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By J. Jorn. Talladega College.

Such support can also en- courage consistent practices across the Army facilities buy cialis sublingual 20 mg with visa. The nature of this support evolved during the demonstration, ultimately including preparation of a toolkit of support materials, hands-on technical support through site visits, and coordination of information ex- change among the MTFs. MEDCOM staff limitations led to some de- lays in preparing the low back pain toolkit materials, especially at the start of the demonstration. We believe this committed support by MEDCOM has been a powerful foundation for the practice im- provements achieved in the guideline demonstrations, as MEDCOM learned from each field test and applied those lessons to subsequent demonstrations. From the start, MEDCOM identified Army-wide guideline champions who were re- spected leaders with a commitment to using the guideline to im- prove the quality of care. The participating MTFs also identified well- respected physicians to serve as guideline champions, and most of these physicians showed a commitment to leading the implementa- tion activities for their facilities. Some of the initial champions were replaced in the course of the demonstration because of rotations and deployments. This demonstration highlighted that it sometimes will be difficult to find a champion who both has enthusiasm for the guideline and is a respected opinion leader, and at times, facilities will have to make trade-offs between these factors. All of the MTF commanders designated champions to lead the implementation of the guideline, but few of the champions received tangible support for their activi- xxiv Evaluation of the Low Back Pain Practice Guideline Implementation ties (other than attendance at the kickoff conference). Most of them had to perform the implementation work in addition to their regular workload. In most of the MTFs, a facilitator designated by the MTF commander provided staff support to the champion, and for some facilitators, this role was an integral part of their regular job. The need to do "double duty" means that champions are able to make only a time-limited commitment to such an initiative, after which they either "burn out" or must turn their attention to other priorities.

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It is also the primary signaling system in relationship-defining interactions (Johnson order cialis sublingual 20 mg, 1998). Expressions of affect pull for particular re- sponses from others and are central in organizing interactions. As one spouse, for example, angrily insists that his partner has neglected him re- peatedly, his partner braces and withdraws in self-protection. Later, how- ever, when he moves through his anger and accesses emotions involving being hurt, and his fear that he no longer really matters to his spouse, his partner is drawn toward him. ATTACHMENT THEORY Attachment theory (Bowlby, 1969, 1988; Johnson, 2003a) provides a theory of healthy and unhealthy functioning, a way of answering the whys behind couple conflicts. The EFT therapist perceives symptoms of marital distress as distorted expressions of normal attachment-related emotion (Johnson, 1986). The experiential focus on affect and the systemic focus on interper- sonal patterns are understood within an attachment context of separation distress and an insecure bond. In attachment terms, a bond refers to an emotional tie, that is, a set of attachment behaviors to create and manage proximity to the attachment figure and regulate emotion. The accessibility and responsiveness of attachment figures are necessary to a feeling of per- sonal security. Separation anxiety and efforts to cope with it are believed to occur in both infant-caregiver relationships and in romantic adult relation- ships (Hazan & Shaver, 1987, 1994). Attachment theory offers a much-needed theory of adult love relation- ships (Roberts, 1992). It is a systemic theory of development that has been studied extensively with families and couples across many forms of psycho- pathology and approaches to psychotherapy (Bartholomew & Perlman, 1994; Cassidy & Shaver, 1999). Bowlby believed in the power of social inter- actions to organize and define inner and outer realities. Human beings nat- urally seek love and connection from other human beings—that is how we flourish and that is how we know who we are.

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