However purchase yasmin 3.03 mg without a prescription, when the patient was stabilized trusted 3.03 mg yasmin, his art, as well as his delu- sional system, focused on superheroes and the armed services. Since the cli- ent was stabilized on his medication it was time to begin a treatment plan that touched upon his delays and promoted autonomy. Thus, the use of plastic models was employed (initially in individual sessions) to provide him with structured play, and then he was incorporated into groups with peers to lessen his dependency on institutional personnel. The process of collecting, organizing, and classifying is exceedingly im- portant to the growing individual, or delayed client, as it ushers in the en- suing age of adolescence. As a ﬁnal word on collecting, I am certain that most readers of this book will know an adult in their lives who is an avid collector, thus proving that the art of collecting is not merely a childish ac- tivity. To own "all" of something and to be able to direct and organize (and in the case of obses- sional collecting, to consume) it in whatever fashion one desires offers the individual a special place. Freud began his collecting 2 months after his father’s death, and it is believed that his collection assuaged the loss and grief that threatened to overwhelm him. At the end of his life these minia- ture statues lined his desk like an audience (Gamwell & Wells, 1989), of- 96 Adaptation and Integration fering a much-needed sense of solace and calm, much like what occurs in the stage latency. Summary We began the chapter by asking a series of questions: Is the presenting problem a function of the personality? We must end the chapter by stating that the answer most certainly de- pends upon the client, for the function of personality does not rest on one theory, one belief, or one therapeutic intervention. As humans, we are complex creatures, for we are not the same today as we were 10 years prior, nor will we remain unchanged by life’s events 10 years into the future. Thus, a basic understanding of the norms of development can offer the cli- nician insight into the complexity of issues that may besiege a client at any given point in life. For the purposes of this book only three theorists, out of a host of researchers, are featured, because their models have been use- ful in assessing the difﬁcult client. In the end, the clinician should seek the repetition of behavior that is calling out for mastery. The recurrence of be- havior in clients’ life stories; their behavior outside of the therapeutic hour; their self-concept, fears, and defenses; and of course the symbolism inher- ent in their art is what I refer to as a symbolic abundance of ideas. This patient, a regressed schizophrenic, had a propensity to- ward theft, ﬂushing rolls of toilet paper down commodes, and hoarding found items. All of this information was offered by staff, and these habits were deﬁnitely a point of contention in the dorm where the client lived. Arieti (1955) outlined four stages of the progression of the disease of schizophrenia. In the third stage he not only discusses hoarding but also in- dicates that an absence of symptoms prevails, as the client has learned to conceal his hallucinations and delusions, if only on a surface level. He states: The schizophrenic seems to hoard in order to possess; the objects he collects have no intrinsic value; they are valuable only inasmuch as they are pos- sessed by the patient. The patient seems almost to have a desire to incorpo- rate them, to make them a part of his person.... Thefact remains that this tendency is a non-pathognomonic manifestation of advanced schizophrenic regression. At this juncture, it was becoming more and more ap- parent that this patient was "screaming" to collect, to possess. When developing a treatment plan, one must meet the client within and slightly above his or her level of development to encour- age further developmental growth. Thus, in this case the therapist chose ages 6 to 12: the stage of latency (Freud), concrete operations (Piaget), and industry versus inferiority (Erikson). It was of the utmost importance for the client to complete this treat- ment plan with another person (to promote a sense of social participation and action) and for the clinician to follow through on statements in a timely manner (to circumvent the client’s feeling that only one chance is available and to promote trust). However, the client was not merely pre- sented with an array of models: He had to earn them through a token econ- omy system and incorporate budgeting into his thinking. Consequently, if he was going to "incorporate" as part of his ﬁxation and collect as part of 98 Adaptation and Integration his need to possess, he should do so in a manner that bespoke of mastery and production. Ultimately, utilizing the steps outlined in this chapter, therapists can base treatment plans on not only knowledge of the client (their needs, fears, and defenses), but also knowledge of the existing literature by a wide range of researchers, clinicians, and theorists. In the end Piaget believed that the individual must master emerging conﬂict in order to prepare for future growth and integrity. It is this pattern of living that provides us with our self-concept, our identity, our abilities, and our worth. This ethereal quality that lives nowhere but ex- ists within us all changes for the better or the worse with time and em- braces our anxieties, joys, resentments, responsibilities, pleasures, and fears. How does one break through the well-honed defenses that protect us from psychic pain and emerge with an unvarnished view? In its use the disguise of language, developed ever so carefully over a lifetime, is dropped, and in its place a psyche is projected onto a blank piece of paper—a reﬂection of not only an individual’s self-concept but his or her concept of others. A pro- jection of ourselves and our environment as we see it, from our own view- point, without any inﬂuence from external subjective material. Projective testing has always had many detractors, and we review this literature later in the chapter; however, it is my belief that although the un- conscious nature of art certainly makes its study difﬁcult such study is by no means impossible. In that vein, this chapter focuses on projective methods of personality analysis and spotlights three techniques: the Draw-A-Person (DAP), the House-Tree-Person (HTP), and the Eight-Card Redrawing Test (8CRT). I have selected the ﬁrst two procedures because they are the most frequently utilized of the art projective tests. I include the 8CRT because in my own 103 Reading Between the Lines work with the difﬁcult client this assessment tool has proven to be indis- pensable for evaluating personality decompensation. The history of art projective testing can be traced to Florence Good- enough’s Measurement of Intelligence by Drawings (1926).
All said cheap 3.03 mg yasmin visa, an individual can intellectualize verbally yasmin 3.03mg generic, but an art production opens the window to unconscious meaning. In this project no direct inter- pretation was made of the underlying process, yet this information was uti- lized to help the client produce work that expressed his emotionally laden material while reassuring and supporting his fragile sense of self. Hisego must have time to gradually abandon its dependent position and again take over full responsibility" (Sargent, 1974, p. In Part 3 we will revisit this client as a case study utilizing art ther- apy coupled with the mutual storytelling techniques of Richard Gardner. Beyond individual therapy lies group therapy, yet for many therapists residential, or inpatient, group therapy proves exceedingly challenging. As part of a larger system these groups are often lost within the institu- tionalized setting. Additionally, training for group inpatient therapy at the university level is often lacking, which leaves the clinician to rely on train- ing that may not encompass a focus on interpersonal, here-and-now, in- teractional learning. Yalom (1983), a master of group process, outlined three major options with an inpatient population: to focus on (1) the here- and-now, (2) the then-and-there problem, or (3) a common theme. He ad- vocates the here-and-now focus, which helps clients to observe their own process through group interaction. He further describes the problems en- countered in a then-and-there group, which range from one person’s mo- nopolizing the hour (with little success in solving the issue) to a grousing session that wastes precious therapeutic opportunities. He deﬁnes a com- mon theme discussion as an interesting personal or issue-oriented conver- sation that leaves members with a lack of mastery over their individual concerns. In short, within a content-focused group the therapist has a tendency to neglect the process, and it is through these changes that therapy can move forward for both the individual and the group. Words, which can be denied and shaped into a favorable light by a manipulative client, are useless when faced with an art production. One such example was an adult male with a history of auditory halluci- nations that began when he was a teenager. Extensive testing revealed that 8 Introduction he showed himself in a positive light, while experiencing a great deal of paranoia, rumination, and perceptual disturbances. Results also suggested the presence of anxiety and poor emotional resources for coping. In groups he would sermonize to the other members and was either idolized or ig- nored. His verbal statements were a combination of grandiosity and non- sense, yet to an institutionalized client he appeared conﬁdent and worldly. At the time of this project he had less than one week left in the group, as he had been released. The group was instructed to "Draw a feeling of your choosing" on the fourth side of premade boxes. All these questions need to be asked if the group mem- bers are going to learn to observe their own processes. The steps that the client took to ﬁnish this drawing are as follows: He ﬁnished the hourglass quickly. The ﬁrst addition was the broken glass in the upper portion; note the glass shards at the base. When it was his turn to speak, he proudly explained that this drawing represented his "short time" in the facility. The "doves" represented his up- coming freedom; rendered in the color black, these doves of peace appear more like seagulls, scavengers. It only took one in- dividual to point out the broken glass shards and the brown border before all were agreeing that the image looked anxious and fearful. The client, thrown off guard, attempted to dismiss and minimize the group’s input. However, by stepping back from his defensive position and observing his own art production, he eventually spoke of his fears—without sermoniz- ing, without bravado—just as a person afraid of a community that had not embraced him for numerous years. Yalom (1983) states: One elementary but important goal of the inpatient group is that patients simply learn that talking helps. They learn that unburdening and discussing their problems not only offers immediate relief but also initiates the process of change. To learn, often for the ﬁrst time, that one’s experience is, after all, human and shared by many others is enormously reassuring and one of the most potent antidotes to a state of devastating isolation. Developing the Language of Metaphor One cannot explore consciousness, or self-awareness, without asking how we arrive at such a state. It is widely believed that the portion of our personality that dictates our thoughts, memories, feelings, impulses, and desires is built upon a sequence of phases. As infants we respond on a pri- 10 Introduction mary level of consciousness, which mainly encompasses sensations, in- stincts, and movement. As adults we become increasingly free to experi- ence memory, language, and symbolization. Regardless of whether you subscribe to a psychosocial model, a psychosexual model, or a model that encom- passes intellectual development, the stages of human life must be solved. It is this personality that grapples with outside pressures, copes with cri- sis, interacts in social situations, and builds memories that can be accessed through the conscious and unconscious. Jay Haley (1976) states, "The psy- chodynamic therapist as well as the behavior therapist is interested in metaphors about the past because of an assumption that past traumas lead to present difﬁculties" (p.
Speciﬁc tasks such as have completed before you die but continue to hope that delivering bad news cheap 3.03 mg yasmin with mastercard, discussing advance care planning generic 3.03 mg yasmin mastercard, you are one of the lucky people who gets a bit more helping patients through the transition to hospice care, time. Suggesting that a patient receive palliative care risks conveying a sense of abandonment. Physicians must be References emphatic that palliative care and hospice are active forms of care that meet patients’ varying goals at the end of life. Butow PN, Kazemi JN, Beeney LJ, Grifﬁn AM, Dunn SM, However, further exploration of a patient’s or family’s Tattersall MH. When the diagnosis is cancer: patient com- concerns about abandonment are important to under- munication experiences and preferences. Cancer patients’ concerns: congruence between patients and primary care physicians. Disclosure of concerns by hospice the physician to reframe the patient’s understanding of patients and their identiﬁcation by nurses. The outpatient medical encounter and elderly goals might be in light of this new information. Tulsky end of life by patients, family, physicians, and other care in patients with asthma or rheumatoid arthritis: a random- providers. Communication treatment planning discussions with nursing home resi- between older patients and their physicians. Opening the clues and physician responses in primary care and surgical black box: how do physicians communicate about advance settings. The patient s story: integrating the evidence from the McGill Quality of Life Questionnaire. A review of of informal caregivers’ satisfaction with services for dying the literature. Topics in of physician-patient interaction on the outcomes of chronic Palliative Care, vol 4. Sehgal A, Galbraith A, Chesney M, Schoenfeld P, Charles physician-initiated advance directive discussion. Wenrich MD, Curtis JR, Shannon SE, Carline JD,Ambrozy patient toward life support: a survey of 200 medical in- DM, Ramsey PG. Personal probability of survival on patients’ preferences regarding communication, 2001. This page intentionally left blank 26 Care Near the End of Life Sarah Goodlin Advances in medical science during the past half century physicians who care for elderly patients should know allow people to survive many acute illnesses that previ- how to care for patients at the end of life. Yet, rather than interdisciplinary approach to patients with multiple curing illness, most medical interventions permit us to medical, social, and functional problems utilized in all of manage chronic disease. Most Americans age with one or geriatrics applies equally to all seriously ill and dying more degenerative or disabling diseases and require daily patients. This chapter reviews available data about death assistance toward the end of life. It is difﬁcult or impos- in elderly Americans and presents an approach to care sible to identify a point at which a gradually worsening for those nearing the end of life. In the process of ongoing care, physicians and patients often become aware that the likely beneﬁts of certain treat- Dying in the United States ments or diagnostic tests may be outweighed by their discomfort or other burdens. For some patients, no National data from 1998 death certiﬁcates indicate 33% treatment offers hope for prolongation of life or restora- of deaths were from heart disease, 23% from cancer or tion of function, and their care becomes focused on malignant neoplasm, and 7% from stroke. Evaluation of palliation of symptoms and enhancing the quality of their Medicare claims data for the last year of life shows remaining life. Other patients with advanced illness may multiple diagnoses in the majority of decedents. In that prefer to attempt to prolong life, but they will also beneﬁt analysis, heart diseases are present in 66%, neoplasm in from efforts to reduce symptoms and address social, exis- 31%, pneumonia and inﬂuenza in 29%, chronic obstruc- tential, and spiritual needs. Among Medicare beneﬁciaries better viewed as "shifting the emphasis" of treatment to receiving hospice care, 40% had malignant neoplasm, an intensive focus on maintaining dignity, enhancing 10% had congestive heart failure, and 6% had other heart quality of life, supporting the family, and lessening the disease. All patients with advanced illness will States received hospice care in 1998; more than 80% of beneﬁt from this focus, even when they are still receiving those were white or Caucasian. Refer- palliative care in settings such as the hospital or intensive rals from physicians to hospice programs often come very care unit, associated with the acknowledgment that late in the course of the illness. States annually occur in persons over the age of 65 and In the United States, 50% to 60% of individuals die in 1 26% are in persons age 85 years or older. Goodlin payment system for Medicare in the mid-1980s, the site Reducing highly technical or life-sustaining interventions of death for Medicare recipients shifted from the acute for those who are very near death may yield only small hospital toward nursing homes. The regional number of hospital beds is inversely related to the likelihood of death at Care for patients near the end of life can be viewed as a home. While each individual progresses toward distinct hospitals in the rates of death at home correlated death in his or her own way, the process of providing care with hospital beds per capita when controlled for age, should include certain fundamental steps, which are disease, income, preference for site of death, and family depicted in Figure 26. In 1994 to 1995, the number of days in patterns, physicians identify life expectancy and pro- the hospital in the ﬁnal 6 months of life was 4. Similar variation was observed in intensive care course of their disease (including the fact that they will use, visits by medical specialists, and visits to 10 or more die of this disease at some point), and the beneﬁts and physicians in the last 6 months of life. Death in the hospital often occurs without speciﬁc Physicians must talk with patients and their families plans to meet patient and family needs and is frequently about what is medically possible and reasonable in a accompanied by interventions of uncertain value. Medical options and patient values and pre- developed in several institutions10 but are not the norm. As disease and care progress, the goals may change; sions to withhold or remove life-prolonging therapies.
Most libraries purchase yasmin 3.03mg otc, including most local public libraries now have computer terminals for keyword and title searches cheap 3.03 mg yasmin amex. Library staff are usually keen to help with difﬁcult searches and to help locate speciﬁc information. Clinical trials in the 1970s and later showed that it reduced the length of relapses or exacerbations in MS. More recently, a different family of steroids (gluco- corticosteroids) has been found to have fewer side effects, as well as generally being more effective. So ACTH is used less in MS than previously, although some neurologists feel that ACTH still has signiﬁcant value in treating MS relapses. Some degree of tremor is normal for all people, but a tremor that interferes with ordinary activity may be a symptom of neuromuscular disorder. Some particular sets of activities, as well as formalized procedures for measuring the performance of those activities, have become established as assessments of the degree of disability caused by MS. Such ADL scores may be used to record the progress of MS, to assess domestic needs or to test the effects of drugs in clinical trials. The name refers to the way in which the drugs work by affecting the parasympathetic nervous system, reducing spasms (contractions) in the bladder and thus reducing the likelihood of involuntary or too frequent urination. Tests can reveal changes in the speed, shape and distribution of these signals which are indicative of a diagnosis of MS. The systematic study of autoimmune diseases as a group is an important part of research into MS. In normal circumstances, essential nutrients can cross the barrier from the blood into the brain and waste products cross from the brain into the blood, but the cells of the brain are shielded from potentially harmful substances. Borrelia burgdorferii The Latin name for the infectious organism that causes Lyme disease, an entirely treatable infection spread by ticks, which has many symptoms in common with MS and can be mistaken for it. Dietary changes include an increase in ﬁbre and ﬂuid intake to increase the bulk and to soften bowel movements and a reduction in intestinal irritants such as coffee and alcohol. A bowel regimen may also employ laxatives and drugs to help complete emptying of the bowel at predictable times. Candida albicans Also known as thrush, this is a fungus that is often present in the genitals, mouth and other moist parts of the body. Symptoms of candidiasis include irritation, itching, abnormal discharges and discomfort on passing water. The CSF contains proteins and tissue fragments that can aid the diagnosis of neurological disorders and differentiate MS from other conditions (such as a haemorrhage) with similar or overlapping symptoms. Changes in cognitive ability are often subtle and not apparent without sophisticated testing. Computerized manipulation of the exposures results in clear images of ﬁne structures such as sclerotic plaques within the brain or spinal column. Exercises to maintain the ﬂexibility of joints are particularly important because contractures may be made worse by lack of joint use. The breakdown of myelin leads to poor or weak messages to various parts of the body and may lead, in the case of MS, to the formation of plaques or scarring with hardened (sclerotic) tissue. Often epidemiological studies try to ﬁnd relationships between the frequency of MS and variations in other factors (such as diet or exposure to infections). They cannot be synthesized by the body and must be obtained from the diet – these are the families of linoleic, linolenic and arachidonic acids. Treatment of faecal incontinence with a bowel regimen is often completely successful in preventing involuntary bowel movements. This can be due to an inherited susceptibility to the disease (nature) or to the environmental and other exposures that families inevitably share (nurture). The condition results from weakness in the ankle and foot muscles, caused by weakening of nervous system control of these muscles. A number of objective tests have been developed to assess the extent to which these abilities may be affected by the progression of MS. They have been widely used in MS because immune responses are considered to be directed against the person’s own body in the disease. Improved case ascertainment is the increased ability of the medical services to identify correctly such existing cases which have been previously undetected. When the incidence of a disease is low, incidence will be reported per 100,000 people per year. Incontinence may result in occasional accidents or in more serious loss of voluntary control of urination or bowel movements. In other words, the further you go from the equator, the more increases in MS cases there are, but cases lessen towards the polar regions. The nature of the relationship has not been fully unravelled, and there many explanations as to why it should exist. Not all legally available drugs are licensed, such as new and untested drugs as well as some private treatments, supplements and complementary treatments. Unlike X-ray imaging, MRI can image soft tissue such as the brain, spinal cord and blood vessels. A diagnosis of malignant MS may be made, based on a particularly severe instance of MS, an uncharacteristically rapid progression or the absence of distinct periods of remission. The boundaries between primary progressive and malignant MS are indistinct and dependent upon clinical judgement. The taking of a medical history (the interview in which a doctor asks how an illness or symptoms started) is a crucial ﬁrst phase in the diagnosis of any condition. In the case of MS, where diagnosis can be a long, tedious and complex procedure, the collection of an accurate and complete medical history is of particular importance.
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