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By U. Taklar. Hope College. 2018.

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With John taking on increased responsibility for his own therapy buy generic lasix 40 mg on line, his in- teractions within the milieu showed improvement safe 40 mg lasix. He no longer preached to the light fixtures; instead lasix 40 mg without a prescription, he saved that for the dayroom, where he had a dynamic audience. Once we returned from our session I instructed him to speak with the nurses, and I watched, from a distance, as he followed through on my request. A series of tests revealed that John was extremely ill and would have to be transferred to a medical facility. For this reason, our last sessions focused on closure and the creation of a transitional object as John adapted to changing circumstances. In this way John could take his beloved garden with him, and hope- fully the comfort that he derived there would transpose into his new envi- ronment. If therapy had continued, my path for John would have been toward the further management and understanding of his psychotic symptomology, continued interaction within the environment, and supportive living man- agement skills. Ultimately, the connection that we were able to achieve be- gan with understanding and compassion as I allowed him to assert himself, feel wanted, and branch out of his dependent role. Regrettably, his inherited biological disorder, com- bined with his anxiety, confusion, and stress, transferred into the fixed false beliefs of today, the private symbols that allowed John to dream while awake. Clinical Background Dion had a history of substance abuse since the age of 13 and paranoid schizophrenia since the age of 18. With a remorseful and often apprehen- sive affect, he moved about in a restless manner. His eagerness to apply him- self was overshadowed only by his intense need to rectify his past mistakes. This scenario took many forms, one of which was his desire to involve him- self in every available activity, much to the detriment of realistic planning. The defense of undoing appeared in his repetitious verbal comment "I’m paying my tab," which refers to expiative undoing or the annulment of prior acts. Furthermore, his history of substance abuse and his recollections, memories, and discussions often revealed what Laughlin (1970) refers to as the "Hangover Paradox," which, simply stated, means that atonement is of- ten found within the pain and physicality of the morning-after hangover. For these reasons, Dion’s motivation toward erasure prohibited his abil- ity to problem solve, visualize consequences, surmount issues related to guilt, and effectively free himself from his dependency reactions. He belonged to a family of four boys (including Dion) and three girls, and since both parents worked, they left the older children to raise the younger children. Dion was the fourth of six children, and his sibling relationships were strained even in childhood. Presently, his brothers are either battling drug abuse issues through recovery or actively using. Of his sisters, the oldest "is just like mom, she babies me," while his younger sister is "the only one I can talk to. When asked to describe his mother he stated, 216 Individual Therapy: Three Cases Revealed "She was always there. Dur- ing this particular session, the group had been discussing the offenses that had placed them within the criminal justice system. The essence of the offense is that he held his wife captive for over 1 hour, alternately having her read from the Bible and beat- ing her about the face and body. At the time he was stabilized on his antipsychotic medication, and they married very soon after. At the time of the birth of their first child Dion suddenly stopped tak- ing his medication, and within 7 months his delusional thinking was so se- vere that his paranoid mindset returned and he assaulted his wife.

Academic Press purchase lasix 40 mg otc, San Diego generic lasix 100 mg with visa, pp 1–30 Kellenberger E order lasix 40 mg overnight delivery, Dürrenberger M, Villiger W, Carlemalm E, Wurtz M (1987) The efficiency of immunolabel on Lowicryl sections compared to theoretical predictions. J Histochem Cytochem 35:959–969 Kemplay SK, Webster KE (1986) A qualitative and quantitative analysis of the distributions of cells in the spinal cord and spinomedullary junction projecting to the thalamus of the rat. Neuroscience 17:769–789 Kemplay S, Webster KE (1989) A quantitative study of the projections of the gracile, cuneate and trigeminal nuclei and of the medullary reticular formation to the thalamus in the rat. Neuroscience 32:153–167 Kennedy PG, Grinfeld E, Gow J (1998) Latent varicella-zoster virus is located predominantly in neurons in human trigeminal ganglia. Proc Natl Acad Sci U S A 95:4658–4662 Kenshalo DR, Chudler EH, Anton F, Dubner R (1988) SI cortical nociceptive neurons par- ticipate in the encoding process by which monkeys perceive the intensity of noxious thermal stimulation. Brain Res 454:378–382 Kerr FWL (1975a) Neuroanatomical substrates of nociception in the spinal cord. Pain 1:325– 336 Kerr FWL (1975b) The ventral spinothalamic tract and other ascending systems of the ventral funiculus of the spinal cord. J Comp Neurol 159:335–356 Kevetter GA, Willis WD (1982) Spinothalamic cells in the rat lumbar cord with collaterals to the medullary reticular formation. Brain Res 238:181–185 Kevetter GA, Willis WD (1983) Collaterals of spinothalamic cells in the rat. J Comp Neurol 215:453–464 92 References Kevetter GA, Willis WD (1984) Collateralization in the spinothalamic tract: new methodol- ogy to support or deny phylogenetic theories. Brain Res Rev 7:1–14 Kevetter GA, Haber LH, Yezierski RP, Vhung JM, Martin RF, Willis WD (1982) Cells of origin of the spinoreticular tract in the monkey. J Comp Neurol 207:61–74 Khan GM, Chen SR, Pan HL (2002) Role of primary afferent nerves in allodynia caused by diabetic neuropathy in rats. Neuroscience 114:291–299 Kharazia VN, Weinberg RJ (1994) Glutamate and thalamic fibers terminating in layer IV of primary sensory cortex. J Neurosci 14:6021–6032 Kharazia VN, Wenthold RJ, Weinberg RJ (1996) GluR1-immunopositive interneurons in rat neocortex. J Comp Neurol 368:399–412 Kharazia VN, Phend KD, Rustioni A, Weinberg RJ (1996) EM colocalization of AMPA and NMDA receptor subunits at synapses in rat cerebral cortex. Neurosci Lett 210:37–40 Khasabov SG, Ghilardi JR, Mantyh PW, Simone DA (2005) Spinal neurons that express NK-1 receptors modulate descending controls that project through the dorsolateral funiculus. J Neurophysiol 93:998–1006 Kim SH, Chung JM (1992) An experimental model for peripheral neuropathy produced by segmental spinal nerve ligation in the rat. Pain 50:355–363 Kingery WS (1997) A critical review of controlled clinical trials for peripheral neuropathic pain and complex regional pain syndromes. Pain 73:123–139 Kitamura T, Yamada J, Sato H, Yamashita K (1993) Cells of origin of the spinoparabrachial fibers in the rat. J Comp Neurol 328:449–461 Kitamura T, Nagao S, Kunimoto K, Shirama K, Yamada J (2001) Cytoarchitectonic subdi- visions of the parabrachial nucleus in the Japanese monkey (Macacus fuscatus) with special reference to spinoparabrachial fiber terminals. Neurosci Res 39:95–108 Klassen KP, Morton DR, Curtis GM (1951) the clinical physiology of the human bronchi. The effect of the vagus section on the cough reflex, bronchial calibre and clearance of bronchial secretions. Surgery 29:483–490 Kleinschmidt-DeMasters BK, Gilden DH (2001) Varicella-zoster virus infections of the nervous system. Arch Pathol Lab Med 125:770–780 Kleinschmidt-DeMasters BK, Amlie-Lefond C, Gilden DH (1996) The pattern of varicella zoster virus encephalitis. Hum Pathol 27:927–938 Klop EM, Mouton LJ, Holstege G (2004a) How many spinothalamic tract cells are there? Neurosci Lett 360:121–124 Klop EM, Mouton LJ, Holstege G (2004b) Less than 15% of the spinothalamic fibers originate from neurons in lamina I in cat. Neurosci Lett 360:125–128 Koerber HR, Mirnics K, Kavookjian AM, Light AR (1999) Ultrastructural analysis of ec- topic synaptic boutons arising from peripherally regenerated primary afferent fibers.

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The extended family work was an outcome of the individual work and Suzanne’s readiness to deal with family patterns and interactions buy lasix 40 mg without prescription. In Step 4 generic lasix 100 mg visa, Harry’s individual work begins to give him some understanding of why he acts and reacts as he does generic 40 mg lasix mastercard. Since the couple has a better under- standing of where they begin and end as individuals and within the system (differentiation), the couple is able to begin improving their com- munication (Step 5). As a result of communication improving, more inter- generational work can be done with Harry’s family (Step 6), allowing him to grow further and differentiate himself. As a result of improved com- munication within the couple, Harry was able to see how he accepted un- warranted projections from Suzanne, which enabled him to further differentiate his functioning and create a more solid self. Harry was able to realize that he needed to do joint work with his family of origin to fur- ther free himself of old roles and patterns of behavior (Step 7). Within the 224 THEORETICAL PERSPECTIVES ON WORKING WITH COUPLES context of Harry’s intergenerational work, communication enhancement between the generations became a focus (Step 8). In integrative healing couples therapy, the growth of one individual en- ables the system. As a consequence, members of the system interact with the ability to grow and differentiate as long as the individual maintains his or her new, healthier functioning (solid self). When working with Harry’s extended family, Harry’s use of splitting when dealing with toxic issues be- came apparent. This realization lent itself to work on Harry’s individual is- sues through understanding the concept of splitting and its application to himself and interactions with others (Step 9). After working with the ex- tended family and after focusing on Harry’s use of the defense of splitting, he no longer saw himself as "the boy who runs," but as a capable man. He was able to change his cognitions about self and then act as the mature man he was becoming (Step 10). When he felt more manly and in charge of self, he began to pursue Suzanne in the way she really wanted from the begin- ning of treatment. We discussed pursuit and distance strategies, which en- abled him to change his behaviors (Step 11). As he began to pursue his wife through verbal communication, sexual issues came to the forefront. Through the use of improved communication skills and individual work, looking at feelings and beliefs about sexuality, the couples’ sexual function- ing improved (Step 12). The last step in the couple’s work was for Suzanne to own her fears around dealing with money issues. We explored her internalized images of being a woman and how they relate to making, spending, and sharing money. As Suzanne was able to act more appropriately, more mutual sharing with money, respect, and sexuality ensued (Step 13). The couple felt that concerns about the relationship were resolved at this point and they were ready to leave therapy and to enjoy the new life they had created. Taking responsibility—enabling partners to take responsibility for their parts in the dysfunction 3. Remediate and heal wounds—work toward self-healing and forgiveness, which will lead to self nurturing enabling mutual healing to occur 4. Developing a more mature connection and relationship with intimacy and friendship at the core intertwined with passion Integrative Healing Couples Therapy: A Search for the Self 225 It is most essential to calm the anxiety in the system and in the couple (Step 1). The therapist needs to focus on either the individual’s anxiety re- duction or on the couple’s interactions (around issues of abandonment, money, sex, children, etc. The less anxiety the couple demonstrates, the more the therapist is able to focus on the couple’s interactions. For some couples, healing the hurt and reaching forgiveness needs to be the focus before each can "own re- sponsibility. Steps 6 and 7 help the couple to allow for themselves what they expect from the relationship. Steps 8 and 9 are the results of previous steps whereby individuals have developed a more differentiated and mature self.

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In fact the word ‘care’ is used in such a range of ways that discount 40mg lasix with amex, to a degree purchase lasix 100mg without a prescription, it has lost much of its original and particular meaning 100mg lasix free shipping. In this chapter we focus on ‘care’ in the sense of the formal provision of services by mainly statutory health or social care bodies for people with MS and their families. The degree to which such services constitute individual ‘care’ as considered for people with MS and their families is a matter of (their) judgement. Indeed the perennial issue for people with MS is the degree to which health care and social care services can meet both the diversity and scale of their care needs. Care in the community ‘Community care’ is the general name given to services provided to help people with an illness or disability to continue to live in their own homes. At the same time, there has been an associated policy to provide sheltered housing and residential and nursing homes in ‘the community’ for such people who cannot continue to live in their own home. This Act gives Social Services Departments the responsibility to assess people’s needs through a ‘needs assessment’, and to provide, or to purchase from others, a range of services to meet those needs. The assumption behind the provision of these services is that they will enable the person to remain in their own homes as long as possible. As might be expected, local financial constraints have a major effect on what services are provided, and indeed when a judgement may be made that it is no longer viable to support someone at home. It is important to note that local authorities (through their Social Services Departments) are not obliged to continue to support someone at home, if this would cost more than 167 168 MANAGING YOUR MULTIPLE SCLEROSIS moving them to a residential or nursing home – although sometimes they may continue to provide services for the person at home. This issue, amongst several other major issues, has been – and indeed still is – the subject of legal argument as to the exact obligations of local authorities under the Community Care Act. Health services versus social services In addition there can be problems in ‘community care’ arising from the role of health services in relation to social services. Some community- based services, such as nursing help or physiotherapy, are obtained through the NHS (via your GP or hospital specialist), whilst others, such as home help or meals on wheels, are obtained via social services (usually through a needs assessment under the Community Care Act). However, a number of practical difficulties have arisen as to when a service is a ‘health’ service, when it is a ‘social’ service, and, most importantly, who (the NHS or local authorities) should pay for it. Although there has been a series of firm government attempts to produce a cooperative environment between health and social services, people with MS may still find that they are in an uncomfortable position between two major service suppliers. Nevertheless, if you feel that you are in need of community service support, you must ask for a Social Services needs assessment. Community health services are now being increasingly provided through a new range of organizations called ‘Primary Health Care Trusts’. Although such Trusts are not yet established in all areas of the UK, their numbers are increasing rapidly. It has been government policy that priority must be given to primary health and community-based care, whereas previously the focus was much more on hospital care. In a number of cases ‘Community Health Care Trusts’, which had combined the provision of both hospital and community-based care, are now giving way to Trusts based entirely on primary and community are. The services provided through the community/primary care-based trusts include district nurses, health visitors, community psychiatric and mental health nurses, psychologists, physiotherapists, occupational therapists, speech and language therapists, dietitians and chiropodists. There may also be specific services for incontinence, cardiac care, mastectomy and colostomy. Most of these services are obtained through your GP or practice nurse, but in some areas they may still be organized through hospitals. There are a range of collaborative arrangements between Community Health Services. Increasingly formal collaborative arrangements are CARE 169 being set up, with the Social Services care manager acting as the main liaison between the person with MS and the service providers. However, as the management structures, funding sources and professional tasks of Social Services and Community Health Services are different, the link between the two may not always work well – even though they both emphasize their service to the person with MS.

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People with Parkinson’s must be careful not to use antihistamines on their own to control allergies purchase lasix 40mg visa, colds discount 40mg lasix with mastercard, or insomnia: these may upset the balance of the Parkinson’s medications and cause bizarre reactions discount lasix 100 mg with mastercard. Some antidepressants also have sedative quali- ties that work best for depressed patients who suffer from insom- nia. Other antidepressants without sedative qualities are better for depressed people with Parkinson’s who don’t have insomnia. Again, these drugs must be coordinated carefully with the rest of the drug regimen. A very important drug that is sometimes started early in Par- kinson’s is bromocriptine (Parlodel). It is a limited dopamine agonist because it doesn’t stimulate all three types of receptors, but it’s very useful in relieving slowness of movement, rigidity, and leg cramping. Some doctors recommend an early drug regimen that consists of an anticholinergic medication to relieve tremor and bromocriptine to relieve the other primary symptoms. Bromocriptine, taken along with Sinemet, is also useful in the middle and later stages of Parkinson’s. But bromocriptine has two serious side effects in some patients: it can cause both low blood pressure and psychosis. Other possible side effects are nausea, in- voluntary movements, confusion, dizziness, drowsiness, visual dis- turbances, shortness of breath, and constipation. Because of its possible effect on blood pressure, the first dose should be very small, and increases should be gradual. Never increase the dose of this drug on your own, and never take it more often than your doctor has prescribed. Patients who cannot tolerate bromocriptine or who no longer respond well to it may try a newer dopamine agonist, pergolide (Permax). Pergolide stimulates two types of dopamine receptors and is much stronger and longer acting than bromocriptine. It 82 living well with parkinson’s also is especially useful for patients who no longer respond well to Sinemet. Pergolide, too, has possible side effects: involuntary movements (twisting, jerking, and so on) and some cardiovascular problems, as well as the problems listed for bromocriptine. Another dopamine agonist, lisuride, is not available in the United States at the time of this writing. As most people with Parkinson’s know, when their symptoms are no longer controlled by the medications used in the earliest stages of the disease, the next medication is Sinemet. It contains levo- dopa, the most important drug used in treating Parkinson’s disease since 1970. The carbidopa stops levodopa from being converted into dopamine in other parts of the body (where dopamine is not only wasted but causes severe nausea and vomiting). Carbidopa is called an inhibitor because it inhibits the enzyme that converts levodopa into dopamine. Another inhibitor, benserazide, is combined with levodopa in a less widely used drug, Madopar. With the addition of inhibitors, much more of the lev- odopa gets to the brain than was the case with earlier levodopa drugs, and smaller amounts of it are sufficient. The top number represents milligrams of carbidopa, and the bottom number represents milligrams of levodopa. Then he increased the dose slowly, so that after eight years I was taking three or four 10/100s per day, depending on my needs.

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