << /Cs14 189 0 R >> >> endobj 190 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 189 0 obj [/Separation /Auto /DeviceCMYK 190 0 R] endobj 192 0 obj << /Length 9100 >> 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. 4 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (279)Tj 11 0 0 11 121.5 723.99 Tm -0.0019 Tc 0.1385 Tw [(MAIN STUD)66.3(Y FINDINGS)]TJ -5.0455 -1.4536 TD -0.0045 Tc 0.0168 Tw [(Mental Health Ser)-12.7(vice Use Baseline \(Y)74.6(ear 1\))]TJ /TT2 1 Tf 10 0 0 10 84 684.66 Tm -0.0047 Tc -0.0625 Tw (The demographic profile for our study population is pre-)Tj -1.8 -1.401 TD -0.0034 Tc -0.0277 Tw [(sented in )14.7(T)73.4(able 2. )53.7(As reported previously)59.6(, our weighted final)]TJ T* -0.0156 Tc -0.0625 Tw (sample closely matched the demographic profile of adult NYC)Tj 0 -1.398 TD -0.0033 Tc 0.0467 Tw [(residents \(Adams et al., 2006b\). )50.6(As can be seen in )17.6(T)73.5(able 2,)]TJ 0 -1.401 TD -0.0034 Tc -0.0568 Tw (more than half of our population was a member of a minority)Tj T* -0.0038 Tc -0.0005 Tw (group, 57% were female, and about 30% had high exposure)Tj 0 -1.398 TD -0.0033 Tc 0.025 Tw (to the WTCD event, meaning that they had fairly extensive)Tj 0 -1.401 TD -0.0036 Tc 0.0033 Tw [(exposure to the attack and its aftermath \(Boscarino, )50.6(Adams,)]TJ T* -0.0124 Tc -0.0625 Tw [(& Figley)62.6(, 2004\). )53.6(Analyses from one year post-disaster showed)]TJ 0 -1.398 TD -0.0076 Tc [(that prevalence of current PTSD was about 5% and the preva-)]TJ 0 -1.401 TD -0.0037 Tc 0.0044 Tw [(lence of current major depression was about 12% \(T)65.3(able 3\).)]TJ T* -0.0076 Tc -0.0621 Tw [(Furthermore, 20% of New )28.5(Y)105.6(orkers had had mental health vis-)]TJ 0 -1.398 TD -0.0035 Tc -0.01 Tw (its in the past 12 months and 12.9% reported one or more of)Tj 0 -1.401 TD -0.0038 Tc 0.0773 Tw (these mental health visits was related to the WTCD event.)Tj T* -0.0033 Tc -0.0354 Tw [(Compared to the year before the attacks, 8.6% of New )32.8(Y)103.9(ork-)]TJ 0 -1.398 TD -0.0036 Tc -0.0412 Tw (ers had increased post-disaster mental health visits and 5.3%)Tj 0 -1.401 TD -0.0037 Tc 0.0306 Tw (had a new post-disaster treatment episode in the 12 months)Tj T* -0.0036 Tc 0.0426 Tw [(post-disaster \(T)68.4(able 3\). In terms of medications, 8.1% used)]TJ 0 -1.398 TD -0.017 Tc -0.0624 Tw [(psychotropic drugs \(Boscarino, )52.1(Adams, & Figley)58(, 2004\). Post-)]TJ 0 -1.401 TD -0.0037 Tc 0.0707 Tw (disaster psychotropic medication use related to the WTCD)Tj T* -0.0108 Tc -0.0621 Tw (event was 4.5%. Increased post-disaster medication use, com-)Tj 0 -1.398 TD -0.0072 Tc [(pared to the year before the disaster)37.8(, was 4.1% and new medi-)]TJ 0 -1.401 TD 0.0389 Tc 0.1251 Tw [(cation episodes occurred among 3% of New )30(Y)107.1(orkers)]TJ T* -0.0035 Tc -0.0256 Tw [(\(Boscarino, )53.5(Adams, & Figley)59.5(, 2004\). )50.5(As with outpatient vis-)]TJ 0 -1.398 TD 0.0121 Tw (its, post-disaster medication usage was lower than expected)Tj 0 -1.401 TD -0.0102 Tc -0.0621 Tw [(\(Boscarino, )50.2(Adams, & Figley)64.8(, 2004\).)]TJ 1.8 -2.001 TD -0.002 Tc 0.125 Tw (In multivariate logistic regression analyses, increased)Tj -1.8 -1.398 TD -0.0033 Tc -0.0019 Tw (mental health visits were associated with younger age, peri-)Tj 0 -1.401 TD 0.075 Tw (event panic attack, negative life events, and depression. In)Tj T* 0.0196 Tc 0.125 Tw (addition, WTCD-related visits had a positive dose-re-)Tj 0 -1.398 TD -0.0148 Tc -0.0621 Tw (sponse association with level of WTCD exposure \()Tj /TT5 1 Tf 19.644 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.486 0 TD -0.0149 Tc -0.0625 Tw [( < 0.0001)]TJ -20.13 -1.401 TD -0.0035 Tc -0.0043 Tw (for trend\). WTCD-related visits also were positively associ-)Tj T* -0.0073 Tc -0.0621 Tw [(ated with peri-event panic, anxiety)58.7(, lower self-esteem, PTSD,)]TJ 0 -1.398 TD -0.0037 Tc 0.0375 Tw (and depression. Increased post-disaster medication use was)Tj 0 -1.401 TD -0.0032 Tc 0.0943 Tw (positively related to PTSD and depression, and negatively)Tj T* -0.0183 Tc -0.0624 Tw [(associated with )44.8(African )47.8(American status. )14.8(WTCD-related medi-)]TJ 0 -1.398 TD -0.003 Tc -0.0433 Tw (cation use also was positively related to younger age, female)Tj 0 -1.401 TD -0.0039 Tc 0.0407 Tw [(gender)35.1(, )17.1(WTCD exposure level, negative life events, PTSD,)]TJ T* -0.005 Tc -0.0619 Tw [(anxiety)58(, and lower self-esteem.)]TJ 1.8 -1.998 TD -0.0035 Tc -0.0437 Tw [(In summary)62.5(, while the percentage of New )32.6(Y)103.7(orkers seek-)]TJ -1.8 -1.401 TD -0.0089 Tc -0.0622 Tw (ing post-disaster treatment did not increase substantially from)Tj T* -0.0036 Tc 0.0207 Tw (the pre-disaster period, the volume of visits among existing)Tj 0 -1.398 TD -0.0033 Tc 0.0413 Tw [(patients apparently increased. )14.6(W)97.5(e)0.5( concluded that exposure)]TJ 0 -1.401 TD -0.004 Tc 0.0133 Tw (to WTCD events was related to post-disaster PTSD and de-)Tj 25.5 65.199 TD -0.0038 Tc -0.0469 Tw (pression, as well as WTCD-related mental health service use)Tj 0 -1.398 TD -0.0035 Tc 0.0815 Tw [(in New )32.6(Y)103.7(ork. However)35.5(, contrary to expectations, although)]TJ 0 -1.401 TD -0.0041 Tc 0.0133 Tw (the WTCD did have an impact on treatment seeking among)Tj T* 0.0066 Tc 0.125 Tw (existing patients, it did not substantially increase mental)Tj 0 -1.398 TD -0.0039 Tc -0.0543 Tw (health treatment seeking among the general NYC population)Tj 0 -1.401 TD -0.0096 Tc -0.0622 Tw [(\(Boscarino, )50.7(Adams, & Figley)59.4(, 2004\). Given the availability of)]TJ T* -0.0034 Tc 0.125 Tw (post-disaster mental health services \(Felton, 2002\), it was)Tj 0 -1.398 TD -0.0038 Tc 0.0458 Tw [(thought that services use would be much higher)50.2(.)]TJ /F1 1 Tf 11 0 0 11 321 591.99 Tm -0.0045 Tc 0.03 Tw [(Mental Health Service Use Follow-up)]TJ 0 -1.4536 TD 0.0545 Tw [(\()5.5(Y)71.9(ear 2\))]TJ /TT2 1 Tf 10 0 0 10 339 552.66 Tm -0.0028 Tc 0.025 Tw (Analysis of treatment seeking at follow-up \(i.e., year 2)Tj -1.8 -1.401 TD 0.0055 Tc 0.125 Tw (post-disaster\) revealed that there were some increases in)Tj T* -0.004 Tc -0.0469 Tw (obtaining treatment in comparison to before the WTCD. The)Tj 0 -1.398 TD -0.0034 Tc 0.0467 Tw (most noteworthy increase was for psychotropic medication)Tj 0 -1.401 TD -0.0041 Tc 0.058 Tw (use, which went from 8.5% before the WTCD to 12% two)Tj T* -0.0026 Tc -0.0212 Tw (years after the attack \()Tj /TT5 1 Tf 8.739 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.495 0 TD -0.0024 Tc -0.0214 Tw [( < .001\). )18.6(T)71.4(wo )]TJ 5.5202 0 TD (years after )Tj 4.3682 0 TD -0.0064 Tc -0.036 Tw (the WTCD,)Tj -19.1223 -1.398 TD -0.0035 Tc -0.043 Tw (24% of NYC adults had received some type of mental health)Tj 0 -1.401 TD -0.0032 Tc -0.0268 Tw (treatment in the form of therapy or medication in the past 12)Tj T* -0.0275 Tw [(months. This was an increase from the baseline survey \(i.e.,)]TJ 0 -1.398 TD -0.0361 Tw (year 1 post-disaster\), which was 20%. In addition, at follow-)Tj 0 -1.401 TD -0.0625 Tw (up, the majority of the time NYC residents reported that their)Tj T* -0.0039 Tc -0.0469 Tw (post-disaster treatment was related to the WTCD, which was)Tj 0 -1.398 TD 0.0046 Tc 0.125 Tw [(not the case one-year post-disaster)55.6(. Detailed multivariate)]TJ 0 -1.401 TD -0.0037 Tc 0.0056 Tw (analyses for those who sought treatment after the WTCD in)Tj T* -0.0031 Tc 0.0088 Tw (the year 2 follow-up survey suggested that those who expe-)Tj 0 -1.398 TD -0.007 Tc -0.0622 Tw (rienced negative life events were more likely to seek counsel-)Tj 0 -1.401 TD -0.0033 Tc 0.001 Tw (ing and those with low self-esteem were more likely to take)Tj T* -0.0032 Tc 0.0748 Tw [(psychotropic medications. Finally)62.8(, those who reported that)]TJ 0 -1.398 TD -0.004 Tc -0.0622 Tw (their counseling or medication use was related to the WTCD,)Tj 0 -1.401 TD -0.0036 Tc 0.0972 Tw (were more likely to report greater exposure to the WTCD)Tj T* 0.0325 Tw (event. \(Results available on request.\))Tj /F1 1 Tf 11 0 0 11 321 240 Tm 0.1409 Tw [(T)81.1(reatment Barrier)10.1(s)]TJ /TT2 1 Tf 10 0 0 10 339 216.66 Tm -0.0033 Tc 0.1222 Tw [(A second focus of the original study was to examine)]TJ -1.8 -1.401 TD -0.0034 Tc 0.0656 Tw (potential barriers related to using mental health services in)Tj T* -0.0042 Tc -0.048 Tw [(NYC after the WTCD. When we examined at baseline those)]TJ 0 -1.398 TD -0.0037 Tc -0.0569 Tw [(who met criteria for PTSD or major depression post-disaster)35.3(,)]TJ 0 -1.401 TD -0.0035 Tc -0.0564 Tw (only 45% reported using post-disaster mental health services)Tj T* -0.0031 Tc 0.0639 Tw (and only 33% indicated that they sought these services for)Tj 0 -1.398 TD -0.0041 Tc 0.0482 Tw [(WTCD-related problems \(Boscarino, )50.6(Adams, S)16.9(tuber)34.9(, et al.,)]TJ 0 -1.401 TD -0.0089 Tc -0.0625 Tw (2005\). In a multivariate logistic model, only WTCD exposure)Tj T* -0.0037 Tc -0.0542 Tw (was significant in predicting post-disaster service use among)Tj 0 -1.398 TD -0.0033 Tc 0.0257 Tw (persons with these psychological disorders. For service uti-)Tj 0 -1.401 TD -0.0039 Tc 0.0314 Tw [(lization related to the )14.3(WTCD, results indicated that )50.2(African)]TJ ET endstream endobj 193 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 195 0 obj << /Length 7201 >> 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 -0.009 Tc 0 Tw (280)Tj /TT3 1 Tf 1.65 0 TD -0.0058 Tc 0.115 Tw [( Boscarino and Adams)]TJ /F1 1 Tf 11.07 0 TD -0.0061 Tc 0.1156 Tw [(  )]TJ /TT3 1 Tf 1.125 0 TD -0.0056 Tc 0.1163 Tw (World Trade Center Disaster Outcomes Study)Tj /TT2 1 Tf 10 0 0 10 54 225.66 Tm -0.0033 Tc 0.0228 Tw (Americans were less likely to have had mental health visits)Tj 0 -1.401 TD -0.0039 Tc 0.0378 Tw [(compared to )17.1(Whites, while those who had a regular doctor)35.1(,)]TJ T* -0.0105 Tw (had greater exposure to WTCD events, and those who had a)Tj 0 -1.398 TD -0.0032 Tc -0.0111 Tw (peri-event panic attack were more likely to have such visits.)Tj 0 -1.401 TD -0.0038 Tc 0.0275 Tw (In terms of medication use, 26% of these PTSD-depression)Tj T* -0.0033 Tc 0.065 Tw (cases used psychotropic drugs in the year after the WTCD)Tj 0 -1.398 TD -0.0034 Tc 0.0985 Tw [(and 16% reported that this use was related to the disaster)50.6(.)]TJ 0 -1.401 TD -0.001 Tc 0.1255 Tw [(Multivariate results, again, suggested that )53.5(African )47.5(Ameri-)]TJ T* -0.0132 Tc -0.0625 Tw (cans were less likely to use post-disaster medications, whereas)Tj 0 -1.398 TD 0.0004 Tc 0.125 Tw [(persons 45+ years old, those with a regular doctor)36.4(, those)]TJ 0 -1.401 TD -0.004 Tc 0.05 Tw (exposed to more WTCD events, and those who had a peri-)Tj T* -0.0033 Tc 0.0656 Tw (event panic attack were more likely to have taken medica-)Tj 25.5 15.351 TD -0.0034 Tc -0.0525 Tw [(tions related to the disaster \(Boscarino, )50.9(Adams, S)17.6(tuber)35.6(, et al.,)]TJ 0 -1.401 TD -0.0038 Tc -0.0145 Tw [(2005\). When we asked this group of respondents at baseline)]TJ 0 -1.398 TD -0.0025 Tc -0.0286 Tw (why they did not seek help, many indicated that they did not)Tj 0 -1.401 TD -0.0056 Tc -0.0625 Tw (think that they had a problem, that they had the help of family)Tj T* -0.0013 Tc 0.125 Tw (and friends, or that they tried to solve these problems on)Tj 0 -1.398 TD -0.0045 Tc -0.0618 Tw [(their own \(Boscarino, )52.8(Adams, S)16.5(tuber)34.5(, et al., 2005\).)]TJ /F1 1 Tf 11 0 0 11 309 122.49 Tm -0.0047 Tc 0.0455 Tw (Racial and Ethnic Group Results)Tj /TT2 1 Tf 10 0 0 10 327 99.15 Tm -0.0116 Tc -0.0621 Tw (The discovery of racial/ethnic disparities in seeking treat-)Tj -1.8 -1.401 TD -0.0033 Tc 0.0156 Tw (ment led us to assess the association between race/ethnicity)Tj 0 -1.398 TD -0.0012 Tc 0.1249 Tw [(and psychological health status in more detail at baseline)]TJ /F1 1 Tf -24.45 58.65 TD -0.0445 Tc 0 Tw (Age)Tj /TT3 1 Tf 1.2 -1.401 TD -0.0394 Tc (18-29)Tj T* (30-44)Tj 0 -1.398 TD (45-64)Tj 0 -1.401 TD -0.0231 Tc (65+)Tj /F1 1 Tf -1.2 -1.401 TD -0.0252 Tc (Gender)Tj /TT3 1 Tf 1.2 -1.398 TD -0.0225 Tc (Male)Tj 0 -1.401 TD -0.0219 Tc (Female)Tj /F1 1 Tf -1.2 -1.401 TD -0.0467 Tc (Race)Tj /TT3 1 Tf 1.2 -1.398 TD -0.0203 Tc (White)Tj 0 -1.401 TD -0.0053 Tc -0.035 Tw (African American)Tj T* -0.0116 Tc 0 Tw (Hispanic/Latino)Tj 0 -1.398 TD -0.0066 Tc (Asian)Tj 0 -1.401 TD -0.0252 Tc (Other)Tj /F1 1 Tf -1.2 -1.401 TD -0.0096 Tc -0.0675 Tw (Borough of Residence)Tj /TT3 1 Tf 1.2 -1.398 TD -0.0188 Tc 0 Tw (Manhattan)Tj 0 -1.401 TD -0.0156 Tc (Bronx)Tj T* -0.0094 Tc (Brooklyn)Tj 0 -1.398 TD -0.0255 Tc (Queens)Tj 0 -1.401 TD -0.0052 Tc (Staten Island)Tj /F1 1 Tf -1.2 -1.401 TD -0.0102 Tc -0.0666 Tw [(Exposure to )71.7(WTCD)]TJ /TT3 1 Tf 1.2 -1.398 TD -0.0077 Tc -0.07 Tw (Low Exposures)Tj 0 -1.401 TD -0.0092 Tc (Moderate Exposures)Tj T* -0.0069 Tc (High Exposures)Tj 0 -1.398 TD -0.0054 Tc -0.035 Tw (Very High Exposures)Tj 21.3 32.133 TD -0.0047 Tc -0.0275 Tw [(27.2 \(483\) 24.8-29.7)]TJ 0 -1.434 TD [(34.2 \(866\) 31.8-36.7)]TJ 0 -1.401 TD [(28.8 \(726\) 26.5-31.1)]TJ 0.75 -1.398 TD -0.0045 Tc -0.0128 Tw [(9.8 \(248\) 8.5-11.4)]TJ -2.475 -2.802 TD -0.009 Tw [( 46.2 \(1016\) 43.6-48.8)]TJ 1.5 -1.398 TD -0.0049 Tc -0.043 Tw [(53.8 \(1352\) 51.2-56.4)]TJ 0.3 -2.802 TD -0.06 Tw [(39.3 \(1015\) 36.9-41.7)]TJ -0.075 -1.398 TD -0.0047 Tc -0.0275 Tw [(26.3 \(606\) 24.2-28.6)]TJ 0 -1.401 TD [(25.7 \(559\) 23.5-28.1)]TJ 0.6 -1.401 TD -0.0041 Tc 0.0055 Tw [(5.2 \(99\) 4.1-6.6)]TJ 0 -1.398 TD [(3.5 \(89\) 2.7-4.5)]TJ -0.6 -2.802 TD -0.0047 Tc -0.0275 Tw [(21.1 \(555\) 19.8-22.5)]TJ 0 -1.398 TD [(15.6 \(373\) 14.4-16.8)]TJ 0 -1.401 TD [(30.1 \(707\) 28.5-31.7)]TJ T* [(27.9 \(594\) 26.4-29.4)]TJ 0.675 -1.398 TD -0.0012 Tw (5.4 \(139\) 4.7- 6.2)Tj -0.675 -2.802 TD -0.0275 Tw [(26.5 \(510\) 24.2-28.9)]TJ 0.075 -1.398 TD -0.0049 Tc -0.06 Tw [(44.0 \(1003\) 41.4-46.6)]TJ -0.075 -1.401 TD -0.0047 Tc -0.0275 Tw [(22.0 \(594\) 20.0-24.2)]TJ 0.675 -1.464 TD -0.0012 Tw (7.5 \(261\) 6.4- 8.8)Tj 12.975 32.265 TD -0.0275 Tw [(22.7 \(284\) 20.1-25.6)]TJ 0 -1.401 TD [(32.9 \(596\) 30.1-35.8)]TJ T* [(32.5 \(586\) 29.8-35.4)]TJ 0 -1.398 TD [(11.9 \(215\) 10.1-13.9)]TJ 0 -2.802 TD [(46.2 \(693\) 43.2-49.3)]TJ 0 -1.398 TD [(53.8 \(988\) 50.7-56.9)]TJ 0 -2.802 TD [(43.0 \(782\) 40.1-45.9)]TJ 0 -1.398 TD [(26.0 \(422\) 23.4-28.7)]TJ 0 -1.401 TD [(24.1 \(367\) 21.5-26.9)]TJ 0.6 -1.401 TD -0.0041 Tc 0.0055 Tw [(4.6 \(62\) 3.4- 6.1)]TJ 0 -1.398 TD [(2.4 \(48\) 1.7- 3.4)]TJ -0.6 -2.802 TD -0.0047 Tc -0.0275 Tw [(21.0 \(411\) 19.5 -22.6)]TJ 0 -1.398 TD [(15.5 \(252\) 14.1-17.0)]TJ 0 -1.401 TD [(30.3 \(490\) 28.4-32.2)]TJ T* [(27.7 \(423\) 26.0-29.5)]TJ 0.45 -1.398 TD -0.0044 Tc -0.0081 Tw [(5.5 \(105\) 4.65 -6.3)]TJ -0.45 -2.802 TD -0.0047 Tc -0.0275 Tw [(26.7 \(362\) 24.0-29.6)]TJ -0.6 -1.398 TD -0.0143 Tw [( 43.9 \(719\) 40.9-47.0)]TJ 0.6 -1.401 TD -0.0275 Tw [(21.8 \(416\) 19.4-24.4)]TJ -0.825 -1.401 TD -0.004 Tc 0.0078 Tw [( 7.6 \(184\) 6.3- 9.1)]TJ /F1 1 Tf -35.676 35.535 TD -0.0178 Tc 0 Tw (Demographics)Tj 22.515 2.301 TD -0.0083 Tc -0.186 Tw [(1 Y)82.7(ear )-118.1(P)33.7(ost )-117.7(Disaster)]TJ 2.55 -1.2 TD -0.0316 Tc 0 Tw (\(N=2368\))Tj -2.925 -1.2 TD -0.0049 Tc -0.0107 Tw [(Percent \(N\) 95% CI)]TJ 13.611 2.301 TD -0.0092 Tc -0.1851 Tw [(2 Y)81.8(ear)11.8(s )-117.6(P)29.8(ost )-117.2(Disaster)]TJ 2.814 -1.2 TD -0.0316 Tc 0 Tw (\(N=1681\))Tj -2.775 -1.2 TD -0.005 Tc -0.0167 Tw [(Percent \(N\) 95% CI)]TJ ET 2.01 w 1000 M /GS1 gs 56.005 709.995 490.99 -395.99 re S 0.99 w 10 M 259.515 711 m 259.515 315 l 399.495 710.01 m 399.495 314.01 l 54.99 669.495 m 548.01 669.495 l 56.01 597.495 m 548.01 597.495 l 54.99 554.505 m 546 554.505 l 54.99 471.495 m 546 471.495 l 56.01 387.495 m 546 387.495 l S BT /TT3 1 Tf 10 0 0 10 80.76 724.41 Tm /GS2 gs -0.0473 Tw (Table 2. Demographic Profile for Baseline \(Year 1\) and Follow-up \(Year 2\) for WTCD Outcome Study*)Tj -2.625 -42.261 TD -0.0048 Tc -0.0346 Tw [(*Note: All Ns are unweighted. Percentages and confidence intervals shown represent the weighted data \(i.e.,)]TJ 0 -1.2 TD -0.0235 Tw (adjustments to the sample for the number of telephone lines and adults in the household, the treatment over-)Tj T* -0.0046 Tc -0.0231 Tw [(sample, and survey stratification\). CI = Confidence interval; WTCD = World Trade Center Disaster.)]TJ ET endstream endobj 196 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 198 0 obj << /Length 8748 >> 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. 4 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (281)Tj /TT2 1 Tf 10 0 0 10 66 722.64 Tm -0.0093 Tc -0.0625 Tw (\(Adams & Boscarino, 2005a\). When we did this, there was no)Tj 0 -1.398 TD -0.0035 Tc -0.0607 Tw (evidence of racial/ethnic differences for PTSD, PTSD symp-)Tj 0 -1.401 TD -0.0023 Tc 0.1249 Tw [(tom severity)63.7(, or the likelihood of being classified in poor)]TJ T* -0.0066 Tc -0.0622 Tw [(physical health on the SF-12 physical health scale, once other)]TJ 0 -1.398 TD -0.0036 Tc -0.0447 Tw [(risk factors were controlled. In fact, )50.7(African )53.7(Americans were)]TJ 0 -1.401 TD -0.0031 Tc -0.0368 Tw (less likely to meet criteria for major depression or to be clas-)Tj T* -0.0034 Tc -0.0384 Tw (sified as unhealthy on the SF-12 mental health scale \(Adams)Tj 0 -1.398 TD -0.0033 Tc 0.0081 Tw (& Boscarino, 2005a\). Only for peri-event panic attack were)Tj 0 -1.401 TD -0.0031 Tc 0.0358 Tw [(there significant dif)17.9(ferences by ethnicity)62.9(, with both )51(African)]TJ T* -0.0034 Tc -0.0566 Tw (Americans and Puerto Ricans more likely to meet criteria for)Tj 0 -1.398 TD -0.0039 Tc -0.0468 Tw (this mental disorder relative to Whites \(Adams & Boscarino,)Tj 0 -1.401 TD -0.042 Tc 0 Tw (2005a\).)Tj /F1 1 Tf 11 0 0 11 66 536.01 Tm -0.0047 Tc 0.056 Tw (Functional Health Status Outcomes)Tj /TT2 1 Tf 10 0 0 10 84 512.64 Tm -0.0036 Tc 0.0221 Tw (Using baseline data, we also examined the relationship)Tj -1.8 -1.398 TD -0.004 Tc -0.0225 Tw (between exposure to the WTCD and functional health status)Tj 0 -1.401 TD -0.0079 Tc -0.0625 Tw (following the attacks based on the SF-12 scale. Overall the)Tj T* -0.0036 Tc 0.0956 Tw (greater the exposure to WTCD events, the poorer psycho-)Tj 0 -1.398 TD -0.0037 Tc -0.0465 Tw (logical well-being even after controlling for demographic)Tj 0 -1.401 TD -0.0032 Tc 0.0392 Tw (characteristics, other stressors, and social psychological re-)Tj T* -0.0036 Tc 0.0563 Tw [(sources \(Adams & Boscarino, 2005b\). Exposure was only)]TJ 0 -1.398 TD -0.0031 Tc 0.0406 Tw [(weakly related to physical well-being, however)35.9(, once other)]TJ 0 -1.401 TD -0.0036 Tc -0.005 Tw (factors were controlled.)Tj 1.8 -2.001 TD -0.0042 Tc 0.0002 Tw [(W)93.6(e)-0.6( also examined the consequences of the )17(WTCD lon-)]TJ -1.8 -1.398 TD -0.0031 Tc -0.0026 Tw [(gitudinally)62.9(. In ordinary least-squares regression models that)]TJ 0 -1.401 TD 0.001 Tc 0.125 Tw (contained demographic characteristics, stress risk factors,)Tj T* -0.0035 Tc 0.0137 Tw (and stress moderators as independent variables, level of ex-)Tj 0 -1.398 TD -0.0034 Tc 0.1231 Tw (posure to the disaster was associated with follow-up \(i.e.,)Tj 0 -1.401 TD -0.0029 Tc -0.0158 Tw (year 2 post-disaster\) physical and psychological well-being.)Tj T* -0.0037 Tc -0.0182 Tw [(However)35.3(, we found that level of exposure was not related to)]TJ 0 -1.398 TD -0.0032 Tc 0.0927 Tw (these outcomes, once the baseline \(year 1\) measure of the)Tj 0 -1.401 TD -0.0038 Tc 0.0479 Tw (follow-up dependent variable was controlled in these mod-)Tj T* -0.0035 Tc 0.0825 Tw (els. This suggested that disaster exposure did not continue)Tj 0 -1.398 TD -0.0031 Tc -0.0155 Tw (to have a lasting negative impact on physical or psychologi-)Tj 0 -1.401 TD -0.0035 Tc -0.0479 Tw (cal health status \(Adams, Boscarino, & Galea, 2006a\).)Tj 1.8 -2.001 TD -0.0039 Tc 0.0357 Tw (Our results did indicate that experiencing a WTCD-re-)Tj -1.8 -1.398 TD -0.0032 Tc -0.0532 Tw (lated peri-traumatic panic attack was related to poorer physi-)Tj 0 -1.401 TD -0.0034 Tc 0.0068 Tw (cal health status post-disaster at baseline, while meeting the)Tj T* -0.0036 Tc 0.0058 Tw (criteria for alcohol dependence post-disaster was associated)Tj 0 -1.398 TD 0.0359 Tc 0.125 Tw (with poorer mental health status at baseline \(Adams,)Tj 0 -1.401 TD -0.0119 Tc -0.0622 Tw [(Boscarino, & Galea, 2006a\). )48.1(At follow-up, however)36.1(, and con-)]TJ T* -0.0037 Tc -0.0625 Tw (trary to expectations, WTCD-related peri-traumatic panic at-)Tj 0 -1.398 TD -0.0035 Tc 0.093 Tw (tack did not have an adverse impact on health, once other)Tj 0 -1.401 TD -0.0038 Tc -0.0599 Tw [(risk factors were controlled \(Boscarino & )50.3(Adams, 2008\).)]TJ /F1 1 Tf 11 0 0 11 321 723.99 Tm -0.0049 Tc 0.0485 Tw (Results Related to PTSD Onset and Course)Tj /TT2 1 Tf 10 0 0 10 339 700.65 Tm -0.0035 Tc 0.0913 Tw (As noted, our results suggested that the prevalence of)Tj -1.8 -1.401 TD -0.0023 Tc 0.125 Tw (PTSD 12 months post-disaster was about 5% \(Boscarino,)Tj 0 -1.398 TD -0.0031 Tc 0.1137 Tw [(Adams, & Figley)62.9(, 2004\). Further analyses suggested that)]TJ 0 -1.401 TD -0.0065 Tc -0.0622 Tw (there were significant associations between PTSD at baseline)Tj T* -0.0034 Tc -0.0007 Tw [(and being female, being younger)35.6(, having lower self-esteem,)]TJ 0 -1.398 TD -0.0021 Tc 0.125 Tw (having lower social support, having greater WTCD event)Tj 0 -1.401 TD -0.0045 Tc -0.0622 Tw (exposures, having greater lifetime traumatic events, and hav-)Tj T* -0.0028 Tc 0.09 Tw (ing a history of depression \(all )Tj /TT5 1 Tf 12.891 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.495 0 TD -0.004 Tc 0.0911 Tw [(-values < 0.05; )52.9(Adams &)]TJ -13.386 -1.398 TD -0.0036 Tc 0.0963 Tw [(Boscarino, 2006\). However)38.4(, the results were dif)14.4(ferent for)]TJ 0 -1.401 TD -0.0077 Tc -0.0625 Tw [(PTSD at follow-up \(year 2 post-disaster\). )52.3(At follow-up, being)]TJ T* -0.0048 Tc (middle-aged, being Latino, having lower self-esteem, having)Tj 0 -1.398 TD -0.0035 Tc 0.0619 Tw (more negative life events, and having higher traumatic life)Tj 0 -1.401 TD -0.0039 Tc 0.0312 Tw (events were now significant predictors of PTSD \(Adams &)Tj T* 0.0072 Tw (Boscarino, 2006\). Noteworthy was that WTCD event expo-)Tj 0 -1.398 TD -0.0034 Tc 0.0257 Tw [(sure now was not significant at follow-up. Further analyses)]TJ 0 -1.401 TD -0.0003 Tc 0.125 Tw (suggested that the onset of delayed PTSD at follow-up)Tj T* -0.0034 Tc -0.0305 Tw (tended to be associated with the onset of negative life events)Tj 0 -1.398 TD -0.0046 Tc -0.0625 Tw (and decreases in self-esteem, not with previous WTCD event)Tj 0 -1.401 TD -0.0036 Tc 0.0173 Tw [(exposure, per se. \(Adams & Boscarino, 2006\). The finding)]TJ T* -0.0038 Tc 0.0273 Tw (for self-esteem and PTSD outcomes are shown in Figure 1.)Tj 0 -1.398 TD 0.0063 Tc 0.125 Tw (As can be seen, increased self-esteem is associated with)Tj 0 -1.401 TD -0.0064 Tc -0.0625 Tw [(remitted PTSD at follow-up \(i.e., PTSD at baseline, but not at)]TJ T* -0.0036 Tc 0.0164 Tw (follow-up\) and decreased self-esteem is associated with de-)Tj 0 -1.398 TD -0.0114 Tc -0.0625 Tw (layed PTSD at follow-up \(i.e., no PTSD at baseline, but PTSD)Tj 0 -1.401 TD -0.0129 Tc -0.0621 Tw [(at follow-up\). )47.2(Also noteworthy is that the resilient PTSD cases)]TJ T* -0.0094 Tc -0.0625 Tw (\(i.e., no PTSD at baseline or follow-up\) have the lowest levels)Tj 0 -1.398 TD -0.0034 Tc 0.0505 Tw (of low self-esteem of any of the PTSD groups studied \(see)Tj 0 -1.401 TD -0.0149 Tc -0.06 Tw (Figure 1\).)Tj /F1 1 Tf 11 0 0 11 321 285 Tm -0.0058 Tc 0.0909 Tw (Alcohol Abuse)Tj /TT2 1 Tf 10 0 0 10 339 261.66 Tm -0.0034 Tc 0.0636 Tw (Since research has suggested that exposure to psycho-)Tj -1.8 -1.401 TD -0.0036 Tc 0.0106 Tw (logical trauma was associated with increased abuse of alco-)Tj T* -0.0063 Tc -0.0624 Tw [(hol \(Boscarino, )47.8(Adams, & Galea, 2006\), we analyzed alcohol)]TJ 0 -1.398 TD -0.0095 Tc -0.0625 Tw (consumption, binge drinking, and alcohol dependence among)Tj 0 -1.401 TD -0.0027 Tc 0.1043 Tw [(study participants at one year and two years post-disaster)51.3(.)]TJ T* -0.0037 Tc 0.0192 Tw (In multivariate models controlling for demographic factors,)Tj 0 -1.398 TD -0.0033 Tc 0.085 Tw (other stressor exposures, psychological resources, and his-)Tj 0 -1.401 TD 0.0237 Tw [(tory of anti-social behavior)35.7(, we found that greater exposure)]TJ T* -0.0039 Tc -0.0417 Tw (to the WTCD event was associated with greater alcohol con-)Tj 0 -1.398 TD 0.0444 Tc 0.125 Tw (sumption at one year and two years after this event)Tj 0 -1.401 TD -0.0084 Tc -0.0623 Tw [(\(Boscarino, )51.8(Adams, & Galea, 2006\). In addition, our analyses)]TJ T* -0.004 Tc 0.0944 Tw (indicated that exposure to the WTCD was associated with)Tj 0 -1.398 TD -0.0028 Tc 0.0318 Tw (binge drinking at one year after but not two years after this)Tj 0 -1.401 TD -0.0004 Tc 0.125 Tw [(event. )50.6(Alcohol dependence, assessed as present in either)]TJ T* -0.0026 Tc 0.006 Tw (year 1 or year 2, also was positively associated with greater)Tj ET endstream endobj 199 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 202 0 obj << /Length 8741 >> 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 -0.009 Tc 0 Tw (282)Tj /TT3 1 Tf 1.65 0 TD -0.0058 Tc 0.115 Tw [( Boscarino and Adams)]TJ /F1 1 Tf 11.07 0 TD -0.0061 Tc 0.1156 Tw [(  )]TJ /TT3 1 Tf 1.125 0 TD -0.0056 Tc 0.1163 Tw (World Trade Center Disaster Outcomes Study)Tj /TT2 1 Tf 10 0 0 10 54 280.65 Tm -0.0039 Tc 0.015 Tw [(WTCD exposure. Posttraumatic stress disorder was not as-)]TJ 0 -1.401 TD -0.004 Tc 0.0494 Tw (sociated with alcohol use, once WTCD exposure and other)Tj 0 -1.398 TD -0.0035 Tc 0.1132 Tw (covariates were controlled. In addition, we found that our)Tj 0 -1.401 TD -0.0047 Tc -0.0622 Tw (alcohol abuse measures were positively associated with most)Tj T* -0.0029 Tc 0.125 Tw (adverse mental health measures, including PTSD, depres-)Tj 0 -1.398 TD 0.0101 Tc 0.1249 Tw [(sion, anxiety)58.1(, and poor functional health status \(Adams,)]TJ 0 -1.401 TD -0.0147 Tc -0.0616 Tw (Boscarino, & Galea, 2006a\).)Tj /F1 1 Tf 11 0 0 11 54 164.01 Tm -0.0051 Tc 0.087 Tw [(T)79.5(reatment Effectiveness)]TJ /TT5 1 Tf 0 -1.5136 TD 0.022 Tc 0.1272 Tw (Conventional Interventions)Tj /TT2 1 Tf 10 0 0 10 72 127.65 Tm -0.0031 Tc 0.0018 Tw (As noted above, a central focus of our study was to use)Tj -1.8 -1.401 TD -0.0037 Tc 0.0192 Tw (our prospective, population-based research design to evalu-)Tj 0 -1.398 TD -0.0039 Tc 0.0479 Tw (ate intervention outcomes among those who obtained post-)Tj 0 -1.401 TD 0.0021 Tc 0.125 Tw (disaster mental health services, which were made widely)Tj T* -0.0094 Tc -0.0625 Tw (available in NYC post-disaster \(Felton, 2002\). This basic pro-)Tj 25.5 20.901 TD 0.0065 Tc 0.125 Tw (spective evaluation design was used successfully in past)Tj 0 -1.401 TD -0.0037 Tc 0.0528 Tw [(mental health ef)14.3(fectiveness studies \(Bovasso, Eaton, & )53.2(A)7.5(r)14.3(-)]TJ 0 -1.398 TD -0.0034 Tc 0.0907 Tw [(menian, 1999\). )17.7(T)70.4(o)-0.1( assess the ef)17.6(fectiveness of various psy-)]TJ 0 -1.401 TD 0.0166 Tw (chotherapy treatments, we identified individuals who either)Tj T* -0.0022 Tc 0.125 Tw (had PTSD or subsyndromal PTSD \(Galea et al., 2003\) at)Tj 0 -1.398 TD -0.0062 Tc -0.0614 Tw (baseline and who were re-interviewed at follow-up \()Tj /TT5 1 Tf 20.226 0 TD -0.006 Tc 0 Tw (n )Tj /TT2 1 Tf 0.678 0 TD -0.065 Tw (= 490\).)Tj -20.904 -1.401 TD -0.0188 Tc -0.0625 Tw [(Using a propensity score method \(Rosenbaum & Rubin, 1983\),)]TJ T* -0.0033 Tc -0.0016 Tw (we then matched cases that received different types of post-)Tj 0 -1.398 TD -0.0035 Tc 0.0481 Tw (disaster interventions to comparable cases that did not. For)Tj 0 -1.401 TD 0.0019 Tw (these analyses we compared outcomes at follow-up for sev-)Tj T* -0.0033 Tc -0.0143 Tw (eral standards of treatment that patients received \(e.g., those)Tj 0 -1.398 TD -0.0032 Tc -0.0619 Tw [(receiving 3-6 psychotherapy sessions for 30 minutes or more)]TJ 0 -1.401 TD 0.075 Tw (post-disaster vs. those that did not, etc.\).)Tj 1.8 -2.001 TD -0.0039 Tc -0.0375 Tw (The health outcomes examined included alcohol depen-)Tj -1.8 -1.398 TD -0.0091 Tc -0.0622 Tw (dence, binge drinking, mental health symptoms, SF-12 physi-)Tj 11.365 0 0 11.3677 52.89 696.42 Tm 0 0 0 rg /GS1 gs 0 Tc 0 Tw ( )Tj ET 1 1 1 rg 57.36 701.37 486.24 -300.36 re f q 52.89 706.8 491.1 -314.31 re W n 0 0 0 RG 1 J 0.196 w 8 M 57.36 401.01 486.24 300.36 re S Q 138.66 676.86 314.79 -197.34 re f 149.76 527.07 22.89 -49.29 re f 0 0 0 RG 1 J 0.901 w 8 M 149.76 477.78 22.89 49.29 re S 228.45 611.49 22.89 -133.71 re f 228.45 477.78 22.89 133.71 re S 307.14 586.29 22.86 -108.51 re f 307.14 477.78 22.86 108.51 re S 385.83 627.93 22.86 -150.15 re f 385.83 477.78 22.86 150.15 re S 0 0 0 rg 172.65 539.13 21.96 -61.35 re f 172.65 477.78 21.96 61.35 re S 251.34 568.77 21.96 -90.99 re f 251.34 477.78 21.96 90.99 re S 330 627.93 21.99 -150.15 re f 330 477.78 21.99 150.15 re S 408.69 645.45 21.96 -167.67 re f 408.69 477.78 21.96 167.67 re S 0 J 1 j 1.425 w 10 M 133.29 675.09 m 133.35 477.78 l 128.7 477.78 m 133.29 477.72 l 128.7 501.87 m 133.29 501.84 l 128.7 527.07 m 133.29 527.01 l 128.7 551.19 m 133.29 551.13 l 128.7 576.42 m 133.29 576.39 l 128.7 600.54 m 133.29 600.48 l 128.7 625.74 m 133.29 625.68 l 128.7 649.83 m 133.29 649.8 l 128.7 675.09 m 133.29 675.03 l 133.29 477.78 m 448.05 477.72 l 133.29 472.29 m 133.35 477.78 l 211.98 472.29 m 212.04 477.78 l 290.67 472.29 m 290.7 477.78 l 369.36 472.29 m 369.42 477.78 l 448.05 472.29 m 448.11 477.78 l S BT /TT7 1 Tf 10.3853 0 0 10.3877 149.49 536.88 Tm -0.0073 Tc [(30)-17.3(%)]TJ /TT6 1 Tf 2.0048 0 TD 0 Tc ( )Tj /TT7 1 Tf 20.946 10.0561 TD -0.0073 Tc [(71)-17.3(%)]TJ /TT6 1 Tf 2.0048 0 TD 0 Tc ( )Tj /TT7 1 Tf -9.8505 -4.358 TD -0.0073 Tc [(54)-17.3(%)]TJ /TT6 1 Tf 2.0048 0 TD 0 Tc ( )Tj /TT7 1 Tf -9.2265 2.5472 TD -0.0073 Tc [(64)-17.3(%)]TJ /TT6 1 Tf 2.0048 0 TD 0 Tc ( )Tj /TT7 1 Tf 7.4095 1.5653 TD -0.0073 Tc [(71)-17.3(%)]TJ /TT6 1 Tf 2.0048 0 TD 0 Tc ( )Tj /TT7 1 Tf 5.9363 1.8859 TD -0.0073 Tc [(78)-17.3(%)]TJ /TT6 1 Tf 2.0048 0 TD 0 Tc ( )Tj /TT7 1 Tf -17.0722 -7.4338 TD -0.0073 Tc [(47)-17.3(%)]TJ /TT6 1 Tf 2.0048 0 TD 0 Tc ( )Tj /TT7 1 Tf -9.68 -2.4721 TD -0.0073 Tc [(35)-17.3(%)]TJ /TT6 1 Tf 2.0048 0 TD 0 Tc ( )Tj /TT7 1 Tf 11.365 0 0 11.3677 97.65 475.92 Tm -0.0018 Tc [(10)-15.8(%)]TJ /TT6 1 Tf 2.0035 0 TD 0 Tc ( )Tj /TT7 1 Tf -2.1593 2.1192 TD -0.0018 Tc [(20)-15.8(%)]TJ /TT6 1 Tf 2.0035 0 TD 0 Tc ( )Tj /TT7 1 Tf -2.0035 2.2089 TD -0.0018 Tc [(30)-15.8(%)]TJ /TT6 1 Tf 2.0035 0 TD 0 Tc ( )Tj /TT7 1 Tf -2.0035 2.1376 TD -0.0018 Tc [(40)-15.8(%)]TJ /TT6 1 Tf 2.0035 0 TD 0 Tc ( )Tj /TT7 1 Tf -2.0035 2.2063 TD -0.0018 Tc [(50)-15.8(%)]TJ /TT6 1 Tf 2.0035 0 TD 0 Tc ( )Tj /TT7 1 Tf -2.0035 2.1218 TD -0.0018 Tc [(60)-15.8(%)]TJ /TT6 1 Tf 2.0035 0 TD 0 Tc ( )Tj /TT7 1 Tf -2.0035 2.2221 TD -0.0018 Tc [(70)-15.8(%)]TJ /TT6 1 Tf 2.0035 0 TD 0 Tc ( )Tj /TT7 1 Tf -2.0035 2.1218 TD -0.0018 Tc [(80)-15.8(%)]TJ /TT6 1 Tf 2.0035 0 TD 0 Tc ( )Tj /TT7 1 Tf -2.0035 2.2247 TD -0.0018 Tc [(90)-15.8(%)]TJ /TT6 1 Tf 2.0035 0 TD 0 Tc ( )Tj /TT7 1 Tf 13.3244 0 0 13.3276 145.17 447.51 Tm 0.0033 Tc (Resilient)Tj /TT6 1 Tf 4.199 0 TD 0 Tc ( )Tj /TT7 1 Tf -3.8456 -1.722 TD 0.005 Tc (n=1495)Tj /TT6 1 Tf 3.447 0 TD 0 Tc ( )Tj /TT7 1 Tf 1.844 1.722 TD -0.0016 Tc [(Re)-6.1(mit)-6.3(t)-8.6(e)-6.1(d)]TJ /TT6 1 Tf 4.3026 0 TD 0 Tc ( )Tj /TT7 1 Tf -3.2129 -1.722 TD 0.0053 Tc (n=92)Tj /TT6 1 Tf 2.3281 0 TD 0 Tc ( )Tj /TT7 1 Tf 2.8279 1.722 TD 0.002 Tc [(Dela)-16(y)26.8(e)-2.5(d)]TJ /TT6 1 Tf 3.8478 0 TD 0 Tc ( )Tj /TT7 1 Tf -3.5371 -1.722 TD 0.0053 Tc (n=66)Tj /TT6 1 Tf 2.3281 0 TD 0 Tc ( )Tj /TT7 1 Tf 3.035 1.722 TD -0.0018 Tc [(Pers)-6.3(is)-6.3(t)-8.8(e)-4(n)-10.1(t)]TJ /TT6 1 Tf 4.8632 0 TD 0 Tc ( )Tj /TT7 1 Tf -3.8163 -1.722 TD 0.0053 Tc (n=28)Tj /TT6 1 Tf 2.3281 0 TD 0 Tc ( )Tj /TT7 1 Tf 0 15.284 -15.2876 0 85.29 489.24 Tm -0.0043 Tc 0.0091 Tw [(Percen)-7.8(t)-5( L)-7.8(o)4(w)-9.6( Sel)-9.1(f)-5(-)-5(E)-4.7(st)-5(eem)]TJ /TT6 1 Tf 11.9262 0 TD 0 Tc 0 Tw ( )Tj ET 1 1 1 rg 456.48 608.25 70.41 -55.92 re f 1 J 0 j 1.42 w 8 M 456.48 552.33 70.41 55.92 re S 465.42 595.05 8.22 -9.87 re f 0.906 w 465.42 585.18 8.22 9.87 re S q 478.35 586.41 34.17 12.69 re W n BT /TT7 1 Tf 11.365 0 0 11.3677 478.35 588.8101 Tm 0 0 0 rg (Y)Tj ET Q BT /TT7 1 Tf 11.365 0 0 11.3677 485.82 588.8101 Tm 0 0 0 rg 0.0117 Tc -0.015 Tw [(ea)16.2(r 1)]TJ /TT6 1 Tf 2.3493 0 TD 0 Tc 0 Tw ( )Tj ET 465.42 567.66 8.22 -9.87 re f 465.42 557.79 8.22 9.87 re S q 478.35 558.96 34.17 12.69 re W n BT /TT7 1 Tf 11.365 0 0 11.3677 478.35 561.36 Tm (Y)Tj ET Q BT /TT7 1 Tf 11.365 0 0 11.3677 485.82 561.36 Tm 0.0117 Tc -0.015 Tw [(ea)16.2(r 2)]TJ /TT6 1 Tf 2.3493 0 TD 0 Tc 0 Tw ( )Tj ET q 52.89 706.8 491.1 -311.76 re W n 1.42 w 57.36 401.01 486.24 300.36 re S Q BT /TT3 1 Tf 10 0 0 10 170.76 722.79 Tm 0 0 0 1 k /GS2 gs -0.0051 Tc -0.0287 Tw [(Figure 1. Percent of Respondents Having Low Self-Esteem)]TJ 6.45 -1.2 TD -0.01 Tw (by PTSD Status at Follow-up*)Tj -18.075 -32.358 TD -0.0048 Tc -0.0113 Tw [(*PTSD groups were defined as follows: Resilient = no PTSD in year 1 or year 2; Remitted = PTSD in year 1 but)]TJ 0 -1.2 TD -0.0047 Tc -0.0009 Tw (not year 2; Delayed = no PTSD in year 1 but PTSD in year 2; Persist = PTSD in year 1 and year 2.)Tj 0 -2.4 TD -0.0048 Tc -0.0091 Tw (Figure adopted with permission from Lippincott Williams & Wilkins \(copyright 2006\): Adams, RE, Boscarino, JA.)Tj 0 -1.2 TD -0.0233 Tw [(\(2006\). Predictors of PTSD and delayed-PTSD after disaster: The impact of exposure and psychosocial re-)]TJ T* -0.0055 Tc 0 Tw (sources.)Tj /F32 1 Tf 10 0 2.1256 10 91.89 327.21 Tm -0.005 Tc -0.0493 Tw [( Journal of Nervous and Mental Disease, 195)]TJ /TT3 1 Tf 10 0 0 10 286.44 327.21 Tm -0.0055 Tc -0.05 Tw (, 485-493.)Tj ET endstream endobj 203 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /F32 188 0 R /TT2 9 0 R /TT3 10 0 R /TT5 21 0 R /TT6 22 0 R /TT7 30 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 205 0 obj << /Length 9179 >> 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. 4 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (283)Tj /TT2 1 Tf 10 0 0 10 66 722.64 Tm -0.0032 Tc 0.0127 Tw (cal and mental health status, and PTSD. For these analyses,)Tj 0 -1.398 TD -0.0033 Tc 0.1084 Tw (propensity scores were used to match treated cases to un-)Tj 0 -1.401 TD -0.0035 Tc 0 Tw (treated controls. These results, based on conditional logistic)Tj T* 0.095 Tw (regression, suggested that conventional post-disaster inter-)Tj 0 -1.398 TD 0.0175 Tw [(ventions for traumatic stress exposures appeared to be inef-)]TJ 0 -1.401 TD 0.0169 Tc 0.125 Tw (fective. That is, participants in our study who received)Tj T* -0.0015 Tc (traditional psychotherapy at baseline were not less symp-)Tj 0 -1.398 TD -0.0038 Tc 0.0206 Tw (tomatic based on our outcome measures at follow-up, com-)Tj 0 -1.401 TD 0.0367 Tw (pared to those individuals with baseline PTSD who did not)Tj T* -0.001 Tc 0.125 Tw (receive these interventions. In fact, our results suggested,)Tj 0 -1.398 TD 0.0005 Tc 0.1249 Tw [(paradoxically)66.5(, that the treated cases often had worse out-)]TJ 0 -1.401 TD -0.0034 Tc 0.0545 Tw [(comes than the untreated cases. In addition, this treatment)]TJ T* -0.0109 Tw (exposure revealed a negative dose-response effect, whereby)Tj 0 -1.398 TD 0.0655 Tw (the more treatment a patient received, the worse his or her)Tj 0 -1.401 TD -0.0041 Tc 0.1157 Tw (mental health outcomes at follow-up. When we examined)Tj T* 0.004 Tc 0.125 Tw (outcomes for all respondents, regardless of whether they)Tj 0 -1.398 TD -0.0035 Tc -0.006 Tw (met the case definition or not for PTSD or depression, these)Tj 0 -1.401 TD -0.0029 Tc 0.0333 Tw (results were basically the same. )Tj /TT5 1 Tf 13.239 0 TD -0.0038 Tc 0.0338 Tw (In other words, those who)Tj -13.239 -1.401 TD 0.0277 Tw [(r)34.4(eceived psychotherapy)53.2(, r)32.2(egar)29.2(dless of their level of psycho-)]TJ 0 -1.398 TD -0.0037 Tc 0.0412 Tw (logical impairment at baseline, had worse outcomes at fol-)Tj 0 -1.401 TD -0.0041 Tc 0 Tw (low-up. )Tj /TT2 1 Tf 3.294 0 TD -0.0036 Tc 0.0466 Tw (\(Results available upon request.\))Tj /TT5 1 Tf 11 0 0 11 66 416.34 Tm 0.018 Tc 0.1273 Tw (Brief Interventions)Tj /TT2 1 Tf 10 0 0 10 84 396.66 Tm -0.0036 Tc 0.0119 Tw (When we assessed the effects of brief emergency men-)Tj -1.8 -1.401 TD 0.118 Tw [(tal health counseling post-disaster)35.4(, the results were dif)17.4(fer)17.4(-)]TJ T* 0.001 Tc 0.1249 Tw [(ent. )54.9(Although there has been controversy associated with)]TJ 0 -1.398 TD -0.012 Tc -0.062 Tw [(this modality \(Gist & )-6.8(Devilly)60(, 2002; Kaplan, Iancu & Bodner)39(,)]TJ 0 -1.401 TD -0.0042 Tc -0.0417 Tw (2001; van Emmerik, Kamphuis, Hulsbosch, & Emmelkamp,)Tj T* -0.0073 Tc -0.0621 Tw (2002\), consistent with some reports \(e.g., Basoglu, Salcioglu,)Tj 0 -1.398 TD -0.0094 Tc -0.0624 Tw [(Livanou, & Kalender)35.6(, 2005\), we found that brief post-disaster)]TJ 0 -1.401 TD -0.0035 Tc 0.076 Tw (interventions significantly reduced mental health problems)Tj T* 0.0122 Tc 0.125 Tw [(and symptoms up to two years after these interventions)]TJ 0 -1.398 TD -0.0036 Tc -0.0571 Tw [(\(Boscarino, )53.4(Adams, & Figley)62.4(, 2005; Boscarino, )50.4(Adams, Foa,)]TJ 0 -1.401 TD -0.0033 Tc -0.0567 Tw [(et al., 2006\). In our study)59.7(,)0.5( about 10% of NYC adults reported)]TJ T* 0.0045 Tc 0.125 Tw (receiving some type of crisis interventions conducted by)Tj 0 -1.398 TD -0.0032 Tc 0.1119 Tw (mental health professionals within a year after the attacks)Tj 0 -1.401 TD -0.0037 Tc 0.0119 Tw [(\(T)68.3(able 3\). Based on our sample, approximately 7% of NYC)]TJ T* -0.012 Tc -0.0625 Tw (adults \(~ 425,000 persons\) reported receiving employer-spon-)Tj 0 -1.398 TD -0.0005 Tc 0.125 Tw (sored, worksite crisis interventions related to the WTCD.)Tj 0 -1.401 TD -0.0036 Tc -0.0169 Tw (These interventions were delivered at the worksite and were)Tj T* -0.0034 Tc 0.0685 Tw [(defined as a brief session related to coping with the )14.6(W)97.4(orld)]TJ 0 -1.398 TD -0.0028 Tc 0.0483 Tw (Trade Center disaster shortly after this event, directed by a)Tj 0 -1.401 TD -0.0032 Tc 0.0436 Tw (mental health professional and arranged by area employers)Tj T* -0.0034 Tc -0.0567 Tw (for their employees. Crisis interventions following traumatic)Tj 0 -1.398 TD -0.0202 Tc -0.0622 Tw [(events have been utilized for a number of years \(Gist & Devilly)57.8(,)]TJ 0 -1.401 TD -0.0318 Tc -0.0624 Tw [(2002; Kaplan, Iancu, & Bodner)34.2(, 2001; van Emmerik et al., 2002\).)]TJ 25.5 63.399 TD -0.0035 Tc -0.0123 Tw [(However)35.5(, the ef)17.5(fectiveness and safety of these interventions)]TJ 0 -1.398 TD -0.0104 Tw [(have been challenged \(Boscarino, )50.7(Adams, Foa, et al., 2006;)]TJ 0 -1.401 TD -0.0215 Tc -0.0616 Tw [(Gist & Devilly)65.5(, 2002\).)]TJ 1.8 -2.001 TD -0.0034 Tc 0.0843 Tw (In the past, evaluation of these interventions has been)Tj -1.8 -1.398 TD -0.0037 Tc 0.1036 Tw [(hampered by limited research designs \(Boscarino, )50.6(Adams,)]TJ 0 -1.401 TD -0.003 Tc 0.115 Tw (Foa et al., 2006\). The purpose of our recent study was to)Tj T* -0.0034 Tc 0.0775 Tw (conduct a more advanced and focused analysis of prelimi-)Tj 0 -1.398 TD 0.0025 Tc 0.125 Tw (nary findings reported elsewhere based on a multivariate)Tj 0 -1.401 TD -0.0117 Tc -0.0623 Tw [(covariate model \(Boscarino, )48.5(Adams, & Figley)57.3(, 2005\). Our ini-)]TJ T* -0.0036 Tc -0.0625 Tw (tial analysis, which examined both mental health and alcohol)Tj 0 -1.398 TD -0.0037 Tc -0.0412 Tw (abuse outcomes, suggested that those who attended 1-3 brief)Tj 0 -1.401 TD -0.0031 Tc 0.0828 Tw (sessions had significantly better outcomes 2 years post-di-)Tj T* -0.0034 Tc 0.0107 Tw [(saster \(Boscarino, )53.7(Adams, & Figley)62.6(, 2005\). Based on these)]TJ 0 -1.398 TD -0.0125 Tc -0.0622 Tw (initial findings we refined our analysis and expanded the num-)Tj 0 -1.401 TD -0.0035 Tc 0.0061 Tw (ber of covariates to control for potential bias and confound-)Tj T* 0.0333 Tw (ing. The latter was achieved through use of more advanced)Tj 0 -1.398 TD -0.0157 Tw (propensity score matching to assess the average treatment)Tj 0 -1.401 TD -0.0037 Tc 0.0379 Tw [(ef)17.3(fect of worksite interventions \(Boscarino, )53.3(Adams, Foa, et)]TJ T* -0.032 Tc -0.06 Tw (al., 2006\).)Tj 1.8 -1.998 TD -0.003 Tc 0.0294 Tw (A description of the services received by employees at)Tj -1.8 -1.401 TD -0.0009 Tc 0.1249 Tw [(the worksite and the patient)56.1(s rating of these services are)]TJ T* -0.0033 Tc 0.0209 Tw [(shown in )14.8(T)73.5(able 4. )17.8(The data for this analysis was based on a)]TJ 0 -1.398 TD -0.0032 Tc -0.0519 Tw (subset of 1,121 employed adults interviewed by telephone in)Tj 0 -1.401 TD -0.0037 Tc 0.0612 Tw (our household WTCD survey at baseline and at follow-up.)Tj T* -0.0031 Tc 0.0983 Tw [(For the current study)62.9(, we used propensity scores to match)]TJ 0 -1.398 TD -0.0037 Tc 0.05 Tw (worksite intervention cases \()Tj /TT5 1 Tf 11.514 0 TD 0 Tc 0 Tw (n)Tj /TT2 1 Tf 0.495 0 TD -0.0035 Tc 0.051 Tw [( = 150\) to worksite noninter-)]TJ -12.009 -1.401 TD -0.0038 Tc 0.0225 Tw (vention controls \()Tj /TT5 1 Tf 7.035 0 TD 0 Tc 0 Tw (n)Tj /TT2 1 Tf 0.495 0 TD -0.0035 Tc 0.0238 Tw [( = 971\) using a 1:5 matching ratio based)]TJ -7.53 -1.401 TD -0.0037 Tc 0.012 Tw (on a bias-corrected, nearest-neighbor algorithm \(Boscarino,)Tj 0 -1.398 TD -0.0035 Tc -0.015 Tw (Adams, Foa, et al., 2006\). Unlike more conventional mental)Tj 0 -1.401 TD 0.0742 Tw (health treatments, these worksite interventions appeared to)Tj T* -0.0027 Tc 0.125 Tw (be effective across a spectrum of outcomes, including re-)Tj 0 -1.398 TD -0.0098 Tc -0.0625 Tw (duced alcohol dependence, binge drinking, depression, PTSD)Tj 0 -1.401 TD -0.0045 Tc -0.0621 Tw [(severity)61.5(, and reduced anxiety symptoms \(T)64.5(able 5; Boscarino,)]TJ T* -0.0031 Tc 0.0606 Tw (Adams, Foa, et al., 2006\). While this propensity study had)Tj 0 -1.398 TD -0.0033 Tc 0.0592 Tw (limitations, it suggested that brief post-disaster crisis inter-)Tj 0 -1.401 TD -0.0032 Tc -0.0344 Tw (ventions may be effective for employees following mass ex-)Tj T* 0.0022 Tc 0.125 Tw [(posure to psychologically traumatic events. None of the)]TJ 0 -1.398 TD -0.0036 Tc 0.0312 Tw (other interventions that we studied came close to achieving)Tj 0 -1.401 TD -0.0033 Tc 0.07 Tw (these results. The reasons for the effectiveness of the brief)Tj T* -0.0036 Tc 0.04 Tw (worksite interventions were unclear and warrant further in-)Tj 0 -1.398 TD 0.0333 Tw [(vestigations. Other than for the outcome of alcohol depen-)]TJ 0 -1.401 TD -0.0037 Tc 0.0199 Tw [(dence and binge drinking, those who received conventional)]TJ T* 0.0017 Tc 0.125 Tw (therapy sessions tended to do worse after these interven-)Tj 0 -1.398 TD -0.0032 Tc 0.0975 Tw (tions. In addition, the more conventional sessions they re-)Tj 0 -1.401 TD 0.1227 Tw (ceived, the worse they did in terms of PTSD, depression,)Tj T* -0.0158 Tc -0.0625 Tw [(anxiety)65.2(, and global severity)59.2(, a worrisome finding. )53.2(As discussed)]TJ ET endstream endobj 206 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 208 0 obj << /Length 3747 >> 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 -0.009 Tc 0 Tw (284)Tj /TT3 1 Tf 1.65 0 TD -0.0058 Tc 0.115 Tw [( Boscarino and Adams)]TJ /F1 1 Tf 11.07 0 TD -0.0061 Tc 0.1156 Tw [(  )]TJ /TT3 1 Tf 1.125 0 TD -0.0056 Tc 0.1163 Tw (World Trade Center Disaster Outcomes Study)Tj /F1 1 Tf 10 0 0 10 64.5 671.76 Tm -0.0092 Tc -0.0675 Tw (Mental Health Status)Tj /TT3 1 Tf 0 -1.2 TD -0.0064 Tc 0 Tw (PTSD Ever)Tj 0 -2.4 TD -0.0062 Tc -0.035 Tw (PTSD since WTCD)Tj T* -0.0087 Tc -0.07 Tw (Depression Ever)Tj T* -0.0081 Tc -0.0675 Tw (Depression since WTCD)Tj /F1 1 Tf T* -0.0053 Tc -0.0599 Tw [(Mental Health )75.8(Visits)]TJ /TT3 1 Tf 0 -1.2 TD -0.04 Tw (Any Mental Health Treatment)Tj T* -0.0048 Tc 0.125 Tw (Visits Ever)Tj 0 -2.4 TD -0.0052 Tc -0.04 Tw (Any Mental Health Treatment)Tj 0 -1.2 TD 0.0275 Tw (Visits since WTCD)Tj 0 -2.4 TD -0.04 Tw (Any Mental Health Treatment)Tj 0 -1.2 TD -0.0049 Tc -0.0117 Tw (Visits related to WTCD)Tj 0 -2.4 TD -0.0059 Tc -0.0675 Tw (Increased Mental Health)Tj 0 -1.2 TD -0.0051 Tc -0.0017 Tw (Treatment Visits since WTCD)Tj 0 -2.4 TD -0.0069 Tc -0.0683 Tw (New Mental Health Treatment)Tj 0 -1.2 TD -0.0052 Tc 0.0125 Tw (Visit since WTCD)Tj 20.739 26.268 TD -0.0467 Tc 0 Tw (284)Tj 0 -2.4 TD (196)Tj T* (621)Tj T* (416)Tj 10.725 7.302 TD -0.0238 Tc (8.15)Tj 0 -2.4 TD (5.25)Tj -0.264 -2.4 TD -0.0256 Tc (19.00)Tj T* (11.76)Tj 9.174 7.2 TD -0.0219 Tc (6.87-9.42)Tj 0 -2.4 TD (4.23-6.26)Tj -0.525 -2.4 TD -0.0238 Tc (17.11-20.83)Tj T* (10.29-13.22)Tj -19.299 -4.977 TD -0.0415 Tc (1242)Tj 0.264 -3.798 TD -0.0467 Tc (766)Tj 0 -3.42 TD (547)Tj 0 -3.6 TD (332)Tj T* (189)Tj 10.485 14.52 TD -0.0256 Tc (38.98)Tj 0 -3.6 TD (19.99)Tj T* (12.88)Tj 0.117 -3.6 TD -0.006 Tc -0.025 Tw [( 8.57)]TJ T* [( 5.28)]TJ 8.559 14.4 TD -0.0238 Tc 0 Tw (36.56-41.39)Tj 0 -3.6 TD (18.20-21.77)Tj T* (11.51-14.25)Tj 0.525 -3.6 TD -0.0219 Tc (7.36-9.79)Tj T* (4.32-6.25)Tj /F1 1 Tf 0.399 29.649 TD -0.018 Tc (95%CI*)Tj -40.899 -0.099 TD -0.0236 Tc (Outcomes)Tj 18.165 0 TD -0.0106 Tc -0.07 Tw (Unweighted N)Tj 5.8 0 0 5.8 310.89 693.54 Tm 0 Tc 0 Tw ()Tj 10 0 0 10 359.25 690.21 Tm -0.0063 Tc -0.06 Tw (Weighted %)Tj ET 2.01 w 1000 M /GS1 gs 55.505 701.995 489.99 -313.99 re S 0.99 w 10 M 54.51 685.335 m 546 685.335 l 55.5 575.805 m 544.5 575.805 l 217.995 702 m 217.995 387.99 l S BT /TT3 1 Tf 10 0 0 10 54 362.01 Tm /GS2 gs -0.0048 Tc -0.0411 Tw (*CI = Confidence interval; WTCD = World Trade Center Disaster.)Tj 5.8 0 0 5.8 54 353.34 Tm -0.0081 Tc 0 Tw ( )Tj 10 0 0 10 58.59 350.01 Tm -0.0047 Tc -0.035 Tw [(All Ns are unweighted. Percentages and confidence intervals shown represent the weighted data \(i.e., adjust-)]TJ -0.459 -1.2 TD -0.0048 Tc -0.0235 Tw (ments to the sample for the number of telephone lines and adults in the household, the treatment over-sample,)Tj T* -0.0045 Tc 0.0125 Tw [(and survey stratification\).)]TJ 0 -3.201 TD -0.0047 Tc -0.0133 Tw (For additional information, see: Boscarino, JA, Adams, RE, Figley, CR. \(2004\). Mental health service use 1-year)Tj 0 -1.2 TD -0.0045 Tc -0.0255 Tw (after the World Trade Center disaster: Implications for medical care. )Tj /F32 1 Tf 10 0 2.1256 10 351.21 282 Tm -0.0051 Tc -0.0248 Tw [(Gener)6.9(al Hospital Psychiatr)-35.1(y)101.9(,)0.6( 26)]TJ /TT3 1 Tf 10 0 0 10 488.25 282 Tm -0.0054 Tc -0.03 Tw (, 346-358.)Tj -36.186 44.301 TD -0.0047 Tc -0.0223 Tw (Table 3. Baseline Psychological Disorders and Mental Health Service Utilization)Tj 1.836 -1.2 TD -0.0048 Tc -0.041 Tw (Following the World Trade Center Disaster in New York City \()Tj /F32 1 Tf 10 0 2.1256 10 409.59 713.01 Tm -0.009 Tc 0 Tw (N )Tj /TT3 1 Tf 10 0 0 10 419.1 713.01 Tm -0.0053 Tc -0.045 Tw (= 2,368\))Tj ET endstream endobj 209 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /F32 188 0 R /TT3 10 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 211 0 obj << /Length 5436 >> 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. 4 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (285)Tj 10 0 0 10 75.51 671.49 Tm -0.0052 Tc -0.05 Tw (Number of Brief Crisis Sessions)Tj /TT3 1 Tf 0 -1.5 TD -0.0469 Tc 0 Tw (None)Tj T* -0.0451 Tc (One)Tj T* -0.0056 Tc -0.065 Tw (Two to Three)Tj T* -0.0086 Tc -0.0675 Tw (Four or more)Tj T* -0.0048 Tc 0.0175 Tw (Percent any Brief Crisis Sessions)Tj /F1 1 Tf T* -0.0052 Tc -0.0574 Tw [(Number of Brief Crisis Sessions at )75.9(W)62.8(orksite)]TJ /TT3 1 Tf T* -0.0469 Tc 0 Tw (None)Tj T* -0.0451 Tc (One)Tj T* -0.0056 Tc -0.065 Tw (Two to Three)Tj T* -0.0086 Tc -0.0675 Tw (Four or more)Tj T* -0.0047 Tc 0.0158 Tw (Percent any Brief Crisis Sessions at Worksite)Tj /F1 1 Tf 0 -1.365 TD -0.0052 Tc -0.0625 Tw (Content of Brief Sessions, among those having)Tj ET 0.5 w 92.55 477.5 m 75.51 477.5 l S BT 10 0 0 10 75.51 478.5 Tm -0.0064 Tc -0.044 Tw [(any)-6.4( sessions \()]TJ 10 0 2.1256 10 142.8 478.5 Tm -0.01 Tc 0 Tw (n )Tj 10 0 0 10 151.14 478.5 Tm -0.0058 Tc -0.05 Tw (= 356\))Tj /TT3 1 Tf -7.563 -1.5 TD -0.0055 Tc 0.0134 Tw (Educated about Stress Symptoms)Tj T* -0.0053 Tc -0.0575 Tw (Talked about Experiences)Tj T* -0.0437 Tw (Taught to Cope with Things)Tj T* -0.0048 Tc 0.0233 Tw (Taught to Think Positively)Tj T* -0.0053 Tc -0.035 Tw (Taught to Evaluate Thoughts)Tj T* -0.0051 Tc -0.025 Tw (Taught to Deal with Emotions)Tj T* -0.0053 Tc -0.0425 Tw (Taught to Relax)Tj /F1 1 Tf 0 -1.365 TD -0.0066 Tc -0.069 Tw (Reported Helpfulness of Crisis Intervention Ses-)Tj 0 -1.299 TD -0.0054 Tc -0.0613 Tw (sions, among those having )Tj ET 220.44 345.86 m 203.4 345.86 l S BT 10 0 0 10 203.4 346.86 Tm -0.0065 Tc -0.0615 Tw [(any)-6.5( sessions \()]TJ 10 0 2.1256 10 270.36 346.86 Tm 0 Tc 0 Tw (n)Tj 10 0 0 10 276.39 346.86 Tm -0.0065 Tc (=356\))Tj /TT3 1 Tf -20.088 -1.437 TD -0.0046 Tc -0.0066 Tw (Not at All Helpful)Tj 0 -1.5 TD -0.0049 Tc -0.05 Tw (Helped a Little)Tj T* -0.0139 Tc -0.07 Tw (Helped Some)Tj T* -0.0055 Tc -0.0675 Tw (Helped a Lot)Tj 27.975 36.762 TD -0.0238 Tc 0 Tw (89.9)Tj 0.525 -1.5 TD -0.0201 Tc (4.4)Tj T* (3.6)Tj T* (2.1)Tj -0.525 -1.5 TD -0.0238 Tc (10.2)Tj 0 -3 TD (93.5)Tj 0.525 -1.5 TD -0.0201 Tc (3.4)Tj T* (2.3)Tj T* (0.9)Tj T* (6.5)Tj -0.525 -4.152 TD -0.0238 Tc (63.7)Tj 0 -1.5 TD (62.9)Tj T* (65.1)Tj T* (64.1)Tj T* (57.7)Tj T* (69.1)Tj T* (65.9)Tj 0 -4.059 TD (17.7)Tj 0 -1.5 TD (24.5)Tj T* (25.4)Tj T* (32.4)Tj ET 0.99 w /GS1 gs 67.5 607.005 m 559.5 607.005 l 66.51 592.005 m 559.5 592.005 l 66.51 517.995 m 559.5 517.995 l 66 502.995 m 559.5 502.995 l 66 370.995 m 558.51 370.995 l S BT 10 0 0 10 417.75 657.09 Tm /GS2 gs -0.0219 Tc (88.4-91.3)Tj 0.525 -1.5 TD -0.0189 Tc (3.4-5.6)Tj T* (2.9-4.5)Tj T* (1.7-2.8)Tj -0.261 -1.5 TD -0.0206 Tc (8.9-11.8)Tj -0.264 -3 TD -0.0219 Tc (92.4-94.5)Tj 0.525 -1.5 TD -0.0189 Tc (2.6-4.4)Tj T* (1.8-2.8)Tj T* (0.6-1.3)Tj T* (5.5-7.6)Tj -0.525 -4.308 TD -0.0219 Tc (56.2-70.7)Tj 0 -1.5 TD (55.0-70.1)Tj T* (57.8-71.7)Tj T* (56.8-70.8)Tj T* (50.4-64.6)Tj T* (61.8-75.5)Tj T* (58.6-72.4)Tj 0 -4.002 TD (12.0-25.4)Tj 0 -1.5 TD (18.9-31.1)Tj T* (20.2-31.6)Tj T* (26.0-39.5)Tj /F1 1 Tf -34.125 40.152 TD -0.015 Tc -0.07 Tw (Intervention Characteristics)Tj 25.776 0 TD -0.0103 Tc (% \(Weighted\))Tj /TT3 1 Tf 16.575 -3.552 TD -0.0415 Tc 0 Tw (2012)Tj 0.264 -1.5 TD -0.0467 Tc (123)Tj T* (134)Tj 0.261 -1.5 TD -0.0623 Tc (89)Tj -0.261 -1.5 TD -0.0467 Tc (356)Tj -0.264 -3 TD -0.0415 Tc (2124)Tj 0.264 -1.5 TD -0.0467 Tc (103)Tj 0.261 -1.5 TD -0.0623 Tc (99)Tj T* (42)Tj -0.261 -1.5 TD -0.0467 Tc (244)Tj 0 -4.218 TD (244)Tj 0 -1.5 TD (264)Tj T* (246)Tj T* (238)Tj T* (206)Tj T* (255)Tj T* (245)Tj 0.261 -4.08 TD -0.0623 Tc (47)Tj 0 -1.5 TD (84)Tj -0.261 -1.5 TD -0.0467 Tc (101)Tj T* (124)Tj /F1 1 Tf -2.34 40.35 TD -0.0164 Tc -0.07 Tw (N \(Unweighted\))Tj -5.859 0.099 TD -0.0068 Tc -0.02 Tw (95% CI)Tj ET 2.01 w 1000 M /GS1 gs 67.505 703.495 491.49 -421.49 re S 0.99 w 10 M 322.005 703.5 m 322.005 281.01 l 403.995 704.49 m 403.995 283.5 l 473.505 704.01 m 473.505 284.01 l 66.51 686.505 m 557.49 686.505 l S BT /TT3 1 Tf 10 0 0 10 95.25 723.21 Tm /GS2 gs -0.0044 Tc 0.0105 Tw [( Table 4. Descriptive Statistics for Brief Intervention Exposures in Baseline Survey \()]TJ /F32 1 Tf 10 0 2.1256 10 481.14 723.21 Tm -0.011 Tc 0 Tw (N )Tj /TT3 1 Tf 10 0 0 10 491.16 723.21 Tm -0.0053 Tc 0.015 Tw (= 2,368\)*)Tj -42.516 -47.082 TD -0.0047 Tc -0.035 Tw [(*All Ns are unweighted. Percentages and confidence intervals shown represent the weighted data \(i.e., adjust-)]TJ 0 -1.2 TD -0.0048 Tc -0.0235 Tw (ments to the sample for the number of telephone lines and adults in the household, the treatment over-sample,)Tj T* -0.0046 Tc -0.0259 Tw (and survey stratification\). CI = Confidence interval; WTCD = World Trade Center Disaster.)Tj 0 -2.4 TD -0.0048 Tc -0.0067 Tw (Table adopted with permission from Lippincott Williams & Wilkins \(copyright 2006\): Boscarino, JA, Adams, RE,)Tj 0 -1.2 TD -0.0045 Tc -0.006 Tw (Foa, EB, Landrigan, PJ. \(2006\). A propensity score analysis of brief worksite crisis interventions after the World)Tj T* -0.0046 Tc -0.045 Tw (Trade Center disaster: Implications for intervention and research. )Tj /F32 1 Tf 10 0 2.1256 10 350.04 180.39 Tm -0.0053 Tc (Medical Care, 44)Tj /TT3 1 Tf 10 0 0 10 423.96 180.39 Tm -0.0055 Tc -0.05 Tw (, 454-462.)Tj ET endstream endobj 212 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /F32 188 0 R /TT3 10 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 214 0 obj << /Length 8350 >> 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 -0.009 Tc 0 Tw (286)Tj /TT3 1 Tf 1.65 0 TD -0.0058 Tc 0.115 Tw [( Boscarino and Adams)]TJ /F1 1 Tf 11.07 0 TD -0.0061 Tc 0.1156 Tw [(  )]TJ /TT3 1 Tf 1.125 0 TD -0.0056 Tc 0.1163 Tw (World Trade Center Disaster Outcomes Study)Tj /TT2 1 Tf 10 0 0 10 54 415.14 Tm -0.0031 Tc -0.0437 Tw [(previously)59.9(, our study included extensive risk factor data \(see)]TJ 0 -1.398 TD -0.0036 Tc 0.071 Tw [(T)73.2(able 1\); we used these data to risk adjust our treatment)]TJ 0 -1.401 TD 0.0002 Tc 0.125 Tw (models. For conventional treatments, this risk adjustment)Tj T* -0.0091 Tc -0.0625 Tw (made little difference.)Tj /F1 1 Tf 11 0 0 11 134.25 340.5 Tm 0.0258 Tc 0 Tw (CONCLUSION)Tj /TT2 1 Tf 10 0 0 10 72 317.16 Tm -0.0041 Tc -0.0238 Tw [( )51.1(As noted, following exposure to the )17(WTCD, the major)16.9(-)]TJ -1.8 -1.401 TD -0.003 Tc 0.0394 Tw (ity of individuals exposed to these events generally did not)Tj T* -0.0033 Tc 0.0187 Tw (seek mental health treatment, even though some clearly ex-)Tj 0 -1.398 TD -0.0062 Tc -0.0617 Tw [(perienced mental problems \(Boscarino, )48.2(Adams, S)20.8(tuber)32.8(, et al.,)]TJ 0 -1.401 TD -0.0066 Tc -0.0622 Tw (2005\). In addition, some persons experienced delayed mental)Tj T* -0.0034 Tc -0.005 Tw (health problems two years after the initial exposure \(Adams)Tj 0 -1.398 TD -0.0389 Tw (& Boscarino, 2006\). Our main study objective was to under-)Tj 0 -1.401 TD -0.0032 Tc -0.0384 Tw (take analyses that could provide insight related to the impact)Tj T* -0.0036 Tc 0.1206 Tw (of treatment-seeking and the onset of mental health prob-)Tj 0 -1.398 TD -0.0071 Tc -0.0625 Tw (lems following a major traumatic event exposure informa-)Tj 0 -1.401 TD 0.0368 Tc 0.125 Tw (tion that could inform health professionals about the)Tj T* -0.0035 Tc 0.0614 Tw (consequences of exposure to psychological trauma and the)Tj 0 -1.398 TD -0.0072 Tc -0.0625 Tw [(impact of treatment interventions following such events. Our)]TJ 0 -1.401 TD -0.0033 Tc -0.0053 Tw [(study)50.7(s main findings are as follows:)]TJ 1.2 -2.001 TD -0.0035 Tc -0.0327 Tw [()-1453.4(Generally)62.5(, those who sought mental health treatment)]TJ 1.8 -1.398 TD -0.004 Tc -0.04 Tw (after the WTCD tended to be individuals who sought)Tj 0 -1.401 TD 0 Tw (treatment )Tj /TT5 1 Tf 4.065 0 TD -0.0051 Tc (before)Tj /TT2 1 Tf 2.529 0 TD -0.0029 Tc 0.0772 Tw [( this event. They also tended to be)]TJ -6.594 -1.401 TD -0.0051 Tc -0.0622 Tw (individuals highly exposed to the WTCD event. Con-)Tj 25.5 34.05 TD -0.0032 Tc 0.1023 Tw [(versely)59.8(, symptomatic individuals who did not seek)]TJ 0 -1.398 TD -0.0034 Tc 0.0057 Tw (treatment tended to be members of minority groups,)Tj 0 -1.401 TD -0.0035 Tc 0.0237 Tw [(did not have health insurance coverage, and tended)]TJ T* 0.0029 Tc 0.125 Tw (to have sought informal support from friends and)Tj 0 -1.398 TD 0.009 Tc 0 Tw (neighbors.)Tj -1.8 -2.001 TD -0.0009 Tc 0.125 Tw [()-1450.8(Those who experienced delayed PTSD after the)]TJ 1.8 -1.401 TD -0.0038 Tc -0.0461 Tw (WTCD event \(i.e., no PTSD at baseline, but PTSD at)Tj 0 -1.398 TD -0.0036 Tc 0.05 Tw (follow-up\), tended to be Hispanic, non-native born,)Tj 0 -1.401 TD -0.0034 Tc 0.0167 Tw [(to have recently experienced lower self-esteem and/)]TJ T* -0.0031 Tc -0.0064 Tw (or negative life events. Contrary to expectations, the)Tj 0 -1.398 TD -0.0038 Tc 0.09 Tw (degree of WTCD exposure did not predict delayed)Tj 0 -1.401 TD 0.0116 Tc 0.125 Tw (PTSD. Persistent PTSD cases \(i.e., had PTSD at)Tj T* -0.0033 Tc 0.1122 Tw (baseline and at follow-up\) were similar to delayed)Tj 0 -1.398 TD -0.0035 Tc -0.0175 Tw [(cases, except that these cases had higher exposure to)]TJ 0 -1.401 TD -0.0033 Tc 0.0555 Tw (the WTCD events and they had a history of mental)Tj T* -0.0038 Tc 0.03 Tw (health disorders )Tj /TT5 1 Tf 6.609 0 TD -0.0051 Tc 0 Tw (before)Tj /TT2 1 Tf 2.532 0 TD -0.0048 Tc 0.0333 Tw [( the WTCD event.)]TJ -10.941 -1.998 TD -0.0029 Tc 0.125 Tw [()-1452.8(The outcomes of mental health treatment after the)]TJ 1.8 -1.401 TD -0.0038 Tc 0.0429 Tw (WTCD attack and what types of interventions were)Tj T* -0.0135 Tc -0.0622 Tw (the most beneficial were a major focus of our research.)Tj 0 -1.398 TD -0.0033 Tc -0.0017 Tw (Our findings suggested that early brief interventions)Tj 0 -1.401 TD -0.0035 Tc 0.0121 Tw (at the worksite were the most effective post-disaster)Tj T* -0.0049 Tc -0.0625 Tw (treatment. In addition, informal support seeking from)Tj 0 -1.398 TD -0.0037 Tc 0.116 Tw (friends, neighbors, and from spiritual communities)Tj 0 -1.401 TD -0.0033 Tc 0.0029 Tw [(also appeared beneficial. Conversely)59.7(, those who re-)]TJ T* 0.0101 Tc 0.125 Tw (ceived more extensive post-disaster interventions)Tj /F1 1 Tf 3.15 63.486 TD -0.0061 Tc 0.0136 Tw [( Mean)-2430.1( Mean)-2631.1( )16.4( )16.4(Mean)]TJ -24.201 -1.2 TD -0.0054 Tc 0.0203 Tw [( PTSD)-1181.4( )65.5( )65.5(Depression)-704.4( )5( )5( )5(Alcohol)-1655.4( )]TJ 18.2801 0 TD -0.0084 Tc 0.0223 Tw [( Binge)-2009.4( PTSD)-2282.4( )94.3(Depression)-1058.4( )93.9(Anxiety)]TJ -18.2801 -1.2 TD -0.0057 Tc -0.0012 Tw [( )53.9(Diagnosis)-56.7( Diagnosis)]TJ 11.55 0 TD -0.0273 Tc 0.0375 Tw [(Dependence)-477.3( )]TJ 7.3027 0 TD -0.0066 Tc 0.0213 Tw [(Drinking)-1332.6( Symptom)-1005.6( Symptom)-1206.6(Symptom)]TJ 5.3483 -1.2 TD -0.0054 Tc 0.0134 Tw [( Level)-2429.4( Level)-2630.4( )16( )16(Level)]TJ -30.801 -3.6 TD -0.0105 Tc 0 Tw (Significance)Tj 0 -1.2 TD -0.0123 Tc (level)Tj /TT3 1 Tf 7.8 0 TD -0.0392 Tc 0.051 Tw [(NS)-2889.2( )]TJ /F32 1 Tf 10 0 2.1256 10 188.34 616.5 Tm 0 Tc 0 Tw (p)Tj /TT3 1 Tf 10 0 0 10 193.86 616.5 Tm -0.0048 Tc 0.0175 Tw [( < .05)]TJ /F32 1 Tf 10 0 2.1256 10 248.49 616.5 Tm -0.01 Tc 0 Tw (p )Tj /TT3 1 Tf 10 0 0 10 256.86 616.5 Tm -0.0052 Tc 0.0188 Tw [(< )8.8(.01)-2927.2( )]TJ /F32 1 Tf 10 0 2.1256 10 317.31 616.5 Tm -0.008 Tc 0 Tw (p )Tj /TT3 1 Tf 10 0 0 10 325.74 616.5 Tm -0.0055 Tc 0.02 Tw (< .05)Tj /F32 1 Tf 10 0 2.1256 10 374.49 616.5 Tm 0.006 Tc 0 Tw ( p)Tj /TT3 1 Tf 10 0 0 10 382.89 616.5 Tm -0.005 Tc 0.0156 Tw [( < .05)-2630( )]TJ /F32 1 Tf 10 0 2.1256 10 440.34 616.5 Tm -0.009 Tc 0 Tw (p )Tj /TT3 1 Tf 10 0 0 10 448.74 616.5 Tm -0.0055 Tc 0.0186 Tw [(< .05)-2030.5( )]TJ /F32 1 Tf 10 0 2.1256 10 497.34 616.5 Tm 0 Tc 0 Tw (p)Tj /TT3 1 Tf 10 0 0 10 502.86 616.5 Tm -0.0048 Tc 0.0175 Tw [( < .10)]TJ /F1 1 Tf -44.037 -2.4 TD -0.0056 Tc -0.05 Tw (Impact of)Tj 0 -1.2 TD -0.0258 Tc 0 Tw (treatment)Tj T* -0.009 Tc -0.07 Tw (vs. no)Tj T* -0.0234 Tc 0 Tw (treatment**)Tj /TT3 1 Tf 7.8 0 TD -0.007 Tc 0.0261 Tw [( )29.9(-)-3607( 7.2%)-3157(4.8%)-3757( 5.5%)-3157( )]TJ 24.2969 0 TD -0.0042 Tc 0.0193 Tw [( )-6( )-6(.8)-3679.2( 1.8)-3154.2( 1.4)]TJ ET 2.01 w 1000 M /GS1 gs 55.505 711.695 489.99 -166.99 re S 0.99 w 10 M 180.015 712.71 m 180.015 544.71 l 238.995 711.69 m 238.995 545.01 l 304.005 712.71 m 304.005 545.01 l 367.005 712.71 m 367.005 544.71 l 424.995 712.71 m 424.995 545.01 l 490.005 711.69 m 490.005 543.99 l 124.005 712.71 m 124.005 546.69 l 55.5 658.185 m 544.5 658.185 l 55.5 649.185 m 546.51 649.185 l 56.49 551.205 m 544.5 551.205 l S BT 10 0 0 10 108 723.09 Tm /GS2 gs -0.0047 Tc -0.013 Tw (Table 5. Summary Results for Brief Worksite Interventions for 7 Outcomes at Follow-up*)Tj -5.25 -19.26 TD -0.0048 Tc -0.0061 Tw [(*For additional information, see: )-5.9(Boscarino, JA, Adams, RE, Foa, EB, Landrigan, PJ. \(2006\). A propensity score)]TJ 0 -1.2 TD -0.0044 Tc -0.0125 Tw (analysis of brief worksite crisis interventions after the World Trade Center disaster: Implications for intervention)Tj T* -0.0052 Tc -0.065 Tw (and research. )Tj /F32 1 Tf 10 0 2.1256 10 117.45 506.49 Tm -0.0675 Tw (Medical Care, 44)Tj /TT3 1 Tf 10 0 0 10 190.89 506.49 Tm -0.07 Tw (, 454-462.)Tj -13.539 -2.4 TD -0.0047 Tc -0.0071 Tw (**As an example of the brief treatment outcome impact, the results for depression suggest that the prevalence of)Tj 0 -1.2 TD -0.005 Tc -0.035 Tw (depression was about 7% lower among treated cases at follow-up compared to matched untreated cases. Like-)Tj T* -0.0213 Tw (wise, treated cases had lower mean depression symptom scores by about 2 points compared to matched un-)Tj T* -0.0051 Tc 0.01 Tw (treated cases.)Tj ET endstream endobj 215 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /F32 188 0 R /TT2 9 0 R /TT3 10 0 R /TT5 21 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 217 0 obj << /Length 8220 >> 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. 4 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (287)Tj /TT2 1 Tf 10 0 0 10 96 722.64 Tm -0.003 Tc 0.0358 Tw (\(e.g., formal psychotherapy sessions for 30 minutes)Tj 0 -1.398 TD -0.052 Tw (or more\) did not benefit and, in fact, they appeared to)Tj 0 -1.401 TD -0.0035 Tc -0.0519 Tw (have worse outcomes. The reasons for the latter find-)Tj T* -0.0064 Tc -0.0624 Tw [(ing were unclear)38.6(, since we controlled for an extensive)]TJ 0 -1.398 TD -0.003 Tc 0.0036 Tw (number of risk factors in these analysis, presumably)Tj 0 -1.401 TD -0.0036 Tc 0.04 Tw (controlling for selection bias and confounding.)Tj -1.8 -2.001 TD -0.05 Tw [()-1453.4(In terms of those who were the most resilient to men-)]TJ 1.8 -1.398 TD -0.0037 Tc -0.0321 Tw (tal health problems following the WTCD event, they)Tj 0 -1.401 TD -0.0035 Tc 0.0131 Tw (tended to be males, older persons, those with higher)Tj T* -0.0015 Tc 0.125 Tw (self-esteem and stronger social support. They also)Tj 0 -1.398 TD 0.0099 Tc (tended to be persons )Tj /TT5 1 Tf 9.15 0 TD 0.0084 Tc 0 Tw (without)Tj /TT2 1 Tf 3.066 0 TD 0.011 Tc 0.125 Tw [( a history of mental)]TJ -12.216 -1.401 TD -0.0123 Tc -0.06 Tw (health problems )Tj /TT5 1 Tf 6.354 0 TD -0.014 Tc 0 Tw [(befor)31(e)]TJ /TT2 1 Tf 2.442 0 TD -0.0115 Tc -0.0625 Tw [( the )19(WTCD event. Finally)63.5(, they)]TJ -8.796 -1.401 TD -0.0036 Tc 0.1064 Tw (tended to be persons with fewer lifetime traumatic)Tj 0 -1.398 TD 0.0894 Tw (events and those with fewer stressful life events in)Tj 0 -1.401 TD -0.0024 Tc 0.0525 Tw [(the past year)51.6(.)]TJ -1.8 -2.001 TD -0.0021 Tc 0.125 Tw [()-1452(Our study suggests that exposure to psychological)]TJ 1.8 -1.398 TD -0.0036 Tc -0.0586 Tw (trauma is associated with increases in problem drink-)Tj 0 -1.401 TD 0.0963 Tw (ing and alcohol abuse long after exposure and that)Tj T* -0.0037 Tc 0.0672 Tw (these substance use outcomes tend to be associated)Tj 0 -1.398 TD -0.0038 Tc 0.0375 Tw (with other adverse mental health outcomes post-ex-)Tj 0 -1.401 TD 0.014 Tc 0 Tw (posure.)Tj /F1 1 Tf 11 0 0 11 126.39 396.39 Tm 0.0178 Tc [(RECOMMEND)31.4(A)93.4(TIONS)]TJ /TT2 1 Tf 10 0 0 10 84 373.05 Tm -0.0035 Tc 0.0357 Tw (Based on our study findings, our recommendations for)Tj -1.8 -1.401 TD -0.0037 Tc -0.004 Tw (future post-trauma research include the following:)Tj 1.2 -1.998 TD -0.0033 Tc 0.0022 Tw [()-1453.2(Additional research is needed related to why receiv-)]TJ 1.8 -1.401 TD -0.0036 Tc 0.095 Tw (ing brief post-disaster treatment interventions were)Tj T* -0.008 Tc 0 Tw (effective.)Tj -1.8 -1.998 TD -0.0034 Tc -0.0007 Tw [()-1453.3(Conversely)59.6(, research is needed to confirm that those)]TJ 1.8 -1.401 TD -0.0038 Tc 0.0987 Tw (who received conventional post-disaster treatments)Tj T* -0.0026 Tc -0.0605 Tw (actually did worse, and if so, why this may have been)Tj 0 -1.398 TD -0.0034 Tc 0.11 Tw (the case.)Tj -1.8 -2.001 TD 0.0188 Tc 0.125 Tw [()-1431.1(Additional research is needed to determine why)]TJ 1.8 -1.401 TD 0.0061 Tc (clearly symptomatic members of minority groups)Tj 0 -1.398 TD -0.0034 Tc (tended not to seek post-disaster treatment. For ex-)Tj 0 -1.401 TD -0.0035 Tc 0.0471 Tw (ample, was this because of differences in perceived)Tj T* -0.0225 Tw (stigma, because of informal or alternative treatment-)Tj 0 -1.398 TD -0.0033 Tc 0.0287 Tw (seeking, or some other reason?)Tj -1.8 -2.001 TD -0.0041 Tc -0.0621 Tw [()-1454(Further research is needed to determine the effective-)]TJ 1.8 -1.401 TD -0.0035 Tc 0.0069 Tw (ness and nature of informal social support and alter-)Tj 0 -1.398 TD -0.0012 Tc 0.125 Tw (native interventions in protecting individuals from)Tj 0 -1.401 TD -0.0038 Tc 0.04 Tw (post-disaster mental health problems.)Tj 23.7 62.559 TD -0.0036 Tc 0.0436 Tw [()-1453.5(Research is recommended related to factors that af-)]TJ 1.8 -1.398 TD -0.0166 Tc -0.0626 Tw [(fect post-disaster resiliency)61.4(. For example, persons with)]TJ 0 -1.401 TD 0.0048 Tc 0.125 Tw (higher self-esteem post-disaster tended to be pro-)Tj T* -0.0037 Tc -0.0157 Tw (tected from future mental health problems. Some re-)Tj 0 -1.398 TD 0.0378 Tc 0.125 Tw (search questions are: Why were these persons)Tj 0 -1.401 TD -0.0036 Tc -0.0375 Tw (protected from mental health problems? Should self-)Tj T* 0.0412 Tw (esteem be a focus of post-event interventions in the)Tj 0 -1.398 TD -0.0033 Tc 0.0767 Tw (future? In the past, post-disaster interventions have)Tj 0 -1.401 TD -0.0029 Tc 0.0449 Tw [(usually focused on psychopathology)63.1(, rather than on)]TJ T* -0.0033 Tc -0.0178 Tw [(wellness and positive psychological factors. Our re-)]TJ 0 -1.398 TD -0.0035 Tc -0.0206 Tw (search suggests that this clinical focus might be mis-)Tj 0 -1.401 TD -0.0016 Tc 0 Tw (placed.)Tj -1.8 -2.001 TD -0.0021 Tc 0.125 Tw [()-1452(Our study suggests that exposure to psychological)]TJ 1.8 -1.398 TD -0.0034 Tc 0.0021 Tw (trauma may be associated with increases in problem)Tj 0 -1.401 TD -0.0037 Tc -0.035 Tw (drinking and alcohol abuse after these exposures and)Tj T* -0.0035 Tc 0.125 Tw (deserves further investigation.)Tj /F1 1 Tf 11 0 0 11 400.89 474 Tm 0.021 Tc 0 Tw (REFERENCES)Tj /TT2 1 Tf 10 0 0 10 321 456.66 Tm -0.0188 Tc -0.0625 Tw (Adams, R.E., & Boscarino, J.A. \(2005a\). Differences in mental)Tj 1.2 -1.401 TD -0.0044 Tc 0.0301 Tw [(health outcomes among )16.7(Whites, )49.7(African )49.7(Americans, and)]TJ T* -0.0036 Tc 0.0135 Tw (Hispanics following the September 11 attacks. )Tj /TT5 1 Tf 19.035 0 TD -0.0048 Tc 0 Tw (Psychia-)Tj -19.035 -1.398 TD -0.02 Tc -0.058 Tw [(tr)-5(y)54.8(,)-2( 68)]TJ /TT2 1 Tf 2.37 0 TD -0.0187 Tc -0.06 Tw (, 250-265.)Tj -3.57 -1.8 TD -0.0035 Tc -0.0606 Tw (Adams, R.E., & Boscarino, J.A. \(2005b\). Stress and well-be-)Tj 1.2 -1.401 TD -0.0034 Tc -0.0239 Tw [(ing in the aftermath of the )14(W)97.4(orld )18.7(T)37.4(rade Center attack: the)]TJ T* -0.0035 Tc -0.0333 Tw [(continuing ef)17.5(fects of a community-wide disaster)50.5(. )]TJ /TT5 1 Tf 19.419 0 TD -0.005 Tc 0 Tw (Journal)Tj -19.419 -1.398 TD -0.0042 Tc -0.0514 Tw [(of Community Psychology)52.8(, 33)]TJ /TT2 1 Tf 11.679 0 TD -0.0036 Tc -0.055 Tw (, 175-190.)Tj -12.879 -1.8 TD 0.0119 Tw (Adams, R.E., & Boscarino J.A. \(2006\). Predictors of PTSD)Tj 1.2 -1.401 TD 0.0079 Tw [(and delayed-PTSD after disaster: the impact of exposure)]TJ T* 0.0183 Tc 0.125 Tw (and psychosocial resources. )Tj /TT5 1 Tf 12.279 0 TD 0.0178 Tc (Journal of Nervous and)Tj -12.279 -1.398 TD -0.0054 Tc -0.06 Tw (Mental Disease, 195)Tj /TT2 1 Tf 8.031 0 TD -0.065 Tw (, 485-493.)Tj -9.231 -1.8 TD -0.0125 Tc -0.062 Tw [(Adams, R.E., & Boscarino, J.A., & Galea, S. \(2006a\). )53.7(Alcohol)]TJ 1.2 -1.401 TD -0.0034 Tc 0.0193 Tw (use, mental health status and psychological well-being 2)Tj T* -0.0033 Tc 0.0573 Tw [(years after the )17.8(W)94.5(orld )17.8(T)37.5(rade Center attacks in New )32.8(Y)103.9(ork)]TJ 0 -1.398 TD -0.0005 Tc 0 Tw [(City)62.5(. )]TJ /TT5 1 Tf 2.199 0 TD -0.0041 Tc 0.0462 Tw [(American Journal of Drug and )16.7(Alcohol )16.7(Abuse, 32)]TJ /TT2 1 Tf 20.052 0 TD 0 Tc 0 Tw (,)Tj -22.251 -1.401 TD -0.0511 Tc (203-224.)Tj -1.2 -1.8 TD -0.0132 Tc -0.0622 Tw (Adams, R.E., Boscarino, J.A., & Galea, S. \(2006b\). Social and)Tj 1.2 -1.401 TD -0.0035 Tc -0.0224 Tw [(psychological resources and health outcomes after )14.6(W)97.3(o)1.5(rld)]TJ 0 -1.398 TD 0.0648 Tw [(T)37.3(rade Center disaster)53.5(. )]TJ /TT5 1 Tf 9.081 0 TD -0.0038 Tc 0.065 Tw (Social Science and Medicine, 62)Tj /TT2 1 Tf 13.17 0 TD 0 Tc 0 Tw (,)Tj -22.251 -1.401 TD -0.0511 Tc (176-188.)Tj -1.2 -1.8 TD 0.0197 Tc 0.125 Tw (Adams, R.E., Bromet, E.J., Panina, N., Golovakha, E.,)Tj 1.2 -1.401 TD -0.0195 Tc -0.0622 Tw [(Goldgaber)37.5(, D., & Bluzman, S. \(2002\). S)13.5(tress and well-being)]TJ 0 -1.398 TD -0.0028 Tc 0.1024 Tw [(in mothers of young children 11 years after Chornobyl)]TJ 0 -1.401 TD -0.0004 Tc 0.125 Tw (nuclear power plant accident. )Tj /TT5 1 Tf 12.51 0 TD -0.0009 Tc (Psychological Medicine,)Tj -12.51 -1.401 TD -0.034 Tc 0 Tw (32)Tj /TT2 1 Tf 0.945 0 TD -0.027 Tc -0.06 Tw (, 143-156.)Tj ET endstream endobj 218 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 220 0 obj << /Length 10485 >> 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 -0.009 Tc 0 Tw (288)Tj /TT3 1 Tf 1.65 0 TD -0.0058 Tc 0.115 Tw [( Boscarino and Adams)]TJ /F1 1 Tf 11.07 0 TD -0.0061 Tc 0.1156 Tw [(  )]TJ /TT3 1 Tf 1.125 0 TD -0.0056 Tc 0.1163 Tw (World Trade Center Disaster Outcomes Study)Tj /TT2 1 Tf 10 0 0 10 54 722.64 Tm -0.0122 Tc -0.0625 Tw [(Adams, R.E., Figley)62.8(, C.R., & Boscarino J.A. \(2008\).The com-)]TJ 1.2 -1.398 TD -0.0036 Tc -0.0568 Tw (passion fagtigue scale: Its use with social workers follow-)Tj 0 -1.401 TD -0.0034 Tc -0.0036 Tw [(ing urban disaster)53.6(. )]TJ /TT5 1 Tf 7.479 0 TD -0.004 Tc -0.0048 Tw [(Resear)32(ch in Social W)83(ork Practice, 18)]TJ /TT2 1 Tf 14.772 0 TD 0 Tc 0 Tw (,)Tj -22.251 -1.401 TD -0.0511 Tc (238-250.)Tj -1.2 -1.8 TD -0.0166 Tc -0.0611 Tw [(Basoglu, M.)-4.6(, Salcioglu, E., Livanou, M., Kalender)31.4(, D., & )53.4(Acar)37.4(,)]TJ 1.2 -1.398 TD -0.0035 Tc 0.0817 Tw [(G)124.7(.)0( \(2005\). Single-session behavioral treatment of earth-)]TJ 0 -1.401 TD -0.0047 Tc -0.062 Tw (quake-related posttraumatic stress disorder: a randomized)Tj T* -0.0076 Tc -0.0612 Tw (waiting list controlled trial. )Tj /TT5 1 Tf 10.659 0 TD -0.0084 Tc -0.0631 Tw [(Journal of T)51.6(rauma S)30.6(t)4.6(r)30.6(ess, 8, )]TJ /TT2 1 Tf 11.022 0 TD -0.014 Tc 0 Tw (1-)Tj -21.681 -1.398 TD -0.0625 Tc (11.)Tj -1.2 -1.8 TD -0.0036 Tc -0.0049 Tw [(Boscarino, J.A. \(1995\). Post-traumatic stress and associated)]TJ 1.2 -1.401 TD 0 Tc 0.125 Tw [(disorders among )15(V)62.2(ietnam veterans: the significance of)]TJ T* 0.0035 Tc (combat exposure and social support. )Tj /TT5 1 Tf 15.585 0 TD 0.1252 Tw [(Journal of T)54.5(rau-)]TJ -15.585 -1.398 TD -0.0098 Tc -0.06 Tw (matic Stress, 8)Tj /TT2 1 Tf 5.601 0 TD -0.0104 Tc -0.065 Tw (, 317-336.)Tj -6.801 -1.8 TD -0.0036 Tc -0.04 Tw [(Boscarino, J.A. \(1996\). Post-traumatic stress disorder)35.4(, expo-)]TJ 1.2 -1.401 TD -0.0051 Tc -0.0623 Tw [(sure to combat, and lower plasma cortisol among )13.1(V)69.1(ietnam)]TJ T* -0.002 Tc 0.125 Tw [(veterans: findings and clinical implications. )]TJ /TT5 1 Tf 18.261 0 TD -0.0027 Tc (Journal of)Tj -18.261 -1.398 TD -0.0041 Tc 0.0401 Tw [(Consulting and Clinical Psychology)49.9(, 64)]TJ /TT2 1 Tf 15.93 0 TD -0.0037 Tc 0.045 Tw (, 191-201.)Tj -17.13 -1.8 TD -0.0033 Tc 0.0212 Tw (Boscarino, J.A. \(1997\). Diseases among men 20 years after)Tj 1.2 -1.401 TD -0.0107 Tc -0.0621 Tw (exposure to severe stress: implications for clinical research)Tj T* -0.0035 Tc -0.0467 Tw (and medical care. )Tj /TT5 1 Tf 7.074 0 TD -0.0042 Tc -0.045 Tw (Psychosomatic Medicine, 59)Tj /TT2 1 Tf 11.277 0 TD -0.0038 Tc -0.05 Tw (, 605-614.)Tj -19.551 -1.8 TD 0.077 Tw [(Boscarino, J.A. \(2004\). )50.2(Association between posttraumatic)]TJ 1.2 -1.398 TD -0.0033 Tc 0.0629 Tw (stress disorder and physical illness: results and implica-)Tj 0 -1.401 TD -0.0036 Tc 0.0525 Tw (tions from clinical and epidemiologic studies. )Tj /TT5 1 Tf 18.675 0 TD -0.0045 Tc 0.055 Tw (Annals of)Tj -18.675 -1.401 TD -0.0042 Tc -0.0183 Tw [(New Y)85.8(ork )16.5(Academy of Sciences, 1032)]TJ /TT2 1 Tf 14.721 0 TD -0.0038 Tc -0.02 Tw (, 141-153.)Tj -15.921 -1.8 TD -0.0085 Tc -0.0626 Tw [(Boscarino, J.A. \(2006\). PTSD and mortality among US )51.4(Army)]TJ 1.2 -1.398 TD -0.0057 Tc -0.061 Tw [(veterans: )54.5(A)59.5( 30-year follow-up. )]TJ /TT5 1 Tf 12.051 0 TD -0.0068 Tc -0.0631 Tw [(Annals of Epidemiolgy)53.2(, 16)]TJ /TT2 1 Tf 10.2 0 TD 0 Tc 0 Tw (,)Tj -22.251 -1.401 TD -0.0511 Tc (248-256.)Tj -1.2 -1.8 TD -0.0034 Tc 0.1106 Tw [(Boscarino, J.A. \(2008\). )50.6(A)58.8( Prospective study of PTSD and)]TJ 1.2 -1.401 TD -0.0031 Tc 0.0833 Tw [(early-age heart disease mortality among )17.9(V)62.1(ietnam veter)17.9(-)]TJ 0 -1.398 TD -0.0064 Tc -0.0625 Tw (ans: implications for surveillance and prevention. )Tj /TT5 1 Tf 19.329 0 TD -0.0083 Tc 0 Tw (Psycho-)Tj -19.329 -1.401 TD -0.004 Tc -0.06 Tw (somatic Medicine, 70)Tj /TT2 1 Tf 8.385 0 TD -0.0037 Tc (, 668-676.)Tj -9.585 -1.8 TD -0.0036 Tc -0.0099 Tw [(Boscarino, J.A., & )50.5(Adams, R.E. \(2008\). Peritraumatic panic)]TJ 1.2 -1.401 TD -0.0031 Tc 0.0371 Tw (attacks and health outcomes two years after psychologi-)Tj 0 -1.398 TD -0.0131 Tc -0.0621 Tw (cal trauma: implications for intervention and research. )Tj /TT5 1 Tf 20.769 0 TD -0.0153 Tc 0 Tw (Psy-)Tj -20.769 -1.401 TD -0.004 Tc 0.045 Tw (chiatry Research, 160)Tj /TT2 1 Tf 8.814 0 TD -0.003 Tc 0.0475 Tw [( \(in press\).)]TJ -10.014 -1.8 TD -0.0285 Tc -0.0625 Tw [(Boscarino, J.A., )49.5(Adams, R.E., Figley)64.5(, C.R. \(2004\). 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Meta-)]TJ 1.2 -1.401 TD -0.0032 Tc 0.0786 Tw (analysis of risk factors for posttraumatic stress disorder)Tj T* 0.0058 Tc 0.125 Tw (in trauma-exposed adults. )Tj /TT5 1 Tf 11.466 0 TD 0.0054 Tc (Journal of Consulting and)Tj -11.466 -1.398 TD -0.004 Tc -0.0197 Tw [(Clinical Psychology)53(, 68)]TJ /TT2 1 Tf 9.399 0 TD -0.0036 Tc -0.025 Tw (, 748-766.)Tj -10.599 -1.8 TD -0.0078 Tc -0.0622 Tw [(Bromet, E.J. & Dew)61.2(, M.A. \(1995\). Review of psychiatric epi-)]TJ 1.2 -1.401 TD -0.009 Tc -0.061 Tw (demiologic research on disasters. )Tj /TT5 1 Tf 13.161 0 TD -0.0097 Tc -0.065 Tw (Epidemiologic Reviews,)Tj -13.161 -1.401 TD -0.034 Tc 0 Tw (17)Tj /TT2 1 Tf 0.945 0 TD -0.027 Tc -0.06 Tw (, 113-119.)Tj -2.145 -1.8 TD -0.0155 Tc -0.0622 Tw [(Caldera, )14.8(T)76.3(., Palma, L., Penayo, U., & Kullgren, G)119.5(.)-0.5( \(2001\). Psy-)]TJ 1.2 -1.398 TD -0.0071 Tc (chological impact of the hurricane Mitch in Nicaragua in a)Tj 0 -1.401 TD -0.0028 Tc 0.0084 Tw (one-year perspective. )Tj /TT5 1 Tf 9.015 0 TD -0.0039 Tc 0.01 Tw (Social Psychiatry and Psychiatric)Tj -9.015 -1.401 TD -0.0056 Tc -0.0594 Tw [(Epidemiology)48.4(, 36)]TJ /TT2 1 Tf 6.861 0 TD -0.0061 Tc -0.0596 Tw [(, 108-1)29.9(14.)]TJ -8.061 -1.8 TD -0.0036 Tc 0.0886 Tw (Centers for Disease Control \(2002\). Community needs as-)Tj 1.2 -1.398 TD 0.0118 Tc 0.125 Tw (sessment of lower Manhattan residents following the)Tj 0 -1.401 TD -0.0061 Tc -0.0625 Tw [(W)97.7(orld )20.9(T)37.7(rade Center attacks - Manhattan, New )35.9(Y)107.1(ork, 2001.)]TJ /TT5 1 Tf T* -0.0041 Tc 0.0672 Tw [(Morbidity and Mortality W)85.9(eekly Report)]TJ /TT2 1 Tf 15.921 0 TD -0.001 Tc 0 Tw (, )Tj /TT5 1 Tf 0.564 0 TD -0.0075 Tc (288)Tj /TT2 1 Tf 1.485 0 TD -0.0039 Tc 0.07 Tw (\(10\), 1227-)Tj -17.97 -1.398 TD -0.0562 Tc 0 Tw (1228.)Tj -1.2 -1.8 TD -0.0217 Tc -0.062 Tw [(Chrousos, G)113.3(.)4.5(P)107.3(.)-0.8( \(1995\). )17.3(The hypothalamic-pituitary-adrenal axis)]TJ 1.2 -1.401 TD -0.0042 Tc -0.0449 Tw [(and immune-mediated inflammation. )]TJ /TT5 1 Tf 14.835 0 TD -0.0045 Tc -0.0475 Tw (New England Jour-)Tj -14.835 -1.401 TD -0.0035 Tc -0.0588 Tw [(nal of Medicine, 332)]TJ /TT2 1 Tf 8.22 0 TD -0.0039 Tc -0.06 Tw (, 1351-1362.)Tj -9.42 -1.8 TD -0.0032 Tc -0.0613 Tw [(Felton, C.J. \(2002\). 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Natural)]TJ 1.2 -1.398 TD -0.0034 Tc 0.0427 Tw [(disasters and mental health: )17.4(Theory)59.6(, assessment, and in-)]TJ 0 -1.401 TD -0.0035 Tc 0.0175 Tw [(tervention. In )50.5(Allen, R. \(Ed.\) Handbook of post-disaster)]TJ T* -0.0037 Tc 0 Tw (interventions. [special issue]. )Tj /TT5 1 Tf 11.799 0 TD -0.0039 Tc -0.0017 Tw (Journal of Social Behavior)Tj -11.799 -1.398 TD -0.0042 Tc -0.046 Tw [(and Personality)49.8(, 8)]TJ /TT2 1 Tf 7.146 0 TD -0.0036 Tc -0.05 Tw (, 49-103.)Tj -8.346 -1.8 TD -0.003 Tc 0.003 Tw [(Galea, S., )53.9(Ahern, J., Resnick, H., Kilpatrick, D., Bucuvalas,)]TJ 1.2 -1.401 TD -0.0066 Tc -0.0619 Tw [(M., Gold, J., & )18(Vlahov)59.4(, D. \(2002\). Psychological sequelae)]TJ T* -0.0036 Tc 0.0287 Tw (of the September 11 terrorist attacks in Manhattan, New)Tj 0 -1.398 TD -0.0026 Tc -0.0025 Tw [(Y)104.6(ork City)63.4(.)-6.1( )]TJ /TT5 1 Tf 4.335 0 TD -0.004 Tc -0.0049 Tw (New England Journal of Medicine, 346)Tj /TT2 1 Tf 15.855 0 TD -0.0036 Tc (, 982-)Tj -20.19 -1.401 TD -0.0583 Tc 0 Tw (987.)Tj -1.2 -1.8 TD -0.0044 Tc -0.062 Tw [(Galea, S., Boscarino, J.A., Resnick, H., & )22.8(Vlahov)58.6(, D. \(2003\).)]TJ 1.2 -1.401 TD -0.0034 Tc 0.0611 Tw [(Mental health in New )32.6(Y)103.8(ork City after the September 1)32.6(1)]TJ 0 -1.398 TD -0.0033 Tc -0.0122 Tw (terrorist attacks: Results from two population surveys. In)Tj 0 -1.401 TD 0.0118 Tc 0.1252 Tw [(Manderscheid, R.W)86.8(., Henderson, M.J. \(Eds.\), )]TJ /TT5 1 Tf 19.614 0 TD 0.0107 Tc 0 Tw (Mental)Tj -19.614 -1.401 TD -0.0037 Tc 0.0599 Tw [(Health, United S)32.3(tates, 2001.)]TJ /TT2 1 Tf 11.379 0 TD -0.0042 Tc 0.0612 Tw [( )16(W)93.6(ashington, DC: US Gov-)]TJ -11.379 -1.398 TD -0.0113 Tc -0.0625 Tw (ernment Printing Office, pp. 83-91.)Tj -1.2 -1.8 TD -0.0033 Tc -0.0396 Tw [(Gist, R., & Devilly)62.7(, G)116.7(.J. \(2002\). Post-trauma debriefing: )18.1(The)]TJ 1.2 -1.401 TD -0.0029 Tc -0.0375 Tw (road too frequently travelled. )Tj /TT5 1 Tf 11.676 0 TD -0.0041 Tc -0.04 Tw (Lancet, 360)Tj /TT2 1 Tf 4.638 0 TD -0.0036 Tc (, 741-742.)Tj -17.514 -1.8 TD -0.0092 Tc -0.062 Tw [(Goenjian, )56.9(A.K., Molina, L., S)14.8(teinber)20.8(g, )50.9(A.M., Fairbanks, L.A.,)]TJ 1.2 -1.401 TD -0.0201 Tc -0.0625 Tw (alvarez, M.L., Goenjian, H.A., & Pynoos, R.S. \(2001\). Post-)Tj 0 -1.398 TD -0.0037 Tc 0.035 Tw (traumatic stress and depressive reactions among Nicara-)Tj 0 -1.401 TD -0.0036 Tc 0.02 Tw (guan adolescents after Hurricane Mitch. )Tj /TT5 1 Tf 16.23 0 TD -0.0045 Tc 0.025 Tw (American Jour-)Tj -16.23 -1.401 TD -0.0068 Tc -0.0594 Tw [(nal of Psychiatry)53.1(,)-7.8( 158)]TJ /TT2 1 Tf 8.466 0 TD -0.0063 Tc -0.065 Tw [(\(5\), 788-794.)]TJ -9.666 -1.8 TD -0.0035 Tc 0.0457 Tw [(Groves, R.M., Fowler)38.5(, F)74.5(.J, Couper)38.5(, M.P)107.5(., Lepkowski, J.M.,)]TJ 1.2 -1.398 TD -0.0075 Tc -0.061 Tw [(Singer)37.5(, E., & )20.2(T)72.3(ourangeau, R. \(2004\). )]TJ /TT5 1 Tf 14.334 0 TD -0.0092 Tc -0.0644 Tw [(Sur)-6.2(vey methodology)]TJ /TT2 1 Tf 7.917 0 TD 0 Tc 0 Tw (.)Tj -22.251 -1.401 TD -0.0225 Tc -0.0932 Tw [(New Y)99.7(ork, )-29.6(NY)82.5(: )-15(W)51.3(iley)61.5(.)]TJ -1.2 -1.8 TD -0.0117 Tc -0.0626 Tw [(Hulley)57.3(, S.B., Cummings, S.R., Browner)33.3(, )18.2(W)107.1(.S., Grady)63.3(, D.G)117.3(., &)]TJ 1.2 -1.401 TD -0.0035 Tc 0.1075 Tw [(Newman, T)76.3(.B. )-18.5(\(2007\). )]TJ /TT5 1 Tf 9.516 0 TD 0.1252 Tw [(Designing clinical r)32.4(esear)29.4(ch: )17.6(A)6.2(n)]TJ -9.516 -1.398 TD -0.0045 Tc 0.03 Tw (epidemiologic approach)Tj /TT2 1 Tf 9.684 0 TD -0.0036 Tc (. Third Edition. Baltimore, MD:)Tj -9.684 -1.401 TD -0.0104 Tc -0.0798 Tw [(Lippincott W)51.4(illiams )-17.8(& W)51.4(ilkins.)]TJ -1.2 -1.8 TD -0.0153 Tc -0.0623 Tw [(Kaplan, Z., Iancu, I., & Bodner)38.7(, E. \(2001\). )56.7(A)61.9( review of psycho-)]TJ 1.2 -1.401 TD -0.0034 Tc 0.103 Tw (logical debriefing after extreme stress. )Tj /TT5 1 Tf 15.984 0 TD -0.0039 Tc 0.105 Tw (Psychiatric Ser-)Tj -15.984 -1.398 TD -0.0147 Tc -0.06 Tw (vices, 52)Tj /TT2 1 Tf 3.309 0 TD (, 824-827.)Tj -4.509 -1.8 TD -0.0037 Tc -0.0362 Tw [(Kessler)35.3(, R.C. \(2000\). Posttraumatic stress disorder: )17.5(The bur)17.3(-)]TJ 1.2 -1.401 TD -0.003 Tc 0.0642 Tw [(den to the individual and to society)63(. )]TJ /TT5 1 Tf 14.829 0 TD -0.0039 Tc 0.065 Tw (Journal of Clinical)Tj -14.829 -1.401 TD -0.004 Tc -0.044 Tw [(Psychiatry)55.8(,)-1( 61)]TJ /TT2 1 Tf 5.625 0 TD -0.0032 Tc -0.0467 Tw [( \(suppl 5\), 4-12.)]TJ -6.825 -1.8 TD -0.0083 Tc -0.0623 Tw [(Kilpatrick, D.G)117.7(.)-6.6(,)-6.5( )48.9(Acierno, R., Resnick, H.S., Sanders, B.E., &)]TJ 1.2 -1.398 TD -0.0028 Tc 0.0825 Tw [(Best, C.L. \(1997\). )51.2(A)59.4( 2-year longitudinal analysis of the)]TJ 0 -1.401 TD -0.0037 Tc 0.0992 Tw (relationships between violent assault and substance use)Tj T* -0.0042 Tc 0.0675 Tw (in women. )Tj /TT5 1 Tf 4.569 0 TD -0.0039 Tc 0.069 Tw (Journal of Consulting and Clinical Psychol-)Tj -4.569 -1.398 TD -0.0182 Tc -0.0588 Tw [(ogy)44.8(, 65)]TJ /TT2 1 Tf 2.721 0 TD -0.016 Tc -0.06 Tw (, 834-847.)Tj -3.921 -1.8 TD -0.003 Tc 0.0335 Tw [(Kulka, R.A., Schlenger)39(, )14.9(W)106.8(.E., Fairbank, J.A., Hough, R.L.,)]TJ 1.2 -1.401 TD -0.0132 Tc -0.0623 Tw [(Jordan, B.K., Marmar)37.8(, C.R., & )17(W)96.6(eiss, D.S. \(1990\). )]TJ /TT5 1 Tf 19.47 0 TD -0.0168 Tc 0 Tw [(T)53.4(rauma)]TJ -19.47 -1.401 TD -0.004 Tc 0.0325 Tw [(and the V)71(ietnam generation: Repor)-7(t of findings fr)32(om the)]TJ ET endstream endobj 224 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 226 0 obj << /Length 10832 >> 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 -0.009 Tc 0 Tw (290)Tj /TT3 1 Tf 1.65 0 TD -0.0058 Tc 0.115 Tw [( Boscarino and Adams)]TJ /F1 1 Tf 11.07 0 TD -0.0061 Tc 0.1156 Tw [(  )]TJ /TT3 1 Tf 1.125 0 TD -0.0056 Tc 0.1163 Tw (World Trade Center Disaster Outcomes Study)Tj /TT5 1 Tf 10 0 0 10 66 721.65 Tm 0.0394 Tc 0.1251 Tw [(National V)69.4(ietnam Readjustment S)27.4(tudy)]TJ /TT2 1 Tf 16.911 0 TD 0.041 Tc 0.1256 Tw [(. New )38.6(Y)103.2(ork:)]TJ -16.911 -1.401 TD -0.0118 Tc 0 Tw (Brunner/Mazel.)Tj -1.2 -1.8 TD -0.0034 Tc 0.0309 Tw [(McFarlane, )53.7(A.C. \(1988\). )50.7(Aetiology of post-traumatic stress)]TJ 1.2 -1.398 TD -0.0037 Tw [(disorders following a natural disaster)50.6(. )]TJ /TT5 1 Tf 15.366 0 TD -0.0039 Tc -0.005 Tw (British Journal of)Tj -15.366 -1.401 TD -0.0073 Tc -0.0592 Tw [(Psychiatry)55.5(,)-0.8( 152)]TJ /TT2 1 Tf 6.054 0 TD -0.0086 Tc -0.0594 Tw [(, 1)24.4(16-121.)]TJ -7.254 -1.8 TD -0.0141 Tc -0.0621 Tw [(McFarlane, )57.9(A.C. \(1989\). )21.9(The aetiology of post-traumatic mor)12.9(-)]TJ 1.2 -1.401 TD -0.0033 Tc 0.0017 Tw (bidity: Predisposing, precipitating and perpetuating fac-)Tj 0 -1.398 TD -0.0023 Tc -0.0125 Tw (tors. )Tj /TT5 1 Tf 2.211 0 TD -0.0037 Tc -0.0139 Tw [(British Journal of Psychiatry)56.1(,)0.1( 154)]TJ /TT2 1 Tf 13.404 0 TD -0.015 Tw (, 221-228.)Tj -16.815 -1.8 TD -0.0033 Tc -0.013 Tw [(McFarlane, )53.8(A.C., )50.8(Atchison, M., Rafalowicz, E., & Papay)59.7(, P)107.7(.)]TJ 1.2 -1.401 TD -0.0045 Tc -0.0625 Tw (\(1994\). 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Psychiatric)Tj T* -0.0037 Tc 0.025 Tw (disorders among survivors of the Oklahoma City bomb-)Tj 0 -1.398 TD -0.0032 Tc 0 Tw (ing. )Tj /TT5 1 Tf 1.815 0 TD -0.0039 Tc 0.0542 Tw (Journal of the American Medical Association, 282)Tj /TT2 1 Tf 20.334 0 TD 0 Tc 0 Tw (,)Tj -22.149 -1.401 TD -0.0511 Tc (755-762.)Tj -1.2 -1.8 TD -0.0123 Tc -0.0621 Tw [(Resnick, H.S., Kilpatrick, D.G)119.7(., Dansky)62.7(, B.S., Saunders, B.E.,)]TJ 1.2 -1.401 TD -0.0288 Tc -0.0623 Tw (& Best, C.L. \(1993\). Prevalence of civilian trauma and PTSD)Tj 0 -1.398 TD -0.0035 Tc -0.05 Tw (in a representative national sample of women. )Tj /TT5 1 Tf 18.351 0 TD -0.0043 Tc (Journal of)Tj -18.351 -1.401 TD -0.0041 Tc 0.0401 Tw [(Consulting and Clinical Psychology)49.9(, 61)]TJ /TT2 1 Tf 15.93 0 TD -0.0037 Tc 0.045 Tw (, 984-991.)Tj -17.13 -1.8 TD -0.0227 Tc -0.0624 Tw [(Rogers, )16.4(W)108.1(.J., Canto, J.G)115.3(., Barron, H.V)124.3(., Boscarino, J.A., Shoult,)]TJ 1.2 -1.401 TD -0.0247 Tc -0.0625 Tw [(D.A., & Every)59.3(, N.R. \(2000\).T)35.3(reatment and outcome of myo-)]TJ 0 -1.398 TD -0.0036 Tc 0.0429 Tw (cardial infarction in hospitals with and without invasive)Tj 0 -1.401 TD -0.002 Tc 0.0245 Tw [(capability)64(. )]TJ /TT5 1 Tf 4.65 0 TD -0.0041 Tc 0.0226 Tw [(Journal of the )14(American College of Car)31.9(diol-)]TJ -4.65 -1.401 TD -0.0182 Tc -0.0588 Tw [(ogy)44.8(, 35)]TJ /TT2 1 Tf 2.721 0 TD -0.016 Tc -0.06 Tw (, 371-379.)Tj -3.921 -1.8 TD -0.0035 Tc -0.0232 Tw [(Rosenbaum, P)107.5(.R., & Rubin, D.R. \(1983\). )14.6(The central role of)]TJ 1.2 -1.398 TD -0.0033 Tc 0.0957 Tw (the propensity score in observational studies for causal)Tj 0 -1.401 TD -0.0029 Tc 0 Tw (effects. )Tj /TT5 1 Tf 3.111 0 TD -0.0042 Tc -0.03 Tw (Biometrika, 70)Tj /TT2 1 Tf 5.859 0 TD -0.0033 Tc (, 41-55.)Tj -10.17 -1.8 TD -0.0037 Tc -0.0141 Tw [(Rosenheck, R., S)14.3(tolar)38.3(, M., & Fontana, )50.6(A. \(2000\). Outcomes)]TJ 1.2 -1.401 TD -0.0034 Tc -0.0378 Tw (monitoring and the testing of new psychiatric treatments:)Tj 0 -1.398 TD -0.0033 Tc 0.0564 Tw (work therapy in the treatment of chronic post-traumatic)Tj 0 -1.401 TD -0.0013 Tc 0.125 Tw [(stress disorder)49.7(.)-6.3( )]TJ /TT5 1 Tf 6.435 0 TD 0.1248 Tw [(Health Services Resear)28.6(ch, 35)]TJ /TT2 1 Tf 12.09 0 TD 0.0001 Tc 0.125 Tw [( \(1 Pt 1\),)]TJ -18.525 -1.401 TD -0.0511 Tc 0 Tw (133-151.)Tj -1.2 -1.8 TD -0.0037 Tc -0.0353 Tw [(Rubonis, )50.7(A.V)128.3(. & Bickman, L. \(1991\). Psychological impair)14.3(-)]TJ 1.2 -1.398 TD -0.0034 Tc -0.0064 Tw (ment in the wake of disaster: The disaster-psychopathol-)Tj 0 -1.401 TD -0.0027 Tc 0.0175 Tw (ogy relationship. )Tj /TT5 1 Tf 6.96 0 TD -0.0039 Tc 0.02 Tw (Psychological Bulletin, 109)Tj /TT2 1 Tf 11.019 0 TD -0.0036 Tc (, 384-399.)Tj 6.522 66.201 TD -0.0172 Tc -0.0614 Tw [(Schnurr)39.8(, P)108.8(.)3(P)108.8(.)-0.2( & Green, B.L. \(eds.\). \(2004\). )]TJ /TT5 1 Tf 15.993 0 TD -0.0183 Tc -0.0625 Tw [(T)57.9(rauma and health:)]TJ -14.793 -1.401 TD -0.004 Tc 0.1091 Tw [(Physical health consequences of extr)32(eme str)32(ess)]TJ /TT2 1 Tf 19.215 0 TD -0.0039 Tc 0.0929 Tw [(. W)94(ash-)]TJ -19.215 -1.401 TD -0.0684 Tw [(ington, )-52.8(DC: American )-50.5(Psychological Association.)]TJ -1.2 -1.8 TD -0.0137 Tc -0.0621 Tw [(Shalev)64.3(, )52.7(A.Y)124.3(. \(1996\). S)16.3(tress versus traumatic stress: from acute)]TJ 1.2 -1.398 TD 0.0015 Tc 0.1251 Tw [(homeostatic reactions to chronic psychopathology)64.5(. In:)]TJ 0 -1.401 TD -0.0231 Tc -0.0622 Tw [(van der Kolk, B.A., McFarlane, )45.9(A.C., & )15.9(W)95.7(eisaeth, L. \(Eds.\).)]TJ /TT5 1 Tf T* -0.0063 Tc -0.0623 Tw [(T)54.9(raumatic str)29.7(ess: The effects of overwhelming experience)]TJ 0 -1.398 TD -0.0081 Tc -0.0612 Tw [(on mind, body)54.9(, and society)]TJ /TT2 1 Tf 10.215 0 TD -0.0626 Tw [(. New )33.9(Y)102.2(ork: Guilford Press, pp.)]TJ -10.215 -1.401 TD -0.0513 Tc 0 Tw (77-101.)Tj -1.2 -1.8 TD -0.0034 Tc -0.0168 Tw [(Smith, D.W)86.6(., Christiansen, E.H., )17.7(V)64.8(incent, R., & Hann, N.E.)]TJ 1.2 -1.401 TD -0.0039 Tc -0.003 Tw (\(1999\). Population effects of the bombing of Oklahoma)Tj 0 -1.398 TD -0.0008 Tc 0.0908 Tw [(City)65.2(. )]TJ /TT5 1 Tf 2.583 0 TD -0.0042 Tc 0.09 Tw [(Journal of Oklahoma S)28.8(tate Medical )13.8(Association,)]TJ -2.583 -1.401 TD -0.034 Tc 0 Tw (92)Tj /TT2 1 Tf 0.945 0 TD -0.027 Tc -0.06 Tw (, 193-198.)Tj -2.145 -1.8 TD -0.0035 Tc 0.0483 Tw [(van der Kolk, B.A. \(1996\). )17.8(The body keeps the score: )50.8(Ap-)]TJ 1.2 -1.401 TD 0.0021 Tc 0.125 Tw (proaches to the psychobiology of posttraumatic stress)Tj 0 -1.398 TD 0.0088 Tc 0.1251 Tw [(disorder)53.8(. In van der Kolk, B.A., McFarlane, )53.9(A.C., &)]TJ 0 -1.401 TD -0.0028 Tc -0.0433 Tw [(W)98(e)0(isaeth, L. \(eds.\). )]TJ /TT5 1 Tf 7.8 0 TD -0.0038 Tc -0.0448 Tw [(T)57.3(raumatic str)32.2(ess: The effects of over)14.2(-)]TJ -7.8 -1.401 TD 0.1017 Tw [(whelming experience on mind, body)53.2(, and society)]TJ /TT2 1 Tf 19.824 0 TD -0.0045 Tc 0.105 Tw (. New)Tj -19.824 -1.398 TD -0.0196 Tc -0.0614 Tw [(Y)102.6(ork, NY)88.4(: )-6(Guilford Press, pp. 214-241.)]TJ -1.2 -1.8 TD -0.0283 Tc -0.0623 Tw [(van der Kolk, B.A., McFarlane, )52.7(A.C., & van der Hart, O. \(1996\).)]TJ 1.2 -1.401 TD -0.0036 Tc 0.0521 Tw (A general approach to treatment of posttraumatic stress)Tj T* 0.0012 Tc 0.1252 Tw [(disorder)52.2(. In van der Kolk, B.A., McFarlane, )52.4(A.C., &)]TJ 0 -1.398 TD -0.0031 Tc -0.0617 Tw [(W)97.7(eisaeth, L. \(Eds.\). )]TJ /TT5 1 Tf 7.905 0 TD -0.0043 Tc -0.0619 Tw [(T)56.8(raumatic str)31.7(ess: The effects of over)16.7(-)]TJ -7.905 -1.401 TD -0.0038 Tc 0.0575 Tw [(whelming experience on mind, body)50.2(, and society)]TJ /TT2 1 Tf 19.56 0 TD 0.06 Tw [(. New)]TJ -19.56 -1.401 TD -0.0158 Tc -0.062 Tw [(Y)103.4(ork: Guilford Press, pp. 417-440.)]TJ -1.2 -1.8 TD -0.0036 Tc 0.0437 Tw [(van Emmerik, )53.4(A.A., Kamphuis, J.H., Hulsbosch, )53.3(A.M., &)]TJ 1.2 -1.398 TD -0.0061 Tc -0.0624 Tw [(Emmelkamp, P)104.9(.M. \(2002\). Single session debriefing after)]TJ 0 -1.401 TD -0.0064 Tc -0.0611 Tw [(psychological trauma: )47.7(A)61.8( meta-analysis. )]TJ /TT5 1 Tf 15.483 0 TD -0.0072 Tc -0.06 Tw (Lancet, 360)Tj /TT2 1 Tf 4.587 0 TD -0.0078 Tc -0.065 Tw (, 766-)Tj -20.07 -1.401 TD -0.0625 Tc 0 Tw (71.)Tj -1.2 -1.8 TD -0.0101 Tc -0.0618 Tw [(Vlahov)64.9(, D., Galea, S., Resnick, H., )56.3(Ahern, J., Boscarino, J.A.,)]TJ 1.2 -1.398 TD -0.0035 Tc 0.07 Tw (Bucuvalas, M., et al. \(2004\). Increased consumption of)Tj 0 -1.401 TD -0.0034 Tc -0.0336 Tw [(cigarettes, alcohol, and marijuana among New )32.6(Y)103.8(ork City)]TJ T* -0.0036 Tc -0.01 Tw (residents six to nine months after the September 11)Tj 5.8 0 0 5.8 525.36 255 Tm -0.002 Tc 0 Tw (th)Tj 10 0 0 10 529.86 251.64 Tm -0.0034 Tc -0.01 Tw [( ter-)]TJ -20.685 -1.398 TD -0.0032 Tc 0.1025 Tw (rorists attacks. )Tj /TT5 1 Tf 6.18 0 TD -0.0041 Tc 0.103 Tw (American Journal of Drug and Alcohol)Tj -6.18 -1.401 TD -0.0149 Tc -0.06 Tw (Abuse, 30)Tj /TT2 1 Tf 3.753 0 TD -0.0143 Tc (, 385-407.)Tj -4.953 -1.8 TD -0.0101 Tc -0.0618 Tw [(Vlahov)64.9(, D., Galea, S., Resnick, H., )56.3(Ahern, J., Boscarino, J.A.,)]TJ 1.2 -1.401 TD -0.0033 Tc 0.03 Tw (Bucuvalas, M. et al. \(2002\). Increased use of cigarettes,)Tj 0 -1.398 TD -0.0038 Tc -0.0033 Tw (alcohol, and marijuana among Manhattan residents after)Tj 0 -1.401 TD -0.0035 Tc -0.03 Tw (September 11 terrorist attacks. )Tj /TT5 1 Tf 12.24 0 TD -0.0041 Tc -0.0317 Tw (American Journal of Epi-)Tj -12.24 -1.401 TD -0.0083 Tc -0.0589 Tw [(demiology)48.7(, 155)]TJ /TT2 1 Tf 5.943 0 TD -0.0077 Tc -0.06 Tw (, 988-996.)Tj /TT5 1 Tf 9 0 0 9 342.75 114.99 Tm -0.0049 Tc -0.0028 Tw (Manuscript submitted and accepted: September 18, 2008)Tj ET endstream endobj 227 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 229 0 obj << /Length 5850 >> 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. 4 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (291)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. 4, pp. 291-298 2008 Chevron Publishing ISSN 1522-4821)]TJ /TT4 1 Tf 10 0 0 10 101.01 534.36 Tm 0.0086 Tc 0 Tw (Abstract: )Tj /TT5 1 Tf 4.239 0 TD 0.0089 Tc 0.125 Tw [(A review of secondary trauma is presented. Secondary trauma involves the transfer and)]TJ -4.239 -1.302 TD -0.0036 Tc -0.002 Tw (acquisition of negative affective and dysfunctional cognitive states due to prolonged and extended contact)Tj 0 -1.299 TD 0.0232 Tw [(with others, such as family members, who have been traumatized. As such, secondary trauma refers to a)]TJ T* 0.065 Tw [(spread of trauma from the victim to those who have close contact with the traumatized individual. It is)]TJ 0 -1.302 TD -0.0622 Tw (claimed by some that exposure to intense video presentations of traumatic events can also lead to secondary)Tj 0 -1.299 TD 0.0019 Tc 0.125 Tw [(traumatization. Assessment devices are reviewed and most of these appear to be designed to assess)]TJ T* -0.0037 Tc 0.0843 Tw [(secondary or vicarious traumatization in therapists rather than in the general population. Most scales)]TJ 0 -1.302 TD -0.0036 Tc -0.0167 Tw (lack cutoff scores and this is a significant weakness. The modified Stroop procedure is presented as a non-)Tj 0 -1.299 TD 0.0002 Tc 0.125 Tw [(paper and pencil method of assessing secondary trauma reactions. The evaluation of the efficacy of)]TJ T* -0.0009 Tc [(therapeutic interventions for secondary traumatization is virtually non-existent. Systematic studies of)]TJ 0 -1.302 TD -0.0014 Tc [(secondary trauma are in their infancy and a good deal of further research is needed. [International)]TJ 0 -1.299 TD -0.0035 Tc 0.0762 Tw (Journal of Emergency Mental Health, 2008, 10\(4\), pp. 291-298].)Tj /TT1 1 Tf 9 0 0 9 127.41 348.99 Tm -0.0055 Tc 0.0361 Tw (Key words: )Tj /TT5 1 Tf 5.1833 0 TD -0.0049 Tc 0.0368 Tw (secondary trauma, vicarious trauma, secondary traumatization, Stroop procedure, observational)Tj 12.4367 -1.3333 TD -0.0079 Tc 0 Tw (learning)Tj ET /GS1 gs 66 165.765 m 302.01 165.765 l S BT /TT2 1 Tf 9 0 0 9 66 147.99 Tm /GS2 gs -0.005 Tc 0.0512 Tw [(Robert )11.9(W)102.2(.)-0.1( Motta, PhD is the Director of the Doctoral Program in)]TJ 0 -1.22 TD 0.0576 Tc 0.1522 Tw (School-Community Psychology at Hofstra University in)Tj 0 -1.2233 TD -0.0049 Tc -0.0276 Tw [(Hempstead, NY)125.1(. He is board certified in Cognitive and Behavioral)]TJ T* -0.0032 Tc 0.1263 Tw [(Psychology by the )51(American )]TJ 12.1947 0 TD -0.0049 Tc 0.1257 Tw [(Psychological )52.1(Association and has)]TJ -12.1947 -1.22 TD -0.0046 Tc -0.0037 Tw (published extensively in the areas of PTSD and secondary trauma.)Tj 0 -1.2233 TD -0.0044 Tc 0.0231 Tw [(The author wishes to thank )12.1(T)66.4(eresa Silva, PsyD for her review and)]TJ T* -0.0051 Tc 0.0667 Tw [(editing of this manuscript. Correspondence regarding this article)]TJ 0 -1.22 TD -0.0054 Tc 0.1128 Tw [(should be directed to Robert.W)81.3(.Motta@hofstra.edu.)]TJ /F1 1 Tf 14 0 0 14 246.9 630.36 Tm 0.0109 Tc 0.047 Tw [(Secondar)-21.2(y T)75.5(rauma)]TJ /TT2 1 Tf 10 0 0 10 84.99 288.66 Tm -0.004 Tc -0.06 Tw (The term, )Tj /TT5 1 Tf 3.981 0 TD -0.0053 Tc -0.065 Tw (secondary trauma)Tj /TT2 1 Tf 7.104 0 TD -0.0041 Tc -0.062 Tw [(, refers to the experience of)]TJ -12.885 -1.401 TD -0.0022 Tc 0.125 Tw (negative psychological states which typically result from)Tj T* -0.0036 Tc -0.0273 Tw (extended and close contact with others who have been trau-)Tj 0 -1.398 TD 0.1165 Tw [(matized. Those experiencing secondary trauma have not)]TJ 0 -1.401 TD -0.0019 Tc 0.125 Tw (directly experienced a traumatic event but have acquired)Tj T* -0.0034 Tc 0.1216 Tw [(trauma symptoms vicariously)59.6(, often through contact with)]TJ 0 -1.398 TD -0.0037 Tc -0.0086 Tw [(trauma victims \(Figley)59.3(, 1995; McCann & Pearlman, 1990\).)]TJ 0 -1.401 TD -0.0036 Tc 0.1067 Tw (One might conceive of secondary trauma as a spread of)Tj 12 0 0 12 273.66 593.64 Tm -0.0058 Tc -0.0388 Tw [(Robert W)95.5(.)-0.5( )-12.3(Motta)]TJ 10 0 0 10 275.49 581.01 Tm 0.0017 Tc 0 Tw (Hofstra University)Tj 4.551 -29.337 TD -0.0035 Tc 0.0855 Tw (effect of trauma from the impacted person or situation to)Tj 0 -1.398 TD -0.0037 Tc -0.0238 Tw (those who have close involvement with the traumatized per-)Tj 0 -1.401 TD -0.0035 Tc 0.0239 Tw [(son. Hearing about or witnessing trauma situations, and an)]TJ T* -0.0032 Tc -0.0294 Tw (inclination to identify with those in the trauma situation, can)Tj 0 -1.398 TD -0.0029 Tc -0.0106 Tw (also result in secondary trauma reactions, especially if these)Tj 0 -1.401 TD -0.0121 Tc -0.0625 Tw (vicarious experiences evoke fear reactions in the witness \(e.g.,)Tj T* 0.0122 Tc 0.1249 Tw [(Marshall & Galea, 2004; Propper)36.2(, S)15.2(tickgold, Keeley)57.2(, &)]TJ 0 -1.398 TD -0.0062 Tc -0.0625 Tw [(Christman, 2007\). The range of secondary trauma symptoms)]TJ 0 -1.401 TD -0.0065 Tc -0.0621 Tw [(can include anger)38.5(, anxiety)65.5(, depression, low self-esteem, emo-)]TJ T* -0.0037 Tc -0.0625 Tw (tional exhaustion, difficulty concentrating, body aches, sleep)Tj 0 -1.398 TD -0.0035 Tc -0.0175 Tw (problems, changes in eating habits, increase in addictive be-)Tj 0 -1.401 TD -0.0034 Tc -0.031 Tw [(haviors, and withdrawal from others. It should be noted that)]TJ T* -0.0027 Tc -0.013 Tw (the study of secondary trauma is in its infancy and therefore)Tj 0 -1.398 TD -0.0035 Tc 0.0305 Tw [(well grounded empirical studies in this area are scant when)]TJ 0 -1.401 TD -0.025 Tw (compared to the related area of PTSD.)Tj ET endstream endobj 230 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 233 0 obj << /Length 9388 >> 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 0.0792 Tw [(292 )]TJ /TT3 1 Tf 2.715 0 TD -0.0055 Tc 0.0813 Tw [( Motta Secondary Trauma)]TJ /TT2 1 Tf 10 0 0 10 72 722.64 Tm -0.0034 Tc 0.0714 Tw (Secondary trauma and vicarious trauma are terms that)Tj -1.8 -1.398 TD 0.0256 Tw [(have been used in somewhat different contexts. Secondary)]TJ 0 -1.401 TD -0.0031 Tc -0.0263 Tw (trauma, or secondary traumatic stress, are terms that parallel)Tj T* 0.0022 Tc 0.125 Tw (diagnostic categories that are presented for posttraumatic)Tj 0 -1.398 TD -0.0035 Tc -0.0367 Tw (stress disorder \(PTSD\) and acute stress disorder in the )Tj /TT5 1 Tf 21.39 0 TD -0.0058 Tc 0 Tw (Diag-)Tj -21.39 -1.401 TD -0.004 Tc 0.0499 Tw [(nostic and S)29(tatistical Manual\(4)]TJ 5.8 0 0 5.8 179.79 656.01 Tm -0.002 Tc 0 Tw (th)Tj 10 0 0 10 184.29 652.65 Tm -0.0042 Tc 0.05 Tw [( ed.\) )]TJ /TT2 1 Tf 2.106 0 TD -0.0034 Tc 0.0518 Tw [(of the )50.7(American Psy-)]TJ -15.135 -1.401 TD -0.0038 Tc 0.0623 Tw [(chiatric )50.5(Association \(AP)86.2(A, 2004\). )]TJ /TT5 1 Tf 14.181 0 TD -0.0044 Tc 0.065 Tw [(V)78.4(icarious trauma)]TJ /TT2 1 Tf 6.948 0 TD -0.0033 Tc [( refers)]TJ -21.129 -1.398 TD 0.0362 Tw (more specifically to the cognitive schemas and core beliefs)Tj 0 -1.401 TD -0.0034 Tc -0.0066 Tw (that are often altered when, for example, therapists have ex-)Tj T* -0.0037 Tc 0.0635 Tw (tensive contact with clients who have undergone traumatic)Tj 0 -1.398 TD -0.0033 Tc 0.0088 Tw [(experiences. In vicarious traumatization the focus is the al-)]TJ 0 -1.401 TD -0.0037 Tc 0.0175 Tw [(teration of one)50.3(s cognitions and basic life assumptions such)]TJ T* -0.0099 Tc -0.0622 Tw [(as beliefs in environmental stability)59.1(, safety)65.1(, and a secure sense)]TJ 0 -1.398 TD -0.0032 Tc -0.0467 Tw [(of self. However)35.8(, it is increasingly recognized that vicarious)]TJ 0 -1.401 TD 0.0688 Tw (trauma and secondary trauma are not entirely distinct con-)Tj T* -0.0036 Tc -0.0434 Tw [(cepts \(Bober & Regehr)38.4(, 2006; Jenkins & Baird, 2002\) in that)]TJ 0 -1.398 TD -0.0031 Tc -0.0372 Tw (they both involve the transfer of trauma symptoms to others.)Tj 0 -1.401 TD -0.0038 Tc -0.03 Tw (For this reason the terms secondary trauma and vicarious)Tj T* 0.0052 Tc 0.1251 Tw [(trauma will be used synonymously in this review)59.2(. )14.3(T)5.5(h)5.5(e)]TJ 0 -1.398 TD -0.0032 Tc 0.125 Tw (overarching issue between the terms is the disturbance of)Tj 0 -1.401 TD -0.0037 Tc -0.0099 Tw [(one)53.3(s emotions and/or cognitions as a result of experiencing)]TJ T* -0.0035 Tc -0.003 Tw (the impact of trauma on others.)Tj /F1 1 Tf 11 0 0 11 54 396 Tm -0.0046 Tc 0.0252 Tw [(Areas of In)36.3(vestigation)]TJ /TT1 1 Tf 10 0 0 10 72 372.66 Tm 0 Tc 0 Tw ( )Tj /TT2 1 Tf 0.36 0 TD -0.0035 Tc 0.1119 Tw (In one of the first documented investigations of sec-)Tj -2.16 -1.401 TD 0.0965 Tw (ondary trauma, Rosenheck and Nathan \(1985\) presented a)Tj T* -0.0031 Tc -0.0021 Tw [(case history of a 10-year)17.9(-old son of a )18.3(V)62.1(ietnam veteran. )18.3(This)]TJ 0 -1.398 TD -0.0034 Tc 0.1007 Tw [(child had an unusually intense involvement in his father)-39.4()53.6(s)]TJ 0 -1.401 TD -0.0032 Tc 0.0162 Tw [(emotional life and experienced high levels of guilt, anxiety)59.8(,)]TJ T* -0.0037 Tc 0.0593 Tw (and aggressiveness, and a morbid preoccupation with trau-)Tj 0 -1.398 TD 0.0025 Tc 0.125 Tw [(matic events that his father had encountered. In another)]TJ 0 -1.401 TD -0.0037 Tc -0.0014 Tw [(study)62.3(, Parsons, Kehle, and Owen \(1990\) compared )17.3(V)61.5(ietnam)]TJ T* -0.004 Tc -0.0585 Tw [(combat veterans with PTSD to )17.1(V)61.2(ietnam-era veterans without)]TJ 0 -1.398 TD -0.0062 Tc -0.0622 Tw [(PTSD on their ratings of their children)47.8(s social and emotional)]TJ 0 -1.401 TD -0.0036 Tc 0.11 Tw [(functioning. Overall, veterans with PTSD perceived their)]TJ T* -0.0034 Tc -0.0407 Tw (children as having substantially greater social and emotional)Tj 0 -1.398 TD -0.0029 Tc 0.065 Tw (difficulties, marked by an inability to initiate and maintain)Tj 0 -1.401 TD -0.0035 Tc -0.0445 Tw [(relationships. It was also found that children of PTSD veter-)]TJ T* -0.003 Tc 0.0455 Tw (ans were significantly more likely to demonstrate a lack of)Tj 0 -1.398 TD -0.0033 Tc 0.1034 Tw (self-control resulting in more aggressive, hyperactive, and)Tj 0 -1.401 TD -0.0017 Tc 0.125 Tw (delinquent behaviors.)Tj 1.8 -2.001 TD -0.0036 Tc -0.0289 Tw (There are a number of other situations in which second-)Tj -1.8 -1.398 TD -0.003 Tc 0.0914 Tw [(ary traumatization can occur)54(. It has been reported to take)]TJ 0 -1.401 TD -0.0034 Tc 0.0775 Tw (place in families living with a traumatized family member)Tj T* -0.0097 Tc -0.0622 Tw (\(Catherall, 1992\), in partners of those who have been sexually)Tj 0 -1.398 TD -0.0056 Tc -0.0619 Tw [(abused \(Nelson & )18.7(W)92.2(ampler)33.4(, 2000\), in wives of combat veter)15.4(-)]TJ 25.5 64.998 TD 0.0395 Tc 0.1246 Tw [(ans with PTSD \(W)78.5(aysman, Milkulincer)36.5(, Solomon, &)]TJ 0 -1.398 TD -0.0036 Tc 0.0152 Tw [(W)94.2(eisenber)17.4(g, 1993\), in children of )17.6(V)64.6(ietnam veterans \(Motta,)]TJ 0 -1.401 TD -0.0037 Tc -0.0081 Tw (Joseph, Rose, Suozzi, & Leiderman, 1997; Suozzi & Motta,)Tj T* -0.0111 Tc -0.0622 Tw [(2004\), in wives of police of)18.9(ficers \(Dwyer)36.9(, 2005\), in Holocaust)]TJ 0 -1.398 TD 0.004 Tc 0.125 Tw (survivors through intergenerational transfer of symptoms)Tj 0 -1.401 TD -0.0155 Tc -0.0623 Tw (\(Kassai & Motta, 2006; Kellerman, 2001\), and in family mem-)Tj T* -0.0031 Tc -0.0591 Tw [(bers of those with a serious illness \(Boyer et al., 2002; Libov)59.9(,)]TJ 0 -1.398 TD -0.0151 Tc -0.0625 Tw [(Nevid, Pelcovitz, & Carmony)59.9(, 2002; Lombardo, 2005\).)]TJ /F1 1 Tf 11 0 0 11 309 591.99 Tm -0.0057 Tc 0.0534 Tw [(Therapists and Secondar)-13.9(y )92.9(T)78.9(rauma)]TJ /TT2 1 Tf 10 0 0 10 327 568.65 Tm -0.0039 Tc 0.0633 Tw (There are also numerous studies documenting second-)Tj -1.8 -1.401 TD -0.0026 Tc 0.125 Tw (ary trauma reactions among therapists working with indi-)Tj 0 -1.398 TD -0.0115 Tc -0.0623 Tw [(viduals who have been traumatized \(e.g. Brady)63.5(, Guy)63.5(, Polestra,)]TJ 0 -1.401 TD -0.004 Tc 0.0828 Tw [(& Fletcher)14(-Brokaw)62(, 1999; Figley)62(, 1995; Ghahamanolou &)]TJ T* -0.0037 Tw (Broadback, 2000; McCann & Pearlman, 1990; Pearlman &)Tj 0 -1.398 TD -0.0038 Tc 0.0801 Tw [(MacIan, 1995; Schauben & Frazier)35.2(, 1995\). Research sug-)]TJ 0 -1.401 TD -0.0022 Tc 0.125 Tw (gests that exposure to patient reports of traumatic experi-)Tj T* 0.0038 Tc (ences can have a negative effect on therapists cognitive)Tj 0 -1.398 TD -0.0036 Tc -0.0175 Tw [(schemas and emotional functioning. In this instance, cogni-)]TJ 0 -1.401 TD 0.0078 Tw (tive schemas refer to beliefs, assumptions, and expectations)Tj T* -0.0033 Tc 0.034 Tw [(as they relate to one)50.7(s self-view and one)50.7(s beliefs about the)]TJ 0 -1.398 TD -0.0114 Tc -0.0623 Tw [(world \(McCann & Pearlman, 1990\). Previously held views of)]TJ 0 -1.401 TD -0.0035 Tc 0.0534 Tw [(one)53.5(s self and one)50.5(s environment may be shaken or altered)]TJ T* -0.0032 Tc -0.0138 Tw (by trauma exposure or by on-going interaction with trauma-)Tj 0 -1.398 TD -0.0036 Tc 0.0545 Tw [(tized individuals. For example, one)50.4(s view of the environ-)]TJ 0 -1.401 TD -0.003 Tc -0.0094 Tw (ment as being relatively safe and predictable may be altered)Tj T* -0.0036 Tc 0.1015 Tw (to a more negative view in which the environment is per-)Tj 0 -1.398 TD -0.0033 Tc 0.108 Tw [(ceived as threatening. Similarly one)53.7(s self-view might be)]TJ 0 -1.401 TD -0.0035 Tc -0.0481 Tw (shifted from that of an assured, stable self-perception toward)Tj T* -0.0075 Tc -0.0621 Tw (a more vulnerable and fragile perspective following on-going)Tj 0 -1.398 TD -0.0098 Tc [(exposure to traumatized individuals. Pearlman and Saakvitne)]TJ 0 -1.401 TD -0.0035 Tc 0.0536 Tw (\(1995\) view vicarious traumatization as a process whereby)Tj T* 0.0014 Tc 0.125 Tw [(the therapist)52.4(s self view is transformed through empathic)]TJ 0 -1.398 TD -0.0036 Tc 0.0125 Tw [(exposure to the victim)53.4(s trauma. )17.4(These changes can lead to)]TJ 0 -1.401 TD -0.0033 Tc 0.1088 Tw [(alteration in one)50.7(s identity)62.7(, how one views the world, and)]TJ T* 0.0085 Tc 0.1252 Tw [(one)47.5(s feeling of personal safety and trust. McCann and)]TJ 0 -1.398 TD -0.0036 Tc -0.0385 Tw [(Pearlman state that vicarious traumatization in therapists oc-)]TJ 0 -1.401 TD -0.0158 Tw (curs because therapists may experience painful images and)Tj T* -0.0038 Tc 0.0699 Tw [(emotions associated with their client)50.2(s traumatic memories)]TJ 0 -1.398 TD -0.0033 Tc 0.0987 Tw [(and may)62.7(, over time, incorporate these memories into their)]TJ 0 -1.401 TD -0.0029 Tc -0.0575 Tw [(own memory systems. )51.1(As a result, therapists may find them-)]TJ T* 0.0074 Tc 0.125 Tw (selves experiencing PTSD symptoms including intrusive)Tj 0 -1.398 TD -0.0037 Tc 0.02 Tw (thoughts or images and painful emotional reactions \(1990,)Tj 0 -1.401 TD -0.0247 Tc -0.06 Tw (p. 144\).)Tj 1.8 -2.001 TD -0.0035 Tc 0.0956 Tw [(V)64.7(icarious traumatization can also be viewed as a side)]TJ -1.8 -1.398 TD -0.0099 Tc -0.0625 Tw (effect or occupational hazard of working with trauma victims.)Tj ET endstream endobj 234 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 236 0 obj << /Length 9202 >> 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. 4 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (293)Tj /TT2 1 Tf 10 0 0 10 66 722.64 Tm -0.0031 Tc 0.0191 Tw [(Figley \(1995, p.1\) notes that there is a cost to caring and)]TJ 0 -1.398 TD -0.0036 Tc -0.0166 Tw (uses the term )Tj /TT5 1 Tf 5.43 0 TD -0.0044 Tc -0.015 Tw (compassion fatigue)Tj /TT2 1 Tf 7.659 0 TD -0.0036 Tc -0.0175 Tw [( to describe the cumulative)]TJ -13.089 -1.401 TD 0.0031 Tc 0.1249 Tw [(stress incurred by the constant giving of one)54.1(s self in an)]TJ T* -0.0032 Tc -0.0362 Tw [(ef)17.8(fort to help others. Increasingly)62.8(, mental health profession-)]TJ 0 -1.398 TD -0.0033 Tc 0.005 Tw (als are being called upon to treat survivors of violent crime,)Tj 0 -1.401 TD 0.0031 Tc 0.125 Tw (terrorism, natural disasters, childhood abuse, torture, and)Tj T* -0.0034 Tc 0.0417 Tw [(war-trauma victims. Therapists may experience symptoms)]TJ 0 -1.398 TD -0.0064 Tc -0.0622 Tw [(similar to their clients and these can result in changes in their)]TJ 0 -1.401 TD -0.0034 Tc 0.0083 Tw [(occupational and personal relationships. Boscarino, Figley)59.6(,)]TJ T* 0.0189 Tc 0.1252 Tw [(and )49.1(Adams \(2004\) found extensive compassion fatigue)]TJ 0 -1.398 TD -0.0039 Tc 0.0725 Tw (among social workers who were involved in helping those)Tj 0 -1.401 TD -0.0036 Tc 0.07 Tw (exposed to the September 11, 2001 terrorist attack in New)Tj T* -0.0016 Tc -0.0272 Tw [(Y)105.6(ork City)64.4(. )]TJ /TT5 1 Tf 4.506 0 TD -0.0059 Tc 0 Tw (Empathy)Tj /TT2 1 Tf 3.519 0 TD -0.0037 Tc -0.03 Tw [( and )]TJ /TT5 1 Tf 1.869 0 TD -0.0044 Tc (emotional contagion)Tj /TT2 1 Tf 8.142 0 TD -0.0035 Tc [( are also terms)]TJ -18.036 -1.398 TD -0.0033 Tc -0.0582 Tw [(that have been used to explain vicarious traumatization. In a)]TJ 0 -1.401 TD -0.0031 Tc -0.0519 Tw (therapeutic relationship, empathy may be viewed as the abil-)Tj T* -0.0023 Tc 0.125 Tw [(ity to understand the client)51.7(s experience of being trauma-)]TJ 0 -1.398 TD -0.0038 Tc 0.0206 Tw [(tized. )50.2(According to Pearlman and MacIan \(1995\) vicarious)]TJ 0 -1.401 TD 0.001 Tc 0.125 Tw (traumatization occurs through empathic engagement with)Tj T* -0.0033 Tc 0.0023 Tw [(clients)71.7( trauma material. Similarly)62.7(,)0.5( emotional contagion in-)]TJ 0 -1.398 TD -0.0035 Tc 0.0275 Tw [(volves the experiencing of another person)53.5(s distress, but on)]TJ 0 -1.401 TD -0.0311 Tw [(an unconscious level. For example, a therapist observes and)]TJ T* -0.0073 Tc -0.0622 Tw (interacts with a trauma victim and feels parallel emotions, but)Tj 0 -1.398 TD -0.0037 Tc 0.0313 Tw (has no conscious awareness of the relationship between his)Tj 0 -1.401 TD -0.0033 Tc 0.0308 Tw [(or her feelings and those of the patient \(Figley)59.7(, 1995\). )18(The)]TJ T* -0.0035 Tc -0.0325 Tw [(above studies \(e.g. Figley)59.5(, 1995; Pearlman & MacIan, 1995\))]TJ 0 -1.398 TD -0.0086 Tc -0.0621 Tw (highlight the conditions under which secondary trauma might)Tj 0 -1.401 TD -0.0031 Tc -0.0323 Tw [(occur)35.9(, but it remains unclear as to why many experience this)]TJ T* 0.0025 Tc 0 Tw (condition.)Tj /F1 1 Tf 11 0 0 11 66 312 Tm -0.005 Tc 0.0515 Tw (Hypothesized Mechanisms of Action)Tj /TT2 1 Tf 10 0 0 10 84 288.66 Tm -0.0044 Tc -0.0621 Tw (It would appear that exposure to traumatized individuals)Tj -1.8 -1.401 TD 0.0039 Tc 0.1249 Tw [(and situations can alter one)54.9(s perceptions of the self and)]TJ T* -0.0046 Tc -0.0623 Tw [(one)49.4(s milieu through an alteration of cognitive schemata, and)]TJ 0 -1.398 TD -0.0033 Tc -0.0417 Tw [(also negatively impact one)50.7(s emotional status. In addition to)]TJ 0 -1.401 TD -0.0038 Tc -0.007 Tw [(the disruption of one)53.2(s cognitive schemas through therapeu-)]TJ T* -0.0063 Tc -0.0625 Tw (tic work, secondary trauma might also be transmitted directly)Tj 0 -1.398 TD -0.0018 Tc 0.125 Tw [(through observational learning as explained by Bandura)52.2(s)]TJ 0 -1.401 TD -0.0062 Tc -0.0617 Tw [(\(1967\) social learning theory)62.8(.)]TJ 1.8 -2.001 TD -0.0035 Tc -0.0474 Tw [(In the social learning view)62.5(, one need not alter one)50.5(s cog-)]TJ -1.8 -1.398 TD -0.0179 Tc -0.0625 Tw [(nitive schemata in order for secondary trauma to occur)51.1(. Rather)36.1(,)]TJ 0 -1.401 TD -0.0031 Tc 0.0894 Tw (social learning theory posits that simply observing the be-)Tj T* -0.0033 Tc 0.1204 Tw [(havior of another can alter one)53.7(s perception of events. )50.6(A)]TJ 0 -1.398 TD -0.0038 Tc 0.0325 Tw (cognitive processing component, whether conscious or not,)Tj 0 -1.401 TD -0.0034 Tc -0.0305 Tw (is not a requirement for learning to occur according to social)Tj T* 0.049 Tw [(learning theorists. Perhaps the best example of this can be)]TJ 0 -1.398 TD 0.0377 Tw [(found in the functioning of primates. Rhesus monkeys ob-)]TJ 25.5 64.998 TD -0.0033 Tc 0.0912 Tw (serving fear reactions in other monkeys will acquire those)Tj 0 -1.398 TD -0.0066 Tc -0.0622 Tw [(fear reactions. This might be analogous to the situation where)]TJ 0 -1.401 TD -0.0035 Tc -0.049 Tw (a therapist can acquire the anxieties of patients. What is even)Tj T* 0.0656 Tw (more surprising than the occurrence of this direct observa-)Tj 0 -1.398 TD -0.055 Tw (tional learning process among primates is the fact that rhesus)Tj 0 -1.401 TD -0.006 Tc -0.0625 Tw (monkeys will acquire fear reactions of monkeys displayed on)Tj T* -0.0036 Tc -0.0622 Tw [(videotape \(Mineka & Zinbarg, 2006\). The fact that monkeys)]TJ 0 -1.398 TD -0.0034 Tc 0.1165 Tw (acquire fear reactions by viewing videotaped material has)Tj 0 -1.401 TD -0.0038 Tc 0.0322 Tw (implications regarding the degree to which humans acquire)Tj T* -0.017 Tc -0.0622 Tw [(fear reactions by watching television. In fact, Singer)37(, Flannery)61(,)]TJ 0 -1.398 TD -0.0192 Tc [(Guo, Miller)34.8(, and Leibbrandi \(2004\) found that while there were)]TJ 0 -1.401 TD -0.0035 Tc 0.0179 Tw (many contributing factors to childhood trauma, exposure to)Tj T* -0.035 Tw (violent material on television was an important element.)Tj 1.8 -1.998 TD -0.0031 Tc 0.0225 Tw (Trauma exposure by way of television is considered to)Tj -1.8 -1.401 TD -0.003 Tc -0.0577 Tw [(be one way in which secondary traumatization can occur)39(, i.e.)]TJ T* -0.0037 Tc 0.0107 Tw (the acquisition of trauma responses through exposure to the)Tj 0 -1.398 TD 0.0412 Tw (trauma and violence occurring among others, as viewed on)Tj 0 -1.401 TD -0.0242 Tc -0.0622 Tw [(television \(Marshall & Galea, 2004; Propper)35.8(, S)14.8(tickgold, Keeley)59.8(,)]TJ T* -0.0097 Tc -0.0623 Tw [(& Christman, 2007\). )50.3(A)58.5( question might be asked as to why we)]TJ 0 -1.398 TD -0.0034 Tc 0.0672 Tw (are so sensitive to acquiring the trauma reactions of others)Tj 0 -1.401 TD -0.003 Tc -0.0127 Tw [(who have been traumatized? It is possible that the ability to)]TJ T* -0.0035 Tc 0.0143 Tw [(become affected or traumatized by experiencing the trauma)]TJ 0 -1.398 TD -0.0032 Tc -0.02 Tw (of others has survival value and we are therefore genetically)Tj 0 -1.401 TD -0.0035 Tc 0.0893 Tw [(predisposed to developing these reactions. )17.4(W)94.3(e)-0.1( are geneti-)]TJ T* -0.0033 Tc 0.1055 Tw (cally programmed to be social beings and thus we are af-)Tj 0 -1.398 TD 0.0272 Tc 0.125 Tw (fected by the concerns of the members of our society)Tj 0 -1.401 TD -0.0033 Tc -0.0493 Tw [(\(Cacioppo & Patrick, 2008\). Historically)62.7(, our ancient ances-)]TJ T* -0.0384 Tw [(tors who were unaffected by the trauma experience of others)]TJ 0 -1.398 TD -0.0032 Tc 0.0777 Tw [(may have been less capable of adapting to life threatening)]TJ 0 -1.401 TD -0.0036 Tc 0.0321 Tw (situations and therefore their survival prospects might have)Tj T* -0.0113 Tc -0.0625 Tw [(been compromised \(e.g., Dawkins, 1976\). The increased dan-)]TJ 0 -1.398 TD -0.0034 Tc 0.0445 Tw (ger and threat to our ancestors who were unable to react to)Tj 0 -1.401 TD -0.0035 Tc 0.0685 Tw (the trauma of others would be expected to lower their sur-)Tj T* -0.0096 Tc -0.0625 Tw [(vival chances. Dawkins might take the position that the genes)]TJ 0 -1.398 TD -0.0134 Tc (underlying secondary trauma would eventually become domi-)Tj 0 -1.401 TD -0.0035 Tc 0.0761 Tw (nant among our ancestral survivors and we, the carriers of)Tj T* -0.0038 Tc 0.1031 Tw (those genes, would become more abundant than those not)Tj 0 -1.398 TD -0.0032 Tc 0.0317 Tw [(carrying the dominant genes. It is possible that individuals)]TJ 0 -1.401 TD -0.0034 Tc 0.0143 Tw (not carrying the genetic predisposition to acquiring second-)Tj T* 0.105 Tw (ary trauma reactions would have had lower survival pros-)Tj 0 -1.398 TD 0.0147 Tc 0.1249 Tw (pects and therefore would be less likely to become our)Tj 0 -1.401 TD 0.0064 Tc 0 Tw (progenitors.)Tj /F1 1 Tf 11 0 0 11 321 110.01 Tm -0.0056 Tc 0.0479 Tw [(Scales f)13.5(or Assessing Secondar)-16.5(y )95.5(T)79(rauma)]TJ /TT2 1 Tf 10 0 0 10 339 86.64 Tm -0.0036 Tc 0.0333 Tw (Assessment of secondary trauma has been problematic)Tj -1.8 -1.398 TD -0.0022 Tc 0.125 Tw (because its effects are often less severe and consequently)Tj ET endstream endobj 237 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 239 0 obj << /Length 9256 >> 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 0.0792 Tw [(294 )]TJ /TT3 1 Tf 2.715 0 TD -0.0055 Tc 0.0813 Tw [( Motta Secondary Trauma)]TJ /TT2 1 Tf 10 0 0 10 54 722.64 Tm -0.0064 Tc -0.0625 Tw (more difficult to detect than those seen in primary trauma and)Tj 0 -1.398 TD -0.0036 Tc -0.0265 Tw [(PTSD. )14.4(W)55.2(ith the exception of research studies using a modi-)]TJ 0 -1.401 TD -0.0033 Tc 0.1082 Tw [(fied S)17.7(t)0.4(roop procedure, to be described below)62.7(,)-1.2( virtually all)]TJ T* -0.0034 Tc 0.0019 Tw (assessment devices for secondary trauma have relied on pa-)Tj 0 -1.398 TD 0.003 Tc 0.125 Tw (per and pencil measures or interviews and are subject to)Tj 0 -1.401 TD -0.0034 Tc -0.0421 Tw [(measurement and interpretation errors. )50.6(Another dif)17.6(ficulty in)]TJ T* -0.0002 Tc 0.125 Tw (secondary trauma research is the relative lack of psycho-)Tj 0 -1.398 TD -0.0028 Tc (metrically sound measuring instruments for assessing this)Tj 0 -1.401 TD 0.0021 Tc (phenomenon, in comparison to the relative abundance of)Tj T* 0.0015 Tc (measures that assess the primary traumatic experience of)Tj 0 -1.398 TD -0.0025 Tc [(PTSD. While the Secondary Trauma Scale \(STS; Motta,)]TJ 0 -1.401 TD -0.0037 Tc -0.0621 Tw (Hafeez, Sciancalepore, & Diaz, 2001\) presents cutoff scores,)Tj T* -0.0033 Tc 0.1187 Tw (all other measures of secondary trauma lack these cutoffs)Tj 0 -1.398 TD -0.0035 Tc -0.0554 Tw [(and so one)53.5(s scores on the measures do not tell the researcher)]TJ 0 -1.401 TD -0.0043 Tc -0.0622 Tw (or clinician whether or not the individual being evaluated has)Tj T* -0.0037 Tc -0.06 Tw (a significant problem.)Tj 1.8 -1.998 TD -0.0036 Tc -0.0394 Tw [(Figley)59.4(, for example, developed the Compassion Fatigue)]TJ -1.8 -1.401 TD -0.0183 Tc -0.0621 Tw [(Self-T)65.7(est for Psychotherapists \(CFST)53.7(; Figley 1995\). )15.1(This scale)]TJ T* -0.0033 Tc -0.0566 Tw (is used specifically for mental health workers and although it)Tj 0 -1.398 TD 0.0569 Tw (lacks cutoff scores that would be indicative of emotionally)Tj 0 -1.401 TD -0.0035 Tc -0.0339 Tw (troubled or pathological reactions, it has had wide usage and)Tj T* -0.0032 Tc 0.0769 Tw [(is well regarded. Similarly)62.8(, Bride, Robinson, )32.8(Y)104(egidis, and)]TJ 0 -1.398 TD -0.0207 Tc -0.0621 Tw (Figley \(2003\) developed a 17-item Secondary Traumatic Stress)Tj 0 -1.401 TD 0.007 Tc 0.125 Tw (Scale \(STSS\), which measures intrusion, avoidance, and)Tj T* -0.0035 Tc 0.0143 Tw (arousal symptoms associated with the stress of professional)Tj 0 -1.398 TD -0.0037 Tc 0.07 Tw (relationship between social work practitioners and trauma-)Tj 0 -1.401 TD -0.0033 Tc 0.0256 Tw [(tized clients. The scale shows strong psychometric charac-)]TJ T* -0.0035 Tc 0.017 Tw [(teristics but, like the CFST)71.5(, does not have cutof)17.5(f scores and)]TJ 0 -1.398 TD -0.0032 Tc -0.0515 Tw (is designed primarily for therapists. The same can be said for)Tj 0 -1.401 TD -0.0037 Tc 0.095 Tw (the Traumatic Stress Institute Belief Scale \(TSI; Pearlman)Tj T* -0.0033 Tc 0.0505 Tw [(1996\) which measures disruption of beliefs of safety)59.7(, trust,)]TJ 0 -1.398 TD -0.0035 Tc 0.0621 Tw [(esteem, intimacy)59.5(, and control among mental health profes-)]TJ 0 -1.401 TD -0.0032 Tc 0.0613 Tw [(sionals. )50.7(A)59( significant issue is that, except for the STS, the)]TJ T* -0.0036 Tc 0.0122 Tw (above noted scales have been designed with the clinician in)Tj 0 -1.398 TD -0.039 Tw [(mind. The scales assess the extent to which clinicians work-)]TJ 0 -1.401 TD -0.0034 Tc -0.0565 Tw (ing with traumatized patients are negatively impacted during)Tj T* -0.0027 Tc 0.125 Tw (the therapeutic process.)Tj 1.8 -1.998 TD -0.0036 Tc 0.0812 Tw (Unlike the other measures noted in this section which)Tj -1.8 -1.401 TD -0.0031 Tc 0.0325 Tw (deal primarily with therapists reactions to their clients, the)Tj T* -0.0034 Tc -0.0083 Tw (Secondary Trauma Scale \(STS; Motta et al., 2001\) has been)Tj 0 -1.398 TD -0.0102 Tc -0.0621 Tw [(validated with samples involving members of the community)58.8(,)]TJ 0 -1.401 TD -0.0034 Tc 0.12 Tw (students, and practicing therapists. The STS has a test-re-)Tj T* -0.0029 Tc -0.0275 Tw (test reliability of .87 for a one to two week interval, an alpha)Tj 0 -1.398 TD 0.0005 Tc 0.125 Tw (reliability of .89, and demonstrates sound concurrent and)Tj 0 -1.401 TD -0.0032 Tc 0.0034 Tw [(discriminant validity)59.8(. )18(There are 18 items that are rated on a)]TJ T* -0.0033 Tc 0.0175 Tw (five-point scale and so the range of scores is from 18 to 90.)Tj 25.5 64.2 TD -0.0035 Tc 0.0383 Tw (Scores at or above 38 on the STS are suggestive of mild to)Tj 0 -1.398 TD -0.0032 Tc 0.1083 Tw (moderate anxiety; scores of 45 or higher are indicative of)Tj 0 -1.401 TD -0.003 Tc -0.0429 Tw [(moderate to severe anxiety)63(. Similarly)63(, scores of 38 or higher)]TJ T* -0.0081 Tc -0.0625 Tw (are associated with mild to moderate depression, while scores)Tj 0 -1.398 TD -0.0007 Tc 0.125 Tw (of 49 and higher can be indicative of moderate to severe)Tj 0 -1.401 TD -0.0122 Tc -0.0625 Tw (depression \(Motta, Newman, Lombardo, & Silverman, 2004\).)Tj T* -0.0031 Tc 0.067 Tw (The availability of cutoff scores can be helpful to both the)Tj 0 -1.398 TD -0.0034 Tc 0.0313 Tw (clinician and researcher in their efforts to better understand)Tj 0 -1.401 TD -0.0035 Tc 0.0887 Tw [(the nature and impact of secondary traumatization. When)]TJ T* -0.0031 Tc 0.0989 Tw [(one)53.9(s score on the STS is high, that person is likely to be)]TJ 0 -1.398 TD -0.0038 Tc -0.0233 Tw (experiencing significant emotional upset.)Tj /F1 1 Tf 11 0 0 11 309 549.99 Tm -0.0059 Tc 0.0415 Tw [(Secondar)-16.8(y )95.6(T)76(rauma Assessment and the)]TJ 0 -1.0909 TD -0.0043 Tc 0.1409 Tw (Stroop Procedure)Tj /TT2 1 Tf 10 0 0 10 327 514.65 Tm -0.0049 Tc -0.062 Tw [(As mentioned earlier)40.1(, modifications of the S)16.1(troop proce-)]TJ -1.8 -1.401 TD -0.0034 Tc -0.0233 Tw (dure \(Stroop, 1935\) have also been used to assess secondary)Tj 0 -1.398 TD -0.0058 Tc -0.0619 Tw [(trauma. Specifically)60.2(, a variant of the S)15.2(troop procedure some-)]TJ 0 -1.401 TD -0.0032 Tc -0.046 Tw (times referred to as the )Tj /TT5 1 Tf 9.105 0 TD -0.0045 Tc -0.045 Tw (modified Stroop)Tj /TT2 1 Tf 6.309 0 TD -0.0023 Tc [( or )]TJ /TT5 1 Tf 1.236 0 TD -0.0044 Tc -0.05 Tw (emotional Stroop)Tj /TT2 1 Tf 6.801 0 TD 0 Tc 0 Tw (,)Tj -23.451 -1.401 TD -0.0034 Tc 0.0928 Tw [(has been employed for this purpose. The standard Stroop)]TJ 0 -1.398 TD -0.0006 Tc 0.125 Tw (procedure involves a series of color words such as RED,)Tj 0 -1.401 TD -0.0069 Tc -0.0035 Tw [(GREEN, YELLOW)83.1(, )]TJ 8.3914 0 TD -0.0033 Tc 0.0256 Tw [(etc. )17.7(These words are printed in colors)]TJ -8.3914 -1.401 TD 0.0036 Tc 0.125 Tw (such that the color and the word do not agree with each)Tj 0 -1.398 TD -0.0037 Tc 0.0135 Tw [(other)50.3(. )14.6(The word RED, for example, might be printed in the)]TJ 0 -1.401 TD -0.0034 Tc 0.055 Tw [(color green. Researchers note that participants take longer)]TJ T* -0.0033 Tc 0.1025 Tw (to name the color of the word, when the underlying word)Tj 0 -1.398 TD -0.0002 Tc 0.1249 Tw [(meaning and the word color don)17.8(t agree with each other)50.8(.)]TJ 0 -1.401 TD -0.0036 Tc 0.0162 Tw (When the word and the color in which it is printed do coin-)Tj T* -0.0033 Tc -0.0146 Tw (cide, the time required to name the color of the word is less-)Tj 0 -1.398 TD -0.0034 Tc 0.0335 Tw [(ened. The delay in color naming, when word meaning and)]TJ 0 -1.401 TD 0.0568 Tw (word color do not coincide, is said to occur because of the)Tj T* -0.0171 Tw (cognitive and perceptual interference caused by the dissimi-)Tj 0 -1.398 TD -0.0048 Tc -0.0622 Tw (larity of word and color and is appropriately referred to as the)Tj 0 -1.401 TD -0.0047 Tc 0 Tw (Stroop )Tj /TT5 1 Tf 2.904 0 TD -0.0037 Tc 0.015 Tw (interference effect)Tj /TT2 1 Tf 7.197 0 TD 0 Tc 0 Tw (.)Tj -8.301 -2.001 TD -0.0038 Tc 0.0657 Tw (The modified or emotional Stroop procedure has been)Tj -1.8 -1.398 TD -0.0035 Tc 0.1032 Tw (used to assess emotional concerns, such as affective diffi-)Tj 0 -1.401 TD -0.0034 Tc 0.0239 Tw [(culties related to war experiences. Here, war related words)]TJ T* -0.0047 Tc 0.1011 Tw [(such as COMBA)103.3(T)78.1(,)-4.1( )13.8(WEAPON, BLAST)70.3(, etc. are printed in)]TJ 0 -1.398 TD 0.0041 Tc 0.125 Tw [(colors and the participant)52.1(s task is to name the colors in)]TJ 0 -1.401 TD -0.0035 Tc 0.071 Tw (which the words are printed, but not read the words them-)Tj T* 0.1061 Tw [(selves. )17.3(W)94.3(ords that have emotional significance, as would)]TJ 0 -1.398 TD 0.093 Tw (the above words to a combat veteran, take longer to color)Tj 0 -1.401 TD -0.0125 Tc -0.062 Tw [(name than neutral words \(CHAIR, CAR, P)86.5(AINT)74.5(, etc.\) or posi-)]TJ T* -0.0048 Tc -0.0618 Tw [(tive words \(HAPPY)130.2(, PLEASED, CONTENT)70.2(, etc\). Similarly)]TJ 0 -1.398 TD -0.0038 Tc 0.0038 Tw (non-combatants name the colors of the combat words faster)Tj 0 -1.401 TD -0.0169 Tw (than those who have experienced combat because the words)Tj T* -0.0036 Tc 0.11 Tw [(have less emotional significance to them. This procedure)]TJ ET endstream endobj 240 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 8647 >> 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. 4 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (295)Tj /TT2 1 Tf 10 0 0 10 66 722.64 Tm -0.0034 Tc 0.0228 Tw (has been used to evaluate response delays due to emotional)Tj 0 -1.398 TD -0.0035 Tc -0.0185 Tw [(concerns related to war)35.5(, rape, PTSD, interpersonal violence,)]TJ 0 -1.401 TD -0.0034 Tc 0.1162 Tw (and other traumas and sources of emotional distress \(e.g.,)Tj T* -0.0035 Tc -0.0342 Tw [(Foa, Feske, Murdock, Kozac, & McCArthy)59.5(, 1991; McNally)62.5(,)]TJ 0 -1.398 TD -0.0037 Tc -0.0384 Tw [(Kaspi, Riemann, & Zeitlin, 1990\). )17.4(The S)17.3(troop)50.3(s usage in as-)]TJ 0 -1.401 TD 0 Tc 0.125 Tw (sessing secondary trauma has been limited but, neverthe-)Tj T* -0.0032 Tc 0.07 Tw (less, useful.)Tj 1.8 -1.998 TD -0.0029 Tc 0.0928 Tw (In a study of secondary trauma, adult children of war)Tj -1.8 -1.401 TD -0.0072 Tc -0.0622 Tw (veterans and those of non-veterans named the colors in which)Tj T* -0.0033 Tc -0.023 Tw [(war related words were printed \(Motta et al., 1997\). Partici-)]TJ 0 -1.398 TD -0.0036 Tc 0.0725 Tw (pants also completed a series of standardized measures re-)Tj 0 -1.401 TD -0.0107 Tc -0.0625 Tw [(lated to in impact of war experience. )49.3(A)60.5( statistically significant)]TJ T* -0.0035 Tc -0.0611 Tw (difference in color- naming time between the children of vet-)Tj 0 -1.398 TD -0.02 Tw (erans and non-veterans was found only on the Stroop stimu-)Tj 0 -1.401 TD -0.0005 Tc 0.125 Tw [(lus card containing war related words. There were other)]TJ T* 0.0097 Tc (cards involving neutral, positive, and cleanliness-related)Tj 0 -1.398 TD -0.0047 Tc -0.0623 Tw [(stimuli in addition to the standardized measures. These other)]TJ 0 -1.401 TD -0.0037 Tc 0.0106 Tw (measures did not show differences between children of vet-)Tj T* -0.0032 Tc 0.0622 Tw [(erans and children of non-veterans. This initial study sug-)]TJ 0 -1.398 TD -0.0037 Tc 0.1028 Tw (gested that the Stroop procedure involving words relevant)Tj 0 -1.401 TD -0.0034 Tc 0.0569 Tw (to emotional concerns could be successfully used to assess)Tj T* -0.0033 Tc -0.0049 Tw (secondary trauma. It also revealed that the modified Stroop)Tj 0 -1.398 TD -0.0034 Tc -0.0256 Tw (procedure was able to detect secondary trauma effects while)Tj 0 -1.401 TD -0.0035 Tc 0.04 Tw (standard measures were not able to do so.)Tj 1.8 -2.001 TD -0.0031 Tc 0.0929 Tw (A related study of secondary traumatization using the)Tj -1.8 -1.398 TD -0.0035 Tc 0.0345 Tw [(Stroop was conducted \(Suozzi & Motta, 2004\). This study)]TJ 0 -1.401 TD -0.0032 Tc 0.095 Tw (systematically investigated the relationship between inten-)Tj T* -0.0033 Tc 0.0133 Tw [(sity of )17.7(V)64.9(ietnam combat exposure and the transfer of trauma)]TJ 0 -1.398 TD -0.0032 Tc -0.002 Tw (symptoms to adult children of veterans. It was thus specifi-)Tj 0 -1.401 TD 0.0042 Tc 0.125 Tw (cally designed to assess secondary traumatization effects)Tj T* -0.0036 Tc -0.0049 Tw (due to combat. Forty male combat veterans who comprised)Tj 0 -1.398 TD 0.0637 Tw (high and low combat intensity groups were administered a)Tj 0 -1.401 TD 0.0045 Tc 0.125 Tw (series of measures designed to assess PTSD, depression,)Tj T* -0.0033 Tc 0.0764 Tw [(anxiety)62.7(, intrusive thoughts, and avoidance responses. )17.7(V)112.9(et-)]TJ 0 -1.398 TD -0.0038 Tc -0.0307 Tw (erans also completed an emotional Stroop procedure involv-)Tj 0 -1.401 TD -0.0036 Tc 0.0275 Tw [(ing combat relevant and non-relevant stimuli. Offspring of)]TJ T* -0.0037 Tc -0.005 Tw (veterans \()Tj /TT5 1 Tf 3.876 0 TD -0.004 Tc 0 Tw (n )Tj /TT2 1 Tf 0.738 0 TD -0.0035 Tc -0.0075 Tw [(= 53\) completed similar measures. It was found)]TJ -4.614 -1.398 TD -0.0033 Tc 0.0844 Tw (that affective responses of the offspring were impacted by)Tj 0 -1.401 TD -0.0003 Tc 0.125 Tw [(level of combat intensity of their fathers. The most pro-)]TJ T* -0.0038 Tc 0.0479 Tw (nounced effects occurred on the emotional Stroop stimulus)Tj 0 -1.398 TD -0.0164 Tc -0.0625 Tw (card involving war-related words, where children of high com-)Tj 0 -1.401 TD -0.0036 Tc 0.075 Tw (bat veterans showed the longest Stroop response latencies.)Tj T* 0.0009 Tc 0.125 Tw (Results of this study supported the Stroop paradigm as a)Tj 0 -1.398 TD -0.0033 Tc 0.0693 Tw (research tool for investigating secondary trauma in parent-)Tj 0 -1.401 TD -0.0025 Tc 0.07 Tw (child dyads.)Tj 27.3 62.799 TD -0.0037 Tc 0.0813 Tw (The value of the modified or emotional Stroop proce-)Tj -1.8 -1.398 TD -0.0033 Tc 0.0045 Tw (dure is that it presents an objective methodology for assess-)Tj 0 -1.401 TD -0.0029 Tc 0.046 Tw [(ing secondary trauma. It is a highly sensitive procedure in)]TJ T* -0.0158 Tc -0.0622 Tw (that it will often pick up differences between secondary trauma)Tj 0 -1.398 TD -0.0037 Tc 0.0963 Tw [(groups where standardized measures will not. The proce-)]TJ 0 -1.401 TD -0.0031 Tc 0.083 Tw [(dure has two apparent drawbacks. First, it is necessary to)]TJ T* -0.0034 Tc -0.003 Tw (use stimulus words that are relevant to the particular area of)Tj 0 -1.398 TD 0.0305 Tw [(trauma, whether it be rape, war)35.6(, combat exposure, interper)17.6(-)]TJ 0 -1.401 TD -0.0035 Tc 0.002 Tw (sonal violence, etc. This can be cumbersome and time con-)Tj T* 0.0381 Tw (suming during initial stages of development of the relevant)Tj 0 -1.398 TD 0.0444 Tw [(stimuli. Second, while the procedure does provide reliable)]TJ 0 -1.401 TD -0.0034 Tc -0.0622 Tw (and replicable outcomes, it, like many other measures of sec-)Tj T* -0.0032 Tc 0.0462 Tw (ondary trauma, lacks cutoff scores and therefore has inher-)Tj 0 -1.398 TD -0.006 Tc -0.06 Tw (ent limitations.)Tj 1.8 -2.001 TD -0.0036 Tc 0.0125 Tw (Perhaps the real strength of the modified Stroop proce-)Tj -1.8 -1.401 TD -0.0034 Tc -0.0354 Tw (dure is that it provides a means of validating the existence of)Tj 0 -1.398 TD -0.0033 Tc -0.0528 Tw (secondary trauma reactions without a reliance on self-report.)Tj 0 -1.401 TD -0.003 Tc 0.125 Tw (The data derived from the Stroop are simple response la-)Tj T* 0.0215 Tw [(tency measures and as such are far less influenced by one)51(s)]TJ 0 -1.398 TD -0.0035 Tc 0.0733 Tw (perceptions and beliefs than are the paper and pencil mea-)Tj 0 -1.401 TD -0.0005 Tc 0.125 Tw [(sures. The Stroop appears to be relatively impervious to)]TJ T* -0.0032 Tc 0.0125 Tw (social desirability influences as participants are characteris-)Tj 0 -1.398 TD -0.0033 Tc 0.0294 Tw (tically unfamiliar with what constitutes an adaptive or mal-)Tj 0 -1.401 TD -0.0031 Tc 0.1083 Tw (adaptive response; this adds to its utility for both practice)Tj T* -0.0014 Tc 0.125 Tw (and research purposes.)Tj /F1 1 Tf 11 0 0 11 321 348 Tm -0.0056 Tc 0.0702 Tw [(Inter)-16.5(ventions f)13.5(or Secondar)-13.8(y )93.1(T)79(rauma)]TJ /TT2 1 Tf 10 0 0 10 339 324.66 Tm -0.0032 Tc 0.0725 Tw (There are virtually no agreed upon treatments that are)Tj -1.8 -1.401 TD -0.003 Tc 0.1 Tw (specifically targeted for treating secondary traumatization.)Tj T* 0.0418 Tw [(Generally)63(, when treatments are attempted, they tend to fol-)]TJ 0 -1.398 TD -0.0029 Tc -0.0437 Tw [(low those typically seen for treating PTSD. Thus, one sees a)]TJ 0 -1.401 TD -0.0033 Tc 0.01 Tw (variety of interventions from re-exposure to trauma stimuli,)Tj T* -0.0225 Tw (pharmacotherapy aimed at reducing anxiety and depression,)Tj 0 -1.398 TD -0.0024 Tc 0.0249 Tw [(psychotherapy)63.6(, peer participation, family therapy)63.6(, etc. Ele-)]TJ 0 -1.401 TD -0.0034 Tc 0.125 Tw (ments of treatment involve establishing a therapeutic alli-)Tj T* 0.0055 Tc [(ance, providing education, managing anxiety)62.5(, facilitating)]TJ 0 -1.398 TD -0.0035 Tc 0.0508 Tw (re-experiencing, and integration of the trauma experiences.)Tj 0 -1.401 TD 0.0012 Tc 0.125 Tw (Exposure therapy has been used for at least the past two)Tj T* -0.0034 Tc 0.111 Tw (decades and is one of the more common ways of treating)Tj 0 -1.398 TD 0.0221 Tw [(PTSD. It is assumed that it might also be useful in treating)]TJ 0 -1.401 TD -0.0031 Tc 0.0236 Tw (secondary trauma, although there are virtually no empirical)Tj T* -0.0034 Tc -0.0625 Tw [(studies in this area. Exposure therapy involves re-experienc-)]TJ 0 -1.398 TD -0.0043 Tc -0.0623 Tw (ing \(for example, through verbal recounting, the use of imag-)Tj 0 -1.401 TD 0.0206 Tc 0.1248 Tw [(ery)62.6(, or through other techniques such as virtual reality)]TJ T* -0.0068 Tc -0.0622 Tw (procedures\) and re-processing traumatic material in a graded,)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 8846 >> 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 0.0792 Tw [(296 )]TJ /TT3 1 Tf 2.715 0 TD -0.0055 Tc 0.0813 Tw [( Motta Secondary Trauma)]TJ /TT2 1 Tf 10 0 0 10 54 722.64 Tm 0.027 Tc 0.125 Tw (controlled fashion and within the safe confines of the)Tj 0 -1.398 TD -0.0028 Tc [(therapist)51.2(s of)15.2(fice or clinical setting. )18.2(The vast majority of)]TJ 0 -1.401 TD -0.0118 Tc -0.0625 Tw (cognitive-behavioral interventions for dealing with PTSD and)Tj T* -0.0036 Tc -0.0275 Tw (acute trauma reactions involve some form of re-exposure to,)Tj 0 -1.398 TD -0.0032 Tc 0.075 Tw (and re-experiencing of, formerly traumatizing events \(e.g.,)Tj 0 -1.401 TD -0.0126 Tc -0.0621 Tw [(L)58.2(yons 1987; Saigh, 1987\). )17.5(Therefore the assumption has been)]TJ T* -0.0034 Tc 0.052 Tw (that a similar process might be of value for those suffering)Tj 0 -1.398 TD -0.0033 Tc 0.0614 Tw [(from secondary traumatization. )50.9(As stated earlier)38.7(, there are)]TJ 0 -1.401 TD -0.0031 Tc 0.0175 Tw (virtually no controlled and validated studies in this area.)Tj 1.8 -2.001 TD -0.0035 Tc 0.0736 Tw (It is important to determine effective interventions for)Tj -1.8 -1.398 TD -0.0048 Tc -0.0625 Tw (treating of mental health professionals because there are high)Tj 0 -1.401 TD -0.0036 Tc -0.0305 Tw (rates of burnout and turnover in therapists working in outpa-)Tj T* 0.1206 Tw (tient and inpatient settings where trauma victims are seen)Tj 0 -1.398 TD -0.0051 Tc -0.0623 Tw [(\(Kottler)39.9(, 1993\). )22.1(The question arises as to what can be done to)]TJ 0 -1.401 TD -0.007 Tc -0.0625 Tw (protect therapists from secondary traumatization within these)Tj T* -0.0036 Tc -0.0518 Tw [(environments. )53.5(According to Killian \(2008\), social support is)]TJ 0 -1.398 TD 0.095 Tw (the most significant factor in protecting against treatment-)Tj 0 -1.401 TD 0.0064 Tc 0.125 Tw (induced psychological strain and enhancing employment)Tj T* 0.0067 Tc [(satisfaction. Maintaining peer contact and consultation)]TJ 0 -1.398 TD -0.0035 Tc 0.086 Tw [(provides an opportunity to share how one)50.5(s work and per)17.5(-)]TJ 0 -1.401 TD -0.0034 Tw [(sonal life interact and af)14.5(fect each other)35.5(, to examine what ar)17.5(-)]TJ T* -0.0031 Tc 0.1003 Tw [(eas of one)53.9(s life have been disrupted by this work, and to)]TJ 0 -1.398 TD 0.1189 Tw (reality test by stepping back and assessing how much the)Tj 0 -1.401 TD -0.0033 Tc -0.0299 Tw [(work has increased one)53.7(s cynicism or alienation \(p. 40\).)]TJ 1.8 -2.001 TD -0.0036 Tc -0.0082 Tw (A number of factors have been associated with increas-)Tj -1.8 -1.398 TD -0.0032 Tc 0.0462 Tw [(ing levels of secondary traumatization in therapists. These)]TJ 0 -1.401 TD -0.0074 Tc -0.0622 Tw (include the number of cases typically seen, whether the thera-)Tj T* -0.0053 Tc -0.0623 Tw (pist has their own work space, the degree of control the thera-)Tj 0 -1.398 TD -0.0031 Tc 0.0068 Tw (pist has over such issues as how many days are worked and)Tj 0 -1.401 TD 0.064 Tw (how many cases are seen, and whether or not the therapist)Tj T* -0.0037 Tc 0.0393 Tw (has experienced personal traumas \(Jenkins & Baird, 2002\).)Tj 0 -1.398 TD -0.0033 Tc 0.001 Tw (Those who see many cases and have little control over their)Tj 0 -1.401 TD 0.0115 Tc 0.125 Tw (schedules are more likely to develop secondary trauma.)Tj T* -0.0035 Tc 0.0244 Tw (Killian \(2008\) suggests that agencies should take on the re-)Tj 0 -1.398 TD -0.0032 Tc 0.1222 Tw (sponsibility of modifying the variables that produce work)Tj 0 -1.401 TD -0.0035 Tc 0.0106 Tw (stress and compassion fatigue in therapists rather than plac-)Tj T* -0.0031 Tc 0.0945 Tw (ing the onus of responsibility on therapists to take care of)Tj 0 -1.398 TD 0.0002 Tc 0.125 Tw [(these matters themselves. Such an approach is proactive)]TJ 0 -1.401 TD -0.0037 Tc 0.0037 Tw (and attempts to prevent problems rather than allowing them)Tj T* -0.0066 Tc -0.0622 Tw (to develop and then devising strategies for dealing with them.)Tj 1.8 -1.998 TD -0.0011 Tc 0.125 Tw (Bober and Regehr \(2006\) found that while therapists)Tj -1.8 -1.401 TD -0.0033 Tc -0.0621 Tw [(agreed that having more time for leisure activity)62.7(, social inter)14.7(-)]TJ T* 0.1099 Tw [(actions, and other self-care activities such as exercise and)]TJ 0 -1.398 TD -0.0032 Tc 0.0467 Tw (hobbies, would be helpful in reducing their stress, they did)Tj 0 -1.401 TD -0.003 Tc -0.0106 Tw [(not necessarily pursue these activities for themselves. They)]TJ T* 0.1249 Tw (seemed much better at advising others to engage in these)Tj 25.5 64.8 TD -0.0035 Tc 0.0665 Tw [(activities than in following their own advice. However)35.5(, a)]TJ 0 -1.398 TD -0.003 Tc 0.0825 Tw (qualitative study by Killian \(2008\) did not find significant)Tj 0 -1.401 TD -0.0035 Tc 0.0312 Tw (correlations between the use of these various coping strate-)Tj T* -0.0033 Tc 0.0463 Tw (gies and the reduction of secondary traumatization, but did)Tj 0 -1.398 TD -0.0037 Tc 0.11 Tw (find that reducing hours worked per week, having control)Tj 0 -1.401 TD 0.0618 Tw (over ones work environment and schedule, and social sup-)Tj T* -0.0033 Tc 0.0944 Tw [(port were effective in reducing secondary trauma. Phipps)]TJ 0 -1.398 TD -0.0034 Tc -0.0408 Tw (and Mitchell \(2003\) suggest that interventions for secondary)Tj 0 -1.401 TD -0.0038 Tc 0.0557 Tw (trauma should include components that involve social sup-)Tj T* -0.0034 Tc 0.125 Tw [(port, normalization of the therapists experiences, and the)]TJ 0 -1.398 TD -0.0035 Tc 0.1237 Tw (provision of some of the self-help strategies noted above.)Tj 0 -1.401 TD 0.0849 Tw [(Similarly)59.4(, Munroe and colleagues \(2003\) stress the impor)17.4(-)]TJ T* 0.0017 Tc 0.125 Tw (tance of professional social support with an emphasis on)Tj 0 -1.398 TD -0.0012 Tc (advising therapists to pursue personal self-care strategies.)Tj 0 -1.401 TD -0.0031 Tc -0.0538 Tw [(Clearly)62.9(, this is an area much in need of additional research as)]TJ T* -0.0029 Tc 0.0761 Tw (there are virtually no systematic studies with regard to the)Tj 0 -1.398 TD -0.0035 Tc 0.095 Tw (treatment of secondary traumatization among therapists or)Tj 0 -1.401 TD 0.0114 Tc 0 Tw (non-therapists.)Tj /F1 1 Tf 11 0 0 11 309 452.01 Tm 0.0019 Tc (Summary)Tj /TT2 1 Tf 10 0 0 10 327 428.64 Tm -0.0082 Tc -0.0622 Tw [(Recent research and clinical observation shows that trau-)]TJ -1.8 -1.398 TD -0.0035 Tc 0.1066 Tw [(matic experiences have a contagious nature to them. The)]TJ 0 -1.401 TD -0.003 Tc 0.049 Tw (impact of trauma is experienced not only by the victims of)Tj T* 0.0041 Tc 0.125 Tw (trauma but also spreads to those who have close contact)Tj 0 -1.398 TD -0.0032 Tc -0.0195 Tw [(with the victims. It also spreads to those who strongly iden-)]TJ 0 -1.401 TD 0.0944 Tw (tify with trauma victims and who might be repeatedly ex-)Tj T* -0.0036 Tc -0.037 Tw [(posed to trauma through video or )14.5(T)9.4(V)128.4(.)-6.2( )-6.1( )17.5(The fact that fears can)]TJ 0 -1.398 TD 0.0856 Tw (be acquired through observation has been seen at both the)Tj 0 -1.401 TD -0.0033 Tc -0.0368 Tw (human and at the primate level; this suggests that we may be)Tj T* 0.0391 Tw (genetically hard-wired to acquiring secondary trauma re-)Tj 0 -1.398 TD -0.0038 Tc 0.0783 Tw (actions through vicarious exposure.)Tj 1.8 -2.001 TD 0.0143 Tc 0.125 Tw (There is comparatively little research on secondary)Tj -1.8 -1.401 TD -0.0035 Tc -0.0486 Tw [(trauma measurement; the majority of the assessment devices)]TJ 0 -1.398 TD -0.0033 Tc 0.0795 Tw (that do exist tend to be designed for therapists and not for)Tj 0 -1.401 TD 0.0035 Tc 0.125 Tw [(the general population. There is no systematic and con-)]TJ T* -0.0066 Tc -0.0625 Tw (trolled research focusing upon an evaluation of various thera-)Tj 0 -1.398 TD -0.0032 Tc 0.0393 Tw [(peutic interventions for secondary trauma. These are areas)]TJ 0 -1.401 TD -0.003 Tc -0.0012 Tw [(that are much in need of further study)63(. It is unfortunate that)]TJ T* -0.0028 Tc 0.025 Tw [(we, and especially the younger generation, are increasingly)]TJ 0 -1.398 TD -0.0036 Tc 0.0069 Tw (exposed to traumatic events such as terrorism on television.)Tj 0 -1.401 TD -0.0034 Tc 0.0405 Tw (The existence of a video generation as we have today all)Tj T* -0.0033 Tc -0.0475 Tw (but assures that terrorist acts, and other forms of trauma, will)Tj 0 -1.398 TD -0.0031 Tc 0.0236 Tw (have an increasingly wider negative impact, particularly on)Tj 0 -1.401 TD 0.0404 Tw [(the young. )53.8(A)59.1( good deal of additional research is needed in)]TJ T* -0.003 Tc -0.0311 Tw (areas such as the nature of secondary trauma, the underlying)Tj 0 -1.398 TD 0.0004 Tc 0.125 Tw (process by which it spreads to others, and its assessment)Tj ET endstream endobj 246 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 248 0 obj << /Length 10825 >> 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. 4 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (297)Tj /TT2 1 Tf 10 0 0 10 66 722.64 Tm -0.0033 Tc -0.0156 Tw [(and treatment. Research on treatment is particularly needed)]TJ 0 -1.398 TD -0.0031 Tc 0.0283 Tw (as there are no systematic, comparative studies in this area.)Tj 0 -1.401 TD -0.0029 Tc 0.0031 Tw (Nevertheless, it is gratifying to see that secondary traumati-)Tj T* -0.0033 Tc -0.0569 Tw [(zation is increasingly recognized as a real phenomenon. This)]TJ 0 -1.398 TD -0.0032 Tc 0.0777 Tw (will doubtlessly lead to further research and the growth of)Tj 0 -1.401 TD -0.0036 Tc -0.018 Tw (our knowledge in this important area.)Tj /F1 1 Tf 11 0 0 11 145.89 608.79 Tm 0.021 Tc 0 Tw (REFERENCES)Tj /TT2 1 Tf 10 0 0 10 66 585.84 Tm -0.0035 Tc 0.1075 Tw [(American Psychiatric )53.5(Association. \(2004\). )]TJ /TT5 1 Tf 17.511 0 TD -0.0046 Tc 0.11 Tw (Diagnostic and)Tj -16.311 -1.398 TD -0.004 Tc -0.0012 Tw [(statistical manual of mental disor)29(ders )]TJ /TT2 1 Tf 15.231 0 TD -0.008 Tc 0 Tw (\(4)Tj 5.8 0 0 5.8 238.56 575.19 Tm -0.002 Tc (th)Tj 10 0 0 10 243.06 571.86 Tm -0.0036 Tc -0.0032 Tw [( ed.\). )19.2(W)97.2(ashing-)]TJ -16.506 -1.401 TD -0.0046 Tc -0.0418 Tw [(ton, DC: )50.1(Author)49.4(.)]TJ -1.2 -1.8 TD -0.0034 Tc -0.0273 Tw [(Bandura, )50.8(A. \(1967\). )17.8(The role of modeling personality devel-)]TJ 1.2 -1.401 TD 0.0349 Tw [(opment. In C. Lavatelli & F)77.6(.)-2.4( )-6.5(S)24.8(tendler \(eds.\) )]TJ /TT5 1 Tf 17.754 0 TD -0.0044 Tc 0.0401 Tw (Readings in)Tj -17.754 -1.398 TD 0.0019 Tc 0.125 Tw (childhood and development)Tj /TT2 1 Tf 11.355 0 TD 0.0023 Tc 0.1252 Tw [( \(pp. 334-343\). New )26.5(Y)103.5(ork:)]TJ -11.355 -1.401 TD -0.004 Tc 0.005 Tw (Harcourt Brace Jovanovich.)Tj -1.2 -1.8 TD -0.0037 Tc 0.008 Tw [(Bober)38.3(,)-5.9( )14.5(T)79.1(., & Regehr)35.3(, C. \(2006\). S)14.3(trategies for reducing sec-)]TJ 1.2 -1.401 TD -0.0027 Tc 0.0593 Tw (ondary or vicarious trauma: Do they work? )Tj /TT5 1 Tf 17.826 0 TD -0.0045 Tc 0.0604 Tw [(Brief T)52.5(r)33.7(eat-)]TJ -17.826 -1.398 TD -0.0034 Tc 0.009 Tw (ment and Crisis Intervention, 6, )Tj /TT2 1 Tf 12.906 0 TD -0.0047 Tc 0 Tw (1-9.)Tj -14.106 -1.8 TD -0.0153 Tc -0.0624 Tw [(Boscarino, J.A., Figley)62.7(, C.R., & )56.8(Adams, R.E. \(2004\). Compas-)]TJ 1.2 -1.401 TD -0.0037 Tc 0.0705 Tw [(sion fatigue following September 1)29.3(1)-0.4( terrorist attacks: )50.8(A)]TJ T* -0.003 Tc 0.03 Tw [(study of secondary trauma among New )33(Y)104.2(ork City social)]TJ 0 -1.398 TD 0.006 Tc 0.125 Tw (workers. )Tj /TT5 1 Tf 4.284 0 TD 0.0055 Tc (International Journal of Emergency Mental)Tj -4.284 -1.401 TD -0.0145 Tc -0.06 Tw (Health, 6)Tj /TT2 1 Tf 3.534 0 TD -0.0148 Tc (\(2\), 57-66.)Tj -4.734 -1.8 TD -0.0062 Tc -0.0624 Tw [(Boyer)38.8(, B., Bubel, D., Jacobs, S.R., Knolls, M., Harwell, )14.6(V)137(.D.,)]TJ 1.2 -1.401 TD -0.0036 Tc -0.0078 Tw [(Goscicka, M., & Keenan, )50.5(A. \(2002\). Posttraumatic stress)]TJ 0 -1.398 TD 0.0018 Tc 0.125 Tw (in women with breast cancer and their daughters. )Tj /TT5 1 Tf 21 0 TD 0 Tc 0 Tw (The)Tj -21 -1.401 TD -0.0039 Tc 0.0433 Tw [(American Journal of Family Therapy)50.1(, 30, 323-338.)]TJ /TT2 1 Tf -1.2 -1.8 TD -0.0098 Tc -0.0622 Tw [(Brady)65.2(, J.L., Guy)59.2(, J.D., Poelstra, P)104.2(.L., & Fletcher)20.2(-Brokaw)59.2(, B.F)74.2(.)]TJ 1.2 -1.401 TD -0.0153 Tc -0.0625 Tw [(\(1999\). )18.2(V)64.9(icarious traumatization, spirituality)65.7(, and treatment)]TJ 0 -1.398 TD -0.0035 Tc 0.0925 Tw [(of sexual abuse survivors: )53.5(A)58.7( national survey of women)]TJ 0 -1.401 TD -0.0064 Tc 0 Tw (psychotherapists. )Tj /TT5 1 Tf 6.996 0 TD -0.0078 Tc -0.0616 Tw (Professional Psychology: Research and)Tj -6.996 -1.401 TD -0.0112 Tc -0.06 Tw (Practice, 30)Tj /TT2 1 Tf 4.701 0 TD -0.011 Tc (, 368-393.)Tj -5.901 -1.8 TD -0.028 Tc -0.0621 Tw [(Bride, B.E., Robinson, M.M., )32.1(Y)103.2(e)-0.4(gidis, B., & Figley)62(, C.R. \(2003\).)]TJ 1.2 -1.398 TD -0.0037 Tc -0.0044 Tw [(Development and )-5.6(validation of the Secondary Traumatic)]TJ 0 -1.401 TD -0.0033 Tc -0.04 Tw [(S)21.9(tress Scale. )]TJ /TT5 1 Tf 5.16 0 TD -0.0038 Tc -0.0398 Tw [(Resear)32.2(ch on Social W)86.2(o)-0.5(rk Practice, 13, )]TJ /TT2 1 Tf 15.276 0 TD -0.0048 Tc 0 Tw (1-16.)Tj -21.636 -1.8 TD -0.0045 Tc -0.0622 Tw [(Cacioppo, J.T)73.5(., & Patrick, )22.8(W)102.3(.)-0.4( \(2008\). )]TJ /TT5 1 Tf 14.559 0 TD -0.0061 Tc -0.0625 Tw (Loneliness: Human na-)Tj -13.359 -1.401 TD -0.0037 Tc -0.0431 Tw [(tur)32.3(e and the need for social connection.)]TJ /TT2 1 Tf 15.48 0 TD -0.0039 Tc -0.0432 Tw [( New )32.7(Y)103.3(ork: )14.6(W)105.9(.)13.9(W)86.1(.)]TJ -15.48 -1.398 TD -0.0043 Tc -0.04 Tw (Norton & Co.)Tj -1.2 -1.8 TD -0.0089 Tc -0.0616 Tw (Catherall, D.R. \(1992\). )Tj /TT5 1 Tf 9.075 0 TD -0.0095 Tc -0.0622 Tw (Back from the brink: A family guide to)Tj -7.875 -1.401 TD -0.0043 Tc -0.0249 Tw [(over)31.7(coming traumatic str)28.7(ess.)]TJ /TT2 1 Tf 11.409 0 TD -0.0042 Tc -0.0278 Tw [( New )29(Y)103(ork: Bantam Books.)]TJ -12.609 -1.8 TD -0.0133 Tc -0.0617 Tw (Dawkins, R. \(1976\). )Tj /TT5 1 Tf 7.941 0 TD -0.014 Tc -0.06 Tw (The selfish gene)Tj /TT2 1 Tf 6.105 0 TD -0.0139 Tc -0.0633 Tw (. Oxford: Oxford Univer-)Tj -12.846 -1.401 TD -0.0021 Tc 0.09 Tw (sity Press.)Tj 24.3 63.48 TD -0.0048 Tc -0.0615 Tw [(Dwyer)34.2(, L.A. \(2005\). )]TJ /TT5 1 Tf 8.154 0 TD -0.006 Tc -0.062 Tw (An investigation of secondary trauma in)Tj -6.954 -1.398 TD -0.0038 Tc 0.005 Tw (police wives.)Tj /TT2 1 Tf 5.124 0 TD 0.007 Tw [( Unpublished )-6.5(doctoral dissertation, Hofstra)]TJ -5.124 -1.401 TD -0.0068 Tc -0.0618 Tw [(University)56.2(, Hempstead, New )35.1(Y)100.4(ork.)]TJ -1.2 -1.8 TD -0.0031 Tc -0.0358 Tw [(Figley)59.9(, C.R. \(Ed.\). \(1995\). Compassion fatigue as secondary)]TJ 1.2 -1.401 TD -0.0038 Tc 0.0795 Tw [(traumatic stress disorder: )52.2(An overview)59.2(. In )]TJ /TT5 1 Tf 17.604 0 TD -0.0055 Tc 0 Tw (Compassion)Tj -17.604 -1.398 TD -0.0037 Tc 0.125 Tw (fatigue: Coping with secondary traumatic stress disor-)Tj 0 -1.401 TD -0.0032 Tc (der in those who treat the traumatized )Tj /TT2 1 Tf 16.281 0 TD -0.0033 Tc (\(pp.1-19\). New)Tj -16.281 -1.401 TD -0.0142 Tc -0.0625 Tw [(Y)102(ork: Brunner /Mazel.)]TJ -1.2 -1.8 TD -0.0227 Tc -0.0622 Tw [(Foa, E.B., Feske, U., Murdock, R.G)118.3(., Kozac, M.J., & McCarthy)61.3(,)]TJ 1.2 -1.398 TD -0.0034 Tc 0.0207 Tw [(P)111.8(.R. \(1991\). Processing of threat-related material in rape)]TJ 0 -1.401 TD -0.0037 Tc 0 Tw (victims. )Tj /TT5 1 Tf 3.39 0 TD -0.004 Tc -0.0246 Tw [(Journal of )14.4(Abnormal Psychology)53(, 100, )]TJ /TT2 1 Tf 15.411 0 TD -0.0049 Tc 0 Tw (156-162.)Tj -20.001 -1.8 TD -0.0036 Tc -0.0057 Tw (Ghahramanlou, M.A., & Brodbeck, C. \(2000\). Predictors of)Tj 1.2 -1.401 TD -0.0033 Tc 0.0825 Tw (secondary trauma in sexual assault counselors. )Tj /TT5 1 Tf 19.254 0 TD -0.0044 Tc 0 Tw (Interna-)Tj -19.254 -1.398 TD -0.0036 Tc 0.0021 Tw (tional Journal of Emergency Mental Health, 1, )Tj /TT2 1 Tf 18.876 0 TD -0.0049 Tc 0 Tw (229-240.)Tj -20.076 -1.8 TD -0.0031 Tc 0.0481 Tw (Jenkins, S., & Baird, S. \(2002\). Secondary traumatic stress)Tj 1.2 -1.401 TD -0.0042 Tc -0.0624 Tw [(and vicarious trauma: )52.9(A)58( validation study)58.8(.)-7.7( )]TJ /TT5 1 Tf 16.089 0 TD -0.0056 Tc -0.062 Tw [(Journal of T)48.4(rau-)]TJ -16.089 -1.401 TD -0.008 Tc -0.0617 Tw (matic Stress, 15, )Tj /TT2 1 Tf 6.534 0 TD -0.0096 Tc 0 Tw (423-432.)Tj -7.734 -1.8 TD -0.0037 Tc 0.0028 Tw [(Kassai, S.C., & Motta, R.W)86.3(. \(2006\). )50.3(An investigation of the)]TJ 1.2 -1.398 TD -0.0035 Tc 0.045 Tw (spread of potential Holocaust-related secondary trauma-)Tj 0 -1.401 TD -0.0032 Tc 0.06 Tw (tization to the third generation. )Tj /TT5 1 Tf 12.801 0 TD -0.004 Tc 0.0625 Tw (International Journal of)Tj -12.801 -1.401 TD -0.0053 Tc 0 Tw (Emergency)Tj /TT2 1 Tf 4.455 0 TD 0 Tc ( )Tj /TT5 1 Tf 0.201 0 TD -0.0039 Tc -0.055 Tw (Mental Health, 8)Tj /TT2 1 Tf 6.633 0 TD -0.0033 Tc (\(1\), 35-47.)Tj -12.489 -1.8 TD -0.0032 Tc -0.0479 Tw (Kellerman, N. \(2001\). 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Unpub-)Tj -18.981 -1.401 TD 0.0591 Tc 0.1813 Tw [(lished doctoral dissertation, Hofstra University)59.1(,)]TJ T* -0.0097 Tc -0.0625 Tw [(Hempstead, New )32.3(Y)100.5(ork.)]TJ -1.2 -1.8 TD -0.0032 Tc -0.0186 Tw [(L)58.6(yons, J.A. \(1987\). Posttraumatic stress disorder in children)]TJ 1.2 -1.398 TD -0.0034 Tc 0.0059 Tw [(and adolescents: )50.8(A)58.8( review of the literature. )]TJ /TT5 1 Tf 17.22 0 TD -0.0051 Tc 0 Tw (Developmen-)Tj -17.22 -1.401 TD -0.0035 Tc (tal and Behavioral Pediatrics, 8,)Tj /TT2 1 Tf 12.996 0 TD -0.0037 Tc 0.0044 Tw ( 349-356.)Tj -14.196 -1.8 TD -0.0156 Tc -0.062 Tw [(McCann, I.L., & Pearlman, L.A. \(1990\). )14.5(V)61.6(i)0.3(carious traumatiza-)]TJ 1.2 -1.401 TD -0.0036 Tc 0.1243 Tw [(tion: )51(A)58.6( framework for understanding the psychological)]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 9927 >> 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 0.0792 Tw [(298 )]TJ /TT3 1 Tf 2.715 0 TD -0.0055 Tc 0.0813 Tw [( Motta Secondary Trauma)]TJ /TT2 1 Tf 10 0 0 10 66 722.64 Tm 0.0017 Tc 0.1253 Tw [(ef)16.7(fects of working with victims. )]TJ /TT5 1 Tf 13.725 0 TD 0.0011 Tc 0.1254 Tw [(Journal of T)52.1(raumatic)]TJ -13.725 -1.398 TD -0.0158 Tc -0.0625 Tw (Stress, 3, )Tj /TT2 1 Tf 3.594 0 TD -0.0181 Tc 0 Tw (131-150.)Tj -4.794 -1.8 TD -0.0035 Tc -0.0568 Tw (Marshall, R.D., & Galea, S. \(2004\). 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Figley \(Ed.\). )]TJ /TT5 1 Tf 20.304 0 TD -0.0087 Tc 0 Tw (Com-)Tj -20.304 -1.401 TD -0.0039 Tc 0.0167 Tw (passion fatigue: Coping with secondary traumatic stress)Tj T* -0.0037 Tc -0.0536 Tw (disorder in those who treat the traumatized )Tj /TT2 1 Tf 17.049 0 TD -0.004 Tc 0 Tw (\(pp.209-231\).)Tj -17.049 -1.398 TD -0.0153 Tc -0.0625 Tw [(N)10(Y)89.7(: Brunner /Mazel.)]TJ -1.2 -1.8 TD -0.0033 Tc 0.0484 Tw [(Nelson, B.S., & )18(W)94.5(ampler)38.7(, K.S. \(2000\). Systemic ef)14.7(fects of)]TJ 1.2 -1.401 TD -0.0031 Tc -0.04 Tw [(trauma in clinic couples: )53.9(An exploratory study of second-)]TJ T* -0.0006 Tc 0.125 Tw (ary trauma resulting from childhood abuse. )Tj /TT5 1 Tf 18.249 0 TD -0.0014 Tc (Journal of)Tj -18.249 -1.398 TD -0.0041 Tc -0.0448 Tw [(Marital and Family Therapy)49.9(, 26)]TJ /TT2 1 Tf 12.621 0 TD -0.0038 Tc -0.05 Tw (\(2\), 171-184.)Tj -13.821 -1.8 TD -0.0125 Tc -0.0625 Tw (Pearlman, L.A. \(1996\). Psychometric review of the TSI Belief)Tj 1.2 -1.401 TD -0.0271 Tc (Scale, Revision-L. In B. Stamm \(ed.\), )Tj /TT5 1 Tf 13.959 0 TD -0.0278 Tc (Measurement of stress,)Tj -13.959 -1.401 TD -0.0044 Tc 0.065 Tw (trauma and adaptation)Tj /TT2 1 Tf 9.264 0 TD -0.0035 Tc 0.0662 Tw [( \(pp. 381-383\). 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Secondary traumatiza-)]TJ 1.2 -1.401 TD -0.0035 Tc 0.125 Tw [(tion in the children of )17.5(V)61.7(ietnam veterans with posttrau-)]TJ 0 -1.398 TD -0.0038 Tc 0.0383 Tw [(matic stress disorder)50.2(.)-5.5( )]TJ /TT5 1 Tf 8.706 0 TD -0.0043 Tc 0.04 Tw (Hospital and Community Psychia-)Tj -8.706 -1.401 TD -0.0162 Tc -0.0625 Tw [(t)5.8(r)-1.2(y)58.6(,)0( 36, )]TJ /TT2 1 Tf 2.781 0 TD -0.0199 Tc 0 Tw (538-539.)Tj -3.981 -1.8 TD -0.0035 Tc 0.0367 Tw [(Saigh, P)104.5(.A. \(1987\). 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Studies of interference in serial verbal)Tj 1.2 -1.401 TD 0 Tw (reactions. )Tj /TT5 1 Tf 4.101 0 TD -0.0039 Tc 0.0302 Tw [(Journal of Experimental Psychology)50.1(, 18,)]TJ /TT2 1 Tf 16.305 0 TD -0.0048 Tc 0.03 Tw [( 643-)]TJ -20.406 -1.398 TD -0.0583 Tc 0 Tw (661.)Tj -1.2 -1.8 TD -0.0037 Tc 0.013 Tw [(Suozzi, J., & Motta, R.W)86.3(. \(2004\). )17.2(The relationship between)]TJ 1.2 -1.401 TD -0.0034 Tc 0.1021 Tw [(combat exposure and the transfer of trauma-like symp-)]TJ T* -0.0072 Tc -0.0609 Tw [(toms to of)16.8(fspring of veterans. )]TJ /TT5 1 Tf 11.514 0 TD -0.0082 Tc -0.0588 Tw [(T)56(raumatology)48.8(, 10)]TJ /TT2 1 Tf 6.876 0 TD -0.0074 Tc -0.065 Tw (\(1\), 17-37.)Tj -19.59 -1.8 TD -0.0035 Tc -0.0224 Tw [(W)94.3(aysman, M., Mikulinger)35.5(, M., Solomon, Z., & )18(W)97.3(eisenber)14.5(g,)]TJ 1.2 -1.398 TD -0.0137 Tc -0.0621 Tw (M. \(1993\). Secondary traumatization among wives of post-)Tj 0 -1.401 TD -0.003 Tc -0.0358 Tw [(traumatic combat veterans: )51(A)59.2( family topology)60(. )]TJ /TT5 1 Tf 18.441 0 TD -0.0044 Tc -0.04 Tw (Journal of)Tj -18.441 -1.401 TD -0.004 Tc -0.0607 Tw [(Family Psychology)56(, 7, )]TJ /TT2 1 Tf 8.865 0 TD -0.0066 Tc 0 Tw [(104-1)26.4(18.)]TJ /TT5 1 Tf 9 0 0 9 345.75 87.99 Tm -0.0049 Tc -0.0037 Tw (Manuscript submitted and accepted September 24, 2008)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 5656 >> 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. 4 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (299)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. 4, pp. 299-308 2008 Chevron Publishing ISSN 1522-4821)]TJ /TT4 1 Tf 10 0 0 10 104.01 510.36 Tm -0.0004 Tc 0 Tw (Abstract: )Tj /TT5 1 Tf 4.155 0 TD 0.0008 Tc 0.125 Tw (Despite new frontiers in suicide research over the past ten years, police suicide remains a)Tj -4.155 -1.302 TD 0.0078 Tc [(difficult, persistent, and controversial problem. Controversy appears to focus on the accuracy and)]TJ 0 -1.299 TD -0.0033 Tc 0.0389 Tw (validity of police suicide rates, but other controversies exist as well. This is likely due to studies that are)Tj T* -0.0035 Tc 0.0132 Tw [(methodologically flawed, incomplete, or specific to limited geographic areas. The objective of this paper)]TJ 0 -1.302 TD 0.1137 Tw [(is to review issues related to both conflicts and consensus on police suicide. [International Journal of)]TJ 0 -1.299 TD 0.0892 Tw (Emergency Mental Health, 2008, 10\(4\), pp. 299-308].)Tj /TT1 1 Tf 9 0 0 9 214.74 411 Tm -0.0055 Tc -0.0389 Tw (Key words: )Tj /TT5 1 Tf 5.0333 0 TD -0.0048 Tc -0.0411 Tw (police suicide, occupational suicide, suicide rates)Tj ET /GS1 gs 66.99 124.755 m 300 124.755 l S BT /TT2 1 Tf 9 0 0 9 66.99 107.01 Tm /GS2 gs 0.0803 Tw [(John M. )11.8(V)60.6(iolanti is a research professor in the School of Public)]TJ 0 -1.2233 TD -0.0053 Tc 0.0173 Tw (Health & Health Professions, Department of Social & Preventive)Tj T* -0.0051 Tc -0.0451 Tw [(Medicine, S)11.6(tate University of NY)31.6( at Buf)11.6(falo, NY)121.6(. Correspondence)]TJ 0 -1.22 TD -0.0166 Tw (regarding this article should be directed to violanti@buffalo.edu)Tj /F1 1 Tf 14 0 0 14 142.41 628.86 Tm 0.0037 Tc 0.1378 Tw [(P)38.6(olice Suicide Resear)14.4(c)13.3(h)4.8(:)31.6( Conflict and Consensus)]TJ 11 0 0 11 73.74 363 Tm 0.0005 Tc 0.1394 Tw (POLICE SUICIDE RESEARCH: CONFLICT)Tj 5.4927 -1.0909 TD 0.0124 Tc 0.1409 Tw (AND CONSENSUS)Tj /TT2 1 Tf 10 0 0 10 84.99 327.66 Tm -0.0036 Tc 0.0231 Tw (Considerable research has been done over the past ten)Tj -1.8 -1.401 TD -0.0032 Tc 0.1083 Tw (years on suicide in police work. Despite new frontiers in)Tj T* -0.0033 Tc 0.0592 Tw (suicide research, police suicide remains a difficult, persis-)Tj 0 -1.398 TD -0.0035 Tc -0.0481 Tw (tent, and controversial problem. The volume of literature on)Tj 0 -1.401 TD -0.0031 Tc 0.004 Tw (this topic has rendered it to closer scrutiny more than other)Tj T* 0.0742 Tw (occupational groups. The majority of controversy appears)Tj 0 -1.398 TD -0.0028 Tc -0.039 Tw (to focus on the accuracy and validity of police suicide rates,)Tj 0 -1.401 TD -0.0031 Tc 0.078 Tw (but other controversies exist as well. This is likely due to)Tj T* -0.0033 Tc -0.0607 Tw (studies that are methodologically flawed, incomplete, or not)Tj 0 -1.398 TD -0.0034 Tc 0.11 Tw [(generalizable to wide geographic areas. The goal of this)]TJ 0 -1.401 TD -0.0036 Tc 0.0605 Tw (paper is to review some of the conflicts and consensus on)Tj T* -0.0034 Tc -0.025 Tw [(police suicide research. It should be noted that the problem)]TJ 0 -1.398 TD -0.0029 Tc 0.0794 Tw (of suicide rate inconsistency does not only exist in police)Tj 0 -1.401 TD -0.0035 Tc 0.0042 Tw (work, but also in the general population.)Tj 12 0 0 12 275.4 593.64 Tm -0.0279 Tc -0.0611 Tw [(John M. )11.4(V)66.8(iolanti)]TJ 10 0 0 10 207.51 581.01 Tm -0.0015 Tc -0.0624 Tw [(S)26.7(tate University of New )28.6(Y)105.7(ork at Buf)19.5(falo, Buf)16.5(falo, NY)]TJ /F1 1 Tf 11 0 0 11 321 362.01 Tm 0.004 Tc 0 Tw (Conflict)Tj /TT2 1 Tf 10 0 0 10 339 338.64 Tm -0.0039 Tc 0.0452 Tw [(Kappeler)35.1(, Blumber)17.1(g, and Potter \(1993\) ar)17.1(gued that the)]TJ -1.8 -1.398 TD -0.0044 Tc -0.0622 Tw (connection between police stress and suicide is a myth which)Tj 0 -1.401 TD -0.0038 Tc 0.0886 Tw (perpetuates public perception of battered and blue crime-)Tj T* -0.0012 Tc 0.125 Tw (fighters. Other researchers have attributed police suicide)Tj 0 -1.398 TD -0.0034 Tc -0.0455 Tw (more to the facts that \(1\) the police occupation is male domi-)Tj 0 -1.401 TD -0.0394 Tw (nated and statistically males commit suicide more often than)Tj T* -0.0188 Tc -0.0622 Tw (females, and \(2\) officers have a readily available, lethal method)Tj 0 -1.398 TD -0.005 Tc -0.0625 Tw (with which to commit suicide \(Alpert and Dunham, 1988\).)Tj 1.8 -2.001 TD -0.0038 Tc 0.0491 Tw (Aamodt and Stalnaker \(2001\) suggested that, although)Tj -1.8 -1.401 TD -0.0036 Tc -0.0449 Tw [(the suicide rate of 18.1/100,000 for law enforcement person-)]TJ 0 -1.398 TD -0.0034 Tc -0.0528 Tw (nel is higher than the 11.4/100,000 in the general population,)Tj 0 -1.401 TD -0.0055 Tw (it is not higher than would be expected for people of similar)Tj T* -0.0033 Tc 0.0232 Tw [(age, race, and gender)50.7(. )17.6(Thus any dif)14.7(ference between law en-)]TJ 0 -1.398 TD -0.0035 Tc 0.0917 Tw (forcement rates and rates in the general population can be)Tj 0 -1.401 TD -0.0029 Tc 0.0005 Tw [(adequately explained by the race, gender)39.1(, and age of people)]TJ T* -0.0035 Tc 0.1005 Tw (who enter the law enforcement field. This is an important)Tj 0 -1.398 TD -0.0022 Tc 0.125 Tw (point because it suggests that speculation about such fac-)Tj 0 -1.401 TD 0.0021 Tc [(tors as job stress and the availability of weapons are not)]TJ T* -0.0034 Tc -0.025 Tw (factors that are exclusively associated with law enforcement)Tj ET endstream endobj 255 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 257 0 obj << /Length 10534 >> 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 -0.009 Tc 0 Tw (300)Tj /TT3 1 Tf 1.65 0 TD -0.0049 Tc 0.0453 Tw [( Violanti )]TJ /F1 1 Tf 4.5188 0 TD -0.008 Tc 0 Tw ( )Tj /TT3 1 Tf 0.6637 0 TD -0.0057 Tc 0.0458 Tw (Issues in Police Suicide)Tj /TT2 1 Tf 10 0 0 10 54 722.64 Tm -0.0035 Tc 0.0137 Tw [(suicide. The authors conclude that allocating mental health)]TJ 0 -1.398 TD -0.0033 Tc 0.125 Tw (resources to law enforcement personnel at the expense of)Tj 0 -1.401 TD -0.0035 Tc -0.0315 Tw (other professions does not appear justified. Furthermore, the)Tj T* 0.055 Tw (reasons that officers commit suicide are similar to those of)Tj 0 -1.398 TD 0.0656 Tw (the general population with the possible exception of legal)Tj 0 -1.401 TD -0.009 Tc 0 Tw (problems.)Tj 1.8 -2.001 TD -0.0035 Tc -0.0078 Tw (Hem, Berg, and Ekeberg \(2002\) published a systematic)Tj -1.8 -1.398 TD -0.0033 Tc 0.0532 Tw (critical review of suicide among police. They identified 41)Tj 0 -1.401 TD -0.0037 Tc -0.0121 Tw [(original studies from North )53.3(America, Europe, and )50.3(Australia.)]TJ T* -0.0036 Tc 0.0656 Tw (The results indicated that some studies found elevated sui-)Tj 0 -1.398 TD 0.0381 Tw (cide rates among police officers; others showed an average)Tj 0 -1.401 TD -0.0032 Tc -0.001 Tw [(or low rate of suicide. However)35.8(, the rates varied widely and)]TJ T* -0.0037 Tc 0.02 Tw (were inconsistent and inconclusive. Most studies were con-)Tj 0 -1.398 TD -0.0062 Tc -0.0625 Tw (ducted in limited specific police populations, where local and)Tj 0 -1.401 TD -0.0033 Tc 0.0855 Tw (regional variations in suicide can affect the rates of police)Tj T* -0.0586 Tw [(suicide. Moreover)35.7(, the reason for studying police suicide in a)]TJ 0 -1.398 TD -0.0031 Tc -0.0025 Tw [(specific region may be due to a suicide cluster)50.9(.)]TJ 1.8 -2.001 TD -0.0034 Tc -0.015 Tw (Loo \(2003\) conducted a meta-analysis of police suicide)Tj -1.8 -1.401 TD -0.0035 Tc -0.0155 Tw (rates and ratios using 101 samples from the literature. Large)Tj 0 -1.398 TD 0.1222 Tw (effect sizes showed that suicide rates based on short time)Tj 0 -1.401 TD -0.0033 Tc 0.0325 Tw (frames were significantly higher than for long time frames.)Tj T* -0.0036 Tc -0.0403 Tw [(There were regional dif)17.4(ferences such that rates in the )50.7(Ameri-)]TJ 0 -1.398 TD -0.0038 Tc -0.0248 Tw [(cas and Europe were higher than in the Caribbean and )50.4(Asian)]TJ 0 -1.401 TD -0.0034 Tc -0.0175 Tw (regions. There were differences in rates between federal, re-)Tj T* -0.0035 Tc 0.0444 Tw (gional, and municipal police forces. Loo concludes that re-)Tj 0 -1.398 TD -0.0525 Tw (searchers need to include the use of longer time frames when)Tj 0 -1.401 TD -0.003 Tc 0.0089 Tw (studying police suicide and include controls for year of sui-)Tj T* -0.0035 Tc 0.1006 Tw [(cide, gender)35.5(, ethnic groups, and rates for population com-)]TJ 0 -1.398 TD 0.0006 Tc 0.125 Tw (parison groups.)Tj 1.8 -2.001 TD -0.0037 Tc 0.0722 Tw [(Marzuk, Nock, Leon, Portera, and )17.4(T)70.1(ardif)17.3(f \(2002\) con-)]TJ -1.8 -1.401 TD -0.0206 Tc -0.0624 Tw [(ducted a study on New )33.5(Y)107.6(ork City police of)18.4(ficer suicide. Marzuk)]TJ 0 -1.398 TD -0.0037 Tc -0.0581 Tw [(and colleagues concluded that the suicide rates for New )32.5(Y)103.5(ork)]TJ 0 -1.401 TD -0.0077 Tc -0.0623 Tw [(City police of)19.3(ficers were below that of the adjusted New )31.5(Y)105.5(ork)]TJ T* -0.0038 Tc 0.1125 Tw [(population. )50.2(Among the 668 deaths of police of)17.2(ficers from)]TJ 0 -1.398 TD -0.0271 Tc -0.0617 Tw (1977 to 1996, 80)Tj 5.8 0 0 5.8 115.59 231.99 Tm 0 Tc 0 Tw ( )Tj 10 0 0 10 116.55 228.66 Tm -0.0268 Tc -0.0621 Tw (were certified suicides \(mean age = 33.5 years\).)Tj -6.255 -1.401 TD -0.0036 Tc 0.0211 Tw (Firearms were used in 93.8% of these suicides; other meth-)Tj T* -0.0042 Tc -0.005 Tw (ods included)Tj 5.8 0 0 5.8 104.31 204 Tm 0 Tc 0 Tw ( )Tj 10 0 0 10 105.69 200.64 Tm -0.0038 Tc -0.01 Tw (hanging, carbon monoxide poisoning, and fall-)Tj -5.169 -1.398 TD -0.0239 Tc 0 Tw (ing)Tj 5.8 0 0 5.8 66.15 189.99 Tm 0 Tc ( )Tj 10 0 0 10 67.14 186.66 Tm -0.0209 Tc -0.0625 Tw (from a height.)Tj 5.8 0 0 5.8 119.4 189.99 Tm 0 Tc 0 Tw ( )Tj 10 0 0 10 120.39 186.66 Tm -0.021 Tc -0.0625 Tw (The overall suicide rate among police officers)Tj -6.639 -1.401 TD -0.0073 Tc -0.06 Tw (during the period)Tj 5.8 0 0 5.8 120.45 176.01 Tm 0 Tc 0 Tw ( )Tj 10 0 0 10 121.5 172.65 Tm -0.007 Tc -0.0625 Tw (was 14.9 per 100,000 person-years \(95% )Tj /TT5 1 Tf 15.966 0 TD -0.016 Tc 0 Tw (CI)Tj /TT2 1 Tf -22.716 -1.401 TD -0.0035 Tc 0.06 Tw (= 11.918.6\),)Tj 5.8 0 0 5.8 108.15 162 Tm 0 Tc 0 Tw ( )Tj 10 0 0 10 110.01 158.64 Tm -0.0037 Tc 0.0638 Tw (compared with the demographically adjusted)Tj -5.601 -1.398 TD -0.0202 Tc -0.06 Tw (suicide rate for)Tj 5.8 0 0 5.8 109.59 147.99 Tm 0 Tc 0 Tw ( )Tj 10 0 0 10 110.55 144.66 Tm -0.0203 Tc -0.0621 Tw [(the New )30.7(Y)101.9(ork City population \(18.3 per 100,000)]TJ -5.655 -1.401 TD -0.0028 Tc 0 Tw (person-years,)Tj 5.8 0 0 5.8 107.25 134.01 Tm 0 Tc ( )Tj 10 0 0 10 108.75 130.65 Tm -0.0063 Tc (95% )Tj /TT5 1 Tf 2.079 0 TD -0.0055 Tc (CI )Tj /TT2 1 Tf 1.257 0 TD -0.0033 Tc 0.015 Tw (= 18.018.6\). The suicide rate for the)Tj -8.811 -1.401 TD -0.0043 Tc 0 Tw (upper end)Tj 5.8 0 0 5.8 93.36 120 Tm 0 Tc ( )Tj 10 0 0 10 94.86 116.64 Tm -0.0034 Tc 0.005 Tw (of the range, which included the 80 police officer)Tj -4.086 -1.398 TD -0.0047 Tc 0 Tw (suicides)Tj 5.8 0 0 5.8 85.89 105.99 Tm 0 Tc ( )Tj 10 0 0 10 87.69 102.66 Tm -0.0031 Tc 0.065 Tw (plus 22 additional deaths by methods usually seen)Tj -3.369 -1.401 TD -0.0212 Tc -0.06 Tw (in suicides,)Tj 5.8 0 0 5.8 95.91 92.01 Tm 0 Tc 0 Tw ( )Tj 10 0 0 10 96.9 88.65 Tm -0.0211 Tc -0.0625 Tw (was 19.0 per 100,000 person-years \(95% )Tj /TT5 1 Tf 15.414 0 TD -0.031 Tc 0 Tw (CI)Tj /TT2 1 Tf 0.957 0 TD -0.0214 Tc -0.0625 Tw [( = 15.5)]TJ -20.661 -1.401 TD -0.0046 Tc 0 Tw (23.1\).)Tj 5.8 0 0 5.8 77.1 78 Tm 0 Tc ( )Tj 10 0 0 10 78.21 74.64 Tm -0.0052 Tc -0.0625 Tw [( Marzuk and colleagues \(2002\) added that although the)]TJ 23.079 64.8 TD -0.0035 Tc -0.0384 Tw (annual suicide rates varied,)Tj 5.8 0 0 5.8 415.74 726 Tm 0 Tc 0 Tw ( )Tj 10 0 0 10 416.94 722.64 Tm -0.0035 Tc -0.04 Tw (there were no evident trends. For)Tj -10.794 -1.398 TD -0.003 Tc 0.0541 Tw (17 of the 20 years examined, the)Tj 5.8 0 0 5.8 441.54 711.99 Tm 0 Tc 0 Tw ( )Tj 10 0 0 10 443.34 708.66 Tm -0.0034 Tc 0.055 Tw (police officer suicide rate)Tj -13.434 -1.401 TD -0.0035 Tc -0.013 Tw (remained below that of the demographically)Tj 5.8 0 0 5.8 483.81 698.01 Tm 0 Tc 0 Tw ( )Tj 10 0 0 10 485.19 694.65 Tm -0.0035 Tc -0.015 Tw (adjusted rate of)Tj -17.619 -1.401 TD -0.04 Tw [(the New )32.5(Y)103.7(ork City population)]TJ 1.8 -1.998 TD -0.0068 Tc -0.0622 Tw (Earlier studies have also found a police suicide rate simi-)Tj -1.8 -1.401 TD -0.0034 Tc -0.0232 Tw [(lar to or lower than the general population. Dash and Reiser)]TJ T* -0.0037 Tc 0.0816 Tw [(\(1978\) found Los )53.2(Angeles police of)14.3(ficers to have a seven-)]TJ 0 -1.398 TD -0.0032 Tc -0.0361 Tw (year average suicide rate of 8.1/100,000 compared to a 12.6/)Tj 0 -1.401 TD -0.0026 Tc -0.0547 Tw [(100,00 rate nationally)60.4(. )51.7(A)59.6( twelve-year follow-up study by Jo-)]TJ T* -0.0038 Tc -0.0122 Tw (sephson and Reiser \(1990\) of the same department found an)Tj 0 -1.398 TD -0.0084 Tc -0.0625 Tw (average suicide rate of 12/100,000 among police compared to)Tj 0 -1.401 TD -0.0057 Tc [(13.4 /100,000 in Los )54.3(Angeles and 14.8/100,000 in the state of)]TJ T* -0.0037 Tc 0.0672 Tw [(California. )53.4(Although police suicides were lower than other)]TJ 0 -1.398 TD -0.0035 Tc -0.0206 Tw (geographic rates, these authors also found that the incidence)Tj 0 -1.401 TD -0.0038 Tc 0.0658 Tw [(of suicide in the Los )53.4(Angeles Police Department increased)]TJ T* -0.025 Tc -0.0621 Tw (from 8.1/100,000 in 1976 to 12/100,000 in 1988.)Tj 1.8 -1.998 TD -0.0038 Tc -0.0625 Tw (Stack and Kelley \(1994\) completed an analysis of police)Tj -1.8 -1.401 TD -0.0146 Tc [(suicide data from the 1985 National Mortality Detail File. Sta-)]TJ T* -0.0031 Tc -0.0043 Tw [(tistically controlling for age, gender)38.9(, and race, these authors)]TJ 0 -1.398 TD -0.0035 Tc 0.0143 Tw (found the police suicide proportional mortality ratio \(PMR\))Tj 0 -1.401 TD -0.0031 Tc 0.0054 Tw (rate to exceed the rate of matched controls by 8%. This rate)Tj T* -0.0034 Tc -0.0505 Tw (was not significantly higher than the rate among white males)Tj 0 -1.398 TD -0.0036 Tc 0.0234 Tw (in the general population.)Tj 1.8 -2.001 TD -0.0038 Tc 0.0157 Tw [(Burnett, Boxer)35.2(, and Swanson \(1992\) conducted a case-)]TJ -1.8 -1.401 TD -0.0031 Tc -0.0478 Tw [(control study on suicide death certificate data from 26 states.)]TJ 0 -1.398 TD -0.0035 Tc 0.0743 Tw (After adjusting for age, marital, and socioeconomic status,)Tj 0 -1.401 TD -0.0032 Tc 0.012 Tw [(they found that police officers did have an increased risk of)]TJ T* -0.001 Tc 0.125 Tw (suicide \(1.3 fold risk\) over population controls, but not a)Tj 0 -1.398 TD -0.0137 Tc -0.0625 Tw (higher risk than some other professions. Examples were: phar-)Tj 0 -1.401 TD -0.0072 Tc -0.0622 Tw (macists \(3.3 fold risk\), physicians \(2.8 fold risk\), lawyers \(2.1)Tj T* -0.0032 Tc -0.045 Tw (fold risk\) and dentists \(1.8 fold risk\).)Tj /F1 1 Tf 11 0 0 11 309 252 Tm -0.0005 Tc 0 Tw (Consensus)Tj /TT2 1 Tf 10 0 0 10 327 228.66 Tm -0.0036 Tc -0.0472 Tw (One would expect that the police suicide rates should be)Tj -1.8 -1.401 TD -0.0049 Tc -0.0625 Tw [(lower than they are, given that they are an employed, healthy)58.1(,)]TJ T* -0.0028 Tc 0.0219 Tw (and psychologically tested group, and fall into the category)Tj 0 -1.398 TD -0.0033 Tc -0.0088 Tw [(of a healthy worker group \(McMichael, 1976\). Certainly)59.7(,)]TJ 0 -1.401 TD -0.0422 Tw (they should be lower than the U.S. general population, given)Tj T* -0.0035 Tc -0.0193 Tw (that this reference group includes the institutionalized, men-)Tj 0 -1.398 TD -0.0617 Tw (tally ill, and unemployed.)Tj 1.8 -2.001 TD -0.0067 Tc -0.062 Tw (Substantial epidemiological evidence suggests that there)Tj -1.8 -1.401 TD -0.0034 Tc 0.125 Tw [(is an elevated rate of suicide within law enforcement. )50.6(A)9.8(n)]TJ 0 -1.398 TD -0.003 Tc -0.0528 Tw (early national occupational study by Guralnick \(1963\) found)Tj 0 -1.401 TD -0.0032 Tc 0.0908 Tw (the suicide ratio of male police to be 1.8 times that of the)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 9354 >> 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. 4 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (301)Tj /TT2 1 Tf 10 0 0 10 66 722.64 Tm -0.0038 Tc 0.0467 Tw (Caucasian male general population. Suicides accounted for)Tj 0 -1.398 TD -0.0035 Tc -0.0482 Tw (13.8% of police deaths compared to 3% of deaths in all other)Tj 0 -1.401 TD -0.0024 Tc 0.125 Tw (occupations, and more officers died as a result of suicide)Tj T* -0.004 Tc -0.0479 Tw [(than homicide. Milham \(1979\) found )17(W)93.8(ashington S)17(tate male)]TJ 0 -1.398 TD -0.014 Tc -0.0623 Tw (police officers from 1950-1971 to have a suicide mortality rate)Tj 0 -1.401 TD -0.0034 Tc 0.0638 Tw (higher than normally expected in the general male popula-)Tj T* -0.0014 Tc 0 Tw (tion.)Tj 1.8 -1.998 TD -0.0036 Tc -0.0535 Tw [(V)112.6(ena, )17.5(V)64.6(iolanti, Marshall, and Fiedler \(1986\) found male)]TJ -1.8 -1.401 TD -0.0032 Tc -0.0444 Tw (officers to have an age-adjusted mortality ratio for suicide of)Tj T* -0.0034 Tc -0.0394 Tw (approximately three times that of male municipal workers in)Tj 0 -1.398 TD -0.0098 Tc -0.0623 Tw (the same cohort. Lester \(1992\) found that 7 of 26 countries for)Tj 0 -1.401 TD -0.0036 Tc 0.0306 Tw (the decade of 1980-1989 had police suicide rates above the)Tj T* -0.003 Tc 0.069 Tw [(general population. )51.1(A)59.2( mortality study of police of)18(ficers in)]TJ 0 -1.398 TD -0.0033 Tc -0.0417 Tw (Rome, Italy found the suicide ratio among male police offic-)Tj 0 -1.401 TD -0.0284 Tw (ers to be 1.97 times as high as the general male Italian popu-)Tj T* 0.0112 Tw [(lation \(Forastiere et al., 1994\). )14.7(V)64.9(iolanti, )14.7(V)115.9(ena, and Marshall)]TJ 0 -1.398 TD -0.0096 Tc -0.0623 Tw (\(1996\) found that male police officers had a suicide rate of 8.3)Tj 0 -1.401 TD -0.0035 Tc -0.0034 Tw (times that of homicide and 3.1 times that of work accidents.)Tj T* -0.0038 Tc 0.0515 Tw (Compared to male municipal workers, male police officers)Tj 0 -1.398 TD -0.0034 Tc 0.0215 Tw (had a 53% increased rate of suicide over homicide, a three-)Tj 0 -1.401 TD -0.0032 Tc 0.0955 Tw (fold rate of suicide over accidents, and a 2.65-fold rate of)Tj T* -0.0038 Tc 0.011 Tw (suicide over homicide and accidents combined.)Tj 1.8 -1.998 TD -0.0036 Tc 0.035 Tw (Darragh \(1991\) conducted an epidemiological analysis)Tj -1.8 -1.401 TD 0.0793 Tw (on factors based on 558 consecutive cases of self-inflicted)Tj T* -0.0156 Tw (death in the United Kingdom, which revealed a dramatic in-)Tj 0 -1.398 TD -0.0074 Tc -0.0625 Tw [(crease in suicide among security force personnel. Helmkamp)]TJ 0 -1.401 TD -0.0035 Tc 0.0108 Tw [(\(1996\), in a study of suicide among males in the US )53.8(Armed)]TJ T* -0.0032 Tc -0.0622 Tw (Forces, found military security and law enforcement special-)Tj 0 -1.398 TD -0.0033 Tc -0.0461 Tw (ists had a significant increased rate ratio for suicide. Hartwig)Tj 0 -1.401 TD -0.0032 Tc 0.0006 Tw [(and )17.9(V)62(iolanti \(1999\) found that the frequency of police sui-)]TJ T* -0.0034 Tc -0.0165 Tw [(cide occurrence in )14.5(W)97.4(estphalia, Germany)59.6(, has increased over)]TJ 0 -1.398 TD -0.0076 Tc -0.0625 Tw (the past seven years, particularly in the 21-30 and 51-60 years)Tj 0 -1.401 TD -0.0035 Tc 0.0512 Tw (of age categories. Most suicides were male officers \(92%\).)Tj T* -0.0033 Tc -0.0414 Tw [(Cantor)35.7(, )14.8(T)73.5(yman, and Slatter \(1999\) found the high rate of sui-)]TJ 0 -1.398 TD -0.0035 Tc 0.1021 Tw [(cide among )50.5(Australian police attributable to stress, health,)]TJ 0 -1.401 TD -0.0038 Tc -0.045 Tw (and domestic difficulties. Occupational problems were more)Tj T* -0.0037 Tc 0.115 Tw [(intense than personal ones.)]TJ 1.8 -1.998 TD -0.0167 Tc -0.0625 Tw (Charbonneau \(2000\), in a study in Quebec, Canada, found)Tj -1.8 -1.401 TD -0.0033 Tc 0.118 Tw (police suicide rates to be almost twice that of the general)Tj T* -0.0078 Tw (population. Rates were elevated mostly among young offic-)Tj 0 -1.398 TD -0.0152 Tc -0.0622 Tw [(ers \(20-39 years of age\). Gershon, Lin, and Li \(2002\) provided)]TJ 0 -1.401 TD -0.0037 Tc -0.015 Tw (recent evidence of job-related problems among police offic-)Tj T* -0.0034 Tc -0.04 Tw [(ers related to suicide. Officers had an approximate four-fold)]TJ 0 -1.398 TD -0.0035 Tc -0.0225 Tw (risk of being exposed to traumatic work events, a 3-fold risk)Tj 0 -1.401 TD -0.0064 Tc -0.0622 Tw (of exhibiting PTSD symptoms, a 4-fold risk of alcohol abuse,)Tj T* -0.0036 Tc -0.0066 Tw [(and a 4-fold risk of aggressive behavior)50.4(.)]TJ 27.3 64.8 TD 0.0185 Tw (Other factors associated with increased rates of suicide)Tj -1.8 -1.398 TD -0.0039 Tc -0.0481 Tw (have been examined in police work. Rothmann and Strijdom)Tj 0 -1.401 TD -0.0036 Tc 0.0305 Tw [(\(2002\) found suicide ideation in South )53.3(African Police to be)]TJ T* -0.0481 Tw [(associated with a sense of incoherence. Officers were unable)]TJ 0 -1.398 TD -0.0037 Tc -0.0193 Tw (to perceive traumatic police work exposures as manageable.)Tj 0 -1.401 TD -0.0028 Tc -0.053 Tw [(They did not feel that they had the resources available, either)]TJ T* -0.0034 Tc -0.0586 Tw [(personally or or)14.6(ganizationally)62.6(, to meet the demands imposed)]TJ 0 -1.398 TD -0.0111 Tc -0.0622 Tw [(upon them by their difficult work. Berg, Hem, Lau, Loeb, and)]TJ 0 -1.401 TD -0.0054 Tc (Ekeberg \(2003\) in a nationwide study on suicide ideation and)Tj T* -0.0038 Tc -0.0413 Tw (attempts among 3272 Norwegian police, found that 24% felt)Tj 0 -1.398 TD -0.0032 Tc -0.0511 Tw (that life was not worth living, 6.4% seriously considered sui-)Tj 0 -1.401 TD -0.0035 Tc 0.0475 Tw [(cide, and 0.7% attempted suicide. Serious suicide ideation)]TJ T* -0.0245 Tc -0.062 Tw [(was mainly attributed to personal and family problems. )20.7(V)61.7(iolanti)]TJ 0 -1.398 TD -0.0037 Tc 0.095 Tw (\(2004\) found that certain traumatic police work exposures)Tj 0 -1.401 TD -0.0029 Tc 0.125 Tw (increased the risk of having a high level of posttraumatic)Tj T* -0.0034 Tc 0.1058 Tw (stress disorder \(PTSD\) symptoms, which subsequently in-)Tj 0 -1.398 TD 0.0035 Tc 0.125 Tw (creased the risk of alcohol use and suicide ideation. The)Tj 0 -1.401 TD -0.0037 Tc -0.047 Tw (combined impact of PTSD and increased alcohol use led to a)Tj T* -0.0035 Tc -0.004 Tw [(ten-fold increased risk of suicide )6.1(ideation.)]TJ 1.8 -1.998 TD -0.0037 Tc -0.0207 Tw (Depression associated with work stress and suicide ide-)Tj -1.8 -1.401 TD -0.0033 Tc 0.0775 Tw (ation may also be possible precipitants of increased police)Tj T* -0.0062 Tc -0.0621 Tw [(suicide risk. )17.9(V)62(iolanti and colleagues \(2008\) examined the as-)]TJ 0 -1.398 TD -0.0036 Tc -0.0609 Tw (sociation between depressive symptoms and suicide ideation)Tj 0 -1.401 TD -0.0034 Tc -0.028 Tw [(in a sample of police officers. Prevalence of depression was)]TJ T* -0.0037 Tc 0.0575 Tw (higher among women than men officers \(12.5% vs. 6.2%\).)Tj 0 -1.398 TD -0.0015 Tc 0.125 Tw (For each standard deviation increase in depression symp-)Tj 0 -1.401 TD -0.0035 Tc -0.0275 Tw (toms, the prevalence ratio \(PR\) of suicide ideation increased)Tj T* -0.0039 Tc -0.0525 Tw (73% in women officers \()Tj /TT5 1 Tf 9.645 0 TD -0.0127 Tc 0 Tw (PR)Tj /TT2 1 Tf 1.209 0 TD -0.0031 Tc -0.0537 Tw [( = 1.73, 95% )]TJ /TT5 1 Tf 5.145 0 TD -0.01 Tc 0 Tw (CI)Tj /TT2 1 Tf 0.99 0 TD -0.0033 Tc -0.0533 Tw [( = 1.32-2.27\) and)]TJ -16.989 -1.398 TD -0.0159 Tc -0.0625 Tw (67% in men officers \()Tj /TT5 1 Tf 8.139 0 TD -0.0217 Tc 0 Tw (PR)Tj /TT2 1 Tf 1.191 0 TD -0.0152 Tc -0.0625 Tw [( = 1.67, 95% )]TJ /TT5 1 Tf 4.95 0 TD -0.025 Tc 0 Tw (CI)Tj /TT2 1 Tf 0.966 0 TD -0.0155 Tc -0.0625 Tw [( = 1.21-2.30\).)]TJ /F1 1 Tf 11 0 0 11 321 291.99 Tm -0.0047 Tc 0.0136 Tw (What are the Issues?)Tj /TT2 1 Tf 10 0 0 10 339 268.65 Tm -0.0061 Tc -0.0625 Tw (Issues are complex in any investigation of suicide. There)Tj -1.8 -1.401 TD -0.0029 Tc 0.0793 Tw [(any many facets to consider)36.1(, both in a contextual and per)18.1(-)]TJ 0 -1.398 TD -0.0033 Tc 0.0618 Tw [(sonal sense. Some of the issues that lead to police suicide)]TJ 0 -1.401 TD -0.0018 Tc 0.125 Tw [(rates are discussed below)64.2(.)-0.8( )13.2(This is not meant to reflect all)]TJ T* -0.0031 Tc 0.0289 Tw (relevant issues; there are some that are not yet known.)Tj /TT5 1 Tf 11 0 0 11 321 179.34 Tm 0.0121 Tc 0.1253 Tw [(Police Suicide and the W)85.7(orkplace)]TJ /TT2 1 Tf 10 0 0 10 339 159.66 Tm -0.0037 Tc 0.0317 Tw (How does one define the term )Tj /TT5 1 Tf 12.36 0 TD -0.0038 Tc 0.035 Tw (police suicide)Tj /TT1 1 Tf 5.511 0 TD 0 Tc 0 Tw (?)Tj /TT2 1 Tf 0.495 0 TD -0.0039 Tc 0.0325 Tw [( Jenkins)]TJ -20.166 -1.401 TD -0.003 Tc 0.0206 Tw [(\(2005\) points out that most occupational injury fatality sur-)]TJ T* -0.0013 Tc 0.125 Tw (veillance systems capture only incidents that occur on an)Tj 0 -1.398 TD -0.0035 Tc 0.0473 Tw (employers premises or while a worker is engaged in work)Tj 0 -1.401 TD -0.0037 Tc 0.0068 Tw [(activities. )17.2(This does not mean, however)35.3(, that suicide among)]TJ T* -0.0033 Tc 0.0822 Tw (police officers is unrelated to their work. Suicides that are)Tj 0 -1.398 TD -0.0179 Tc -0.0624 Tw [(indeed driven by work related factors may occur at the of)18.1(ficer)-38.9()54.1(s)]TJ ET endstream endobj 261 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 264 0 obj << /Length 8740 >> 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 -0.009 Tc 0 Tw (302)Tj /TT3 1 Tf 1.65 0 TD -0.0049 Tc 0.0453 Tw [( Violanti )]TJ /F1 1 Tf 4.5188 0 TD -0.008 Tc 0 Tw ( )Tj /TT3 1 Tf 0.6637 0 TD -0.0057 Tc 0.0458 Tw (Issues in Police Suicide)Tj /TT2 1 Tf 10 0 0 10 54 722.64 Tm -0.0074 Tc -0.0622 Tw (home. If the stress that comes from police work is or becomes)Tj 0 -1.398 TD -0.0036 Tc -0.0625 Tw (negative, it may become a risk factor \(Jenkins, 2005\).)Tj 1.8 -2.001 TD 0.0059 Tc 0.1249 Tw (What are the parameters of the police workplace?)Tj -1.8 -1.401 TD -0.0079 Tc -0.0621 Tw (Johnson \(1995\) has commented that workplace violence does)Tj 0 -1.398 TD -0.0035 Tc -0.0305 Tw (not have a uniform definition and that different kinds of vio-)Tj 0 -1.401 TD -0.0015 Tc 0.125 Tw (lence require different insights and solutions. In addition,)Tj T* -0.0036 Tc -0.0169 Tw (situational and contextual cues must be considered to define)Tj 0 -1.398 TD 0.0001 Tc 0.125 Tw [(circumstances that lead to dif)15.1(ferent kinds of violence. )15.1(T)70.9(o)]TJ 0 -1.401 TD -0.009 Tc -0.0623 Tw [(clarify this important issue, )15.2(The )51.2(Association for )18.2(V)68.2(ital Records)]TJ T* -0.0048 Tc [(and Health S)22.2(tatistics \(A)124.2(VRHS\), the National Institute for Oc-)]TJ 0 -1.398 TD -0.0035 Tc 0.0021 Tw (cupational Safety and Health \(NIOSH\), the National Center)Tj 0 -1.401 TD -0.0067 Tc -0.0622 Tw (for Health Statistics \(NCHS\), and the National Center for En-)Tj T* -0.0163 Tc (vironmental Health and Injury Control \(NCEHIC\) have jointly)Tj 0 -1.398 TD -0.0027 Tc 0.125 Tw (developed classification guidelines for what is considered)Tj 0 -1.401 TD -0.0034 Tc -0.0112 Tw [(injury at work. In the category law enforcement of)17.6(ficer)35.6(,)]TJ T* -0.0024 Tc 0.0306 Tw (these guidelines specifically state that any injury or fatality)Tj 0 -1.398 TD -0.0033 Tc 0.056 Tw (occurring to a police officer eithe)Tj /TT5 1 Tf 13.521 0 TD -0.0034 Tc 0.055 Tw (r on or off)Tj /TT2 1 Tf 4.215 0 TD -0.0029 Tc 0.0575 Tw [( employer pre-)]TJ -17.736 -1.401 TD -0.0036 Tc 0.0484 Tw (mises must be considered as a workplace injury or death)Tj T* -0.0109 Tc -0.0625 Tw [(\(NIOSH, 1993, )55.1(Appendix I\). )13.1(The reasoning behind this classi-)]TJ 0 -1.398 TD -0.0032 Tc -0.005 Tw (fication guideline is not discussed by the joint committee. It)Tj 0 -1.401 TD -0.0035 Tc 0.0907 Tw [(appears, however)38.5(, that researchers view police work as an)]TJ T* 0.0025 Tc 0.125 Tw (occupation which encompasses the life of any individual)Tj 0 -1.398 TD -0.0035 Tc -0.0625 Tw [(within its ranks whether they are on or of)14.5(f duty)62.5(. Based on this)]TJ 0 -1.401 TD -0.0048 Tc -0.0622 Tw (definition, a suicide committed by a police officer away from)Tj T* 0.0021 Tc 0.125 Tw (or at the actual worksite may be considered a workplace)Tj 0 -1.398 TD -0.0032 Tc 0.0783 Tw [(death. It may be useful, however)35.8(, to examine correlates of)]TJ 0 -1.401 TD -0.0034 Tc 0.0586 Tw (police suicides which occur at the actual )Tj /TT5 1 Tf 16.68 0 TD -0.0042 Tc 0 Tw (physical )Tj /TT2 1 Tf 3.609 0 TD -0.0047 Tc (worksite)Tj -20.289 -1.401 TD -0.0032 Tc 0.0711 Tw (\(e.g. police station\) and those which occur away from that)Tj 0 -1.398 TD 0.0028 Tc 0 Tw (site.)Tj 1.8 -2.001 TD -0.0033 Tc -0.0237 Tw (The work experiences that officers encounter on a daily)Tj -1.8 -1.401 TD -0.003 Tc 0.0665 Tw (basis can certainly lead to stress, psychological anomalies,)Tj 0 -1.398 TD -0.0029 Tc 0.0145 Tw [(and family disruption. In many cases, these after-effects of)]TJ 0 -1.401 TD -0.0138 Tc -0.0622 Tw (work experience are taken home. Officers have a difficult time)Tj T* -0.0036 Tc -0.0515 Tw (switching off their work and taking on other life roles such)Tj 0 -1.398 TD 0.0761 Tw [(as spouse or parent \(V)56.4(iolanti, 1997\). For example, 68% of)]TJ 0 -1.401 TD -0.0034 Tc 0.0839 Tw (police officers who complete suicide do so away from the)Tj T* 0.017 Tc 0.125 Tw (worksite. The most common location is their residence)Tj 0 -1.398 TD -0.0031 Tc 0.0188 Tw [(\()8.1(V)56.9(iolanti, 1996\). )14.8(The majority of police departments in the)]TJ 0 -1.401 TD -0.0035 Tc 0.0519 Tw (United States provide a personal issued police service fire-)Tj T* -0.0034 Tc 0.0665 Tw [(arm for each of)17.6(ficer)50.6(. In addition, most police of)17.6(ficers will)]TJ 0 -1.398 TD -0.003 Tc -0.0044 Tw [(carry their firearms of)15(f-duty)63(, or will take them home. )18.1(Thus,)]TJ 0 -1.401 TD -0.0043 Tc -0.0622 Tw (the means to commit suicide is generally available to officers)Tj T* -0.0038 Tc -0.0617 Tw (away from the worksite.)Tj /TT5 1 Tf 11 0 0 11 309 723.36 Tm 0.0091 Tc 0.125 Tw (Collecting Data on Police Suicide)Tj /TT2 1 Tf 10 0 0 10 327 703.65 Tm -0.0037 Tc -0.0365 Tw (Obtaining information on suicide from police sources is)Tj -1.8 -1.401 TD -0.003 Tc 0.0581 Tw (difficult. Suicide is not openly discussed by police person-)Tj 0 -1.398 TD -0.0034 Tc 0.041 Tw (nel; officers tend to view suicide as dishonorable to the of-)Tj 0 -1.401 TD 0.017 Tc 0.1249 Tw [(ficer and profession \(V)56(iolanti, )19.9(V)112.2(ena, & Petralia, 1998\).)]TJ T* -0.0034 Tc -0.0206 Tw (Departmental statistics on police suicide are rare, and police)Tj 0 -1.398 TD -0.0036 Tc -0.0464 Tw (agencies are sometimes reluctant to allow researchers access)Tj 0 -1.401 TD -0.0095 Tw (to existing data. Heiman \(1977\) attempted to collect data on)Tj T* -0.0101 Tc -0.0625 Tw (police suicide from 23 major U.S. cities and met with discour-)Tj 0 -1.398 TD -0.0036 Tc -0.0275 Tw (aging results. Even the Federal Bureau of Investigation Uni-)Tj 0 -1.401 TD -0.0038 Tc -0.0388 Tw (form Crime Report \(UCR\) does not provide such data.)Tj 1.8 -2.001 TD -0.0128 Tw (Another problem which muddles police suicide rate ac-)Tj -1.8 -1.398 TD -0.0028 Tc 0.002 Tw (curacy is the difficulty in gathering data on a national level.)Tj 0 -1.401 TD -0.0038 Tc -0.0444 Tw (Countries such as Finland and Sweden have national records)Tj T* -0.0029 Tc 0.0405 Tw (of causes of death over many years, but such databases are)Tj 0 -1.398 TD -0.0034 Tc -0.0432 Tw (not available in the United States. If one wanted to conduct a)Tj 0 -1.401 TD 0.1043 Tw (national epidemiological study on police suicide, it would)Tj T* -0.0284 Tw [(take an enormous amount of resources and time. It is meth-)]TJ 0 -1.398 TD -0.0028 Tc -0.0156 Tw (odologically possible to verifiably collect data on every sui-)Tj 0 -1.401 TD -0.0029 Tc -0.0365 Tw (cide in every police agency in the United States, where there)Tj T* -0.022 Tc -0.0621 Tw (are approximately 708,000 sworn officers \(Hickman & Reaves,)Tj 0 -1.398 TD -0.0035 Tc 0.0211 Tw [(2006\). Several national databases such as the National Oc-)]TJ 0 -1.401 TD -0.0034 Tc 0.0043 Tw (cupational Mortality Survey \(NOMS\) do provide death cer-)Tj T* -0.0059 Tc -0.0625 Tw (tificate data on suicides for 28 states from 1984 -1998. Future)Tj 0 -1.398 TD 0.0125 Tc 0.125 Tw (inclusion of more states and updated data may enhance)Tj 0 -1.401 TD -0.0037 Tc 0.0113 Tw (knowledge on police suicide rates.)Tj 1.8 -2.001 TD -0.0034 Tc 0.0059 Tw (One attempt to study cross-jurisdictional police suicide)Tj -1.8 -1.398 TD -0.0013 Tc 0.125 Tw (rates was conducted by Langston \(1995\) for the National)Tj 0 -1.401 TD -0.0177 Tc -0.0625 Tw (Fraternal Order of Police \(FOP\). Langston examined data from)Tj T* -0.0035 Tc -0.0362 Tw (life insurance policy claims of 38,000 FOP members nation-)Tj 0 -1.398 TD -0.0032 Tc 0.0034 Tw (wide from 1992-94. These officers were from all types and)Tj 0 -1.401 TD -0.0035 Tc 0.0978 Tw (sizes of departments including urban, suburban, and rural.)Tj T* 0.0021 Tc 0.125 Tw (She found that 37% of accidental police deaths were the)Tj 0 -1.398 TD -0.0036 Tc 0.0028 Tw (result of suicide. Homicide was the second leading cause of)Tj 0 -1.401 TD -0.0063 Tc -0.0625 Tw (accidental death at 26%, followed by motor vehicle accidents)Tj T* -0.0037 Tc -0.0206 Tw (\(26%\) and other accidents \(11%\). Langston found that older)Tj 0 -1.398 TD -0.0034 Tc 0.1121 Tw (officers committed suicide more often than younger ones,)Tj 0 -1.401 TD -0.0035 Tc 0.0765 Tw (with the most suicides occurring after the age of 55. Guns)Tj T* -0.0032 Tc 0.1025 Tw (were used in the majority of suicides. The average age of)Tj 0 -1.398 TD -0.003 Tc -0.0387 Tw (police suicide was 49.7 years.)Tj 1.8 -2.001 TD -0.0016 Tc 0.125 Tw (The significance of the Langston study is that it was)Tj -1.8 -1.401 TD -0.0036 Tc 0.1006 Tw [(conducted on a wide geographical scale. Is was, however)35.4(,)]TJ 0 -1.398 TD -0.003 Tc 0.083 Tw (limited in its scope due to several factors. First, this study)Tj ET endstream endobj 265 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 267 0 obj << /Length 9541 >> 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. 4 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (303)Tj /TT2 1 Tf 10 0 0 10 66 722.64 Tm -0.0027 Tc -0.0389 Tw (covered only three years of police policy claims. Most retro-)Tj 0 -1.398 TD -0.0042 Tc -0.0625 Tw (spective epidemiological mortality studies cover longer peri-)Tj 0 -1.401 TD -0.0189 Tc -0.0623 Tw (ods \(20-25 years for example\) to get the full impact of exposure)Tj T* -0.0028 Tc -0.0417 Tw [(on the cohort involved. )18.2(T)74(wo or three years may not indicate)]TJ 0 -1.398 TD 0.125 Tw [(a true overall number)33.3(, as some years may have higher or)]TJ 0 -1.401 TD -0.0032 Tc 0.0338 Tw [(lower rates than others and not reflect a true picture of co-)]TJ T* 0.0083 Tc 0.1249 Tw [(hort death rates. Secondly)62.3(, the study was conducted on)]TJ 0 -1.398 TD -0.0031 Tc 0.0911 Tw (only FOP members. Not all police officers in this country)Tj 0 -1.401 TD -0.0042 Tc 0.015 Tw [(belong to the FOP)103.8(.)]TJ 1.8 -2.001 TD -0.0101 Tc -0.0621 Tw (Another problem concerns the accuracy of death records.)Tj -1.8 -1.398 TD -0.0034 Tc -0.0245 Tw (Not all states record occupation on death certificates and the)Tj 0 -1.401 TD -0.0032 Tc 0.0656 Tw (accuracy of those occupations that are recorded is at times)Tj T* -0.0037 Tc 0.0161 Tw [(questionable. Those persons listed as police on the death)]TJ 0 -1.398 TD -0.003 Tc 0.005 Tw (certificate may have only worked in policing for a short pe-)Tj 0 -1.401 TD -0.0033 Tc -0.012 Tw [(riod of time, or the term police may have been interpreted)]TJ T* -0.0034 Tc 0.032 Tw (differently across different medical examiner/coroner juris-)Tj 0 -1.398 TD 0.0042 Tc 0 Tw (dictions.)Tj 1.8 -2.001 TD -0.0058 Tc -0.0625 Tw (The reference group to which police suicide is compared)Tj -1.8 -1.401 TD -0.0035 Tc -0.0293 Tw [(presents an additional methodological problem. Many stud-)]TJ 0 -1.398 TD -0.0062 Tc -0.0625 Tw (ies on suicide in general utilize the U.S. general population as)Tj 0 -1.401 TD -0.0032 Tc 0.0178 Tw (a comparison group. This may end in a biased result, as the)Tj T* -0.0035 Tc 0.114 Tw (general population includes the unemployed, institutional-)Tj 0 -1.398 TD -0.0141 Tc -0.0621 Tw [(ized, incarcerated, and mentally ill \(Kramer)36.9(, Pollack, Reddick,)]TJ 0 -1.401 TD -0.0035 Tc -0.0525 Tw (and Locke, 1972\).These population groups generally experi-)Tj T* -0.0032 Tc -0.0406 Tw (ence higher suicide rates. Thus, in essence, the police )Tj /TT5 1 Tf 21.06 0 TD -0.0054 Tc 0 Tw (should)Tj -21.06 -1.398 TD -0.0035 Tc -0.018 Tw (have relatively low suicide rates )Tj /TT2 1 Tf 12.984 0 TD -0.0039 Tc -0.0188 Tw (when compared to the gen-)Tj -12.984 -1.401 TD -0.0033 Tc 0.0589 Tw [(eral population. )50.7(As previously mentioned, the police are a)]TJ T* -0.0106 Tc -0.0625 Tw (physically and psychologically healthy working group, which)Tj 0 -1.398 TD -0.0098 Tc -0.0622 Tw (can lead to a healthy worker effect bias \(McMichael, 1976\).)Tj 0 -1.401 TD -0.0034 Tc 0.071 Tw (Even if such a comparison were close to accurate, the fact)Tj T* -0.0032 Tc -0.0155 Tw (that many studies show police officers to have a suicide rate)Tj 0 -1.398 TD 0 Tc 0.125 Tw (equal to or higher than the general population suggests a)Tj 0 -1.401 TD -0.0036 Tc 0.055 Tw (cause for concern.)Tj 1.8 -2.001 TD -0.0038 Tc -0.0207 Tw (The work exposures involved in policing are confound-)Tj -1.8 -1.398 TD -0.0032 Tc 0.0989 Tw (ers that add considerable weight to an analysis of suicide.)Tj 0 -1.401 TD 0.0079 Tc 0.125 Tw (Incidents such as witnessing death, encountering abused)Tj T* -0.0033 Tc 0.0188 Tw (children, and street combat weigh heavily as precipitants to)Tj 0 -1.398 TD -0.0028 Tc 0.1251 Tw [(depression, alcohol use, and suicide. )54.3(Any study on police)]TJ 0 -1.401 TD -0.0037 Tc 0.0656 Tw (suicide should thus compare the police with an occupation)Tj T* -0.0035 Tc -0.0138 Tw (similar in confounder weight distributions, in addition to in-)Tj 0 -1.398 TD 0.0118 Tc 0.125 Tw (cluding such confounders in the analysis to assess their)Tj 0 -1.401 TD -0.0202 Tc 0 Tw (impact.)Tj /TT5 1 Tf 11 0 0 11 321 723.36 Tm 0.0073 Tc 0.1255 Tw [(Measur)34.6(ement: Police Suicide Rates or Risk?)]TJ /TT2 1 Tf 10 0 0 10 339 703.65 Tm 0.0137 Tc 0.125 Tw (Many police suicide studies use a suicide rate per)Tj -1.8 -1.401 TD -0.0034 Tc -0.046 Tw [(100,000 to make comparisons and as a way to assess differ-)]TJ 0 -1.398 TD -0.0036 Tc -0.0344 Tw (ences between groups. There is a difference between suicide)Tj /TT5 1 Tf 0 -1.401 TD -0.004 Tc 0 Tw (rates )Tj /TT2 1 Tf 2.265 0 TD -0.0038 Tc 0.04 Tw (and suicide )Tj /TT5 1 Tf 4.815 0 TD -0.004 Tc 0 Tw (risk.)Tj /TT2 1 Tf 1.734 0 TD -0.0034 Tc 0.04 Tw [( These measures reflect different as-)]TJ -8.814 -1.401 TD -0.0031 Tc -0.0033 Tw (pects of mortality and should not be compared directly with)Tj 0 -1.398 TD -0.0034 Tc 0.0128 Tw [(one another \(Greenber)17.6(g, Daniels, Flanders, Eley)59.6(, & Boring,)]TJ 0 -1.401 TD -0.0035 Tc -0.0115 Tw [(1996\). Rates are preferred if assessment centers on the how)]TJ T* -0.0116 Tc -0.0625 Tw [(quickly \(in time\) new suicides arise. Risk is most useful if one)]TJ 0 -1.398 TD -0.0043 Tc -0.0623 Tw (wants to assess the probability that an individual will commit)Tj 0 -1.401 TD -0.0155 Tc (suicide over a specified period of time \(e.g. a number of years\).)Tj T* -0.0025 Tc 0.1249 Tw [(Generally)60.5(, the word )]TJ /TT5 1 Tf 8.484 0 TD -0.0039 Tc 0 Tw (rate)Tj /TT2 1 Tf 1.602 0 TD -0.0028 Tc 0.125 Tw [( should be restricted to measures)]TJ -10.086 -1.398 TD -0.0038 Tc 0.0242 Tw (involving instantaneous changes and omit it from measures)Tj 0 -1.401 TD -0.0036 Tc -0.0257 Tw (that can be viewed as proportions \(Friedman, 1994\).)Tj 1.8 -2.001 TD -0.0032 Tc 0.0575 Tw [(Another way to assess risk is to determine the ratio of)]TJ -1.8 -1.398 TD -0.0033 Tc 0.0786 Tw [(the rates of one group to another)53.7(. )14.6(The ratio of two rates is)]TJ 0 -1.401 TD -0.0034 Tc 0.0175 Tw (called the )Tj /TT5 1 Tf 4.11 0 TD -0.0038 Tc 0.02 Tw (risk ratio)Tj /TT2 1 Tf 3.681 0 TD -0.0026 Tc 0.0194 Tw [(. The latter term is typically used when)]TJ -7.791 -1.401 TD -0.0126 Tc -0.0622 Tw (mortality rates are compared to a standard or benchmark \(such)Tj 0 -1.398 TD -0.0032 Tc -0.0236 Tw (as the U.S. population\). It is also used in the equivalent ratio)Tj 0 -1.401 TD -0.004 Tc 0.06 Tw (comparison of )Tj /TT5 1 Tf 6.066 0 TD -0.0042 Tc 0.065 Tw (cases observed)Tj /TT2 1 Tf 6.033 0 TD -0.0029 Tc 0.06 Tw [( to )]TJ /TT5 1 Tf 1.392 0 TD -0.0039 Tc 0.065 Tw (cases expected,)Tj /TT2 1 Tf 6.174 0 TD -0.0037 Tc 0.0625 Tw [( given the)]TJ -19.665 -1.401 TD -0.0036 Tc 0.095 Tw (standard rates.)Tj /TT5 1 Tf 5.82 0 TD 0 Tc 0 Tw ( )Tj /TT2 1 Tf 0.351 0 TD -0.0033 Tc 0.0981 Tw (When any of these ratios is calculated in a)Tj -6.171 -1.398 TD -0.0032 Tc 0.0594 Tw (way that takes into account differences with respect to age)Tj 0 -1.401 TD -0.0166 Tw (or other characteristics, the ratio is said to be )Tj /TT5 1 Tf 17.859 0 TD -0.0047 Tc 0 Tw (standardized)Tj /TT2 1 Tf 5.115 0 TD -0.024 Tc ( )Tj -22.974 -1.401 TD -0.0033 Tc -0.0217 Tw (thus the term, )Tj /TT5 1 Tf 5.61 0 TD -0.004 Tc -0.025 Tw (standardized rate ratio)Tj /TT2 1 Tf 9.084 0 TD -0.0044 Tc -0.0234 Tw [( \(SMR\). Whether stan-)]TJ -14.694 -1.398 TD -0.0032 Tc -0.005 Tw (dardized or not, the ratio of two proportional mortality rates)Tj 0 -1.401 TD -0.0075 Tw (is the )Tj /TT5 1 Tf 2.355 0 TD -0.004 Tc (proportional mortality ratio)Tj /TT2 1 Tf 11.1 0 TD -0.01 Tw [( \(PMR; Friedman, 1994\).)]TJ -11.655 -2.001 TD -0.0034 Tc -0.0478 Tw [(W)55.4(ill we better understand police suicide if we assess the)]TJ /TT5 1 Tf -1.8 -1.398 TD -0.008 Tc 0 Tw (risk)Tj /TT2 1 Tf 1.476 0 TD -0.0059 Tc -0.0622 Tw [( of suicide in police work and not simply )]TJ /TT5 1 Tf 15.834 0 TD -0.0073 Tc 0 Tw (rates)Tj /TT2 1 Tf 1.971 0 TD -0.0059 Tc -0.0625 Tw [( of suicide?)]TJ -19.281 -1.401 TD -0.0031 Tc 0.1125 Tw [(H)6.1(o)6.1(w)62.9(, then, do we assess the )]TJ /TT5 1 Tf 12.015 0 TD -0.005 Tc 0 Tw (risk)Tj /TT2 1 Tf 1.485 0 TD -0.0037 Tc 0.1137 Tw [( of suicide among police)]TJ -13.5 -1.401 TD -0.0031 Tc -0.0235 Tw (officers? This is a difficult question, as the risk predictors of)Tj 0 -1.398 TD 0.059 Tw [(police suicide are not yet well defined. )14.9(T)73.7(o)0.4( date, there have)]TJ 0 -1.401 TD 0.0289 Tw (been no definitive studies that lay the foundation for police)Tj T* -0.0036 Tc -0.0622 Tw [(suicide risk predictors. )20.4(W)97.2(e)0.1( know that there are certain factors)]TJ 0 -1.398 TD -0.0034 Tc 0.1205 Tw (that occur more often than not in police suicides, but can)Tj 0 -1.401 TD -0.0028 Tc -0.0472 Tw (they effectively predict such suicides? This is a crucial ques-)Tj T* -0.0031 Tc -0.045 Tw (tion for prevention. Psychological autopsies may help in this)Tj 0 -1.398 TD 0.0268 Tw [(regard. Factors that are part of suicide risk assessment are)]TJ 0 -1.401 TD -0.0069 Tc -0.0625 Tw (believed to be better at predicting suicide than are other avail-)Tj T* -0.0036 Tc -0.0138 Tw (able measures. Some suicide risk factors are developed sub-)Tj 0 -1.398 TD -0.003 Tc 0.1248 Tw [(jectively)63(, by asking knowledgeable professionals to select)]TJ 0 -1.401 TD -0.0034 Tc -0.0344 Tw (items their experience tells them are predictive. Other police)Tj T* -0.0032 Tc 0.1122 Tw (measures are empirical, using statistical analyses to select)Tj ET endstream endobj 268 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 270 0 obj << /Length 9091 >> 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 -0.009 Tc 0 Tw (304)Tj /TT3 1 Tf 1.65 0 TD -0.0049 Tc 0.0453 Tw [( Violanti )]TJ /F1 1 Tf 4.5188 0 TD -0.008 Tc 0 Tw ( )Tj /TT3 1 Tf 0.6637 0 TD -0.0057 Tc 0.0458 Tw (Issues in Police Suicide)Tj /TT2 1 Tf 10 0 0 10 54 722.64 Tm -0.0035 Tc -0.0488 Tw (among a set of available data elements that capture attributes)Tj 0 -1.398 TD -0.025 Tw (of suicide \(Gonzales, Henke, & Flores, 2005\). Gonzales and)Tj 0 -1.401 TD -0.0427 Tw (colleagues \(2005\) provide five steps to be followed in devel-)Tj T* 0.0333 Tw (oping a methodologically sound)Tj /TT5 1 Tf 12.855 0 TD -0.0037 Tc 0.035 Tw [( risk)]TJ /TT2 1 Tf 1.77 0 TD -0.0038 Tc [( prediction:)]TJ -13.425 -1.998 TD -0.0009 Tc 0.125 Tw [()-1450.8(First, define the behavior or event to be predicted)]TJ 1.8 -1.401 TD -0.0021 Tc (and develop procedures for classifying persons on)Tj T* -0.0033 Tc 0.0883 Tw (the basis of their performance in regard to that be-)Tj 0 -1.398 TD -0.0035 Tc 0.025 Tw (havior or event.)Tj -1.8 -2.001 TD -0.0034 Tc -0.0078 Tw [()-1453.3(Second, select and define the attributes or character-)]TJ 1.8 -1.401 TD -0.0032 Tc -0.0194 Tw (istics on which the predictions may be based. Critics)Tj 0 -1.398 TD 0.0052 Tc 0.125 Tw (of prediction methods often argue that the proce-)Tj 0 -1.401 TD -0.0133 Tc -0.062 Tw [(dures ignore dif)16.7(ferences among individuals. However)34.7(,)]TJ T* 0.0014 Tc 0.125 Tw (such differences, often assumed to be a source of)Tj 0 -1.398 TD -0.0029 Tc 0.028 Tw (error in other problems, are in fact the basis for any)Tj 0 -1.401 TD -0.0033 Tc -0.0519 Tw (prediction effort. If the persons studied are alike with)Tj T* 0.0019 Tc 0.125 Tw (respect to the predictor candidates, no differential)Tj 0 -1.398 TD -0.0031 Tc -0.0389 Tw (prediction can be made. If they are alike with respect)Tj 0 -1.401 TD -0.0067 Tc -0.0625 Tw (to the criterion categories, there is no prediction prob-)Tj T* -0.0582 Tc 0 Tw (lem.)Tj -1.8 -1.998 TD -0.0122 Tc -0.062 Tw [()-1462.1(Third, determine relationships between predictor vari-)]TJ 1.8 -1.401 TD -0.0034 Tc 0.0344 Tw (ables and criterion in a sample representative of the)Tj T* -0.0036 Tc 0.0008 Tw (population for which inferences are to be drawn.)Tj -1.8 -1.998 TD -0.0187 Tc -0.0625 Tw [()-1468.6(Fourth, verify the relations found in the original sample)]TJ 1.8 -1.401 TD -0.0033 Tc -0.0537 Tw (by testing the prediction procedures in a new sample,)Tj T* -0.0036 Tc -0.0435 Tw [(or samples, of the population. )50.5(Although this verifica-)]TJ 0 -1.398 TD -0.0032 Tc -0.0244 Tw (tion \(cross-validation\) often is omitted, it is a critical)Tj 0 -1.401 TD 0.0223 Tc 0 Tw (step.)Tj -1.8 -2.001 TD -0.0032 Tc 0.0921 Tw [()-1453.1(Fifth, apply the prediction method in situations for)]TJ 1.8 -1.398 TD -0.0469 Tw (which it was developed, provided that the stability of)Tj 0 -1.401 TD -0.0036 Tc 0.1016 Tw (predictions has been supported in the cross-valida-)Tj T* 0.125 Tw (tion step and appropriate samples have been used.)Tj 0 -1.398 TD -0.0165 Tc -0.0616 Tw (\(Gonzales, et al., 2005\).)Tj /TT5 1 Tf -1.2 -2.001 TD -0.0048 Tc 0.07 Tw (An example)Tj /TT2 1 Tf 4.719 0 TD -0.0034 Tc 0.0707 Tw [(. )15.3(V)64.8(iolanti, )15.3(V)112.8(ena, and Marshall \(1996\) as-)]TJ -6.519 -1.401 TD 0.0856 Tw (sessed the risk of suicide, homicide, and accidental deaths)Tj 0 -1.398 TD -0.0122 Tc -0.0622 Tw (among 2,611 police officers and compared that risk to munici-)Tj 0 -1.401 TD -0.0033 Tc -0.0295 Tw (pal workers. Data was obtained from a mortality database of)Tj T* 0.0531 Tw [(municipal workers and police officers. The study used his-)]TJ 0 -1.398 TD -0.04 Tw (torical information as well as death certificates on each case.)Tj 0 -1.401 TD -0.0036 Tc 0.0312 Tw (Findings indicated that police officers had a higher number)Tj T* -0.0046 Tc -0.0623 Tw (of total suicides than municipal workers, but fewer total acci-)Tj 0 -1.398 TD -0.0037 Tc 0.0587 Tw (dents, homicides, and undetermined deaths.)Tj 1.8 -2.001 TD -0.005 Tc -0.0625 Tw (Interesting were ratios between suicides, homicides, and)Tj -1.8 -1.401 TD 0.0028 Tc 0.125 Tw (accidents within police and municipal worker categories.)Tj 0 -1.398 TD -0.0034 Tc 0.0595 Tw [(W)55.4(ithin the police occupation, of)17.6(ficers had a suicide rate of)]TJ /TT5 1 Tf 25.5 64.398 TD -0.0039 Tc 0.065 Tw (8.3 times)Tj /TT2 1 Tf 3.645 0 TD -0.0031 Tc 0.0665 Tw [( that of police homicide, and a suicide rate of )]TJ /TT5 1 Tf 18.816 0 TD -0.0055 Tc 0 Tw (3.1)Tj -22.461 -1.398 TD -0.005 Tc (times)Tj /TT2 1 Tf 2.091 0 TD -0.0035 Tc 0.0088 Tw [( that of police accidents. )17.6(W)55.3(ithin other municipal occu-)]TJ -2.091 -1.401 TD -0.0381 Tw (pations, the suicide-homicide ratio was 3.25 and the suicide-)Tj T* -0.0038 Tc 0.0832 Tw [(accident ratio .20. When compared to municipal workers,)]TJ 0 -1.398 TD -0.0082 Tc -0.0625 Tw (police officers had a 53% increased risk of suicide over homi-)Tj 0 -1.401 TD -0.0114 Tc (cide, a 310% risk of suicide over accidents, and a 265% risk of)Tj T* -0.0037 Tc -0.0157 Tw (suicide over homicide and accidents combined. Overall, po-)Tj 0 -1.398 TD -0.0033 Tc -0.0524 Tw [(lice officers had an increased relative risk for suicide over all)]TJ 0 -1.401 TD -0.0123 Tc -0.0622 Tw (types of death in comparison to municipal workers. This study)Tj T* -0.0104 Tc -0.0625 Tw (provided some evidence that police officers have an increased)Tj 0 -1.398 TD -0.0038 Tc -0.0512 Tw (risk of suicide over homicides and accidents when compared)Tj 0 -1.401 TD -0.0034 Tc 0.05 Tw (to municipal workers. Suicide may thus be considered as a)Tj T* -0.0033 Tc 0.0981 Tw (potentially higher risk to officers when compared to other)Tj 0 -1.398 TD -0.0036 Tc 0.047 Tw (hazards of policing and other occupations.)Tj /TT5 1 Tf 11 0 0 11 309 507.36 Tm 0.0099 Tc 0.125 Tw [(A)6.3(r)31.7(e Some Police Suicides Misclassified?)]TJ /TT2 1 Tf 10 0 0 10 327 487.65 Tm -0.0036 Tc 0.0444 Tw (Adding to the problem of counting police suicides is a)Tj -1.8 -1.401 TD -0.0046 Tc -0.0622 Tw (supposition that such suicides may be routinely misclassified)Tj 0 -1.398 TD -0.0037 Tc -0.0206 Tw (as accidents or undetermined deaths \(Phillips & Ruth, 1993;)Tj 0 -1.401 TD 0.0131 Tw (Aldridge & St. John, 1991; OCarroll, 1989; Pescosolido &)Tj T* -0.0041 Tc -0.0291 Tw [(Mendelsohn, 1986\). )17(The police of)13.9(ficer)-40.1()55.9(s)0.5( working personal-)]TJ 0 -1.398 TD -0.005 Tc -0.0621 Tw (ity \(Skolnick, 1972\) includes a perception of invulnerability)Tj 0 -1.401 TD -0.0034 Tc 0.1161 Tw (that views suicide as disgraceful to the victim officer and)Tj T* 0.0121 Tc 0.125 Tw (profession. Police investigators at the scene of a fellow)Tj 0 -1.398 TD -0.0034 Tc 0.0987 Tw [(of)17.6(ficer)-39.4()53.6(s)-0.2( suicide can readily control information to protect)]TJ 0 -1.401 TD -0.0031 Tc 0.0054 Tw [(the victim officer and family from the stigma of suicide. In)]TJ T* 0.0272 Tw (effect, the initial police investigator is the gatekeeper of in-)Tj 0 -1.398 TD -0.0078 Tc -0.0622 Tw (formation at the scene, and medical examiners may have only)Tj 0 -1.401 TD -0.0032 Tc 0.0729 Tw [(secondary level discretion in the classification process. )50.8(A)10(n)]TJ T* -0.0164 Tc -0.0622 Tw (early study of the Chicago Police department by Cronin \(1982\))Tj 0 -1.398 TD -0.0035 Tc 0.0427 Tw (found fifteen cases of suspected suicide in the Chicago po-)Tj 0 -1.401 TD 0.0215 Tc 0.125 Tw (lice department officially listed as accidental gunshot)Tj T* 0.0135 Tc 0 Tw (wounds.)Tj 1.8 -1.998 TD 0.0175 Tc 0.125 Tw (There is scant scientific evidence of police suicide)Tj -1.8 -1.401 TD -0.0031 Tc -0.0125 Tw (misclassification. In an attempt to help clarify this situation,)Tj T* -0.0039 Tc -0.0623 Tw [(V)64.3(iolanti, )14(V)112.3(ena, and Marshall \(1996\) conducted a study to test)]TJ 0 -1.398 TD -0.0132 Tc -0.06 Tw (how well officially )Tj /TT5 1 Tf 8.28 0 TD -0.0141 Tc 0 Tw (reported )Tj /TT2 1 Tf 3.504 0 TD -0.0136 Tc -0.0616 Tw (police suicide rates represented)Tj -11.784 -1.401 TD -0.0063 Tc 0 Tw (the)Tj /TT5 1 Tf 1.209 0 TD -0.0035 Tc -0.0175 Tw [( actual )]TJ /TT2 1 Tf 2.94 0 TD -0.0032 Tc -0.0187 Tw (police suicide rate. The study was conducted on a)Tj -4.149 -1.401 TD -0.0084 Tc -0.0621 Tw (large epidemiological database of 11,760 city workers, which)Tj 0 -1.398 TD -0.0034 Tc -0.0114 Tw [(included police of)17.6(ficers and persons in other city jobs \(V)104.6(ena)]TJ 0 -1.401 TD -0.0033 Tc 0.0417 Tw [(et al., 1986\). )14.7(V)64.9(ital status and death classifications were ob-)]TJ T* -0.0139 Tc -0.0625 Tw (tained for police officers who worked a minimum of five years)Tj 0 -1.398 TD -0.0033 Tc -0.0325 Tw [(in their specific occupational group between the years 1950-)]TJ 0 -1.401 TD -0.0035 Tc 0.0089 Tw (1990. Sources of vital status follow up included benefit and)Tj T* -0.0033 Tc 0.0686 Tw (pension programs, the state retirement system, voter regis-)Tj 0 -1.398 TD -0.0034 Tc 0.01 Tw (tration records, the department of motor vehicles, the social)Tj ET endstream endobj 271 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 9678 >> 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. 4 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (305)Tj /TT2 1 Tf 10 0 0 10 66 722.64 Tm -0.0029 Tc 0.0592 Tw (security administration, city directories, obituaries, and the)Tj 0 -1.398 TD -0.0038 Tc -0.0114 Tw (National Death Index Database. Information was located on)Tj 0 -1.401 TD -0.0036 Tc -0.034 Tw (98% of officers and other workers.)Tj 1.8 -2.001 TD 0.0082 Tc 0.125 Tw [(In this study)65.2(, deaths listed as suicides, accidents, or)]TJ -1.8 -1.398 TD -0.0038 Tc 0.0316 Tw [(undetermined causes were collected. )50.1(Accident and undeter)17.2(-)]TJ 0 -1.401 TD -0.0035 Tc 0.0106 Tw (mined death classifications were selected in addition to sui-)Tj T* -0.0031 Tc 0.0687 Tw (cides because suicide has been shown to be systematically)Tj 0 -1.398 TD 0.0315 Tc 0.125 Tw (misreported within these categories \(OCarroll, 1989;)Tj 0 -1.401 TD -0.0061 Tc -0.0625 Tw [(Pescosolido & Mendelsohn, 1986\). Information on each per-)]TJ T* -0.0037 Tc -0.0193 Tw (son was compiled from death certificates, medical examiner)Tj 0 -1.398 TD -0.0005 Tc 0.125 Tw (reports, autopsies, police investigative reports, newspaper)Tj 0 -1.401 TD -0.0034 Tc 0.093 Tw (accounts, and obituaries and given to a panel of one chief)Tj T* -0.0201 Tc -0.0625 Tw (and two associate county-level medical examiners, all of whom)Tj 0 -1.398 TD -0.0031 Tc 0.0628 Tw [(had M.D. degrees, investigated at least 300 cases per year)35.9(,)]TJ 0 -1.401 TD -0.0054 Tc -0.062 Tw [(and were employed an average of 30.6 years. )54.8(After investiga-)]TJ T* -0.0034 Tc 0.065 Tw (tion, suicides were reclassified as suicides. Police and mu-)Tj 0 -1.398 TD -0.0182 Tc -0.0625 Tw [(nicipal worker suicide rates were then compared for sensitivity)59.8(.)]TJ 0 -1.401 TD -0.0033 Tc 0.0257 Tw (Results indicated that twenty \(83.3%\) police suicides origi-)Tj T* -0.0032 Tc -0.005 Tw (nally classified as suicides were still considered suicides af-)Tj 0 -1.398 TD -0.0253 Tc -0.0624 Tw [(ter the medical examiner panel)55.7(s review)58.7(. For municipal workers,)]TJ 0 -1.401 TD -0.0033 Tc 0.065 Tw (twelve \(92.3%\) of suicides originally classified as suicides)Tj T* 0.0806 Tw [(were still suicides after panel review)62.7(. )14.6(Thus, approximately)]TJ 0 -1.398 TD -0.0035 Tc -0.0532 Tw (17% of police suicides, as opposed to 8% of suicides in other)Tj 0 -1.401 TD 0.0001 Tc 0.125 Tw [(occupations, were misclassified. )51.1(A)56.3( proportional equation)]TJ T* -0.0031 Tc -0.0583 Tw (developed from this study indicated that for every 100 police)Tj 0 -1.398 TD -0.0028 Tc -0.0156 Tw (suicides officially reported there may actually be 117 police)Tj 0 -1.401 TD 0.0067 Tc 0 Tw (suicides.)Tj /F1 1 Tf 11 0 0 11 66 320.01 Tm -0.0001 Tc (Conclusions)Tj /TT2 1 Tf 10 0 0 10 84 296.64 Tm -0.0033 Tc 0.0228 Tw (Given the present state of research on police suicide, it)Tj -1.8 -1.398 TD 0.0315 Tc 0.125 Tw (is likely that data inaccuracies will continue to exist.)Tj 0 -1.401 TD -0.0037 Tc 0.056 Tw (Underreporting, misclassification, lack of nationwide com-)Tj T* -0.0033 Tc -0.045 Tw (prehensive data, and the difficulty associated with collecting)Tj 0 -1.398 TD -0.0087 Tc -0.0625 Tw [(data leaves us with this dilemma. Exposure and job socializa-)]TJ 0 -1.401 TD -0.0033 Tc 0.0011 Tw (tion in policing have profound impacts on officers. Exactly)Tj T* -0.0036 Tc -0.0455 Tw (how to measure the impact over time that police work has on)Tj 0 -1.398 TD -0.0076 Tc -0.0622 Tw [(individuals is a difficult question. It will likely take long term)]TJ 0 -1.401 TD -0.0036 Tc 0.0587 Tw (prospective studies to make sense out of such exposure.)Tj 1.8 -2.001 TD -0.004 Tc -0.0585 Tw (While we cannot state absolutes concerning police work)Tj -1.8 -1.398 TD -0.0031 Tc 0.097 Tw (and suicide, we can state within a degree of certainty that)Tj 0 -1.401 TD -0.0035 Tc 0.0068 Tw (police work exacerbates the conditions for suicide. This oc-)Tj T* -0.0033 Tc 0.0733 Tw (cupation serves as a plausible fertile arena for suicide pre-)Tj 0 -1.398 TD -0.0145 Tc -0.062 Tw (cipitants, including relationship problems, culturally approved)Tj 0 -1.401 TD -0.0108 Tc -0.0621 Tw [(alcohol use and maladaptive coping, firearms availability)58.2(, and)]TJ T* -0.0031 Tc -0.0393 Tw [(exposure to psychologically aversive incidents. Given these)]TJ 25.5 64.2 TD -0.0035 Tc -0.0522 Tw (conditions, the contextual nature of police work is a probabi-)Tj 0 -1.398 TD -0.0032 Tc -0.0243 Tw (listic link in the causal chain of suicide.)Tj 1.8 -2.001 TD -0.0033 Tc -0.007 Tw [( The controversies reflected in this paper tell us that we)]TJ -1.8 -1.401 TD -0.0034 Tc -0.0154 Tw (need to look deeper into police suicide and its root causes in)Tj 0 -1.398 TD -0.0031 Tc -0.0311 Tw [(the coming years. )17.9(W)94.8(e)0.1( may be better informed for prevention)]TJ 0 -1.401 TD -0.0037 Tc 0.0237 Tw (if we know the inherent)Tj /TT5 1 Tf 9.51 0 TD -0.0035 Tc 0.025 Tw [( risk)]TJ /TT2 1 Tf 1.761 0 TD -0.0033 Tc [( of police suicide in a quantita-)]TJ -11.271 -1.401 TD 0.0275 Tw (tive, qualitative, and contextual sense.)Tj /F1 1 Tf 11 0 0 11 400.89 600 Tm 0.021 Tc 0 Tw (REFERENCES)Tj /TT2 1 Tf 10 0 0 10 321 582.66 Tm -0.0037 Tc -0.0077 Tw [(Aamodt, M.G)116.3(., & S)17.3(talnaker)35.3(, N.A. \(2001\). Police of)14.3(ficer sui-)]TJ 1.2 -1.401 TD -0.0032 Tc 0.0262 Tw (cide: Frequency and officer profiles. In D.C. Sheehan &)Tj T* -0.0028 Tc -0.0232 Tw [(J.I. W)95.1(arren )-17.7(\(Eds.\) )]TJ /TT5 1 Tf 7.206 0 TD -0.0041 Tc -0.0048 Tw [(Suicide and law enfor)31.9(cement )]TJ /TT2 1 Tf 11.67 0 TD -0.0046 Tc -0.0044 Tw (\(pp 383-)Tj -18.876 -1.398 TD -0.0074 Tc -0.0626 Tw [(398\). )16.5(W)96.4(ashington, DC: US Government Printing Of)16.6(fice.)]TJ -1.2 -1.8 TD -0.0036 Tc -0.0576 Tw [(Aldridge, D., & S)14.4(t. John, K. \(1991\). )50.6(Adolescent and pre-ado-)]TJ 1.2 -1.401 TD -0.0049 Tc -0.061 Tw (lescent suicide in Newfoundland and Labrador)Tj /TT5 1 Tf 18.171 0 TD -0.0056 Tc -0.065 Tw (. Canadian)Tj -18.171 -1.401 TD -0.0035 Tc -0.0483 Tw [(Journal of Psychiatry)56.4(,)-2.2( 36, )]TJ /TT2 1 Tf 10.326 0 TD -0.0049 Tc 0 Tw (432-436.)Tj -11.526 -1.8 TD -0.0162 Tc -0.061 Tw [(Alpert, G)118.8(.)1(P)106.8(., & Dunham, R.G)115.8(. \(1988\).)]TJ /TT5 1 Tf 14.13 0 TD -0.0171 Tc -0.0631 Tw [( Policing urban )13.1(America.)]TJ /TT2 1 Tf -12.93 -1.398 TD -0.0037 Tc 0.0168 Tw [(Prospect Heights, Illinois: )17.4(W)94.1(aveland.)]TJ -1.2 -1.8 TD -0.0175 Tc -0.0622 Tw [(Ber)18.5(g, )51.6(A.M., Hem, E., Lau, B., Loeb, M., & Ekeber)18.5(g, O. \(2003\).)]TJ 1.2 -1.401 TD -0.0036 Tc 0.0135 Tw (Suicidal ideation and attempts in Norwegian police. )Tj /TT5 1 Tf 20.904 0 TD -0.005 Tc 0 Tw (Sui-)Tj -20.904 -1.401 TD -0.0039 Tc -0.001 Tw (cide and Life Threatening Behavior 33)Tj /TT2 1 Tf 15.381 0 TD -0.005 Tw (, 302-312.)Tj -16.581 -1.8 TD -0.0034 Tc -0.0485 Tw [(Burnett, C.A., Boxer)38.6(, P)104.6(.A., & Swanson, N.G)116.6(. \(1992\), )]TJ /TT5 1 Tf 20.784 0 TD -0.0046 Tc 0 Tw (Suicide)Tj -19.584 -1.398 TD -0.0037 Tc -0.041 Tw (and occupation: Is there a relationship?,)Tj /TT2 1 Tf 16.035 0 TD -0.0039 Tc -0.0425 Tw [( Paper presented)]TJ -16.035 -1.401 TD -0.0036 Tc 0.0232 Tw [(at the )50.3(American Psychological )53.3(Association- National In-)]TJ T* -0.0037 Tc 0.0031 Tw [(stitute for Occupational Health Conference, )14.4(W)97.1(ashington,)]TJ 0 -1.398 TD -0.0232 Tc -0.0625 Tw (DC, November 19-22.)Tj -1.2 -1.8 TD -0.0031 Tc 0.0238 Tw [(Cantor)35.9(, C.H., )15.2(T)73.7(yman, R., & Slater)35.9(, P)104.9(.J. \(1995\). )54.2(A)59.1( historical)]TJ 1.2 -1.401 TD 0.002 Tc 0.1252 Tw [(survey of police in Queensland, )47.2(Australia, 1843-1992.)]TJ /TT5 1 Tf T* -0.0041 Tc -0.0225 Tw [(Suicide and Life Thr)28.9(eatening Behavior)]TJ /TT2 1 Tf 15.285 0 TD -0.0033 Tc -0.025 Tw (, 25, 499-507.)Tj -16.485 -1.8 TD -0.0085 Tc -0.0623 Tw [(Charbonneau, F)78.5(.)-0.3( \(2000\). Suicide among the police in Quebec.)]TJ /TT5 1 Tf 1.2 -1.398 TD -0.0112 Tc 0 Tw (Population)Tj /TT2 1 Tf 4.341 0 TD -0.0095 Tc -0.0625 Tw (, 55, 367-378.)Tj -5.541 -1.8 TD -0.0034 Tc -0.0101 Tw [(Cronin, T)76.4(.J. )-18.2(\(1982\).)]TJ /TT5 1 Tf 7.8 0 TD -0.0039 Tc 0.0077 Tw [( Police suicides: )16.8(A)21.9( compr)29.1(ehensive study)]TJ -6.6 -1.401 TD 0.1217 Tw (of the Chicago Police Department 1970-1979. )Tj /TT2 1 Tf 19.365 0 TD -0.0052 Tc 0 Tw (Masters)Tj -19.365 -1.401 TD -0.0037 Tc -0.0616 Tw [(thesis, Lewis University)65.3(, Illinois.)]TJ -1.2 -1.8 TD -0.0035 Tc 0.0564 Tw [(Darragh P)107.5(.M. \(1991\). Epidemiology of suicide in Northern)]TJ 1.2 -1.398 TD -0.0033 Tc 0 Tw (Ireland. )Tj /TT5 1 Tf 3.255 0 TD -0.0036 Tc -0.05 Tw (Irish Journal of Medical Science,)Tj /TT2 1 Tf 13.041 0 TD -0.0038 Tc -0.0525 Tw [( 160, 354-357.)]TJ -17.496 -1.8 TD -0.0035 Tc -0.061 Tw [(Dash, J., & Reiser)35.5(, M. \(1978\). Suicide among police in urban)]TJ 1.2 -1.401 TD -0.0038 Tc -0.025 Tw (law enforcement agencies.)Tj /TT5 1 Tf 10.491 0 TD -0.0037 Tc -0.026 Tw [( Journal of Police Science and)]TJ -10.491 -1.401 TD -0.0042 Tc -0.04 Tw (Administration, 6)Tj /TT2 1 Tf 6.894 0 TD -0.0028 Tc (, 18- 21.)Tj -8.094 -1.8 TD -0.0186 Tc -0.0621 Tw [(Forastiere, F)77.4(., Perucci, C.A., DiPietro, a., Miceli, M., Rapiti, E.,)]TJ 1.2 -1.398 TD -0.0035 Tc -0.0348 Tw [(Bar)17.5(gagli, )50.7(A., & Bor)17.5(gia, P)107.5(.)-0.3( \(1994\). Mortality among urban)]TJ 0 -1.401 TD -0.0093 Tc -0.0616 Tw (policemen in Rome. )Tj /TT5 1 Tf 7.974 0 TD -0.0095 Tc -0.0625 Tw (American Journal of Industrial Medi-)Tj -7.974 -1.401 TD -0.0138 Tc -0.06 Tw (cine, 26)Tj /TT2 1 Tf 3 0 TD (, 785-798.)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 11142 >> 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 -0.009 Tc 0 Tw (306)Tj /TT3 1 Tf 1.65 0 TD -0.0049 Tc 0.0453 Tw [( Violanti )]TJ /F1 1 Tf 4.5188 0 TD -0.008 Tc 0 Tw ( )Tj /TT3 1 Tf 0.6637 0 TD -0.0057 Tc 0.0458 Tw (Issues in Police Suicide)Tj /TT2 1 Tf 10 0 0 10 54 722.64 Tm -0.0271 Tc -0.06 Tw [(Friedman, G)119.9(.D. \(1994\).)]TJ /TT5 1 Tf 8.61 0 TD -0.0277 Tc -0.0634 Tw [( Primer for epidemiology)]TJ /TT2 1 Tf 9.285 0 TD -0.0287 Tc -0.0626 Tw [(. NY)85.3(: McGraw-)]TJ -16.695 -1.398 TD -0.0686 Tc 0 Tw (Hill)Tj -1.2 -1.8 TD -0.003 Tc -0.06 Tw [(Gershon, R.R., Lin, S., & Li, X. \(2002\). )18(W)94.8(o)0.6(rk stress in aging)]TJ 1.2 -1.401 TD 0.0027 Tc 0.125 Tw (police officers. )Tj /TT5 1 Tf 6.546 0 TD 0.0019 Tc (Journal of Occupational and Environ-)Tj -6.546 -1.401 TD -0.0043 Tc -0.055 Tw [(mental Medicine)]TJ /TT2 1 Tf 6.576 0 TD -0.001 Tc 0 Tw (, )Tj /TT5 1 Tf 0.444 0 TD -0.01 Tc (44)Tj /TT2 1 Tf 0.99 0 TD -0.0037 Tc -0.06 Tw (, 160-167.)Tj -9.21 -1.8 TD -0.0102 Tc -0.0622 Tw [(Gonzales, )50.1(A.R., Henke, )14.1(T)75.6(.A., & Flores, J.R. \(2005\).The math-)]TJ 1.2 -1.398 TD -0.0034 Tc 0.065 Tw (ematics of risk classification: )Tj /TT5 1 Tf 12.096 0 TD -0.0039 Tc (National Center for Juve-)Tj -12.096 -1.401 TD -0.0624 Tw (nile Justice Report, )Tj /TT2 1 Tf 7.734 0 TD -0.0035 Tc -0.0625 Tw [(July)59.5(. NCJ 209158, pp. 1-6.)]TJ -8.934 -1.8 TD -0.0054 Tc -0.0621 Tw [(Greenber)12.6(g, R.S., Daniels, S.R., Flanders, D.W)84.6(., Eley)66.6(, J.W)87.6(., &)]TJ 1.2 -1.401 TD -0.0189 Tc -0.0617 Tw [(Boring, J.R. \(1996\). )]TJ /TT5 1 Tf 7.671 0 TD -0.0202 Tc -0.06 Tw [(Medical epidemiology)48.8(.)]TJ /TT2 1 Tf 8.634 0 TD -0.0199 Tc -0.0644 Tw [( S)16.1(tanford, Conn:)]TJ -16.305 -1.398 TD -0.0043 Tc 0.0225 Tw (Appleton & Lange.)Tj -1.2 -1.8 TD -0.003 Tc -0.0072 Tw (Guralnick, L. \(1963\) . Mortality by occupation and cause of)Tj 1.2 -1.401 TD -0.0033 Tc -0.0341 Tw (death among men 20-64 years of age.)Tj /TT5 1 Tf 14.706 0 TD -0.0036 Tc -0.036 Tw [( V)71.4(ital S)32.4(tatistics Spe-)]TJ -14.706 -1.401 TD -0.0033 Tc -0.0001 Tw (cial Reports, 53, )Tj /TT2 1 Tf 6.804 0 TD -0.0044 Tc 0.0025 Tw [(Bethesda, Maryland: DHEW)82.6(.)]TJ -8.004 -1.8 TD -0.0212 Tc -0.062 Tw [(Hartwig, D., & )21(V)65(iolanti, J.M. \(1999\). Suicide by police of)14.8(ficials)]TJ 1.2 -1.398 TD -0.0041 Tc 0.0106 Tw [(in North Rhine-W)76.9(estphalia. )49.8(An evaluation of 58 suicides)]TJ 0 -1.401 TD -0.025 Tw (between 1992-1998. )Tj /TT5 1 Tf 8.289 0 TD (Archives of Kriminologie,)Tj /TT2 1 Tf 10.215 0 TD 0 Tc 0 Tw ( )Tj /TT5 1 Tf 0.225 0 TD -0.0053 Tc (204,)Tj /TT2 1 Tf 1.737 0 TD -0.0048 Tc -0.03 Tw [( 129-)]TJ -20.466 -1.401 TD -0.0583 Tc 0 Tw (142.)Tj -1.2 -1.8 TD -0.0039 Tc -0.035 Tw [(Heiman, M.F)77.1(.\(1977\). Suicide among police)]TJ /TT5 1 Tf 17.07 0 TD -0.0043 Tc -0.0512 Tw [(. American )-13.6(Jour)16.7(-)]TJ -15.87 -1.398 TD -0.0035 Tc -0.025 Tw [(nal of Psychiatry)53.3(,)-0.7( 134,)]TJ /TT2 1 Tf 8.874 0 TD -0.0038 Tc -0.03 Tw [( 1288.)]TJ -10.074 -1.8 TD -0.0117 Tc -0.0625 Tw [(Helmkamp J.C. \(1996\). Occupation and suicide among males)]TJ 1.2 -1.401 TD -0.004 Tc 0.009 Tw [(in the US )50(Armed Forces. )]TJ /TT5 1 Tf 10.125 0 TD -0.0043 Tc 0.01 Tw (Annals of Epidemiology)Tj /TT2 1 Tf 9.54 0 TD 0 Tc 0 Tw (,)Tj /TT5 1 Tf 0.249 0 TD 0.006 Tc ( 6)Tj /TT2 1 Tf 0.756 0 TD -0.0033 Tc 0.01 Tw (, 83-)Tj -20.67 -1.401 TD -0.0625 Tc 0 Tw (88.)Tj -1.2 -1.8 TD -0.0235 Tc -0.0624 Tw [(Hem, E., Ber)18.5(g, )48.6(A.M., & Ekeber)24.5(g, .\(2001\). Suicide in police)]TJ 1.2 -1.398 TD -0.0031 Tc 0.1097 Tw [(a critical review)62.9(. )]TJ /TT5 1 Tf 7.149 0 TD -0.0041 Tc 0.11 Tw [(Suicide & Life Thr)28.9(eatening Behavior)]TJ /TT2 1 Tf 15.102 0 TD 0 Tc 0 Tw (,)Tj /TT5 1 Tf -22.251 -1.401 TD -0.031 Tc (31)Tj /TT2 1 Tf 0.954 0 TD -0.0216 Tc -0.06 Tw (, 224233.)Tj -2.154 -1.8 TD -0.0227 Tc -0.0625 Tw (Hickman, M.J., & Reaves, B.A. \(2006\). Law enforcement man-)Tj 1.2 -1.401 TD -0.0038 Tc 0.113 Tw [(agement and administrative statistics. )17.2(W)94(ashington, DC:)]TJ 0 -1.398 TD -0.0034 Tc 0.0478 Tw (U.S. Department of Justice, Bureau of Justice Statistics,)Tj 0 -1.401 TD -0.0403 Tc -0.06 Tw (NCJ, 210118.)Tj -1.2 -1.8 TD -0.0154 Tc -0.0612 Tw [(Jenkins, E.L. \(2005\). Suicide. In)]TJ /TT1 1 Tf 12.225 0 TD 0 Tc 0 Tw ( )Tj /TT2 1 Tf 0.18 0 TD -0.0161 Tc -0.0619 Tw [(B.S. Levy)61.9(, G)115.9(.R.W)76.9(agner)37.9(, K.M.)]TJ -11.205 -1.401 TD -0.0041 Tc 0.0848 Tw [(Rest, & J.L.W)76.9(eeks \(Eds.\))]TJ /TT5 1 Tf 10.275 0 TD 0.0859 Tw [(, Pr)31.8(eventing)]TJ /TT4 1 Tf 4.896 0 TD 0 Tc 0 Tw ( )Tj /TT5 1 Tf 0.333 0 TD -0.0047 Tc (occupational)Tj /TT4 1 Tf 5.172 0 TD 0 Tc ( )Tj /TT5 1 Tf 0.339 0 TD -0.005 Tc (dis-)Tj -21.015 -1.398 TD 0.0586 Tc 0.53 Tw (ease and injury \(2)Tj 5.8 0 0 5.8 165 237.99 Tm 0.0603 Tc 0 Tw (nd)Tj 10 0 0 10 171.51 234.66 Tm 0.0585 Tc 0.53 Tw [( Edition)]TJ /TT2 1 Tf 4.2 0 TD 0.0591 Tc (\), \(pp.473-475\).)Tj -14.751 -1.401 TD -0.0043 Tc -0.0022 Tw [(W)93.5(a)0.3(shington,DC: )50(American Public Health )50(Association)]TJ -1.2 -1.8 TD -0.0105 Tc -0.0617 Tw (Johnson, D.L. \(1995, September\))Tj /TT5 1 Tf 12.801 0 TD -0.0108 Tc -0.0616 Tw [(. W)85.2(orkplace violence: Prac-)]TJ -11.601 -1.401 TD -0.0033 Tc 0.125 Tw (tical strategies involving EAPs and mental health pro-)Tj 0 -1.398 TD -0.0037 Tc 0 Tw (fessionals. )Tj /TT2 1 Tf 4.359 0 TD -0.045 Tw [(Symposium conducted at the )14.3(W)94.1(ork, S)17.3(tress and)]TJ -4.359 -1.401 TD -0.0038 Tc -0.0136 Tw [(Health 95 conference, )14.4(W)97(ashington, DC.)]TJ -1.2 -1.8 TD -0.0034 Tc -0.0044 Tw [(Josephson, R.L., & Reiser)38.6(, M. \(1990\). Of)14.6(ficer suicide in the)]TJ 1.2 -1.401 TD -0.0036 Tc -0.0275 Tw [(Los )50.8(Angeles police department: )50.8(A)58.6( twelve year follow-up.)]TJ /TT5 1 Tf 0 -1.398 TD 0.0879 Tw (Journal of Police Science and Administration, 17, )Tj /TT2 1 Tf 20.685 0 TD -0.006 Tc 0 Tw (227-)Tj -20.685 -1.401 TD -0.0583 Tc (229.)Tj 24.3 62.199 TD -0.0116 Tc -0.0621 Tw [(Kappeler)33.4(,)-8.7( )18.4(V)137.6(.E., Blumber)12.4(g, M., & Potter)33.4(, G)114.4(.)18.2(W)81.4(.)-1.1( \(1993\).)]TJ /TT5 1 Tf 20.409 0 TD -0.0119 Tc -0.0625 Tw [( The my-)]TJ -19.209 -1.398 TD -0.0036 Tc -0.03 Tw (thology of crime and criminal justice )Tj /TT2 1 Tf 14.739 0 TD -0.0039 Tc [(\(pp.134-136\). Pros-)]TJ -14.739 -1.401 TD -0.0036 Tc 0.0036 Tw [(pect Heights, Illinois: )17.7(W)94.2(aveland.)]TJ -1.2 -1.8 TD -0.0031 Tc -0.0371 Tw [(Kirsher)35.9(,)-5.4( )18.1(T)76.7(., Nelson, J., & Burdo, H. \(1985\). )18.1(The autopsy as a)]TJ 1.2 -1.401 TD -0.0029 Tc -0.0219 Tw (measure of the accuracy of the death certificate. )Tj /TT5 1 Tf 19.086 0 TD -0.0054 Tc -0.025 Tw [(New En-)]TJ -19.086 -1.398 TD -0.0037 Tc -0.0175 Tw (gland Journal of Medicine, 313,)Tj /TT2 1 Tf 12.705 0 TD -0.0043 Tc -0.02 Tw [( 1263-1269.)]TJ -13.905 -1.8 TD -0.0232 Tc -0.0613 Tw [(Kramer)36.8(, M., Pollack, E., Reddick, R., & Locke, B. \(1972.\))]TJ /TT5 1 Tf 21.504 0 TD -0.0247 Tc -0.065 Tw [( Men-)]TJ -20.304 -1.401 TD 0.0114 Tc 0.125 Tw (tal disorders/suicide. )Tj /TT2 1 Tf 9.21 0 TD (Cambridge: Harvard University)Tj -9.21 -1.401 TD 0.0077 Tc 0 Tw (Press.)Tj -1.2 -1.8 TD -0.0035 Tc 0.0338 Tw (Langston, E. \(1995, March\). )Tj /TT5 1 Tf 11.649 0 TD -0.0034 Tc 0.035 Tw (Police suicide. )Tj /TT2 1 Tf 6.156 0 TD -0.0039 Tc (Presentation at)Tj -16.605 -1.398 TD -0.0024 Tc 0.1251 Tw [(American Criminal Justice Society )51.7(Annual conference.)]TJ 0 -1.401 TD -0.0045 Tc 0.1 Tw (Boston, MA.)Tj -1.2 -1.8 TD -0.0032 Tc -0.0127 Tw [(Lester)35.8(, D. \(1992\). Suicide in police of)17.8(ficers: )51.1(A)59( survey of na-)]TJ 1.2 -1.401 TD -0.0033 Tc 0 Tw (tions. )Tj /TT5 1 Tf 2.4 0 TD -0.0034 Tc -0.025 Tw [( Police Studies, 15,)]TJ /TT2 1 Tf 7.554 0 TD -0.004 Tc -0.03 Tw [( 146-148.)]TJ -11.154 -1.8 TD -0.0038 Tc -0.0622 Tw [(Loo, R. \(2003\). )53.2(A)58.4( meta-analysis of police suicide rates: Find-)]TJ 1.2 -1.398 TD 0.0047 Tc 0.125 Tw (ings and issues. )Tj /TT5 1 Tf 6.954 0 TD 0.004 Tc [(Suicide & Life-Thr)28(eatening Behavior)103(,)]TJ -6.954 -1.401 TD -0.034 Tc 0 Tw (33)Tj /TT2 1 Tf 0.945 0 TD -0.027 Tc -0.06 Tw (, 313-325.)Tj -2.145 -1.8 TD -0.006 Tc -0.0621 Tw [(Marzuk P)105(.M., Nock, M.K., Leon, )54.1(A.C., Portera, L., & )21.1(T)73.8(ardif)15(f,)]TJ 1.2 -1.401 TD -0.0034 Tc -0.023 Tw [(K. \(2002\). Suicide among New )32.7(Y)103.8(ork City police of)17.6(ficers,)]TJ 0 -1.398 TD -0.0044 Tc 0 Tw (19771996. )Tj /TT5 1 Tf 4.941 0 TD -0.004 Tc -0.0167 Tw (American Journal of Psychiatry)Tj /TT2 1 Tf 12.633 0 TD -0.014 Tc 0 Tw ( ,)Tj /TT5 1 Tf 0.486 0 TD -0.0075 Tc (159)Tj /TT2 1 Tf 1.485 0 TD -0.0042 Tc -0.02 Tw (, 2069)Tj -19.545 -1.401 TD -0.0563 Tc 0 Tw (2071.)Tj -1.2 -1.8 TD -0.0117 Tc -0.0621 Tw [(McMichael, )54.3(A.J. \(1976\). S)18.3(tandardized mortality ratios and the)]TJ 1.2 -1.401 TD 0.0033 Tc 0.125 Tw (healthy worker effect: Scratching beneath the surface)Tj /TT5 1 Tf 22.251 0 TD 0 Tc 0 Tw (.)Tj -22.251 -1.398 TD -0.0038 Tc 0.0112 Tw (Journal of Occupational Medicine, 18,)Tj /TT2 1 Tf 15.459 0 TD -0.004 Tc 0.015 Tw [( 165-168.)]TJ -16.659 -1.8 TD -0.0036 Tc 0.115 Tw (Milham, S. \(1979\). )Tj /TT5 1 Tf 8.169 0 TD -0.0043 Tc 0.117 Tw [(Occupational mortality in W)85.7(ashington)]TJ -6.969 -1.401 TD -0.0029 Tc 0 Tw (state. )Tj /TT2 1 Tf 2.421 0 TD -0.0033 Tc 0.0549 Tw [(U.S. Dept. of Health,Education, and )17.6(W)94.5(elfare, 1-3.)]TJ -2.421 -1.401 TD -0.0054 Tc -0.0619 Tw [(W)92.5(ashington)-5.4(, DC: US Government Printing Of)15.6(fice.)]TJ -1.2 -1.8 TD -0.0109 Tc -0.0621 Tw (National Institute for Occupational Safety and Health. \(1993\).)Tj /TT5 1 Tf 1.2 -1.398 TD -0.0044 Tc -0.0624 Tw [(Fatal injuries to workers in the United States, 1980-1989:)]TJ 0 -1.401 TD -0.0197 Tc -0.0617 Tw (A decade of surveillance)Tj /TT2 1 Tf 9.204 0 TD -0.0202 Tc -0.0625 Tw [( \(DHHS NIOSH No. 93-108\). Cin-)]TJ -9.204 -1.401 TD -0.0152 Tc (cinnati, Ohio: NIOSH.)Tj -1.2 -1.8 TD -0.0033 Tc 0.0613 Tw [(OCarroll. P)104.7(.)14.5(W)89.7(.)-0.7( \(1989\). )50.7(A)58.9( consideration of the validity and)]TJ 1.2 -1.398 TD 0.0077 Tc 0.125 Tw (reliability of suicide mortality data.)Tj /TT5 1 Tf 14.931 0 TD 0.0066 Tc [( Suicide and Life-)]TJ -14.931 -1.401 TD -0.0044 Tc 0.0408 Tw [(Thr)31.6(eatening Behavior)103.6(, 19,)]TJ /TT2 1 Tf 10.395 0 TD -0.0036 Tc 0.04 Tw [( 1-16.)]TJ -11.595 -1.8 TD -0.0171 Tw (Pescosolido, B., & Mendelsohn, R. \(1986\). 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298.604 l 468.161 296.533 l 466.701 296.533 l f* 470.63 299.305 m 469.995 299.305 l 469.995 294.6 l 473.014 294.6 l 473.014 295.164 l 470.63 295.164 l 470.63 299.305 l f* 444.206 291.425 0.635 -4.706 re f 448.987 287.624 m 448.974 287.624 l 446.623 291.424 l 445.87 291.424 l 445.87 286.72 l 446.485 286.72 l 446.485 290.52 l 446.499 290.52 l 448.889 286.72 l 449.603 286.72 l 449.603 291.424 l 448.987 291.424 l 448.987 287.624 l f* 454.363 290.009 m 454.271 290.796 453.642 291.549 452.432 291.549 c 451.063 291.549 450.238 290.546 450.238 289.098 c 450.238 287.29 451.286 286.594 452.353 286.594 c 452.707 286.594 454.147 286.673 454.408 288.45 c 453.793 288.45 l 453.577 287.355 452.864 287.159 452.452 287.159 c 451.286 287.159 450.893 288.011 450.893 289.118 c 450.893 290.357 451.58 290.985 452.432 290.985 c 452.884 290.985 453.57 290.835 453.747 290.009 c 454.363 290.009 l f* 455.122 291.425 0.635 -4.706 re f 456.819 286.72 m 458.698 286.72 l 460.244 286.72 460.702 288.083 460.702 289.138 c 460.702 290.494 459.949 291.424 458.724 291.424 c 456.819 291.424 l 456.819 286.72 l h 457.454 290.881 m 458.639 290.881 l 459.504 290.881 460.047 290.284 460.047 289.098 c 460.047 287.912 459.51 287.264 458.685 287.264 c 457.454 287.264 l 457.454 290.881 l f* 464.9 287.283 m 462.064 287.283 l 462.064 288.856 l 464.638 288.856 l 464.638 289.419 l 462.064 289.419 l 462.064 290.861 l 464.854 290.861 l 464.854 291.424 l 461.429 291.424 l 461.429 286.72 l 464.9 286.72 l 464.9 287.283 l f* 468.711 287.624 m 468.698 287.624 l 466.347 291.424 l 465.594 291.424 l 465.594 286.72 l 466.21 286.72 l 466.21 290.52 l 466.223 290.52 l 468.613 286.72 l 469.327 286.72 l 469.327 291.424 l 468.711 291.424 l 468.711 287.624 l f* 469.766 290.861 m 471.357 290.861 l 471.357 286.719 l 471.992 286.719 l 471.992 290.861 l 473.584 290.861 l 473.584 291.424 l 469.766 291.424 l 469.766 290.861 l f* 449.822 282.168 m 449.796 282.686 449.632 283.669 447.988 283.669 c 446.849 283.669 446.371 282.948 446.371 282.214 c 446.371 281.395 447.065 281.179 447.373 281.107 c 448.335 280.884 l 449.108 280.701 449.337 280.543 449.337 280.052 c 449.337 279.377 448.565 279.259 448.106 279.259 c 447.504 279.259 446.81 279.508 446.81 280.36 c 446.213 280.36 l 446.213 279.921 446.292 279.528 446.692 279.167 c 446.901 278.977 447.242 278.714 448.113 278.714 c 448.918 278.714 449.953 279.023 449.953 280.137 c 449.953 280.884 449.495 281.251 448.886 281.395 c 447.543 281.703 l 447.268 281.768 446.986 281.9 446.986 282.299 c 446.986 283.013 447.661 283.125 448.06 283.125 c 448.591 283.125 449.193 282.896 449.226 282.168 c 449.822 282.168 l f* 450.215 282.981 m 451.806 282.981 l 451.806 278.839 l 452.441 278.839 l 452.441 282.981 l 454.032 282.981 l 454.032 283.544 l 450.215 283.544 l 450.215 282.981 l f* 455.211 280.858 m 456.75 280.858 l 457.509 280.858 457.588 280.406 457.588 280.019 c 457.588 279.842 457.608 279.128 457.699 278.84 c 458.478 278.84 l 458.478 278.945 l 458.282 279.056 458.249 279.154 458.243 279.416 c 458.203 280.268 l 458.177 280.923 457.909 281.041 457.64 281.153 c 457.941 281.33 458.295 281.585 458.295 282.28 c 458.295 283.276 457.522 283.544 456.75 283.544 c 454.575 283.544 l 454.575 278.84 l 455.211 278.84 l 455.211 280.858 l h 455.211 283 m 456.796 283 l 457.11 283 457.64 282.941 457.64 282.214 c 457.64 281.52 457.149 281.402 456.684 281.402 c 455.211 281.402 l 455.211 283 l f* 462.611 279.403 m 459.775 279.403 l 459.775 280.976 l 462.349 280.976 l 462.349 281.539 l 459.775 281.539 l 459.775 282.981 l 462.565 282.981 l 462.565 283.544 l 459.14 283.544 l 459.14 278.84 l 462.611 278.84 l 462.611 279.403 l f* 466.737 282.168 m 466.711 282.686 466.547 283.669 464.903 283.669 c 463.764 283.669 463.286 282.948 463.286 282.214 c 463.286 281.395 463.98 281.179 464.288 281.107 c 465.25 280.884 l 466.023 280.701 466.252 280.543 466.252 280.052 c 466.252 279.377 465.48 279.259 465.021 279.259 c 464.418 279.259 463.724 279.508 463.724 280.36 c 463.129 280.36 l 463.129 279.921 463.207 279.528 463.606 279.167 c 463.816 278.977 464.157 278.714 465.028 278.714 c 465.833 278.714 466.868 279.023 466.868 280.137 c 466.868 280.884 466.409 281.251 465.8 281.395 c 464.458 281.703 l 464.183 281.768 463.901 281.9 463.901 282.299 c 463.901 283.013 464.576 283.125 464.975 283.125 c 465.505 283.125 466.108 282.896 466.141 282.168 c 466.737 282.168 l f* 470.968 282.168 m 470.941 282.686 470.777 283.669 469.134 283.669 c 467.994 283.669 467.516 282.948 467.516 282.214 c 467.516 281.395 468.21 281.179 468.518 281.107 c 469.481 280.884 l 470.254 280.701 470.483 280.543 470.483 280.052 c 470.483 279.377 469.71 279.259 469.252 279.259 c 468.649 279.259 467.955 279.508 467.955 280.36 c 467.359 280.36 l 467.359 279.921 467.438 279.528 467.837 279.167 c 468.047 278.977 468.387 278.714 469.258 278.714 c 470.064 278.714 471.098 279.023 471.098 280.137 c 471.098 280.884 470.64 281.251 470.031 281.395 c 468.688 281.703 l 468.413 281.768 468.132 281.9 468.132 282.299 c 468.132 283.013 468.806 283.125 469.206 283.125 c 469.736 283.125 470.339 282.896 470.372 282.168 c 470.968 282.168 l f* 439.337 273.096 m 441.642 273.096 l 441.642 273.659 l 439.337 273.659 l 439.337 275.101 l 441.957 275.101 l 441.957 275.664 l 438.702 275.664 l 438.702 270.958 l 439.337 270.958 l 439.337 273.096 l f* 446.2 273.312 m 446.2 272.204 445.585 271.398 444.563 271.398 c 443.542 271.398 442.926 272.204 442.926 273.312 c 442.926 274.419 443.542 275.225 444.563 275.225 c 445.585 275.225 446.2 274.419 446.2 273.312 c h 446.855 273.312 m 446.855 274.327 446.318 275.789 444.563 275.789 c 442.808 275.789 442.271 274.327 442.271 273.312 c 442.271 272.296 442.808 270.834 444.563 270.834 c 446.318 270.834 446.855 272.296 446.855 273.312 c f* 450.536 275.664 m 450.536 272.689 l 450.536 271.667 449.881 271.398 449.298 271.398 c 448.728 271.398 448.106 271.68 448.106 272.703 c 448.106 275.664 l 447.471 275.664 l 447.471 272.526 l 447.471 271.647 448.015 270.834 449.279 270.834 c 450.569 270.834 451.171 271.647 451.171 272.611 c 451.171 275.664 l 450.536 275.664 l f* 455.145 271.864 m 455.132 271.864 l 452.781 275.664 l 452.029 275.664 l 452.029 270.96 l 452.645 270.96 l 452.645 274.76 l 452.658 274.76 l 455.047 270.96 l 455.761 270.96 l 455.761 275.664 l 455.145 275.664 l 455.145 271.864 l f* 456.638 270.96 m 458.518 270.96 l 460.063 270.96 460.522 272.322 460.522 273.377 c 460.522 274.734 459.769 275.664 458.544 275.664 c 456.638 275.664 l 456.638 270.96 l h 457.274 275.12 m 458.459 275.12 l 459.323 275.12 459.867 274.524 459.867 273.338 c 459.867 272.152 459.33 271.503 458.505 271.503 c 457.274 271.503 l 457.274 275.12 l f* 463.548 272.329 m 464.012 270.958 l 464.707 270.958 l 463.004 275.664 l 462.284 275.664 l 460.515 270.958 l 461.17 270.958 l 461.661 272.329 l 463.548 272.329 l h 461.858 272.892 m 462.611 274.963 l 462.624 274.963 l 463.318 272.892 l 461.858 272.892 l f* 463.96 275.101 m 465.551 275.101 l 465.551 270.958 l 466.187 270.958 l 466.187 275.101 l 467.778 275.101 l 467.778 275.664 l 463.96 275.664 l 463.96 275.101 l f* 468.341 275.664 0.635 -4.706 re f 473.692 273.312 m 473.692 272.204 473.076 271.398 472.054 271.398 c 471.033 271.398 470.417 272.204 470.417 273.312 c 470.417 274.419 471.033 275.225 472.054 275.225 c 473.076 275.225 473.692 274.419 473.692 273.312 c h 474.346 273.312 m 474.346 274.327 473.81 275.789 472.054 275.789 c 470.299 275.789 469.762 274.327 469.762 273.312 c 469.762 272.296 470.299 270.834 472.054 270.834 c 473.81 270.834 474.346 272.296 474.346 273.312 c f* 478.06 271.864 m 478.047 271.864 l 475.696 275.664 l 474.943 275.664 l 474.943 270.96 l 475.558 270.96 l 475.558 274.76 l 475.571 274.76 l 477.962 270.96 l 478.674 270.96 l 478.674 275.664 l 478.06 275.664 l 478.06 271.864 l f* 0.161 0.145 0.149 RG 0.332 w 2.613 M 456.908 339.105 m 460.245 339.105 l 460.244 335.682 l 463.005 337.483 l 464.597 334.889 l 461.642 333.167 l 464.619 331.479 l 463.089 328.821 l 460.224 330.483 l 460.224 326.989 l 456.921 326.989 l 456.92 330.405 l 453.997 328.72 l 452.466 331.496 l 455.357 333.144 l 452.413 334.869 l 453.939 337.448 l 456.908 335.681 l 456.908 339.105 l b* 1 1 1 rg 458.95 337.599 m 458.553 338.297 458.208 337.589 y 458.542 328.632 l 458.668 328.381 458.721 328.656 y 458.95 337.599 l f* 1 1 1 RG 0.166 w 458.315 334.745 m 458.088 334.886 457.983 335.008 y 457.408 335.623 457.396 336.094 y 457.38 336.508 457.523 336.743 y 457.641 337 458.007 337.135 y 458.224 337.219 458.254 337.196 y 458.542 337.192 458.683 336.959 y 459.15 336.625 458.541 336.635 y 458.252 336.677 458.167 336.741 y 457.809 336.645 457.88 336.114 y 457.952 335.799 458.142 335.455 458.294 335.376 c 458.315 334.745 l b* 458.54 336.938 m 458.493 336.943 458.443 336.922 458.4 336.943 c 458.381 336.954 458.373 336.979 458.38 336.995 c 458.386 337.008 458.417 337.03 458.439 337.021 c 458.483 337.005 458.494 336.951 458.54 336.938 c b* 458.51 330.434 m 458.538 330.601 458.617 330.726 v 458.686 330.834 458.745 330.891 458.859 331.012 c 458.923 331.08 459.012 331.205 459.077 331.283 c 459.299 331.562 459.114 331.862 v 459.029 331.99 458.801 332.189 v 458.806 331.576 l 458.803 331.432 458.414 330.989 y 458.316 330.865 458.267 330.806 458.22 330.456 c 458.22 330.455 458.183 330.053 458.512 329.624 c 458.492 330.272 l 458.498 330.381 458.51 330.434 v b* 458.869 334.358 m 458.903 334.254 458.364 333.689 y 458.317 333.635 458.262 333.575 458.201 333.506 c 457.862 333.14 457.88 332.836 v 457.897 332.414 458.31 332.017 v 458.361 331.975 458.431 331.899 v 458.413 332.479 l 458.368 332.533 458.317 332.617 458.275 332.746 c 458.23 332.837 458.353 333.032 v 458.57 333.231 459.272 334.064 v 459.476 334.411 459.315 334.64 v 459.16 334.869 458.886 335.049 v 458.869 334.358 l b* 458.733 329.342 m 458.754 329.267 458.743 329.175 458.652 329.071 c 458.457 328.79 l 458.677 328.884 458.781 329.015 v 458.912 329.144 458.88 329.382 v 458.858 329.495 458.745 329.678 v 458.733 329.342 l b* 0.161 0.145 0.149 rg 0.161 0.145 0.149 RG 1 j 0.332 w 459.045 242.72 m 459.2 242.766 459.317 242.674 459.473 242.766 c 459.784 242.905 460.056 242.998 460.329 243.229 c 460.523 243.367 460.64 243.598 460.835 243.783 c 460.913 243.829 461.038 243.832 461.068 243.69 c 461.107 243.506 461.224 243.46 461.341 243.413 c 461.924 243.183 462.508 243.321 463.092 243.414 c 463.754 243.506 464.221 244.107 464.843 244.384 c 465.154 244.569 465.39 244.923 465.699 244.985 c 465.933 245.031 466.205 245.031 466.4 245.216 c 466.516 245.308 466.478 245.447 v 466.905 245.493 467.217 245.816 467.489 246.186 c 467.567 246.232 467.684 246.324 467.801 246.278 c 467.762 246.278 l 470.641 249.928 l 470.602 250.02 l 470.563 250.158 470.641 250.297 470.563 250.435 c 461.885 248.078 l 461.846 247.755 461.496 247.339 461.301 247.062 c 461.336 247.112 460.644 247.514 460.708 247.642 c 461.123 248.472 461.018 249.238 460.59 249.976 c 460.512 250.161 460.434 250.23 460.317 250.392 c 460.021 250.802 459.539 251.039 459.033 250.946 c 458.916 250.946 l 458.41 251.039 458.06 250.808 457.691 250.484 c 457.522 250.337 457.224 250.023 457.146 249.838 c 456.718 249.099 456.894 248.198 457.225 247.476 c 457.285 247.346 456.585 247.117 456.62 247.067 c 456.426 247.344 456.076 247.76 456.037 248.083 c 447.359 250.438 l 447.281 250.3 447.359 250.161 447.32 250.023 c 447.281 249.93 l 450.161 246.282 l 450.122 246.282 l 450.239 246.328 450.356 246.235 450.433 246.189 c 450.706 245.82 451.017 245.497 451.445 245.45 c 451.406 245.312 451.523 245.219 y 451.718 245.035 451.99 245.035 452.224 244.989 c 452.533 244.927 452.768 244.573 453.08 244.388 c 453.702 244.111 454.168 243.511 454.83 243.418 c 455.414 243.326 455.998 243.187 456.582 243.418 c 456.698 243.465 456.815 243.511 456.854 243.695 c 456.884 243.837 457.01 243.834 457.087 243.788 c 457.282 243.603 457.399 243.372 457.593 243.233 c 457.866 243.003 458.138 242.91 458.45 242.772 c 458.605 242.679 458.722 242.772 458.878 242.726 c 459.045 242.72 l b* 1 1 1 rg 451.951 248.657 m 455.823 247.713 l 455.803 247.713 455.803 247.737 455.784 247.737 c 455.881 247.436 455.998 247.136 456.076 246.813 c 456.184 246.364 456.076 245.866 456.056 245.404 c 455.861 245.497 455.842 245.635 v 455.764 245.958 455.764 246.189 455.686 246.512 c 455.667 246.536 455.55 246.651 455.531 246.697 c 455.402 247.002 455.239 247.044 454.966 247.205 c 454.655 247.367 454.344 247.621 454.052 247.76 c 453.43 248.037 452.768 248.083 452.165 248.383 c 452.146 248.406 452.087 248.429 452.068 248.499 c 452.054 248.547 451.893 248.545 451.951 248.657 c f* 452.905 247.875 m 452.944 247.829 452.983 247.737 453.021 247.713 c 453.197 247.621 453.372 247.644 453.546 247.644 c 453.508 247.667 453.469 247.713 453.43 247.713 c 453.215 247.713 453.08 247.783 452.905 247.875 c f* 453.487 247.275 m 453.664 247.275 453.818 247.298 453.993 247.275 c 454.013 247.251 453.993 247.205 453.974 247.182 c 453.818 247.136 453.664 247.044 453.508 246.998 c 453.469 246.974 453.41 246.998 y 453.333 246.928 453.131 246.897 453.158 246.974 c 453.197 247.09 453.333 247.159 453.43 247.228 c 453.487 247.275 l f* 453.508 246.489 m 453.565 246.489 453.625 246.466 453.682 246.512 c 453.799 246.605 453.993 246.744 454.13 246.767 c 453.508 246.489 l f* 453.974 246.143 m 454.149 246.143 454.363 246.097 454.499 246.166 c 454.558 246.212 454.636 246.305 454.674 246.42 c 454.421 246.374 454.266 246.212 454.013 246.212 c 453.974 246.143 l f* 455.18 245.982 m 455.142 245.982 455.103 246.005 455.064 245.982 c 454.927 245.889 454.772 245.866 454.674 245.727 c 454.636 245.658 454.636 245.566 454.636 245.497 c 454.674 245.497 454.713 245.473 454.733 245.497 c 454.83 245.681 455.005 245.727 455.103 245.889 c 455.18 245.982 l f* 454.83 245.127 m 454.83 245.104 454.83 245.058 454.83 245.035 c 455.064 244.966 455.219 245.173 455.395 245.335 c 455.531 245.45 455.395 245.543 455.278 245.45 c 455.219 245.404 455.122 245.335 455.044 245.266 c 454.986 245.196 454.889 245.243 454.811 245.173 c 454.83 245.15 454.83 245.127 v f* 455.57 244.942 m 455.667 244.942 455.686 245.058 455.764 245.104 c 455.57 244.942 l f* 455.998 244.919 m 455.998 244.873 455.998 244.85 455.998 244.804 c 456.037 244.804 l 456.037 244.758 456.037 244.688 456.037 244.642 c 455.998 244.919 l f* 448.176 249.422 m 448.293 249.445 448.39 249.399 448.487 249.353 c 448.507 249.353 448.546 249.307 448.585 249.284 c 448.702 249.238 448.818 249.191 448.935 249.145 c 449.305 249.03 449.694 249.053 450.044 248.845 c 450.18 248.776 450.336 248.706 450.472 248.66 c 450.842 248.568 451.173 248.568 451.543 248.499 c 451.601 248.476 451.659 248.406 451.737 248.406 c 451.348 248.429 450.959 248.36 450.55 248.429 c 450.336 248.476 450.122 248.452 449.908 248.522 c 449.85 248.545 449.83 248.614 449.772 248.637 c 449.558 248.706 449.363 248.614 449.168 248.683 c 449.091 248.706 448.993 248.706 448.916 248.753 c 448.643 248.845 448.468 249.099 448.254 249.33 c 448.234 249.353 448.274 249.399 448.234 249.422 c 448.176 249.422 l f* 448.624 248.614 m 448.702 248.522 448.76 248.406 448.877 248.36 c 449.071 248.314 449.246 248.175 449.441 248.129 c 449.674 248.06 449.889 248.014 450.122 247.99 c 450.414 247.944 450.686 247.944 450.978 247.852 c 450.998 247.852 451.058 247.837 451.076 247.829 c 451.523 247.621 451.99 247.713 452.438 247.713 c 452.457 247.852 452.399 248.037 452.263 248.06 c 452.049 248.106 451.854 247.99 451.64 247.967 c 451.367 247.921 451.115 247.921 450.842 247.967 c 450.745 247.99 450.667 248.014 450.589 248.06 c 450.336 248.175 450.083 248.06 449.83 248.175 c 449.733 248.221 449.655 248.245 449.558 248.291 c 449.285 248.36 449.013 248.406 448.76 248.522 c 448.624 248.614 l f* 449.558 247.483 m 449.986 247.459 450.433 247.575 450.862 247.436 c 450.939 247.413 450.998 247.298 451.095 247.275 c 451.251 247.251 451.406 247.298 451.562 247.321 c 451.893 247.39 452.224 247.298 452.554 247.367 c 451.971 246.905 451.212 247.067 450.55 247.113 c 450.394 247.113 450.278 247.251 450.142 247.275 c 450.025 247.275 449.889 247.275 449.772 247.321 c 449.713 247.344 449.674 247.39 449.616 247.413 c 449.558 247.483 l f* 450.686 246.42 m 450.667 246.443 450.706 246.466 450.706 246.489 c 451.056 246.466 451.406 246.582 451.757 246.651 c 452.146 246.721 452.535 246.559 452.924 246.721 c 452.866 246.697 452.805 246.67 452.749 246.651 c 452.068 246.42 451.465 246.466 450.803 246.443 c 450.686 246.42 l f* 451.445 245.773 m 451.659 245.727 451.932 245.773 452.146 245.773 c 452.418 245.82 452.705 245.754 452.983 245.82 c 453.177 245.866 453.158 246.028 453.391 246.282 c 453.099 246.259 452.963 246.235 452.613 246.259 c 452.391 246.273 452.243 246.12 452.029 246.051 c 451.854 246.005 451.854 246.097 451.718 245.982 c 451.445 245.773 l f* 452.185 245.219 m 452.496 245.196 452.788 245.219 453.099 245.289 c 453.119 245.312 453.158 245.335 453.177 245.358 c 453.294 245.404 453.43 245.358 453.546 245.45 c 453.628 245.515 453.682 245.589 453.779 245.635 c 453.799 245.658 453.839 245.889 453.818 245.889 c 453.741 245.912 453.625 245.773 453.546 245.727 c 453.487 245.727 453.469 245.658 453.41 245.635 c 453.158 245.543 453.138 245.681 452.905 245.52 c 452.768 245.427 452.321 245.45 452.204 245.289 c 452.185 245.219 l f* 453.041 244.711 m 453.254 244.688 453.449 244.781 453.643 244.85 c 453.818 244.919 454.013 245.012 454.168 245.173 c 453.839 245.266 453.546 244.989 453.215 244.896 c 453.177 244.896 453.08 244.827 453.099 244.734 c 453.041 244.711 l f* 453.508 244.434 m 453.546 244.296 453.721 244.319 453.799 244.365 c 453.955 244.481 454.188 244.527 454.227 244.758 c 454.149 244.758 454.091 244.781 454.013 244.734 c 453.955 244.688 453.916 244.642 453.877 244.573 c 453.799 244.457 453.643 244.55 453.565 244.411 c 453.508 244.434 l f* 454.208 244.065 m 454.363 244.065 454.519 244.065 454.674 244.065 c 454.655 244.25 454.713 244.434 454.83 244.573 c 454.83 244.596 454.83 244.642 454.83 244.665 c 454.733 244.711 454.655 244.596 454.577 244.527 c 454.519 244.457 454.519 244.342 454.538 244.25 c 454.441 244.25 454.344 244.204 454.285 244.111 c 454.208 244.065 l f* 455.005 243.949 m 455.18 243.995 455.278 244.18 455.433 244.25 c 455.005 243.949 l f* 455.453 243.972 m 455.57 243.972 455.628 244.157 455.725 244.25 c 455.453 243.972 l f* 455.9 243.949 m 456.042 243.949 456.192 243.88 456.329 243.949 c 456.329 244.019 l 456.231 244.065 456.192 244.25 456.076 244.204 c 456.056 244.204 456.037 244.088 455.998 244.042 c 455.978 244.042 455.959 244.042 455.939 244.042 c 455.9 244.019 455.881 243.949 455.9 243.949 c f* 465.971 248.653 m 462.099 247.709 l 462.118 247.709 462.118 247.732 462.138 247.732 c 462.04 247.432 461.924 247.131 461.846 246.808 c 461.738 246.359 461.846 245.861 461.866 245.399 c 462.06 245.492 462.08 245.631 v 462.158 245.954 462.157 246.185 462.235 246.508 c 462.255 246.531 462.371 246.647 462.391 246.693 c 462.519 246.998 462.683 247.039 462.955 247.201 c 463.266 247.363 463.578 247.617 463.87 247.755 c 464.492 248.033 465.154 248.079 465.757 248.379 c 465.776 248.402 465.835 248.425 465.854 248.495 c 465.868 248.544 466.029 248.541 465.971 248.653 c f* 465.018 247.871 m 464.979 247.825 464.94 247.732 464.901 247.709 c 464.726 247.617 464.551 247.64 464.376 247.64 c 464.415 247.663 464.453 247.709 464.492 247.709 c 464.706 247.709 464.842 247.779 465.018 247.871 c f* 464.434 247.271 m 464.259 247.271 464.103 247.294 463.928 247.271 c 463.908 247.247 463.928 247.201 463.947 247.178 c 464.103 247.132 464.259 247.04 464.415 246.993 c 464.453 246.97 464.512 246.993 y 464.59 246.924 464.791 246.893 464.765 246.97 c 464.726 247.086 464.59 247.155 464.492 247.224 c 464.434 247.271 l f* 464.415 246.486 m 464.356 246.486 464.298 246.462 464.24 246.509 c 464.123 246.601 463.928 246.739 463.792 246.762 c 464.415 246.486 l f* 463.948 246.139 m 463.773 246.139 463.559 246.093 463.422 246.162 c 463.364 246.208 463.286 246.3 463.247 246.416 c 463.5 246.37 463.656 246.208 463.909 246.208 c 463.948 246.139 l f* 462.741 245.977 m 462.78 245.977 462.819 246 462.858 245.977 c 462.994 245.885 463.15 245.862 463.247 245.723 c 463.286 245.654 463.286 245.562 463.286 245.492 c 463.247 245.492 463.209 245.469 463.189 245.492 c 463.092 245.677 462.916 245.723 462.819 245.885 c 462.741 245.977 l f* 463.092 245.123 m 463.092 245.1 463.092 245.053 463.092 245.03 c 462.858 244.961 462.703 245.169 462.527 245.33 c 462.391 245.446 462.527 245.538 462.644 245.446 c 462.703 245.4 462.8 245.33 462.877 245.261 c 462.936 245.192 463.033 245.238 463.111 245.169 c 463.092 245.146 463.092 245.123 v f* 462.352 244.938 m 462.255 244.938 462.235 245.053 462.158 245.099 c 462.352 244.938 l f* 461.924 244.915 m 461.924 244.868 461.924 244.845 461.924 244.799 c 461.885 244.799 l 461.885 244.753 461.885 244.684 461.885 244.638 c 461.924 244.915 l f* 469.746 249.419 m 469.629 249.442 469.532 249.396 469.434 249.35 c 469.415 249.35 469.376 249.304 469.337 249.281 c 469.221 249.234 469.104 249.188 468.987 249.142 c 468.617 249.027 468.228 249.05 467.878 248.841 c 467.742 248.772 467.586 248.703 467.45 248.657 c 467.08 248.564 466.749 248.564 466.38 248.495 c 466.321 248.472 466.263 248.402 466.185 248.402 c 466.574 248.426 466.963 248.356 467.372 248.426 c 467.586 248.472 467.8 248.449 468.014 248.518 c 468.073 248.541 468.092 248.611 468.15 248.634 c 468.364 248.703 468.559 248.611 468.754 248.68 c 468.832 248.703 468.929 248.703 469.007 248.749 c 469.279 248.842 469.454 249.096 469.668 249.327 c 469.687 249.35 469.649 249.396 469.687 249.419 c 469.746 249.419 l f* 469.298 248.611 m 469.221 248.519 469.162 248.403 469.045 248.357 c 468.851 248.311 468.676 248.172 468.481 248.126 c 468.248 248.057 468.034 248.01 467.8 247.987 c 467.508 247.941 467.236 247.941 466.944 247.848 c 466.925 247.848 466.865 247.834 466.847 247.825 c 466.399 247.617 465.932 247.71 465.485 247.71 c 465.465 247.848 465.524 248.033 465.66 248.056 c 465.874 248.102 466.068 247.987 466.283 247.964 c 466.555 247.918 466.808 247.918 467.08 247.964 c 467.178 247.987 467.255 248.01 467.333 248.057 c 467.586 248.172 467.839 248.057 468.092 248.172 c 468.19 248.218 468.267 248.241 468.364 248.288 c 468.637 248.357 468.909 248.403 469.162 248.519 c 469.298 248.611 l f* 468.365 247.479 m 467.937 247.456 467.489 247.571 467.061 247.433 c 466.983 247.41 466.925 247.294 466.827 247.271 c 466.672 247.248 466.516 247.294 466.36 247.317 c 466.03 247.387 465.699 247.294 465.368 247.363 c 465.952 246.901 466.711 247.063 467.372 247.11 c 467.528 247.11 467.645 247.248 467.781 247.271 c 467.898 247.271 468.034 247.271 468.151 247.318 c 468.209 247.341 468.248 247.387 468.306 247.41 c 468.365 247.479 l f* 467.236 246.417 m 467.256 246.44 467.217 246.463 467.217 246.486 c 466.866 246.463 466.516 246.578 466.166 246.647 c 465.777 246.717 465.388 246.555 464.998 246.717 c 465.057 246.693 465.117 246.666 465.173 246.647 c 465.855 246.416 466.458 246.463 467.12 246.44 c 467.236 246.417 l f* 466.477 245.77 m 466.263 245.724 465.991 245.77 465.777 245.77 c 465.505 245.816 465.218 245.75 464.94 245.816 c 464.746 245.862 464.765 246.024 464.531 246.277 c 464.823 246.255 464.959 246.231 465.31 246.255 c 465.531 246.269 465.679 246.116 465.894 246.047 c 466.069 246.001 466.069 246.093 466.205 245.978 c 466.477 245.77 l f* 465.738 245.216 m 465.427 245.192 465.135 245.216 464.823 245.285 c 464.804 245.308 464.765 245.331 464.746 245.354 c 464.629 245.4 464.493 245.354 464.376 245.446 c 464.295 245.51 464.24 245.585 464.142 245.631 c 464.123 245.654 464.084 245.885 464.104 245.885 c 464.181 245.908 464.298 245.77 464.376 245.723 c 464.434 245.723 464.454 245.654 464.512 245.631 c 464.765 245.539 464.784 245.677 465.018 245.516 c 465.154 245.423 465.602 245.447 465.719 245.285 c 465.738 245.216 l f* 464.882 244.708 m 464.668 244.684 464.473 244.776 464.279 244.846 c 464.104 244.915 463.909 245.007 463.753 245.169 c 464.084 245.261 464.376 244.984 464.707 244.892 c 464.746 244.892 464.843 244.823 464.824 244.731 c 464.882 244.708 l f* 464.415 244.43 m 464.376 244.292 464.201 244.315 464.123 244.361 c 463.967 244.476 463.734 244.522 463.695 244.753 c 463.773 244.753 463.831 244.776 463.909 244.73 c 463.967 244.684 464.006 244.638 464.045 244.569 c 464.123 244.453 464.279 244.546 464.357 244.407 c 464.415 244.43 l f* 463.715 244.061 m 463.559 244.061 463.403 244.061 463.247 244.061 c 463.267 244.245 463.209 244.43 463.092 244.568 c 463.092 244.592 463.092 244.638 463.092 244.661 c 463.189 244.707 463.267 244.592 463.345 244.522 c 463.403 244.453 463.403 244.338 463.384 244.245 c 463.481 244.245 463.578 244.199 463.637 244.107 c 463.715 244.061 l f* 462.917 243.945 m 462.742 243.991 462.644 244.176 462.489 244.245 c 462.917 243.945 l f* 462.469 243.968 m 462.352 243.968 462.294 244.153 462.197 244.245 c 462.469 243.968 l f* 462.022 243.945 m 461.88 243.945 461.73 243.876 461.593 243.945 c 461.593 244.014 l 461.691 244.06 461.73 244.245 461.846 244.199 c 461.866 244.199 461.885 244.083 461.924 244.037 c 461.944 244.037 461.963 244.037 461.983 244.037 c 462.022 244.014 462.041 243.945 462.022 243.945 c f* 458.382 247.351 m 458.558 247.294 458.746 247.262 458.941 247.262 c 459.899 247.262 460.675 248.008 460.675 248.928 c 460.675 249.848 459.899 250.593 458.941 250.593 c 457.984 250.593 457.208 249.848 457.208 248.928 c 457.208 248.196 457.699 247.574 458.382 247.351 c f* 1 J 458.382 247.351 m 458.558 247.294 458.746 247.262 458.941 247.262 c 459.899 247.262 460.675 248.008 460.675 248.928 c 460.675 249.848 459.899 250.593 458.941 250.593 c 457.984 250.593 457.208 249.848 457.208 248.928 c 457.208 248.196 457.699 247.574 458.382 247.351 c S 0.166 w 460.293 249.602 m 458.104 247.662 l 458.06 247.645 l 458.936 250.485 l 458.951 250.433 l 459.783 247.593 l 457.657 249.561 l 457.637 249.602 l 460.293 249.602 l S 458.448 249.032 m 458.458 249.009 458.496 248.919 458.51 248.899 c 458.549 248.841 458.562 248.843 458.552 248.762 c 458.545 248.704 458.551 248.701 458.593 248.659 c 458.652 248.6 458.65 248.467 458.718 248.41 c 458.747 248.387 458.893 248.565 458.904 248.576 c 458.982 248.647 459.029 248.534 459.184 248.418 c 459.27 248.354 459.278 248.679 459.257 248.825 c 459.253 248.85 459.423 249.009 459.423 249.032 c 459.452 249.275 459.444 249.189 459.298 249.385 c 459.279 249.396 459.114 249.511 459.105 249.535 c 458.968 249.719 458.966 249.648 458.801 249.613 c 458.791 249.613 458.774 249.552 458.78 249.53 c 458.81 249.422 458.612 249.47 458.573 249.447 c 458.505 249.389 458.474 249.377 458.425 249.296 c 458.396 249.226 458.396 249.146 458.386 249.076 c 458.448 249.032 l f* 1 1 1 RG 458.448 249.032 m 458.458 249.009 458.496 248.919 458.51 248.899 c 458.549 248.841 458.562 248.843 458.552 248.762 c 458.545 248.704 458.551 248.701 458.593 248.659 c 458.652 248.6 458.65 248.467 458.718 248.41 c 458.747 248.387 458.893 248.565 458.904 248.576 c 458.982 248.647 459.029 248.534 459.184 248.418 c 459.27 248.354 459.278 248.679 459.257 248.825 c 459.253 248.85 459.423 249.009 459.423 249.032 c 459.452 249.275 459.444 249.189 459.298 249.385 c 459.279 249.396 459.114 249.511 459.105 249.535 c 458.968 249.719 458.966 249.648 458.801 249.613 c 458.791 249.613 458.774 249.552 458.78 249.53 c 458.81 249.422 458.612 249.47 458.573 249.447 c 458.505 249.389 458.474 249.377 458.425 249.296 c 458.396 249.226 458.396 249.146 458.386 249.076 c S 0.161 0.145 0.149 rg 0 J 0 j 0.332 w 459.052 246.347 m 459.185 246.347 l 459.219 246.311 459.282 246.323 459.335 246.377 c 459.388 246.431 459.439 246.499 459.449 246.535 c 459.566 246.657 459.756 246.605 459.973 246.451 c 460.036 246.369 460.382 246.092 460.812 245.902 c 460.875 245.827 460.606 245.904 460.555 245.923 c 460.637 245.869 460.545 245.823 460.355 245.913 c 460.407 245.825 460.296 245.849 460.167 245.917 c 460.241 245.828 460.116 245.841 460.011 245.909 c 460.055 245.826 459.939 245.831 459.849 245.916 c 459.894 245.837 459.786 245.837 459.707 245.912 c 459.754 245.829 459.601 245.854 459.548 245.917 c 459.59 245.852 459.405 245.888 459.389 245.954 c 459.363 245.865 459.209 245.848 459.173 245.917 c 459.061 245.917 l 458.969 245.824 458.826 245.878 458.811 246.072 c 458.67 245.847 458.466 245.804 458.53 245.925 c 458.419 245.821 458.358 245.856 458.374 245.917 c 458.21 245.775 458.202 245.896 458.218 245.919 c 458.109 245.832 458.017 245.849 458.046 245.907 c 457.945 245.853 457.824 245.843 457.877 245.92 c 457.758 245.849 457.591 245.852 457.663 245.924 c 457.496 245.856 457.313 245.87 457.47 245.935 c 457.941 246.13 458.092 246.315 458.267 246.454 c 458.542 246.673 458.754 246.621 458.801 246.505 c 458.846 246.396 458.994 246.284 459.047 246.34 c 459.052 246.347 l b* 459.052 243.488 m 459.052 243.457 459.065 243.435 459.108 243.435 c 459.151 243.435 459.164 243.462 459.164 243.49 c 459.189 246.431 l 459.045 246.432 l 459.052 243.488 l b* 459.109 246.377 m 459.109 246.394 459.168 246.399 459.168 246.38 c 459.146 243.54 l 459.146 243.52 459.136 243.477 459.121 243.477 c 459.111 243.477 459.109 243.516 459.109 243.54 c 459.109 246.377 l b* 459.439 246.175 m 459.404 246.199 459.359 246.192 y 459.415 246.168 459.434 246.146 459.408 246.015 c 459.439 246.175 l f* 459.439 246.175 m 459.404 246.199 459.359 246.192 y 459.415 246.168 459.434 246.146 459.408 246.015 c S 460.223 246.238 m 460.245 246.22 460.111 246.21 y 460.138 246.188 459.98 246.192 y 460.005 246.163 459.882 246.154 y 459.898 246.13 459.768 246.116 y 459.783 246.095 459.677 246.094 y 459.687 246.072 459.569 246.083 y 459.577 246.055 459.42 246.091 y 460.223 246.238 l f* 460.223 246.238 m 460.245 246.22 460.111 246.21 y 460.138 246.188 459.98 246.192 y 460.005 246.163 459.882 246.154 y 459.898 246.13 459.768 246.116 y 459.783 246.095 459.677 246.094 y 459.687 246.072 459.569 246.083 y 459.577 246.055 459.42 246.091 y S 460.039 246.393 m 460.037 246.346 459.893 246.385 y 459.89 246.345 459.756 246.37 y 459.765 246.335 459.629 246.339 y 459.638 246.305 459.551 246.314 y 459.578 246.26 459.489 246.236 y 459.51 246.181 459.405 246.19 y 460.039 246.393 l f* 460.039 246.393 m 460.037 246.346 459.893 246.385 y 459.89 246.345 459.756 246.37 y 459.765 246.335 459.629 246.339 y 459.638 246.305 459.551 246.314 y 459.578 246.26 459.489 246.236 y 459.51 246.181 459.405 246.19 y S 458.796 246.177 m 458.831 246.2 458.877 246.193 y 458.82 246.169 458.801 246.148 458.826 246.016 c 458.796 246.177 l f* 458.796 246.177 m 458.831 246.2 458.877 246.193 y 458.82 246.169 458.801 246.148 458.826 246.016 c S 458.013 246.242 m 457.99 246.225 458.124 246.214 y 458.097 246.192 458.256 246.195 y 458.23 246.167 458.353 246.157 y 458.337 246.133 458.467 246.118 y 458.452 246.097 458.558 246.096 y 458.547 246.074 458.666 246.084 y 458.657 246.057 458.815 246.092 y 458.013 246.242 l f* 458.013 246.242 m 457.99 246.225 458.124 246.214 y 458.097 246.192 458.256 246.195 y 458.23 246.167 458.353 246.157 y 458.337 246.133 458.467 246.118 y 458.452 246.097 458.558 246.096 y 458.547 246.074 458.666 246.084 y 458.657 246.057 458.815 246.092 y S 458.198 246.397 m 458.199 246.349 458.343 246.388 y 458.346 246.348 458.48 246.373 y 458.472 246.337 458.607 246.341 y 458.597 246.307 458.685 246.316 y 458.658 246.262 458.746 246.237 y 458.726 246.182 458.83 246.191 y 458.198 246.397 l f* 458.198 246.397 m 458.199 246.349 458.343 246.388 y 458.346 246.348 458.48 246.373 y 458.472 246.337 458.607 246.341 y 458.597 246.307 458.685 246.316 y 458.658 246.262 458.746 246.237 y 458.726 246.182 458.83 246.191 y S 459.116 246.419 m 459.019 246.419 458.94 246.482 458.94 246.558 c 458.94 246.635 459.019 246.697 459.117 246.697 c 459.214 246.697 459.294 246.634 459.293 246.558 c 459.293 246.481 459.213 246.419 459.116 246.419 c b* 459.1 246.626 m 459.123 246.63 459.109 246.654 459.087 246.654 c 459.025 246.651 458.987 246.603 458.986 246.556 c 458.986 246.533 458.994 246.504 459.008 246.487 c 459.017 246.477 459.04 246.455 459.027 246.46 c 458.984 246.477 458.963 246.518 458.963 246.559 c 458.963 246.627 459.032 246.681 459.118 246.681 c 459.203 246.681 459.273 246.626 459.272 246.558 c 459.272 246.495 459.209 246.44 459.125 246.436 c 459.111 246.435 459.09 246.436 459.083 246.443 c 459.082 246.445 459.111 246.443 459.125 246.445 c 459.19 246.453 459.234 246.495 459.23 246.546 c 459.229 246.559 459.202 246.584 459.205 246.563 c 459.21 246.529 459.168 246.502 459.124 246.501 c 459.089 246.501 459.045 246.529 459.045 246.564 c 459.045 246.598 459.056 246.619 459.1 246.626 c b* 458.683 245.596 m 458.657 245.26 459.682 245.598 459.655 245.172 c 459.629 244.765 458.859 245.047 458.884 244.824 c 458.897 244.709 459.561 244.786 459.505 244.52 c 459.453 244.272 458.908 244.394 458.929 244.284 c 458.952 244.162 459.485 244.222 459.385 244 c 459.304 243.821 458.89 243.945 458.885 243.748 c 458.733 243.925 459.224 243.91 459.254 244.027 c 459.28 244.127 458.814 244.081 458.768 244.274 c 458.71 244.517 459.285 244.407 459.31 244.543 c 459.332 244.66 458.727 244.561 458.664 244.764 c 458.533 245.187 459.333 244.946 459.384 245.172 c 459.431 245.378 458.572 245.134 458.495 245.534 c 458.466 245.685 458.591 245.73 458.667 245.76 c 458.697 245.772 458.69 245.801 458.76 245.813 c 458.822 245.823 458.872 245.806 458.996 245.682 c 459.013 245.666 458.967 245.636 458.929 245.629 c 458.891 245.623 458.795 245.609 458.755 245.64 c 458.72 245.667 458.686 245.635 458.683 245.596 c b* 459.546 245.595 m 459.571 245.259 458.548 245.6 458.572 245.174 c 458.595 244.767 459.367 245.046 459.341 244.823 c 459.328 244.708 458.664 244.788 458.718 244.521 c 458.768 244.273 459.314 244.393 459.293 244.284 c 459.269 244.162 458.736 244.223 458.835 244.002 c 458.915 243.821 459.33 243.944 459.333 243.747 c 459.486 243.924 458.996 243.91 458.966 244.028 c 458.941 244.128 459.406 244.08 459.454 244.274 c 459.512 244.515 458.937 244.408 458.913 244.544 c 458.892 244.661 459.497 244.56 459.561 244.763 c 459.694 245.185 458.893 244.947 458.843 245.174 c 458.797 245.379 459.655 245.132 459.734 245.531 c 459.765 245.683 459.64 245.728 459.564 245.758 c 459.533 245.77 459.541 245.8 459.471 245.811 c 459.409 245.822 459.359 245.805 459.234 245.682 c 459.216 245.666 459.263 245.635 459.301 245.629 c 459.339 245.622 459.434 245.609 459.475 245.638 c 459.511 245.665 459.544 245.633 459.546 245.595 c b* 459.384 244.905 m 459.422 244.912 459.523 244.886 459.51 244.819 c 459.467 244.598 458.882 244.704 458.875 244.561 c 458.87 244.476 459.017 244.468 458.95 244.456 c 458.87 244.441 458.755 244.494 458.757 244.558 c 458.764 244.755 459.339 244.7 459.379 244.813 c 459.4 244.873 459.343 244.896 459.384 244.905 c b* 459.429 245.245 m 459.474 245.254 459.578 245.221 459.566 245.142 c 459.523 244.857 458.829 245.03 458.812 244.852 c 458.803 244.752 458.98 244.742 458.902 244.728 c 458.807 244.711 458.685 244.779 458.693 244.854 c 458.719 245.113 459.384 244.969 459.424 245.137 c 459.441 245.209 459.382 245.235 459.429 245.245 c b* 459.347 244.59 m 459.379 244.597 459.452 244.577 459.441 244.521 c 459.405 244.333 458.925 244.421 458.901 244.301 c 458.886 244.226 459.013 244.221 458.956 244.211 c 458.888 244.198 458.798 244.249 458.8 244.298 c 458.807 244.465 459.302 244.421 459.336 244.517 c 459.354 244.568 459.312 244.583 459.347 244.59 c b* 459.322 244.329 m 459.35 244.334 459.409 244.318 459.403 244.27 c 459.386 244.137 458.984 244.151 458.94 244.041 c 458.916 243.98 459.035 243.973 458.987 243.965 c 458.929 243.954 458.86 243.997 458.855 244.039 c 458.835 244.188 459.288 244.164 459.313 244.266 c 459.324 244.31 459.293 244.323 459.322 244.329 c b* 458.911 243.84 m 458.938 243.93 459.268 243.914 459.277 244.03 c 459.28 244.068 459.26 244.078 459.285 244.083 c 459.308 244.088 459.355 244.075 459.353 244.033 c 459.349 243.906 458.974 243.898 458.911 243.84 c b* 459.49 245.761 m 459.644 245.714 459.673 245.618 459.661 245.548 c 459.599 245.213 458.78 245.409 458.759 245.198 c 458.748 245.08 458.958 245.069 458.865 245.052 c 458.753 245.031 458.614 245.109 458.621 245.2 c 458.644 245.527 459.455 245.289 459.567 245.528 c 459.592 245.581 459.587 245.719 459.462 245.715 c 459.369 245.712 459.325 245.722 459.377 245.762 c 459.417 245.791 459.473 245.784 459.49 245.761 c b* 458.569 245.55 m 458.619 245.396 458.822 245.43 458.793 245.44 c 458.723 245.463 458.679 245.488 458.649 245.537 c 458.582 245.647 458.635 245.745 458.762 245.721 c 458.853 245.704 458.906 245.723 458.853 245.763 c 458.814 245.792 458.758 245.785 458.741 245.763 c 458.586 245.717 458.539 245.64 458.569 245.55 c b* 459.408 246.015 m 459.393 245.938 459.351 245.875 459.264 245.874 c 459.197 245.874 459.182 245.911 y 459.408 246.015 l f* 459.408 246.015 m 459.393 245.938 459.351 245.875 459.264 245.874 c 459.197 245.874 459.182 245.911 y S 459.854 245.916 m 459.884 245.897 459.839 245.836 459.782 245.869 c 459.603 245.974 459.569 246.083 y 459.473 246.138 459.439 246.175 y 459.854 245.916 l f* 459.854 245.916 m 459.884 245.897 459.839 245.836 459.782 245.869 c 459.603 245.974 459.569 246.083 y 459.473 246.138 459.439 246.175 y S 459.702 245.923 m 459.745 245.895 459.703 245.833 459.621 245.876 c 459.501 245.94 459.42 246.091 y 459.702 245.923 l f* 459.702 245.923 m 459.745 245.895 459.703 245.833 459.621 245.876 c 459.501 245.94 459.42 246.091 y S 459.185 246.351 m 459.257 246.273 459.397 246.423 459.439 246.514 c 459.48 246.603 459.655 246.697 459.981 246.443 c 460.127 246.328 460.238 246.166 460.791 245.919 c 460.859 245.889 460.819 245.865 460.726 245.881 c 460.394 245.936 460.111 246.21 y 459.98 246.273 459.893 246.385 y 459.822 246.455 459.758 246.484 y 459.185 246.351 l f* 459.185 246.351 m 459.257 246.273 459.397 246.423 459.439 246.514 c 459.48 246.603 459.655 246.697 459.981 246.443 c 460.127 246.328 460.238 246.166 460.791 245.919 c 460.859 245.889 460.819 245.865 460.726 245.881 c 460.394 245.936 460.111 246.21 y 459.98 246.273 459.893 246.385 y 459.822 246.455 459.758 246.484 y S 460.554 245.928 m 460.618 245.894 460.58 245.849 460.484 245.871 c 460.222 245.932 459.98 246.192 y 459.869 246.255 459.756 246.37 y 459.642 246.457 459.593 246.464 y 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0 cm 0 G 2 j 0.03 w 10 M 101.603 625.783 m 101.806 625.752 101.896 626.166 101.536 626.224 c 101.148 626.287 101.058 626.293 100.962 626.302 c 100.783 626.322 100.795 626.573 101.193 626.564 c 100.9 626.561 l 100.407 626.549 100.575 626.116 100.966 626.138 c 101.358 626.162 101.651 626.084 101.553 625.935 c 101.493 625.844 101.436 625.823 y 101.527 625.823 101.584 625.795 101.603 625.783 c b Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 101.557 625.428 m 101.693 625.396 101.867 625.751 101.508 625.814 c 101.161 625.877 101.104 625.839 101.031 625.883 c 100.923 625.947 100.958 626.162 101.212 626.138 c 101.029 626.135 l 100.662 626.185 100.673 625.756 100.967 625.756 c 101.259 625.756 101.619 625.698 101.524 625.554 c 101.471 625.471 101.4 625.467 y 101.482 625.467 101.518 625.447 101.557 625.428 c b Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 101.533 625.08 m 101.662 625.049 101.738 625.41 101.484 625.454 c 101.172 625.511 101.121 625.477 101.054 625.517 c 100.958 625.574 100.951 625.748 101.228 625.737 c 101.068 625.748 l 100.72 625.814 100.763 625.381 101.025 625.381 c 101.286 625.381 101.509 625.374 101.499 625.221 c 101.494 625.154 101.4 625.119 y 101.474 625.119 101.509 625.104 101.533 625.08 c b Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 101.506 624.791 m 101.669 624.763 101.686 625.084 101.453 625.112 c 101.185 625.145 101.144 625.156 101.088 625.189 c 101.005 625.238 101.091 625.381 101.236 625.374 c 101.068 625.385 l 100.818 625.431 100.817 625.067 101.04 625.067 c 101.262 625.067 101.537 625.023 101.466 624.913 c 101.424 624.85 101.385 624.834 y 101.447 624.834 101.474 624.814 101.506 624.791 c b Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 101.451 624.564 m 101.557 624.572 101.592 624.799 101.419 624.83 c 101.207 624.867 101.176 624.842 101.13 624.869 c 101.065 624.908 101.107 625.06 101.243 625.056 c 101.107 625.06 l 100.889 625.104 100.909 624.765 101.088 624.765 c 101.265 624.765 101.486 624.73 101.428 624.642 c 101.389 624.581 101.361 624.599 y 101.396 624.592 101.436 624.572 101.451 624.564 c b Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 101.294 624.228 m 101.318 624.335 101.392 624.38 101.424 624.408 c 101.533 624.466 101.503 624.566 101.385 624.596 c 101.307 624.615 101.213 624.612 101.182 624.631 c 101.135 624.658 101.119 624.76 101.26 624.752 c 101.173 624.763 l 100.912 624.752 101.017 624.545 101.17 624.549 c 101.294 624.551 101.447 624.514 101.345 624.439 c 101.267 624.382 101.302 624.349 101.294 624.228 c b Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 101.135 624.552 m 101.076 624.534 101.025 624.433 101.115 624.396 c 101.201 624.361 101.279 624.299 101.279 624.181 c 101.283 624.268 101.283 624.419 101.208 624.432 c 101.109 624.448 101.177 624.537 101.232 624.545 c 101.135 624.552 l b Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 100.783 627.079 m 100.801 627.079 100.815 627.094 100.815 627.111 c 100.815 627.13 100.801 627.145 100.783 627.145 c 100.765 627.145 100.75 627.13 100.75 627.111 c 100.75 627.094 100.765 627.079 100.783 627.079 c b Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 100.783 627.111 m B Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 101.814 627.079 m 101.833 627.079 101.848 627.094 101.848 627.111 c 101.848 627.13 101.833 627.145 101.814 627.145 c 101.796 627.145 101.781 627.13 101.781 627.111 c 101.781 627.094 101.796 627.079 101.814 627.079 c b Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 101.814 627.111 m B Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 98.779 627.916 m 98.497 627.792 98.076 627.573 98.262 627.526 c 98.45 627.479 98.716 627.651 98.779 627.698 c B Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 98.403 627.526 m 98.45 627.417 98.841 627.401 99.029 627.62 c B Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 98.669 627.448 m 98.762 627.306 99.31 627.417 99.325 627.604 c B Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 99.029 627.401 m 99.153 627.292 99.481 627.338 99.544 627.557 c B Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 99.357 627.354 m 99.45 627.213 99.763 627.369 99.81 627.479 c B Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 99.591 627.306 m 99.716 627.197 99.95 627.306 99.998 627.464 c B Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 99.81 627.276 m 99.966 627.151 100.2 627.229 100.216 627.369 c B Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 100.076 627.213 m 100.2 627.073 100.388 627.292 100.451 627.354 c B Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 100.966 627.041 m 101.029 626.963 101.201 626.963 y B Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 101.412 627.651 m 101.631 627.635 101.974 627.713 101.966 627.94 c 101.959 628.166 102.154 628.714 102.717 628.479 c 103.279 628.244 102.795 628.307 102.623 628.339 c B Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 102.873 628.307 m 102.888 628.214 102.67 628.214 102.482 628.276 c B Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 102.732 628.229 m 102.717 628.166 102.482 628.182 102.341 628.214 c B Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 102.529 628.182 m 102.482 628.057 102.326 628.182 102.295 628.12 c 102.263 628.057 102.077 628.166 102.045 627.87 c 102.013 627.573 101.467 627.604 101.404 627.573 c B Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 102.998 628.307 m 103.404 628.198 103.826 627.948 103.826 627.854 c 103.826 627.76 103.217 628.104 103.077 628.151 c B Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 103.701 627.839 m 103.701 627.76 103.482 627.839 102.951 628.073 c B Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 103.451 627.87 m 103.451 627.792 103.232 627.792 102.701 628.026 c B Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 103.248 627.792 m 103.248 627.713 102.935 627.76 102.467 628.026 c B Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 102.951 627.776 m 102.951 627.698 102.748 627.666 102.31 627.963 c B Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 102.748 627.745 m 102.795 627.589 102.436 627.713 102.186 627.885 c B Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 102.576 627.698 m 102.576 627.62 102.279 627.666 102.122 627.807 c B Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 102.326 627.651 m 102.326 627.573 102.122 627.573 102.06 627.698 c B Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 102.122 627.589 m 102.122 627.51 101.935 627.526 101.888 627.62 c B Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 101.951 627.542 m 101.951 627.464 101.763 627.479 101.717 627.573 c B Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 101.795 627.51 m 101.795 627.432 101.607 627.448 101.56 627.542 c B Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 101.622 627.464 m 101.622 627.385 101.436 627.401 101.389 627.495 c B Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 103.795 627.916 m 104.077 627.792 104.498 627.573 104.311 627.526 c 104.123 627.479 103.858 627.651 103.795 627.698 c B Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 104.17 627.526 m 104.123 627.417 103.732 627.401 103.545 627.62 c B Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 103.905 627.448 m 103.811 627.306 103.263 627.417 103.248 627.604 c B Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 103.545 627.401 m 103.42 627.292 103.091 627.338 103.029 627.557 c B Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 103.217 627.354 m 103.123 627.213 102.81 627.369 102.763 627.479 c B Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 102.982 627.306 m 102.858 627.197 102.623 627.306 102.576 627.464 c B Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 102.763 627.276 m 102.608 627.151 102.373 627.229 102.357 627.369 c B Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 102.498 627.213 m 102.373 627.073 102.217 627.292 102.154 627.354 c B Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 101.607 627.041 m 101.544 626.963 101.372 626.963 y B Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 101.06 627.338 m 101.013 627.26 l B Q q 1.0111 0 0 0.989 0 0 cm 0 G 2 j 0.03 w 10 M 101.529 627.306 m 101.544 627.26 101.56 627.213 y B Q BT /F52 1 Tf 10 0 0 10.0001 183.97 78.6011 Tm /Cs18 cs 0 scn /GS1 gs -0.0121 Tc -0.061 Tw (3290 Pine Orchard Lane, Suite 106)Tj /F53 1 Tf 13.392 0 TD 0 Tc 0 Tw ( )Tj /G2 1 Tf 0.192 0 TD <0099>Tj /F52 1 Tf 0.84 0 TD -0.0134 Tc -0.062 Tw [( )6.6(Ellicott City)58.6(, MD 21042)]TJ -15.744 -1.488 TD -0.018 Tc 0 Tw (Phone:)Tj /F50 1 Tf 2.688 0 TD 0 Tc ( )Tj /F52 1 Tf 0.168 0 TD -0.0182 Tc -0.06 Tw (\(410\) 750-9600)Tj /F53 1 Tf 5.928 0 TD 0 Tc 0 Tw ( )Tj /G2 1 Tf 0.192 0 TD <0099>Tj /F52 1 Tf 0.792 0 TD -0.0182 Tc -0.0625 Tw [( )-22.7(Fax: \(410\) 750-9601)]TJ /F53 1 Tf 7.992 0 TD 0 Tc 0 Tw ( )Tj /G2 1 Tf 0.168 0 TD <0099>Tj /F52 1 Tf 0.816 0 TD -0.0195 Tc -0.0865 Tw [( W)84.3(e)0.5(b: )-23.6(www)52.5(.icisf.org)]TJ /F54 1 Tf 12 0 0 12.0002 116.53 563.8874 Tm /Cs17 cs 1 scn -0.0215 Tc -0.0073 Tw (January 29- February 1, 2009)Tj /G2 1 Tf 0 -1.08 TD 0 Tc 0 Tw <0099>Tj /F55 1 Tf 0.9 0 TD -0.0003 Tc 0.0375 Tw (Reno, NV)Tj /F51 1 Tf -0.9 -1.08 TD -0.0035 Tc -0.0694 Tw (Sierra Nevada CISM Network)Tj /F54 1 Tf 0 -2.18 TD -0.0213 Tc -0.0167 Tw (February 24- March 1, 2009)Tj /G2 1 Tf 0 -1.08 TD 0 Tc 0 Tw <0099>Tj /F55 1 Tf 0.88 0 TD -0.0027 Tc -0.0708 Tw (Baltimore, MD)Tj /F51 1 Tf -0.88 -1.08 TD -0.0046 Tc -0.0695 Tw (ICISFs 10th World Congress)Tj T* -0.0031 Tc -0.0696 Tw [(on S)56.9(tress )17.1(T)27.7(rauma and Coping)]TJ /F54 1 Tf 0 -2.18 TD -0.0215 Tc -0.0187 Tw (March 26-29, 2009)Tj /G2 1 Tf 0 -1.08 TD 0 Tc 0 Tw <0099>Tj /F55 1 Tf 0.9 0 TD 0.0006 Tc -0.0479 Tw (St. Louis, MO)Tj /F51 1 Tf -0.9 -1.08 TD -0.005 Tc -0.0697 Tw [(Central Missouri CISM )14.7(T)105.8(eam)]TJ /F54 1 Tf 0 -2.16 TD -0.0205 Tc -0.0625 Tw (April 22-26, 2009)Tj /G2 1 Tf 0 -1.08 TD 0 Tc 0 Tw <0099>Tj /F55 1 Tf 0.88 0 TD -0.0014 Tc -0.0708 Tw (Atlanta, GA)Tj /F51 1 Tf -0.88 -1.1 TD -0.0055 Tc -0.0699 Tw [(GA)54.5( Critical Incident S)34.5(tress Foundation)]TJ /F54 1 Tf 0 -2.16 TD -0.0223 Tc -0.0042 Tw (May 27-31, 2009)Tj /G2 1 Tf 0 -1.08 TD 0 Tc 0 Tw <0099>Tj /F55 1 Tf 0.9 0 TD 0.0005 Tc 0.0083 Tw (Columbia, MD)Tj /F51 1 Tf -0.9 -1.08 TD -0.0289 Tc 0 Tw (ICISF)Tj /F54 1 Tf 0 -2.18 TD -0.0207 Tc -0.0042 Tw (June 3-7, 2009)Tj /G2 1 Tf 0 -1.08 TD 0 Tc 0 Tw <0099>Tj /F55 1 Tf 0.9 0 TD -0.0021 Tc -0.0292 Tw [(Denver)57.9(, CO)]TJ /F51 1 Tf -0.9 -1.08 TD -0.0041 Tc -0.0697 Tw [(Mayflower Crisis Support )15.6(T)106.7(eam)]TJ /F54 1 Tf 0 -2.16 TD -0.0211 Tc -0.0063 Tw (June 23-26, 2009)Tj /G2 1 Tf 0 -1.08 TD 0 Tc 0 Tw <0099>Tj /F55 1 Tf 0.88 0 TD -0.0035 Tc -0.0709 Tw (Appleton, WI)Tj /F51 1 Tf -0.88 -1.1 TD -0.0068 Tc -0.0691 Tw [(Fox V)73.2(alley CISM )13.5(T)104(e)5.9(a)5.9(m)]TJ /F54 1 Tf 0 -2.16 TD -0.0205 Tc -0.0396 Tw (August 6-9, 2009)Tj /G2 1 Tf 0 -1.08 TD 0 Tc 0 Tw <0099>Tj /F55 1 Tf 0.9 0 TD -0.0004 Tc -0.025 Tw (Detroit, MI)Tj /F51 1 Tf -0.9 -1.08 TD -0.0074 Tc -0.0687 Tw (Neighborhood Service Organization/)Tj T* -0.0137 Tc -0.0696 Tw [(W)30.1(ayne County CISM )26.1(T)117.1(eam)]TJ /F54 1 Tf 18.16 34.74 TD -0.0211 Tc -0.0104 Tw (August 17-20, 2009)Tj 0 -1.08 TD -0.0202 Tc -0.0646 Tw (Spiritual Care in Crisis Intervention)Tj /G2 1 Tf T* 0 Tc 0 Tw <0099>Tj /F55 1 Tf 0.9 0 TD -0.0021 Tc -0.0292 Tw [(Denver)57.9(, CO)]TJ /F51 1 Tf -0.9 -1.08 TD -0.011 Tc -0.0709 Tw (Denver Seminary)Tj /F54 1 Tf 0 -2.16 TD -0.0206 Tc 0.0041 Tw (September 16-19, 2009)Tj /G2 1 Tf 0 -1.1 TD 0 Tc 0 Tw <0099>Tj /F55 1 Tf 0.88 0 TD -0.0058 Tc -0.0708 Tw (Bakersfield, CA)Tj /F51 1 Tf -0.88 -1.08 TD -0.0051 Tc -0.07 Tw [(Kern Critical Incident Response )14.7(T)105.7(eam)]TJ /F54 1 Tf 0 -2.16 TD -0.0204 Tc -0.0354 Tw (October 1-4, 2009)Tj /G2 1 Tf 0 -1.08 TD 0 Tc 0 Tw <0099>Tj /F55 1 Tf 0.9 0 TD -0.0012 Tc -0.0041 Tw (Boston, MA)Tj /F51 1 Tf -0.9 -1.08 TD -0.0078 Tc -0.1209 Tw [(Fallon Ambulance )-52.5(Services)]TJ /F54 1 Tf 0 -2.18 TD -0.0206 Tc -0.0396 Tw (October 22-25, 2009)Tj /G2 1 Tf 0 -1.08 TD 0 Tc 0 Tw <0099>Tj /F55 1 Tf 0.9 0 TD -0.0018 Tc -0.0709 Tw (Chicago, IL)Tj /F51 1 Tf -0.9 -1.08 TD -0.0133 Tc -0.0695 Tw [(Northern Illinois CISM )6.6(T)117.5(eam)]TJ /F54 1 Tf 0 -2.16 TD -0.0211 Tc 0.0125 Tw (November 5-8, 2009)Tj /G2 1 Tf 0 -1.1 TD 0 Tc 0 Tw <0099>Tj /F55 1 Tf 0.9 0 TD 0.0003 Tc -0.0417 Tw (Albuquerque, NM)Tj /F51 1 Tf -0.9 -1.08 TD -0.0007 Tc -0.0608 Tw [(NM Crisis Support )19.6(T)110.1(eam)]TJ /F54 1 Tf 0 -2.16 TD -0.0208 Tc 0.0042 Tw [(November 1)39.2(1-15, 2009)]TJ /G2 1 Tf 0 -1.08 TD 0 Tc 0 Tw <0099>Tj /F55 1 Tf 0.9 0 TD 0.0005 Tc -0.0458 Tw (Nashville, TN)Tj /F51 1 Tf -0.9 -1.08 TD -0.0128 Tc 0 Tw (Centerstone)Tj /F55 1 Tf 0 -2.18 TD -0.0017 Tc -0.0354 Tw (December 3-6, 2009)Tj /G2 1 Tf 0 -1.08 TD 0 Tc 0 Tw <0099>Tj /F55 1 Tf 0.9 0 TD 0.0003 Tc -0.0167 Tw (San Diego, CA)Tj /F51 1 Tf -0.9 -1.08 TD -0.0025 Tc -0.0698 Tw [(San Diego County CISM )17.5(T)108.3(eam)]TJ ET q 11.01 764.01 573 -763.995 re W n 1 J 2.88 w 150.332 142.562 m 150.332 142.562 l 157.215 142.562 m 157.215 142.562 l 164.098 142.562 m 164.098 142.562 l 170.979 142.562 m 170.979 142.562 l 177.862 142.562 m 177.862 142.562 l 184.745 142.562 m 184.745 142.562 l 191.626 142.562 m 191.626 142.562 l 198.509 142.562 m 198.509 142.562 l 205.392 142.562 m 205.392 142.562 l 212.273 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One was a review for a)]TJ T* -0.0043 Tc 0.03 Tw (nursing home.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc 0.1129 Tw (Health care providers reported that 18 patients \(49%\))Tj 0 -1.401 TD -0.0033 Tc 0.1 Tw [(presented as depressed as assessed by their interview)59.7(.)]TJ 0 -1.398 TD -0.003 Tc 0.0638 Tw (This was significantly more likely to occur in patients)Tj 0 -1.401 TD -0.0051 Tc -0.0607 Tw (older than 60 \(Pearson c)Tj 5.8 0 0 5.8 165.54 476.61 Tm -0.0017 Tc 0 Tw (2 )Tj 10 0 0 10 169.5 473.25 Tm -0.0042 Tc -0.0625 Tw (= 14.83, )Tj /TT5 1 Tf 3.399 0 TD -0.0128 Tc 0 Tw (df)Tj /TT2 1 Tf 0.765 0 TD -0.0028 Tc -0.0633 Tw [( = 2, )]TJ /TT5 1 Tf 1.857 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.495 0 TD -0.0047 Tc -0.0625 Tw [( = .001\).)]TJ /F56 1 Tf -18.066 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0021 Tc 0.125 Tw (Thirty-one health care providers \()Tj /TT5 1 Tf 13.926 0 TD 0 Tc 0 Tw (n)Tj /TT2 1 Tf 0.495 0 TD -0.0026 Tc 0.125 Tw [( = 84%\) indicated)]TJ -14.421 -1.401 TD -0.0033 Tc 0.0756 Tw (they had developed a good rapport with the deceased,)Tj T* -0.002 Tc 0.125 Tw (four described their interviews as difficult and two)Tj 0 -1.398 TD -0.0036 Tc 0.06 Tw (indicated that the patient was guarded or disengaged.)Tj /F56 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc 0.0812 Tw (In 14 interviews a formal suicide risk assessment was)Tj 0 -1.398 TD -0.0074 Tc -0.0621 Tw (undertaken but none of the healthcare providers believed)Tj 0 -1.401 TD -0.0035 Tc 0.025 Tw (the patient was suicidal.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0033 Tc -0.0525 Tw (Family informants reported a change in 11 of the 28 sui-)Tj 0 -1.401 TD -0.0108 Tc -0.06 Tw (cides \(39%\).)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0034 Tc 0.0313 Tw (Fifteen \(54%\) of the family members indicated the de-)Tj 0 -1.401 TD -0.0038 Tc 0.108 Tw (ceased had made statements of hopelessness.)Tj /TT1 1 Tf 11 0 0 11 54 280.86 Tm 0.0217 Tc 0 Tw [(CONCLUSIONS/SUMMAR)32.6(Y)]TJ /F56 1 Tf 10 0 0 10 54 264.84 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0029 Tc 0.0615 Tw (The pilot study suggests that such a study will be fea-)Tj 0 -1.398 TD -0.0032 Tc -0.0087 Tw (sible on a large scale.)Tj /F56 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0035 Tc -0.0365 Tw (Previous studies have indicated that failure to recognize)Tj 0 -1.398 TD -0.0031 Tc 0.0963 Tw (depression by health care providers is a critical issue.)Tj 0 -1.401 TD -0.003 Tc -0.0118 Tw (This study offers partial support for this theory because)Tj T* -0.0031 Tc 0.0289 Tw (approximately 75% of the deceased in this study had a)Tj 0 -1.398 TD -0.0034 Tc 0.0627 Tw (diagnosed and treated mental illness at the time of the)Tj 0 -1.401 TD -0.0086 Tc -0.0621 Tw (last contact. The majority of participants were prescribed)Tj T* 0.0108 Tc 0.125 Tw (antidepressant medication two-thirds of which were)Tj 0 -1.398 TD -0.0091 Tc -0.06 Tw (medication compliant.)Tj /F56 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc 0.0205 Tw (Over 60% of the deceased were found not suicidal in a)Tj 0 -1.398 TD -0.0082 Tw (formal suicide risk assessment during the last visit with)Tj 0 -1.401 TD -0.0117 Tw [(a health care provider)50.5(.)]TJ /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD 0.0035 Tc 0.125 Tw (Family informants appeared to have a more detailed)Tj 25.5 64.578 TD -0.0038 Tc 0.0817 Tw (knowledge of behavior suggestive of potential suicide)Tj 0 -1.398 TD -0.0036 Tc 0.005 Tw (as compared with health care providers.)Tj /TT1 1 Tf 11 0 0 11 309 678.24 Tm 0.0267 Tc 0 Tw [(LIMIT)62.2(A)72.5(TIONS)]TJ /F56 1 Tf 10 0 0 10 309 662.25 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc -0.0081 Tw [(The health care provider interviews took place on aver-)]TJ 0 -1.401 TD -0.0033 Tc 0.041 Tw (age 10 14 months after the suicides which may have)Tj 0 -1.398 TD -0.0032 Tc 0.0187 Tw (affected the recall of the events that took place.)Tj /F56 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0034 Tc -0.0541 Tw (It is not possible to know if the knowledge of the suicide)Tj 0 -1.398 TD -0.003 Tc 0.0331 Tw (biased the recall of the events by the providers.)Tj /F56 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD 0.0064 Tc 0.125 Tw (This study was not controlled so there is no way to)Tj 0 -1.398 TD -0.0035 Tc 0.0689 Tw (know if the last appointment with the health care pro-)Tj 0 -1.401 TD 0.02 Tw (vider was different to other appointments.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0042 Tc -0.0625 Tw (The sample size is small.)Tj ET 3.99 w /GS1 gs 309 503.595 m 546 503.595 l S BT /TT1 1 Tf 11 0 0 11 309 484.59 Tm /GS2 gs -0.003 Tc 0.094 Tw [(Updegraff, J. )49.1(A., Silver)89.7(, R. C., Holman, )51.8(A. \(2008\).)]TJ 0 -1.1809 TD 0.0137 Tc 0.125 Tw (Searching for and finding meaning in collective)Tj T* -0.0033 Tc -0.003 Tw (trauma: Results from a national longitudinal study)Tj 0 -1.1836 TD 0.0004 Tc 0.1251 Tw [(of the 9/1)54.9(1 terr)14(orist attacks.)]TJ /TT4 1 Tf 12.3055 0 TD 0 Tc 0.1258 Tw [( Journal of Personal-)]TJ ET 0.99 w /GS1 gs 309 424.095 m 546 424.095 l S BT 11 0 0 11 309 432.6 Tm /GS2 gs 0.0047 Tc 0.125 Tw [(ity and Social Psychology)32(, 95)]TJ /TT1 1 Tf 12.6327 0 TD 0.0053 Tc 0 Tw (\(3\),)Tj /TT4 1 Tf 1.44 0 TD 0 Tc ( )Tj /TT1 1 Tf 0.3818 0 TD 0.0044 Tc (709-722.)Tj -14.4545 -2.9782 TD -0.008 Tc 0.1236 Tw [(TYPE OF)27.5( )46.5(A)10(R)27.4(TICLE)]TJ /F56 1 Tf 10 0 0 10 309 383.85 Tm 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.006 Tc (Longitudinal)Tj /TT1 1 Tf 11 0 0 11 309 353.46 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 /F56 1 Tf 10 0 0 10 309 337.44 Tm 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0033 Tc 0.0858 Tw (This study investigated how early coping processes)Tj 0 -1.398 TD -0.0039 Tc 0.093 Tw (searching for meaningaccount for long-term adjust-)Tj 0 -1.401 TD -0.0137 Tc -0.0613 Tw [(ment to the 9/1)31.3(1 attacks.)]TJ /TT1 1 Tf 9.189 0 TD 0 Tc 0 Tw ( )Tj /TT2 1 Tf 0.18 0 TD -0.0131 Tc -0.0636 Tw [(Specifically)61.9(, what factors predict)]TJ -9.369 -1.401 TD -0.0031 Tc 0.096 Tw [(the degree of a person)53.9(s search for and ability to find)]TJ 0 -1.398 TD -0.003 Tc 0.104 Tw (meaning in the 9/11 attacks, and is the ability to find)Tj 0 -1.401 TD -0.0038 Tc -0.025 Tw (meaning related to long-term adjustment.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD 0.0009 Tc 0.1249 Tw (Authors hypothesized that individuals who were less)Tj 0 -1.401 TD -0.0036 Tc 0.1239 Tw (able to find meaning in the 9/11 events would report)Tj T* 0.0792 Tw (more long-term fears and greater posttraumatic symp-)Tj 0 -1.398 TD -0.0037 Tc -0.0137 Tw (toms than individuals who were able to find meaning.)Tj /TT1 1 Tf 11 0 0 11 309 179.04 Tm 0.0265 Tc 0 Tw (PROCEDURE)Tj 0 -1.4536 TD 0.0026 Tc (Participants)Tj /F56 1 Tf 10 0 0 10 309 147.06 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0032 Tc 0.0162 Tw [(At the time of the first survey)62.8(, 931 respondents partici-)]TJ 0 -1.401 TD -0.0033 Tc -0.0365 Tw (pated in this study \( 50.8 % of whom were women\).)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0034 Tc -0.0308 Tw (Seventy percent of participants identified themselves as)Tj 0 -1.401 TD -0.0045 Tc -0.0619 Tw [(White, 12.5 % as Hispanic, 1)31.5(1.3 % as )49.8(African )49.8(American,)]TJ T* -0.0035 Tc -0.0125 Tw [(and 6.7 % as other)50.5(.)]TJ ET endstream endobj 321 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /F56 317 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 323 0 obj << /Length 9460 >> 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. 4 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (311)Tj /F56 1 Tf 10 0 0 10 66 721.65 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.01 Tc -0.0625 Tw [(Sixty percent of the sample were married, 22 % divorced)]TJ 0 -1.401 TD -0.0035 Tc -0.0111 Tw [(or separated, 16 % single, and 18% separate/divorced/)]TJ 0 -1.398 TD -0.013 Tc 0 Tw (widowed.)Tj /F56 1 Tf -1.8 -1.602 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0072 Tc -0.0622 Tw (For the sample, 60.5 % reported indirect exposure, 8.2 %)Tj 0 -1.398 TD -0.006 Tc (reported residing within 100 miles of the attacks, and 2.7)Tj 0 -1.401 TD -0.0037 Tc -0.0017 Tw (% reported direct exposure.)Tj /TT1 1 Tf 11 0 0 11 66 619.26 Tm 0.0242 Tc 0 Tw (Procedure)Tj /F56 1 Tf 10 0 0 10 66 603.24 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc 0.0289 Tw (Prior to September 11, 2001 a pool of participants was)Tj 0 -1.398 TD -0.0034 Tc -0.0492 Tw (generated from a nationally representative sample using)Tj 0 -1.401 TD 0.073 Tw (traditional probability methods \(random digit dialing\).)Tj T* -0.0029 Tc -0.0468 Tw (The pool was created for a variety of surveys to be com-)Tj 0 -1.398 TD -0.0034 Tc -0.02 Tw (pleted, unrelated to 9/11.)Tj /F56 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0037 Tc 0.0817 Tw (Participants were provided an Internet connection and)Tj 0 -1.398 TD -0.0034 Tc -0.0073 Tw [(W)94.4(eb )17.8(T)9.6(V)17.6( in exchange for completing surveys.)]TJ /F56 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0032 Tc 0.0687 Tw (Upon entry to the panel, participants completed a sur-)Tj 0 -1.398 TD -0.0026 Tc 0.0394 Tw (vey of mental and physical health that assessed if they)Tj 0 -1.401 TD -0.0027 Tc 0.0517 Tw (had ever been diagnosed by a physician for a physical)Tj T* -0.0037 Tc -0.0267 Tw [(or mental health disorder)50.3(.)]TJ /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 0.42 0 TD -0.0102 Tc -0.0625 Tw [()-1057.2(Between September 20 and October 4, 2001 and Novem-)]TJ 1.38 -1.401 TD -0.0037 Tc 0.0294 Tw (ber 10 and December 3, 2001 participants completed a)Tj 0 -1.398 TD -0.0033 Tc 0.0794 Tw (web survey in which acute responses as well as ques-)Tj 0 -1.401 TD -0.0106 Tc -0.0625 Tw (tions regarding searching for meaning of the attacks were)Tj T* 0.0327 Tc 0 Tw (assessed.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.016 Tc -0.0625 Tw (Between September 20 and October 24 2002 and Septem-)Tj 0 -1.401 TD -0.0036 Tc -0.06 Tw (ber 12 and October 31, 2003 participants completed sur-)Tj 0 -1.398 TD 0.0156 Tc 0.125 Tw (veys addressing their efforts to search for and find)Tj 0 -1.401 TD -0.0039 Tc -0.0083 Tw [(meaning from the events.)]TJ /TT1 1 Tf 11 0 0 11 66 298.86 Tm 0.0557 Tc 0 Tw (Measures)Tj /F56 1 Tf 10 0 0 10 66 282.84 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0033 Tc 0.0243 Tw (Three indices were created to objectively measure par-)Tj 0 -1.398 TD -0.0036 Tc -0.0219 Tw (ticipants exposure to the 9/11 attacks: 1\) a dichotomous)Tj 0 -1.401 TD -0.0126 Tc -0.0625 Tw (measure of whether the participant lived within 100 miles)Tj T* -0.0037 Tc 0.0168 Tw [(of the )17.3(W)94.1(orld )17.3(T)37.1(rade Center \(WTC\) at the time of the at-)]TJ 0 -1.398 TD -0.0015 Tc 0.125 Tw (tacks; 2\) if the participant had direct exposure to the)Tj 0 -1.401 TD 0.002 Tc (attacks \(was in the WTC or pentagon, witnessed the)Tj T* -0.0028 Tc 0.0918 Tw [(attacks directly)60.2(, etc.\); and 3\) indirectly witnessed the)]TJ 0 -1.398 TD -0.0035 Tc 0.0325 Tw (attacks via television.)Tj /F56 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 0.1092 Tw (Stress Reaction Questionnaire which was modified to)Tj 0 -1.401 TD -0.0062 Tc -0.0622 Tw (ask if participants experienced or did not experience)Tj T* -0.0033 Tc -0.0067 Tw (symptoms with regard to the 9/11 attacks.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0038 Tc 0.0064 Tw (Coping strategies were assessed using the Brief COPE.)Tj 0 -1.401 TD -0.0033 Tc 0.055 Tw (Participants were asked to use a 5-point scale \(1 = no,)Tj 0 -1.398 TD -0.003 Tc -0.0546 Tw (never to 5 = yes, all the time\) to respond to items such as)Tj 25.5 63.978 TD -0.0029 Tc 0.0006 Tw (Over the past week, have you ever found yourself try-)Tj 0 -1.398 TD -0.0035 Tc -0.018 Tw (ing to make sense of the September 11 attacks and their)Tj 0 -1.401 TD -0.0069 Tc 0 Tw (aftermath?)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0039 Tc 0.0632 Tw [(The )14.2(V)115.3(aughan Perceived Risk Scale was used to assess)]TJ 0 -1.401 TD -0.0033 Tc 0.03 Tw (participants fears about future terrorist attacks.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD 0.0043 Tc 0.125 Tw (Posttraumatic symptoms were assessed at the 1-year)Tj 0 -1.401 TD -0.0038 Tc -0.0625 Tw (and 2-year follow up using the Posttraumatic Stress Dis-)Tj T* -0.0109 Tc -0.0626 Tw [(order ChecklistCivilian )16(V)111.3(ersion.)]TJ /TT1 1 Tf 11 0 0 11 321 590.25 Tm 0.0154 Tc 0 Tw [(RESUL)83.6(TS)]TJ /F56 1 Tf 10 0 0 10 321 574.26 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0035 Tc -0.0465 Tw [(Individuals who did not complete the follow-up surveys)]TJ 0 -1.401 TD -0.0034 Tc 0.1186 Tw (were not significantly different from those who com-)Tj T* -0.0032 Tc -0.0249 Tw [(pleted the follow-up surveys with regard to psychologi-)]TJ 0 -1.398 TD -0.0034 Tc 0.0269 Tw [(cal diagnoses, gender)35.6(, exposure to the attacks, or acute)]TJ 0 -1.401 TD -0.0035 Tc 0.0606 Tw [(stress symptoms. However)35.5(, non-respondents to the 1-)]TJ T* -0.0002 Tc 0.125 Tw (year and 2-year follow-up surveys were significantly)Tj 0 -1.398 TD -0.0034 Tc -0.0207 Tw (younger than respondents \(mean differences = 5.71 and)Tj 0 -1.401 TD -0.0058 Tc -0.0625 Tw (9.39, respectively; )Tj /TT5 1 Tf 7.374 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.492 0 TD -0.0059 Tc -0.0625 Tw [()57.1(s)0( < .01\).)]TJ /F56 1 Tf -9.666 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD 0.0043 Tc 0.1251 Tw [(Respondents had a higher mean \(5.03\) on the )49.4(Acute)]TJ 0 -1.401 TD -0.0038 Tc 0.0107 Tw (Stress measure as compared to individuals not exposed)Tj T* -0.0032 Tc -0.0275 Tw (to trauma \(4.9\) suggesting that participants in this study)Tj 0 -1.398 TD -0.0034 Tc -0.006 Tw (experienced a higher level of stress.)Tj /F56 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0034 Tc 0.0042 Tw (The majority of respondents \(68.4%\) reported some at-)Tj 0 -1.398 TD -0.0037 Tc 0.1156 Tw (tempt to search for meaning in the two-month period)Tj 0 -1.401 TD -0.0069 Tc -0.0622 Tw (following 9/11/2001, although there were no specifics of)Tj T* -0.0033 Tc -0.0368 Tw [(how this occurred. However)38.7(, 59.7 % reported they were)]TJ 0 -1.398 TD 0.0425 Tw (not able to do so.)Tj /F56 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0034 Tc -0.0587 Tw (One -year post-9/11, 58.7 % of respondents were unable)Tj 0 -1.398 TD -0.0038 Tc -0.0375 Tw (to find meaning.)Tj /F56 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0022 Tc 0.125 Tw (A hierarchical regression indicated that older respon-)Tj 0 -1.398 TD -0.0028 Tc 0.0325 Tw (dents \( = .23, )Tj /TT5 1 Tf 6.096 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.495 0 TD -0.0028 Tc 0.0335 Tw [( < .01\), women \( = .15, )]TJ /TT5 1 Tf 10.155 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.495 0 TD -0.0029 Tc 0.0333 Tw [( < .01\), and)]TJ -17.241 -1.401 TD -0.0025 Tw (singles \( = .09, )Tj /TT5 1 Tf 6.615 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.495 0 TD -0.0029 Tc -0.003 Tw ( < .05\) were more likely to search for)Tj -7.11 -1.401 TD -0.0142 Tc -0.0622 Tw (meaning as were individuals who initially reported higher)Tj 0 -1.398 TD -0.0033 Tc 0.0667 Tw (levels of acute stress.)Tj /F56 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc 0.05 Tw (A hierarchical regression indicated that men and those)Tj 0 -1.398 TD -0.0068 Tc -0.0621 Tw (with some college education \( = .14, )Tj /TT5 1 Tf 14.625 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.489 0 TD -0.0068 Tc -0.0625 Tw [( < .01\) were more)]TJ -15.114 -1.401 TD -0.0042 Tc [(likely to find meaning. )49.8(At two months post-9/1)34.8(1, search-)]TJ T* -0.0076 Tc -0.0621 Tw (ing for meaning was positively correlated with outcomes)Tj 0 -1.398 TD -0.0032 Tc 0.0313 Tw (of fears of future terrorism at 1-year and posttraumatic)Tj 0 -1.401 TD -0.0023 Tc -0.014 Tw (symptoms at 1-year and 2-years \()Tj /TT5 1 Tf 13.215 0 TD 0 Tc 0 Tw (r)Tj /TT2 1 Tf 0.384 0 TD -0.0025 Tc -0.014 Tw [()54.5(s)0( = .28, .25, and .26,)]TJ -13.599 -1.401 TD -0.0026 Tc 0 Tw (respectively; )Tj /TT5 1 Tf 5.28 0 TD 0 Tc (p)Tj /TT2 1 Tf 0.495 0 TD -0.0028 Tc -0.045 Tw [()54.2(s)0( < .01\).)]TJ /F56 1 Tf -7.575 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0039 Tc 0.1086 Tw (At two months post-9/11, finding meaning was nega-)Tj 0 -1.401 TD -0.0032 Tc -0.0443 Tw (tively correlated with outcomes of fears of future terror-)Tj 0 -1.398 TD -0.0029 Tc -0.0481 Tw (ism at 1-year and posttraumatic symptoms at 1-year and)Tj 0 -1.401 TD -0.0076 Tc -0.06 Tw (2-years \()Tj /TT5 1 Tf 3.399 0 TD 0 Tc 0 Tw (r)Tj /TT2 1 Tf 0.381 0 TD -0.0081 Tc -0.0621 Tw [()54.9(s)0( = -.21, -.13, and -.13, respectively; )]TJ /TT5 1 Tf 14.271 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.489 0 TD -0.0089 Tc -0.0625 Tw [()54.1(s)0( < .01\).)]TJ ET endstream endobj 324 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /F56 317 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 327 0 obj << /Length 8809 >> 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 [(312 )]TJ /TT3 1 Tf 2.8388 0 TD -0.0058 Tc (Selected Annotated Journal Resources)Tj /F56 1 Tf 10 0 0 10 54 722.64 Tm 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0042 Tc 0.0736 Tw (Respondents who found more meaning at two months)Tj 0 -1.398 TD -0.0031 Tc -0.0611 Tw (reported fewer fears of future terrorism at the 1-year fol-)Tj 0 -1.401 TD -0.0036 Tc 0.125 Tw (low-up \()Tj /TT5 1 Tf 3.516 0 TD 0 Tc 0 Tw (B)Tj /TT2 1 Tf 0.609 0 TD -0.0023 Tc 0.125 Tw [( = -.07\) compared to those who found less)]TJ -4.125 -1.401 TD -0.0031 Tc -0.0164 Tw (meaning in the early aftermath of the attacks.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD 0.012 Tc 0.125 Tw (There was a significant interaction between finding)Tj 0 -1.401 TD -0.0034 Tc 0.0794 Tw (meaning and proximity such that there was a stronger)Tj 0 -1.398 TD 0.0125 Tc 0.125 Tw (link between finding meaning and subsequent fears)Tj 0 -1.401 TD -0.0039 Tc -0.0356 Tw [(among respondents who resided within 100 miles of the)]TJ T* -0.0089 Tc 0.06 Tw (WTC \()Tj /TT5 1 Tf 2.829 0 TD 0 Tc 0 Tw (B)Tj /TT2 1 Tf 0.606 0 TD -0.0022 Tc 0.06 Tw [( = -.25, )]TJ /TT5 1 Tf 3.309 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.495 0 TD -0.0034 Tc 0.06 Tw [( <.01\) compared to all other respon-)]TJ -7.239 -1.398 TD -0.0065 Tc -0.06 Tw (dents \()Tj /TT5 1 Tf 2.589 0 TD 0 Tc 0 Tw (B)Tj /TT2 1 Tf 0.6 0 TD -0.0052 Tc -0.06 Tw [( = -.07, )]TJ /TT5 1 Tf 2.925 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.492 0 TD -0.0063 Tc -0.065 Tw [( <.05\).)]TJ /F56 1 Tf -8.406 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD 0.0107 Tc 0.125 Tw (Respondents who were searching for meaning at 2-)Tj 0 -1.398 TD -0.0037 Tc 0.09 Tw (months reported greater posttraumatic symptoms over)Tj 0 -1.401 TD -0.0105 Tw (time than those who were not searching for meaning \()Tj /TT5 1 Tf 21.294 0 TD 0 Tc 0 Tw (B)Tj /TT2 1 Tf -21.294 -1.401 TD -0.0196 Tc -0.06 Tw (= -.13, )Tj /TT5 1 Tf 2.619 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.477 0 TD -0.0213 Tc -0.065 Tw [( <.05\).)]TJ /TT1 1 Tf 11 0 0 11 54 506.25 Tm 0.0217 Tc 0 Tw [(CONCLUSIONS/SUMMAR)32.6(Y)]TJ /F56 1 Tf 10 0 0 10 54 490.26 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0035 Tc 0.0193 Tw (The degree of objective exposure did not predict either)Tj 0 -1.401 TD 0.0606 Tw (the degree to which participants searched for or found)Tj T* 0.0033 Tw (meaning in the attacks.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0057 Tc -0.0625 Tw (Searching for and finding meaning was related to adjust-)Tj 0 -1.401 TD -0.0074 Tc (ment over time.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0037 Tc 0.095 Tw (Participants who were able to find meaning were less)Tj 0 -1.401 TD 0.0003 Tc 0.125 Tw (likely to report subsequent fears of terrorism and re-)Tj 0 -1.398 TD -0.0035 Tc -0.0217 Tw (ported fewer symptoms of posttraumatic stress disorder)Tj 0 -1.401 TD -0.0038 Tc -0.0287 Tw (over time when compared to participants who could not)Tj T* -0.0035 Tc -0.0038 Tw (find meaning of the attacks.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.003 Tc -0.0139 Tw (This study provides a link between the theory that find-)Tj 0 -1.401 TD -0.0062 Tc -0.0625 Tw (ing meaning in negative life events plays a role in adjust-)Tj 0 -1.398 TD -0.003 Tc -0.024 Tw [(ment by reducing feelings of vulnerability)60(.)]TJ /TT1 1 Tf 11 0 0 11 54 285.84 Tm 0.0267 Tc 0 Tw [(LIMIT)62.2(A)72.5(TIONS)]TJ /F56 1 Tf 10 0 0 10 54 269.85 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0034 Tc 0.0043 Tw (Due to the many constructs being assessed, single-item)Tj 0 -1.401 TD -0.0037 Tc -0.0494 Tw (measures were used for searching for and finding mean-)Tj 0 -1.398 TD -0.0129 Tc -0.0625 Tw [(ing. This limits the manner in which people find meaning)]TJ 0 -1.401 TD -0.0028 Tc -0.0278 Tw (is assessed and may not incorporate the many ways that)Tj T* -0.0037 Tc -0.015 Tw (people find meaning from negative live events.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.012 Tc -0.0622 Tw (The attrition rate was not completely random in that more)Tj 0 -1.401 TD -0.0094 Tc [(African )50.6(Americans and Hispanics dropped out over time.)]TJ /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0029 Tc 0.125 Tw (The sample of individuals directly exposed to the at-)Tj 0 -1.401 TD -0.0036 Tc 0.114 Tw (tacks was a small number and so there was a limited)Tj 0 -1.398 TD -0.018 Tw (power to detect similarities and differences.)Tj ET 3.99 w /GS1 gs 309 728.985 m 546 728.985 l S BT /TT1 1 Tf 11 0 0 11 309 710.01 Tm /GS2 gs -0.0029 Tc 0.1254 Tw (Blodgett, C., Behan, K., Erp, M., Harrington, R.,)Tj 0 -1.1836 TD 0.0924 Tw (Souers, K. \(2008\). Crisis intervention for children)Tj 0 -1.1809 TD 0.0137 Tc 0.125 Tw [(and caregivers exposed to intimate partner vio-)]TJ T* 0.0171 Tc 0 Tw (lence.)Tj /TT4 1 Tf 2.5173 0 TD 0.0174 Tc 0.125 Tw [( Best Practices in Mental Health, 4)]TJ /TT1 1 Tf 15.7773 0 TD 0.0171 Tc 0 Tw (\(1\),)Tj /TT4 1 Tf 1.4864 0 TD 0 Tc ( )Tj /TT1 1 Tf 0.4009 0 TD 0.0153 Tc (74-)Tj ET 0.99 w /GS1 gs 309 649.485 m 546 649.485 l S BT 11 0 0 11 309 657.99 Tm /GS2 gs 0.0568 Tc (91.)Tj 0 -2.9755 TD -0.008 Tc 0.1236 Tw [(TYPE OF)27.5( )46.5(A)10(R)27.4(TICLE)]TJ /F56 1 Tf 10 0 0 10 309 609.24 Tm 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0034 Tc -0.0024 Tw (Logistical Regression used to analyze clinical records)Tj /TT1 1 Tf 11 0 0 11 309 578.85 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 /F56 1 Tf 10 0 0 10 309 562.86 Tm 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0132 Tc -0.0621 Tw (Identify the common characteristics of children and fami-)Tj 0 -1.401 TD -0.0033 Tc -0.0028 Tw (lies who experience violence as well as the type of vio-)Tj T* -0.0061 Tc -0.06 Tw (lence experienced.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0031 Tc 0.1158 Tw (Identify the effectiveness of crisis intervention strate-)Tj 0 -1.401 TD -0.0091 Tc -0.0622 Tw (gies in engaging families in informal supportive relation-)Tj 0 -1.398 TD -0.0027 Tc 0.125 Tw (ships who have been exposed to violence in order to)Tj 0 -1.401 TD -0.0035 Tc -0.03 Tw (reduce the immediate effects of the trauma.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0033 Tc -0.0494 Tw (Determine if there is benefit in crisis intervention strate-)Tj 0 -1.401 TD -0.0035 Tc -0.0264 Tw (gies for children and families exposed to violence.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc 0.0657 Tw (Determine variables that predict the success of engag-)Tj 0 -1.401 TD -0.0033 Tc -0.0267 Tw (ing families in crisis in outreach services.)Tj /TT1 1 Tf 11 0 0 11 309 386.46 Tm 0.0265 Tc 0 Tw (PROCEDURE)Tj 0 -1.4564 TD 0.0026 Tc (Participants)Tj /F56 1 Tf 10 0 0 10 309 354.45 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc 0.0142 Tw (Referrals were made from law enforcement, social ser-)Tj 0 -1.401 TD 0.055 Tw (vice agencies, and domestic violence advocates.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0031 Tc 0.041 Tw (All families in the study were required to have at least)Tj 0 -1.401 TD -0.0034 Tc -0.0091 Tw (one child under the age of six as this was a requirement)Tj 0 -1.398 TD -0.0035 Tc 0.0056 Tw [(for state funding. However)35.5(,)-0.4( services were of)17.5(fered to all)]TJ 0 -1.401 TD -0.011 Tc -0.0616 Tw [(members of the family)64(.)]TJ /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0167 Tc -0.0625 Tw (Referrals for 972 children and 464 families were received.)Tj 0 -1.401 TD -0.0032 Tc -0.0183 Tw (Fifty-seven children from 15 families are in the data set)Tj T* -0.0034 Tc 0.0244 Tw (twice because they had two or more independent crisis)Tj 0 -1.398 TD -0.0145 Tc 0 Tw (referrals.)Tj /F56 1 Tf -1.8 -1.602 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0034 Tc 0.0381 Tw (Eighty-three percent \(388 of 464 families\) and 85% of)Tj 0 -1.398 TD -0.0076 Tc -0.0621 Tw (children \(828 of 973 children\) were in treatment.)Tj /F56 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0032 Tc 0.0162 Tw (Seventy-nine percent of children \()Tj /TT5 1 Tf 13.62 0 TD 0 Tc 0 Tw (n)Tj /TT2 1 Tf 0.495 0 TD -0.0036 Tc 0.018 Tw [( = 654\) and 86% of)]TJ -14.115 -1.398 TD -0.016 Tc -0.06 Tw (families \()Tj /TT5 1 Tf 3.591 0 TD 0 Tc 0 Tw (n)Tj /TT2 1 Tf 0.48 0 TD -0.016 Tc -0.0622 Tw [( = 335\) were exposed to interpersonal violence.)]TJ /F56 1 Tf -5.871 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0031 Tc 0.0775 Tw (The mean age of children was 5.89 years \()Tj /TT5 1 Tf 17.46 0 TD -0.0132 Tc 0 Tw (SD)Tj /TT2 1 Tf 1.209 0 TD -0.003 Tc 0.08 Tw [( = 4.05;)]TJ -18.669 -1.398 TD -0.0035 Tc 0.0605 Tw (range = 0-19\) while the mean age of adults was 31.12)Tj ET endstream endobj 328 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /F56 317 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 330 0 obj << /Length 8683 >> 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. 4 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (313)Tj /TT2 1 Tf 10 0 0 10 84 722.64 Tm -0.0048 Tc -0.06 Tw (years \()Tj /TT5 1 Tf 2.601 0 TD -0.0116 Tc 0 Tw (SD )Tj /TT2 1 Tf 1.383 0 TD -0.0074 Tc -0.0622 Tw [( = 7.98; range = 18.6-53.40\). The mean assail-)]TJ -3.984 -1.398 TD -0.0619 Tw [(ant age was 32.44 years \()]TJ /TT5 1 Tf 9.615 0 TD -0.0162 Tc 0 Tw (SD)Tj /TT2 1 Tf 1.2 0 TD -0.0079 Tc -0.062 Tw [( = 8.06; range = 18.9-55.40\).)]TJ /F56 1 Tf -12.615 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0086 Tc -0.0625 Tw [(V)62.6(ictims were 93% female and assailants were 90% male.)]TJ /TT1 1 Tf 11 0 0 11 66 662.25 Tm 0.0242 Tc 0 Tw (Procedure)Tj /F56 1 Tf 10 0 0 10 66 646.26 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0037 Tc -0.0157 Tw [(Four master)-36.7()53.3(s-level clinicians with a clinical supervisor)]TJ 0 -1.401 TD 0.0134 Tw (provided 24-hour crisis services.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD 0.0023 Tc 0.125 Tw (Clinicians used a blend of engagement, support, and)Tj 0 -1.401 TD -0.0037 Tc -0.0285 Tw [(solution-focused problem-solving in order to build a re-)]TJ T* 0.0019 Tc 0.125 Tw (lationship that would facilitate on-going support ser-)Tj 0 -1.398 TD 0.0041 Tc 0 Tw (vices.)Tj /F56 1 Tf -1.8 -1.602 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0033 Tc -0.0464 Tw (Intervention goals were: 1\) establish on-going safety; 2\))Tj 0 -1.398 TD -0.003 Tc 0.0064 Tw (identify practical actions to increase physical and emo-)Tj 0 -1.401 TD -0.0035 Tc 0.0264 Tw (tional comfort; 3\) decrease emotional distress; 4\) iden-)Tj T* -0.0173 Tc -0.0625 Tw (tify goals for extended support; 5\) empower the individual)Tj 0 -1.398 TD -0.0026 Tc 0.125 Tw (to use coping skills; and 6\) connect the individual to)Tj 0 -1.401 TD -0.0024 Tc (social support resources.)Tj /TT1 1 Tf 11 0 0 11 66 457.86 Tm 0.0557 Tc 0 Tw (Measures)Tj /F56 1 Tf 10 0 0 10 66 441.84 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0035 Tc 0.0264 Tw (Crisis clinicians maintained clinical records in order to)Tj 0 -1.398 TD -0.009 Tw (provide professionally informed data while minimizing)Tj 0 -1.401 TD -0.0029 Tc -0.0328 Tw (invasion to family privacy during times of crisis.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0033 Tc 0.0793 Tw (Families were categorized as referral only \(no contact)Tj 0 -1.401 TD -0.0031 Tc -0.026 Tw (made by crisis clinician\) or engaged.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc 0.0736 Tw (Clinical records were evaluated on four rating catego-)Tj 0 -1.401 TD -0.0029 Tc -0.003 Tw (ries: 1\) quality of the clinical record; 2\) level of service)Tj T* -0.0032 Tc -0.0244 Tw (provided to each family; 3\) the level of receptiveness to)Tj 0 -1.398 TD -0.0028 Tc 0.067 Tw (help by each family; and 4\) evidence of benefit to the)Tj 0 -1.401 TD -0.0409 Tc 0 Tw [(family)64.1(.)]TJ /F56 1 Tf -1.8 -1.599 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0099 Tc -0.0625 Tw (Each record was independently evaluated by two or three)Tj 0 -1.401 TD -0.0037 Tc -0.0289 Tw (raters and rater agreement exceeded 90%.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0114 Tc -0.0625 Tw [( Record quality was evaluated as good, fair)39.6(, or poor based)]TJ 0 -1.401 TD -0.0036 Tc 0.04 Tw (on completeness of the record.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0033 Tc 0.0725 Tw (Service level and intensity were rated on a continuum)Tj 0 -1.401 TD -0.0107 Tc -0.0625 Tw (ranging from time-limited crisis intervention to sustained)Tj T* -0.0111 Tc (services in the form of problem solving, supportive coun-)Tj 0 -1.398 TD -0.0036 Tc 0.0156 Tw (seling, and the development of formal plans to connect)Tj 0 -1.401 TD -0.0438 Tw (families with social service agencies.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0032 Tc 0.0794 Tw (Evidence of benefit to the family was evaluated as an)Tj 0 -1.401 TD -0.0036 Tc -0.0092 Tw (end of the violent relationship, improved functional ad-)Tj T* 0.0378 Tw (justment, or sustained engagement in health and social)Tj 0 -1.398 TD 0.0068 Tc 0 Tw (services.)Tj /TT1 1 Tf 11 0 0 11 321 722.64 Tm 0.0154 Tc [(RESUL)83.6(TS)]TJ /F56 1 Tf 10 0 0 10 321 706.65 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0034 Tc 0.015 Tw (Eighty-three percent of adult victims reported previous)Tj 0 -1.401 TD 0.0009 Tc 0.125 Tw (exposure to interpersonal violence and 53% reported)Tj 0 -1.398 TD -0.0034 Tc -0.0464 Tw (exposure to interpersonal violence when they were chil-)Tj 0 -1.401 TD -0.0005 Tc 0 Tw (dren.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0032 Tc -0.0595 Tw [(T)73.6(wenty three percent of adult victims and 82% of assail-)]TJ 0 -1.401 TD -0.0035 Tc 0.114 Tw (ants reported histories of substance abuse.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0034 Tc 0.001 Tw (At the time of the crisis, 33% of families were engaged)Tj 0 -1.401 TD -0.0032 Tc 0.0293 Tw (with a heath or social service support system.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0032 Tc 0.0479 Tw (The majority of referrals resulted in crisis intervention)Tj 0 -1.401 TD -0.0035 Tc 0.0325 Tw (contact of one the three sessions \(78% of children,)Tj /TT5 1 Tf 20.274 0 TD 0.03 Tc 0 Tw ( n)Tj /TT2 1 Tf 0.78 0 TD 0.032 Tc ( =)Tj -21.054 -1.401 TD -0.052 Tc (211\).)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0035 Tc -0.055 Tw (In 22% of the children \()Tj /TT5 1 Tf 9.225 0 TD 0 Tc 0 Tw (n)Tj /TT2 1 Tf 0.495 0 TD -0.0033 Tc -0.055 Tw [( = 59\) intervention resulted in a)]TJ -9.72 -1.401 TD -0.0038 Tc 0.02 Tw (more extended supportive relationship.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc 0.0981 Tw (In clinical records that were rated good, 13% showed)Tj 0 -1.401 TD 0.0263 Tw (evidence of substantial benefit to the child and/or fam-)Tj 0 -1.398 TD -0.0373 Tc 0 Tw [(ily)67.7(.)]TJ /F56 1 Tf -1.8 -1.602 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0032 Tc 0.125 Tw (The presence or absence of support was significantly)Tj 0 -1.398 TD -0.0034 Tc 0.0533 Tw (related to the duration of support. Of the families who)Tj 0 -1.401 TD -0.004 Tc 0.0893 Tw (engaged in engaged in extended support 42% showed)Tj T* -0.0031 Tc 0.02 Tw [(benefit. The families that only received crisis interven-)]TJ 0 -1.398 TD -0.0037 Tc 0.0564 Tw (tion showed 4% showed benefit \(chi square \()Tj /TT5 1 Tf 18.261 0 TD -0.0068 Tc 0 Tw (df)Tj /TT2 1 Tf 0.768 0 TD -0.0025 Tc 0.0583 Tw [( = 1\) =)]TJ -19.029 -1.401 TD -0.0223 Tc 0 Tw (60.83, )Tj /TT5 1 Tf 2.535 0 TD 0 Tc (p)Tj /TT2 1 Tf 0.474 0 TD -0.0223 Tc -0.0625 Tw [( < .01\).)]TJ /F56 1 Tf -4.809 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0038 Tc 0.0725 Tw (Benefits were greatest among children whose families)Tj 0 -1.401 TD -0.0035 Tc -0.0543 Tw (received more than five direct contacts \(Chi square \()Tj /TT5 1 Tf 20.376 0 TD -0.0068 Tc 0 Tw (df)Tj /TT2 1 Tf 0.768 0 TD -0.058 Tc ( =)Tj -21.144 -1.401 TD -0.0192 Tc -0.0616 Tw (2\) = 91.60, )Tj /TT5 1 Tf 4.236 0 TD 0 Tc 0 Tw (p)Tj /TT2 1 Tf 0.48 0 TD -0.0197 Tc -0.0625 Tw [( < .01\).)]TJ /F56 1 Tf -6.516 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD 0.003 Tc 0.125 Tw (The variables that were significantly associated with)Tj 0 -1.401 TD -0.0033 Tc 0.0518 Tw (progression through the levels of support were type of)Tj 0 -1.398 TD -0.0135 Tc -0.062 Tw (intimate relationship \(cohabitating or separate residence\),)Tj 0 -1.401 TD -0.0035 Tc 0.03 Tw (substance abuse, and victim employment.)Tj /TT1 1 Tf 11 0 0 11 321 268.26 Tm 0.0217 Tc 0 Tw [(CONCLUSIONS/SUMMAR)32.6(Y)]TJ /F56 1 Tf 10 0 0 10 321 252.24 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.003 Tc -0.0329 Tw (This study confirmed the feasibility and potential effec-)Tj 0 -1.398 TD -0.0032 Tc 0.1138 Tw (tiveness of crisis intervention as a response to family)Tj 0 -1.401 TD -0.0423 Tw [(violence. )17.8(T)73.7(wo thirds of the participants in this study had)]TJ T* -0.0035 Tc 0.0233 Tw (no other relationship with social service agencies.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0035 Tc -0.0286 Tw (Initial findings suggest that assailant and victim charac-)Tj 0 -1.401 TD -0.0033 Tc 0.0871 Tw (teristics may be predictive of service engagement and)Tj 0 -1.398 TD -0.0038 Tc 0 Tw (benefit.)Tj /F56 1 Tf -1.8 -1.602 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0037 Tc 0.1184 Tw (Increased contact with families and children provides)Tj 0 -1.398 TD -0.0034 Tc 0.0016 Tw (greater benefit in comparison to brief contact.)Tj ET endstream endobj 331 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /F56 317 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 333 0 obj << /Length 9385 >> 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 [(314 )]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 0.0267 Tc 0 Tw [(LIMIT)62.2(A)72.5(TIONS)]TJ /F56 1 Tf 10 0 0 10 54 706.65 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0072 Tc -0.0625 Tw (Standardized reporting tools would help consistency and)Tj 0 -1.401 TD -0.0038 Tc -0.02 Tw (support a common definition of terms.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.004 Tc 0.1129 Tw (More thorough reporting methods would give a more)Tj 0 -1.401 TD -0.0033 Tc -0.0307 Tw (detailed analysis of families who declined to participate)Tj 0 -1.398 TD -0.0025 Tc 0.035 Tw (in any services.)Tj ET 3.99 w /GS1 gs 54 609.585 m 291 609.585 l S BT /TT1 1 Tf 11 0 0 11 54 590.61 Tm /GS2 gs 0.0207 Tc 0.125 Tw [(Ehring, )17.7(T)74.1(., Frank, S., & Ehlers, )50.4(A. )17.7(The r)9.8(ole of)]TJ 0 -1.1836 TD -0.0034 Tc 0.0439 Tw (rumination and reduced concreteness in the main-)Tj 0 -1.1809 TD 0.0052 Tc 0.125 Tw (tenance of posttraumatic stress disorder and de-)Tj T* -0.0017 Tc 0.1242 Tw (pression following trauma. )Tj /TT4 1 Tf 12 0 TD -0.0021 Tc 0.1273 Tw (Cognitive Therapy Re-)Tj ET 0.99 w /GS1 gs 54 530.085 m 291 530.085 l S BT 11 0 0 11 54 538.59 Tm /GS2 gs 0.0198 Tc 0.125 Tw (search, 32, )Tj /TT1 1 Tf 5.2145 0 TD 0.0192 Tc 0 Tw (488-506.)Tj -5.2145 -3.1227 TD -0.008 Tc 0.1236 Tw [(TYPE OF)27.5( )46.5(A)10(R)27.5(TICLE)]TJ /F56 1 Tf 10 0 0 10 54 488.25 Tm 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0089 Tc -0.0625 Tw (Original empirical investigation)Tj /TT1 1 Tf 11 0 0 11 54 457.86 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 /F56 1 Tf 10 0 0 10 54 441.84 Tm 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0164 Tc -0.0625 Tw [(T)75.4(o)0( examine the variables maintaining posttraumatic stress)]TJ 0 -1.398 TD -0.0015 Tc 0 Tw (symptoms.)Tj /F56 1 Tf -1.8 -1.602 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.009 Tc -0.0625 Tw [(T)70.8(o)0( replicate earlier findings regarding the role of rumina-)]TJ 0 -1.398 TD -0.0038 Tc -0.0562 Tw (tion in the maintenance of PTSD and depression follow-)Tj 0 -1.401 TD -0.0069 Tc -0.06 Tw (ing trauma.)Tj /TT1 1 Tf 11 0 0 11 54 353.46 Tm 0.0344 Tc 0 Tw (METHODS)Tj 0 -1.4564 TD 0.0026 Tc (Participants)Tj /F56 1 Tf 10 0 0 10 54 321.45 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0214 Tc -0.0625 Tw [(Participants were recruited from King)53.6(s College Hospital)50.6(s)]TJ 0 -1.401 TD -0.0038 Tc 0.023 Tw (Accident and Emergency Department \(A&E\), London,)Tj 0 -1.398 TD -0.0031 Tc 0.0306 Tw (subsequent to suffering an injury in a road traffic acci-)Tj 0 -1.401 TD 0.0133 Tc 0 Tw (dent.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.003 Tc -0.0169 Tw [(Inclusion criteria were: injury in a road traffic accident;)]TJ 0 -1.401 TD -0.0034 Tc -0.0136 Tw (injuries exceeded blue triage injuries \(very mild inju-)Tj T* -0.0036 Tc -0.0622 Tw (ries\); age between 18 and 65; address in greater London.)Tj 0 -1.398 TD -0.0225 Tc (Exclusion criteria were: left before receiving medical treat-)Tj 0 -1.401 TD -0.003 Tc 0.0859 Tw [(ment; current psychosis or suicidality; attending )54.1(A)6.9(&)6.9(E)]TJ T* -0.0033 Tc 0.0062 Tw (Department more than three days.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0032 Tc 0.125 Tw (Study 1 was a cross-sectional investigation and com-)Tj 0 -1.401 TD -0.0037 Tc 0.0759 Tw (prised 101 participants \(56% male; age )Tj /TT5 1 Tf 16.2 0 TD -0.009 Tc 0 Tw (M )Tj /TT2 1 Tf 1.149 0 TD -0.0026 Tc 0.075 Tw (= 34. )Tj /TT5 1 Tf 2.451 0 TD -0.0132 Tc 0 Tw (SD)Tj /TT2 1 Tf 1.209 0 TD 0.077 Tc ( =)Tj -21.009 -1.398 TD -0.0036 Tc 0.03 Tw (10.60\). Participants were interviewed on one occasion.)Tj 0 -1.401 TD 0.0042 Tc 0.125 Tw [(T)69(wenty-three percent of participants experienced the)]TJ T* -0.0035 Tc 0.0478 Tw [(accident as a car driver)35.5(, 22% as a passenger)35.5(, 29% as a)]TJ 0 -1.398 TD -0.0027 Tc -0.0121 Tw (motorcyclist, and 27% as a bicyclist. Sixty-five percent)Tj 0 -1.401 TD -0.0035 Tc -0.0372 Tw (of participants received minor injuries, 29% urgent, and)Tj T* -0.0487 Tw (6% received life threatening injuries.)Tj /F56 1 Tf 23.7 64.32 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD 0.0041 Tc 0.125 Tw (Study 2 was a prospective longitudinal investigation)Tj 0 -1.398 TD -0.0036 Tc -0.005 Tw (and the sample was comprised of 147 participants. Par-)Tj 0 -1.401 TD -0.0034 Tc 0.0881 Tw (ticipants attended an interview 2 weeks after the inci-)Tj T* -0.0032 Tc -0.0225 Tw [(dent and were followed for 6 months. Thirty percent of)]TJ 0 -1.398 TD -0.0034 Tc -0.0329 Tw (participants had experienced the accident as car drivers,)Tj 0 -1.401 TD 0.0512 Tw (16% as passengers, 38% as motorcyclists, and 26% as)Tj T* -0.0029 Tc 0.1122 Tw [(bicyclists. Sixty percent of participants injuries were)]TJ 0 -1.398 TD -0.0038 Tc -0.059 Tw [(minor)35.2(, 36% were ur)17.2(gent, and 4% were life threatening.)]TJ /F56 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0034 Tc 0.0986 Tw (In both studies, a high comorbidity between posttrau-)Tj 0 -1.398 TD -0.0036 Tc 0.1157 Tw [(matic stress disorder)38.4(, acute stress disorder)35.4(, and major)]TJ 0 -1.401 TD -0.0622 Tw (depression was found: Fourty-one percent \(Study 1\) and)Tj T* 0.1 Tw (52% \(Study 2\) of participants with PTSD/ASD at the)Tj 0 -1.398 TD 0.1129 Tw (initial assessments also met criteria for major depres-)Tj 0 -1.401 TD -0.0031 Tc 0.034 Tw (sion; and 64% \(Study 1\) and 86% \(Study 2\) of partici-)Tj T* -0.0038 Tc -0.0186 Tw (pants with major depression also suffered from PTSD.)Tj /TT1 1 Tf 11 0 0 11 309 494.25 Tm 0.0233 Tc 0 Tw (Materials)Tj /F56 1 Tf 10 0 0 10 309 478.26 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0037 Tc 0.105 Tw (In both studies, PTSD and major depression were as-)Tj 0 -1.401 TD -0.0067 Tc -0.0622 Tw (sessed with the SCID \(First et al., 1996\). In Study 2, only)Tj T* -0.0136 Tc 0 Tw (the )Tj /TT5 1 Tf 1.359 0 TD -0.0144 Tc -0.0612 Tw [(Acute S)33.6(t)1.6(r)33.6(ess Disor)30.6(der Scale )]TJ /TT2 1 Tf 10.701 0 TD 0 Tc 0 Tw (\()Tj /TT5 1 Tf 0.321 0 TD -0.0177 Tc (ASDS)Tj /TT2 1 Tf 2.268 0 TD -0.0129 Tc -0.0633 Tw [(; Bryant & Harvey)59.1(,)]TJ -14.649 -1.398 TD -0.0036 Tc 0.0261 Tw (2000\) was conducted as an interview at the 2-week as-)Tj 0 -1.401 TD 0.0143 Tw (sessment. Researchers rated the presence or absence of)Tj T* -0.0161 Tc -0.0617 Tw [(DSM-IV)13.9( symptom criteria for )50.3(ASD based on participant)46.9(s)]TJ 0 -1.398 TD 0.0235 Tc 0 Tw (responses.)Tj /F56 1 Tf -1.8 -1.602 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0033 Tc -0.0058 Tw (Posttraumatic stress disorder symptom severity was as-)Tj 0 -1.398 TD -0.005 Tc -0.0617 Tw (sessed using the )Tj /TT5 1 Tf 6.429 0 TD -0.0053 Tc (posttraumatic Diagnostic Scale )Tj /TT2 1 Tf 12.51 0 TD 0 Tc 0 Tw (\()Tj /TT5 1 Tf 0.33 0 TD -0.0114 Tc (PTSD)Tj /TT2 1 Tf 2.355 0 TD 0 Tc (;)Tj -21.624 -1.401 TD -0.0114 Tc -0.0619 Tw [(Foa, Cashman, Jaycox, & Perry)57.6(, 1997\).)]TJ /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0116 Tc (The )Tj /TT5 1 Tf 1.704 0 TD -0.0112 Tc -0.0618 Tw [(Beck Depr)33.8(ession Inventor)-5.2(y )]TJ /TT2 1 Tf 10.575 0 TD 0 Tc 0 Tw (\()Tj /TT5 1 Tf 0.327 0 TD -0.0155 Tc (BDI)Tj /TT2 1 Tf 1.629 0 TD -0.0112 Tc -0.0617 Tw [(; Beck, Rush, Shaw)57.8(,)]TJ -14.235 -1.401 TD -0.0162 Tc -0.0624 Tw [(& Emery)64.8(, 1979\) assessed the severity of depressive symp-)]TJ T* -0.005 Tc 0 Tw (toms.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc -0.005 Tw (The rumination subscale of the )Tj /TT5 1 Tf 12.501 0 TD -0.0041 Tc (Responses to Intrusions)Tj -12.501 -1.401 TD 0.0114 Tc 0 Tw (Questionnaire)Tj /TT2 1 Tf 5.874 0 TD 0.137 Tc ( \()Tj /TT5 1 Tf 0.741 0 TD 0.007 Tc (RIQ)Tj /TT2 1 Tf 1.695 0 TD 0.0128 Tc 0.125 Tw (\) was used to assess rumination)Tj -8.31 -1.398 TD 0.005 Tc (about the trauma and/or its consequences. This self-)Tj 0 -1.401 TD -0.0035 Tc 0.0579 Tw (report scale assesses different aspects of trauma survi-)Tj T* -0.0037 Tc 0.105 Tw (vors responses to intrusive memories and consists of)Tj 0 -1.398 TD -0.05 Tw (eight items.)Tj /F56 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0035 Tc 0.0384 Tw (The 10-item version of the rumination scale of the )Tj /TT5 1 Tf 20.526 0 TD -0.0068 Tc 0 Tw (Re-)Tj -20.526 -1.398 TD -0.0039 Tc 0.0483 Tw (sponse Style Questionnaire )Tj /TT2 1 Tf 11.181 0 TD 0 Tc 0 Tw (\()Tj /TT5 1 Tf 0.33 0 TD -0.009 Tc (RSQ)Tj /TT2 1 Tf 1.815 0 TD -0.0047 Tc 0.05 Tw (; Nolen-Hoeksema &)Tj -13.326 -1.401 TD -0.0039 Tc 0.0788 Tw [(Morrow)62.1(, 1991\) was used to assess depressive rumina-)]TJ T* -0.0054 Tc -0.0621 Tw [(tion defined as perseverative thinking about one)54.6(s symp-)]TJ 0 -1.398 TD 0.0588 Tc 0.36 Tw (toms of depression and possible causes and)Tj 0 -1.401 TD -0.0024 Tc 0.125 Tw (consequences of these symptoms.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0084 Tc -0.0621 Tw (The Rumination Interview generated the material for rat-)Tj 0 -1.401 TD 0.0129 Tc 0.125 Tw (ing the concreteness of the participants ruminative)Tj T* -0.0036 Tc -0.0486 Tw (thoughts. It was adapted from the Catastrophizing Inter-)Tj 0 -1.398 TD -0.003 Tc 0.0399 Tw [(views used by )17.9(V)113.2(asey and Borkovec \(1992\). In the first)]TJ ET endstream endobj 334 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /F56 317 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 336 0 obj << /Length 8651 >> 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. 4 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (315)Tj /TT2 1 Tf 10 0 0 10 84 722.64 Tm -0.0032 Tc -0.0331 Tw [(part of the interview)62.8(, participants were asked to identify)]TJ 0 -1.398 TD -0.0035 Tc 0.0744 Tw (their main concern related to the accident and explore)Tj 0 -1.401 TD -0.035 Tw (the question of what concerns them the most about their)Tj T* -0.0143 Tw [(identified concern. For the second part of the interview)59.5(,)]TJ 0 -1.398 TD -0.0031 Tc 0.055 Tw (participants were asked to identify a topic of recent or)Tj 0 -1.401 TD -0.0037 Tc 0.0468 Tw (current sad mood and the interview followed the same)Tj T* -0.0027 Tc 0.125 Tw (procedure with the question What is it about X that)Tj 0 -1.398 TD -0.0033 Tc 0.0543 Tw (makes you feel sad? Graduate students rated answers)Tj 0 -1.401 TD -0.0036 Tc 0.0736 Tw (from the interview transcripts using a scale developed)Tj T* -0.0033 Tc -0.0287 Tw (by Stober and colleagues \(2002\).)Tj /TT1 1 Tf 11 0 0 11 66 566.25 Tm 0.0242 Tc 0 Tw (Procedure)Tj /F56 1 Tf 10 0 0 10 66 550.26 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0034 Tc 0.0242 Tw (Study 1: Participants received the questionnaire packet)Tj 0 -1.401 TD -0.0033 Tc 0.0106 Tw (and completed the packets the day before attending the)Tj T* 0.0114 Tc 0.125 Tw (assessment session. During the session, participants)Tj 0 -1.398 TD -0.0041 Tc -0.0622 Tw (completed the Rumination Interview and the SCID. Par-)Tj 0 -1.401 TD -0.0035 Tc -0.06 Tw (ticipants received $30 as a reimbursement for their time.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0006 Tc 0.125 Tw (Study 2: The study comprised four assessments. The)Tj 0 -1.401 TD -0.0038 Tc 0.0657 Tw (first assessment conducted at 2 weeks posttrauma was)Tj T* -0.0029 Tc 0.0393 Tw (identical to Study 1. Symptom severity measures were)Tj 0 -1.398 TD -0.0034 Tc 0.0712 Tw (repeated at 1, 3, and 6 months following the accident.)Tj 0 -1.401 TD -0.0074 Tc -0.0623 Tw (The SCID was also repeated by telephone at the 6-month)Tj T* -0.004 Tc 0.0625 Tw (follow up assessment.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD 0.0231 Tc 0.125 Tw (Diagnostic groups were compared with )Tj /TT5 1 Tf 17.454 0 TD 0.0192 Tc 0 Tw (t-)Tj /TT2 1 Tf 0.66 0 TD 0.0237 Tc 0.125 Tw (tests and)Tj -18.114 -1.401 TD -0.0052 Tc -0.0623 Tw [(Pearson)51.8(s product-moment correlation coef)15.8(ficients were)]TJ 0 -1.398 TD -0.0037 Tc 0.0633 Tw (computed to investigate the relationship between vari-)Tj 0 -1.401 TD -0.0033 Tc 0.0375 Tw (ables of interest.)Tj /TT1 1 Tf 11 0 0 11 66 319.86 Tm 0.0154 Tc 0 Tw [(RESUL)83.6(TS)]TJ /F56 1 Tf 10 0 0 10 66 303.84 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0049 Tc (The )Tj /TT5 1 Tf 1.86 0 TD (t-)Tj /TT2 1 Tf 0.606 0 TD -0.0039 Tc 0.0733 Tw [(tests showed that participants with )53.1(ASD, PTSD,)]TJ -2.466 -1.398 TD -0.0443 Tw (or major depression reported more rumination about the)Tj 0 -1.401 TD -0.0092 Tc -0.0625 Tw (trauma and more depressive rumination than participants)Tj T* -0.0038 Tc 0.1175 Tw (without these disorders.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0069 Tc -0.0625 Tw (Rumination about the trauma as well as depressive rumi-)Tj 0 -1.401 TD -0.0035 Tc 0.0792 Tw (nation correlated significantly with PTSD and depres-)Tj 0 -1.398 TD -0.0033 Tc 0.034 Tw (sive symptom severities in all assessments.)Tj /F56 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0039 Tc 0.0266 Tw (Trauma-related rumination at 2 weeks predicted PTSD)Tj 0 -1.398 TD -0.0031 Tc -0.0413 Tw (symptom severity at 6 months over and above symptom)Tj 0 -1.401 TD -0.0038 Tc -0.015 Tw (levels at 2 weeks. Trauma-related rumination measured)Tj T* -0.0149 Tc -0.0622 Tw (at 1 month predicted PTSD symptom severity at 6 months)Tj 0 -1.398 TD -0.0032 Tc 0.0575 Tw [(over and above symptom levels at 1 month. Similarly)59.8(,)]TJ 0 -1.401 TD -0.0092 Tc -0.0625 Tw (self-reported depressive rumination measured at 2 weeks)Tj T* -0.0036 Tc 0.048 Tw (and at 1 month predicted BDI scores at 6 months over)Tj 0 -1.398 TD -0.0037 Tc 0.1129 Tw (and above what was predicted from initial depressive)Tj 0 -1.401 TD -0.0033 Tc -0.0129 Tw (symptoms at 2 weeks and at 1 month.)Tj /F56 1 Tf 23.7 63.279 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.003 Tc 0.1239 Tw [(T)73.8(o)0( rule out the possibility that the results represent a)]TJ 0 -1.398 TD -0.0038 Tc 0.049 Tw (shared relationship between re-experiencing and rumi-)Tj 0 -1.401 TD -0.0034 Tc 0.0206 Tw (nation, the analyses were rerun with an adjusted PTSD)Tj T* -0.0033 Tc 0.109 Tw (symptom severity score that removed re-experiencing)Tj 0 -1.398 TD -0.0036 Tc 0.0309 Tw [(items. )53.5(All correlations and partial correlations between)]TJ 0 -1.401 TD 0.0086 Tw (the rumination scales and PTSD severity remained sig-)Tj T* -0.0034 Tc 0.03 Tw (nificant for the adjusted score.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0037 Tc 0.029 Tw (For concurrent assessments, PTSD symptom severities)Tj 0 -1.401 TD -0.0033 Tc 0.0609 Tw (were still significantly correlated with both trauma-re-)Tj 0 -1.398 TD -0.0018 Tc 0.125 Tw (lated as well as depressive rumination scores in both)Tj 0 -1.401 TD -0.0032 Tc -0.0334 Tw (samples when statistically controlling for symptom lev-)Tj T* -0.0046 Tc -0.0624 Tw [(els of depression. Similarly)61.4(, BDI scores still showed sig-)]TJ 0 -1.398 TD 0.0082 Tc 0.125 Tw (nificant correlations with depressive rumination and)Tj 0 -1.401 TD 0.0052 Tc 0.1249 Tw [(trauma-related rumination when controlling for PDS)]TJ T* 0.0168 Tc 0 Tw (scores.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0033 Tc -0.04 Tw [(For the prediction of future symptoms in Sample 2, spe-)]TJ 0 -1.401 TD -0.0036 Tc -0.0625 Tw (cific associations emerged. PTSD symptom severities at)Tj 0 -1.398 TD -0.0045 Tc -0.0622 Tw (6 months follow-up were only significantly predicted by)Tj 0 -1.401 TD -0.0034 Tc 0.0192 Tw (trauma-related rumination, but not by depressive rumi-)Tj T* 0.0426 Tc 0.125 Tw [(nation when symptom levels of depression were)]TJ 0 -1.398 TD -0.0062 Tc -0.0625 Tw [(partialled out. Similarly)62.8(, only depressive rumination, but)]TJ 0 -1.401 TD -0.0059 Tc -0.0621 Tw (not trauma-related rumination, predicted BDI scores at 6)Tj T* -0.0038 Tc -0.005 Tw (months when PDS scores were partialled out.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0072 Tc -0.0625 Tw (For trauma-related rumination scores, a significant inter-)Tj 0 -1.401 TD -0.0039 Tc -0.0104 Tw [(action between )53.3(ASD at 2 weeks and time of assessment)]TJ 0 -1.398 TD -0.0037 Tc 0.0913 Tw (was found. Follow-up tests showed that the degree of)Tj 0 -1.401 TD -0.0035 Tc -0.0038 Tw (trauma-related rumination significantly decreased from)Tj T* -0.011 Tc -0.0621 Tw [(2 weeks to 1 month in participants without )55.1(ASD, whereas)]TJ 0 -1.398 TD -0.0038 Tc -0.0472 Tw [(participants with )53.2(ASD did not show a change in rumina-)]TJ 0 -1.401 TD -0.0035 Tc 0.0221 Tw (tion scores during this interval. For depressive rumina-)Tj T* -0.0034 Tc -0.0505 Tw (tion scores, there was no significant main effect of time)Tj 0 -1.398 TD -0.0007 Tc 0.125 Tw (of assessment.)Tj /F56 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0037 Tc -0.0081 Tw (The mean number of steps participants generated in the)Tj 0 -1.398 TD -0.0038 Tc 0.049 Tw (trauma-related rumination part and depressive rumina-)Tj 0 -1.401 TD -0.0091 Tc -0.0622 Tw (tion part of the Rumination Interview significantly corre-)Tj T* -0.0035 Tc -0.043 Tw (lated with self-report levels of rumination.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0033 Tc -0.0275 Tw (In Study 2, concreteness in the Rumination Interview at)Tj 0 -1.401 TD -0.003 Tc 0.0221 Tw (2 weeks was significantly negatively related to depres-)Tj 0 -1.398 TD -0.01 Tc -0.0622 Tw [(sive symptom severity at 3 and 6 months. Similarly)62(, there)]TJ 0 -1.401 TD -0.0037 Tc -0.01 Tw (were differences between participants with and without)Tj T* -0.0036 Tc 0.015 Tw (major depression in concreteness levels at 2 weeks.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0032 Tc 0.105 Tw (In all analyses with PTSD symptom scores as depen-)Tj 0 -1.401 TD 0.0592 Tw (dent variable, the frequency of trauma related rumina-)Tj 0 -1.398 TD -0.0033 Tc 0.0933 Tw (tion entered in the fist step of the regression equation)Tj 0 -1.401 TD -0.003 Tc 0.015 Tw [(predicted symptom severity)60(.)]TJ ET endstream endobj 337 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /F56 317 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 339 0 obj << /Length 8590 >> 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 [(316 )]TJ /TT3 1 Tf 2.8388 0 TD -0.0058 Tc (Selected Annotated Journal Resources)Tj /F56 1 Tf 10 0 0 10 54 722.64 Tm 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0034 Tc -0.0333 Tw (Regression analyses with symptom levels of depression)Tj 0 -1.398 TD 0.0517 Tw (as dependent variables only showed significant effects)Tj 0 -1.401 TD -0.0012 Tc 0.125 Tw (for the self-reported frequency of depressive rumina-)Tj T* -0.0036 Tc 0.0859 Tw (tion. Neither concreteness nor the interaction between)Tj 0 -1.398 TD -0.0004 Tc 0.125 Tw (concreteness and self-reported rumination scores sig-)Tj 0 -1.401 TD -0.0032 Tc 0.0125 Tw (nificantly improved the prediction of depressive symp-)Tj T* -0.0037 Tc -0.005 Tw (tom severities.)Tj /TT1 1 Tf 11 0 0 11 54 608.25 Tm 0.0217 Tc 0 Tw [(CONCLUSIONS/SUMMAR)32.6(Y)]TJ /F56 1 Tf 10 0 0 10 54 592.26 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc 0.0028 Tw ( Self-reported rumination about the trauma was signifi-)Tj 0 -1.401 TD -0.0027 Tc 0.0514 Tw (cantly and substantially correlated with the severity of)Tj T* -0.0034 Tc 0.0964 Tw (PTSD symptoms. Rumination was not only related to)Tj 0 -1.398 TD -0.0036 Tc 0.0558 Tw (concurrent PTSD symptoms, but also predicted subse-)Tj 0 -1.401 TD 0.0986 Tw (quent symptoms at 6 months. Rumination predicted a)Tj T* -0.012 Tc -0.0625 Tw (substantial about of the variance \(between 36% and 50%\))Tj 0 -1.398 TD -0.0032 Tc -0.0516 Tw [(of PTSD symptom severity)59.8(.)]TJ /F56 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0037 Tc 0.0343 Tw (The findings extended previous studies in that rumina-)Tj 0 -1.398 TD -0.0033 Tc 0.095 Tw (tion not only predicted self-reported PTSD symptoms)Tj 0 -1.401 TD -0.0036 Tc -0.0168 Tw [(but also a diagnosis of )50.4(ASD at 2 weeks, and a diagnosis)]TJ T* 0.001 Tw (of PTSD at 6 months after the traumatic event. In addi-)Tj 0 -1.398 TD -0.0032 Tc 0.0336 Tw (tion, rumination predicted the severity of PTSD symp-)Tj 0 -1.401 TD -0.0082 Tc -0.0622 Tw (toms over and above what could be predicted from initial)Tj T* -0.0032 Tc -0.06 Tw (symptom levels.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0035 Tc 0.0595 Tw (In sum, the results support the view that rumination is)Tj 0 -1.401 TD 0.0113 Tc 0.125 Tw (an important maintaining factor of PTSD following)Tj 0 -1.398 TD -0.0169 Tc 0 Tw (trauma.)Tj /F56 1 Tf -1.8 -1.602 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc 0.0744 Tw (The finding that rumination is a powerful predictor of)Tj 0 -1.398 TD -0.0034 Tc 0.0087 Tw (PTSD symptom severity from 2 weeks onward is valu-)Tj 0 -1.401 TD -0.003 Tc -0.003 Tw (able for the early detection of people at risk for chronic)Tj T* -0.0186 Tc -0.0625 Tw (PTSD. Research into early interventions following trauma)Tj 0 -1.398 TD -0.0037 Tc -0.0008 Tw (has shown discouraging results for debriefing interven-)Tj 0 -1.401 TD -0.0034 Tc -0.0061 Tw [(tions that are of)14.6(fered to every trauma survivor)38.6(, whereas)]TJ T* -0.0036 Tc -0.0521 Tw (a course of cognitive behavioral interventions with indi-)Tj 0 -1.398 TD -0.0037 Tc -0.018 Tw (viduals high at risk of chronic PTSD has been shown to)Tj 0 -1.401 TD 0.0062 Tc 0.125 Tw (be effective. The present study suggests that the as-)Tj T* -0.0033 Tc (sessment of rumination might help improve the early)Tj 0 -1.398 TD -0.0032 Tc -0.0306 Tw (identification of trauma survivors in need of early inter-)Tj 0 -1.401 TD 0.0072 Tc 0 Tw (vention.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc -0.0516 Tw (In the past, trauma-related rumination and re-experienc-)Tj 0 -1.401 TD -0.0033 Tc 0.0693 Tw (ing symptoms have sometimes been treated as unitary)Tj T* -0.0034 Tc 0.0138 Tw (phenomena. The current study supports the view of ru-)Tj 0 -1.398 TD -0.0035 Tc 0.0242 Tw (mination and re-experiencing as conceptually and phe-)Tj 0 -1.401 TD -0.0135 Tc -0.0625 Tw [(nomenologically distinct. In the current study)61.5(, rumination)]TJ T* -0.0241 Tc (still predicted the maintenance of PTSD when initial symp-)Tj 0 -1.398 TD -0.0032 Tc -0.0366 Tw (toms were statistically controlled and for and the size of)Tj 0 -1.401 TD -0.0037 Tc 0.04 Tw (the correlations did not change when PTSD symptoms)Tj 25.5 64.239 TD 0.0072 Tc 0.125 Tw (severity was calculated omitting the re-experiencing)Tj 0 -1.398 TD -0.0015 Tc 0 Tw (symptoms.)Tj /F56 1 Tf -1.8 -1.602 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0032 Tc -0.0093 Tw (The current study extended previous research by show-)Tj 0 -1.398 TD -0.0035 Tc 0.0814 Tw (ing that levels of depressive rumination assessed after)Tj 0 -1.401 TD -0.0021 Tc 0.125 Tw (the trauma are highly associated with concurrent and)Tj T* -0.0034 Tc 0.0907 Tw (subsequent levels of depression. The study suggests a)Tj 0 -1.398 TD -0.0038 Tc -0.028 Tw (relationship between trauma-related rumination and de-)Tj 0 -1.401 TD 0.01 Tw (pressive rumination.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0034 Tc 0.1107 Tw (This study attempted to better understand the process)Tj 0 -1.401 TD -0.0036 Tc 0.0579 Tw (of rumination and its effects on maintaining post-trau-)Tj T* 0.0594 Tc 0.231 Tw (matic distress symptoms by incorporating the)Tj 0 -1.398 TD 0.0031 Tc 0.1253 Tw [(Catastrophizing Interview)63.1(. In the current studies, the)]TJ 0 -1.401 TD -0.0088 Tc -0.0625 Tw (number of steps in the Rumination Interview was signifi-)Tj T* -0.0048 Tc -0.0624 Tw [(cantly related to naturally occurring perseverative think-)]TJ 0 -1.398 TD -0.0093 Tc 0 Tw (ing.)Tj /F56 1 Tf -1.8 -1.602 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0037 Tc 0.0992 Tw (While previous research has supported the hypothesis)Tj 0 -1.398 TD -0.0032 Tc 0.0557 Tw (that recurrent negative thinking is characterized by re-)Tj 0 -1.401 TD 0.0062 Tc 0.125 Tw (duced concreteness in individuals experiencing non-)Tj T* 0.0075 Tc 0.1249 Tw [(clincial worry and generalized anxiety disorder)34.5(, this)]TJ 0 -1.398 TD -0.0034 Tc 0.0107 Tw (association was not supported in the current study with)Tj 0 -1.401 TD -0.0037 Tc 0.1007 Tw (individuals who have experienced a trauma. This dis-)Tj T* -0.003 Tc -0.0325 Tw (crepancy may be related to differences in the methodol-)Tj 0 -1.398 TD 0.0336 Tc 0.125 Tw (ogy of the studies. The results may also point to)Tj 0 -1.401 TD -0.0035 Tc -0.02 Tw (differences between worry and rumination.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD 0.0001 Tc 0.125 Tw (The significant relation between the number of steps)Tj 0 -1.401 TD -0.0041 Tc -0.0625 Tw (generated in the Rumination Interview and concreteness)Tj T* 0.0101 Tc 0.125 Tw (ratings in Study 1 supported the hypothesis that re-)Tj 0 -1.398 TD 0.0586 Tc 0.272 Tw (duced concreteness would be associated with)Tj 0 -1.401 TD -0.0037 Tc 0.1092 Tw (perseveration of negative thinking in individuals with)Tj T* -0.0035 Tc -0.0383 Tw [(emotional disorders. However)35.5(, S)17.5(tudy 2 did not replicate)]TJ 0 -1.398 TD -0.0031 Tc -0.0217 Tw (this result. It may be that the observed relationship with)Tj 0 -1.401 TD -0.0034 Tc 0.0714 Tw (reduced concreteness only applies to chronic forms of)Tj T* -0.0002 Tc 0.125 Tw [(rumination, as the negative findings in Study 2 were)]TJ 0 -1.398 TD -0.0032 Tc 0.0639 Tw (obtained only 2 weeks after the event, when the event)Tj 0 -1.401 TD -0.0123 Tc -0.0625 Tw (may have been very prominent on all participants minds.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0027 Tc 0.1212 Tw [(Finally)63.3(,)0.1( the study only received weak support for the)]TJ 0 -1.401 TD -0.0035 Tc 0.0059 Tw (hypothesis that reduced concreteness would predict the)Tj T* 0.0047 Tc 0.1252 Tw [(severity of psychological problems after trauma. )55.9(Al-)]TJ 0 -1.398 TD -0.0036 Tc 0.0107 Tw (though there were significant group differences in con-)Tj 0 -1.401 TD -0.0038 Tc 0.0542 Tw (creteness between participants with and without major)Tj T* -0.0034 Tc 0.0981 Tw (depressive disorder at 2 weeks after the accident, and)Tj 0 -1.398 TD 0.0557 Tw (low concreteness at 2 weeks was positively associated)Tj 0 -1.401 TD -0.0048 Tc -0.0622 Tw (with severity of depressive symptoms at 3 and 6 months,)Tj T* -0.0041 Tc -0.0625 Tw (overall, the correlations were small. Thus, it remains un-)Tj 0 -1.398 TD -0.0034 Tc 0.125 Tw (clear whether reduced concreteness of thinking about)Tj 0 -1.401 TD -0.0007 Tc (the trauma is associated with the maintenance of de-)Tj T* -0.0039 Tc -0.022 Tw (pression and PTSD following the trauma.)Tj ET endstream endobj 340 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /F56 317 0 R /TT1 8 0 R /TT2 9 0 R /TT3 10 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 342 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 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. 4 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (317)Tj /TT1 1 Tf 11 0 0 11 66 722.64 Tm 0.0255 Tc [(CONTRIBUTIONS/IMPLICA)63.7(TIONS)]TJ /F56 1 Tf 10 0 0 10 66 706.65 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0033 Tc -0.0513 Tw (The results from the study replicate and extend previous)Tj 0 -1.401 TD -0.0035 Tc 0.0881 Tw (findings regarding the role of ruination in the mainte-)Tj 0 -1.398 TD -0.0089 Tc -0.0625 Tw (nance of emotional disorders following trauma. Rumina-)Tj 0 -1.401 TD -0.0035 Tc -0.0091 Tw (tion at 2 weeks and 1 month after the trauma appears to)Tj T* -0.0037 Tc -0.033 Tw (be an important predictor of PTSD.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc 0.0675 Tw (It remains unclear whether low concreteness is an im-)Tj 0 -1.401 TD 0.0017 Tc 0.125 Tw (portant dimension underlying dysfunctional forms of)Tj 0 -1.398 TD -0.0037 Tc 0.0225 Tw (recurrent negative thinking.)Tj /F56 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0076 Tc -0.0625 Tw (Future work is needed to clarify the relationship between)Tj 0 -1.398 TD -0.0032 Tc 0.0125 Tw (functional versus dysfunctional ways of thinking about)Tj 0 -1.401 TD -0.0047 Tc -0.0625 Tw (problems or negative experiences and to isolate the most)Tj T* -0.0056 Tc -0.0622 Tw (relevant processes involved in the maintenance of PTSD)Tj 0 -1.398 TD -0.0037 Tc 0.0317 Tw (and depression after trauma.)Tj ET 3.99 w /GS1 gs 66 495.585 m 303 495.585 l S BT /TT1 1 Tf 11 0 0 11 66 476.61 Tm /GS2 gs 0.0011 Tc 0.1249 Tw [(W)24.7(illiams, J. K., )20.1(W)41.1(yatt, G)118.4(.)0.6( E., Rivkin, I., Codathi)]TJ 0 -1.1836 TD 0.0215 Tc 0.1253 Tw (Ramamurthi, H., Li, X., & Liu,H. \(2008\). Risk)Tj 0 -1.1809 TD 0.0068 Tc 0.1251 Tw [(r)19.7(eduction of HIV)69.5(-positive )47.4(African )52.8(American and)]TJ T* 0.0319 Tc 0.125 Tw (Latino men with histories of childhood sexual)Tj ET 0.99 w /GS1 gs 66 416.085 m 303 416.085 l S BT 11 0 0 11 66 424.59 Tm /GS2 gs 0.0046 Tc 0 Tw (abuse. )Tj /TT4 1 Tf 3.1009 0 TD 0.0049 Tc 0.1261 Tw [(Archives of Sexual Behavior)51.3(, 37)]TJ /TT1 1 Tf 13.9118 0 TD 0.0055 Tc 0.1273 Tw (, 763-772.)Tj -17.0127 -2.9755 TD -0.008 Tc 0.1236 Tw [(TYPE OF)27.5( )46.5(A)10(R)27.5(TICLE)]TJ /F56 1 Tf 10 0 0 10 66 375.84 Tm 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0089 Tc -0.0625 Tw (Original empirical investigation)Tj /TT1 1 Tf 11 0 0 11 66 345.45 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 /F56 1 Tf 10 0 0 10 66 329.46 Tm 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0033 Tc 0.0685 Tw (The purpose of this study was to conduct a small ran-)Tj 0 -1.401 TD -0.0036 Tc -0.0356 Tw (domized clinical trial whose aims were to reduce sexual)Tj T* 0.0571 Tw (risk behaviors, number of sexual partners, and depres-)Tj 0 -1.398 TD -0.0027 Tc 0.1172 Tw [(sive symptoms for gay and non-gay identifying HIV)87.3(-)]TJ 0 -1.401 TD -0.0074 Tc -0.0624 Tw [(positive )49.7(African )46.7(American and Latino men who have sex)]TJ T* -0.0041 Tc -0.029 Tw (with men \(MSM\) and men who have sex with both men)Tj 0 -1.398 TD -0.006 Tc -0.0622 Tw (and women \(MSMW\) with histories of childhood sexual)Tj 0 -1.401 TD -0.0044 Tc -0.015 Tw (abuse \(CSA\).)Tj /TT1 1 Tf 11 0 0 11 66 201.06 Tm 0.0344 Tc 0 Tw (METHODS)Tj 0 -1.4564 TD 0.0026 Tc (Participants)Tj /F56 1 Tf 10 0 0 10 66 169.05 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0039 Tc -0.0613 Tw [(A)58.3( community sample of HIV)86.1(-positive )53.5(African )53.5(American)]TJ 0 -1.401 TD -0.0046 Tc 0.0207 Tw (and Latino MSM and MSMW was recruited from HIV)Tj 0 -1.398 TD -0.0034 Tc 0.0793 Tw [(and other service agencies in Los )53.5(Angeles County us-)]TJ 0 -1.401 TD -0.0058 Tw (ing fliers, print advertisements and face-to-face recruit-)Tj T* -0.0186 Tc 0 Tw (ment.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc -0.0286 Tw (Potential participants were screened and included in the)Tj 0 -1.401 TD -0.0039 Tc -0.0623 Tw (study if they indicated meeting all of the following crite-)Tj 0 -1.398 TD -0.0122 Tc -0.062 Tw [(ria: male, 18 years of age or older)32.8(, English-speaking, self-)]TJ 25.5 65.358 TD -0.02 Tc -0.0623 Tw [(identified as )49.2(African )49.2(American/Black or Latino, HIV)85(-posi-)]TJ 0 -1.398 TD -0.0033 Tc 0.0155 Tw (tive, had sex with a male partner in the prior 6 months,)Tj 0 -1.401 TD -0.0035 Tc 0.0505 Tw (and prior to age 18, had an experience of unwanted or)Tj T* -0.0411 Tw (coerced sexual contact with an adult or someone at least)Tj 0 -1.398 TD -0.0025 Tc -0.04 Tw [(5 years older)51.5(.)]TJ /F56 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0031 Tc 0.0336 Tw [(Initially)62.9(, 164 men enrolled but only 137 completed the)]TJ 0 -1.398 TD -0.0034 Tc -0.0625 Tw (intervention due to death \(n = 5\) or lost to follow-up \(n =)Tj 0 -1.401 TD -0.0036 Tc 0.0294 Tw (22\). The sample size of the Sexual Health Intervention)Tj T* -0.0245 Tc -0.0622 Tw [(for Men \(S-HIM\) was 62 \(African )50.5(Americans = 36, Latinos)]TJ 0 -1.398 TD -0.0037 Tc -0.0438 Tw (= 26\) and the Standard Health Prevention \(SHP\) control)Tj 0 -1.401 TD -0.0068 Tc -0.0624 Tw [(was 75 \(African )53.3(Americans = 53, Latinos = 22\).)]TJ /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0116 Tc -0.062 Tw (The participants were a middle-aged \()Tj /TT5 1 Tf 14.451 0 TD 0 Tc 0 Tw (M)Tj /TT2 1 Tf 0.813 0 TD -0.0103 Tc -0.0625 Tw [( age = 43.5 years,)]TJ /TT5 1 Tf -15.264 -1.401 TD -0.0132 Tc 0 Tw (SD)Tj /TT2 1 Tf 1.209 0 TD -0.0032 Tc -0.04 Tw [( = 8.0\), high school educated \()]TJ /TT5 1 Tf 11.835 0 TD 0 Tc 0 Tw (M)Tj /TT2 1 Tf 0.825 0 TD -0.0024 Tc -0.041 Tw [( = 12.3 years of edu-)]TJ -13.869 -1.401 TD -0.0032 Tc 0 Tw (cation, )Tj /TT5 1 Tf 2.931 0 TD -0.0132 Tc (SD)Tj /TT2 1 Tf 1.209 0 TD -0.0029 Tc 0.0137 Tw [( = 3.4\), poor \(average per capita monthly in-)]TJ -4.14 -1.398 TD -0.02 Tc -0.0616 Tw (come = $906.61, )Tj /TT5 1 Tf 6.48 0 TD -0.0312 Tc 0 Tw (SD)Tj /TT2 1 Tf 1.176 0 TD -0.0198 Tc -0.062 Tw [( = 3,065\), and underemployed \(87.5%)]TJ -7.656 -1.401 TD -0.0041 Tc -0.06 Tw (unemployed\) sample.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0112 Tc -0.0621 Tw (Regarding sexual partners, 41% reported having sex with)Tj 0 -1.401 TD -0.0034 Tc -0.0413 Tw (only male partners, while 59% reported having sex with)Tj T* -0.0036 Tc 0.0494 Tw (male and female partners. When asked what they con-)Tj 0 -1.398 TD -0.009 Tc -0.0623 Tw (sidered their sexual identity label to be, 58% identified as)Tj 0 -1.401 TD -0.0034 Tc 0.0311 Tw [(homosexual or gay)59.6(, 29% as bisexual, 9% as straight or)]TJ T* -0.0032 Tc 0.125 Tw (heterosexual, and 4%as undecided or not defined. Of)Tj 0 -1.398 TD -0.0035 Tc -0.0083 Tw [(the men who identified as homosexual or gay)62.5(, 23% had)]TJ 0 -1.401 TD -0.0244 Tw (sex with a female partner in the previous 6 months.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0037 Tc 0.0107 Tw (The relationship status of this group included predomi-)Tj 0 -1.401 TD -0.0033 Tc -0.0085 Tw (nantly single men who were not in a committed or seri-)Tj T* -0.0036 Tc -0.017 Tw [(ous relationship and living alone \(81%\).)]TJ /TT1 1 Tf 11 0 0 11 321 320.25 Tm 0.0233 Tc 0 Tw (Materials)Tj /F56 1 Tf 10 0 0 10 321 304.26 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0039 Tc 0.125 Tw (A comprehensive 90-minute structured interview was)Tj 0 -1.401 TD -0.0036 Tc -0.0517 Tw (administered to participants. The interview included de-)Tj T* 0.0793 Tw (mographic variables and an assessment of history and)Tj 0 -1.398 TD -0.0029 Tc -0.025 Tw (severity of CSA.)Tj /F56 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0034 Tc -0.035 Tw (The vast majority of participants \(87.6%\) reported CSA)Tj 0 -1.398 TD -0.0036 Tc 0.0815 Tw (that included performing and/or receiving oral or anal)Tj 0 -1.401 TD -0.0034 Tc 0.065 Tw (sex, digital penetration or penetration with objects. Of)Tj T* -0.0036 Tc 0.0258 Tw (those participants, 53% reported anal penetration, 37%)Tj 0 -1.398 TD 0.0578 Tw (reported performing or receiving oral sex against their)Tj 0 -1.401 TD -0.0037 Tc 0.0738 Tw (will and 10% reported both. The remaining 12.4% re-)Tj T* -0.0032 Tc 0.125 Tw (ported CSA that included touching, fondling, or frot-)Tj 0 -1.398 TD 0.0086 Tc 0 Tw (tage.)Tj /F56 1 Tf -1.8 -1.602 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0038 Tc -0.0088 Tw (Among the sample, 52% reported one incident of CSA,)Tj 0 -1.398 TD -0.0289 Tw (48% reported two or more incidents and the mean num-)Tj 0 -1.401 TD -0.0033 Tc -0.0187 Tw (ber of incidents for the total sample was 1.7.)Tj -1.8 -1.599 TD -0.0087 Tc -0.0625 Tw [()-1475.7(Intrafamilial CSA where the perpetrator of the abuse was)]TJ 1.8 -1.401 TD -0.0224 Tc (a family member was reported by 27%, while extrafamilial)Tj ET endstream endobj 343 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /F56 317 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 345 0 obj << /Length 8495 >> 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 [(318 )]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 -0.0035 Tc -0.0625 Tw (CSA where the perpetrator of the abuse was not a family)Tj 0 -1.398 TD -0.0575 Tw (member was reported by 73%.)Tj /F56 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.007 Tc -0.0625 Tw (Sexual risk behaviors were measured with 11 items from)Tj 0 -1.398 TD -0.0032 Tc 0.1139 Tw [(the Revised )17.5(W)73.6(yatt Sex History Questionnaire \(W)56.8(yatt,)]TJ 0 -1.401 TD -0.0516 Tc 0 Tw (1984\).)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0037 Tc -0.0289 Tw (The number of sexual partners in the previous 6 months)Tj 0 -1.401 TD 0.01 Tw (was assessed with 1 item.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0181 Tc -0.062 Tw (The Center for Epidemiological Studies-Depression Scale)Tj 0 -1.401 TD 0.0256 Tc 0.125 Tw (\(CES-D\) was used to assess depressive symptoms)Tj T* -0.0118 Tc -0.0621 Tw (\(Radloff, 1977\). Participants rated the occurrence of vari-)Tj 0 -1.398 TD -0.0034 Tc 0.028 Tw (ous feelings on a four-point scale.)Tj /TT1 1 Tf 11 0 0 11 54 544.65 Tm 0.0242 Tc 0 Tw (Procedure)Tj /F56 1 Tf 10 0 0 10 54 528.66 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0033 Tc -0.0393 Tw [(The Men)50.7(s Health Project was a 3-year study conducted)]TJ 0 -1.401 TD -0.008 Tc -0.0622 Tw (from 2003 to 2006 to develop and test an HIV risk reduc-)Tj T* 0.0223 Tc 0.125 Tw (tion intervention. Participants were administered a)Tj 0 -1.398 TD -0.0035 Tc -0.0072 Tw (baseline assessment and then randomly assigned to one)Tj 0 -1.401 TD -0.0038 Tc 0.045 Tw (of two conditions.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0038 Tc 0.0185 Tw (The S-HIM focused on decreasing high-risk sexual be-)Tj 0 -1.401 TD -0.0031 Tc 0.015 Tw (haviors and psychological distress, specifically depres-)Tj T* -0.0033 Tc 0.045 Tw (sive symptoms.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD 0.0074 Tc 0.125 Tw (The attention-control SHP comparison condition fo-)Tj 0 -1.401 TD -0.0035 Tc 0.0137 Tw [(cused on health issues unrelated to sexual behavior)35.5(, in-)]TJ 0 -1.398 TD 0.0047 Tc 0.1249 Tw [(cluding diet, exercise, adequate rest, and medication)]TJ 0 -1.401 TD 0.0053 Tc 0 Tw (adherence.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0003 Tc 0.125 Tw (Both interventions included six weekly 2-hour group)Tj 0 -1.401 TD -0.004 Tc -0.0624 Tw [(sessions with of 57 )50.1(African-American or Latino men in)]TJ T* -0.0032 Tc 0.0375 Tw (each group. If participants missed a session, they were)Tj 0 -1.398 TD -0.0039 Tc 0.1092 Tw (given an abbreviated 30-min one-on-one session with)Tj 0 -1.401 TD -0.0032 Tc 0.0033 Tw (the facilitator prior to the next session.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0131 Tc -0.0625 Tw (After completing the intervention, participants were post-)Tj 0 -1.401 TD -0.0033 Tc 0.0639 Tw [(tested immediately and at 3 and 6 months. )50.7(All partici-)]TJ T* 0.0096 Tc 0.125 Tw (pants were reimbursed $10 per session and $15 per)Tj 0 -1.398 TD 0.0181 Tc 0 Tw (assessment.)Tj /F56 1 Tf -1.8 -1.602 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD 0.0289 Tc 0.1251 Tw [(The S-HIM was adapted from the evidence-based)]TJ 0 -1.398 TD -0.0042 Tc -0.0487 Tw [(W)93.6(omen)49.8(s Enhanced Sexual Health Intervention \(ESHI\),)]TJ 0 -1.401 TD -0.0052 Tc -0.0626 Tw [(an 1)30.8(1-session intervention for HIV)84.8(-positive women with)]TJ T* -0.0137 Tc -0.0622 Tw [(histories of child sexual abuse \(W)55.3(yatt et al., 2004\), guided)]TJ 0 -1.398 TD 0.0015 Tc 0.1249 Tw (by cognitive-behavioral approaches \(Bandura, 1986\).)Tj 0 -1.401 TD -0.0034 Tc 0.0272 Tw [(Additionally)59.6(, the S-HIM was guided by formative data)]TJ T* -0.0029 Tc 0.029 Tw (from four ethnic- and gay/non-gay-identifying specific)Tj 0 -1.398 TD -0.0028 Tc 0.1251 Tw [(focus groups \(i.e., )51.3(African )54.3(American gay versus non-)]TJ 0 -1.401 TD -0.0023 Tc -0.0275 Tw (gay identifying, Latino gay versus non-gay identifying\))Tj T* -0.0211 Tc -0.0616 Tw [(\()19.8(W)35.9(illiams et al., 2004\).)]TJ /F56 1 Tf 23.7 62.4 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0041 Tc 0.06 Tw (The S-HIM curriculum emphasized personal responsi-)Tj 0 -1.398 TD -0.0031 Tc -0.0122 Tw (bility for self-care and protection of health and well be-)Tj 0 -1.401 TD -0.0034 Tc -0.0624 Tw [(ing \(Chin, )17.7(W)73.4(yatt, Carmona, Loeb, & Myers, 2004\). HIV)]TJ T* -0.0033 Tc -0.0574 Tw [(skills were taught within the context of personal, family)59.7(,)]TJ 0 -1.398 TD 0.0045 Tc 0.125 Tw (and community values so that participants could ac-)Tj 0 -1.401 TD -0.0037 Tc -0.0364 Tw (knowledge the cultural and religious messages that pos-)Tj T* -0.0032 Tc -0.0138 Tw (sibly contradict HIV prevention efforts.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0039 Tc 0.082 Tw (Choices regarding sexual behaviors and consequences)Tj 0 -1.401 TD -0.0034 Tc -0.0543 Tw (were discussed within a culturally congruent social con-)Tj 0 -1.398 TD -0.0065 Tc -0.0619 Tw [(text, specifically for HIV)83.5(-positive ethnic men.)]TJ /F56 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0017 Tc 0.125 Tw (Consensual and non-consensual childhood sexual ex-)Tj 0 -1.398 TD -0.0035 Tc 0.0362 Tw (periences were discussed, as well as how these experi-)Tj 0 -1.401 TD -0.01 Tc -0.062 Tw (ences affect current sexual decision-making. Participants)Tj T* -0.0032 Tc -0.0068 Tw (learned how to identify triggers to risk behaviors, espe-)Tj 0 -1.398 TD 0.0066 Tc 0.125 Tw (cially feelings that were connected to such previous)Tj 0 -1.401 TD -0.0077 Tc -0.06 Tw (sexual experiences.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0035 Tc -0.0022 Tw [(Finally)62.5(,)0.1( the S-HIM included treatment of cognitive dis-)]TJ 0 -1.401 TD 0.0022 Tc 0.125 Tw [(tortions and negative thoughts and emotions and ad-)]TJ T* 0.0287 Tc (dressed affective dysregulation that can limit risk)Tj 0 -1.398 TD 0.007 Tc (reduction. Emphasis was placed on problem-solving)Tj 0 -1.401 TD -0.0037 Tc -0.0125 Tw (strategies and communication skills training.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0038 Tc 0.04 Tw (The SHP was the control condition designed to reduce)Tj 0 -1.401 TD -0.0034 Tc -0.0106 Tw (the likelihood that effects of the S-HIM could be attrib-)Tj T* 0.0049 Tc 0.125 Tw (uted to special attention and group interaction. Both)Tj 0 -1.398 TD -0.0098 Tc -0.0625 Tw (conditions received a valuable intervention that extended)Tj 0 -1.401 TD -0.0038 Tc 0.0532 Tw [(beyond )71.2(usual care)71.2(. )17.1(The SHP)29.2( intervention addressed)]TJ T* -0.0032 Tc 0.116 Tw (health issues, including certain cancers, hypertension,)Tj 0 -1.398 TD -0.0035 Tc 0.1219 Tw (diabetes, and heart disease, all of which are common)Tj 0 -1.401 TD -0.003 Tc -0.0157 Tw (among ethnic minority men, but did not specifically fo-)Tj T* -0.0039 Tc 0.0167 Tw [(cus on sexual behavior)50.1(.)]TJ /F56 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 (Participants were taught that these diseases could be)Tj 0 -1.401 TD -0.0036 Tc 0.0425 Tw (prevented by changing personal behaviors or managed)Tj 0 -1.398 TD -0.0028 Tc 0.125 Tw (with early detection and screening behaviors. Partici-)Tj 0 -1.401 TD -0.0036 Tc -0.0493 Tw (pants were also taught information and skills to increase)Tj T* -0.0037 Tc 0.0143 Tw (their adherence to medical regimes. The SHP interven-)Tj 0 -1.398 TD -0.0032 Tc -0.04 Tw (tion was structurally similar to the S-HIM.)Tj /TT1 1 Tf 11 0 0 11 309 192.24 Tm 0.0154 Tc 0 Tw [(RESUL)83.6(TS)]TJ /F56 1 Tf 10 0 0 10 309 176.25 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0039 Tc 0.0657 Tw (The covariate adjusted 2 \(condition: S-HIM and SHP\))Tj 0 -1.401 TD -0.0031 Tc 0.098 Tw (by 4 \(time: baseline, post, 3 month, and 6 month\) re-)Tj 0 -1.398 TD -0.0103 Tc -0.0624 Tw [(peated measures analysis of variance \(ANOV)124.7(A\) revealed)]TJ 0 -1.401 TD -0.0035 Tc -0.0483 Tw [(a significant main ef)14.5(fect of time on sexual risk behavior)50.5(.)]TJ T* 0.075 Tw (The sample as a whole reported reductions in level of)Tj 0 -1.398 TD -0.06 Tw (sexual risk behavior from baseline to post-test, and from)Tj 0 -1.401 TD -0.0037 Tc 0.0778 Tw (the 3 month to the 6 month follow-up. Further simple)Tj ET endstream endobj 346 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /F56 317 0 R /TT1 8 0 R /TT2 9 0 R /TT3 10 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 348 0 obj << /Length 8884 >> 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. 4 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (319)Tj /TT2 1 Tf 10 0 0 10 84 722.64 Tm -0.0038 Tc -0.0622 Tw (effects tests revealed that the reduction in level of sexual)Tj 0 -1.398 TD -0.0036 Tc 0.0265 Tw (risk behavior from baseline to post-test was significant)Tj 0 -1.401 TD -0.0037 Tc -0.0494 Tw (for S-HIM participants but not significant for SHP com-)Tj T* -0.0036 Tc 0.0142 Tw [(parison participants. However)38.4(, there was no significant)]TJ 0 -1.398 TD -0.0411 Tw (main effect of condition on level of sexual risk behavior)Tj 0 -1.401 TD -0.0032 Tc 0.0058 Tw (and no significant condition by time interaction.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0037 Tc 0.0541 Tw (The covariate adjusted repeated measures \(condition x)Tj 0 -1.401 TD -0.0045 Tc -0.0625 Tw [(time\) analysis of variance \(ANOV)130.5(A\) revealed a main ef-)]TJ T* -0.0039 Tc [(fect of time on number of sexual partners. The sample as)]TJ 0 -1.398 TD -0.009 Tc -0.0622 Tw (a whole reported reductions in the number of sexual part-)Tj 0 -1.401 TD -0.0035 Tc 0.0225 Tw (ners from baseline to post-test. This reduction was sig-)Tj T* -0.0165 Tc -0.0625 Tw (nificant for S-HIM participants and marginally significant)Tj 0 -1.398 TD -0.0039 Tc -0.0621 Tw (for SHP participants. There was a marginally significant)Tj 0 -1.401 TD -0.0036 Tc -0.0287 Tw (reduction in number of sexual partners from post-test to)Tj T* -0.0037 Tc 0.0056 Tw (the 3 month follow-up and a significant reduction from)Tj 0 -1.398 TD -0.0107 Tc -0.0623 Tw (the 3 month to the 6 month follow-up. There was no main)Tj 0 -1.401 TD -0.0036 Tc -0.0166 Tw (effect of condition on number of sexual partners and no)Tj T* -0.0031 Tc -0.0134 Tw (condition by time interaction.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD 0.0186 Tc 0.125 Tw (The sample evidenced high levels of depression at)Tj 0 -1.401 TD -0.0035 Tc 0 Tw (baseline, )Tj /TT5 1 Tf 3.705 0 TD -0.008 Tc (M )Tj /TT2 1 Tf 1.035 0 TD -0.0034 Tc -0.0425 Tw (= 23 \()Tj /TT5 1 Tf 2.295 0 TD -0.0132 Tc 0 Tw (SD)Tj /TT2 1 Tf 1.209 0 TD -0.0031 Tc -0.0414 Tw [( = 11\). The clinical cutoff score for)]TJ -8.244 -1.398 TD -0.0129 Tc -0.0625 Tw (the CES-D is 16 for mild depressive symptoms and 21 for)Tj 0 -1.401 TD -0.0035 Tc 0.0267 Tw (moderate to severe symptoms.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD 0.012 Tc 0.125 Tw (Covariate adjusted repeated measures \(condition by)Tj 0 -1.401 TD -0.0045 Tc -0.0625 Tw [(time\) analysis of variance \(ANOV)130.5(A\) revealed a main ef-)]TJ T* -0.0035 Tc -0.0599 Tw [(fect of time on depression. Simple effects tests indicated)]TJ 0 -1.398 TD -0.0034 Tc -0.0072 Tw (a significant decrease in depressive symptoms from the)Tj 0 -1.401 TD -0.0037 Tc 0.1055 Tw (3 month to the 6 month follow-up assessment for the)Tj T* -0.0036 Tc 0.0305 Tw [(sample as a whole. However)35.4(, there were no significant)]TJ 0 -1.398 TD 0.0007 Tw (changes in depressive symptoms from baseline to post-)Tj 0 -1.401 TD 0.0778 Tw (test or from post-test to the 3 month follow-up. There)Tj T* 0.0749 Tw [(was no main effect of condition on depression and no)]TJ 0 -1.398 TD 0.0016 Tc 0.125 Tw (condition by time interaction, suggesting that the re-)Tj 0 -1.401 TD -0.0033 Tc -0.0229 Tw (duction in depression was not significantly different for)Tj T* -0.0041 Tc -0.04 Tw (S-HIM and SHP participants.)Tj /TT1 1 Tf 11 0 0 11 66 224.25 Tm 0.0217 Tc 0 Tw [(CONCLUSIONS/SUMMAR)32.6(Y)]TJ /F56 1 Tf 10 0 0 10 66 208.26 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD 0.0066 Tc 0.1249 Tw (The results of this study suggest that participants in)Tj 0 -1.401 TD -0.0039 Tc 0.1207 Tw (both the S-HIM condition and SHP condition experi-)Tj T* 0.0021 Tc 0.125 Tw (enced decreased sexual risk behavior and depression)Tj 0 -1.398 TD -0.0168 Tc -0.0621 Tw [(over time. However)40.2(, only the S-HIM participants reported)]TJ 0 -1.401 TD -0.0036 Tc -0.0493 Tw (reductions in sexual risk behavior from baseline to post-)Tj T* 0.0216 Tc 0 Tw (test.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.004 Tc 0.0634 Tw (Both S-HIM and SHP participants reported reductions)Tj 0 -1.401 TD -0.0035 Tc 0.0019 Tw (in number of sexual partners from baseline to post-test,)Tj 0 -1.398 TD -0.0059 Tc -0.0621 Tw (with a greater reduction observed in S-HIM participants.)Tj /F56 1 Tf 23.7 62.838 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.004 Tc 0.0122 Tw (While reductions in sexual risk behavior were immedi-)Tj 0 -1.398 TD -0.0035 Tc (ate, reductions in depressive symptoms were not found)Tj 0 -1.401 TD -0.0037 Tc -0.045 Tw (until the 6-month follow up.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0035 Tc 0.0606 Tw (The decreases in sexual risk behavior and sexual part-)Tj 0 -1.401 TD -0.0033 Tc 0.0656 Tw (ners were greatest at post-test, but this trend also con-)Tj T* 0.125 Tw (tinued from the 3 to 6 month follow-ups. The sexual)Tj 0 -1.398 TD -0.0036 Tc -0.0622 Tw (decision-making skills provided in the S-HIM may have)Tj 0 -1.401 TD -0.0063 Tc (helped the men to reduce sexual risk behaviors and num-)Tj T* -0.0034 Tc -0.0317 Tw [(ber of sexual partners immediately)59.6(. However)38.6(, the use of)]TJ 0 -1.398 TD -0.0005 Tc 0.125 Tw (these skills may fluctuate over time, and participants)Tj 0 -1.401 TD -0.0032 Tc -0.05 Tw (may benefit from ongoing support for change. This may)Tj T* -0.0036 Tc 0.0971 Tw (include booster sessions to maintain effects over time)Tj 0 -1.398 TD -0.0185 Tc -0.0628 Tw [(\(Chesney)62.5(, Chambers, )17.2(T)70.3(aylor)35.5(, Johnson, & Folkman, 2003\).)]TJ /F56 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0038 Tc 0.1083 Tw (While the S-HIM curriculum more directly addressed)Tj 0 -1.398 TD 0.0041 Tc 0.125 Tw (sexual risk and depression and provided participants)Tj 0 -1.401 TD -0.0035 Tc 0.0572 Tw (with skills to examine cognitive, affective, and behav-)Tj T* -0.0034 Tc -0.055 Tw [(ioral patterns than the SHP)107.6(,)-0.2( both interventions may have)]TJ 0 -1.398 TD -0.0038 Tc 0.0675 Tw (produced benefits. Both conditions showed a decrease)Tj 0 -1.401 TD -0.0036 Tc 0.0332 Tw (in number of sexual partners from baseline to post-test)Tj T* 0.0357 Tw (and in depressive symptoms at the 6-month follow-up.)Tj 0 -1.398 TD -0.0038 Tc 0.0125 Tw (The focus on health promotion in the SHP intervention)Tj 0 -1.401 TD -0.0034 Tc 0.0794 Tw (may have encouraged men to consider areas of health)Tj T* -0.0033 Tc 0.0436 Tw (not directly addressed in the SHP intervention, includ-)Tj 0 -1.398 TD -0.0036 Tc -0.0325 Tw (ing sexual health.)Tj /F56 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0038 Tc -0.0129 Tw (Emotion regulation was addressed in the SHP interven-)Tj 0 -1.398 TD -0.0103 Tc -0.0622 Tw (tion in the context of relaxation, which may have resulted)Tj 0 -1.401 TD -0.0038 Tc 0.0122 Tw [(in decreased depression and risk behavior)35.2(, and reduced)]TJ T* -0.0037 Tc 0.0512 Tw (differences between the two conditions.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0091 Tc -0.0625 Tw (The weekly group format of both interventions may have)Tj 0 -1.401 TD -0.0035 Tc 0.1128 Tw (provided social support that helped to alleviate social)Tj 0 -1.398 TD 0.1017 Tw (isolation contributing to symptoms of depression. So-)Tj 0 -1.401 TD -0.0033 Tc -0.0513 Tw (cial support may be an important variable to incorporate)Tj T* 0.0086 Tc 0.125 Tw (in interventions for participants who endure a triple)Tj 0 -1.398 TD -0.0038 Tc 0.0443 Tw [(stigma of being HIV)86.2(-positive and an ethnic and sexual)]TJ 0 -1.401 TD -0.0061 Tc -0.0628 Tw [(minority)59.9(. )17.6(The support of other group members who were)]TJ T* -0.004 Tc -0.0623 Tw (facing similar issues may have served as a buffer against)Tj 0 -1.398 TD -0.0034 Tc -0.0131 Tw (rejection and racial and health stigma for these men.)Tj /F56 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0029 Tc 0.067 Tw (It is possible that more time may be necessary to pro-)Tj 0 -1.398 TD 0.0069 Tc 0.125 Tw (cess and absorb the benefit from the intervention to)Tj 0 -1.401 TD -0.0038 Tc 0.0266 Tw (demonstrate further improvements in depression for S-)Tj T* -0.0034 Tc 0.0706 Tw (HIM participants. It is also possible that the treatment)Tj 0 -1.398 TD 0.012 Tc 0.1249 Tw [(dosage was simply inadequate for such a high-risk,)]TJ 0 -1.401 TD -0.0167 Tc -0.06 Tw (marginalized sample.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0035 Tc 0.0432 Tw (Overall, the sample had limited material and social re-)Tj 0 -1.401 TD 0.0051 Tc 0.125 Tw (sources, which when combined with their history of)Tj T* -0.0036 Tc 0.0028 Tw (abuse and experiences with stigma and isolation result-)Tj ET endstream endobj 349 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /F56 317 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 351 0 obj << /Length 8697 >> 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 [(320 )]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 -0.0018 Tc 0.125 Tw (ing from their sexual identity likely contribute to the)Tj 0 -1.398 TD -0.0033 Tc -0.0371 Tw (moderately high symptoms of depression in the sample.)Tj /TT1 1 Tf 11 0 0 11 54 678.24 Tm 0.0255 Tc 0 Tw [(CONTRIBUTIONS/IMPLICA)63.7(TIONS)]TJ /F56 1 Tf 10 0 0 10 54 662.25 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.003 Tc 0.0225 Tw (The participants in this study were materially poor and)Tj 0 -1.401 TD -0.004 Tc 0.06 Tw (undereducated multiple minorities who were predomi-)Tj 0 -1.398 TD -0.0086 Tc -0.0625 Tw (nantly single and lacking both primary or long-term part-)Tj 0 -1.401 TD -0.0032 Tc -0.0106 Tw (ners and family support. These factors, along with their)Tj T* -0.0036 Tc 0.0693 Tw (abuse histories, are important to consider when devel-)Tj 0 -1.398 TD 0.0139 Tw [(oping sexual risk reduction interventions. )50.4(Additionally)59.5(,)]TJ 0 -1.401 TD -0.0033 Tc -0.0543 Tw (discomfort with specific sexual labels and possibly their)Tj T* -0.003 Tc 0.07 Tw [(sexual identity)60(, may contribute to stigma, social isola-)]TJ 0 -1.398 TD -0.0053 Tc -0.0621 Tw (tion and further marginalization within their ethnic com-)Tj 0 -1.401 TD -0.0118 Tc 0 Tw (munities.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0037 Tc 0.0744 Tw (The effects of CSA on high-risk sexual behaviors and)Tj 0 -1.401 TD -0.0027 Tc -0.04 Tw (psychosocial dysfunction are complicated by frequency)Tj T* -0.0039 Tc 0.065 Tw (with which CSA survivors experience revictimization.)Tj 0 -1.398 TD -0.005 Tc -0.0625 Tw (While the S-HIM focused on sexual ownership and link-)Tj 0 -1.401 TD -0.0037 Tc 0.0971 Tw (ing past CSA experience with current sexual decision)Tj T* -0.0033 Tc 0.0068 Tw (making, future interventions may need to also focus on)Tj 0 -1.398 TD -0.0035 Tc -0.009 Tw (adult sexual relations, including sexual abuse.)Tj /F56 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0035 Tc 0.1029 Tw (Learning from past experiences and applying them to)Tj 0 -1.398 TD -0.0033 Tc 0.04 Tw (current adult relationships may be complicated and re-)Tj 0 -1.401 TD -0.0037 Tc 0.045 Tw (quire longer interventions.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0065 Tc -0.0625 Tw (The S-HIM is among the first to attempt to reduce sexual)Tj 0 -1.401 TD -0.0035 Tc 0.0571 Tw (risk behaviors, number of sexual partners, and depres-)Tj T* -0.0085 Tc -0.0621 Tw [(sive symptoms among gay and non-gay identifying HIV)87.5(-)]TJ 0 -1.398 TD -0.0123 Tc -0.0623 Tw [(positive )47.5(African )50.5(American and Lation MSM and MSMW)]TJ 0 -1.401 TD -0.0038 Tc -0.03 Tw (with histories of CSA.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0038 Tc 0.0195 Tw [(More research is needed to further understand how )50.3(Af-)]TJ 0 -1.401 TD -0.0036 Tc -0.0374 Tw [(rican )50.5(American and Latino men define and apply sexual)]TJ T* 0.0056 Tw (labels and how these definitions coincide with their ac-)Tj 0 -1.398 TD -0.0037 Tc 0.005 Tw (tual sexual behaviors.)Tj /F56 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0038 Tc 0.1128 Tw (Risk reduction interventions need to target MSM and)Tj 0 -1.398 TD 0.0017 Tc 0.125 Tw (MSMW populations while also considering ethnicity)Tj 0 -1.401 TD -0.0036 Tc 0.0744 Tw (and culture and the importance of social support from)Tj T* -0.0135 Tc -0.0621 Tw (family friends and community within a sociocultural con-)Tj 0 -1.398 TD -0.0249 Tc 0 Tw (text.)Tj ET 3.99 w /GS1 gs 54 152.805 m 291 152.805 l S BT /TT1 1 Tf 11 0 0 11 54 133.8 Tm /GS2 gs -0.0032 Tc 0.0933 Tw [(Deliramich, )51.5(A. N., Gray)51.3(, M. J. \(2008\). Changes in)]TJ 0 -1.1809 TD -0.0034 Tc 0.0948 Tw [(women)32.1(s sexual behavior)13( following sexual assault.)]TJ ET 0.99 w /GS1 gs 54 99.315 m 291 99.315 l S BT /TT4 1 Tf 11 0 0 11 54 107.79 Tm /GS2 gs 0.0081 Tc 0.1249 Tw [(Behavior Modification, 32)]TJ /TT1 1 Tf 11.3127 0 TD 0.0086 Tc 0.1281 Tw [(, 61)55(1-621.)]TJ 11.8691 55.8955 TD -0.008 Tc 0.1236 Tw [(TYPE OF)27.5( )46.5(A)10(R)27.4(TICLE)]TJ /F56 1 Tf 10 0 0 10 309 706.65 Tm 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0089 Tc -0.0625 Tw (Original empirical investigation)Tj /TT1 1 Tf 11 0 0 11 309 676.26 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 /F56 1 Tf 10 0 0 10 309 660.24 Tm 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc 0.0678 Tw [(T)73.2(o)0( evaluate whether sexual assault survivors are more)]TJ 0 -1.398 TD -0.0077 Tc -0.062 Tw (likely to increase alcohol consumption posttraumatically)Tj 0 -1.401 TD 0.0145 Tc 0.125 Tw (relative to other trauma survivors and to determine)Tj T* -0.0037 Tc 0.0908 Tw (whether changes in post-traumatic alcohol use predict)Tj 0 -1.398 TD -0.0034 Tc 0.0188 Tw [(changes in posttraumatic sexual activity)59.6(.)]TJ /TT1 1 Tf 11 0 0 11 309 573.84 Tm 0.0344 Tc 0 Tw (METHODS)Tj 0 -1.4536 TD 0.0026 Tc (Participants)Tj /F56 1 Tf 10 0 0 10 309 541.86 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0034 Tc -0.0622 Tw (The study investigated sexual behavior and alcohol con-)Tj 0 -1.401 TD -0.0039 Tc -0.005 Tw (sumption among sexual assault \(SA\) and motor vehicle)Tj T* -0.0064 Tc -0.0621 Tw [(accident \(MV)128.6(A\) survivors \(the control group\). )17.6(The study)]TJ 0 -1.398 TD -0.0035 Tc 0.0243 Tw (also included a comparison sample of non-sexually as-)Tj 0 -1.401 TD 0.0331 Tw (saulted individuals to control for changes in sexual ac-)Tj T* -0.0029 Tc -0.012 Tw (tivity related to age or maturation.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0037 Tc -0.0173 Tw [(A)58.5( total of 57 participants \(28 SA)50.3( and 29 MV)128.3(A\) were in-)]TJ 0 -1.401 TD -0.0033 Tc 0.0836 Tw [(cluded in the study)59.7(. )53.6(All participants were between the)]TJ 0 -1.398 TD -0.0031 Tc -0.06 Tw (ages of 18 and 25 years \(SA group: )Tj /TT5 1 Tf 13.8 0 TD -0.009 Tc 0 Tw (M )Tj /TT2 1 Tf 1.014 0 TD -0.0027 Tc -0.06 Tw (= 20.0, )Tj /TT5 1 Tf 2.925 0 TD -0.0132 Tc 0 Tw (SD)Tj /TT2 1 Tf 1.212 0 TD -0.0033 Tc -0.06 Tw [( = 1.77;)]TJ -18.951 -1.401 TD -0.0037 Tc -0.05 Tw [(M)11.6(V)128.3(A)58.5( group: )]TJ /TT5 1 Tf 5.109 0 TD -0.008 Tc 0 Tw (M )Tj /TT2 1 Tf 1.02 0 TD -0.0027 Tc -0.0525 Tw (= 19.6, )Tj /TT5 1 Tf 2.94 0 TD -0.0132 Tc 0 Tw (SD)Tj /TT2 1 Tf 1.212 0 TD -0.0033 Tc -0.0517 Tw [( = 1.68\). )54(All participants were)]TJ -10.281 -1.401 TD -0.0036 Tc 0.125 Tw (either female undergraduate students participating for)Tj 0 -1.398 TD -0.0034 Tc -0.0033 Tw (extra credit or female community participants recruited)Tj 0 -1.401 TD -0.0038 Tc 0.0775 Tw (through local advertisements.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD 0.012 Tc 0.125 Tw [(The mean time since the traumatic incident was 33)]TJ 0 -1.401 TD -0.0047 Tc 0.03 Tw (months \()Tj /TT5 1 Tf 3.525 0 TD -0.0056 Tc 0 Tw (SD )Tj /TT2 1 Tf 1.491 0 TD -0.0036 Tc 0.03 Tw (= 19.8\) for the SA group and 28.2 months)Tj -5.016 -1.401 TD 0 Tc 0 Tw (\()Tj /TT5 1 Tf 0.33 0 TD -0.0057 Tc -0.06 Tw (SD =)Tj /TT2 1 Tf 2.07 0 TD -0.0037 Tc -0.062 Tw [( 22.0\) for the MV)128.3(A)58.5( group.)]TJ /TT1 1 Tf 11 0 0 11 309 297.45 Tm 0.0233 Tc 0 Tw (Materials)Tj /F56 1 Tf 10 0 0 10 309 281.46 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0037 Tc 0.0812 Tw (The Life Events Checklist \(LEC\) consists of 16 items)Tj 0 -1.401 TD -0.0033 Tc 0.04 Tw (inquiring about the experience of 16 different physical)Tj T* -0.0036 Tc -0.02 Tw (traumas known to result in PTSD. It also inquires about)Tj 0 -1.398 TD -0.0329 Tw (other stressful experiences. Items inquiring about SA or)Tj 0 -1.401 TD -0.0031 Tc -0.056 Tw [(M)12.2(V)128.9(A)59.1( exposure within the last 5 years were used to iden-)]TJ T* -0.0025 Tc -0.0225 Tw (tify qualifying participants.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0041 Tc -0.0408 Tw [(The )49.9(Alcohol Use Disorders Identification )16.9(T)72.7(est \(AUDIT)49.9(;)]TJ 0 -1.401 TD -0.0038 Tc -0.0558 Tw [(Saunders, )50.6(Aasland, Babor)35.2(, De la Fuente, & Grant, 1993\))]TJ 0 -1.398 TD -0.0034 Tc 0.0085 Tw (consists of 10 questions that identify alcohol consump-)Tj 0 -1.401 TD -0.0037 Tc -0.018 Tw (tion, drinking behavior and alcohol-related problems.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc 0.0008 Tw (The Sexual Health History Questionnaire SHQ; Cupitt,)Tj 0 -1.401 TD -0.0057 Tc -0.0625 Tw [(1998\) consists of 23 questions that assess an individual)48.3(s)]TJ T* -0.0033 Tc 0.0134 Tw [(sexual history and behavior)50.7(.)]TJ ET endstream endobj 352 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /F56 317 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 354 0 obj << /Length 8801 >> 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. 4 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (321)Tj /TT1 1 Tf 11 0 0 11 66 722.64 Tm 0.0242 Tc (Procedure)Tj /F56 1 Tf 10 0 0 10 66 706.65 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0033 Tc 0.125 Tw [(The study was conducted in two phases. )50.7(All partici-)]TJ 0 -1.401 TD 0.1177 Tw (pants were eligible for the first phase of screening to)Tj 0 -1.398 TD -0.0048 Tc -0.062 Tw (determine appropriate participants who had experienced)Tj 0 -1.401 TD -0.0031 Tc -0.0157 Tw [(a SA)53.9( or MV)125.9(A)59.1( in the past 5 years.)]TJ /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0038 Tc 0.0025 Tw [(S)21.4(tudents who reported a serious SA)53.2( or MV)125.2(A)58.4( in the past)]TJ 0 -1.401 TD -0.003 Tc -0.014 Tw [(5 years were sent an e-mail invitation to participate in a)]TJ T* 0.02 Tw (subsequent related study \(i.e., phase 2 of the investiga-)Tj 0 -1.398 TD 0.0358 Tw [(tion\). )18(T)73.8(o)0( identify possible community participants, ads)]TJ 0 -1.401 TD -0.0037 Tc 0.0075 Tw (were placed in local and campus newspapers.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0035 Tc 0.1243 Tw (During the second phase of the investigation, partici-)Tj 0 -1.401 TD -0.0063 Tc -0.0625 Tw (pants completed a demographics questionnaire and were)Tj T* -0.0041 Tc 0.1142 Tw [(then asked to complete the )53.2(AUDIT)16.9( and SHQ for two)]TJ 0 -1.398 TD -0.0037 Tc 0.0607 Tw (reference points: within the past month and the month)Tj 0 -1.401 TD -0.0034 Tc -0.0267 Tw (prior to the trauma.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD 0.0019 Tc 0.1249 Tw [(After completion of the survey)61.9(, each participant was)]TJ 0 -1.401 TD -0.0032 Tc 0.1039 Tw (given a short debriefing on the purpose of the survey)Tj T* -0.0033 Tc 0.0534 Tw [(and was asked to seek services from a referral sheet if)]TJ 0 -1.398 TD -0.0031 Tc 0.0033 Tw (they were experiencing any chronic emotional difficul-)Tj 0 -1.401 TD 0.0028 Tc 0 Tw (ties.)Tj /TT1 1 Tf 11 0 0 11 66 418.26 Tm 0.0154 Tc [(RESUL)83.6(TS)]TJ /F56 1 Tf 10 0 0 10 66 402.24 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0049 Tc -0.0621 Tw [(T)71.9(o)0( evaluate whether trauma groups dif)13.1(fered with respect)]TJ 0 -1.398 TD -0.0034 Tc -0.0507 Tw (to posttraumatic alcohol consumption, a 2 \(trauma type\))Tj 0 -1.401 TD -0.0115 Tc -0.0622 Tw (x 2 \(time\) )Tj 3.8803 0 TD (mixed-factorial )Tj 6.1157 0 TD -0.0129 Tc -0.0607 Tw [(ANOV)122.1(A)61.3( was conducted. )18.5(There)]TJ -9.996 -1.401 TD -0.0034 Tc 0.0065 Tw (was no significant main effect for time, but there was a)Tj 0 -1.398 TD -0.003 Tc 0.0179 Tw (marginally significant main effect of trauma type. This)Tj 0 -1.401 TD -0.0039 Tc -0.0622 Tw (effect qualified by a significant trauma type x time inter-)Tj T* 0.0011 Tc 0 Tw (action.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc 0.0331 Tw (Trauma groups did not differ with respect to estimated)Tj 0 -1.401 TD -0.0052 Tc -0.0622 Tw (pretraumatic alcohol use but did significantly differ with)Tj 0 -1.398 TD -0.0037 Tc -0.0456 Tw [(respect to estimated current alcohol use. MV)128.3(A)58.5( survivors)]TJ 0 -1.401 TD -0.0033 Tc -0.0581 Tw (reported a decrease in use posttraumatically and SA sur-)Tj T* -0.0036 Tc 0.0583 Tw (vivors reported and increase.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0032 Tc -0.0425 Tw [(T)73.6(o)0( characterize changes in sexual activity as function of)]TJ 0 -1.401 TD -0.0028 Tc -0.0614 Tw (time and trauma type, a 2 x )Tj 10.6539 0 TD (2 repeated )Tj 4.1811 0 TD -0.0062 Tc -0.0595 Tw [(ANOV)122.8(A)56( was con-)]TJ -14.835 -1.398 TD 0.003 Tc 0.125 Tw (ducted with SHQ serving as the dependent measure.)Tj 0 -1.401 TD -0.0063 Tc -0.0625 Tw (There was a significant main effect for trauma type and a)Tj T* -0.0033 Tc 0.0357 Tw (marginally significant main effect of time. These main)Tj 0 -1.398 TD -0.0063 Tc -0.0621 Tw (effects were qualified by a marginally significant trauma)Tj 0 -1.401 TD -0.0033 Tc -0.0618 Tw (type x time interaction. SA survivors reported an overall)Tj T* 0.0778 Tw [(increase in sexual activity posttrauma, where as MV)125.7(A)]TJ 0 -1.398 TD -0.0038 Tc 0.0984 Tw (survivors reported no change.)Tj /F56 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0018 Tc 0.125 Tw (Because trauma groups did not differ with respect to)Tj 0 -1.398 TD -0.003 Tc -0.0592 Tw [(pretraumatic sexual activity)60(, trauma type did not signifi-)]TJ 0 -1.401 TD -0.0028 Tc -0.0608 Tw [(cantly predict current sexual activity)60.2(. )54.2(Accordingly)63.2(, alco-)]TJ 25.5 64.839 TD -0.0036 Tc -0.015 Tw (hol consumption cannot be said to mediate the relation-)Tj 0 -1.398 TD -0.0031 Tc 0.0065 Tw [(ship between trauma type and current sexual activity)59.9(.)]TJ /F56 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0036 Tc 0.0657 Tw (A hierarchical multiple regression was run to evaluate)Tj 0 -1.398 TD -0.0037 Tc 0.045 Tw (whether changes in self-reported alcohol use predicted)Tj 0 -1.401 TD 0.0577 Tc 0.125 Tw (changes in sexual activity after controlling for)Tj T* -0.0033 Tc 0.1032 Tw [(pretraumatic levels of sexual activity)59.7(. Consistent with)]TJ 0 -1.398 TD 0.0014 Tc 0.125 Tw (predictions, changes in alcohol use significantly pre-)Tj 0 -1.401 TD -0.0035 Tc -0.0625 Tw (dicted current levels of sexual activity among all partici-)Tj T* 0.0079 Tc 0.1249 Tw (pants, even after controlling for pretraumatic sexual)Tj 0 -1.398 TD -0.0024 Tc -0.02 Tw (activity levels.)Tj /TT1 1 Tf 11 0 0 11 321 564.24 Tm 0.0217 Tc 0 Tw [(CONCLUSIONS/SUMMAR)32.6(Y)]TJ /F56 1 Tf 10 0 0 10 321 548.25 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0037 Tc 0.0972 Tw (Although most clinicians often focus on reluctance to)Tj 0 -1.401 TD -0.0032 Tc -0.0339 Tw (engage in sexual activity following a SA, it is important)Tj 0 -1.398 TD -0.0035 Tc 0.1239 Tw (to be aware of the diverse courses of adjustment and)Tj 0 -1.401 TD -0.0038 Tc 0.01 Tw (coping patterns following a SA.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0034 Tc -0.025 Tw (While many women may experience psychological dis-)Tj 0 -1.401 TD -0.0032 Tc -0.0325 Tw [(tress after a SA)50.8( and avoid sexual intimacy)62.8(, the results of)]TJ T* 0.0614 Tw (this study demonstrate that many assault survivors are)Tj 0 -1.398 TD -0.0029 Tc 0.0166 Tw (as sexually active or more sexually active within a few)Tj 0 -1.401 TD -0.0027 Tc -0.0317 Tw (years of their trauma.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0039 Tc -0.0231 Tw [(Relative to a comparison sample of MV)125.1(A)58.3( survivors, SA)]TJ 0 -1.401 TD -0.0026 Tc 0.125 Tw (survivors in this study were more likely to report in-)Tj T* -0.0062 Tc -0.0621 Tw (creases in sexual activity following their traumatic expe-)Tj 0 -1.398 TD -0.0112 Tc 0 Tw (rience.)Tj /F56 1 Tf -1.8 -1.602 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0038 Tc 0.1 Tw (There were no differences between trauma conditions)Tj 0 -1.398 TD -0.0035 Tc 0.0378 Tw (with respect to estimated pretraumatic alcohol use, but)Tj 0 -1.401 TD 0.002 Tc 0.125 Tw (the groups reported dramatically different courses of)Tj T* -0.0038 Tc 0.0583 Tw [(alcohol use post-trauma. )50.2(Assault survivors reported an)]TJ 0 -1.398 TD -0.0036 Tc -0.0013 Tw (increase in alcohol use while a decreased was observed)Tj 0 -1.401 TD -0.004 Tc 0.015 Tw [(among MV)125(A)58.2( survivors. )50(Assault survivors may be more)]TJ T* -0.0032 Tc -0.058 Tw (likely to use alcohol to cope with their trauma than other)Tj 0 -1.398 TD -0.0041 Tc 0.055 Tw (trauma groups.)Tj /F56 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0034 Tc 0.0017 Tw (Inclusion of an alternate trauma control group is a rela-)Tj 0 -1.398 TD 0.0837 Tw [(tive strength of the study)62.6(. Based on comparisons with)]TJ 0 -1.401 TD -0.0036 Tc -0.0605 Tw [(the MV)125.4(A)58.6( group, it became clear that increases in alcohol)]TJ T* -0.0007 Tc 0.1249 Tw [(consumption and sexual activity are not the result of)]TJ 0 -1.398 TD -0.004 Tc -0.015 Tw (development or maturation.)Tj /TT1 1 Tf 11 0 0 11 321 159.84 Tm 0.0255 Tc 0 Tw [(CONTRIBUTIONS/IMPLICA)63.7(TIONS)]TJ /F56 1 Tf 10 0 0 10 321 143.85 Tm 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0019 Tc 0.125 Tw (Although the increase in alcohol use observed in SA)Tj 0 -1.401 TD -0.0115 Tc -0.0621 Tw (survivors post-trauma may be ineffectual in helping them)Tj 0 -1.398 TD -0.0033 Tc 0.034 Tw (cope with the trauma, it might also increase the risk of)Tj 0 -1.401 TD -0.004 Tc -0.0621 Tw (future trauma exposure such as SA revictimization. This)Tj T* -0.0032 Tc 0.0034 Tw (possibility is supported by existing research document-)Tj ET endstream endobj 355 0 obj << /ProcSet [/PDF /Text ] /Font << /F1 4 0 R /F56 317 0 R /TT1 8 0 R /TT2 9 0 R /TT3 10 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 358 0 obj << /Length 5480 >> 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 [(322 )]TJ /TT3 1 Tf 2.8388 0 TD -0.0058 Tc (Selected Annotated Journal Resources)Tj /TT2 1 Tf 10 0 0 10 72 721.65 Tm -0.0039 Tc 0.0657 Tw (ing increase substance abuse among SA survivors and)Tj 0 -1.401 TD -0.004 Tc 0.0634 Tw (the associations between alcohol consumption and SA)Tj 0 -1.398 TD 0.0017 Tc 0 Tw [(frequency)61.7(.)]TJ /F56 1 Tf -1.8 -1.602 TD 0 Tc ()Tj /TT2 1 Tf 1.8 0 TD -0.0123 Tc -0.0625 Tw (This offers preliminary support to the importance of care-)Tj 0 -1.398 TD -0.0036 Tc -0.0565 Tw (ful assessment with trauma survivors. Replication of the)Tj 0 -1.401 TD -0.0125 Tc -0.0622 Tw (study with larger samples and longitudinal designs would)Tj T* -0.0034 Tc -0.005 Tw (be necessary for making informed interventions.)Tj /F56 1 Tf -1.8 -1.599 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.0034 Tc -0.01 Tw (The study does support that extreme avoidance of post-)Tj 0 -1.401 TD -0.0029 Tc 0.0706 Tw (assault sexual activity is not necessarily the modal re-)Tj 25.5 11.502 TD 0.0084 Tc 0.125 Tw (sponse, nor is it representative. If clinicians assume)Tj 0 -1.401 TD 0.0095 Tc (sexual activity is uniformly avoided, they may gear)Tj T* -0.0034 Tc 0.0636 Tw (therapy towards resumption of behaviors that have in-)Tj 0 -1.398 TD -0.0035 Tc 0.0834 Tw (creased rather than ceased.)Tj /F56 1 Tf -1.8 -1.602 TD 0 Tc 0 Tw ()Tj /TT2 1 Tf 1.8 0 TD -0.003 Tc -0.0016 Tw (The study findings are important as they call into ques-)Tj 0 -1.398 TD -0.0031 Tc 0.1085 Tw [(tion the assumption that SA survivors typically avoid)]TJ 0 -1.401 TD -0.0028 Tc 0.0158 Tw [(sexual activity posttraumatically)63.2(, and they also suggest)]TJ T* -0.0034 Tc 0.0322 Tw (another important reason to carefully assess and moni-)Tj 0 -1.398 TD -0.0021 Tc 0.125 Tw (tor posttraumatic substance abuse.)Tj /TT10 1 Tf -8.835 -24.267 TD 0.0486 Tc 0.335 Tw (Catalog #MIT5)Tj -0.03 0 TD (Catalog #MIT5)Tj 0.03 0.03 TD (Catalog #MIT5)Tj -0.03 0 TD (Catalog #MIT5)Tj 0.015 -0.015 TD (Catalog #MIT5)Tj 0.015 -1.113 TD 0.048 Tc 0.23 Tw (Paperback 186pp \(2007\))Tj -0.03 0 TD (Paperback 186pp \(2007\))Tj 0.03 0.03 TD (Paperback 186pp \(2007\))Tj -0.03 0 TD (Paperback 186pp \(2007\))Tj 0.015 -0.015 TD (Paperback 186pp \(2007\))Tj 0.015 -1.116 TD 0.0472 Tc 0 Tw (ISBN1)Tj -0.03 0 TD (ISBN1)Tj 0.03 0.03 TD (ISBN1)Tj -0.03 0 TD (ISBN1)Tj 0.015 -0.015 TD (ISBN1)Tj 2.601 -0.015 TD 0.0496 Tc 0.865 Tw (3: 9)Tj -0.03 0 TD (3: 9)Tj 0.03 0.03 TD (3: 9)Tj -0.03 0 TD (3: 9)Tj 0.015 -0.015 TD (3: 9)Tj 2.478 -0.015 TD 0.0473 Tc 0 Tw (78-1-88358)Tj -0.03 0 TD (78-1-88358)Tj 0.03 0.03 TD (78-1-88358)Tj -0.03 0 TD (78-1-88358)Tj 0.015 -0.015 TD (78-1-88358)Tj 5.112 -0.015 TD 0.0465 Tc (1-2)Tj -0.03 0 TD (1-2)Tj 0.03 0.03 TD (1-2)Tj -0.03 0 TD (1-2)Tj 0.015 -0.015 TD (1-2)Tj 1.44 -0.015 TD (4-4)Tj -0.03 0 TD (4-4)Tj 0.03 0.03 TD (4-4)Tj -0.03 0 TD (4-4)Tj 0.015 -0.015 TD (4-4)Tj /F8 1 Tf 11 0 0 11 238.5 325.14 Tm 0.0164 Tc ($30.00)Tj /TT3 1 Tf 14 0 0 14 238.5 309.15 Tm 0.0016 Tc 0.1375 Tw (Group Crisis Support)Tj 0 -1.0007 TD -0.0051 Tc 0.1143 Tw (Why it works)Tj 0 -1.0929 TD 0.0921 Tw (When & How to provide it)Tj /F58 1 Tf 12 0 0 12 238.5 265.86 Tm -0.0033 Tc -0.0514 Tw (Jeffrey T. Mitchell, PhD)Tj /F59 1 Tf 10 0 0 10 238.5 253.5 Tm -0.0017 Tc 0.1099 Tw (Group Crisis Support )Tj /F60 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 /F59 1 Tf 2.109 0 TD -0.0036 Tc (Group Crisis Support)Tj /F60 1 Tf 6.822 0 TD -0.0034 Tc -0.0005 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 /F59 1 Tf 10.476 0 TD -0.0035 Tc 0.0117 Tw (Group Crisis Support )Tj /F60 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 0.0363 Tw [(enforcement organizations, and the military)71.5(.)]TJ ET q 380.95 150.6 9.05 -6.7 re W n /GS1 gs /Fm8 Do Q BT /TT11 1 Tf 30 0 0 30 144.99 428.49 Tm /GS1 gs -0.0054 Tc 0.0425 Tw (Exclusively from Chevron!)Tj 24 0 5.04 24 138.99 398.49 Tm -0.0042 Tc 0.0232 Tw [(A New Book by Jeffrey T. Mitchell)]TJ ET q 151.75 0 0 232 70.55 141.5 cm /Im8 Do Q 0 0 0 0.2 k 0.99 w 1000 M 69.995 128.505 468.01 -49.01 re B* BT /TT3 1 Tf 11 0 0 11 146.91 113.01 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 53.995 458.005 491.51 -386.01 re S endstream endobj 359 0 obj << /ProcSet [/PDF /Text /ImageC ] /Font << /F1 4 0 R /F8 36 0 R /F56 317 0 R /F58 360 0 R /F59 361 0 R /F60 362 0 R /TT2 9 0 R /TT3 10 0 R /TT10 363 0 R /TT11 364 0 R >> /XObject << /Im8 365 0 R /Fm8 366 0 R >> /ExtGState << /GS1 12 0 R /GS2 13 0 R >> >> endobj 368 0 obj << /Length 7569 >> 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. 4 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (323)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 /TT2 1 Tf 10 0 0 10 84 571.65 Tm -0.0033 Tc 0.1178 Tw [(D)7.9(r)50.7(.)-6.4( )17.6(V)64.9(iolanti, in this second edition of )]TJ /TT5 1 Tf 15.756 0 TD -0.004 Tc 0.12 Tw (Police Suicide:)Tj -17.556 -1.401 TD -0.0036 Tc 0.0383 Tw (Epidemic in Blue, )Tj /TT2 1 Tf 7.44 0 TD -0.0037 Tc 0.04 Tw (updates his previous work on police sui-)Tj -7.44 -1.398 TD -0.0035 Tc -0.0372 Tw [(cide, and reviews promising new research. This edition pro-)]TJ 0 -1.401 TD -0.0033 Tc -0.0156 Tw (vides an array of information on prominent theories, current)Tj T* -0.0031 Tc 0.06 Tw (research, special cases \(e.g., suicide by suspect\), and the)Tj 0 -1.398 TD -0.0036 Tc -0.0607 Tw (complex issues surviving family members, friends and agen-)Tj 0 -1.401 TD -0.0032 Tc -0.015 Tw (cies face.)Tj 1.8 -2.001 TD -0.0034 Tc 0.0514 Tw (He begins by reviewing prominent theories of suicide,)Tj -1.8 -1.398 TD -0.0039 Tc 0.0358 Tw (from Freud through Shneidman and others, then introduces)Tj 0 -1.401 TD -0.0036 Tc 0.075 Tw (a theoretical model based on work socialization processes.)Tj T* -0.0016 Tc 0.125 Tw (He posits that officers develop dichotomous thinking and)Tj 0 -1.398 TD -0.0035 Tc 0.0569 Tw (decision making techniques \(right or wrong with no gray)Tj 0 -1.401 TD -0.0068 Tc -0.0625 Tw (area between\), become socialized into the police role \(I am a)Tj T* -0.0033 Tc -0.0607 Tw (cop\), and may develop interpersonal difficulties and/or pur-)Tj 0 -1.398 TD -0.0029 Tc 0.045 Tw (posely isolate themselves from society \(us vs. them\), all of)Tj 0 -1.401 TD -0.0015 Tc 0.125 Tw [(which increases the potential for police suicide. He then)]TJ T* -0.0032 Tc 0.0185 Tw (effectively uses case examples to highlight his points.)Tj 1.8 -1.998 TD -0.0035 Tc 0.0157 Tw (He next reviews current research on police suicide, de-)Tj -1.8 -1.401 TD -0.0034 Tc -0.0072 Tw (lineating the difficulties in gathering accurate police suicide)Tj T* -0.003 Tc 0.125 Tw (data such as the resistance to acknowledging suicide as a)Tj 0 -1.398 TD -0.0037 Tc -0.055 Tw (problem in my department, misclassification of suspicious)Tj 0 -1.401 TD -0.0036 Tc 0.0306 Tw [(deaths, and using inappropriate comparison groups. He re-)]TJ T* -0.0032 Tc 0.0289 Tw (ports that 17% of police suicides are likely misclassified as)Tj 0 -1.398 TD -0.0038 Tc -0.005 Tw (accidental or undetermined.)Tj 1.8 -2.001 TD -0.0035 Tc -0.0607 Tw [(D)7.7(r)50.5(.)-5.2( )17.5(V)64.7(iolanti explores probable precipitants of police sui-)]TJ -1.8 -1.401 TD -0.011 Tc -0.0625 Tw (cide, including relationship problems, alcohol use, inadequate)Tj 0 -1.398 TD -0.0031 Tc -0.0099 Tw [(sleep, constant exposure to misery and death, public apathy)59.9(,)]TJ 0 -1.401 TD -0.046 Tw [(and increased availability of firearms. He adds in the impact)]TJ T* -0.0034 Tc -0.0079 Tw (of trauma and critical incidents, plus organizational tension,)Tj 0 -1.398 TD -0.0036 Tc 0.0357 Tw [(on the of)14.4(ficer)-36.6()53.4(s)-0.1( coping and perceived stress levels.)]TJ 1.8 -2.001 TD -0.0034 Tc 0.0045 Tw (In addition, he points out the apparent increased risk of)Tj -1.8 -1.401 TD 0.0275 Tw (suicide after retirement due to prior trauma, relationship is-)Tj 0 -1.398 TD -0.0033 Tc -0.045 Tw [(sues, and difficulties assuming a civilian role. Many assume)]TJ 0 -1.401 TD -0.0029 Tc 0.125 Tw (that suicide risk decreases in retirement, with presumably)Tj 25.5 48.801 TD -0.0033 Tc 0.0578 Tw (less of the precipitants outlined above, but the research lit-)Tj 0 -1.401 TD 0.0027 Tc 0.125 Tw [(erature reveals the opposite. One of the highest rates of)]TJ T* -0.006 Tc -0.0625 Tw [(suicide is among older Caucasian males. Stephanie Samuels,)]TJ 0 -1.398 TD -0.0034 Tc 0.0414 Tw (a psychotherapist who works with police officers, provides)Tj 0 -1.401 TD -0.0036 Tc -0.015 Tw (several case studies demonstrating the challenges of retiring)Tj T* -0.0052 Tc -0.0625 Tw (from the law enforcement lifestyle.)Tj 1.8 -1.998 TD -0.0061 Tc -0.0622 Tw [(D)8.1(r)50.9(.)-9.3( )17.9(V)68.1(iolanti next addresses a topic of growing concern in)]TJ -1.8 -1.401 TD -0.0028 Tc -0.028 Tw [(police psychology)63.2(, suicide by suspect. He refers to this as)]TJ T* -0.0035 Tc 0.0433 Tw (suicide by cop turned inside out \(also classified as indi-)Tj 0 -1.398 TD -0.006 Tc -0.0625 Tw [(rect self-destructive behaviors\). Many are familiar with sui-)]TJ 0 -1.401 TD -0.0002 Tc 0.125 Tw (cide by cop, or victim precipitated homicide, where an)Tj T* -0.0035 Tc 0.0916 Tw [(individual wants to complete the act of suicide but cannot)]TJ 0 -1.398 TD -0.0038 Tc -0.0622 Tw (bring him/herself to complete the act, so the individual delib-)Tj 0 -1.401 TD -0.0031 Tc -0.0075 Tw [(erately provokes a law enforcement officer to shoot. In sui-)]TJ T* -0.0026 Tc 0.0237 Tw (cide by suspect, the )Tj ET 500 w 10 M 428.64 -628.36 m 402.24 -628.36 l S BT 10 0 0 10 402.24 371.64 Tm -0.0028 Tc 0.0245 Tw [(officer wants to die but for a variety of)]TJ -8.124 -1.398 TD -0.0068 Tc -0.0623 Tw [(reasons, does not want death to be an obvious suicide. There-)]TJ 0 -1.401 TD -0.003 Tc -0.024 Tw (fore, the officer either allows the suspect to use deadly force)Tj T* -0.0032 Tc -0.0618 Tw [(or deliberately places him/herself in harm)50.8(s way where death)]TJ 0 -1.398 TD 0.0561 Tw [(is a likely result. Several case examples illustrate possible)]TJ 0 -1.401 TD 0.0088 Tc 0 Tw (scenarios.)Tj 1.8 -2.001 TD -0.0036 Tc -0.025 Tw (He also devotes a chapter to murder-suicide, or the ex-)Tj -1.8 -1.398 TD -0.0034 Tc -0.0156 Tw [(tended police suicide. His review of the literature suggests)]TJ 0 -1.401 TD -0.0035 Tc 0.0105 Tw (most of these cases involve a perpetrator who is male, Cau-)Tj T* -0.0028 Tc 0.0163 Tw (casian, older than the victim, and may have a history of de-)Tj 0 -1.398 TD -0.0067 Tc -0.0625 Tw [(pression and/or other mental illness. The victims are likely to)]TJ 0 -1.401 TD -0.0037 Tc 0.1161 Tw (be women who have separated or are divorced from their)Tj T* -0.0029 Tc 0.1061 Tw (partners, and typically occurs in the home with a firearm.)Tj 0 -1.398 TD -0.0036 Tc 0.1237 Tw [(Alcohol and domestic violence are often precursors. The)]TJ 0 -1.401 TD -0.0066 Tc -0.0622 Tw (estimated rates of occurrence are 0.2-0.38 per 100,000.)Tj 1.8 -2.001 TD -0.0036 Tc 0.0614 Tw [(Theresa )14.5(T)73.2(ate, a suicide survivor and founder of Survi-)]TJ -1.8 -1.398 TD -0.0233 Tc -0.0625 Tw (vors of Law Enforcement Suicide \(SOLES\), contributes a chap-)Tj 0 -1.401 TD 0.0261 Tc 0.125 Tw (ter on police suicide survivors, which includes family)Tj T* -0.0035 Tc 0.0114 Tw (members, co-workers, friends, and agencies left behind fol-)Tj 0 -1.398 TD -0.0349 Tw [(lowing an of)17.4(ficer)-39.6()56.4(s)-0.2( suicide. She uses case examples to high-)]TJ 0 -1.401 TD 0.0357 Tw (light the need for prompt death notification, compassionate)Tj /TT1 1 Tf 12 0 0 12 203.49 633.66 Tm -0.0087 Tc -0.0611 Tw (Police Suicide: Epidemic in Blue \(2d edition\))Tj /TT2 1 Tf 10 0 0 10 259.74 621 Tm -0.0006 Tc -0.0624 Tw [(By John M. )17.5(V)67.6(iolanti, Ph.D.)]TJ -5.625 -1.2 TD -0.0059 Tc -0.0621 Tw [(Charles C. )12.1(Thomas, 2007, 178 pages, Hardcover)36.1(, $51.95)]TJ ET endstream endobj 369 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 371 0 obj << /Length 8030 >> 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 [(324 )]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 54 721.65 Tm -0.0035 Tc 0.0258 Tw (Agency response, and the importance of educating families)Tj 0 -1.401 TD -0.0034 Tc 0.0795 Tw (on the resources available both to the officer and to them-)Tj 0 -1.398 TD -0.0051 Tc -0.0625 Tw [(selves. She also stresses the importance of having an )54.9(Agency)]TJ 0 -1.401 TD -0.0033 Tc -0.0462 Tw (written policy and guidelines on funeral protocols for officer)Tj T* -0.0011 Tc 0 Tw (suicide.)Tj 1.8 -1.998 TD -0.0034 Tc -0.0401 Tw [(D)7.8(r)50.6(. )14.5(V)64.8(iolanti closes with a chapter on suicide prevention.)]TJ -1.8 -1.401 TD -0.0035 Tc 0.0719 Tw (He offers suggestions on assessing risk, training, access to)Tj T* -0.0033 Tc 0.0743 Tw [(firearms, intervention, peer support, etc.. )50.6(As an additional)]TJ 0 -1.398 TD -0.0036 Tc 0.0045 Tw [(resource, please see the next review)62.4(, the International )50.5(Asso-)]TJ 0 -1.401 TD -0.0041 Tc 0.0415 Tw [(ciation of Chiefs of Police)49.9(s Preventing Law Enforcement)]TJ T* -0.0038 Tc -0.0143 Tw [(O)7.4(f)14.2(ficer Suicide: )50.3(A)58.4( Compilation of Resources and Best Prac-)]TJ 0 -1.398 TD 0.0039 Tc 0 Tw (tices.)Tj 1.8 -2.001 TD -0.0034 Tc 0.056 Tw (Although this is a useful book, with a profusion of re-)Tj -1.8 -1.401 TD -0.0036 Tc -0.0043 Tw (sources, suggestions, and recommendations, I found it chal-)Tj 0 -1.398 TD -0.008 Tc -0.0623 Tw (lenging to read due to the staggering number of typographical)Tj 0 -1.401 TD -0.0035 Tc 0.0266 Tw [(and editing errors. There are missing words, wrong words,)]TJ T* -0.0033 Tc 0.1217 Tw (apparent typos, non-capitalized first words, missing refer-)Tj 0 -1.398 TD -0.0035 Tc 0.0713 Tw (ences, etc., sometimes occurring more than once per page.)Tj 0 -1.401 TD -0.0033 Tc -0.0332 Tw (This second edition is a useful update of the first edition, but)Tj T* -0.0035 Tc -0.0443 Tw (the lack of professional presentation tarnishes the final prod-)Tj 0 -1.398 TD 0.0094 Tc 0 Tw (uct.)Tj 1.8 -2.001 TD -0.0033 Tc 0.1011 Tw [(John M. )14.7(V)64.9(iolanti, Ph.D. is a research professor in the)]TJ -1.8 -1.401 TD -0.0151 Tc -0.0621 Tw (Department of Social and Preventive Medicine \(SPM\), School)Tj 0 -1.398 TD -0.0036 Tc -0.0183 Tw (of Public Health and Health Professions at the State Univer-)Tj 25.599 34.098 TD -0.0096 Tc -0.0623 Tw (sity of NY Buffalo and a member of the University of Buffalo)Tj 0 -1.398 TD -0.006 Tc [(medical school graduate faculty)63(. He is a police veteran, serv-)]TJ 0 -1.401 TD -0.0033 Tc -0.0354 Tw [(ing with the New )32.7(Y)103.9(ork S)14.7(tate Police for 23 years as a trooper)35.7(,)]TJ T* -0.0035 Tc 0.0834 Tw (the Bureau of Criminal Investigation \(BCI\), and later as a)Tj 0 -1.398 TD -0.0062 Tc -0.0624 Tw [(coordinator for the Psychological )53.9(Assistance Program \(EAP\))]TJ 0 -1.401 TD -0.0036 Tc 0.0576 Tw [(for the New )29.2(Y)103.6(ork S)17.4(tate Police. Recent projects include the)]TJ T* -0.004 Tc 0.0268 Tw [(Buf)14(falo Cardio Occupational Police S)17(tress \(BCOPS\) study)59(,)]TJ 0 -1.398 TD -0.008 Tc -0.0622 Tw (research of the health and psychological effects of shift work,)Tj 0 -1.401 TD -0.0032 Tc 0.0155 Tw (and police suicide. He is a respected faculty member of the)Tj T* -0.0164 Tc -0.0761 Tw [(Law )-13.3(Enforcement W)96.4(ellness )36(Association. )-14(Dr)52.6(. V)60.8(iolanti )-13.8(conducts)]TJ 0 -1.398 TD -0.0035 Tc 0.1111 Tw (clinical research on a host of law enforcement health and)Tj 0 -1.401 TD -0.0518 Tw [(wellness issues for The University of Buffalo Department of)]TJ T* -0.0082 Tc -0.0625 Tw (Social and Preventative Medicine. In addition to his research,)Tj 0 -1.398 TD -0.0034 Tc 0.0005 Tw [(D)7.8(r)50.6(. )17.5(V)61.8(iolanti has written and edited several books relating to)]TJ 0 -1.401 TD -0.0064 Tc -0.0617 Tw (law enforcement stress and trauma including )Tj ET 500 w 517.02 -473.35 m 485.16 -473.35 l S BT /TT5 1 Tf 10 0 0 10 485.16 526.65 Tm -0.007 Tc -0.0651 Tw (Police T)Tj ET 546 -473.35 m 516.99 -473.35 l S BT 10 0 0 10 516.99 526.65 Tm -0.0087 Tc 0 Tw (rauma:)Tj ET 485.25 -487.36 m 309.99 -487.36 l S BT 10 0 0 10 309.99 512.64 Tm -0.0037 Tc -0.0353 Tw (Psychological Aftermath of Civilian Combat, )Tj ET 546 -487.36 m 489.9 -487.36 l S BT 10 0 0 10 489.9 512.64 Tm -0.0047 Tc 0 Tw (Posttraumatic)Tj ET 546 -501.34 m 309.99 -501.34 l S BT 10 0 0 10 309.99 498.66 Tm 0.0021 Tc 0.125 Tw (Stress Intervention: Challenges, Issues, and Perspectives)Tj /TT2 1 Tf T* 0.0057 Tc 0 Tw (and )Tj /TT5 1 Tf 1.845 0 TD 0.0068 Tc 0.125 Tw (Copicide: Concepts, Cases, and Controversies of)Tj -1.845 -1.401 TD -0.0042 Tc -0.01 Tw (Suicide by Cop)Tj /TT2 1 Tf 5.982 0 TD -0.0033 Tc -0.0128 Tw (. He has been an invited lecturer on topics of)Tj -5.982 -1.398 TD -0.0034 Tc 0.0694 Tw [(police stress and suicide to the FBI )50.6(Academy at Quantico,)]TJ 0 -1.401 TD -0.0079 Tc -0.0625 Tw [(V)63.3(i)2.9(r)16.1(ginia several times. Prior to his present work with the Uni-)]TJ T* -0.0031 Tc 0.0375 Tw (versity of Buffalo, John was a full professor in the Depart-)Tj 0 -1.398 TD 0.0272 Tc 0.125 Tw (ment of Criminal Justice at the Rochester Institute of)Tj 0 -1.401 TD -0.003 Tc -0.0328 Tw [(T)70.8(echnology in Rochester)39(, New )33.1(Y)104.2(ork for fifteen years.)]TJ /TT1 1 Tf 12 0 0 12 206.25 308.16 Tm -0.0146 Tc -0.0611 Tw (Preventing Law Enforcement Suicide:)Tj -2 -1.1675 TD -0.0056 Tc -0.0299 Tw [(A Compilation of Resources and Best Practices)]TJ /TT2 1 Tf 10 0 0 10 201.75 281.49 Tm 0.0012 Tc -0.0033 Tw [(The International )49.2(Association of Chiefs of Police)]TJ 8.964 -1.2 TD -0.0173 Tc 0 Tw (Free)Tj -21.789 -2.985 TD -0.0036 Tc -0.0027 Tw [(Each year)35.4(, more law enforcement of)17.4(ficers complete the)]TJ -1.8 -1.398 TD -0.0027 Tc -0.0216 Tw [(act of suicide than are killed in the line of duty)63.3(. Many agen-)]TJ 0 -1.401 TD -0.0034 Tc -0.0367 Tw (cies lack the resources to prevent officer suicide from occur-)Tj T* -0.0033 Tc 0.0106 Tw (ring and are unprepared to respond effectively when it does)Tj 0 -1.398 TD -0.0039 Tc 0 Tw [(occur)50.1(.)]TJ 1.8 -2.001 TD -0.0036 Tc 0.0931 Tw [(In response to this need, the International )50.6(Association)]TJ -1.8 -1.401 TD -0.0522 Tw [(of Chiefs of Police \(IACP\); the Bureau of Justice )50.4(Assistance,)]TJ 0 -1.398 TD 0.0263 Tc 0.125 Tw (U.S. Department of Justice; and EEI Communications)Tj 0 -1.401 TD -0.0036 Tc 0.1063 Tw (partnered to produce these resources.)Tj 1.8 -2.001 TD 0.0009 Tc 0.125 Tw (Members of the IACP Police Psychological Services)Tj -1.8 -1.398 TD -0.0037 Tc -0.0386 Tw (Section compiled this interactive CD containing suicide pre-)Tj 0 -1.401 TD -0.0034 Tc 0.0114 Tw [(vention resources from leading agencies across the country)59.6(.)]TJ 25.35 16.599 TD -0.0037 Tc 0.0465 Tw [(The purpose of this CD is to provide samples and resource)]TJ 0 -1.398 TD -0.0035 Tc 0.0121 Tw (materials to establish and develop suicide prevention, inter-)Tj 0 -1.401 TD -0.0038 Tc 0.105 Tw (vention, and postvention programs.)Tj 1.8 -2.001 TD -0.0094 Tc -0.0625 Tw [(The CD runs in a web-based format in your web browser)50.6(.)]TJ -1.8 -1.398 TD -0.0038 Tc 0.0086 Tw (The opening screen contains five major headings: Develop-)Tj 0 -1.401 TD -0.0037 Tc -0.035 Tw (ing a suicide prevention program, sample suicide prevention)Tj T* -0.0036 Tc 0.105 Tw (materials, sample training materials, sample presentations,)Tj 0 -1.398 TD -0.0037 Tc 0.055 Tw [(and sample funeral protocols. Each heading contains mul-)]TJ 0 -1.401 TD -0.0027 Tc -0.0483 Tw (tiple files in a variety of formats.)Tj 1.8 -2.001 TD -0.0036 Tc 0.1086 Tw (For example, the suicide prevention tab contains bro-)Tj -1.8 -1.398 TD -0.0033 Tc 0.0206 Tw (chures, posters, and wallet cards, in addition to suicide pre-)Tj 0 -1.401 TD -0.0041 Tc 0.0321 Tw (vention program summaries from the Miami-Dade and Los)Tj ET endstream endobj 372 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 374 0 obj << /Length 4736 >> 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. 4 2008 )]TJ /F1 1 Tf 15.3188 0 TD -0.009 Tc 0 Tw (325)Tj /TT2 1 Tf 10 0 0 10 66 722.64 Tm -0.0044 Tc 0.0385 Tw [(Angeles Police Departments \(KNOW Suicide\). Some of)]TJ 0 -1.398 TD -0.0072 Tc -0.0622 Tw (the material is agency specific, while other material is labeled)Tj 0 -1.401 TD -0.0038 Tc 0.0825 Tw (reproducible, meaning agency logos have been removed)Tj T* -0.0032 Tc -0.0581 Tw [(to allow other agencies to add their own logo prior to use. )53.8(A)7.1(s)]TJ 0 -1.398 TD -0.0041 Tc 0.0229 Tw [(an example, the Los )49.9(Angeles Sherif)16.9(f)-55.1()52.9(s Department \(LASD\))]TJ 0 -1.401 TD -0.0038 Tc 0.0769 Tw (contributed two AID LIFE cards, one with their internal)Tj T* 0.0244 Tw (phone numbers included and one with their phone numbers)Tj 0 -1.398 TD -0.0036 Tc 0.0037 Tw (removed so gaining agencies can insert their unique contact)Tj 0 -1.401 TD -0.0156 Tc 0 Tw (information.)Tj 1.8 -2.001 TD -0.0056 Tc -0.0625 Tw (The sample training materials tab contains both the Cali-)Tj -1.8 -1.398 TD -0.0092 Tc [(fornia Highway Patrol)50.8(s \(CHP\) Not One More training pro-)]TJ 0 -1.401 TD 0.0081 Tc 0.125 Tw [(gram and Miami-Dade)53.1(s prevention program. )17.1(The CHP)]TJ T* -0.0038 Tc 0.0792 Tw (materials include detailed training notes and recommenda-)Tj 0 -1.398 TD -0.0036 Tc 0.0543 Tw [(tions, plus an 18-minute video. )50.3(Also included are LASD)50.4(s)]TJ 0 -1.401 TD -0.0183 Tc -0.0625 Tw [(excellent Rolling Back Up and CA)50.7( POST)50.7(s Preventing Law)]TJ T* -0.0037 Tc -0.0271 Tw [(Enforcement Suicide training videos. Brochures for super-)]TJ 0 -1.398 TD -0.0029 Tc 0.0388 Tw (visory staff are also enclosed.)Tj 27.201 22.899 TD -0.0034 Tc 0.015 Tw (The sample funeral protocols tab is a true wealth of in-)Tj -1.8 -1.401 TD -0.0036 Tc -0.0444 Tw (formation on the challenging topics of death notification and)Tj 0 -1.398 TD -0.0115 Tw [(funeral protocols. )53.5(Although the focus of this tab shifts from)]TJ 0 -1.401 TD -0.0033 Tc 0.0177 Tw (suicide specific to death issues in general, the forms, proto-)Tj T* -0.0036 Tc 0 Tw (cols, and checklists will prove valuable when death impacts)Tj 0 -1.398 TD -0.0039 Tc -0.06 Tw (the workplace.)Tj 1.8 -2.001 TD -0.0037 Tc -0.0594 Tw (The information contained on the CD is intended for use)Tj -1.8 -1.401 TD -0.0035 Tc 0.0534 Tw (by professional law enforcement agencies. These materials)Tj 0 -1.398 TD -0.0032 Tc 0.0413 Tw (were submitted by agencies throughout the country and re-)Tj 0 -1.401 TD -0.0044 Tc -0.0622 Tw (flect material designed specifically for their law enforcement)Tj T* -0.0036 Tc 0.0162 Tw [(population. However)38.4(, the material on this CD is applicable)]TJ 0 -1.398 TD -0.0032 Tc -0.043 Tw (across a variety of settings both within and outside the emer-)Tj 0 -1.401 TD 0.0275 Tw [(gency responder community)62.8(.)]TJ 1.8 -2.001 TD -0.0028 Tc -0.0345 Tw (If you are interested in obtaining a free copy of this CD,)Tj -1.8 -1.398 TD -0.0038 Tc -0.0436 Tw [(please contact Ms. )17.2(T)37(ia )32.2(Y)103.4(oung \(young@theiacp.or)14.2(g\) at IACP)107.2(.)]TJ 0 -1.401 TD -0.0035 Tc -0.0069 Tw (Upon request, multiple copies are also available for training)Tj T* 0.0006 Tc 0 Tw (environments.)Tj /TT8 1 Tf 16 0 0 16 186 219 Tm 0 0 0 0.5 k /GS1 gs -0.0127 Tc -0.0266 Tw (Practical Police Psychology: Stress Management)Tj 0 -1.125 TD -0.0368 Tw (and Crisis Intervention for Law Enforcement)Tj 10 0 0 10 186 186.99 Tm 0 0 0 1 k /GS2 gs 0.0002 Tc -0.0621 Tw (Patrol tactics, police-citizen interactions, crime victim intervention, officer-)Tj 0 -1.2 TD -0.001 Tc (involved shooting, line-of-duty death, hostage crises, suicide-by-cop, officer)Tj T* 0.0012 Tc -0.0606 Tw (suicide, undercover investigation, testifying in court, officer misconduct and)Tj T* 0.0016 Tc -0.0261 Tw (discipline, critical incidents and job stress, police families, law enforcement)Tj T* 0.0002 Tc -0.0625 Tw (leadership, community policing.)Tj /TT9 1 Tf 0 -2.4 TD 0.0007 Tc 0.0622 Tw [(Thomas, 2006, ISBN: 0398076367, $72.95 \(hardcover\), ISBN: 0398076375,)]TJ 0 -1.2 TD 0.0009 Tc -0.0313 Tw ($48.95 \(softcover\). 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EXm SSteU>݉A"G~wLH^ndM/yKҌ19#t TqVf2 `$W0 BtTNL+.$߅svL9a \W822;:GVmcҷo֋`c׏8F0w{40(=]A2{/ADŽmqUec7} ?Ikiإe0fw|0;?5p'^=fLPF!G6-K6+ʰճϊJ&鐤ٜƄ_V<DjnXuuz{W߼AR޿ox?=)x[\vO);z&އ^wQHqI4v;B|=<Ysi22,vW:NXi =Rjjlj!>3UUIWŸL]2=?44F]kh莘xuZMShĬNߙ[0u\|1+380ϛ>wnr Vab}ޅX :ٙtljy7< q0O[:Z|N>6{z  "Y>l A#'_&Ny"8\=ob`8XwCƖ/ƣcS$4,Lyť;6S sjJXR*R 5H{7# Fڅk5sD>s]^J2i% WJ<8*nu_NBơ(8xކuk2R=yV{`}' /mtmCc \K pʽl/y#:K( 2UĢ9h8=Qpz4h«xG ub7h;hg0S >F1 )67¼0`X34'/l?z$_pA lڅG¢4Ic5ѬӥwR?ʧ8 jemMfUntrZ`Q ZF+MU*HZh$j\CMhJ_Nw.C\HRr3n^4.c19(ɝ`솭{]yފ2ibٖUZ_~~掃 W̫t͆) q+bE*HP-ԕhk cZ5#55*wF̥0&RmY˷df9.ތjw, ԞgK6NA#д4ǖf> ŝ ɴ~¡Xz]hH9JcLjӷң]f 7WiFöO>-<8'wB2q N" 4Q: ҳ*>$l(|LaEHUwڿXt1c$~\K9,e/GyHK-)xpmz %Vj\~uzbpbl8 ۠pݭ"9:G2\Oj8C)Ãԍ:!c_nlg^e_}# bV7Jks 6~e/2Nįt4v<v`Xy3aqV z=GKra\#3PUmY"5KF+x}|{2{Cॏ$zF^*θpn3<~)RxE+(hNp WDẸt BZ);,fMm tي Z\[r*bRIlBliSr`>#[ڬ%mXҠSue ](+G++ $D-v݀h:}nV݃q#r˜B:/u2N@AL]5/p endstream endobj 464 0 obj << /Type /FontDescriptor /Ascent 683 /CapHeight 683 /Descent -220 /Flags 262176 /FontBBox [-179 -250 1007 934] /FontName /BHANAO+GillSans-BoldCondensed /ItalicAngle 0 /StemV 144 /XHeight 462 /StemH 105 /CharSet (/G/e/o/r/g/space/S/period/E/v/l/y/comma/J/a/n/d/f/T/M/i/t/c/h/A/N/w/B/k/b) /FontFile3 465 0 R >> endobj 465 0 obj << /Filter /FlateDecode /Length 2123 /Subtype /Type1C >> stream HtU{Taqgqk5 @v]ܕ*ᨩVS y$KHA$$#֐:!$b B!TE?wQTU3JNSt}b QCfeWl'+h5׿zo3u)=t8l*`:oNאVfI2;JY *ŪρAYEDRh]5CaXxT[(} , i` 3~?K[sO,Gyf^fŎ ԕv!sj˦LzAewQi@BGvP^>4 ANa0xu,m7#s E ^m]A 0ٱ0kV@+Q2, K%nXrQ~u?L|~]eAbe(:ӑ_p跹" e0y| nkWYuƮNPU;dG.4\9h wC0t˨j ih(c8V@6A@nut @=RhU]n02V@a%Rvڒ Wlo]s8 `9G>owށ|ao6 3\Z |G/07/v Kv͊ů:J.uWi ԻNuI(;ޚ?KtִW^ga0:@ sk\y&.UW LtJiuU궼oU%6 $ׂ{W$Ҳ/CĽwV;X/d*bӎ% hZ,4M oo8Vލ:EfڈyAʅ!L'P'ufH\LrMBwj.u)7߯qlЃd8R$1_/D%^x LV~hPB jE"|~GBSTb;$be4ON7pS&vL^1QS03$ RڎvmFzC̓yop 'cuL  Y &EX 4e5H\Kz+ !r+QIkܼe( Un-@9̧"؋+B4\ml+wM/­!zj7uӗOUUƸ_g_ ٜ`۞*y`a9*%yG^B(ϴOz ݕmٓ˝]q DVb4p.x盒}"7TS(nd>Sؔ0h꜠T-\o0ޚ {j/H >ŷL+Q݇l 6+O%B> B"ecvY5N7W܏KC1&@w#/`G9#JYx2 Hq`u ;>:wf:y88gΜ w"?|D,uG endstream endobj 466 0 obj << /Type /FontDescriptor /Ascent 712 /CapHeight 712 /Descent -128 /Flags 32 /FontBBox [-120 -250 1000 990] /FontName /BHANBP+Helvetica-Compressed /ItalicAngle 0 /StemV 158 /XHeight 572 /StemH 102 /CharSet (/A/v/a/i/l/b/e/space/N/O/W/exclam/F/r/o/m/L/u/n/c/M/comma/P/h/D) /FontFile3 467 0 R >> endobj 467 0 obj << /Filter /FlateDecode /Length 1530 /Subtype /Type1C >> stream HT PTUow߽i>S(A*@٨^ vYܩQgB # )2mFtl֬J˙RAs.],fy;{s; 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