\r\n\tThis book aims to explore the issues around the rheology of polymers, with an emphasis on biopolymers as well as the modification of polymers using reactive extrusion.
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1. Introduction
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The Bahamas is an archipelagic nation situated between Florida at the southern tip of the United States of America in the north and Cuba in the south. Once a British colony, the Bahamas is now an independent country and an active member of the British Commonwealth. The population is about 400,000 people, with the majority of the persons under 50 years of age. Most of the people are of African descent, and the rest are a mixture of Caucasians from Europe, North America, South America and Canada. The predominant religion is Christianity although there are representatives of other religions such as Hinduism, Islam, Rastafarianism, etc. The major industries are tourism supplemented by international banking and a few farming and fishing enterprises.
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Once a pristine, quiet paradise, the Bahamas has undergone a serious social fragmentation process associated with the major country-wide crack cocaine epidemic of the 1980s [1] and its continuing sequelae of drug trafficking, chronic addiction and oversupply of powerful guns. This dissociation is manifested by burgeoning murder and violent crime rates (Figure 1) along with high incidences of domestic violence and different forms of child abuse. Crack was the first drug that feminized drug addiction, ejecting mothers from the home, leaving children to fend for themselves. Thus the crack epidemic of the 1980s produced severe family and community disintegration which, combined with the international economic downturn of 2008, led to high youth unemployment and the development of violent gangs which terrorize the community. According to Shaw and McKay, these areas may be referred to as zones of transition, likely formed by a combination of individual choice and a crime-enhancing environment [2]. This regional culture of violence has adversely affected all levels of Bahamian society and contributes to extensive family and community fragmentation [1].
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Figure 1.
Incidence of homicide in the Bahamas (1963–2018).
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2. The formation of The Family: People Helping People Project
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In 2008, while doing follow-up research on the effects of the 1980s crack cocaine epidemic, my team was confronted with the horrible spectra of community dissocialization. There was no need to describe further the destructive nature of the epidemic. The challenge was to develop some type of community intervention to impact the prevailing social chaos which had destroyed so many pristine and well put together neighborhoods. A review of the literature shows there is much debate on the definition of Social Fragmentation and its counterpart, resocialization [3, 4, 5]. In an effort to develop an effective community intervention, Social Fragmentation was defined as a process in which persons, victimized by the negativity of shame, develop a diminished view of themselves and become involved in destructive activities toward themselves and others. Shame, a powerful master emotion, results from the shattering of cherished dreams, hopes and expectations. Covert in nature, shame manifests itself in society as anger, violence, revenge, addiction, intimacy dysfunction, abuse and destructive community relationships [6]. Resocialization, which we refer to as “Discovery,” involves the liberation of persons from the negativity of shame by sharing their painful stories in a contemplative atmosphere of mindfulness, acceptance and non-judgmental listening. The release of shame allows persons to experience the positive emotions of love, humility, forgiveness and gratitude, leading to the development of healing community of caring and service.
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In light of these concepts, the aim was to develop a resocialization intervention using a community process model. Starting with a small group of seven mothers who had lost their sons to murder, we met weekly to share their painful stories. The expression of the deep, painful feelings of shame and grief in this group of mothers was overwhelming. But during the group process, a powerful healing bond developed among us, enhancing cohesion, empathy and a deep sense of community. This healing bond was defined as “Family,” counteracting the mental health stigmatization of participants being seen as patients or victims. This program developed into The Family: People Helping People Project, known as “The Bahamas Family.” Within a year, the group expanded to 30 persons, including relatives of the victims of murder, criminal violence, domestic disputes, multiple types of physical and sexual abuse, and causalities of the international economic collapse. Thus The Family became a powerful group process model, representing a therapeutic replica of the home-based family, allowing members to confront their issues in a safe and non-judgmental environment. Providing support and advocacy for its members, The Family allows persons to discover themselves and grow as individuals. More importantly, The Family offers a sanctuary from normal Bahamian culture, encouraging the expression of emotions that are normally taboo (for example, grief, shame, closeness, love and hope). The primary goal was to improve socialization using the principles of the Contemplative Discovery Pathway Theory (CDPT). The CDPT is a form of positive psychology involving a mixture of cognitive-behavioral therapy, traditional psychodynamic analytic therapy and contemplative, spiritual component [7, 8].
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Unlike classical group therapy, this community process had no restrictions in size, was free of charge and required no contract for attendance. The Family group is an open, dynamic and supportive process involving reflection and transformation through the sharing of personal stories (narrative). The project has increased to 22 groups with an outreach to over 300 people per week. The groups are led by a therapist or facilitator and meet for 2 hours each week. At the end of each group, the facilitator writes a praxis involving: (a) interaction, (b) analysis of overt and covert themes, (c) reflection and (d) lessons learned. These praxes are collected, filed and used for qualitative research to understand the predominant issues in the surrounding society. A thematic analysis was carried out on group sessions held in The Family program. The major themes of sessions are anger, violence, grief, relationship issues, abuse and addiction, indicating the faces of shame and the social fragmentation of the country (Figure 2) [9].
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Figure 2.
Incidence of overt themes in the family sessions.
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In addition to the well-known curative factors described so eminently by Yalom, such as information modeling, cohesion, transference, reconstitution of the early family paradigm, support, etc. [10], we found the following factors helpful in maintaining the therapeutic perspective of the group especially as it increased in size:
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2.1 Creating a contemplative atmosphere
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Each group begins with a stillness exercise involving deep breathing and imagination of following a blue light to reflect the color of the sea and sky. As the group members relax and recollect themselves, a simple prayer is made to God or a higher power. We have found the depth of the stillness exercise to be germane to the quality of the interaction in the group. Some persons, particularly in the Prison group, practice the stillness exercise throughout the week, meditating on the blue sky to experience a sense of inner peace and freedom.
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2.2 Sharing our stories
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Sharing our stories in a contemplative atmosphere is complex and requires patience and time, sometimes from 6 months to a year. Firstly, telling our story is mostly cognitive and since shame forms in the pre-cognitive phase of our development, the cognitive sharing of the story is devoid of releasing painful shame affect, which enhances positive development.
As the group progresses, affective sharing releases some of the painful shame feelings but often reverts back to cognitive sharing with the least distraction.
The deepest form of sharing our story is when we give our life with our story. Combining cognitive and affective elements, the person moves into a deeper communion with themselves and the group. Often, this results in a powerful emotional catharsis, releasing the deep shame and wounds of a lifetime.
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Our experience is that it requires time, patience and understanding to wait for persons to release their stories. When a person is affectively sharing their stories with their life, it connects with the other persons in the group because that which is truly personal, is universal. Dr. Curt Thompson, referencing Dr. Daniel Siegel’s work, writes, “…an important part of how people change…is through the process of telling their stories to an empathic listener. When a person tells their story and is truly heard and understood, both they and the listener undergo actual changes in their brain circuitry. They feel a greater sense of emotional and relational connection, decreased anxiety, and greater awareness of and compassion of others’ suffering [11].”
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In essence then, our stories, like ourselves, connect to each other, creating a vast story of human existence, healing and community.
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2.3 Confidentiality
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Confidentiality is important. But like trust, according to Eckhart Tolle, listening takes time for persons to become a conscious presence to each other [12]. Thus, as the healing bond develops, we tend to see ourselves in each other and feel one another’s pain. Confidentiality is stressed throughout the process but group members are encouraged to examine how the discussion affects them personally. As persons mature in the group, they realize that owning their problems and working on them enables them to move toward their solution. On the other hand, denying their personal issues and focusing on gossip about others, provides little chance of resolving their problems. Our experience is that as persons recognize this, they automatically respect the confidentiality clause, mature to leaving the discussion of others in the room and focusing on their own development. When this happens in the group, the confidentiality principle is internalized and more effective.
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2.4 Silence
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Silence is a powerful absorber of deep negativity and shame, allowing us to heal in an atmosphere of acceptance and love. Often, the sharing of deep pain—e.g., the murder of a relative or the abuse of a child—is so painful that it can only be received at the silent level where words are inadequate and act as a distraction [13]. Opening our hearts to the evocative ability of silence releases the unconscious hurt and wounds of a lifetime. In silence, chronological time (chronos) intercepts with the fullness of time (Kairos), producing what Eliot called “the still point” of the moving world [14]. At the still point, we experience the interconnectedness of all things in the now or present. According to Tolle, the now is not only what is happening at the present, but is the united field of consciousness in which the mystery and content of our life unfurls. At the still point, we experience healing, but in a deep sense, open to the mysterious [13]. Einstein (in a speech to the German League of Human Rights), stated, “The most beautiful emotion we can experience is mysterious. It is the fundamental emotion that stands at the cradle of all true art and science. He to whom this emotion is a stranger, who can no longer wonder and stand rapt in awe, is as good as dead, a snuffed-out candle [15].”
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2.5 Role-playing
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Role playing of painful experiences releases deep hurt and enables participants to open up to love and healthy development. Providing new perspectives on old hurts, role-playing challenges the individual to move from being a victim to becoming a survivor. A profound and complex art, role-playing requires contemplative listening and compassion to understand the pain of another, allowing us to experience the destructive action of the perpetrator in real time. When this occurs, the group is often stunned and challenged by the pathos of the situation resulting in a powerful catharsis releasing deep hurt and pain [13].
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2.6 Centering
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In the process of centering, we invite the person sharing their pain to come to the center of the group where they are joined by the therapist and other participants who identify with their situation. As a result, the group becomes two concentric groups, the inner being the pain sharers and the outer the pain bearers. As the painful story is released, a powerful catharsis results, not only releasing the pain of the victim, but enabling others to express their pain as well. The catharsis is followed by a deep sense of reverential silence, reflection and understanding. At this point, the group is extremely cohesive and persons have difficulty in leaving [13].
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2.7 Social activities
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Social activities—for example a birthday celebration, a hospital visitation, picnic or holiday party—are extremely important and have a powerful healing effect on the group. A recurring observation is that often a very challenged person is deeply encouraged by visiting or celebrating with another hurt person. A number of persons have described how the social activity helped them to release their pain and gave them courage to face the future [13].
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2.8 Singing
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Singing is a powerful unifying force in the group, calming the intense emotional experience of anger, grief and revenge. The Negro Spirituals have proved particularly helpful. For example,
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“Sometimes I feel like a motherless child, a long, long way from home. Sometimes I feel like a fatherless child, a long way from home.”
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The resonance of these words has a powerful effect on the group as they are reminded of home being a place where they felt safe and at peace. As the spiritual is sung, tears stream down the faces of many participants as they release their deep hurt and shame. At the end of the song the silence absorbs the pain and longing so prevalent in the group. Another example of the power of song was when a Family member shared the painful story of being at her sister’s death bed and how her faith enabled her to give her sister hope. At this point of sadness, one of the facilitators sang the song “His Eye is on the Sparrow, and I know He cares for me.” The group experienced a powerful sense of oneness and healing. At the end of our Family sessions, we hold hands and sing the song “Bind Us Together in Love.” As the group separates, this provides a sense of connection and a continuation of the healing effect of the group even after the session is terminated [13].
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2.9 Humor
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The heart with deep pain responds to humor. However, to be effective, the humor must be intimately connected to the process while expressing the opposite. The juxtaposition of these two realities release affect while producing a transcendent joviality. For example, the Bahamas has a Christian cultural orientation. It is not uncommon for people in the group to assure each other by saying “God will be there for you.” At that point, the facilitator may tell a story about the mother who told Johnny to get the broom from outside while it was dark. Johnny replied, “Mummy, I’m afraid of the dark.” Mother said “Johnny, don’t be afraid of the dark. God is everywhere.” Taking her literally, Johnny opens the door and shouts into the darkness “God, since you’re everywhere, can you please pass me the broom?” Despite the sadness, the group breaks into laughter, releasing hurt and shame. Humor allows people to see themselves in perspective and not take themselves too seriously while releasing them, if only temporarily, from their hurt and pain [13].
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2.10 Spiritual teaching
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At the end of the group when people are overwhelmed by the pathos and suffering of others, a psycho-spiritual teaching provides a sense of calm, encouragement and hope. Examples of such spiritual teachings that have been used effectively include: loving when the dream of love has shattered (the Jewish story of Ruth and Naomi), facing the painful giants in our life (the story of David and Goliath) and forgiveness (the story of the prodigal son, particularly as portrayed in Rembrandt’s painting). We also used stories involving Bahamian folklore and parables. For example “you can break one stick but it’s hard to break ten” or “loose goat doesn’t know how tied goat feels” [13].
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2.11 Insights from neuroscience
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Neuroscience offers novel ways to think about the benefits of The Family. In his book “Brainstorm,” Siegel claims that we interact with the world in two views of reality: the physical world of objects and mindsight. Sadly, modern life has become more dependent on physical sight than recognizing the importance of our mind connection. This is challenging because without the mind connection, people can treat others without respect or compassion.
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The Family Project is based on mindsight where we help individuals to develop their internal world to relate more effectively to themselves and others. According to Siegel, focusing our mind on multiple interactions—for example, telling our stories, listening, singing, meditation, social action, etc.—helps us build new circuits in our brain enabling us to adapt creatively to new experiences while increasing our health and developing harmonious relationships. Mindsight includes three fundamental skills: insight, empathy and integration. Insight is our ability to appreciate our inner mental life, helping us to understand the present, past and future. When we reflect on things going on inside of us, we develop mindsight mapping of the brain, activating our pre-frontal circuits where the inner and interpersonal experiences are coordinated and balanced. Empathy is the ability to sense the inner life of another person, enabling us to see them from our perspective and imagine what it is like to walk in their shoes. The gateway to compassion and kindness, empathy is the key to social intelligence, allowing us to understand the intention and needs of others. In this light, relationships can be defined as the sharing of energy and information between persons. Insight and empathy cultivates integration empowering us to coordinate our relationships with each other. Sadly, when integration is blocked, chaos results in our internal and external relationships, developing a powerful rigidity which destroys individual and community development. These neuroscientific insights validate the effect of The Family where people share their stories of pain and shame in a contemplative environment, creating mindsight (insight, empathy and integration) in the participants leading to coordination, balance and self-regulation [13, 16].
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3. Contemplative Discovery Pathway Theory
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A developmental model, the CDPT postulates that the self follows the step-wise path from the natural self at birth to the shame self and its antithesis, the addictive shame false self, leading to the development of the authentic self (Figures 3, 4, 5, 6) [7]. According to the Judeo Christian tradition, human beings are made in the image of God, and are hard wired to seek unconditional love. At birth we have three basic instinctual needs, (a) safety (survival/security), (b) connection (affirmation and esteem) and (c) empowerment (power and control) [17]. These three dimensions are powerful sources of energy, which interact with each other as a child struggles to develop basic trust making the natural self-vulnerable, fragile and extremely dependent on the support of others [13].
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Figure 3.
The natural self.
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Figure 4.
The shame self.
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Figure 5.
The shame false self.
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Figure 6.
The authentic self.
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According to Heinz Kohut, these instinctual needs form the basis of our early self-object transference. Survival security relates to the mirror transference leading to the sense of affirmation. The affection/esteem leads to the twin-ship transference, resulting in the development of empathy and community. Power/control leads to the idealized transference giving rise to respect, honor and worship [18].
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The basic instinctual needs are also the substance of which our dreams are made. When a dream shatters, a lie is born. For example, when the dream of safety shatters, creating an abandonment shame schema, the person believes the lie “I am hopeless. No one wants me and I’m not enough.” When the dream of connection is shattered, creating the rejection shame schema, the lie develops “No one wants me. I am unlovable. I will never have a relationship.” When the dream of empowerment shatters, creating the humiliation shame schema, the lies develop “I am helpless. I am a failure. I can’t cope.” These lies, if not confronted, can become delusions which are fixed false beliefs unalterable to argument and lead a person’s life to destruction. The fact is, it is easier to confront reality than to conquer a lie.
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Life is wounded and we all experience variations of hurt leading to development of SHAME (Self Hatred Aimed at ME) involving feelings of abandonment, rejection and humiliation. Deeply painful to the human psyche, shame is compensated for by the development of the defensive, addictive, shame false self, involving self-absorption, self-gratification and control. The false self is illusory, made up of many layers and enhances negative programs for happiness which hijack the meaning and purpose of our lives, causing us to wander aimlessly in the wilderness of fear and anger [13]. This makes the false self what we call “the Bermuda Triangle of the soul.” It is a perverse rescuer, promising hope but delivering destruction. If the lies from the shattering of the dreams of safety, connection and empowerment are not neutralized, they culminate in the complexity of the development of the false self. In The Family, the loving support of the group allows members to share their stories. As they surrender the grief and shame of their pain, they release their negativity and destructiveness and embrace the positive healing emotions of love and support. As a result, the shame false self melts away, giving rise to Discovery of the Authentic Gracious Self characterized by love, community, humility and gratitude.
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4. The Evil Violence Tunnel
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When a person is deeply shamed and is further hurt or provoked, they develop murderous rage triggering the Evil Violence Tunnel (Figure 7) [19]. The Evil Violence Tunnel has six stages:
Cognitive restriction, in which the person feels trapped and their rage is directed toward the person shaming them (perpetrator).
Physiological arousal—the heart rate and pulse rate rises, the person sweats profusely and often their I.Q. drops, causing them to act irresponsibly and not in keeping with their normal intelligent mode of function.
Emotional numbness—at this stage, the person suffers from a form of alexithemia, dumbs down emotionally and is unable to feel empathically with the other person. They may have a cognitive sense of how the victim feels but are unable to identify with the feelings. As a result, they are totally destructive and unaware of the pain of the victim. For example, a gentleman continued stabbing a lady, who he claimed shamed him by cheating on him. When asked why he continued to stab her, he replied “I wanted her to feel what I was feeling.” But when challenged about what he was feeling, he said “I don’t know.”
Negative energy—persons have shared with us that at this stage, they are flooded with negative emotions and energy and become totally destructive.
Ethical fragmentation—regardless of the person’s moral, ethical or religious background, at this point, their anger is so intense, their values collapse and they become vicious to themselves or others.
Compulsive, repetitive, destructive action—this destructive action may be addressed to the person themselves, leading to self-injury or suicide or it may be projected onto another person, leading to harming them or even homicide.
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Figure 7.
The evil violence tunnel.
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We allowed inmates in the local prison to examine our description of this phenomenon and give us their perspective. The inmates agreed with the stages but did not like the psychological terminology. As a result, they replaced it with their own:
Fixation
Being psyched
Dumbing down to hurt and destroy
Overwhelmed by the devil
Nothing good can happen now
Total destruction against the self or the other
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The Evil Violence Tunnel is triggered by various types of provocation and enhanced by the use of alcohol or drugs. We have found that after a person has been destructive, they go through a time of quiet and relaxation before they recognize the full tragedy of what has occurred. This may be due to intoxication or emotional flooding.
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5. The false self and dualistic thinking
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The false self, unlike our authentic self, involves dualistic thinking where we separate our adequate side from our shame self. This enhances the process of scapegoating to allow the false self to maintain control. According to René Girard, “when human beings cannot, or dare not, take out their anger on the thing (or person) that caused it, they unconsciously search for substitutes, and more often than not, they find them [20].” In sadistic scapegoating, we split off the shame self and project it on to the other person, who is blamed and judged as inferior, making the perpetrator feel more self-righteous or superior. In masochistic scapegoating, we split off our adequate self, leaving us a victim with a deeper sense of shame or what may be called a martyr-like syndrome, where we feel totally inadequate, cry “poor me” and give our power away to others because we see them as superior.
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This is the opposite of our authentic true self, whose thinking is non-dualistic, is not involved in splitting and always presents the adequate and shame self together. In our true self, we talk about our strengths but accept our weaknesses because they cannot be divorced from each other.
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6. Discovery (resocialization)
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“Each person’s life is a challenging journey from being a victim of their shame and False Self based in fear and anger to experience the Discovery of the glorious freedom of their True Authentic Self based in love, gratitude and meaningful community” (Dr. David Allen).
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How do we make the transition from the elusive, victimizing, inner critic of our Shame false self based in fear to discover the freedom of our authentic self based in love and gratitude? The story of the Velveteen rabbit says it all. In this story, the Velveteen rabbit is the newest toy to be added to the young boy’s toy barn. Looking around, the Velveteen rabbit sees the shining tin soldiers, the proud lion and the old skin horse with his tail torn off and his fur worn away. Feeling shy, alone and lost, the old skin horse, who had been in the boy’s toy barn for many years, tells the Velveteen rabbit he needs to become real. Amazed, the Velveteen rabbit asked the skin horse, “What does it mean to become real?” The old skin horse, speaking from his years of experience and wisdom, tells the Velveteen rabbit, “You only become real when someone really loves you!” [13].
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In The Family, people experience an atmosphere of loving concern and non-judgment as they share their painful stories releasing their hurt and shame [13]. As a result, the heart or psyche like a sponge is emptied of the hurt and shame, allowing them to embrace the love in the group. Breaking through the negativity of our shame false self, we face the fear and anger of our shame self involving abandonment, rejection and humiliation. As we confront our shame self and release our painful feelings, we experience the discovery of our true self based in love, gratitude and healing community. Discovery is not an event but a process requiring continual commitment to confront the pain of our shame and release it through the catharsis of grieving and surrender. As we become more open to love, The Family provides an opportunity to practice it and see it demonstrated in ourselves and other persons in the group. In so doing, we make the perceptual shift from fear and shame to the discovery of love and compassion. We can actually see this happen when once angry and hurt people release their shame and become healers in the group. It is important to note, however, that because of the woundedness of life, we will tend to fall back from our true self to our shame false self. But we do not stay there because the vision of love in our heart moves us toward our true self and our potential rather than being addicted or stuck at the limitations of our false self. Discovery is a process of resocialization where our self-esteem and solidarity increases as we become authentic and move in love to create healing community. According to Marcel Proust, “The real voyage of discovery consists not in seeking new landscapes, but in having new eyes” [21].
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7. Research
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Although there was good testimonial evidence of resocialization (see Case Vignettes), we received a grant to carry out a Pilot, quantitative study. Because there was no suitable resocialization instrument, a combination of nine international scales (namely the Beck Depression Inventory, Buss-Durkee Hostility-Guilt Inventory, Gratitude Questionnaire, Hope Scale, Self-Deception Questionnaire, Internalized Shame Scale, Satisfaction with life Scale, Spiritual Well-Being Scale and Transgression-Related Interpersonal Motivations Inventory (TRIM-18)) was used to test participants. Participants also completed a baseline questionnaire to ascertain their impression before The Family. They were studied in two cohorts at 6 month intervals of persons who had been in The Family for over a year or more [13].
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Results showed that persons in The Family a year or more had a decrease in anger (Figure 8), depression, violence, revenge, loneliness and abusive relationships (Figure 9). They also reported an increase in self-esteem, benevolence and contentedness with life with trends toward increases in forgiveness and gratitude (Figure 10) [8, 13].
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Figure 8.
Participants indicated that after joining the family, they felt significantly less anger toward others (t = −2.83, p = 0.0142, Cohen’s d = −0.756). They also showed significantly decreased desire for vengeance (t = −3.32, p = 0.0061, Cohen’s d = −0.922), and experienced significantly fewer thoughts of both violent and nonviolent revenge (t = −2.28, p = 0.0437, Cohen’s d = −0.658).
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Figure 9.
Q34 of the questionnaire asked “Before joining the Family, were you in an abusive relationship?” 32.6% of participants indicated “yes,” 67.4% indicated “no.” Q46 of the questionnaire asked “Are you currently in an abusive relationship?” 15.7% indicated “yes,” 84.3% indicated “no.”
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Figure 10.
Significant areas of change with increased time in the family.
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As a result we received a grant from the Templeton World Charity Foundation, to (a) continue the research and expand The Family Project, (b) develop an international resocialization instrument (Allen Resocialization Scale) and (c) create a program to train lay persons as therapist facilitators [13]. We have completed this grant and the results validate those of the pilot study.
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8. A resocialization intervention model in the prison
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The Family group therapy program was implemented in the Bahamas Department of Corrections over four (4) years ago. Inmates who are in a pre-release program are allowed to attend the sessions. Each week, three trained therapists meet with a group of inmates for 90 minutes. There are two group sessions, one for the male inmates and another for the females. Three principles govern the sessions: confidentiality, non-judgmental approach and free expression. Group members are empowered when they share their stories. Taking ownership of the group, they renamed it the “Free Your Mind Group.” Anger was one of the most prominent themes in the sessions. The therapists worked through the inmates’ anger by exploring the underlying fears and hurts involved. Stories and myths were also used by the therapists to connect with the inmates. An example of one of the stories used is the Slave Myth. In this myth, a slave was tied to a stake. While chained, he would look into the distance and admire the verdant mountains. He often dreamed of what it would be like to be free. One night, an angel broke his chain. Realizing what had happened, he ran toward the mountains to seize his freedom. Unfortunately, he began to fear the unknown. He started to worry about his survival. He looked back at his broken chain and decided to reattach it to himself. In his mind, he figured that being enslaved provided him with the necessities of life, such as food, drink, etc. He walked around his stake for the rest of his life. Although his external chains were broken, the internal chains around his heart were still intact. This particular myth resonated with the inmates and a discussion about physical and mental freedom ensued. The reality that one could be physically free but mentally imprisoned began to set in. At this moment, the therapists stressed that it was The Family’s mission to break the internal chains around their hearts and assist them in developing their inner life.
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The development of trust was another issue initially faced by the therapists. Despite the inmates being skeptical of them, they continued to provide consistency, stability and predictability. In the inception of the group, one of the original therapists was Mr. André Chappelle who was a resocialized drug addict. Mr. Chappelle had been incarcerated five times so the inmates were quite familiar with him. In fact, the miracle of his transformation became a catalyst of hope for them. They told him “you give us hope. If you can change your life, we can also.”
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A thematic analysis carried out on 109 of the group sessions conducted in the prison indicated that the four most common themes of the discussions were violence, anger, revenge and addiction. The inmates indicated that anger fuels their violent acts. Revenge is a justification for violence and addiction to external substances helps them cope. According to one of the inmates “when you kill for the first time, you feel sick and can’t stop thinking about it. You feel like you’re going crazy. After a while, you get used to it, get drunk and high and you feel numb” [22]. Another inmate described the depth of his anger when he disclosed:
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“I hate people. I can’t trust them because they hurt me badly. My mother abandoned me at 8 years old, went to the U.S. and had another family. My father also abandoned me and my grandmother raised me. The rest of my family members and neighbors scorned me. My daughter is my only love but sadly I’ve abandoned her and I hate myself because I’ve done to her what was done to me” [22].
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A female inmate shared her experience of being in the Evil Violence Tunnel:
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“I was raised by my grandmother and I knew all kinds of abuse growing up. When I was in my late 20’s I was a single mother with a good enough job at a hotel. I started dating this [man] because I wanted to play him. I wanted to make him believe I was carrying his child so he could take care of me and my children. As time went by, he started to become more and more violent and I started to hate him deeply. I even told him the child was not his. One day I was back from work and I was combing my hair while he was screaming at me, calling me names and threatening to rape me one more time. Suddenly, I attacked him with the comb in my hand. To my horror, the metal comb went all the way to his skull. The blood came pouring out and he died instantly. I still remember seeing my son cleaning the blood on the floor with the mop. I was in the newspaper and felt ashamed. I attempted suicide by setting the prison cell on fire. I am happy I survived because I realize now that my children and my mother are waiting for me to get out. I have people I love and this keeps me going” [22].
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There are signs of resocialization in the participants. One inmate, imprisoned for 25 years, is running a Toastmaster’s program to assist other inmates who are interested in learning the art of public speaking. The inmates now delay gratification and have better impulse control. They have also developed better conflict resolution skills and now have more effective communication. Even more so, they are now able to express vulnerability by sharing intimate, personal and emotional stories with the group [22].
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9. Case vignettes
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The names used in these vignettes are fictitious to conceal the identity of The Family participants.
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9.1 Abuse
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When Doreen came to The Family she was broken and deeply hurt. Incested and abused by her father for many years, her life was threatened if she ever revealed the family secret. Seeking to escape her abusive family she married a man who at first seemed loving but eventually became verbally and physically abusive, threatening to kill her numerous times. Distraught and depressed, Doreen became suicidal and was referred to The Family. When she was ready to share her story, Doreen was invited to come to the center of the group supported by therapists and persons who identified with her pain. After a while, Doreen was able to verbalize her pain, exploding into a powerful catharsis screaming at the top of her voice for 3 minutes or more, releasing the shame of a lifetime. This was followed by a powerful silence in the group where persons prayed and others meditated or cried. After the catharsis, persons in the group comforted and encouraged Doreen. Having been in The Family group for 5 years, Doreen is a changed person. She is a healer who has helped many persons face and work through their painful experiences of abuse. Recently receiving a promotion at work, she was one of the first graduates of the therapist facilitator training program [13].
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9.2 The terror of poverty and social deprivation
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Rejected by his family, George left home at 13 years old to fend for himself on the streets. Living on the beach and in abandoned buildings, George hustled daily to make ends meet. He was severely abused—physically and sexually. Later on George was shot in his face and side and admitted to hospital. On the third day of his hospitalization, the person who shot George was also shot. Admitted to the same hospital, he was placed two beds away from George. Angry and filled with revenge George wanted him dead. The next day George’s gang came to the hospital seeking to kill the person who shot George. They begged George to identify the shooter, but George refused. Instead, he surrendered his feelings of revenge and prayed for a better life. After release from hospital, George’s life became worse. He lived in a tomb in one of the graveyards and was eventually referred to The Family Project. Facing a loss of confidence in himself, George was shy, ashamed and unable to speak. The group was very receptive and showered him with love, giving him odd jobs, clothes, food and money. After a number of sessions, George began to speak freely and socialize with the participants in the group. A few months later, he shared that when he first came to The Family, he felt his life was hopeless. He said he is now determined to live again because of the love he found in our sessions. George is still in The Family, has a job and volunteers in The Family basketball outreach program to marginalized youth [13].
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9.3 Murder
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The Family has had many experiences working with persons who suffered the murder of a loved one. One of the most outstanding experiences is that of Mrs. Jones who had been a member of The Family for about a year. She had previously brought her young daughter to The Family for help. One evening, I received a call at 11:00 pm that her daughter was shot and killed in the living room. Visiting the family was a painful and horrific experience as the details of the murder were explained. Mrs. Jones, although distraught and grieving, shared that because of her work in The Family, she wanted to work toward forgiveness rather than revenge. This was difficult because she was being encouraged by other family members and neighbors to seek revenge. This is not unusual because revenge is the normal reaction for these types of incidents in marginalized neighborhoods. Returning to The Family meetings, Mrs. Jones worked on expressing her grief. At times she would scream at the top of her voice and describe how she would go to the graveyard at 3:00 am and cry out over her daughter’s body. Most interesting, Mrs. Jones shared that the evening before her daughter was murdered, they watched a film “I Spit on Your Grave,” in which there is a scene where a rape victim says “Vengeance is mine, says the Lord, and I will repay.” According to Mrs. Jones, her daughter stopped the film three times, emphasizing these words. Mrs. Jones’ question to The Family group was whether her daughter knew something that she did not know. Her journey toward forgiveness was not an easy one but as she worked in The Family week after week, expressing her grief and sorrow, eventually she came to a point where she was able to forgive the killer of her daughter.
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Our experience in The Family is that forgiveness is a long road, especially because deep hurts, like murder, are multi-dimensional. Even though Mrs. Jones came out on the side of forgiveness, there are certain periods of time when a development happens in her neighborhood or family and she becomes angry and says to me “Dr. Allen, I want to buy a gun.” But we listen quietly, allowing her to express her anger, hurt and especially her shame. She returns to the desire to forgive rather than seek revenge. It has been two and half years now, and she is still on the journey to forgiveness, with the periodic ups and downs of drifting into revengeful thoughts.
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9.4 Addiction
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The Family groupgreat interest in the process of sharing has been most affected by André Chappelle, who I initially treated for cocaine addiction when he was 15 years old. Although he had flights into sobriety, he would regress and eventually became homeless, indigent and a vagrant. On the street for over 20 years, he had a reputation of being polite and kind. For example, he tutored students at the College of the Bahamas and was very helpful to ladies whose vehicles would break down. On Christmas morning, 2009, at 2:00 am, he described an intense feeling of loneliness and despair as his addictive, destructive lifestyle haunted him. Falling to his knees, he cried out for help. This eventually led to him going to the family’s lawyer, who helped him clear his criminal record and travel to the U.S. to visit his sister. Returning to Nassau, he came to The Family group and expressed great interest in the process of sharing his personal story. He read all the published papers of The Family, studied to become a facilitator, and became my right-hand person in the program. As the addiction lifted, he was able to, in his own words, “squeeze the sponge of his heart to release the hurt and shame and make space for love” from the group, the people around him and of course his early religious faith. Eventually the love he had for a young lady in the eighth grade returned and they were married. He worked very closely with me and became perhaps the best interpreter of the CDPT. Sadly, in 2016, he developed an inoperable colon carcinoma. I walked with him to the very end as he shared his story of life but also the challenge of death. His dying words were “The Family is special because there are not many places in society where people can walk off the street, squeeze the hurt and shame out of the sponge of their heart by sharing their story and experience the discovery of the freedom of becoming authentic.”
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10. Conclusion
\n
The Family has become a healing balm for many in the Bahamian community. In some sense, it is the grieving center for persons who have undergone serious losses of relatives through murder and violent crime. It is a place where people meet others who have suffered the trauma of abuse and shame which has held them captive all their lives. It is very common to hear the shout of “you too?” or “me too,” indicating a harmonious connection among traumatic experiences in the group that liberates people to release their shame and discover the freedom to be essentially who they are. More than that, The Family is a place for dialog. As societies around the world become more polarized, there is an urgent need for creative dialog between races, different socioeconomic groups, political groups, law enforcement and community, etc. The fact is that simply sharing our stories illustrates The Family mantra “jaw jaw stops war war.”
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Acknowledgments
\n
This work was funded by a grant from the Templeton World Charity Foundation.
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Conflicts of interest
None of the authors have any conflicts of interest.
\n',keywords:"social fragmentation, resocialization, group process, family, community",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/66010.pdf",chapterXML:"https://mts.intechopen.com/source/xml/66010.xml",downloadPdfUrl:"/chapter/pdf-download/66010",previewPdfUrl:"/chapter/pdf-preview/66010",totalDownloads:413,totalViews:0,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,dateSubmitted:"October 10th 2018",dateReviewed:"January 31st 2019",datePrePublished:"March 14th 2019",datePublished:"September 25th 2019",dateFinished:null,readingETA:"0",abstract:"This chapter presents a cultural adaptation of a group process model as a resocialization project to confront social fragmentation in the Bahamas. The Family: People Helping People Project seeks to improve communication and socialization in New Providence, the capital of the Bahamas. The chapter provides an overview of The Family and addresses key elements along with clinical examples to show the success of the model. We also present the results of a pilot study carried out on The Family which further outlined the benefits of participating in the program. We hope that these insights are helpful in addressing community problems around the world, with the hope of reducing violence and social fragmentation.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/66010",risUrl:"/chapter/ris/66010",book:{slug:"family-therapy-new-intervention-programs-and-researches"},signatures:"David F. Allen, Keva Bethell, Marie Allen-Carroll and Flavia D’Alessandro",authors:[{id:"280476",title:"Dr.",name:"David",middleName:null,surname:"Allen",fullName:"David Allen",slug:"david-allen",email:"dfallen43@gmail.com",position:null,institution:null},{id:"280479",title:"MSc.",name:"Keva",middleName:null,surname:"Bethell",fullName:"Keva Bethell",slug:"keva-bethell",email:"bet35507@oru.edu",position:null,institution:null},{id:"280480",title:"Dr.",name:"Marie",middleName:null,surname:"Allen-Carroll",fullName:"Marie Allen-Carroll",slug:"marie-allen-carroll",email:"marieall_2000@yahoo.com",position:null,institution:null},{id:"280481",title:"MSc.",name:"Flavia",middleName:null,surname:"D'Alessandro",fullName:"Flavia D'Alessandro",slug:"flavia-d'alessandro",email:"flavia.dalessandro@gmail.com",position:null,institution:null}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. The formation of The Family: People Helping People Project",level:"1"},{id:"sec_2_2",title:"2.1 Creating a contemplative atmosphere",level:"2"},{id:"sec_3_2",title:"2.2 Sharing our stories",level:"2"},{id:"sec_4_2",title:"2.3 Confidentiality",level:"2"},{id:"sec_5_2",title:"2.4 Silence",level:"2"},{id:"sec_6_2",title:"2.5 Role-playing",level:"2"},{id:"sec_7_2",title:"2.6 Centering",level:"2"},{id:"sec_8_2",title:"2.7 Social activities",level:"2"},{id:"sec_9_2",title:"2.8 Singing",level:"2"},{id:"sec_10_2",title:"2.9 Humor",level:"2"},{id:"sec_11_2",title:"2.10 Spiritual teaching",level:"2"},{id:"sec_12_2",title:"2.11 Insights from neuroscience",level:"2"},{id:"sec_14",title:"3. Contemplative Discovery Pathway Theory",level:"1"},{id:"sec_15",title:"4. The Evil Violence Tunnel",level:"1"},{id:"sec_16",title:"5. The false self and dualistic thinking",level:"1"},{id:"sec_17",title:"6. Discovery (resocialization)",level:"1"},{id:"sec_18",title:"7. Research",level:"1"},{id:"sec_19",title:"8. A resocialization intervention model in the prison",level:"1"},{id:"sec_20",title:"9. Case vignettes",level:"1"},{id:"sec_20_2",title:"9.1 Abuse",level:"2"},{id:"sec_21_2",title:"9.2 The terror of poverty and social deprivation",level:"2"},{id:"sec_22_2",title:"9.3 Murder",level:"2"},{id:"sec_23_2",title:"9.4 Addiction",level:"2"},{id:"sec_25",title:"10. Conclusion",level:"1"},{id:"sec_26",title:"Acknowledgments",level:"1"},{id:"sec_29",title:"Conflicts of interest",level:"1"}],chapterReferences:[{id:"B1",body:'Jekel JF, Allen DF, Podlewski H, Clarke N, Dean-Patterson S, Cartwright P. Epidemic free-base cocaine abuse. Case study from the Bahamas. Lancet. 1986;1(8479):459-462'},{id:"B2",body:'Shaw C, McKay H. Juvenile Delinquency and Urban Areas. Chicago, IL: University of Chicago Press; 1942'},{id:"B3",body:'Arrigo B, Takahashi Y. Recommunalization of the disenfranchised: A theoretical and critical criminological inquiry. Theoretical Criminology. 2006;10(3):307-336'},{id:"B4",body:'Liaudinskien G. Resocialization barriers of juvenile delinquents. Social Science. 2005;47(1):41-48'},{id:"B5",body:'Skiecevicius P, Leliugiene I. Empowering partnership as resocialization form of juveniles subject to delinquency: Findings of empirical research. Socialiniai Mokslai. 2012;75(1):30-40'},{id:"B6",body:'Allen DF. Shame: The Human Nemesis. Washington, D.C.: Eleuthera Publications; 2010'},{id:"B7",body:'Allen D, Mayo M, Allen-Carroll M, Manganello J, Allen VS. Cultivating gratitude: Contemplative discovery pathway theory applied to group therapy in the Bahamas. Journal of Trauma & Treatment. 2014;3(3):197'},{id:"B8",body:'Allen D, Allen-Carroll M, Allen V, Bethell K, Manganello J. Community resocialization via instillation of family values through a novel group therapy approach: A pilot study. Journal of Psychotherapy Integration. 2015;25(4):289-298'},{id:"B9",body:'Bethell K, Allen D, Allen-Carroll M. Using a supportive community group process to cope with the trauma of social fragmentation and promote resocialization in the Bahamas. Emergency Medicine: Open Access. 2015;5(2):244'},{id:"B10",body:'Yalom I. The Theory and Practice of Group Psychotherapy. New York: Basic Books; 1970'},{id:"B11",body:'Thompson C. Anatomy of the Soul. Carol Stream: Tyndale House Publishers; 2010'},{id:"B12",body:'Tolle E. Stillness Speaks. Novato: New World Library; 2003'},{id:"B13",body:'Allen DF, Bethell K, Allen-Carroll M. A resocialization intervention model: The family: People helping people project. Clinical Case Reports and Reviews. 2016;2(7):491-495'},{id:"B14",body:'Eliot TS. Collected Poems (1909-1962). New York: Harcourt, Brace & World; 1963'},{id:"B15",body:'Gookin J. Wilderness Wisdom Quotes for Inspirational Explorations. Mechanicsburg: Stackpole Books; 2003'},{id:"B16",body:'Siegel D. Brainstorm. New York, NY: Penguin Press; 2013'},{id:"B17",body:'Keating T. Open Mind Open Heart: The Contemplative Dimension of the Gospel. New York: The Continuum International Publishing Group Inc; 1986'},{id:"B18",body:'Kohut H. How Does Analysis Cure? Chicago: University of Chicago Press; 1984'},{id:"B19",body:'Allen D, Bethell K, Allen-Carroll M. Anger and social fragmentation: The evil violence tunnel. Journal of Psychotherapy Integration. 2016;27(1):79-92'},{id:"B20",body:'Girard R. The One by Whom Scandal Comes. East Lansing: Michigan State University Press; 2014'},{id:"B21",body:'Proust M. In Search of Lost Time. France: Grasset and Gallimard; 1913'},{id:"B22",body:'Allen D, D’Alessandro M, Bethell K. A resocialization intervention model in the prison—The family: People helping people project. Sociology International Journal. 2017;1(4)'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"David F. Allen",address:"dfallen43@gmail.com",affiliation:'
Allen Institute of Research and Training, Nassau, Bahamas
Allen Institute of Research and Training, Nassau, Bahamas
'}],corrections:null},book:{id:"8864",title:"Family Therapy",subtitle:"New Intervention Programs and Researches",fullTitle:"Family Therapy - New Intervention Programs and Researches",slug:"family-therapy-new-intervention-programs-and-researches",publishedDate:"September 25th 2019",bookSignature:"Floriana Irtelli",coverURL:"https://cdn.intechopen.com/books/images_new/8864.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",editors:[{id:"174641",title:"Dr.",name:"Floriana",middleName:null,surname:"Irtelli",slug:"floriana-irtelli",fullName:"Floriana Irtelli"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},chapters:[{id:"66618",title:"A Chronological Map of Common Factors across Three Stages of Marriage and Family Therapy",slug:"a-chronological-map-of-common-factors-across-three-stages-of-marriage-and-family-therapy",totalDownloads:439,totalCrossrefCites:0,signatures:"Hassan Karimi, Fred Piercy and Jyoti Savla",authors:[{id:"290630",title:"Dr.",name:"Hassan",middleName:null,surname:"Karimi",fullName:"Hassan Karimi",slug:"hassan-karimi"},{id:"290773",title:"Prof.",name:"Fred",middleName:null,surname:"Piercy",fullName:"Fred Piercy",slug:"fred-piercy"},{id:"290774",title:"Dr.",name:"Tina",middleName:null,surname:"Savla",fullName:"Tina Savla",slug:"tina-savla"}]},{id:"65598",title:"Emotionally Focused Family Therapy: Rebuilding Family Bonds",slug:"emotionally-focused-family-therapy-rebuilding-family-bonds",totalDownloads:1074,totalCrossrefCites:1,signatures:"Katherine Stavrianopoulos",authors:[{id:"281106",title:"Associate Prof.",name:"Katherine",middleName:null,surname:"Stavrianopoulos",fullName:"Katherine Stavrianopoulos",slug:"katherine-stavrianopoulos"}]},{id:"66318",title:"Family Therapy: New Intervention Programs and Researches: Systemic Family Approach in Health Care",slug:"family-therapy-new-intervention-programs-and-researches-systemic-family-approach-in-health-care",totalDownloads:490,totalCrossrefCites:0,signatures:"Hamilton Lima Wagner and Tania Dalallana",authors:[{id:"281898",title:"M.Sc.",name:"Hamilton",middleName:null,surname:"Wagner",fullName:"Hamilton Wagner",slug:"hamilton-wagner"},{id:"290304",title:"MSc.",name:"Tania",middleName:null,surname:"Madureira Dalallana",fullName:"Tania Madureira Dalallana",slug:"tania-madureira-dalallana"}]},{id:"68320",title:"The DAVAd: A Narrative Tool to Explore the Early Stages of the Adoptive Bond",slug:"the-davad-a-narrative-tool-to-explore-the-early-stages-of-the-adoptive-bond",totalDownloads:313,totalCrossrefCites:0,signatures:"Barbara Cordella, Paola Elia, Marzia Pibiri and Alessia Carleschi",authors:[{id:"290988",title:"Prof.",name:"Barbara",middleName:null,surname:"Cordella",fullName:"Barbara Cordella",slug:"barbara-cordella"},{id:"290992",title:"Dr.",name:"Paola",middleName:null,surname:"Elia",fullName:"Paola Elia",slug:"paola-elia"},{id:"290993",title:"Dr.",name:"Alessia",middleName:null,surname:"Carleschi",fullName:"Alessia Carleschi",slug:"alessia-carleschi"},{id:"290994",title:"Dr.",name:"Marzia",middleName:null,surname:"Pibiri",fullName:"Marzia Pibiri",slug:"marzia-pibiri"}]},{id:"68306",title:"KidsTime Workshops: Strengthening Resilience of Children of Parents with a Mental Illness",slug:"kidstime-workshops-strengthening-resilience-of-children-of-parents-with-a-mental-illness",totalDownloads:426,totalCrossrefCites:1,signatures:"Klaus Henner Spierling, Kirsty Tahta-Wraith, Helena Kulikowska and Dympna Cunnane",authors:[{id:"287221",title:"Mr.",name:"Klaus Henner",middleName:null,surname:"Spierling",fullName:"Klaus Henner Spierling",slug:"klaus-henner-spierling"},{id:"288316",title:"Dr.",name:"Kirsty",middleName:null,surname:"Tatah-Wraith",fullName:"Kirsty Tatah-Wraith",slug:"kirsty-tatah-wraith"},{id:"288320",title:"Mrs.",name:"Helena",middleName:null,surname:"Kulikowska",fullName:"Helena Kulikowska",slug:"helena-kulikowska"},{id:"308129",title:"Dr.",name:"Dympna",middleName:null,surname:"Cunnane",fullName:"Dympna Cunnane",slug:"dympna-cunnane"}]},{id:"66457",title:"Mirage: Possibilities and Limitations of Experiencing Foster Home as a Family",slug:"mirage-possibilities-and-limitations-of-experiencing-foster-home-as-a-family",totalDownloads:267,totalCrossrefCites:0,signatures:"Eva Mydlíková",authors:[{id:"284490",title:"Associate Prof.",name:"Eva",middleName:null,surname:"Mydlíková",fullName:"Eva Mydlíková",slug:"eva-mydlikova"}]},{id:"67729",title:"Family Therapy: When the Adolescents’ Discourse is the Principal Resource",slug:"family-therapy-when-the-adolescents-discourse-is-the-principal-resource",totalDownloads:254,totalCrossrefCites:0,signatures:"Silvia Renata Lordello",authors:[{id:"283776",title:"Dr.",name:"Silvia",middleName:null,surname:"Lordello",fullName:"Silvia Lordello",slug:"silvia-lordello"}]},{id:"66010",title:"Group Process as a Resocialization Intervention: The Family - 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\n
1. Introduction
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Hemodynamic is dealing with blood flow and forces concerned therein to circulate blood through the cardiovascular system. A significant blood flow disruption as seen in cardiovascular diseases and disorders is related to hemodynamic dysfunction. Doppler ultrasound has potential to serve as a non-invasive method for detecting and quantifying blood flow functions in cardiovascular diseases. However, the use of blood flow in clinical application is limited and development of blood flow is prevailing rather than blood flow [1].
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Gender influences the arterial hemodynamic functions. Cardiovascular disease is a leading cause of death for both women and men, but there are crucial gender-related differences in the prevalence and burden of cardiovascular disease. An approach to understand this disparity is to evaluate the underlying changes in hemodynamic functions and discover the relationship between the gender differences and cardiovascular disease risk. Gender-related differences in systolic blood pressure (SBP) are reported in previous studies [2, 3]. It is widely reported that gender differences in blood pressures (i.e. SBP and pulse pressure) and arterial wave reflections are associated to smaller body height of women [4, 5, 6].
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Azhim et al. have developed a Doppler measurement system to evaluate flow velocity functions in common carotid artery with synchronized monitoring of blood pressure (BP) and electrocardiogram (ECG) [6, 7]. Firstly, this chapter presents about characteristic profile of carotid flow velocities in an attempt to extend the fundamental understanding of arterial hemodynamic functions in gender differences. Secondly, comparison of carotid flow velocity and other parameters at resting posture in gender are introduced. The extent to which body size including body height and weight have influenced on blood velocities in carotid artery is described in Section 3. Furthermore, the blood flow velocity also useful for comparing the effect of fat compositions in gender differences as presented in Section 4.
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\n
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2. Normohemodynamics in gender
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In hemodynamics studies, abnormality of blood flow can be detected from Doppler waveforms, vascular structure and function may be identified through various quantitative measurements made [1, 8]. This section does not focus on hemodynamic disorders, aging, and response to exercise or during exercise. But, the findings do fill important literature gap in correlation between gender-related differences with hemodynamic variables. The normohemodynamics of carotid artery and other parameters are determined in healthy sedentary subjects to rule out the effects that exercise may have on the dependent variables. From a total of 85 sedentary subjects, 49 of them are men.
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The Doppler frequency shift represents temporal changes in peak velocities of blood cells movement during particular cardiac cycle. Several analytic techniques have been proposed for analyzing the velocity waveform. Most of these techniques involve analysis of maximum velocity at particular points on Doppler waveforms described as peak velocity envelope. By using the developed measurement system by Azhim et al., carotid blood flow velocity was measured simultaneously with commercialized ECG by three-leads and brachial BP [6, 7]. Measurements of ECG and BP were used as reference data. To extract peak velocity values from its velocity spectra, a threshold method and computation using ensemble averaging technique was implemented in this study. As shown in Figure 1, 30 consecutive cardiac cycles were selected from 2 minutes spectral to characterize the feature points of peak velocity envelope and calculate its indices. In this study, flow velocities in carotid artery were characterized into five feature points [9, 10]. The first peak systolic velocity wave was peak velocity S1. It represents the maximum velocity during systole. Consequently it is usually used as an ejection parameter in cardiac systole [11]. An augmented velocity in late systole wave was the second systolic velocity S2. Augmentation of S2 was related to both reflection of pulse wave velocity at branching site and reflection of pressure wave [1, 9]. The peak diastolic velocity, D velocity was the maximum velocity which rises due vascular elastic recoil during cardiac diastole, insicura between systole and diastole (I) [9] and the end-diastolic velocity, d represents the minimum velocity during diastole [9, 11].
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Figure 1.
Doppler indices derived from peak systolic velocity (S1), second systolic (S2), insicura between systole and diastole (I), peak diastolic (D) and end-diastolic (d) velocities.
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Usually blood velocity indices or ratios were derived from various combinations of the peak systolic velocity, end-diastolic velocity, and temporal mean values of the maximum Doppler frequency shift envelope [11, 12]. Of various indices, resistance index (RI) has been used extensively to measure the pulsatility that reflects the resistance to blood flow [12]. RI has defined range limit which is between value of 0–1.0. It was suggested to be used for analyzing waveforms with continuous forward flow throughout the diastole such as in carotid artery [8]. Unlike S1/d ratio as developed by Stuart and Drumm [13], RI shows Gaussian distribution and therefore can be analyzed through parametric statistical analyses. The RI data also reported to have better discriminatory performance compared to pulsatility index (PI) data [11]. Velocity reflection index (VRI) and velocity elastic index (VEI) were first proposed by [9] to evaluate aging and exercise effects. The VRI was a relation with S1 and S2 which calculated from (S2 − S1)/S1. The validation of VRI was analyzed using linear regression analysis. It increased with pressure reflection wave of augmentation index (r2 = 0.836). The latter index was calculated from (D − I)/D. It corresponds to vascular elasticity properties during cardiac diastole [9] as shown in Figure 1. Because of the velocity features are obtained from same cardiac cycle, the indices are independent of insonation angle [11].
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Rough reference of gender-related differences in hemodynamic characteristics is summarized in Table 1. As previously we have reported that carotid flow velocities have influenced by multiple effects including regular exercise, aging and visceral fat accumulation [7, 14, 15, 16], the presented data of hemodynamics differences in gender are also considering the influenced effects of that. The age differences is taken into account by matching the age variable with keeping not significant mean and low standard error. The range subjects’ age for men and women are 20–58 years (38.4 ± 2.2) and 20–64 years (35.2 ± 1.9) respectively. Generally men are taller than women.
\n
\n
\n
\n
\n
\n\n
\n
Variable
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Women (n = 36)
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Men (n = 49)
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p-value
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\n\n\n
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Age (years)
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35.2 ± 1.9
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38.4 ± 2.2
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NS
\n
\n
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Height (cm)
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157.9 ± 0.9
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168.8 ± 0.9
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<0.01
\n
\n
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Blood pressure data
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\n
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SBP (mmHg)
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118.5 ± 2.4
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129.2 ± 2.1
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<0.01
\n
\n
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DBP (mmHg)
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73.7 ± 1.8
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80.5 ± 1.8
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<0.05
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\n
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MBP (mmHg)
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89.0 ± 2.0
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96.7 ± 1.9
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<0.01
\n
\n
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HR (bpm)
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73.8 ± 2.1
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73.6 ± 1.6
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NS
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\n
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Flow velocity data
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\n
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d (cm/s)
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23.7 ± 0.8
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18.9 ± 0.7
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<0.01
\n
\n
\n
S1 (cm/s)
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96.9 ± 3.2
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91.2 ± 3.1
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NS
\n
\n
\n
S2 (cm/s)
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64.3 ± 2.0
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50.0 ± 1.8
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<0.01
\n
\n
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I (cm/s)
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35.6 ± 1.3
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27.5 ± 0.9
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<0.01
\n
\n
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D (cm/s)
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45.6 ± 1.2
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39.1 ± 1.0
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<0.01
\n
\n
\n
RI
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0.750 ± 0.010
\n
0.785 ± 0.009
\n
<0.05
\n
\n
\n
VRI
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−0.318 ± 0.026
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−0.423 ± 0.028
\n
<0.05
\n
\n
\n
VEI
\n
0.223 ± 0.016
\n
0.298 ± 0.017
\n
<0.01
\n
\n\n
Table 1.
Differences in hemodynamic characteristics in women and men.
Data are presented as mean ± standard error of mean. The p-value indicates significance difference versus women. NS indicates not significant. d: end-diastolic velocity; S1: peak systolic velocity; S2: second systolic velocity; I: insicura between systole and diastole; D: peak diastolic velocity; RI: resistive index; VRI: velocity reflection index; VEI: vascular elasticity index.
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Study of blood pressure to explain gender-related differences in arterial hemodynamic functions is prevailing than blood flow velocity. It has been reported that hemodynamic dysfunction increases with SBP [17]. Women have a lower SBP when measured in both brachial and ankle-arm and pressure index than age-matched men [2]. Gender-related differences in body height has influenced to arterial hemodynamics such as SBP, pulse pressure, wave reflection and pulse wave velocity in carotid artery [4, 5]. We found that the gender differences in arterial hemodynamics in carotid flow velocities are largely accounted for body height and weight [6, 7].
\n
With increases of blood pressure in men, all velocity waveforms were homeostatically lower. Men and women have different envelope velocity waveforms in carotid artery shown in Figure 2. In this study, we found that women have a lower brachial SBP than men, but higher d, S2, I and D velocities. Therefore, women have lower RI and VEI, and had higher VRI than men. Consistent with previous studies, pressure wave reflection and propagation are known to be correlated with body height [2, 3, 18], Azhim et al. also suggests that the reflected wave in flow components was higher in women and is significantly correlated with body height [7]. Men have been reported to have more elastic arterial trees than women [2, 7].
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Figure 2.
Comparison of typical envelope velocity waveforms in carotid artery for age-matched man (dashed line) and woman (solid line). d: end-diastolic velocity; S1: peak systolic velocity; S2: second systolic velocity; I: insicura between systole and diastole; D: peak diastolic velocity. Adapted from Azhim et al. [7].
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\n
\n
3. Arterial hemodynamic changes: role of body size
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Effective regulation of blood flow and blood pressure in order to maintain homeostasis is a primary aspect of cardiovascular health. In general young women have lower resting blood pressure [19, 20, 21] and in response to physiological changing [22]. The systolic and diastolic BP increased in response to the graded, incremental tilt and the difference observed between men and women is reflective of differences in body size (i.e. in particular height) as shown in Figure 3 [22]. Epidemiological studies based on brachial artery pressure indicate that blood pressures were lower in young women than in age-matched men [2, 6]. Generally, SBP and pulse pressure increased as a pulse travels from aorta towards the peripheral, the increase being all the more pronounced as the distance of pulse propagation [2].
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Figure 3.
Blood pressure variability in response to graded, incremental tilt in healthy young men (n = 13) and women (n = 10). (A) Systolic blood pressure and (B) diastolic blood pressure. Tilt angle is indicated in the bar above each panel (i.e., 0° (resting posture), 20°, 40°, 60°, and back to 40°). Adapted from Sarafian and Miles-Chan [22].
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Changes in velocity envelope waveforms at peak systolic velocity, augmented velocity in late systole wave (i.e. S2) and end-diastolic velocity are focused on their relationship with aging and carotid diseases [23]. Addition to S1, d velocities and its index (i.e., RI) decreasing with age, S2, D velocities and its indices (i.e., VRI and VEI) decrease continuously with age that may increase the complication in cardiovascular disease risk [7]. Only few studies have considered the latter velocities and indices in association with gender or disease [22, 24]. To the best of our knowledge, no other studies have characterized the correlations of these velocities with gender, age, visceral fat accumulation and exercise [7, 16]. In this study, we found significant differences in the carotid velocity waveforms of age-matched men and women to contribute to clinical evaluations and healthcare monitoring [6].
\n
Women had larger reflected waves than men, in part due to shorter body height and closer physical proximity between heart and reflecting sites. However, body height was not sufficient to fully explain higher reflected wave flow and pressure in women. In the study we indicated that the reflected wave had higher in women and was significantly correlated to body height and weight as described in Figures 4 and 5 [6]. In addition to knowledge that pressure wave reflection and propagation are known to correlate with body height [2, 3], we also found that increased reflected flow wave was partially influenced by decreased body weight and increased heart rate level [6]. It had been reported that women had lower carotid artery distensibility compared with men [25]. From the proposed velocity indices (i.e. VEI), we agreed that women had lower arterial elasticity [6, 7]. The difference in the velocities and its indices were related to smaller body size in women that largely accounted for the gender differences. The difference in velocity indices may also contributed by concentrations of estrogen in women hormone status of women [26].
\n
Figure 4.
The velocity indices correlated with height. (A) RI: resistive index (1 − d/S1); (B) VRI: velocity reflection index (S2/S1 – 1); (C) VEI: vascular elasticity index (1 − I/D). Men (n = 30) are represented by open circles and women (n = 20) represented by closed circles. Adapted from Azhim et al. [6].
\n
Figure 5.
The velocity indices correlated with weight. (A) RI: resistive index (1 − d/S1); (B) VRI: velocity reflection index (S2/S1 − 1); (C) VEI: vascular elasticity index (1 − I/D). Men (n = 30) are represented by open circles and women (n = 20) represented by closed circles. Adapted from Azhim et al. [6].
\n
\n
\n
4. Arterial hemodynamic changes: role of body compositions
\n
Although the risk for cardiovascular disease increases with age, occurrence and burden of cardiovascular disease may possibly higher in men as described by differences in blood flow velocities and blood pressures [2, 7]. Furthermore body fat composition in the specific body region could explain underlying relationship between the gender-related differences and cardiovascular disease risk such as hypertension [15, 27]. Men tend to accumulate upper body fat which mainly around the abdominal area in the form visceral fat (VF), whereas women tend to have fat deposited in the gluteofemoral region [28, 29]. In the Framingham Heart Study indicated that small differences in VF among three different body mass index classifications; normal-weight, overweight or obese groups can significantly change health risk profile including hypertension [30]. It also widely known that VF increase with aging and associated with clinical features of metabolic variables including elevated triglyceride, glucose and reduced high density lipoprotein [31, 32]. The presented data in Table 2 is to demonstrate a rough reference of gender-related differences in body compositions in sedentary healthy subjects. Men showed a greater body mass index, weight and muscle mass. An alternative to general indication of abdominal VF is waist circumference measurement. The prevalence of having higher VF and waist circumference in men was dominant. But, women showed higher total body fat.
\n
\n
\n
\n
\n
\n\n
\n
Variable
\n
Women (n = 36)
\n
Men (n = 49)
\n
p-Value
\n
\n\n\n
\n
VF (level)
\n
3.1 ± 0.3
\n
8.0 ± 0.7
\n
<0.01
\n
\n
\n
Weight (kg)
\n
52.0 ± 1.1
\n
65.2 ± 1.5
\n
<0.01
\n
\n
\n
BMI (kg/m2)
\n
20.8 ± 0.4
\n
22.8 ± 3.2
\n
<0.01
\n
\n
\n
WC (cm)
\n
72.5 ± 1.2
\n
81.0 ± 1.3
\n
<0.01
\n
\n
\n
Total body fat (kg)
\n
28.2 ± 0.7
\n
19.2 ± 0.8
\n
<0.01
\n
\n
\n
Muscle mass (kg)
\n
34.0 ± 1.1
\n
49.7 ± 0.8
\n
<0.01
\n
\n
\n
TCho (mmol/L)
\n
191.4 ± 6.8
\n
194.3 ± 5.6
\n
NS
\n
\n
\n
LDL (mmol/L)
\n
97.2 ± 7.6
\n
109.8 ± 5.3
\n
<0.01
\n
\n\n
Table 2.
Differences in body compositions in women and men.
Data are presented as mean ± standard error of mean. The p-value indicates significance difference versus women. NS indicates not significant. VF: visceral fat; BMI: body mass index; WC: waist circumference; TCho: total cholesterol; LDL: low-density lipoprotein cholesterol.
\n
Extensive research in obesity when elucidating hypertension showed that site-specific fat accumulation is more important rather than total body fat [27]. Chandra et al. demonstrated that hypertension is mainly influenced by VF accumulation compared to lower body fat and subcutaneous fat [27]. The VF is also associated to coronary heart disease and systemic arteriosclerosis [33, 34]. Consequently, VF accumulation contributed to greater aortic stiffness in older adult as measured by pulse wave velocity [35]. Comparison data of gender difference is essential to provide rough indication risk of developing health problems related to fat composition.
\n
It is widely known from literature that rising blood pressure is associated with increased cardiovascular disease risk. Women has lower blood pressures, homeostatically higher velocity waveforms with the heart rate did not comparable different than men. The VF and age were two important determinants for increase in blood pressures in our study as shown in Table 3. Similar to this study, association between VF and blood pressures is found consistently in some studies [16, 27]. Using multiple regression analysis, VF becomes superior predictor to hypertension compared to lower body fat and subcutaneous fat in other study [27]. Aging is associated with a significant increase in the prevalence of hypertension and especially of systolic hypertension in elderly [36]. Elevation of blood pressure with aging is mostly associated with structural and functional changes in the arteries like large artery stiffness [9, 37]. However, the predictors for modulating blood flow velocities were not only limited on age, but also influenced by several body compositions that largely accounted for the gender differences as presented in Table 4.
\n
\n
\n
\n
\n
\n
\n\n
\n
Variable
\n
Predictor
\n
β
\n
p
\n
r2
\n
\n\n\n
\n
SBP (mmHg)
\n
Constant
\n
107.35
\n
<0.001
\n
0.304
\n
\n
\n
\n
VF (level)
\n
1.30
\n
0.002
\n
\n
\n
\n
\n
Age (years)
\n
0.26
\n
0.045
\n
\n
\n
\n
DBP (mmHg)
\n
Constant
\n
60.64
\n
<0.001
\n
0.354
\n
\n
\n
\n
Age (years)
\n
0.34
\n
0.002
\n
\n
\n
\n
\n
VF (level)
\n
0.78
\n
0.017
\n
\n
\n
\n
MBP (mmHg)
\n
Constant
\n
76.21
\n
<0.001
\n
0.359
\n
\n
\n
\n
Age (years)
\n
0.31
\n
0.005
\n
\n
\n
\n
\n
VF (level)
\n
0.95
\n
0.005
\n
\n
\n\n
Table 3.
Stepwise linear regression analysis of blood pressure measurements.
Beta (β) value indicates regression coefficient. The p-value less than 0.05 indicates predictor variable has significant association with hemodynamic variable. SBP: systolic blood pressure; DBP: diastolic blood pressure; MBP: mean blood pressure.
\n
\n
\n
\n
\n
\n
\n\n
\n
Variable
\n
Predictor
\n
β
\n
p
\n
r2
\n
\n\n\n
\n
d (cm/s)
\n
Constant
\n
30.45
\n
<0.001
\n
0.168
\n
\n
\n
\n
Muscle mass (kg)
\n
−0.22
\n
<0.001
\n
\n
\n
\n
S1 (cm/s)
\n
Constant
\n
125.93
\n
<0.001
\n
0.355
\n
\n
\n
\n
Age (years)
\n
−0.87
\n
<0.001
\n
\n
\n
\n
S2 (cm/s)
\n
Constant
\n
95.36
\n
<0.001
\n
0.308
\n
\n
\n
\n
Muscle mass (kg)
\n
−0.79
\n
<0.001
\n
\n
\n
\n
I (cm/s)
\n
Constant
\n
46.55
\n
<0.001
\n
0.193
\n
\n
\n
\n
Muscle mass (kg)
\n
−0.36
\n
<0.001
\n
\n
\n
\n
D (cm/s)
\n
Constant
\n
46.98
\n
<0.001
\n
0.251
\n
\n
\n
\n
VF (level)
\n
−0.86
\n
<0.001
\n
\n
\n
\n
RI
\n
Constant
\n
0.76
\n
<0.001
\n
0.341
\n
\n
\n
\n
Age (years)
\n
−0.002
\n
<0.001
\n
\n
\n
\n
\n
Muscle mass (kg)
\n
0.002
\n
<0.001
\n
\n
\n
\n
VRI
\n
Constant
\n
−0.58
\n
<0.001
\n
0.667
\n
\n
\n
\n
Age (years)
\n
0.01
\n
<0.001
\n
\n
\n
\n
\n
Muscle mass (kg)
\n
−0.01
\n
<0.001
\n
\n
\n
\n
\n
Total body fat (kg)
\n
0.004
\n
0.045
\n
\n
\n
\n
VEI
\n
Constant
\n
0.24
\n
<0.001
\n
0.344
\n
\n
\n
\n
Age (years)
\n
−0.004
\n
<0.001
\n
\n
\n
\n
\n
Muscle mass (kg)
\n
0.004
\n
<0.001
\n
\n
\n\n
Table 4.
Stepwise linear regression analysis of blood flow velocity measurements.
Beta (β) value indicates regression coefficient. The p-value less than 0.05 indicates predictor variable has significant association with hemodynamic variable. d: end-diastolic velocity; S1: peak systolic velocity; S2: second systolic velocity; I: insicura between systole and diastole; D: peak diastolic velocity; RI: resistive index; VRI: velocity reflection index; VEI: vascular elasticity index.
\n
To evaluate the predisposing factors for flow velocity in common carotid artery, stepwise regression analysis was performed with the following parameters: age, muscle mass, VF and total body fat. This study found that VF is an important predictor that inversely related to carotid peak diastolic velocity waveform. Using the proposed index by Azhim et al., peak diastolic velocity, D is an important feature waveform to determine arterial elasticity [7]. Consequently poor arterial elasticity is attributed by accumulation of VF [16, 32] and lower arterial elasticity through its index, VEI is observed in women compared to men. Vaidya et al. also reported the same results where postmenopausal women had lower carotid elasticity compared to matched-age men based on its carotid distensibility [38]. This study can only speculate that the difference in this index could also be influenced by the sex hormone stimulation [38].
\n
Women had greater vascular reflection wave using the proposed index (i.e. VRI) and second systolic velocity compared with men (see Table 1). The augmentation of second systolic flow velocity in carotid artery was related to wave reflection arriving from the lower body or thoracic aorta [39]. The wave reflection in women was related to shorter body height that reflects shorter distance to reflecting site [2, 3]. However, body height was not fully explaining the higher VRI. Significant correlations were observed between body composition variables and VRI, with age, muscle mass and total body fat also contributing to stepwise model for VRI.
\n
Muscle mass found to be correlated with all blood flow velocities and blood pressures, but not with S1 velocity, likely due to a greater range of muscle mass among men. Interestingly, muscle mass was a stronger predictor for the most correlated blood flow velocities and indices, except for D velocity and all blood pressures. In agreement with the findings, study of healthy adults was shown an inversely correlation between thigh muscle mass and aortic pressure from wave reflections when characterized by augmentation pressure and its index [40]. By physiology and anatomy studies, left ventricular hypertrophy was observed in women via ventricular remodeling [41, 42] and had higher systolic left ventricular chamber function compared to men [43]. These factors might contribute consistent increase in the first velocity wave during systole in women. Furthermore RI was significantly lower due to increase of S1 velocity in women (RI = 1 − d/S1).
\n
\n
\n
5. Conclusion
\n
In conclusion, monitoring of blood flow velocity and blood pressure synchronized measurements may be potential to support the assessment of some main hemodynamic functions in gender difference. A fundamental understanding of gender-related differences in arterial hemodynamics is required for effective prevention and detection of cardiovascular disease at the early stage. Women have lower brachial blood pressure components than men, but higher d, S2, I and D velocities. Therefore, women have lower resistive and vascular elastic indices and had higher velocity reflection than men. Gender difference in arterial hemodynamics in carotid velocity waveforms is largely accounted for body size in particular height and weight. Furthermore unlike blood pressures, the predictors for modulating blood flow velocity not limited on age and VF factors, but also influenced by muscle mass and total body fat. Improvable screening of health problem can be achieved by monitoring the blood flow velocity together with blood pressure measurements and considering its gender-difference to fully assessing hemodynamics function in circulatory system.
\n
\n
Acknowledgments
\n
This study was partly supported by Mediprotech Co. LTD., Korea under International Sponsored Research Grant (C18-058-0231) and Ministry of Higher Education Malaysia under MyBrain15 Postgraduate Scholarship Programme.
\n
Conflict of interest
The authors do not have any conflict of interest.
\n',keywords:"flow velocity, common carotid artery, health, gender, body composition",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/64260.pdf",chapterXML:"https://mts.intechopen.com/source/xml/64260.xml",downloadPdfUrl:"/chapter/pdf-download/64260",previewPdfUrl:"/chapter/pdf-preview/64260",totalDownloads:723,totalViews:0,totalCrossrefCites:0,dateSubmitted:"March 13th 2018",dateReviewed:"August 5th 2018",datePrePublished:"November 5th 2018",datePublished:"September 18th 2019",dateFinished:null,readingETA:"0",abstract:"A significant blood flow disruption as seen in cardiovascular diseases and disorders is related to hemodynamic dysfunction. Gender influences the arterial hemodynamic functions. Understanding of gender-related differences in blood flow and pressure is crucial in the prevalence and burden of cardiovascular disease. This chapter presents about characteristic profile of carotid flow velocities to extend the fundamental understanding of arterial hemodynamic functions in gender differences. Comparison of both synchronized carotid blood flow velocity and blood pressures at normodynamics state are introduced to contribute to targeted therapeutic goal based on gender. Gender-related differences in body size has influenced on arterial hemodynamics in carotid artery. Body height has influenced on systolic blood pressure, pulse pressure, wave reflection, pulse wave velocity in carotid artery. Carotid blood flow velocities are largely accounted for not only body height but also body weight. The predictors for modulating blood flow velocities were not only limited to age, but also influenced by several body compositions that largely accounted for the gender-related differences including visceral fat, muscle mass and total body fat. These data may useful to effective prevention and management of cardiovascular disease by considering the gender-difference.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/64260",risUrl:"/chapter/ris/64260",signatures:"A. Rahman Rasyada and Azran Azhim",book:{id:"7141",title:"Carotid Artery",subtitle:"Gender and Health",fullTitle:"Carotid Artery - Gender and Health",slug:"carotid-artery-gender-and-health",publishedDate:"September 18th 2019",bookSignature:"Rita Rezzani and Luigi Fabrizio Rodella",coverURL:"https://cdn.intechopen.com/books/images_new/7141.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",editors:[{id:"175171",title:"Prof.",name:"Rita",middleName:null,surname:"Rezzani",slug:"rita-rezzani",fullName:"Rita Rezzani"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:[{id:"184934",title:"Prof.",name:"Azran",middleName:null,surname:"Azhim",fullName:"Azran Azhim",slug:"azran-azhim",email:"azr2020@gmail.com",position:null,institution:null},{id:"265179",title:"MSc.",name:"A Rahman",middleName:null,surname:"Rasyada",fullName:"A Rahman Rasyada",slug:"a-rahman-rasyada",email:"rasyadarahman@gmail.com",position:null,institution:null}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Normohemodynamics in gender",level:"1"},{id:"sec_3",title:"3. Arterial hemodynamic changes: role of body size",level:"1"},{id:"sec_4",title:"4. Arterial hemodynamic changes: role of body compositions",level:"1"},{id:"sec_5",title:"5. Conclusion",level:"1"},{id:"sec_6",title:"Acknowledgments",level:"1"},{id:"sec_9",title:"Conflict of interest",level:"1"}],chapterReferences:[{id:"B1",body:'Nichols WW, O\'Rourke MF. McDonald\'s Blood Flow in Arteries: Theoretic, Experimental and Clinical Principles. 5th ed. London: Hodder Arnold; 2005\n'},{id:"B2",body:'London GM, Guerin AP, Pannier B, Marchais SJ, Stimpel M. Influence of sex on arterial haemodynamics and blood pressure: Role of body height. Hypertension. 1995;26:514-519. DOI: 10.1161/01.HYP.26.3.514\n'},{id:"B3",body:'Mitchell GF, Parise H, Benjamin EJ, Larson MG, Keyes MJ, Vita JA, et al. 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Visceral adiposity and insulin resistance are independent predictors of the presence of non-cirrhotic NAFLD-related portal hypertension. International Journal of Obesity. 2011;35:270-278. DOI: 10.1038/ijo.2010.134\n'},{id:"B32",body:'Yamauchi T, Kuno T, Takada H, Nagura Y, Kanmatsuse K, Takahashi S. The impact of visceral fat on multiple risk factors and carotid atherosclerosis in chronic haemodialysis patients. Nephrology Dialysis Transplantation. 2003;18(9):1842-1847. DOI: 10.1093/ndt/gfg261\n'},{id:"B33",body:'Matsuzawa Y, Nakamura T, Shimomura I, Kotani K. Visceral fat accumulation and cardiovascular disease. Obesity. 1995;3(5):645-647. DOI: 10.1002/j.1550-8528.1995.tb00481.x\n'},{id:"B34",body:'Matsuzawa Y, Funahashi T, Nakamura T. The concept of metabolic syndrome: Contribution of visceral fat accumulation and its molecular mechanism. Journal of Atherosclerosis and Thrombosis. 2011;18(8):629-639. DOI: 10.5551/jat.7922\n'},{id:"B35",body:'Sutton-Tyrrell K, Newman A, Simonsick EM, Havlik R, Pahor M, Lakatta E, et al. Aortic stiffness is associated with visceral adiposity in older adults enrolled in the study of health, aging and body composition. Hypertension. 2001;38:429-433. DOI: 10.1161/01.HYP.38.3.429\n'},{id:"B36",body:'Anderson GH. Effect of age on hypertension: Analysis of over 4,800 referred hypertensive patients. Saudi Journal of Kidney Diseases and Transplantation. 1999;10(3):286-297. PMID: 18212439\n'},{id:"B37",body:'Pinto E. Blood pressure and ageing. Postgraduate Medical Journal. 2007;83:109-114. DOI: 10.1136/pgmj.2006.048371\n'},{id:"B38",body:'Vaidya D, Golden SH, Haq N, Heckbert SR, Liu K, Ouyang P. The association of sex hormones with carotid artery distensibility in men and postmenopausal women: Multi-ethnic study of atherosclerosis. Hypertension. 2015;65(5):1020-1025. DOI: 10.1161/HYPERTENSIONAHA.114.04826\n'},{id:"B39",body:'Heffernan KS, Lefferts WK, Augustine JA. Hemodynamic correlates of late systolic flow velocity augmentation in the carotid artery. International Journal of Hypertension. 2013; 2013:1-7. DOI: 10.1155/2013/920605\n'},{id:"B40",body:'Loenneke JP, Christopher A, Fahs CA, Heffernan KS, Rossow LM, Thiebaud RS, et al. Relationship between thigh muscle mass and augmented pressure from wave reflections in healthy adults. European Journal of Applied Physiology. 2013;113:395-401. DOI: 10.1007/s00421-012-2449-y\n'},{id:"B41",body:'Carroll JD, Carroll EP, Feldman T, Ward DM, Lang RM, McGaughey D, et al. Sex-associated differences in left ventricular function in aortic stenosis of the elderly. Circulation. 1992;86:1099-1107. DOI: 10.1161/01.CIR.86.4.1099\n'},{id:"B42",body:'Krumholz HM, Larson M, Levy D. Sex differences in cardiac adaptation to isolated systolic hypertension. American Journal of Cardiology. 1993;72(3):310-313. DOI: 10.1016/0002-9149(93)90678-6\n'},{id:"B43",body:'Hayward CS, Kalnins WV, Kelly RP. Gender-related differences in left ventricular chamber function. Cardiovascular Research. 2001;49:3-350. DOI: 10.1016/S0008-6363(00)00280-7\n'}],footnotes:[],contributors:[{corresp:null,contributorFullName:"A. Rahman Rasyada",address:null,affiliation:'
Department of Biotechnology, Kulliyyah of Sciences, International Islamic University Malaysia, Malaysia
Department of Biomedical Sciences, Kulliyyah of Allied Health Sciences, International Islamic University Malaysia, Malaysia
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As an ecological modeller, his research aims at better understanding of the mechanisms of stability and diversity in ecosystems by combining empirical data and mechanistic models. 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ALPSP
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The Association of Learned and Professional Society Publishers (ALPSP) is the largest association of scholarly and professional publishers in the world. Its mission is to connect, inform, develop and represent the international scholarly and professional publishing community. IntechOpen has been a member of ALPSP since 2016 and has consequently stayed informed about industry trends through connecting with peers and developing jointly.
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OASPA
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The Open Access Scholarly Publishers Association (OASPA) was established in 2008 to represent the interests of Open Access (OA) publishers globally in all scientific, technical and scholarly disciplines. Its mission is carried out through exchange of information, the setting of standards, advancing models, advocacy, education, and the promotion of innovation.
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STM
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COPE
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Creative Commons
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Creative Commons (CC) is a nonprofit organization that enables the sharing and use of creativity and knowledge through free legal tools. IntechOpen uses the CC BY 3.0 license for chapters, meaning Authors retain copyright and their work can be reused and adapted as long as the source is properly cited and Authors are acknowledged.
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Crossref
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Altmetric and Dimensions from Digital Science
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Digital Science is a technology company serving the needs of scientific and research communities at key points along the full cycle of research. They support innovative businesses and technologies that make all parts of the research process more open, efficient and effective. IntechOpen integrates tools such as Altmetric to enable our researchers to track and measure the activity around their academic research and Dimensions, to ease access to the most relevant information and better understand and analyze the global research landscape.
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CLOCKSS
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CLOCKSS preserves scholarly publications in original formats, ensuring that they always remain available and openly accessible to everyone.
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DORA
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iThenticate
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Enago
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DHL
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OASPA
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The Open Access Scholarly Publishers Association (OASPA) was established in 2008 to represent the interests of Open Access (OA) publishers globally in all scientific, technical and scholarly disciplines. Its mission is carried out through exchange of information, the setting of standards, advancing models, advocacy, education, and the promotion of innovation.
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STM
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The International Association of Scientific, Technical and Medical Publishers (STM) is the leading global trade association for academic and professional publishers. As a member, IntechOpen has not only made a commitment to STM's Ethical Principles.
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COPE
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The Committee on Publication Ethics (COPE) provides advice to editors and publishers on all aspects of publication ethics and, in particular, how to handle cases of misconduct in research and publication. IntechOpen has been a member of COPE since 2013 and adheres to the COPE Code of Conduct and Best Practice Guidelines, ensuring that we maintain the highest ethical standards.
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Creative Commons
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Creative Commons (CC) is a nonprofit organization that enables the sharing and use of creativity and knowledge through free legal tools. IntechOpen uses the CC BY 3.0 license for chapters, meaning Authors retain copyright and their work can be reused and adapted as long as the source is properly cited and Authors are acknowledged.
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Crossref
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Crossref is the official Digital Object Identifier (DOI) Registration Agency for scholarly and professional publications with a goal of making scholarly communications more effective. IntechOpen deposits metadata and registers DOIs for all content using the Crossref System. IntechOpen also deposits its references and uses the Crossref Cited-by service that enables researchers to track citation statistics.
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Altmetric and Dimensions from Digital Science
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Digital Science is a technology company serving the needs of scientific and research communities at key points along the full cycle of research. They support innovative businesses and technologies that make all parts of the research process more open, efficient and effective. IntechOpen integrates tools such as Altmetric to enable our researchers to track and measure the activity around their academic research and Dimensions, to ease access to the most relevant information and better understand and analyze the global research landscape.
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CLOCKSS
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CLOCKSS preserves scholarly publications in original formats, ensuring that they always remain available and openly accessible to everyone.
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Counter
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COUNTER provides the Code of Practice that enables publishers and vendors to report usage of their electronic resources in a consistent way. This enables libraries to compare data received from different publishers and vendors.
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DORA
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DORA is a worldwide initiative covering all scholarly disciplines which recognizes the need to improve the ways in which the outputs of scholarly research are evaluated and seeks to develop and promote best practice. To date it has been signed by over 1500 organizations and around 14,700 individuals.
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iThenticate
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iThenticate is the leading provider of professional plagiarism detection and prevention technology and is used worldwide by scholarly publishers and research institutions to ensure the originality of written work before publication. IntechOpen uses the iThenticate plagiarism software to ensure content originality and the research integrity of our published work.
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Enago
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IntechOpen collaborates with Enago, through its sister brand, Ulatus, one of the world’s leading providers of book translation services. Their services are designed to convey the essence of your work to readers from across the globe in the language they understand.
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IntechOpen Authors that wish to use this service will receive a 20% discount on all translation services. To find out more information or obtain a quote, please visit https://www.enago.com/intech
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SPi Global
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Amazon
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Amazon is the world’s largest online retailer and cloud services provider. IntechOpen books have been available on Amazon since 2017, guaranteeing more visibility for our Authors and Academic Editors.
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DHL
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IntechOpen has partnered with DHL since 2011 to ensure the fastest delivery of Print on Demand books.
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He is an expert in structural, absorptive, catalytic and photocatalytic properties, in structural organization and dynamic features of ionic liquids, in magnetic interactions between paramagnetic centers. The author or co-author of 3 books, over 200 articles and reviews in scientific journals and books. He is an actual member of the International EPR/ESR Society, European Society on Quantum Solar Energy Conversion, Moscow House of Scientists, of the Board of Moscow Physical Society.",institutionString:null,institution:{name:"Semenov Institute of Chemical Physics",country:{name:"Russia"}}},{id:"62389",title:"PhD.",name:"Ali Demir",middleName:null,surname:"Sezer",slug:"ali-demir-sezer",fullName:"Ali Demir Sezer",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/62389/images/3413_n.jpg",biography:"Dr. Ali Demir Sezer has a Ph.D. from Pharmaceutical Biotechnology at the Faculty of Pharmacy, University of Marmara (Turkey). 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Focus of his research activity is drug delivery, physico-chemical characterization and biological evaluation of biopolymers micro and nanoparticles as modified drug delivery system, and colloidal drug carriers (liposomes, nanoparticles etc.).",institutionString:null,institution:{name:"Marmara University",country:{name:"Turkey"}}},{id:"61051",title:"Prof.",name:"Andrea",middleName:null,surname:"Natale",slug:"andrea-natale",fullName:"Andrea Natale",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"100762",title:"Prof.",name:"Andrea",middleName:null,surname:"Natale",slug:"andrea-natale",fullName:"Andrea Natale",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"St David's Medical Center",country:{name:"United States of America"}}},{id:"107416",title:"Dr.",name:"Andrea",middleName:null,surname:"Natale",slug:"andrea-natale",fullName:"Andrea Natale",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Texas Cardiac Arrhythmia",country:{name:"United States of America"}}},{id:"64434",title:"Dr.",name:"Angkoon",middleName:null,surname:"Phinyomark",slug:"angkoon-phinyomark",fullName:"Angkoon Phinyomark",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/64434/images/2619_n.jpg",biography:"My name is Angkoon Phinyomark. 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I had been a visiting research student at Faculty of Computer Science, University of Murcia, Murcia, Spain for three months.\n\nI have published over 40 papers during 5 years in refereed journals, books, and conference proceedings in the areas of electro-physiological signals processing and classification, notably EMG and EOG signals, fractal analysis, wavelet analysis, texture analysis, feature extraction and machine learning algorithms, and assistive and rehabilitative devices. I have several computer programming language certificates, i.e. Sun Certified Programmer for the Java 2 Platform 1.4 (SCJP), Microsoft Certified Professional Developer, Web Developer (MCPD), Microsoft Certified Technology Specialist, .NET Framework 2.0 Web (MCTS). 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