Divorce's Impact on Preschool, School-age, and Adolescent Children Essay

Divorce's Impact on Preschool, School-age, and Adolescent Children - Essay Example This more differentiated body of research is helpful in policy formation and for educating divorced parents about known risk factors for their children and what protective behaviors may enhance their children's longer-term adjustment. Life stress associated with marital disruption was found to account for the majority of children's adjustment problems. Children from nonintact homes show poorer adjustment than children from intact homes. Siblings experience increased closeness as a result of the shared experience of going through the divorce of their parents together. The young women also report turning to each other for support as a result of the emotional unavailability of their parents during the divorce. From the point of view of children, divorce is a stressful experience because of the disruption of the home and its financial, emotional, and social costs. The adverse impact, however, can be minimized by realistic and sensitive attention to its effects on children. Although divorce alters the living arrangements of affected families, it does not end family relationships. Most teenagers and their parents adjust to divorce and later regard it as having been a constructive action; but one-third do not. In those instances the turbulence of the post-divorce phase plays a crucial role in influencing pathological reactions in affected teenagers. Divorce is common in the contemporary way of life and deserves objective study. 3. Focus questions Does divorce have effects on children of different age groups What does literature say about it If these are negative how they can be avoided If these are positive, how can they be utilised in clinical practice 4. Review of literature 5. Search strategy based on key words, exclusion and inclusion criteria. 6. Findings from literature review: Critical review of contemporary literature on parental divorce and its effects on children, their mental health, social performances, economic parameters, and performance. Analysis of the causes and effects. Identification of the positive and negative aspects of these effects and their practice relevance. 7. Way forward: Summary of findings of literature review and suggestion for practice. Discussion about the ways to minimise divorce and improvement of coping mechanisms of the children. 8. Conclusion: Summary of the work. Introduction The ratio of marriage and divorce rates has been stable at about 50 percent for the past thirty years, indicating that, during this time, for every two marriages there has been one divorce. The number of divorces peaks only two and a half years after marriage; most divorces occur within ten years. In 2002, the Centers for Disease Control and Prevention released a report about marriage, divorce, and remarriage trends based on a nationally representative sample of women fifteen to forty-four years of age. The data indicated that, after only three years, 12 percent of marriages had ended in either separation or divorce. After five years, 20 percent of all first marriages had ended; after ten years, 33 percent; and after fifteen years, 43 percent. The risk for marital disruption is greatest in the first years of marriage and noticeably levels off after the fifth year. Thus, the risk for divorce decreases with the length of the marriage (Bramlett and Mosher,

Rice and Beans Essay Example for Free

Rice and Beans Essay Rice-and-beans, the staple of Belize Cuisine. Although originally considered primarily a Creole dish, today it’s eaten daily by all and is simply called Belizean rice and beans. Ingredients 1 cup red kidney beans 1 cup thick coconut milk 1 garlic clove (optional) salt pepper 2 cups rice 1 onion, sliced 1 piece of salt meat (cut into small pieces) Preparations 1. Soften beans (soak first) with garlic. 2. Boil until tender and whole, adding salt meat (previously boiled to soften) when almost tender. 3. Add the milk, onion and seasonings. 4. Wash rice, then add to the beans. 5. Cook over gentle heat until liquid is absorbed. 7. Stir gently with a fork, and add a little water from time to time until rice is cooked. Serve hot with a meat dish. (Some favorite meat dishes with rice and beans are: stuffed baked chicken, stew chicken, stew fish, fried fish or meat balls). Yoana Alvarez Period 2.

Business and Economic Environment in Lagos | Analysis

Business and Economic Environment in Lagos | Analysis 1.0  INTRODUCTION Business is seen to operate within an environment. This environment could either present a threat or an opportunity to the organizations that operate in it. This essay aims to describe the business environment in the city where the researcher lives. The first section will give an overview of what business environment is all about. Furthermore, Lagos state will be used as a case study to examine the business environment where the researcher lives. Then, different forces or conditions that encourage or inhibit business activities in Lagos state will be discussed 2.0  AN OVERVIEW OF BUSINESS ENVIRONMENT According to Nyandat (2013) Business environment can be defined as forces or surroundings that affect business operations. These forces may include customers, competitors, suppliers, distributors, industry trends, substitutes, regulations, government activities, and economy, social, political and cultural factors. Ogunro (2014) explained business environment as the combination of all environmental conditions and influences that are capable of affecting or influencing business activities. Furthermore, Obiwuru et al (2011) also defined environment of business as the aggregation of the pattern of all the external and internal conditions and influences that affects the existence, growth and development of the business. For the purpose of this essay, Lagos state in Nigeria will be used as a case study to analyze the business environment in the city where the researcher resides. Lagos state is the former capital of Africa’s largest country, Nigeria; it is the most populated city in sub-Saharan region with more than 15 million people. Lagos is called center of excellence because of its reputation of housing the very best of Nigeria’s skilled workforce. It is also home to the country’s top industries and businesses with over 65% of imported goods passing through its ports and 80% of manufacturing being handled within or around its vicinity. With such massive economic facts, Lagos is the life-wire of the Nigerian economy. This is best explained by the fact that no macro-economic activity can ever succeed with Lagos being alienated. There are forces or conditions that encourage or inhibit business activity in Lagos and these include: 2.1  Human Capital: The population of Lagos is a very good advantage for business entrepreneurs because both skilled and unskilled workforce is available and very cheap. Lagos state has a population of more than 15 million people of which 75% of them are youths and eager to work in order to earn a living. The city has the best of skilled workforce from diverse regions including foreign experts. This has helped the business activity because you can get any expert you want at a very affordable price. 2. 2 Inadequate Power Supply: Inadequate power supply is one of the major challenges that affect the business activity in Lagos. Every company has a standby power generator which is being used when there is power failure .Firms expenditure on diesel and petrol (as the case may be) is unbearable and this is affecting the productivity. This development is impacting negatively on the business investment due to increased expenditure on diesel and petrol by enterprises. This also comes with the consequences of declining productivity and competitiveness. Many companies have been closed down due to inadequate power supply while some companies where forced to relocate to the nearby country. Nigeria has lost very huge amount of money due to inadequate power. â€Å"In 1990, the World Bank estimated the economic loss to the country from power inefficiency, at about N1 billion† (Adenikinju, 2005, p.3). Using telecom industry in Nigeria as an example; which is an Oligopolistic market where we have very few telecom industries; their major challenge is power which they use to power all the base stations across the country. Most of them spend an outrageous amount of money to power these base stations because they cannot afford to have network failure due to power outage. â€Å"Telecom Operators Spend N10 Billion Annually to Power BTS† (Nurudeen, 2014, p.1) 2.3  Security Situation Insecurity is another major concern that affects businesses in Lagos, there is very high rate of insecurity in the city and this made some foreign investors to decline from investing in the country. The security agencies are trying to ensure a secure and peaceful society but the government still needs to do more in order to give the foreign investors courage to come in and invest. Using Oil and Gas sector as an example, where we have Oligopolistic market structure and the price is being controlled and regulated by the government, there is a lot of oil theft and pipeline vandalism in the downstream sector which affects the economy. â€Å"The latest estimates by the Finance Minister, Dr Mrs. Ngozi Okonjo-Iweala put the oil theft at about 400,000 barrels per day; the environment of the affected communities also suffers serious degradation as a consequence of this problem†. (Ibru, 2014, p.2) 2.4 Poor Infrastructures Lack of good infrastructure in the city is another major challenge; many companies have their industries located at the industrial layout which is quite far from the metropolis. Commuters find it very difficult to access some remote places to buy products due to bad roads. (Gilbert, 2009) Access to raw materials for the company use is a major challenge; also distribution of goods and services to the metropolis is also a big problem due to bad roads. There is a lot of traffic congestion in the metropolis and valuable hours are being lost due to traffic which is caused by bad roads. There is no good health care sector for the poor masses, many people could not have access to medical care because of widespread poverty in the country and this is causing very big negative impact to the country due to high mortality rate. 3.0 Conclusion: The economic environment in Lagos state has been facing a lot of challenges but despite all that, they were able to create jobs, wealth for individuals, as well as revenue for the government through employment and taxation. 4.0 References: Adenikinju, F. (2005) Analysis of the cost of infrastructure failures in a developing economy: the case of the electricity sector in Nigeria. Volume 148 of AERC research paper, African Economic Research Consortium. Gilbert, C. (2009). Nigerias Bad Roads Are Getting Worse. Available: http://www.voanews.com/content/nigerias-bad-roads-are-getting-worse-74805987/415952.html. [Accessed 4th June 2014] Ibru, G. (2013) Press conference on the economy by the Lagos chamber of commerce and industry. 2nd Quarter [Online] Available from: [Accessed 27th May 2014]. Neyandat, C. (2013) how do you analyze the business environment? Gakus, 21st Oct. Available from: http://www.gaksu.com/allpdf/140_notes.pdf [Accessed 4th June 2014] Nurudeen, A. (2014) Interview with the C.E.O of Airtel Nigeria, Daily Trust, [Online] 10th February.p.1. Available from: http://allafrica.com/stories/201402100424.html?viewall=1 [Accessed 28th May 2014] Obiwuru T. Oluwalaiye, B. Okwu, T. (2011) External and Internal Environments of Businesses in Nigeria: An Appraisal in International Bulletin of Business Administration (12) OGUNRO, O. (2014).International Journal of Academic Research in Business and Social Sciences. 4th ed. Rufus Giwa Polythecnic, Owo, Ondo state, Nigeria: HR Mars. Question 2 1.0 INRODUCTION: Macroeconomics can be defined as study of economics that is more concerned with government structures, behavior and decision making which affects the country as a whole. It deals more with the country’s economy which includes; gross domestic product (GDP), unemployment rate, price indices, exchange rate, Inflation. When a country is experiencing macroeconomic stability, it means that the country’s economy is very stable; the Gross Domestic Product (GDP) is very good, unemployment is reduced to the minimal rate and low inflation. The aim of this essay is to examine the effectiveness of various approaches that may be used to reduce macroeconomic instability; while exploring different policies which a country’s government could use to achieve macroeconomic goals 2.0 AN OVERVIEW OF MACROECONOMICS: Macroeconomics is concerned with government economic performance, it focuses on the economic trend of a nation. Macroeconomics deals with factors that that affect the country’s economy. Macroeconomic instability is major concern to any government and all possible measure must be taken to ensure that economic stability is maintained. Any country that suffers macroeconomic instability will possibly have a high rate of inflation, unemployment, low GDP or total recession. Different kinds of measure are taking by different countries to ensure that they maintained a stable economy. Below are some highlighted measures/policies which can be used to ensure that macroeconomic instability is reduced. 2.1 Privatization Privatization can be defined as a process by which some inefficient and ineffective sector is being transferred to be managed by more efficient private sector for the benefit of economic growth. This will allow the government to perform its primary functions, that is administration of law and order thereby leaving the actual running of business enterprise to private sectors. Nwoye (2012) defined privatization as the transfer of ownership and control of enterprise from state to the private sector. The main reason why government privatize the public sector is because of economic stability and this could be explained below: To enhance efficiency in the public sector: there are so many inefficiency in public sector due to nonchalant attitude of the workers. Most of the public servants believe that government are for the people, so they can do whatever they want without being fired and this affect the governments economy, there are so many ghost workers being paid by the government which affects the expenditure. But when handed over to private sector, they become more efficient and generate more revenue for the government because the private sector cannot afford to lose money like the government, they will cut down the cost overhead to the barest minimum to be able to generate revenue which will help in the economic growth of the country. To decontrol the economic system by reducing unnecessary administrative controls of the government : deregulating the economic system helps the government to focus more on the administration of the nation by implementing law and order and good policies that will help in the economic growth. The government handing over the business management to the private sector will reduce their cost overhead and also increase efficiency in the administration of the nation. To decrease the volume of unproductive instruments in the public sector: as mentioned earlier, there are a lot of unproductive people and instrument in the public sector, nepotism and godfathers has contributed to inefficiency in the public sector where round peg is been put in a square hole. But when these sectors are being privatized, all these unproductive people and instrument will be removed and replaced with more productive instrument which will increase the employment and delivering of the goods and services thereby generating sufficient revenue for the government. To fortify the role of the private sector in the economy which will warranty employment and higher capacity utilization: Fortification of the role of the private sector in the economy is very important as this will help in decreasing the level of unemployment in the country and which helps in economic stability. Reduction of political interference in the public sector: politicial interference in the public sector increases the rate of corruption which affects the economy, but without the interference of the politicians when privatized, the sectors will be more productive with less corrupt practices. 2.2 Public Private Partnership (PPP) Omoh (2012) confirmed that government across the globe have come to terms with the fact that public sector cannot provide the needed infrastructure and have come to the conclusion that private sector participation in the provision of infrastructure in inevitable. Public private partnership is where the government and private sector goes into partnership to bring economic growth through building and construction of infrastructures, managing them for a shot term or long term and finally hand them over to the government after a stipulated period as agreed. This partnership helps to increase the gross domestic product and it can be done is so many ways; it could take the form of Build-Operate-Transfer (BOT), Build-Operate-Own (BOO), Build-Own-Operate-Transfer (BOOT), Design-Build-Operate-Transfer (DBOT), Design-Build-Finance and Operate (DBFO). Other less common ones are; Build-Rent/Lease-Transfer (BRT or BLT) Build-Transfer and Operate (BTO). Omoh (2012) The Scope for the public private partnership ranges from Power generation plant and transmission, roads and bridges, ports, airports, railways, inland container depots and logistics hubs, gas and petroleum, water supply, housing, educational facilities (e.g. Schools, Universities) and healthcare facilities. This helps the government to spend less money on these areas while the partners will finance and manage these sectors for some time to recover their invested money. 2.3 Fiscal Policy Heakal (2013) defines fiscal policy as the means by which a government adjust its spending activity and tax rates in order to monitor and influence a nation’s economy. Heakal (2003) also confirms that fiscal policy is based on the renowned British economist, John Mynard Keynes, who is known as Keynesian economics; his theory shows that government can influence macroeconomic stability / productivity level by increasing or decreasing tax levels and public spending. This influence will in turn curb inflation, increase employment and maintain a healthy value of money. Gbosi (2008) says that fiscal policy entails the government’s management of the economy through the controlling of its income and spending power in order to achieve certain desired macroeconomics objectives in which economic growth and stability is among them. Jhingan (2006) also acknowledges the power of fiscal policy as an instrument of macroeconomic stabilization. Iyeli Ijomah (2013) also established that if fiscal policy is used with circumspection and synchronized with other measures, it will possibly smoothen out business cycle which leads to economic growth and stability. Based on the above explanations, it could be said that Fiscal policy is a way or method the government is using to control economic goals in order to maintain stability in the nation’s economy. Fiscal policy can come as increase in taxation or government expenditure in order to influence aggregate demand (AD) and level of economic activity. AD can be defined as the total level of planned expenditure in an economy (AD= C+ I + G + X – M) where C= Consumer spending, I= Investment, G=Government Spending, X= export, M= Imports) The government might implement the fiscal policy in order to stimulate economic growth in a period of a recession, the government can also use fiscal policy to keep inflation low. Mainly, fiscal policy aims to stabilize economic growth in order to avoid boom and bust economic cycle. 2.4 Taxation Anyanwu (1997) defined taxation as the compulsory transfer or payment from private individuals, institutions or groups to the government. Nzotta (2007) stated the four key issues that must be understood for taxation to play its function in the society; first, a tax is a compulsory contribution made by citizens to the government and this contributions is for general common use. Secondly, a tax imposes a general obligation on the taxpayer. Thirdly, there is a presumption that the contribution to the public revenue made by taxpayer may not be equivalent to the benefits received. Finally, a tax is not imposed on a citizen by government because it has rendered specific services to him or his family Anyanwu (1993) also pointed out that there are three basic objectives of taxation; these are to raise revenue for the government, to regulate economic activities and to control income and employment. Nzotta (2007) also confirmed that taxes generally have allocation, distribution and stabilization functions. The allocation function of taxes talks about determination of the pattern of production, the goods that should be produced, who produces them, the distribution function of taxes relates to the manner in which the effective demand over economic goods is divided among the individuals in the society while the stabilization function of taxes deals with attaining high level of employment, a reasonable level of price stability and appropriate rate of economic growth, with allowances for effects on trade. Conclusion: The above listed methods/ policies has been used by so many countries to maintain economic stability and Nigeria as a country has introduced these policies which is now helping the government to stabilize the economy. References Anyanwu, J.C., 1993. Monetary Economics: Theory, Policy and Institutions. Hybrid Publishers, Onitsha Anyanwu, J.C., 1997. Nigerian Public Finance. Joanne Educational Publishers, Onitsha Gbosi, A.N (2008) Contemporary Macroeconomic problems and stabilization policies, Portharcourt, Automatic Ventures. Heakal. R. (2013) Investopedia. What is fiscal policy? [Online] Available rom: http://www.investopedia.com/articles/04/051904.asp [accessed 2nd June 2014]. Iyeli I.I Ijomah M.A (2013) A Re-examination of fiscal policy applicability in Nigeria’s economic growth process: An econometric policy evaluation from empirical evidence. Vol 3. (4 July 2013) P.180 – 188 Jhingan, M.L (2006) Macroeconomic Theory. New Delhi. Vrinda Publishers. Nwoye .I. 2013, Privatization of Public Enterprises in Nigeria: The views and counterviews. [Online] Available from: http://www.globalizacija.com/doc_en/e0062pri.htm [Accessed 3rd June 2014] Nzotta, S.M., 2007. Tax evasion problems in Nigeria: A critique. Niger. Account. 40(2): 40-43 Omoh G. (2012) Public Private Partnership: The new way to infrastructural provision, Vanguard, [Online] 17th December. P.7. Available from: www.vanguardngr.com/2012/12/public-private-partnershi-the-new-way-to-infrastructural-provision [Accessed 30th May 2014]

Eye Witness Identification Essays -- essays research papers

Although the phrase â€Å"they all look alike to me† is widely known and used as a joke (Goldstein & Chance, 1985) the implications that the phrase yields may not be as widely understood as they should be. In the criminal justice system, eyewitness identifications can play a major role in the decisions made by jurors even though it has been shown that jurors have little awareness of factors that affect the reliability of eyewitness accounts (Cutler, Penrod, & Dexter, 1990). One such factor is identifications made by people identifying someone of a different race, (when describing race as Caucasian, of African descent, of Asian descent, or Latino), which can be referred to as other-race identification or other-race recognition (Lavrakas, Buri, & Mayzner, 1976). If the phrase â€Å"they all look alike to me†, which states that people of another group appear homogenous, is true for most people then it is possible that other-race identifications should be considered less reliable than within-race identifications. It has in fact been shown that people are more accurate at identifying others of their own race than at identifying others of a different race (Penrod, Shapiro 1986). Since it has been established that the other-race recognition is not always as accurate as within-race recognition, finding the cause for this effect is important. One possible cause is the quantity of experience a person has with another race. People are less accurate at identifying faces of a different racial group than at identifying faces of their own racial group because they have less experience with the other race. We would expect that as the amount of experience a person has with a different racial group decreases the less accurate they will be at identifying faces of that race. It would also be expected that if you raise someone’s level of experience with a different racial group, possibly through training, the ability to identify faces in that racial group should increase. The amount of experience a person has with another racial group should determine how accurate they will be at identifying people of that race. Those who report having large amounts of contact with another race should show better accuracy in identifying people of that race than those reporting small amounts of contact with the other race. In a study done by John ... ...vents the drawing of a firm conclusion. REFERENCES Brigham, John C., & Malpass Roy S., (1985) The role of Experience and Contact in the Recognition of Faces Of Own- and Other-Race Persons. Journal of Social Issues, 41, 139-155. Lavrackas, Paul J., Buri John R., & Mayzner Mark S., (1976) A Perspective on the Recognition of Other-Race Faces. Perception & Psychophysics, 20, 475-481. Shepherd, John, Deregowski, Jan B., & Ellis, Hadyn D., (1974) A Cross-Cultural Study of Recognition Memory For Faces. International Journal of Psychology, 9, 205-211.  Ã‚  Ã‚  Ã‚  Ã‚   Goldstein, Alvin G., & Chance, June, (1985) Effects of Training on Japanese Face Recognition: Reduction of the Other-Race Effect. Bulletin of the Psychonomic Society, 23, 211-214. Anthony, Tara, Copper, Carolyn, & Mullen, Brian, (1992) Cross-Racial Facial Identification: A Social Cognitive Integration. PSPB, 18, 296-301. Shapiro, Peter N., Penrod, Steven D., (1986) Meta-Analysis of Facial Identification Studies. Psychological Bulletin, 100, 139-156. Cutler, B. L., Penrod, Steven D., (1990) Juror Sensitivity to to Eyewitness Identification Evidence. Law and Human Behavior, 14, 185-192.

The Hunters: Phantom Chapter 28

No one answered the door at the Smalwoods' house. The driveway was empty and the house looked deserted, the shades pul ed down. â€Å"Maybe Caleb's not here,† Matt said nervously. â€Å"Could he have gone somewhere else when he got out of the hospital?† â€Å"I can smell him. I can hear him breathing,† Stefan growled. â€Å"He's in there, al right. He's hiding out.† Matt had never seen Stefan look so angry. His usual y calm green eyes were bright with rage, and his fangs seemed to be involuntarily extended, little sharp points showing every time he opened his mouth. Stefan caught Matt looking at them and frowned, running his tongue selfconsciously across his canines. Matt glanced at Alaric, who he'd been thinking of as the only other normal person left in their group, but Alaric was watching Stefan with what was clearly fascination rather than alarm. Not entirely normal, then, either, Matt thought. â€Å"We can get in,† Meredith said calmly. She looked to Alaric. â€Å"Let me know if someone's coming.† He nodded and positioned himself to block the view of anyone walking past on the sidewalk. With cool efficiency, Meredith wedged one end of her fighting stave in the crack of the front door and started to pry it open. The door was made of heavy oak, and clearly had two locks and a chain engaged inside, and it withstood Meredith's leverage against it. Meredith swore, then muttered, â€Å"Come on, come on,† redoubling her efforts. The locks and chains gave suddenly against her strength, and the door flew open, banging into the wal behind it. â€Å"So much for a quiet entrance,† Stefan said. He shifted restlessly on the doorstep as they filed past him. â€Å"You're invited in,† Meredith said, but Stefan shook his head. â€Å"I can't,† he said. â€Å"It only works if you live here.† Meredith's lips tightened, and she turned and ran up the stairs. There was a brief shout of surprise and some muffled thumping. Alaric glanced at Matt nervously, and then up the stairs. â€Å"Should we help her?† he said. Before Matt could answer – and he was pretty sure Meredith wasn't the one who needed help – she returned, shoving Caleb down the stairs before her, twisting one of his arms tightly behind his back. â€Å"Invite him in,† she ordered as Caleb stumbled to the bottom of the stairs. Caleb shook his head, and she yanked his arm up higher so that he yelped in pain. â€Å"I won't,† he said stubbornly. â€Å"You can't come in.† Meredith pushed him toward Stefan, stopping him just at the threshold of the front door. â€Å"Look at me,† Stefan said softly, and Caleb's eyes flew to his. Stefan's pupils widened, swal owing his green irises in black, and Caleb shook his head frantical y, but seemed unable to break his gaze. â€Å"Let. Me. In,† Stefan ordered. â€Å"Come in, then,† said Caleb sul enly. Meredith released him and his eyes cleared. He turned and dashed up the stairs. Stefan burst through the door like he'd been shot through a gun and then stalked up the stairs. His smooth, stealthy movements reminded Matt of a predator's – of a lion or a shark. Matt shivered. Sometimes he forgot how truly dangerous Stefan was. â€Å"I'd better go with him,† Meredith said. â€Å"We don't want Stefan doing anything he'd regret.† She paused. â€Å"Not before we find out what we need to know, anyway. Alaric, you're the one who knows the most about magic, so you come with me. Matt, keep an eye out and warn us if the Smal woods pul into the drive.† She and Alaric fol owed Stefan up the stairs. Matt waited for the screaming to start, but it remained ominously quiet upstairs. Keeping one eye on the driveway through the front windows, Matt prowled through the living room. He and Tyler had been friends once upon a time, or at least had hung out, because they were both first-string on the footbal team. They'd known each other since middle school. Tyler drank too much, partied too hard, was gross and sexist toward girls, but there had been something about him that Matt had sometimes enjoyed. It was the way he'd thrown himself into things, whether it was the no-holdsbarred tackle of an opposing team's quarterback or throwing the absolutely craziest party anyone had ever seen. Or the time when they'd been in seventh grade and he'd gotten obsessed with winning at Street Fighter on PlayStation 2. Every day he'd had Matt and the rest of the guys over, al of them spending hours sitting on the floor of Tyler's bedroom, eating chips and talking trash and pounding the buttons of the control er until Tyler had figured out how to win every fight. Matt heaved a sigh and peered out the front window again. There was a brief muffled thump from upstairs, and Matt froze. Silence. As he turned back to pace across the living room again, Matt noticed a particular photo among the neat row of frames on top of the piano. He crossed over and picked it up. It must have been the footbal banquet, junior year. In the picture, Matt's arm was around Elena, who he'd been dating then, and she was smiling up at him. Next to them stood Tyler, hand in hand with a girl whose name Matt couldn't remember. Alison, maybe, or Alicia. She'd been older than them, a senior, and had graduated that year and left town. They were al dressed up, he and Tyler in jackets and ties, the girls in party dresses. Elena had worn a white, deceptively simple short dress, and looked so lovely that she'd taken Matt's breath away. Things had been so easy then. The quarterback and the prettiest girl in school. They'd been the perfect couple. Then Stefan came to town, a cold, mechanical voice whispered to him, and destroyed everything. Stefan, who had pretended to be Matt's friend. Stefan, who had pretended to be a human being. Stefan, who had pursued Matt's girlfriend, the only girl Matt had ever real y been in love with. Probably the only girl he would ever feel that way about. Sure, they'd broken up just before Elena met Stefan, but Matt might have gotten her back, if not for him. Matt's mouth twisted, and he threw the photo to the floor. The glass didn't break, and the photo just lay there, Matt and Elena and Tyler and the girl whose name he didn't remember smiling innocently up at the ceiling, unaware of what was heading toward them, of the chaos that would erupt less than a year later. Because of Stefan. Stefan. Matt's face was hot with anger. There was a buzzing in his head. Stefan the traitor. Stefan the monster. Stefan who had stolen Matt's girl. Matt stepped deliberately onto the picture and ground it beneath his heel. The wooden frame snapped. The feel of the glass shattering under his foot was oddly satisfying. Without looking back, Matt stomped across the living room toward the stairs. It was time for him to deal with the monster who had ruined his life. â€Å"Confess!† Stefan growled, doing his best to compel Caleb. But he was so weak and Caleb kept throwing up mental blocks. No doubt about it – this boy had access to Power. â€Å"I don't know what you're talking about,† Caleb said, pressing his back against the wal as if he could tunnel into it. His eyes flicked nervously from Stefan's angry face to Meredith, who was holding her staff balanced between her hands, ready to strike, and back to Stefan. â€Å"If you just leave me alone, I won't go to the police. I don't want any trouble.† Caleb looked pale and shorter than Stefan remembered. There were bruises on his face, and one of his arms was in a cast and supported by a sling. Despite everything, Stefan felt a twinge of guilt as he looked at him. He's not human, he reminded himself. Although†¦ Caleb didn't seem al that wolfish either, for a werewolf. Shouldn't there be a little more of the animal in him? Stefan hadn't known many werewolves, but Tyler had been al big white teeth and barely repressed aggression. Next to him, Alaric blinked at the injured boy. Cocking his head to one side and examining him, he echoed Stefan's thoughts, asking skeptical y, â€Å"Are you sure he's a werewolf?† â€Å"A werewolf?† said Caleb. â€Å"Are you al crazy?† But Stefan was watching Caleb careful y, and he saw a tiny flicker in Caleb's eyes. â€Å"You're lying,† Stefan said coldly, reaching out with his mind once more, final y finding a crack in Caleb's defenses. â€Å"You don't think we're crazy. You're just surprised that we know about you.† Caleb sighed. His face was stil white and strained, but a certain falseness went out of it as Stefan spoke. His shoulders slumped and he stepped away from the wal a little, head hanging wearily. Meredith tensed, ready to spring, as he moved forward. He stopped and held up his hands. â€Å"I'm not going to try anything. And I'm not a werewolf. But, yeah, I know Tyler is, and I'm guessing that you know that, too.† â€Å"You've got the werewolf gene,† Stefan told him. â€Å"You could easily be a werewolf, too.† Caleb shrugged and looked Stefan straight in the eye. â€Å"I guess. But it didn't happen to me; it happened to Tyler.† â€Å"Happened to?† Meredith asked, her voice rising with outrage. â€Å"Do you know what Tyler did to become a werewolf?† Caleb glanced at her warily. â€Å"What he did? Tyler didn't do anything. The family curse caught up with him, that's al .† His face was shadowed and anxious. Stefan found his tone gentling despite himself. â€Å"Caleb, you have to kil someone to become a werewolf, even if you carry the gene. Unless you're bitten by a werewolf yourself, there are certain rituals that have to be performed. Blood rituals. Tyler murdered an innocent girl.† Caleb's knees seemed to give out, and he slid to the floor with a muffled thump. He looked sick. â€Å"Tyler wouldn't do that,† he said, but his voice was unsteady. â€Å"Tyler was like a brother to me after my parents died. He wouldn't kil anyone. I don't believe you.† â€Å"He did,† Meredith confirmed. â€Å"Tyler murdered Sue Carson. We negotiated for her to come back to life, but it doesn't change the fact that he did kil her.† Her voice held the unmistakable ring of truth, and al the fight seemed to go out of Caleb. He sank lower and rested his forehead against his knees. â€Å"What do you want from me?† He looked so thin and rumpled that, despite the urgency of their mission, Stefan was distracted. â€Å"Weren't you tal er than this?† he asked. â€Å"Bigger? More†¦ put together? The last time I saw you, I mean.† Caleb mumbled something into his knees, too muffled and distorted for even a vampire to hear properly. â€Å"What?† Stefan asked. Caleb looked up, his face smudged with tears. â€Å"It was a glamour, okay?† he said bitterly. â€Å"I made myself look better because I wanted Elena to want me.† Stefan thought of Caleb's glowing, healthy face, his height, his crowning halo of golden curls. No wonder he had seemed suspicious; subconsciously Stefan must have known how unlikely it was that an ordinary human would look that much like an archangel. No wonder he felt so much lighter than I expected when I threw him across the graveyard, Stefan thought. â€Å"So you are a magic user, even if you aren't a werewolf,† Meredith said swiftly. Caleb shrugged. â€Å"You knew that already,† he said. â€Å"I saw what you did to my workroom in the shed. What more do you want from me?† Meredith stepped forward warningly, stave at the ready, her gaze clear and pitiless, and Caleb flinched away from her. â€Å"What we want,† she said, enunciating every word distinctly, â€Å"is for you to tel us how you summoned the phantom, and how we can get rid of it. We want our friends back.† Caleb stared at her. â€Å"I swear I don't know what you're talking about.† Stefan prowled toward Caleb on his other side, keeping him off balance so that the boy's eyes flicked nervously back and forth between Stefan and Meredith. Then Stefan stopped. He could see that Caleb looked genuinely confused. Was it possible that he was tel ing the truth? Stefan knelt so that he was at eye level with Caleb and tried a softer tone. â€Å"Caleb?† he asked, depleting his last remnants of Power to compel the boy to speak. â€Å"Can you tel us what kind of magic you did? Something with the roses, right? What was the spel supposed to do?† Caleb swal owed, his Adam's apple bobbing. â€Å"I had to find out what happened to Tyler,† he said. â€Å"So I came here for the summer. No one seemed worried, but I knew Tyler wouldn't just drop out of sight. Tyler had talked about you, al of you, and Elena Gilbert. Tyler hated you, Stefan, and at first he liked Elena, and then he real y hated her, too. When I came here, though, everyone knew Elena Gilbert was dead. Her family was stil mourning her. And you were gone, Stefan; you'd left town. I tried to put the pieces together about what had happened – there were some pretty strange stories – and then lots of other weird things happened in town. Violence, and girls going crazy, and children attacking their parents. And then, suddenly, it was over; it just stopped, and it was like I was the only one who remembered it happening. But I also remembered just a normal summer. Elena Gilbert had been here the whole time, and no one thought anything of it, because they didn't remember her dying. Only I seemed to have two sets of memories. People who I'd seen get hurt† – he shuddered at the memory – â€Å"or even kil ed were fine again. I felt like I was going crazy.† Caleb pushed his shaggy dark blond hair back out of his face, rubbed his nose, and took a breath. â€Å"Whatever was going on, I knew you and Elena were at the center of it. The differences between the memories told me that. And I figured that you must be connected to Tyler's disappearance, too. Either you'd done something to him, or you knew something about what had happened to him. I figured if I could pul you and your friends apart, something would come out. Once you were set against one another, I'd be able to work my way in and find out what was going on. Maybe I could get Elena to fal for me with a glamour, or one of the other girls. I just had to know.† He looked from one to another of them. â€Å"The rose spel was supposed to make you irrational, turn you against one another.† Alaric frowned. â€Å"You mean you didn't summon anything?† Caleb shook his head. â€Å"Look,† he said, pul ing a thick leather-bound volume from under his bed. â€Å"The spel I used is in here. That's al I did, honest.† Alaric took the book and flipped through the pages until he found the right spel . He studied it, his forehead crinkling, and said, â€Å"He's tel ing the truth. There isn't anything about summoning a phantom in this book. And the spel here fits what we saw in Caleb's workshop and what I've been reading in his notebooks. This rose spel is a fairly low-level discord spel ; it would make whatever negative emotions we were feeling – hate, anger, jealousy, fear, sorrow – just a little bit stronger, make us a little more likely to blame one another for anything that went wrong.† â€Å"But when combined with the powers of whatever phantom might be hanging around here, the spel would become a feedback loop, just as Mrs. Flowers said could happen, strengthening our emotions and making the phantom more powerful,† Stefan said slowly. â€Å"Jealousy,† said Meredith thoughtful y. â€Å"You know, I hate to admit it, but I was horribly jealous of Celia when she was here.† She glanced apologetical y at Alaric, who reached out and gently touched her hand. â€Å"She was jealous of you, too,† Stefan said matter-offactly. â€Å"I could sense it.† He sighed. â€Å"And I've been feeling jealous as wel .† â€Å"So perhaps a jealousy phantom?† Alaric said. â€Å"Good, that'l give us more of a basis for researching banishing spel s. Although I haven't been feeling jealous at al .† â€Å"Of course not,† Meredith said pointedly. â€Å"You're the one who's had two girls fighting over you.† Suddenly Stefan felt so exhausted that his legs shook. He needed to feed, immediately. He nodded awkwardly to Caleb. â€Å"I'm sorry†¦ for what happened.† Caleb looked up at him. â€Å"Please tel me what happened to Tyler,† he implored. â€Å"I have to know. I'l leave you alone if you just tel me the truth, I promise.† Meredith and Stefan glanced at each other, and Stefan raised his eyebrows slightly. â€Å"Tyler was alive when he left town this past winter,† Meredith said slowly. â€Å"That's al we know about him, I swear.† Caleb stared up at her for a long moment, then nodded. â€Å"Thank you,† he said simply. She nodded back at him crisply, like a general acknowledging the troops, and led the way out of his room. Just then a muffled, cutoff shout came from downstairs, fol owed by a thud. Stefan and Alaric raced after Meredith down the stairs, almost bumping into her as she pul ed to a sudden halt. â€Å"What is it?† Stefan asked. Meredith drew aside. Matt was lying facedown at the foot of the stairs, his arms flung out as though to catch himself. Meredith stepped quickly the rest of the way down the stairs to him and turned him over gently. His eyes were closed, his face pale. He was breathing, slowly but steadily. Meredith felt his pulse, then shook him gently by the shoulder. â€Å"Matt,† she cal ed. â€Å"Matt!† She looked up at Stefan and Alaric. â€Å"Just like the others,† she said grimly. â€Å"The phantom's got him.†

Mtv Research Paper Essay

The first song that was played on MTV was called â€Å"Video killed the Radio Star†. It was sung by a group called The Buggles. This was a very popular song all over and it was deemed a good choice for the first song broadcasted. Many people also believed that the meaning of the song was that MTV, the new music video broadcasting station was going to destroy the radio. Some people thought that the song was performed live, but it was just a video. MTV was quite a big hit by the 1990’s. It was viewed in over 50 million American homes. It became a target for all advertisers because of the number of young viewers that watched MTV. The kids would beg their parents to buy the products they saw on the advertisements and it made out to be a good investment for advertisers. The attention and money that the advertisers brought in was good for MTV because they got more offers to get commercial time which means more money for them. Some people that were on MTV when it was in its first few years were Bob Dylan, Bruce Springsteen, Sheryl Crow, Cranberries, and Nirvana. They helped to kind of kick off the show and set it up for successful years to come. There are also some big-named people who probably played music from that MTV which helped to jump start their career. Madonna, Michael Jackson, Prince, Peter Gabriel, U2, and Duran Duran were some of the people that were all a part of MTV at one time. In a way, these people also helped MTV to get a good start too. The more big names that they brought in the more attention they got from viewers. This was good for the singers and MTV. The target audience that MTV chose was teens age 12 to 21. With this age group, they found that they got very good viewing rates. Artists whose songs were played on MTV found that the sales of their song increased. This is what gave advertisers the idea that they could do good business if they had an ad on MTV. With this targeted audience, they also found that their viewing rates continued to rise. Today they still target the same audience and they are still very successful in the way that they draw the audience. There have been a few changes in MTV since the start. They released a new logo after 30 years. It is not much different. It is just a little bit bigger and it is one color. The last was a mix between a few colors. The old one was designed by Frank Olinsky and it was a very big hit, but it was just time for a change. In 1986, the President and CEO, Robert Pittman left. There is no exact explanation why but he did. Over time, they started to show more reality shows than anything else. Some people liked the change to more reality shows but some people like the old school music videos all the time. There were some companies and investors that made it possible for MTV to even start. Warner Communications and American Express were big investors that helped in the starting of the show. Warner Amex was basically the main establisher and owner for about five years after the start. Then, in 1986, Viacom purchased MTV from Warner Amex. Now Viacom is the owner with all rights to MTV. There are other networks that MTV and Viacom own. They own VH1 that was released in 1985 and its purpose was to play adult contemporary. Then, in 1996, MTV2 was released to allow fans to see commercial free music videos. MTV (the original) became available in Manhattan and Los Angeles. Many people called this the second launch of MTV. They also own all Nickelodeon stations, Comedy Central, and CMT. This is not all; it is just a few that you may know. Although MTV has been very popular, it has also had a few controversial shows that some fans did not agree with. â€Å"Beavis and Butthead† was very controversial because some viewers felt that it was pointless and that the language was a bad influence for some of the younger audience that watched it. â€Å"Celebrity Deathmatch† was a part of this list because it made fun of the celebrities and it had bad language and violence. â€Å"16 and Pregnant† was another show that some people did not like because it could encourage some of the younger viewers to engage in sexual intercourse which is the problem with the people on the show. It is meant to deter kids from ending up like that but it only encourages some. â€Å"Jersey Shore† was the last show that people did not agree with. They believe that the people on the show are irresponsible and kids these days may think it’s cool and try to be like them. Over the years, MTV has had an impact on our generation, but also on our parents’ generation. A lot of younger teens’ parents that are around (14) grow up watching MTV. It is not the same now as it was then because of the popularity in different kinds of music over the years and they are now showing more reality shows. MTV also has an effect on its viewers. Most people that have ever seen MTV are probably hooked on it and they like to watch it. Also, the persuasion by friends to tell other friends to watch it because it is ‘cool’; and you aren’t if you don’t watch it. MTV has been very important over its years in various ways. It has brought a whole new way to experience music. Before MTV, you could only hear music over the radio, but when MTV aired, it played music videos, which was a whole new element to music over all. They have also helped lots of artists to grow and become more popular with just a few minutes of air time. This gas truly helped many people become more popular. With music videos,many people became more persuaded into buying the song even though they may not like the song. Even if they really like the video, they would still buy it because of the video and they weren’t paying attention to the song. It is very smart on the part of the broadcasters because they could just draw in an audience with an exciting video and you would think nothing of the song, just the video.

Grade 11 IPT Term 1 2004 essays

Grade 11 IPT Term 1 2004 essays Artificial Intelligence Minor Project (AI 1) The topic I chose for my system is European flags. I chose this topic because I will try to help people know what European flags are which. In my system there will be a series of questions asked to the user to help classify different flags. Some limitations Ive made are that I have only chosen flags for the most popular and well known countries. To use my system effectively you answer the questions asked to the best of your ability and when you have answered all the questions then you should reach a conclusion. That conclusion will be the name and picture of your flag. I think that my expert system is fairly well done. It helps the user classify the different types of European flags. It also gives a little insight to the country by giving it a brief overview. I believe that my system is extremely helpful to someone trying to find different flag names that are in Europe. If I were to rate my system out of ten, I would rate it 6/10. Some of the weak points in my expert system is that there are so many European flags and I only chose a small quantity of them. This means that there are a lot of flags left out and there is a fair possibility that people want to know those certain flags. Some of the future enhancements are increasing the amount of conclusions in the memory bank. This means increasing the number of flags. I would also if I had plenty of spare time do the world flags and then help other people know all the world flags. ...

Example of Graduate School Admission Essay †Personal Description Paper

Example of Graduate School Admission Essay – Personal Description Paper Free Online Research Papers Example of Graduate School Admission Essay Personal Description Paper Prompt: Give a candid description of yourself, stressing the personal characteristic you feel to be your strengths and weaknesses and the main factors which have influenced your personal development, giving examples if necessary. (400 words app.) The second of three children, I was born in Brazil and lived most of my teenage years in Rio de Janeiro, a very lively and international city. Son of a French entrepreneur, I had the opportunity to be involved in many different aspects of my fatherà ¢Ã¢â€š ¬Ã¢â€ž ¢s business from a young age. Of an athletic nature, sports have always been an important part in my life. At age 17, I moved to the United States in order to pursue a tennis career and to finish high school. Upon my high school graduation, I accepted a scholarship to play tennis at the University of South Florida, an institution with both a reputable academic and athletic programs. During my college years, I was able to improve my leadership and interpersonal skills since I was part of not only the tennis team, but also of many other multi-cultural teams for class assignments. My dynamic nature in business as well as discipline and self-motivation stems from my years on the tennis tournament circuit in Brazil and the United States. I received a degree with honors in business administration and accepted a position with an international company with which I did an internship during the last year of my studies. With a background in international business, I had the chance to work with various multinational companies, working together with such large corporations as Sony on many projects. Recently, I have started my own consulting company in the United States with an American and European client base. Over the years, I have had to adapt to changes in a fast-paced environment, learn quickly, and proactively take initiative. My ability to speak English, French, Portuguese and Spanish, as well as to understand, appreciate, and adapt to different cultures has been refined from extensive travel throughout Europe, North America and South America. I believe some of my strengths when used in the wrong situations become weaknesses. For example, I am a direct and honest person with a passion for perfection. However, there are situations where having more subtlety and knowing when something is good enough would be of beneficial to me. Therefore, I am constantly working on recognizing each situation in order to use my qualities to my advantage. Fortunately, throughout my entire life I have been surrounded by people who guided me, supported me, and taught me valuable lessons. I am continuously learning and growing from every experience I have and from every person who I come across, so each one plays a role on my personal development. Research Papers on Example of Graduate School Admission Essay - Personal Description PaperPersonal Experience with Teen Pregnancy19 Century Society: A Deeply Divided EraMoral and Ethical Issues in Hiring New EmployeesAnalysis of Ebay Expanding into AsiaHip-Hop is ArtTrailblazing by Eric AndersonNever Been Kicked Out of a Place This NiceHarry Potter and the Deathly Hallows EssayPETSTEL analysis of IndiaDefinition of Export Quotas

Cbt Case Study

She feels unable to discuss her issues with her boyfriend. Her parents both have mental health issues and Jane does not feel able to talk to her mother about her problems. She has an older brother she has a good relationship who lives with his girlfriend, a four hour drive away. Jane is educated to degree level, having studied Criminology and is currently working part-time for her father managing his client accounts for a business he runs from home. A typical day involves organising all receipts and creating spreadsheets for each client’s accounts. Jane states she would like to get a full time job and be normal like her friends. Jane has a small circle of friends from university who she states have all gone onto full time employment. Jane also has a puppy she spends time looking after and taking for regular walks. Assessment Jane was referred following a health check at her GP surgery. She had been prescribed Citalopram 20mg by her GP for anxiety symptoms and panic attacks she had been having for two years. Jane has no previous contact with mental health services. Jane’s father had a diagnosis of Bi-Polar Disorder, her brother has Depression and her boyfriend has a diagnosis of Obsessive Compulsive Disorder which he is continuing treatment for. Jane’s anxiety/panic has increased over the past two years. She had read about Cognitive Behavioural Therapy on the Internet and was willing to see if it was help ease her anxiety symptoms. Jane stated that the problem started due to family issues in 2007. Her brother and father were estranged due to a financial disagreement and this resulted in Jane’s brother leaving the country with his girlfriend, causing Jane to become very distressed. Also during this time she was taking her final exams at University, Jane states this was when she experienced her first panic attack. She had spent the evening before her brother left the country, drinking alcohol with friends, she remembers feeling ‘hung-over’ the next day. While travelling in the car to the airport, with her brother and his girlfriend, Jane states she started to feel unwell, she found it difficult to breathe, felt hot, trapped and felt like she was going to faint. Jane stated she felt â€Å"embarrassed† and â€Å"stupid† and had since experienced other panic attacks and increased anxiety, anticipating panic attacks in social situations. Jane had reduced where she went to, finding herself unable to go anywhere she may have to meet new people. Her last panic attack happened when Jane visited her GP for a health check and fainted during the appointment, Jane has blood phobia and she stated she had not eaten since the day before and was extremely anxious about the any medical interventions. Jane believes it was a panic attack that caused her to faint. The GP prescribed her 20mg of Citalopram, a few weeks prior to her initial assessment with the therapist. When Jane and the therapist met for the initial session Jane described herself as feeling inadequate and as if she was trapped in a cycle of panic. Although Jane felt unhappy she had no suicidal ideation and she presented no risk to others. Jane stated she had become more anxious and that she had panic attacks at least twice a week. Prior to and during therapy, Jane was assessed using various measures. These enabled the therapist to formulate a hypothesis regarding the severity of the problem, also acting as a baseline, enabling the therapist and Jane to monitor progress throughout treatment. (Wells, 1997). The measures utilised in the initial assessment were a daily panic diary, Wells (1997) and a diary of obsessive- compulsive rituals, Wells (1997) a self rating scale completed by the client Jane. Other measures used were, The Panic Rating Scale (PRS) Wells (1997), the Social Phobia Scale, Wells (1997), used by the therapist to clarify which specific disorder was the main problem for Jane. Having collated information from the initial measures, a problem list was created so the therapist and Jane could decide what to focus on first. This list was based on Jane’s account of the worst problems which were given priority over those problems which were less distressing. Problem List 1. Anxiety/Panic attacks 2. Obsessive hand washing. 3. My relationship with my family. 4. Not having a full time job. 5. My relationship with my boyfriend Having collaboratively decided on the problem list, the therapist helped Jane reframe the problems into goals. As the problem list highlighted what was wrong, changing them into goals enabled Jane to approach her problems in a more focused way (Wells, 1997), the therapist discussed goals with Jane and she decided what she wanted to get from therapy. It was important for the therapist to ensure that any goals were realistic and achievable in the timeframe and this was conveyed to Jane (Padesky Greenberger, 1995). Jane wanted to reduce her anxiety and expressed these goals:- 1. To understand why I have panic attacks. 2. To have an anxiety free day. 3. To reduce the amount of time worrying . To reduce obsessive hand washing at home. Case Formulation Jane stated that for about a year she had been repeating certain behaviours, which she believed prevented her from having panic attacks. This involved Jane washing her hands and any surrounding objects at least twice. Jane had a fear of consuming alcohol/drugs/caffeine/artificial sweeteners, she stated she had had her first panic attack the day afte r drinking alcohol and had read that all these substances could increase her anxiety. Jane had not drunk alcohol for 18 months as she felt this caused her anxiety and made her nable to control the panic attacks. Jane stated she feared that if any of these substances got on her hands and then into her mouth she would have a panic attack and faint. These beliefs increased Jane’s anxiety when Jane was exposed to any environment where these substances were present. This unfortunately was most of the time, Jane stated that every time she saw any of these substances consumed or even placed near her, she became anxious and had to wash her hands and any surrounding items which she may come into contact with again. These safety behaviours maintained the cycle of panic, Jane would always continue the routines that she believed prevented a panic attack. The worst case scenario for Jane was â€Å"the panic would never stop and I will go mad, causing my boyfriend to leave me†. Jane felt this would make everyone realise what she already knew, that she was worthless. Her last panic attack happened when Jane had visited her GP; this caused Jane feelings of shame. â€Å"There’s all these people achieving, doing great things and I can’t do the most basic things† The therapist used the Cognitive Model of Panic (Clark, 1986), initially developing the three key elements of the model to help socialise Jane to the thoughts, feelings and behaviour cycle (see diagram below) Cognitive Model of Panic Bodily sensations Emotional response Thought about sensation Clark (1986) Using a panic diary and a diary of obsessive-compulsive rituals, Jane was asked to keep a record of situations during the week where she felt anxious, and this was discussed in the next session. Jane stated she had not had any panic during the week, when discussing previous panic attacks during the session, Jane became anxious and the therapist used this incident to develop the following formulation. Heart beating fast/increase in body temperature Fear/dread I feel hot, I can’t control it Clark (1986) Jane stated she felt like she was sweating, she had difficulty breathing; felt faint, had feelings of not being here and felt like she was going crazy. All these symptoms suggested that Jane was experiencing a panic attack and Jane met the criteria for Panic Disorder, defined in the DSM IV and states that â€Å"panic attacks be recurrent and unexpected, at least one of the attacks be followed by at least one month of persistent concern about having additional attacks, worry about the implications or consequence of the attack, or a significant change in behaviour related to the attacks† (APA, 1994). During the sessions the therapist continued to socialise Jane to the model of panic (Clark, 1986); together Jane and the therapist looked at what kept the cycle going. The therapist continued to use the model formulation, with the addition of Jane’s catastrophic interpretation of bodily symptoms, to illustrate the connection between negative thoughts, emotion, physical symptoms. Social situation I will be unable to stay here Everyone will notice I am not coping I’m going to faint Sweating/breathing fast/dizzy Clark’s (1986) Cognitive Model of Panic. Progress of Treatment The therapist hypothesised that Jane’s symptoms continued due to Jane not understanding the physiological effects of anxiety. The results were a misinterpretation of what would happen to her while being anxious, and this maintained the panic cycle. Although Jane tried to avoid any anxiety by using safety behaviours, she eventually increased the anxiety she experienced. Session 1 After the initial assessment sessions, the therapist and Jane agreed to 8 sessions, with a review after 6 sessions. Jane and the therapist discussed that there may only be a small amount of progress or change during the sessions due to the complexity of Jane’s diagnosis and agreed to focus on understanding the cycle of panic (Clark, 1986) From the information gained from the formulation process, the therapist tried psycho education. The therapist was attempting to illicit a shift in Jane’s belief about what, how and why these symptoms were happening. The therapist discussed with Jane what she knew about anxiety and from this the therapist discovered that Jane was unsure of what anxiety was and the effects on the body. For the first few appointments the therapist knew it could be beneficial to concentrate on relaying information about anxiety, (Clark et al, 1989) focusing on Jane’s specific beliefs anxiety, the therapist wanted to try to reduce the problem by helping Jane recognise the connection between her symptoms. As Jane believed, â€Å"she was going mad†, the therapist was trying to help Jane understand the CBT model of anxiety and to alter Jane’s misunderstanding of the symptoms. The therapist and Jane discussed Jane’s belief that she would faint if she panicked, Jane had fixed beliefs about why she fainted. The therapist attempted to enable Jane to describe how her anxiety affected her during a ‘usual panic’. Instead Jane began to describe symptoms of social anxiety, this suggested to the therapist that the main problems could be a combination of /social phobia and obsessive behaviours; the following dialogue may help to illustrate this. T. When you begin to become anxious, what goes through your head? J. I need a backup plan; I need to know how to get out of there. Especially if it’s in an office, or a small room. T. What would happen if you did not get out? J. I would panic, and then pass out T. What would the reasons be for you to pass out? J. Because I was panicking. T. Have you passed out before when you have panicked? J. I have felt like it. T. So what sensations do you have when you’re panicking? J. The feeling rises up, I feel hot and I can’t see straight. I get red flashes in front of my eyes, like a warning. My vision goes hazy. I think everyone is looking at me. T. Do you think other people can see this? J. Yes. T. What do you think they see? J. That I’m struggling and I cannot cope or, I try to get out of the situation by pretending I feel ill before they notice. T. What would they notice, what would be different about you? J. I stick out like a beacon, I’m sweating, loads of sweat and my face is bright red. T. How red would your face be, as red as that â€Å"No Smoking† sign on the wall? J. Yes! I’m dripping with sweat and my eyes are really staring, feels like they stick out like in a cartoon, it’s ridiculous. T. How long before you would leave the situation? J. Sometimes the feeling goes, like I can control it. But I could not leave. There would be a stigma and then I could not go back, the anxiety would increase in that environment or somewhere similar. The therapist persisted with this example and tried to use guided discovery to help Jane get a more balanced view of the situation. (Padesky and Greenberger, 1995) T. So you would not go back? J. I would if I felt safe, like with my boyfriend or I could leave whenever I wanted to. It’s the last straw if I have to go. It makes it even harder. T. You say that sometimes it goes away. What’s different about then and times when you have to leave? J. It’s like I just know I have to leave. T. What do you think may happen if you stay with the feelings? J. That I will pass out. T. hat would that mean if you passed out? J. It would be the ultimate. It would mean that I could not cope with the situation. T. If you could not cope what would that mean? J. I can’t function, I can’t do anything. I‘m just no use. T. How much do you believe that? Can you rate it out of 100%? J. Now. About 60% if I did faint it would be about 100% T. Have you ever fainted due t o the sensations you have described to me? J. No. I have fainted because I’m squeamish. I don’t like blood. Or having any kind of tests at the GP. T. So do I understand you? You have never fainted due to the panic sensations? J. No. I’ve felt like it. T. So you’ve never passed out due to the symptoms? What do you make that? J. I don’t know, that would mean that what I believe is stupid. It’s hard to get my head around it. Session 2-3 The therapist used a social phobia/panic rating scale measures to ascertain the main problem; this was increasingly difficult as throughout each session the patient expanded on her symptoms. The therapist managed to understand that the patient avoided most social situations due to her beliefs about certain substances; this caused the obsessive hand-washing. This then had an impact on Jane’s ability to go anywhere in case she could not wash herself or objects around her. Jane also believed fainting from blood phobia had the same physical effects as panic, and she would faint if she panicked. It was complicated and the therapist attempted to draw out a formulation. I SEE A PERSON DRINKING ALCOHOL IT’S GOING TO GET ON MY HANDS AND INTO MY MOUTH I FEEL SICK, I’M GOING TO FAINT I FEEL DREAD, I FEEL ANXIOUS, SWEATING I MUST WASH MY HANDS TO STOP THE PANIC GETTING WORSE. Session 4 The formulation shows the extent of Jane’s panic and how her safety behaviours were impacting on all aspects of her life. The therapist attempted again to use information about the causes of anxiety and its effects on the body. The therapist explained what happens when you faint due to blood phobia, this was an attempt to supply Jane with counter evidence for her catastrophic interpretations of her panic. The therapist also used evidence to contrast the effects on the body when fainting and when panicking. After two sessions, the therapist continued to provide and attempted to relay the facts about the nature of anxiety/panic/fainting with the inclusion of behavioural experiments. Educational procedures are a valid part of overall cognitive restructuring strategies, incorporated with questioning evidence for misinterpretations and behavioural experiments (Wells, 1997) The therapist asked Jane to explain to the therapist the function/effects of adrenalin, to see if Jane was beginning to understand and if there had been any shift in her beliefs about panic. The following dialogue may help to illustrate the difficulties the therapist encountered; T. Over the last few sessions, we have been discussing anxiety and the function of adrenalin. Do you understand the physical changes we have looked at? Does it make sense to you? J. Yes. Something has clicked inside my head. I feel less insane now, I understand more about what’s going on. It makes things a little bit easier, but it takes time for it to sink in. T. Do you think you could explain to me what you understand about anxiety/adrenalin? J. As I interpret it is, I like to think of it as, â€Å"I’m not anxious it’s just my adrenalin, It’s just the effects of adrenalin effecting my body† but it’s hard to get from there, to accepting the adrenalin is not going to harm me. I know logically it’s not. But it’s still hard. T. That’s great you’re beginning to question what you have believed and are thinking there may be other explanations for your symptoms. J. Yes. But I still think it’s to do with luck. I have good or bad luck each day and that predicts whether I have a panic or not. I think I’ll be unlucky soon. Session 5-6 The therapist continued to try use behavioural experiments during the sessions to provide further evidence to try to alter Jane’s beliefs about anxiety. The therapist agreed with Jane that they would imitate all the symptoms of panic. Making the room hot, exercising to increase heart rate and body temperature, hyperventilation (ten minutes) Focusing on breathing/swallowing. This continued for most of session 5. As neither the therapist nor Jane fainted, they discussed this and Jane stated it was different in the session than when she with other people. Jane also stated she felt safe and trusted the therapist, she did not believe she could be strong enough to try the experiments alone, as it was â€Å"too scary† The therapist asked Jane to draw a picture of how she felt and put them on the diagram of a person, this then was used to compare with anxiety symptoms, while talking through them with the therapist. The therapist and Jane created a survey about fainting and Jane took this away as homework to gain further evidence. The survey included 6 different questions about fainting e. g. – What people knew about fainting/how they would feel about seeing someone faint, etc. Treatment Outcome The treatment with Jane continues. The next session will be the 6th and there will be a review of progress and any improvements. There has been no improvement in measures as noted yet. The therapist intends to use a panic rating scale (PRS) Wells, (1997) during the next session. The therapist will continue to see Jane for two more sess ions, looking at what Jane has found helpful/unhelpful. Discussion Overall the therapist found the therapy unsuccessful. Although Jane stated she found it helpful, it was difficult for the therapist to see the progress due to the many layers of complexity of Jane’s diagnosis. The therapist has grown more confident in the CBT process and understands that as a trainee, the therapist tried to incorporate all the new skills within each session. The therapist was disappointed that they were unable to guide Jane through the therapy process with a better result. The therapist would have like to have been able to fully establish an understanding of Jane’s complex symptoms earlier on in the therapy. The therapist believes that Jane’s symptoms were very complex and the therapist may have been more successful with a client with a less complicated diagnosis. The therapist would then be able to gain more information via the appropriate measures to enable the formulations in a concise manner. This has been a huge learning curve for the therapist and has encouraged them to seek out continuing CBT supervision within the therapist’s workplace. This is essential to continue the development of the therapist’s skills. The therapist feels that although this has not had the outcome that the therapist would have wanted, it has been a positive experience for Jane. There appeared to be a successful therapeutic relationship, Jane appeared comfortable and able to communicate what her problems were to the therapist from the beginning of therapy. The therapist hopes this will encourage Jane to engage with further CBT therapy in the future and the therapist over the final session hopes to be able to support Jane in creating a therapy blueprint, reviewing what Jane has found helpful. Certificate in CBT September – December 2009 CBT Case Study Panic/Social Phobia/OCD WORD COUNT 3,400 References APA (1994). Diagnostic Statistical Manual of Mental Disorders, Revised, 4th edn. Washington, DC: American Psychiatric Association Padesky, C. A Greenberger, D. (1995). Clinicians Guide to Mind Over Mood. New York: Guilford Padesky, C. A Greenberger, D. (1995). Mind Over Mood. New York: Guilford Wells, A (1997). Cognitive Therapy of Anxiety Disorders. Chichester, UK: Wiley Cbt Case Study She feels unable to discuss her issues with her boyfriend. Her parents both have mental health issues and Jane does not feel able to talk to her mother about her problems. She has an older brother she has a good relationship who lives with his girlfriend, a four hour drive away. Jane is educated to degree level, having studied Criminology and is currently working part-time for her father managing his client accounts for a business he runs from home. A typical day involves organising all receipts and creating spreadsheets for each client’s accounts. Jane states she would like to get a full time job and be normal like her friends. Jane has a small circle of friends from university who she states have all gone onto full time employment. Jane also has a puppy she spends time looking after and taking for regular walks. Assessment Jane was referred following a health check at her GP surgery. She had been prescribed Citalopram 20mg by her GP for anxiety symptoms and panic attacks she had been having for two years. Jane has no previous contact with mental health services. Jane’s father had a diagnosis of Bi-Polar Disorder, her brother has Depression and her boyfriend has a diagnosis of Obsessive Compulsive Disorder which he is continuing treatment for. Jane’s anxiety/panic has increased over the past two years. She had read about Cognitive Behavioural Therapy on the Internet and was willing to see if it was help ease her anxiety symptoms. Jane stated that the problem started due to family issues in 2007. Her brother and father were estranged due to a financial disagreement and this resulted in Jane’s brother leaving the country with his girlfriend, causing Jane to become very distressed. Also during this time she was taking her final exams at University, Jane states this was when she experienced her first panic attack. She had spent the evening before her brother left the country, drinking alcohol with friends, she remembers feeling ‘hung-over’ the next day. While travelling in the car to the airport, with her brother and his girlfriend, Jane states she started to feel unwell, she found it difficult to breathe, felt hot, trapped and felt like she was going to faint. Jane stated she felt â€Å"embarrassed† and â€Å"stupid† and had since experienced other panic attacks and increased anxiety, anticipating panic attacks in social situations. Jane had reduced where she went to, finding herself unable to go anywhere she may have to meet new people. Her last panic attack happened when Jane visited her GP for a health check and fainted during the appointment, Jane has blood phobia and she stated she had not eaten since the day before and was extremely anxious about the any medical interventions. Jane believes it was a panic attack that caused her to faint. The GP prescribed her 20mg of Citalopram, a few weeks prior to her initial assessment with the therapist. When Jane and the therapist met for the initial session Jane described herself as feeling inadequate and as if she was trapped in a cycle of panic. Although Jane felt unhappy she had no suicidal ideation and she presented no risk to others. Jane stated she had become more anxious and that she had panic attacks at least twice a week. Prior to and during therapy, Jane was assessed using various measures. These enabled the therapist to formulate a hypothesis regarding the severity of the problem, also acting as a baseline, enabling the therapist and Jane to monitor progress throughout treatment. (Wells, 1997). The measures utilised in the initial assessment were a daily panic diary, Wells (1997) and a diary of obsessive- compulsive rituals, Wells (1997) a self rating scale completed by the client Jane. Other measures used were, The Panic Rating Scale (PRS) Wells (1997), the Social Phobia Scale, Wells (1997), used by the therapist to clarify which specific disorder was the main problem for Jane. Having collated information from the initial measures, a problem list was created so the therapist and Jane could decide what to focus on first. This list was based on Jane’s account of the worst problems which were given priority over those problems which were less distressing. Problem List 1. Anxiety/Panic attacks 2. Obsessive hand washing. 3. My relationship with my family. 4. Not having a full time job. 5. My relationship with my boyfriend Having collaboratively decided on the problem list, the therapist helped Jane reframe the problems into goals. As the problem list highlighted what was wrong, changing them into goals enabled Jane to approach her problems in a more focused way (Wells, 1997), the therapist discussed goals with Jane and she decided what she wanted to get from therapy. It was important for the therapist to ensure that any goals were realistic and achievable in the timeframe and this was conveyed to Jane (Padesky Greenberger, 1995). Jane wanted to reduce her anxiety and expressed these goals:- 1. To understand why I have panic attacks. 2. To have an anxiety free day. 3. To reduce the amount of time worrying . To reduce obsessive hand washing at home. Case Formulation Jane stated that for about a year she had been repeating certain behaviours, which she believed prevented her from having panic attacks. This involved Jane washing her hands and any surrounding objects at least twice. Jane had a fear of consuming alcohol/drugs/caffeine/artificial sweeteners, she stated she had had her first panic attack the day afte r drinking alcohol and had read that all these substances could increase her anxiety. Jane had not drunk alcohol for 18 months as she felt this caused her anxiety and made her nable to control the panic attacks. Jane stated she feared that if any of these substances got on her hands and then into her mouth she would have a panic attack and faint. These beliefs increased Jane’s anxiety when Jane was exposed to any environment where these substances were present. This unfortunately was most of the time, Jane stated that every time she saw any of these substances consumed or even placed near her, she became anxious and had to wash her hands and any surrounding items which she may come into contact with again. These safety behaviours maintained the cycle of panic, Jane would always continue the routines that she believed prevented a panic attack. The worst case scenario for Jane was â€Å"the panic would never stop and I will go mad, causing my boyfriend to leave me†. Jane felt this would make everyone realise what she already knew, that she was worthless. Her last panic attack happened when Jane had visited her GP; this caused Jane feelings of shame. â€Å"There’s all these people achieving, doing great things and I can’t do the most basic things† The therapist used the Cognitive Model of Panic (Clark, 1986), initially developing the three key elements of the model to help socialise Jane to the thoughts, feelings and behaviour cycle (see diagram below) Cognitive Model of Panic Bodily sensations Emotional response Thought about sensation Clark (1986) Using a panic diary and a diary of obsessive-compulsive rituals, Jane was asked to keep a record of situations during the week where she felt anxious, and this was discussed in the next session. Jane stated she had not had any panic during the week, when discussing previous panic attacks during the session, Jane became anxious and the therapist used this incident to develop the following formulation. Heart beating fast/increase in body temperature Fear/dread I feel hot, I can’t control it Clark (1986) Jane stated she felt like she was sweating, she had difficulty breathing; felt faint, had feelings of not being here and felt like she was going crazy. All these symptoms suggested that Jane was experiencing a panic attack and Jane met the criteria for Panic Disorder, defined in the DSM IV and states that â€Å"panic attacks be recurrent and unexpected, at least one of the attacks be followed by at least one month of persistent concern about having additional attacks, worry about the implications or consequence of the attack, or a significant change in behaviour related to the attacks† (APA, 1994). During the sessions the therapist continued to socialise Jane to the model of panic (Clark, 1986); together Jane and the therapist looked at what kept the cycle going. The therapist continued to use the model formulation, with the addition of Jane’s catastrophic interpretation of bodily symptoms, to illustrate the connection between negative thoughts, emotion, physical symptoms. Social situation I will be unable to stay here Everyone will notice I am not coping I’m going to faint Sweating/breathing fast/dizzy Clark’s (1986) Cognitive Model of Panic. Progress of Treatment The therapist hypothesised that Jane’s symptoms continued due to Jane not understanding the physiological effects of anxiety. The results were a misinterpretation of what would happen to her while being anxious, and this maintained the panic cycle. Although Jane tried to avoid any anxiety by using safety behaviours, she eventually increased the anxiety she experienced. Session 1 After the initial assessment sessions, the therapist and Jane agreed to 8 sessions, with a review after 6 sessions. Jane and the therapist discussed that there may only be a small amount of progress or change during the sessions due to the complexity of Jane’s diagnosis and agreed to focus on understanding the cycle of panic (Clark, 1986) From the information gained from the formulation process, the therapist tried psycho education. The therapist was attempting to illicit a shift in Jane’s belief about what, how and why these symptoms were happening. The therapist discussed with Jane what she knew about anxiety and from this the therapist discovered that Jane was unsure of what anxiety was and the effects on the body. For the first few appointments the therapist knew it could be beneficial to concentrate on relaying information about anxiety, (Clark et al, 1989) focusing on Jane’s specific beliefs anxiety, the therapist wanted to try to reduce the problem by helping Jane recognise the connection between her symptoms. As Jane believed, â€Å"she was going mad†, the therapist was trying to help Jane understand the CBT model of anxiety and to alter Jane’s misunderstanding of the symptoms. The therapist and Jane discussed Jane’s belief that she would faint if she panicked, Jane had fixed beliefs about why she fainted. The therapist attempted to enable Jane to describe how her anxiety affected her during a ‘usual panic’. Instead Jane began to describe symptoms of social anxiety, this suggested to the therapist that the main problems could be a combination of /social phobia and obsessive behaviours; the following dialogue may help to illustrate this. T. When you begin to become anxious, what goes through your head? J. I need a backup plan; I need to know how to get out of there. Especially if it’s in an office, or a small room. T. What would happen if you did not get out? J. I would panic, and then pass out T. What would the reasons be for you to pass out? J. Because I was panicking. T. Have you passed out before when you have panicked? J. I have felt like it. T. So what sensations do you have when you’re panicking? J. The feeling rises up, I feel hot and I can’t see straight. I get red flashes in front of my eyes, like a warning. My vision goes hazy. I think everyone is looking at me. T. Do you think other people can see this? J. Yes. T. What do you think they see? J. That I’m struggling and I cannot cope or, I try to get out of the situation by pretending I feel ill before they notice. T. What would they notice, what would be different about you? J. I stick out like a beacon, I’m sweating, loads of sweat and my face is bright red. T. How red would your face be, as red as that â€Å"No Smoking† sign on the wall? J. Yes! I’m dripping with sweat and my eyes are really staring, feels like they stick out like in a cartoon, it’s ridiculous. T. How long before you would leave the situation? J. Sometimes the feeling goes, like I can control it. But I could not leave. There would be a stigma and then I could not go back, the anxiety would increase in that environment or somewhere similar. The therapist persisted with this example and tried to use guided discovery to help Jane get a more balanced view of the situation. (Padesky and Greenberger, 1995) T. So you would not go back? J. I would if I felt safe, like with my boyfriend or I could leave whenever I wanted to. It’s the last straw if I have to go. It makes it even harder. T. You say that sometimes it goes away. What’s different about then and times when you have to leave? J. It’s like I just know I have to leave. T. What do you think may happen if you stay with the feelings? J. That I will pass out. T. hat would that mean if you passed out? J. It would be the ultimate. It would mean that I could not cope with the situation. T. If you could not cope what would that mean? J. I can’t function, I can’t do anything. I‘m just no use. T. How much do you believe that? Can you rate it out of 100%? J. Now. About 60% if I did faint it would be about 100% T. Have you ever fainted due t o the sensations you have described to me? J. No. I have fainted because I’m squeamish. I don’t like blood. Or having any kind of tests at the GP. T. So do I understand you? You have never fainted due to the panic sensations? J. No. I’ve felt like it. T. So you’ve never passed out due to the symptoms? What do you make that? J. I don’t know, that would mean that what I believe is stupid. It’s hard to get my head around it. Session 2-3 The therapist used a social phobia/panic rating scale measures to ascertain the main problem; this was increasingly difficult as throughout each session the patient expanded on her symptoms. The therapist managed to understand that the patient avoided most social situations due to her beliefs about certain substances; this caused the obsessive hand-washing. This then had an impact on Jane’s ability to go anywhere in case she could not wash herself or objects around her. Jane also believed fainting from blood phobia had the same physical effects as panic, and she would faint if she panicked. It was complicated and the therapist attempted to draw out a formulation. I SEE A PERSON DRINKING ALCOHOL IT’S GOING TO GET ON MY HANDS AND INTO MY MOUTH I FEEL SICK, I’M GOING TO FAINT I FEEL DREAD, I FEEL ANXIOUS, SWEATING I MUST WASH MY HANDS TO STOP THE PANIC GETTING WORSE. Session 4 The formulation shows the extent of Jane’s panic and how her safety behaviours were impacting on all aspects of her life. The therapist attempted again to use information about the causes of anxiety and its effects on the body. The therapist explained what happens when you faint due to blood phobia, this was an attempt to supply Jane with counter evidence for her catastrophic interpretations of her panic. The therapist also used evidence to contrast the effects on the body when fainting and when panicking. After two sessions, the therapist continued to provide and attempted to relay the facts about the nature of anxiety/panic/fainting with the inclusion of behavioural experiments. Educational procedures are a valid part of overall cognitive restructuring strategies, incorporated with questioning evidence for misinterpretations and behavioural experiments (Wells, 1997) The therapist asked Jane to explain to the therapist the function/effects of adrenalin, to see if Jane was beginning to understand and if there had been any shift in her beliefs about panic. The following dialogue may help to illustrate the difficulties the therapist encountered; T. Over the last few sessions, we have been discussing anxiety and the function of adrenalin. Do you understand the physical changes we have looked at? Does it make sense to you? J. Yes. Something has clicked inside my head. I feel less insane now, I understand more about what’s going on. It makes things a little bit easier, but it takes time for it to sink in. T. Do you think you could explain to me what you understand about anxiety/adrenalin? J. As I interpret it is, I like to think of it as, â€Å"I’m not anxious it’s just my adrenalin, It’s just the effects of adrenalin effecting my body† but it’s hard to get from there, to accepting the adrenalin is not going to harm me. I know logically it’s not. But it’s still hard. T. That’s great you’re beginning to question what you have believed and are thinking there may be other explanations for your symptoms. J. Yes. But I still think it’s to do with luck. I have good or bad luck each day and that predicts whether I have a panic or not. I think I’ll be unlucky soon. Session 5-6 The therapist continued to try use behavioural experiments during the sessions to provide further evidence to try to alter Jane’s beliefs about anxiety. The therapist agreed with Jane that they would imitate all the symptoms of panic. Making the room hot, exercising to increase heart rate and body temperature, hyperventilation (ten minutes) Focusing on breathing/swallowing. This continued for most of session 5. As neither the therapist nor Jane fainted, they discussed this and Jane stated it was different in the session than when she with other people. Jane also stated she felt safe and trusted the therapist, she did not believe she could be strong enough to try the experiments alone, as it was â€Å"too scary† The therapist asked Jane to draw a picture of how she felt and put them on the diagram of a person, this then was used to compare with anxiety symptoms, while talking through them with the therapist. The therapist and Jane created a survey about fainting and Jane took this away as homework to gain further evidence. The survey included 6 different questions about fainting e. g. – What people knew about fainting/how they would feel about seeing someone faint, etc. Treatment Outcome The treatment with Jane continues. The next session will be the 6th and there will be a review of progress and any improvements. There has been no improvement in measures as noted yet. The therapist intends to use a panic rating scale (PRS) Wells, (1997) during the next session. The therapist will continue to see Jane for two more sess ions, looking at what Jane has found helpful/unhelpful. Discussion Overall the therapist found the therapy unsuccessful. Although Jane stated she found it helpful, it was difficult for the therapist to see the progress due to the many layers of complexity of Jane’s diagnosis. The therapist has grown more confident in the CBT process and understands that as a trainee, the therapist tried to incorporate all the new skills within each session. The therapist was disappointed that they were unable to guide Jane through the therapy process with a better result. The therapist would have like to have been able to fully establish an understanding of Jane’s complex symptoms earlier on in the therapy. The therapist believes that Jane’s symptoms were very complex and the therapist may have been more successful with a client with a less complicated diagnosis. The therapist would then be able to gain more information via the appropriate measures to enable the formulations in a concise manner. This has been a huge learning curve for the therapist and has encouraged them to seek out continuing CBT supervision within the therapist’s workplace. This is essential to continue the development of the therapist’s skills. The therapist feels that although this has not had the outcome that the therapist would have wanted, it has been a positive experience for Jane. There appeared to be a successful therapeutic relationship, Jane appeared comfortable and able to communicate what her problems were to the therapist from the beginning of therapy. The therapist hopes this will encourage Jane to engage with further CBT therapy in the future and the therapist over the final session hopes to be able to support Jane in creating a therapy blueprint, reviewing what Jane has found helpful. Certificate in CBT September – December 2009 CBT Case Study Panic/Social Phobia/OCD WORD COUNT 3,400 References APA (1994). Diagnostic Statistical Manual of Mental Disorders, Revised, 4th edn. Washington, DC: American Psychiatric Association Padesky, C. A Greenberger, D. (1995). Clinicians Guide to Mind Over Mood. New York: Guilford Padesky, C. A Greenberger, D. (1995). Mind Over Mood. New York: Guilford Wells, A (1997). Cognitive Therapy of Anxiety Disorders. Chichester, UK: Wiley

Medication adherence with clients with schizophrenia Essay

Medication adherence with clients with schizophrenia - Essay Example The prevalence of medication non-adherence has been reported to be almost half of the total population of patients with schizophrenia (Tabor & Lopez, 2004). The prevalence could even be higher considering that the figures do not count patient with schizophrenia who decline treatment or quit routine check-up. Hence, a frequent cause of treatment failure is medication non-adherence, and the most widespread kind of non-adherence is inadequate use of these drugs. The consequences of non-adherence involve disruption of work activities and home life, re-hospitalization, and recurrence of psychotic symptoms. Monitoring adherence to medications and evaluating side effects is an important medical task when caring for patients with schizophrenia (Higashi et al., 2013). This essay reviews the literature on medication adherence and non-adherence in patients with schizophrenia. Determinants of non-adherence to medication can be classified into four, namely, patient-based aspects (e.g. gender, age , income, education), health-based aspects (e.g. substance abuse, duration of ailment, symptomatology), aspects related to antipsychotic medication, and socio-environmental aspects (e.g. social support, relationship between healthcare provider and patient). The literature review of Higashi and colleagues (2013) explains that there are numerous studies that investigated the correlation between socio-demographic factors (e.g. gender, age, education) and medication non-adherence but discovered no consistent relationship. There are findings revealing that adolescents are less likely to adhere to medication than their older counterparts. Several studies have discovered no relationship between gender and non-adherence, but some researchers, like Tunnicliffe and associates (1992 as cited in Higashi et al., 2013), discovered that females have a greater tendency than males to adhere to anti-psychotic medication. It has also been reported that certain ethnic minority groups, such as African A mericans, tend to be noncompliant. But there are other researchers, such as Owen and colleagues (1996 as cited in Higashi et al., 2013), who found no correlation between ethnicity and medication non-adherence. The researchers conclude that almost all studies report little or no correlation between socio-demographic factors and medication adherence. Lack of insight is a major attribute of individuals with schizophrenia. It is easy to understand why individuals with poor awareness have showed a greater risk for noncompliance to medication. There is no definite explanation of awareness in psychotherapy, but usually, it means understanding of one’s sickness and its outcomes or effects (Kozuki & Froelicher, 2003). Rusch and Corrigan (2002) enumerate four features of awareness: cognitive features, adherence based features, symptom based features, and temporal features. Lack of awareness has major therapeutic, clinical, and social significance. Nevertheless, its repercussions on med ication adherence are most vital in the recovery period of schizophrenia. The patient’s extent of awareness of the disorder is directly associated with his/her attitudes toward or beliefs about the treatment. Rusch and Corrigan (2002) found out that psychological coping mechanism and neurocognitive problems may worsen lack of awareness. They also discovered that awareness predicted adherence to psychosocial therapies for