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By K. Ugrasal. Stevens-Henager College.

Provide support during disclosure of painful experiences and reassurance when the client becomes discouraged with lengthy treatment discount prednisone 10 mg without a prescription. Possible Etiologies (“related to”) [Severe level of anxiety cheap prednisone 40mg on line, repressed] [Childhood trauma] [Childhood abuse] [Threat to physical integrity] [Threat to self-concept] Defining Characteristics (“evidenced by”) [Alteration in the perception or experience of the self] [Loss of one’s own sense of reality] [Loss of the sense of reality of the external world] Dissociative Disorders ● 199 Goals/Objectives Short-term Goal Client will verbalize adaptive ways of coping with stress. Long-term Goal By time of discharge from treatment, client will demonstrate the ability to perceive stimuli correctly and maintain a sense of reality during stressful situations. The client manifesting these symptoms may express fear and anxiety at experiencing such behaviors. Explain the depersonalization behaviors and the pur- pose they usually serve for the client. This knowledge may help to minimize fears and anxieties associated with their occurrence. Explain the relationship between severe anxiety and deper- sonalization behaviors. The client may be unaware that the occurrence of depersonalization behaviors is related to severe anxiety. Help client relate these behaviors to times of severe psy- chological stress that he or she has experienced personally. Knowledge of this relationship is the first step in the process of behavioral change. Explore past experiences and possibly repressed painful situations such as trauma or abuse. It is thought that trau- matic experiences predispose individuals to dissociative disorders. Discuss these painful experiences with the client and en- courage him or her to deal with the feelings associated with these situations. These interventions serve to decrease the need for the dissociative response to anxiety. Discuss ways the client may more adaptively respond to stress and role-play with him or her to practice using these new methods. Having practiced through role-play helps to pre- pare client to face stressful situations by using these new behaviors when they occur in real life. Client perceives stressful situations correctly and is able to maintain a sense of reality. Sexual dysfunction disorders can be described as an impairment or disturbance in any of the phases of the sexual response cycle. These include disorders of desire, arousal, and orgasm and disorders that relate to the experience of genital pain during intercourse. Paraphilias The term “paraphilia” is used to identify repetitive or preferred sexual fantasies or behaviors that involve any of the following: 1. Repetitive sexual activity with humans involving real or sim- ulated suffering or humiliation. Most individuals with paraphilias are men, and the behavior is generally estab- lished in adolescence (Andreasen & Black, 2006). Common fetish objects include bras, women’s underpants, stockings, shoes, boots, or other wearing apparel. The fetish object is generally used during masturbation or in- corporated into sexual activity with another person to pro- duce sexual excitation. When the fetish involves cross-dressing, the disorder is called transvestic fetishism. Sexual excitement is derived from the actual touching or rubbing, not from the coercive nature of the act. The age of the mo- lester is 16 or older and is at least 5 years older than the child. Examples include becoming sexually aroused by self-inflicted pain or by being restrained, raped, or beaten by a sexual partner. The sadistic activities may be fantasized or acted on with a consenting or nonconsenting partner. In all instances, sexual excitation occurs in response to the suffer- ing of the victim. Sexual excitement is achieved through the act of looking, and no contact with the person is attempted. Masturba- tion usually accompanies the “window peeping” but may Sexual and Gender Identity Disorders ● 203 occur later as the individual fantasizes about the voyeuris- tic act. Biological Factors: Various studies have implicated sev- eral organic factors in the etiology of paraphilias. De- struction of parts of the limbic system in animals has been shown to cause hypersexual behavior (Becker & Johnson, 2008). Temporal lobe diseases, such as psy- chomotor seizures or temporal lobe tumors, have been implicated in some individuals with paraphilias. Abnor- mal levels of androgens also may contribute to inappro- priate sexual arousal. The majority of studies involved violent sex offenders, and the results cannot accurately be generalized.

If the doctor adopts a reasonable and responsible attitude discount prednisone 20 mg fast delivery, he or she will usually receive the sympathetic understanding and cooperation of the law- yers and the court in arranging a time to give evidence that least disrupts his or her practice prednisone 20 mg online. However, any exhibition of belligerence by the doctor can induce a rigid inflexibility in lawyers and court officials—who always have the ability to “trump” the doctor by the issuance of a summons, so be warned and be reasonable. A doctor will usually be allowed to refer to any notes made contemporaneously to “refresh his memory,” although it is courteous to seek the court’s agreement. Demeanor in Court In the space available, it is not possible to do more than to outline good practice when giving evidence. Court appearances are serious matters; an individual’s liberty may be at risk or large awards of damages and costs may rely on the evidence given. The doctor’s dress and demeanor should be appro- priate to the occasion, and he or she should speak clearly and audibly. As with an oral examination for medical finals or the defense of a writ- ten thesis, listen carefully to the questions posed. Think carefully about the reply before opening your mouth and allowing words to pour forth. Answer the question asked (not the one you would like it to have been) concisely and carefully, and then wait for the next question. There is no need to fill all silences with words; the judge and others will be making notes, and it is wise to keep an eye on the judge’s pen and adjust the speed of your words accordingly. Pauses between questions allow the judge to finish writing or counsel to think up his or her next question. If anything you have said is unclear or more is wanted from you, be assured that you will be asked more questions. Be calm and patient, and never show a loss of temper or control regard- less of how provoking counsel may be. An angry or flustered witness is a gift to any competent and experienced counsel, as is a garrulous or evasive wit- ness. Stay well within your area of skill and expertise, and do not be slow to admit that you do not know the answer. Your frankness will be appreciated, whereas an attempt to bluff or obfuscate or overreach yourself will almost certainly be detrimental to your position. Doctors usually seek consensus and try to avoid confrontation (at least in a clinical setting). They should remember that lawyers thrive on the adversarial process and are out to win their case, not to engage on a search for truth. Thus, lawyers will wish to extract from witnesses answers that best sup- port the case of the party by whom they are retained. However, the medical witness is not in court to “take sides” but rather to assist the court, to the best of the expert witness’ ability, to do justice in the case. Therefore, the witness should adhere to his or her evidence where it is right to do so but must be prepared to be flexible and to make concessions if appropriate, for example, because further evidence has emerged since the original statement was pre- pared, making it appropriate to cede points. The doctor should also recall the terms of the oath or affirmation—to tell the truth, the whole truth, and nothing but the truth—and give evidence accordingly. The essential requirements for experts are as follows: • Expert evidence presented to the court should be seen as the independent product of the expert, uninfluenced regarding form or content by the exigencies of litiga- tion (30). If the expert cannot assert that the report contains the truth, the whole truth, and nothing but the truth, that qualification should be stated on the report (32). In England and Wales, new Civil Procedure Rules for all courts came into force on April 16, 1999 (34), and Part 35 establishes rules governing experts. The expert has an overriding duty to the court, overriding any obliga- tion to the person who calls or pays him or her. An expert report in a civil case must end with a statement that the expert understands and has complied with the expert’s duty to the court. The expert must answer questions of clarifica- tion at the request of the other party and now has a right to ask the court for Fundamental Principals 57 directions to assist him in conducting the function as an expert. The new rules make radical changes to the previous use of expert opinion in civil actions. Most pit- falls may be avoided by an understanding of the legal principles and forensic processes—a topic of postgraduate rather than undergraduate education now. The normal “doctor–patient” relationship does not apply; the forensic physi- cian–detained person relationship requires that the latter understands the role of the former and that the former takes time to explain it to the latter. Meticulous attention to detail and a careful documentation of facts are required at all times. You will never know when a major trial will turn on a small detail that you once recorded (or, regrettably, failed to record). Your work will have a real and immediate effect on the liberty of the individual and may be highly influential in assisting the prosecuting authorities to decide whether to charge the detained person with a criminal offense.

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In the right-hand column purchase 5 mg prednisone, list any steps you can take now or in the future that may be useful in solving this problem cheap 40 mg prednisone with amex. Worksheet 5-21 My Reflections Chapter 6 Indicting and Rehabilitating Thoughts In This Chapter Investigating and charging thoughts Putting thoughts on trial Repairing thoughts ost people simply assume that thoughts they have about themselves and the world Mare true. But thoughts don’t always reflect reality, just as funhouse mirrors don’t reflect the way you really look. In Chapter 5, we help you uncover the distortions (also known as reality scramblers) in your thoughts. We show you how to take your distorted thoughts to court and charge them with the crime of inflicting misery on yourself. If you find them guilty (and we think you will), you see how to rehabilitate those criminal thoughts so that they can contribute to your well-being. From Arraignment to Conviction: Thought Court We base our technique called Thought Court on the principles of cognitive therapy. Beck, who discovered that changing the way people think changes the way they feel. Many studies attest to the fact that cognitive therapy works very well to alleviate anxiety and depression. We give you examples of Thought Trackers in this section, but for more information, flip to Chapter 4. Thought Court is a process of indicting the accused thought (the one you pinpoint in your Thought Tracker) and then bringing it to trial. As the defense attorney, you present the evidence that supports the validity or accuracy of the thought. In other words, the defense claims that your thought is true and isn’t culpable for your anguish. On the other side, you, as the prosecutor, lay out a case demonstrating that the thought is actually guilty of distortion and therefore has caused you unnecessary emotional distress. If you find the thought guilty, we give you ways to replace or rehabilitate your thought. Most people learn better through stories and examples than through laborious explana- tions. With that in mind, we help you master the process of Thought Court by presenting a case example in the next section. Then we give you the chance to put your thoughts on trial, and in case you need more help, we follow up your practice with more case examples. Examining a sample case in Thought Court Jeremy is a good looking 23-year-old personal trainer who takes pride in his healthy lifestyle. He’s known at the gym for the colorful, long-sleeved T-shirts that he always wears. Jeremy gets more than his share of attention from women, but he never gets involved because he has a secret: He was seriously burned as a child, and his chest and arms are deeply scarred. Jeremy has never had a serious rela- tionship; he believes any woman seeing his body would recoil in disgust. Rather than face rejection and ridicule, he locks himself away in solitary confinement. His com- bination of fear and yearning motivates him to see a therapist, and he manages to tell his therapist about his lifelong secret. Jeremy’s therapist suggests that he start examining his thoughts with a Thought Tracker (see Worksheet 6-1) and then take his thoughts to Thought Court. Worksheet 6-1 Jeremy’s Thought Tracker Feelings & Sensations Corresponding Events Thoughts/Interpretations (Rated 1–100) Anxiety (85), fear Chelsea asks me out for I can’t possibly go out with her. Anxiety (75), The guys asked me to go The shame would overwhelm shame (85), bitter into the hot tub with them me. Chapter 6: Indicting and Rehabilitating Thoughts 79 Jeremy’s most malicious thoughts: 1. Next, his therapist suggests that Jeremy put the first of these thoughts on trial using a worksheet (later on, they address his other malicious thought). As you can see in Worksheet 6-2, Jeremy writes down the malicious thought first and then in one column defends the thought by listing all the reasons, logic, and evidence he can muster to support the case that the thought is true. In the other column, Jeremy attempts to prosecute the thought by demonstrating that it’s false. Worksheet 6-2 Jeremy’s Thought on Trial Worksheet Accused thought: I couldn’t stand to see the look of repulsion on her face. I’ve seen the look of shock on people’s My family seems to have gotten faces before. After one surgery, a physical therapist made a comment that my burns were permanently deforming and I’d just have to learn to live with them. So far, this case is going very well for the defense and very poorly for the prosecution.

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With process with the universe discount prednisone 40 mg visa, are cocreating a unique the 1998 publication of The Human Becoming becoming buy prednisone 20mg on-line. The mutual process is the all-at- School of Thought, Parse expanded the original onceness of living freely chosen meanings that arise work to include descriptions of three research with multidimensional experiences. The chosen methodologies and a unique practice methodology, meanings are the value priorities cocreated in tran- thus classifying the science of Human Becoming as scending with the possibles in unitary emergence a school of thought (Parse, 1997c). The principles and the assumptions of the human Human Becoming is a basic human science that becoming school of thought make up the ontology. The principles of human becoming, which describe the central phenomenon of nursing (the human- Human Becoming is a basic human science universe-health process), arise from the three that has cocreated human experiences as major themes of the assumptions: meaning, rhyth- its central focus. The ontology—that is, the assumptions and explicates fundamental paradoxes of human be- principles—sets forth beliefs that are clearly differ- coming (Parse, 1998a, p. Discipline-specific knowledge is articulated in Paradoxes are not opposites or problems to be unique language specifying a position on the phe- solved but, rather, are ways humans live their cho- nomenon of concern for each discipline. The principles are the author explicates the idea that humans con- referred to as the Human Becoming Theory. The struct personal realities with unique choosings concepts, with the paradoxes, describe the human- from multidimensional realms of the universe. This ontological base gives Reality, the meaning given to the situation, is the rise to the epistemology and methodologies of individual human’s ever-changing seamless sym- Human Becoming. Consistent with the Human Becoming symphony is the unique story of the human as mys- School of Thought, the focus of inquiry is on tery emerging with the explicit–tacit knowings of humanly lived experiences. The second principle (Parse, 1981, 1998a) de- Sciencing Human Becoming is the process of com- scribes the rhythmical patterns of relating human ing to know; it is an ongoing inquiry to discover with universe. Not all is explicitly methods; two are basic research methods and the known or can be told in the unfolding mystery of other is an applied research method (Parse, 1998a, human becoming. The methods flow from the on- opportunities-restrictions present in all choosings tology of the school of thought. There are oppor- methods are the Parse Method (Parse, 1987, 1990, tunities and restrictions no matter what the choice. It is coming together two methods is to advance the science of Human and moving apart, and there is closeness in the sep- Becoming by studying lived experiences from par- aration and distance in the closeness. The phenomena for study changing; that is, moving beyond with the possibil- with the Parse Method are universal lived experi- ities, which are their intended hopes and dreams. Written texts from any lit- resist with powering in creating new ways of living erary source or any art form may be the subject of the conformity-nonconformity and certainty- research with the Human Becoming Hermeneutic uncertainty of originating, while shedding light on Method. The researcher in affirming being in light of nonbeing” (Parse, 1998a, the Parse Method is truly present as the participant p. The being-nonbeing rhythm is all-at-once moves through an unstructured discussion about living the ever-changing now moment as it melts the lived experience under study. Humans, in originating, seek to the Human Becoming Hermeneutic Method is conform–not conform; that is, to be like others and truly present to the emerging possibilities in the unique all-at-once, while living the ambiguity of horizon of meaning arising in dialogue with texts the certainty-uncertainty embedded in all change. True presence is an intense attentive- The changing diversity arises with transforming the ness to unfolding essences and emergent meanings. The contributions of the findings from edge base underpinning true presence is specified studies using these two methods is “new knowledge in the assumptions and principles of human be- and understanding of humanly lived experiences” coming (Parse, 1981, 1992, 1995, 1997a, 1998a). Many studies have been con- True presence is a free-flowing attentiveness that ducted and some have been published in which arises from the belief that the human in mutual nurse scholars used the Parse Method. Two studies process with the universe is unitary, freely chooses have been published in which the author used the in situations, structures personal meaning, lives Human Becoming Hermeneutic Method (Cody, paradoxical rhythms, and moves beyond with 1995c; Ortiz, 2003). Parse states: “To The applied research method is the descriptive know, understand, and live the beliefs of human be- qualitative preproject-process-postproject method. The different way that arises from the human number of studies have been published in which becoming beliefs is true presence” (Parse, 1987, the authors used this method (Jonas, 1995a; 1998b). Many papers are published explicating Mitchell, 1995; Northrup & Cody, 1998; Santopinto human becoming practice (Arndt, 1995; Banonis, & Smith, 1995), and a synthesis of the findings of 1995; Bournes, 2000, 2003; Bournes & Flint, 2003; these and other such studies was written and pub- Butler, 1988; Butler & Snodgrass, 1991; Chapman, lished (Bournes, 2002b). The goal of the nurse 2002; Quiquero, Knights, & Meo, 1991; Rasmusson, 1995; Rasmusson, Jonas, & Mitchell, 1991; Smith, 2002; Stanley & Meghani, 2001; among others). The goal of the nurse living the human be- True presence is a powerful human-universe coming beliefs is true presence in bearing connection experienced in all realms of the uni- witness and being with others in their verse. Nurses may be with persons in living the human becoming beliefs is true presence discussions, imaginings, or remembrances through in bearing witness and being with others in their stories, films, drawings, photographs, movies, changing health patterns. True presence is lived metaphors, poetry, rhythmical movements, and through the human becoming dimensions and other expressions (Parse, 1998a, p. The nurse with individuals or groups is truly present with the The Human Becoming School of Thought is a unfolding meanings as persons explicate, dwell with, guide for research, practice, education, and admin- and move on with changing patterns of diversity. Scholars Living true presence is unique to the art of from five continents have embraced the belief human becoming. It is sometimes misinterpreted system and live Human Becoming in a variety of as simply asking persons what they want and re- venues, including health-care centers and univer- specting their desires.

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