Long-term outcomes of an intensive outpatient program for missionaries and clergy.

Rosik, Christopher H.

Intensive outpatient programs (IOP) have shown great promise in the alleviation of acute psychiatric distress (Wise, 2005). The standard definition of IOP is a program offering three to four hours of structured programming three to four times a week (American Association of Community Psychiatrists, 1998; Wise, 2003). The IOP modality of treatment has been developed to fill a void in the continuum of care between weekly outpatient psychotherapy on the one hand and partial or full inpatient hospitalization on the other hand. The advantages which gave rise to the IOP model include cost efficiency over hospitalization, increased patient accessibility, and the ongoing application of what is being learned in treatment (Veach, Remley, Kippers, & Sorg, 2000; Wise, 2003). Subsequent research has indicated that IOP services can be just as effective as inpatient treatment, even when the presenting symptoms are more severe (Wise, 2003).

Typically, the literature pertaining to IOPs has focused on their use in the treatment of various substance abuse populations, which may have limited applicability to patients with other psychiatric or relational distress. A few studies have found IOP treatment to be beneficial in care of borderline personality disorder (Gratz, Lacroce, & Gunderson, 2006; Smith, Ruiz-Sancho, & Gunderson, 2001). Another limitation in the literature has been that the great majority of IOP studies provide only a modest (e.g., three month) follow-up assessment, if they include follow-up at all. Moreover, studies of long-term follow-up past six months are rare and generally limited to substance abuse populations (Bottlender & Soyka, 2005). There is a clear need in the literature for long-term outcome studies of IOPs that treat a more diverse variety of clinical conditions.

Recently, Rosik, Summerford, and Tafoya (2009) reported on their initial findings of a longitudinal study examining treatment outcomes among missionaries and clergy who participated in an intensive outpatient program (IOP) at the Link Care Center in Fresno, California. Analyses identified a significant treatment response both at post-treatment and at a three month followup. In order to address the aforementioned gap in the IOP literature as well as gain insight into longer term outcomes of these religious professionals, I sent a second wave of follow-up assessments to accessible participants of the initial study. The intent of this additional follow-up was to not only determine if participants maintained treatment gains up to three years later, but also to obtain information on participants subsequent use of health care services. In addition, I inquired as to their current impressions about their treatment experience and, if they were missionaries, the post-treatment helpfulness of and satisfaction with their mission organization.

Method

Participants

Participants eligible for this study were Christian missionaries and clergy who had completed pre- and post-treatment assessments and had provided e-mail contact information at the time of departure from Link Care Center's IOP program, which is called the Restoration and Personal Growth (R&PG) program. The R&PG program consists of an array of member care services that function as an intensive outpatient psychotherapy and pastoral care program. Participants in the R&PG program engage in 10-15 hours of treatment in a typical week, including individual, marital, and family therapy; pastoral care; group therapy; psychoeducational groups; psychological testing; and referrals to local physicians for medical, and pharmacologic care. Treating therapists included psychologists, marriage and family therapists, and a licensed clinical social worker while three ordained ministers provided concurrent pastoral care. Referrals to the R&PG program are made for a variety of reasons, prominent among them being marital distress, post-traumatic distress, mood disorders, addictive behavior, and concerns about children.

Link Care Center is a faith-based organization committed to "restoring people to health and increased effectiveness in their lives" (Link Care Center, 2003). Several of the treatment providers have missions and/or pastoral experience and all are conversant with the evangelical faith perspective typically espoused by program participants. Christian disciplines such as prayer and Bible study are encouraged and integrated into the curriculum. In addition, much of the reading material and educational DVDs available address a Christian audience, enhancing psychological concepts such as boundaries and recovery with religious insights derived from the typical participants' faith system.

Of the 186 participants who completed both assessments in the original study, 179 provided e-mail contact information and I attempted to contact these individuals in July of 2009. Many participants' e-mails were no longer valid and others did not respond, but a total of 33 did respond (an 18% response rate) and these formed the final sample. The final sample was comprised of 21 (64%) women and 12 (36%) men. Twenty-six (79%) of participants were married, three (9%) single, two (6%) divorced, and two (6%) widowed. The average age of the sample was 50.3 years (SD = 9.4). The majority of the sample (n = 29, 88%) served as missionaries with the remaining four individuals coming from pastoral vocations. Respondents had served an average of 11.1 years (SD = 7.9) in their ministries.

The only significant differences identified between the final sample and the broader sample of the original study had to do with age, marital status, and field of service. The current sample was older (M = 50 years, SD = 9.8) than the remainder of the broader sample (M = 42.9, SD = 10.3, t(283) = 3.61, p < .001 (two-tailed), d = .71), had a still small but greater number of divorced and widowed participants [chi square] (4, N = 289) = 14.02, p = .04, and had more individuals serving in Africa and fewer in North America [chi square] (9, N = 278) = 17.40, p = .007.

Materials

Outcome questionnaire--45 (OQ-45). The OQ-45 is a 45-item self-report instrument designed for repeated measurement of client symptoms during the course of psychotherapy (Lambert, et al., 2004). Instructions direct respondents to answer the items on the basis of how they have felt over the past week. Participants respond to each item on a 5-point Likert scale, including values of 0 (never), 1 (rarely), 2 (sometimes), 3 (frequently), and 4 (almost always). The OQ-45 consists of three subscales--Symptom Distress, Interpersonal Relations, and Social Role--that are aimed at assessing different domains of client functioning (Lambert, et al., 2004). Research has indicated that the OQ-45 is a psychometrically sound instrument, with adequate 3-week test-retest reliability (.84) and excellent internal consistency reliability coefficients (.93; Lambert et al., 2004). Cronbach's alpha for the long-term follow-up administration was .94, very similar to alphas for the earlier administrations (Rosik, et al., 2009). Research on the OQ-45 has also indicated that patients who change their full-scale score in a positive or negative direction by at least 14 points have demonstrated reliable change (Ellsworth, Lambert, & Johnson, 2006; Lambert et al., 2004). Pre-treatment, post-treatment, and follow-up administrations of the OQ-45 formed the dependent (outcome) variable in the present study.

Marlowe-Crowne Social Desirability (MCSD) Scale. The MCSD is a 33-item self-report measure originally intended to identify the distortion of self-presentation toward socially desirable responding (Crowne & Marlowe, 1960). Items describe undesirable but common behaviors (such as gossiping) or desirable but uncommon behaviors (such as never saying something that hurts another's feelings). The scale is arranged in a True or False response format with 18 items keyed in the true direction and 15 in the false direction. Scores thus range from 0 to 33, with higher scores suggesting a higher need for approval. While the MCSD is still generally considered a measure of situational demand, it has more recently been interpreted as reflecting an avoidance of disapproval rather than seeking approval. The MCSD has a long history of displaying good to excellent statistical properties as concerns reliability and validity (Andrews & Meyer, 2003).

Additional measures. In addition to the questionnaires, participants were asked four Likert-style questions related to their sense of ongoing benefit from their time in treatment, their willingness to recommend the R&PG program to others, the helpfulness of their sending organization, and their degree of satisfaction with their sending organization's member care services. The response format ranged from 1 (Strongly Disagree) to 7 (Strongly Agree). Another question inquired about health services that participants had engaged in since departing the R&PG program (e.g., psychological counseling, pastoral care, family retreat, medication, support groups, self-help books). Finally, open-ended questions were asked concerning (1) the biggest help/hindrance to continued healing by participants since leaving Link Care, (2) how the sending organization helped/hindered their continued healing and restoration after Link Care, and (3) what the sending organization could do to facilitate their continued restoration and healing upon departure from Link Care.

Procedure

This additional follow-up analysis was approved by Link Care's Institutional Review Board. The independent variable was the time of assessment. The pre- and post-treatment assessments (T1 and T2) were conducted between April, 2006, and February, 2009. Upon arrival at Link Care, participants were asked to complete the OQ-45 as part of their initial assessment process (T1). Upon departure from the program, participants completed a post-treatment administration of the OQ-45 as part of their final evaluation (T2) and were invited to provide e-mail addresses for future contact related to the study.

Participants in the original study who indicated via e-mail their willingness to participate in this follow-up research, were mailed a final administration of the OQ-45 in July of 2009. A self addressed, stamped envelope was provided for participants inside the U.S.A. For participants outside of the U.S.A., a dollar bill was included with the self-addressed envelope to offset postage costs. The follow-up (T3) OQ-45 data were received from the 33 participants between July, 2009, and January, 2010. The mean duration (in weeks) between T2 and T3 was 109.64 (SD = 42). In light of the findings in the original study, MCSD was included as a covariate. Although duration of treatment was not found to have a significant effect in treatment response in the original study, it was included again as a covariate in the present analysis in light of potential dissimilarities in the two samples. A one-way within-subjects repeated-measures ANCOVA was utilized to examine the longitudinal data and all statistics were computed using PASW 18.0.

There were no missing data among the follow-up OQ-45 questionnaires. Four participants did not have MCSD data, which reduced the sample available for ANCOVA analyses to 29. Univariate analyses indicated that normality assumptions were met for all the OQ-45 independent variables. Tests for violations in the multivariate assumptions of equality of covariances and sphericity were not significant.

Results

ANCOVA analyses

The findings again did not confirm the presence of a significant between-subjects effect of treatment duration, so this covariate was subsequently dropped from the analysis. The one-way repeated measures ANCOVA was significant for the multivariate tests of time, Wilks' Lambda (A) = .42, F(2, 27) = 18.35, p < .001, partial [[eta].sup.2] = .57, when holding the covariate MCSD constant. Within-subject contrasts indicated a large decrease in participants OQ-45 scores from pre- to post-treatment, F(1, 28) = 26.74, p < .001, [[eta].sup.2] = .49, and no discernable change in OQ-45 scores between post-treatment and follow-up, F(1, 28) = .06, p = .81, [[eta].sup.2] = .002. Figure 1 represents this graphically. The interaction of time and MCSD was also significant, [LAMBDA] = .63, F(2, 27) = 7.83, p < .002, partial [[eta].sup.2] = .37. As was the case in the original study, pre-treatment MCSD appeared to wield the most effect on OQ-45 scores at pretreatment, with a lesser impact at post-treatment, and no influence at follow-up.

[FIGURE 1 OMITTED]

Since treatment duration is, in spite of the initial findings, intuitively associated with symptom improvement, I conducted post hoc analyses that treated this factor as a dichotomized independent between-subjects variable to determine if this would reveal insights that might not be obtained when utilizing it as a continuous covariate. The duration of treatment split that divided the sample most equally was that between five or less weeks (n = 14) and six or more weeks (n = 15). Results of this two-way repeated ANCOVA continued to reveal significant time effects, [LAMBDA] = .44, F(2, 25) = 16.02, p < .001, partial [[eta].sup.2] = .56, and time interaction effects with MCSD, [LAMBDA] = .64, F(2, 25) = 7.04, p < .004, partial [[eta].sup.2] = .36. In addition, the interaction of time and treatment duration neared significance, [LAMBDA] = .82, F(2, 25) = 2.74, p < .08, [[eta].sup.2] = .18. Within-subject contrasts indicated this trend was almost completely accounted for by a significant interaction at post-treatment and follow-up, F(1, 26) = 5.61, p < .03, [[eta].sup.2] = .18. Figure 2 displays these patterns and indicates that participants remaining in treatment for six or more weeks continued to show symptomatic improvement at follow-up for up to three years whereas those treated for less than that experienced a noticeable loss of their original treatment gains.

Health care activities since treatment

Participants' uses of various health care activities since departure from the R&PG program are presented in Table 1. Thirty-two participants (97%) reported involvement in at least one such activity, with the sample averaging 3.06 (SD = 1.5) activities and the modal response being 4. Self-help books, individual psychological counseling, individual personal retreat, and medication were the activities that evidenced the highest levels of utilization. Summation of total health care categories utilized by participants was correlated with MCSD, r (33) = -.43, p < .01, indicating that projecting a more favorable self-portrayal at the beginning of treatment was associated with less utilization of health care services during the follow-up period.

Closed-ended (Likert) questions

The statistics pertaining to participants' responses on the closed-ended questions are provided in Table 2. As is evident, these missionaries and clergy generally reported ongoing benefit from the R&PG program and would still recommend it to others up to three years after treatment. However, there was more variability on how helpful their sending organization had been in their transition after treatment and how satisfied they were with their sending organization's current member care services.

[FIGURE 2 OMITTED]

Open-ended questions

What was the biggest help to continuing your healing and restoration after leaving Link Care? What was the biggest hindrance?

Participants indicated a number of activities aided their healing following departure from Link Care's program. Several participants mentioned continuing in individual counseling and/or practicing spiritual disciplines (e.g., prayer, Bible study) as being particularly helpful to them. Other responses included finding an accountability partner or mentor, attending an Adult Child of an Alcoholic group, being with a supportive husband, having the support of the mission, and choosing to leave the mission. One participant commented, "My recent follow-up with another counselor really solidified the teaching I received at Link Care. It completed the solid foundation I received at Link Care."

Regarding hindrances to ongoing healing and restoration, one interesting finding is that five of the 14 married women in the sample (36%) reported a major hindrance to their healing was the unwillingness of their husbands to follow through with continued counseling and the recommendations from Link Care. One missionary wife stated, "My husband refused to use the tools that we learned to use and were successful using." A lack of ongoing support from the sending organization was mentioned by a few participants. For example, one asserted that, "Our sending organization hasn't offered us any follow-up to encourage continued restoration/resettlement." Other participants mentioned hindrances that included the lack of counseling resources at their field location, an inability to find a support group, and the lack of a mentor or mentoring couple who could relate to the missionary.

In what ways did your sending organization help you continue your healing and restoration after Link Care? In what ways did it hinder you? Several participants alluded to their sending organization offering some minimal help with an occasional contact, but not really having a structure that could encourage continued care. Yet there were exceptions. One missionary commented that, "They've helped by really listening to what I've learned about myself and making adjustments to keep me in a situation that's healthy for me." Another reported their mission "... kept us in limited ministry instead of jumping right back in." A third participant was appreciative that, "They [the mission] gave us a 'blank check' in a sense and have allowed us to have a temporary leave of absence to dedicate time to our marriage and family." Other responses referred to the sending organization being helpful by changing the job description to include less international travel, allowing more time at home, giving personal leave, and providing encouragement by an understanding supervisor.

There was not a strong pattern in the nature of the hindrances identified by the participants, although some did report a general lack of care related to follow-up by their sending organization.

   There was not much follow-up, no
   meetings with our counselor. They
   made an indirect request about
   payment and I said I basically
   didn't have any money. They said
   nothing else until 5 months later
   when they asked when to expect
   payment from me.

One participant complained that, "Confidences were shared with many people. Although we terminated the relationship, it left us feeling in limbo for quite awhile." Other identified hindrances were the sending organization not continuing financial assistance and promising but not following through with commitments for support.

What could your sending organization do to facilitate your continued healing and restoration once you departed from Link Care's program? Most of the participants had some clear ideas regarding ways their sending organization could facilitate their healing following their departure from the R&PG program. Several referred to the need for or value of ongoing support involving more counseling and/or pastoral care. A very positive experience was reported by one missionary, who stated, "One key man's words--'Why don't you take some time off and take care of your family'--changed everything for us. He said, 'If your family is doing well, your ministry will do well. If not ...' And they kept us on support."

Unfortunately, other participants appeared to experience a disappointing lack of support from their sending organization, as highlighted in the comments below from two missionaries.

   Get into my husband's life and mine!
   The only reason they know anything
   is my pursuit of them. There was
   minimal time, energy, interest, sense
   of responsibility or care during time
   on the field when they knew of serious
   issues that had happened, or
   afterward once we had returned to
   the USA. The least emotive board
   member was assigned as liaison to
   keep in contact and communicate
   with us. He did not do it more than
   one visit and one e-mail and got furious
   and yelled. Not much help.

   My sense from the National Office in
   the U.S. was that the field leadership
   was to blame for my failure, but all
   of us have felt critical pressure from
   the U.S. to "shape up or ship out"
   because we are costly but apparently
   unfruitful.

Other responses suggested the sending agency become more aware of issues surrounding the care of missionaries, provide an in depth interview before return to the field, have separate follow-up meetings with spouses, admit their part in the problems, and provide for future counseling "check ups."

Discussion

The present study confirmed that IOP treatment of missionaries and clergy can achieve demonstrable symptom improvement that is sustained for an average of over two years. While the main effect of duration of treatment was not related to outcomes when treated as a continuous variable, I did identify a trend toward an interaction effect between duration of treatment and time of assessment when contrasting participants who were treated for less than six weeks with those under care for six or more weeks. Those treated at least six weeks in Link Care's R&PG program displayed continued symptom reduction at follow-up (24% of the total T1-T3 difference). By contrast, participants who remained in treatment no longer than five weeks lost on average 58% of their treatment gains. These findings appear to support Rosik, et al.'s (2009) suspicion that many participants need sufficient duration in treatment so as to gain the "traction" needed to continue their emotional and spiritual healing through less intensive therapeutic modalities.

The vast majority (97%) of participants pursued some form of health care services following departure from Link Care's program. Individual counseling and self-help readings were the most utilized forms of additional care and those who displayed greater concern with presenting favorably engaged in fewer health care activities during the follow-up period. Participants reported highly favorable opinions of their IOP experience at Link Care and its ongoing benefit for them. Missionaries' perspectives regarding the helpfulness of their sending organization after leaving Link Care and their satisfaction with their sending organization's member care services were decidedly mixed. This suggests some degree of disconnect may occur between sending organizations and their missionaries who take time away from ministry to pursue psychological and spiritual care. Some of these organizations may benefit from reexamining how they support their members' healing process and identifying measures to keep them from "falling between the cracks" after receiving intensive treatment.

Responses to the open-ended questions may give some initial direction as to what kinds of additional support missionaries especially would desire from their sending organizations. The experiences of participants indicate that supportive follow-up from the sending organization is highly desired, including supportive communication, flexibility in next assignment, and assisting as able in the provision of ongoing but less intensive care. One finding of particularly interest has to do with the role of husbands. If the comments from participant wives are at all indicative, it appears that sending organizations should pay special attention to how engaged husbands remain in the healing process following intensive care. Targeting husbands for follow-up member care services to ensure their continued motivation for implementing change may significantly improve the probability of these couples returning to effective ministry.

This study is not without limitations that need to be acknowledged. The final sample was relatively small and reflected a fairly low response rate (18%). This figure appears to be at the lower end of the range for postal survey response rates observed in the literature (Sykes, Walker, NgwaKongnwi, & Quan, 2010) and may have been unavoidable given the highly mobile and often internationally located participants in our sample. This limited the power of the analyses, especially for the interaction terms examined, which were nonetheless significant or near significant in spite of this weakness. The sample attrition and pursuit of additional health services by participants also raises the question of the extent to which confounding influences might have been introduced into the analyses. In examining this question, I did find that age correlated with the total number of health and spiritual activities participants had engaged in since leaving IOP treatment, r (33) = -.51, p < .003. This suggests that the younger the participants were, the more they pursued additional care. However, neither variable was correlated with pre-treatment to follow-up difference scores. Adding total health services pursued as a covariate in the original ANCOVA led to a modest attenuation of p levels, but did not significantly alter the nature of previously reported findings.

It should also be noted since this study employed a clinical sample of mostly conservative religious professionals, the findings may not generalize to the larger population of Christian missionaries and clergy. Finally, the treatment provided by the R&PG program was diverse and included individual, marital, and group therapy as well as pastoral care and psycho-educational instruction. It is therefore not possible to ascertain whether some components of the treatment wielded more influence on outcomes than did others.

In spite of such limitations, this study provides the best empirical evidence to date that Christian missionaries and clergy can and do experience long term benefits from professional psychological and pastoral care, delivered in this instance through an IOP modality. Participants clearly appreciated their treatment and pursued further care after departing the R&PG program. Sending organizations wishing to develop or improve their member care services may find a wealth of valuable ideas among their members who have already been consumers of such care.

References

American Association of Community Psychiatrists (1998). Level of care utilization system for psychiatric and addiction services. Pittsburgh, PA: Author.

Andrews, P., & Meyer, R. G. (2003). Marlowe-Crowne Social Desirability Scale and short form C: Forensic norms. Journal of Clinical Psychology, 59, 483-492.

Bottlender, M., & Soyka, M. (2005). Outpatient alcohol treatment: Predictors of outcomes after 3 years. Drug and Alcohol Dependence, 80(1), 83-89.

Crowne, D. P., & Marlowe, D. (1960). A new scale of social desirability independent of psychopathology. Journal of Consulting and Clinical Psychology, 24, 349-354.

Ellsworth, J. R., Lambert, M. J., & Johnson, J. (2006). A comparison of the Outcome Questionnaire-45 and Outcome Questionnaire-30 in classification and prediction of treatment outcome. Clinical Psychology and Psychotherapy, 13, 380-391.

Gratz, K. L., Lacroce, D. M., & Gunderson, J. G. (2006). Measuring changes in symptoms relevant to borderline personality disorder following short-term treatment across partial hospitalization and intensive outpatient levels of care. Journal of Psychiatric Practice, 12, 153-159.

Lambert, M. J., Morton, J. J., Hatfield, D., Harmon, C., Hamilton, S., Reid, R. C., et al. (2004). Administration and Scoring Manual for the OQ-45.2. American Professional Credentialing Services, LLC: Brigham Young University.

Link Care Center (2003). Restoring hearts and celebrating wholeness. Retrieved October 8, 2010, from http: //www.linkcare.org/.

Rosik, C. H., Summerford, A., & Tafoya, J. (2009). Assessing the effectiveness of intensive outpatient care for Christian missionaries and clergy. Mental Health, Religion, & Culture, 12, 687-700.

Smith, G. W., Ruiz-Sancho, A., & Gunderson, J. G. (2001). An intensive outpatient program for patients with borderline personality disorder. Psychiatric Services, 52(4), 532-533.

Skyes, L.L., Walker, R.L., Ngwakongnwi, E., & Quan, H. (2010). A systematic literature review on response rates across racial and ethnic populations. Canadian Journal of Public Health, 101(3), 213-219.

Veach, L. J., Remley, T. P., Kippers, M. K., & Sorg, J. D. (2000). Retention predictors related to intensive outpatient programs for substance use disorders. American Journal of Drug and Alcohol Abuse, 26, 417-428.

Wise, E. A. (2003). Psychotherapy outcome and satisfaction methods applied to intensive outpatient programming in a private practice setting. Psychotherapy: Theory, Research, Practice, Training. 40(3), 203-214.

Wise, E. A. (2005). Effectiveness of intensive outpatient programming in private practice: Integrating practice, outcomes, and business. American Psychologist, 60(8), 885-895.

Christopher H. Rosik

Link Care Center/Fresno Pacific University

Correspondence regarding this article should be addressed to Christopher Rosik, Ph.D., Link Care Center, 1734 West Shaw Ave., Fresno, CA 93711. Email: christopherrosik@linkcare.org.

Author

Christopher H. Rosik, Ph.D., is a psychologist and Director of Research at the Link Care Center in Fresno, California. He is also a member of the clinical faculty at Fresno Pacific University. His areas of interest include missionary and pastoral care, dissociative disorders, human sexuality, and the philosophy of social science.

Table 1

Participants' Utilization of Health Care Services since Departure
from Link Care's R&PGProgram. (N = 33)

                                                Number of Participants
Health Care Activity                                 who Utilized

Individual psychological counseling                   14 (42.4%)
Marital counseling                                     5 (15.2%)
Family counseling                                      2 (6.1%)
Pastoral counseling                                    5 (15.2%)
Individual retreat                                    12 (36.4%)
Marriage retreat                                       2 (6.1%)
Support group                                         10 (30.3%)
Medication evaluation/monitoring                      12 (36.4%)
Self-help books                                       23 (69.7%)
Other (e.g., journaling, prayer, Bible study)         11 (33.3%)

Table 2

Participants' Responses to Closed-Ended Questions on Treatment
Experience and Satisfaction with Sending Organization Aftercare

Question                                     M      SD

The insights and tools I learned while
at Link Care continue to benefit my
healing today. (n = 33)                    6.06     .93

I would recommend Link Care to other
missionaries/pastors who need emotional
and spiritual care. (n = 33)               6.54    1.12

My sending organization was helpful in
my transition after Link Care. (n = 29)    3.83    2.04

I am satisfied with my sending
organization's current member care
services. (n = 27)                         3.04    1.65

                                            Minimum     Maximum
Question                                   Response    Response

The insights and tools I learned while
at Link Care continue to benefit my
healing today. (n = 33)                        4           7

I would recommend Link Care to other
missionaries/pastors who need emotional
and spiritual care. (n = 33)                   3           7

My sending organization was helpful in
my transition after Link Care. (n = 29)        1           7

I am satisfied with my sending
organization's current member care
services. (n = 27)                             1           6

Note. Response format ranged from 1 (Strongly Disagree) to 4
(Neither agree nor disagree) to 7 (Strongly Agree).