Psy 375 Senior Interview Essay Example for Free

Psy 375 Senior Interview Essay 1. What is the environment of your home like? Busy, before they got guardianship of their grandson, life was quiet and there was not very much that had to be done around the home. Once their grandson came to live with them at age 3, life became â€Å"a buzz† again. â€Å"Before our grandson came to us, we usually would get up in the morning, sit and relax as we drank our coffee and had a quiet breakfast together. Now, we (her and her spouse) are up early to get our grandson ready to go to school. † She also says â€Å"We had time for the things that we wanted to do in our later years of life, visiting family, traveling and such. Now our time is dedicated to raising our grandson who keeps us going and on our toes but we would not change the situations we are in now for the world. † 2. Has aging changed the home environment? Yes, when they were younger, they had the energy and health to do the things they wanted to. Sally says â€Å"With age came some small struggles to stay at the pace we had always had when we were younger. Things that were always easy slowly became more time consuming, housekeeping used to be something that I could complete pretty quickly; now, I am a little slower (with the help of my grandson). Otherwise, she says â€Å"life keeps us all busy. † 3. Do you rely on others for help with any activities in the home? Sally answers â€Å"No, we are still able and willing to do our chores and keep up with the necessary tasks that we have. Although, we do have â€Å"John† (grandson) visit family a few times a month so that we have time to recharge. † 4. Do you still drive? If so, how has aging changed how you drive? Sally answered, â€Å"Yes, we both (her and her husband Mike) still drive. Driving is something that you would think would stay the same as you grow old until you get old. When I am driving now, I feel like everyone is in a rush to get where they want to go and here I am taking my time, trying to be safe while all around me are probably cursing me and saying â€Å"Damn old lady is driving so slow. † (She laughed as she made the last remark. ) 5. What changes in your home do you face as you get older? Sally answers, â€Å"As my husband and I get older, we are starting to be slower at things that once took us very little time. I think as we continue to get older, we will continue to get slower. † She also says, â€Å"With having our grandson home with us, he is helping us when he sees us even struggle a little with even small things. I think as we get older, he will be the one to help us more than anyone else. Recreational Activities: 1. In the past, what did you do for recreation? What do you do now for enjoyment? Sally answers, â€Å"When we were younger and our children were at home with us, we would spend a lot of time outdoors. We loved to go camping, fishing and hunting as a family. As our children got older, they all had things that they were involved in that took that time away that we had for the fun things. † She then explained that as her and her husband grew older, that they became more focused on the things that they wanted to do like traveling and visiting family. Sally then explained â€Å"Now that we have our grandson, I go to the movies, library, and toy shopping an awful lot. † But then she explained that she takes pleasure in spending time with her grandson doing the things that he likes to do because she â€Å"loves to see the smile on his face. † Sally also explained that they are active members of a church that they go to twice a week (Wednesdays and Sundays) and they get great pleasure out of the service. 2. How often do you participate in these activities? Sally says â€Å"When â€Å"John† is a good boy at school and does what he is told here we usually take him out about once a week to do something special. † She then explains, â€Å"Church is a large part of our lives. We go to church not only to worship but also to have time with people that are around our age with and are like-minded. † 3. Have the things that do for recreation changed as you aged? As stated above, in their younger years, their recreation revolved around their family. As they got older, she says â€Å"The things we did slowed. We were not out all the time we possibly could have been. † Sally says, â€Å"We now spend time where we feel most comfortable, church and doing things with our grandson are what we do most now. † Social Support and Interactions: 1. Who do you interact with on a regular basis? Is this the same amount of contact you had in younger years of life? Sally says, â€Å"On a daily basis, my husband and grandson. I usually call my sister every couple days and see how she is doing and on a weekly basis the brothers and sisters I have at church. † She also says, â€Å"In the past, we had friends and neighbors that we were in contact with on a daily basis but as time went on, the friends we have kept are passing away or just losing contact with them all together. It is hard getting older and watching the friends you have start to pass away, it make me think that I will not always be here and then it makes me worry about who will keep our grandson when we are gone. † 2. Do you participate in any social clubs? Sally says, â€Å"The only real structured social club, if you can call it that, would be church activities. On Wednesdays, we go to church for bible study and social time where we talk with our friends there and on Sunday, we go to service that provides us with God’s word and time with our church brothers and sisters. † Meaningful Activities: 1. What gives your life meaning? Sally says, â€Å"My family is what gives my life meaning. I try to do as much as possible to stay in the loop of what is going on with my children and grandchildren. My children have always been the reason that we have worked so hard. We always wanted them to have the better things in life and we wanted them to be happy. † She also says â€Å"Now, my life revolves around taking care of â€Å"John† and making sure he feels that everything is okay and that he has a stable home to grow up in. † 2. Do you still engage in these activities as you did when you were younger? Sally says, â€Å"When we were younger, we had a lot more activities when our children were young. As they grew up, moved out on their own and had families of their own, our lives quieted down and the activities we were always doing changed into activities that â€Å"Mike† and I wanted to do until we got â€Å"John† and once we got â€Å"John† life became busy again with all of his activities. † Mental Stimulation: 1. In the past, what did you do to keep your mind sharp? Sally says, â€Å"In the past, I had my work to keep my mind sharp. I was a secretary at the middle school in the town we live for almost 20 years and was always busy with the tasks that were I had to do. My children also kept my mind going and I loved helping them with their homework because this helped me keep my mind working and remembering how to do problems like math and science. † 2. What do you do now to keep your mind sharp? Sally says, â€Å"Now to keep my mind sharp I do a lot of word and number puzzles. I love to do Sudoku puzzles and word find puzzles. Sudoku puzzles really keep my mind working because sometimes I feel like my hair is on fire when I am done with them (she chuckles.) I also spend time with â€Å"John† to helping him with his homework and I think this helps to keep me learning still because I have noticed that the way children are taught now has really changed from when I had my children in school. † Physical Activities: 1. In the past, what did you do to keep physically fit? Sally says, â€Å"In the past, when my children lived at home, we were always on the go. We would go places where we would walk and hike through the woods like when we would go hunting or fishing. We lives close to the corner store so we would also just walk to the store when we needed a few things instead of get in the car and drive. † She also says â€Å"I never was a really big health nut who was always worried about exercise because my weight was never an issue. I felt that is my weight was good then I was getting plenty of exercise. † 2. What do you do to keep physically fit now? Sally says, â€Å"Nowadays we love to take â€Å"John† for walks at the local trails. It’s nice to be out in the fresh air and be able to not only spend time with â€Å"Mike† and â€Å"John† but to get a little exercise because I have noticed that the older I get the less muscle I seem to have. † â€Å"It seems like the little things are more of a challenge than they were in previous years. Even just opening a jar is sometimes a challenge. † 3. Are you able to keep up with the daily physical stresses that you are tasked with on a daily basis? Sally says, â€Å"Yes, it seems like I am still doing a pretty good job keeping up with everything I have to do on a daily basis (as she looks around her living room. ) She also says â€Å"Keeping a house clean is a chore in its own when you have a grandson to pick up after everywhere he goes. † She also says, â€Å"I get around to the things I need to do now when I get to them. I used to try to make sure the house was perfect when my children and â€Å"Mike† would come home each day and thought that having a clean house for them, food cooking and clothes laid out for them daily was what I was supposed to do. Now that I think about it, I would have much rather of been having fun with them instead of being worried about the house. † Ending the interview, her last statement is, â€Å"Life now is a little bit harder than it was when I was younger. It seems like the older I get, the slower I am. † She then tells me, â€Å"Make sure that you spend your time doing what makes you happy. †

Depression and Suicidal Ideation: Mental Health Case Study

Depression and Suicidal Ideation: Mental Health Case Study Introduction Mental health nursing is a complex healthcare practice, because it aims to meet the needs of clients with mental health needs, which are usually also complex and require more than a single therapeutic approach. Mental health nurses usually provide supportive and therapeutic care adhering to nursing and healthcare principles of beneficence and non-maleficence, and adhere to the principles published in the national guidance, of client-centred care focused on service user need, as enshrined in the National Service Framework for Mental Health (Department of Health, 1999). Mental health nursing usually involves the provision of ongoing, supportive therapeutic interventions and ‘talking’ therapies, which can include counselling based on established principles. This role of the mental health nurse involves the formation of a therapeutic relationship with the client, in order to support the client to development self-management and coping strategies for the ongoing control of th eir condition and its symptoms, in conjunction with pharmacological treatments. This critical essay will explore the mental health nursing care of a particular, identified patient encountered in clinical practice, in whose care the author was directly involved. It explores the provision of Cognitive Behavioural Therapy (CBT) to a single client who had complex health needs and challenging symptoms, reviewing the usefulness and appropriateness of the therapy, the effects or projected effects on the client’s wellbeing and symptoms, and the issues surrounding such care for the client in relation to rehabilitation and recovery as part of their mental health journey. The essay will focus on the care of one client with depression and suicidal ideation, looking not at the acute phase of mental health care, but the rehabilitation phase where the client is being supported into ways of managing symptoms and returning to a useful, active social life where they can function effectively within society. The essay focuses on the goals and principles enshrined in the NSF for Mental Health (DoH, 1999), that of achieving the best possible standards of health and wellbeing for the client and the best possible control of their symptoms. It will explore the rationales and process of the therapeutic intervention, and use this intervention within a person-centred model of counselling, support and care. Client Background and History The client, who for the purposes of this essay will be called Lisa (this being a pseudonym used to ensure client confidentiality), is a 19 year old young woman with a history of depression and suicidal ideation. Lisa first presented to the local mental health services at the age of 16, after an acute episode of physical self harm and attempted suicide. Lisa’s self-harming behaviour takes the form of cutting, usually to the arms, legs and abdomen, although she has been known at times to also cut her face and neck. During her first admission, Lisa was diagnosed as having Depression with Psychotic symptoms. She has been managed with a combination of Fluoexetine and a range of other medications, but is known to have frequent relapse due to medication non-compliance. Lisa has a complex personal and social history which goes some way to explaining her current state of mental ill health. She was abandoned by her single parent mother at the age of 11, from which time until the age of 16 she spent in local authority care, a mixture of foster homes and care facilities. At age 16 she left care and went on the streets, but at 17 after her third hospital admission was able to get into a social support programme, secure accommodation for herself, and start to attend college. Lisa is still at college, studying beauty therapy. She has a history of sexual abuse, but for the past year and a half has been living a relatively stable life, with a good social life and a busy college life. Lisa has presented this time with a relapse in her Depression, and has demonstrated a strong suicidal ideation, low mood and being very withdrawn and apathetic. She has, this time, attempted suicide through overdose of a friend’s prescribed medication accompanied by severe cutting to the arms, legs and breasts. After being medically stabilised, she was admitted to the mental health ward, and after two weeks on the ward, fully compliant with her medication, was making some progress towards rehabilitation. Discussion Norman and Ryrie (2004) describe mental health nursing as a process of working with clients to allow them to develop the skills to regain control over their lives through managing their mental health. Ultimately, mental health nursing supports clients into a phase of recovery (Tschudin, 1995), which means that they are not overwhelmed by their symptoms and can manage them through a combination of medication, personal supportive therapies, and other support, in order to lead ‘normal’ lives within society and achieve personal goals. Mental health nursing is based upon a range of principles, some of which are scientific, some of which are more holistic (Norman and Ryrie, 2004). Mental health nursing supports clients through the acute phases of their illness, via crisis management, and through the chronic stages of their illness, through longer-term processes of rehabilitation (Perkins and Repper, 2004). Quite often, mental health service users are viewed in terms of their d isease and its treatment, but the provision of true client-centred care should start off with a good understanding of the client and their condition, their particular needs, and then be followed by a judgement about how best to help them towards recovery along the spectrum of mental health and illness (Perkins and Repper, 2004; Foreyt and Poston, 1999). Recovery cannot be considered as a finite point in time, but as an ongoing balance between the client and their illness, wherein the client aims to achieve the ability to function at the level they desire, through accessing appropriate support (Perkins and Repper, 2004; Greenberger and Padesky, 1995)). The judgement about what kind of support is best is based upon a number of factors, but most often, the decision about which of the many approaches to supportive therapies and counselling will be used is based upon both the client need, and the mental health nurse’s own knowledge about, experience of, and preference for, a parti cular form of therapy (Puentes, 2004). Mental health nurses, therefore, must have a good understanding of themselves, their philosophical orientation in relation to counselling, and the therapies on offer, and are most likely to provide those with which they have the most familiarity. In this case, the author is describing their own philosophical approach as matching that of their clinical practice mentor, who, as an experienced mental health nurse, is a strong advocate of client centred approaches to counselling. Gamble and Curthouys (2004) describe these approaches as being founded on Rogerian principles that include empathy, genuineness and unconditional positive regard. Rogers (1957 in Gamble and Curthouys, 2004) suggest that within a therapeutic relationship, which is a supportive relationship between client and nurse, with the express goal of attaining rehabilitation or recovery, there should be certain features which support the client towards ‘functionality’. Thus, there needs to be contact between tw o people, nurse and client, in which the client is in a condition of incongruence, and the nurse a state of congruence, and in which the nurse displays unconditional positive regard, and empathetic understanding, towards the client (Rogers, 1957 in Gamble and Curthouys, 2004). The nurse must be able to communicate these factors to the client, within the client’s frame of reference (Rogers, 1957 in Gamble and Curthouys, 2004 Bryant-Jefferies (2006) argues that the therapeutic relationship must be founded on empathy, and that in order to achieve empathy the nurse must employ active listening, and must attend to all the signs and the kinds of communication which the client displays, providing a sense of being ‘present’ with the client in whatever experience they are retelling or currently experiencing. One of the more challenging aspects of developing such a relationship with the client is the provision of unconditional positive regard, which Bozarth and Wilkins (2001 in Bryant-Jefferies, 2006) describe as an ongoing, unceasing and unflagging ‘warm acceptance’ of the individual, regardless of what they might say. Some authors describe this as the element of the therapeutic relationship that is most likely to support the client towards recovery (Bozarth and Wilkins, 2001 in Bryant-Jefferies, 2006). In this case, the mental health nurse (the author’s mentor) who was the prima ry support person for the client, fully aspired to such principles and to the concept of developing the best possible therapeutic relationship with the client. The literature consistently demonstrates that the quality of the therapeutic relationship is fundamental to the client achieving a state of mental health and wellbeing (DoH, 2001; DoH, 2006; Nice, 2004). The author agreed with this and felt that their own therapeutic philosophy was founded upon similar principles, making it appropriate to get involved in the case. The client was also happy to have the author present, as they were involved in there are from admission, and had spent some time observing the client during the acute phase to prevent further self harm. Depression is a surprisingly common, yet often serious mental illness, which can present in a variety of ways, with features such as â€Å"low mood, lack of enjoyment and interest, reduced energy, sleep disturbance,appetite disturbance, reduced confidence and self-esteem, and pessimistic thinking† (Embling, 2002; p 33). According to Embling (2002), these symptoms can have a significant effect on people’s ability to take part in normal daily life or social activities, and in particular, the low mood and predisposition towards pessimistic thoughts can have a negative impact on thought processes, leading to suicidal ideation (Rollman et al, 2003).. There are a number of individual and social issues which have been shown to have an association with depression, including physical illness (acute and chronic), poverty or low socioeconomic status and deprivation, divorce, bereavement or relationship breakdown, loss of a job or sudden, negative change in circumstances, ethnic minority status, and concomitant mental illness (Embling, 2002). It is a chronic condition which can manifest in acute episodes which are often successfully managed with pharmacological and non-pharmacological support, but the relapse rate is high for many patients (Embling, 2002). It can range from mild depression to severe depression or anywhere along a spectrum in between (Rollman et al, 2003). A wide variety of therapeutic approaches have been used in treating this illness, and in Lisa’s case, she had had some success previously with solution-focused brief therapy, but had found herself relapsing once regular, close contact with a mental health nurse had lapsed. Lisa admitted that she felt the time was right to take control of her life and find ways of coping with her illness more independently, and was keen for strategies which would allow her to avoid having such serious relapses, because they themselves had a negative effect on her life and potential career. Therefore, it was agreed that CBT might be the optimal approach. Luty et al (2007) argue that CBT is not always the most efficacious therapeutic choice for severe depression, but in Lisa’s case, it seemed worth trying, particularly as her worst symptoms were related to not maintaining her medication, and once she was on her medication, the focus had to be on keeping her well enough to keep taking the tablets. Other literature suggests that CBT is effective in patients who have had a history of sexual abuse (Price et al, 2001) This seemed to imply that the focused approach to support that CBT offered would the right way, particularly as it is so focused on relapse p revention. According to NACBT (2007) cognitive behavioural therapy is the term used to describe a variety of therapeutic or interpersonal interventions, all of which are characterised by a focus on the importance of how clients think, and how this thinking impacts upon their feelings, their responses to stimuli and stressors, and their actions. Its value lies in the fact that it is structured, directive, and also time-limited, strong focusing client and nurse on the current problem, on how the client feels and thinks at the single point in time that therapy is taking place (Embling, 2002). CBT is based on â€Å"the theory that the way an individual behaves is determined by his or her idiosyncratic view of a particular situation, thus the way we think determines the way we feel and behave †(Embling, 2002p 34). According to Embling (2002), Beck et al (1979) introduced CBT , suggesting that â€Å"CBT can treat depression as it helps the client to evaluate and modify distorted thought processes and dysfunctional behaviours† (Embling, 2002) p 38). According to NACBT (2007) CBT has expanded within the therapeutic domain to include a range of approaches based upon the sample principles, including, Rational Behaviour Therapy, Rational Emotive Behaviour Therapy , Rational Living Therapy, Cognitive Therapy, and Dialectic Behaviour Therapy, all of which are based on what are described as â€Å"cognitive models of social response†. These in turn have been based on philosophical principles derived from Socratic thought, wherein individuals aim to attain a state of calm and tranquillity when challenged by stressful or difficult situations and experiences (NACBT, 2007). Thus the idea is to modulate the responses to life and experiences which precipitate symptoms of mental illness. The coun sellor directs the client to use inductive methods combined with principles of rational thinking and educative approaches, to support behavioural self-managed over the longer term , (NACBT, 2007; Sensky et al, 2000) and to prevent relapses (Bruce et al, 1999). Therefore, in CBT, the nurse provides the client with the ability to explore their behaviours, their responses and their typical symptomatic responses in particular in certain situations, and assists them in developing ways of mediating such responses so that they do not relapse into behaviours characteristic of their illness (Sensky et al, 2000; RCP, 2007; BABCP, 2007). Management of Lisa’s Care To begin with, it was really important to ensure that Lisa’s counselling and therapy was truly person-centred, in order to develop a good relationship between Lisa, the primary nurse and the author (NELMH, 2007; Moyle, 2003). The author hoped that Lisa would respond well to this approach because it would allow for the demonstration of empathy and a good understanding of how her life, previous mental illness and personal circumstances were contributing to her current illness, and therefore would support congruence in provision of support to meet her needs and address her specific concerns. However, the difficulty in achieving congruence here was that the author could not really claim to fully understand the effects of Lisa’s previous experience of sexual abuse or really relate to her experiences, and in particular, the author found some elements of her history, including the stories she told relating the sexual abuse, as very disturbing. The author discussed this with th e nurse mentor prior to the counselling sessions, and discussed how to achieve that true sense of congruence and presence, without communication their own abhorrence of the experiences that Lisa was relating. It was decided that it would be acceptable to tell Lisa that the author was appalled by these experiences, because this would underline the fact that she should not have had to suffer this abuse and that she was right to seek help in dealing with the effects on her mental health. Therefore, the author was able to enter into this counselling in supportive frame of mind, and able to achieve empathy without communicating negative feelings to the client. The focus of Lisa’s CBT was on the suicidal ideation/self-harming and the low mood and self-abhorrence that were the main manifestations of her depression. Collins and Cutcliffe (2003) show that one of the most common features displayed by mental health service users with suicidal ideation is hopelessness. This was certainly the case for Lisa, who displayed a sever pessimism about life and her ability to achieve anything like lasting recovery. Her goals to become a beauty therapist seemed unobtainable, and she felt she had no hope of making a new life for herself that was not ‘ruined’ by her previous life. However, Collins and Cutcliffe (2003) recommend CBT for this kind of pessimistic thinking because it focuses the client on establishing ‘hopefulness’ within their thought patterns. Other research shows that suicide risk can be reduced if individuals can experience others showing concern for them (Casey et al, 2006). This was supported by the author’s and the mentor’s firm belief in the efficacy of CBT for clients such as Lisa (Joyce et al, 2007). Thus, it was possible to establish an initial level of trust, and through the therapeutic relationship, the author was able to support Lisa in exploring her conditional assumptions (Curran et al, 2006) which led to the ongoing, spiralling pessimism, and then using CBT, we were able to set goals for each counselling session, set ‘homework’ which focused on self-management, and then reflect on progress as each session followed the previous one (Curran et al, 2006). The sessions focused on relapse prevent ion through changing cognitive patterns and schema, rehearsing relapse drills, and ensuring ongoing compliance with medication (Papakostas et al, 2003. While some authors argue for the need for inclusion of family or carers in therapeutic interventions such as (Chiocca, 2007), this was not possible with Lisa because she had no family and although she had a number of good friends made through her college course, none of them knew of her mental illness. The focus was therefore on health education, developing personal skills, and helping Lisa to cope with issues such as her current socioeconomic status (Jackson et al, 2006; Cutler et al, 2004). . Conclusion If, as Calloway (2007 p 106) suggests â€Å"nursing is defined as a profession that protects, promotes, and restores health and that which prevents illness and injury†, then using such a client-empowering form of therapy, one which is based on the development of realistic coping mechanisms (Salkovskis, 1995; Deakin, 1993), was the right approach with Lisa. Discussion with her revealed that focusing on relapse prevention, within an honest therapeutic relationship which addressed the factors affecting her mental health, and addressed the ways of thinking and behaviours which led to relapse, was the right approach, because these were, fundamentally, her primary needs. The person-centred approach, in particular, seemed to give her the positive, ongoing interpersonal contact she needed, such that she did demonstrate signs of moving into a state of rehabilitation and recovery. References BABCP (2007) CBT Today36 (3) Available form www.babcp.com Accessed 5-1-09 Bozarth, J. and Wilkins, P. (eds) (2001) Rogers’ Therapeutic Conditions: evolution, theory and practice Ross-on-Wye: PCCS Books. In: Bryant-Jeffries, R. (2006) Counselling for Eating Disorders in Women: Person-centred dialogues Oxford: Radcliffe. Bruce, T.J., Spiegel, D.A. and Hegel, M.T. (1999) Cognitive-behavioural therapy helps prevent relapse and recurrence of panic disorder following alprazolam discontinuation. Journal of Consulting and Clinical Psychology 67 (1) 151-156. Bryant-Jeffries, R. (2006) Counselling for Eating Disorders in Women: Person-centred dialogues Oxford: Radcliffe. Calloway, S. (2007) Mental Health Promotion: Is Nursing Dropping the Ball?. 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(2004) The Art and Science of Mental Health Nursing: A Textbook of Principles and Practice Maidenhead: Open University Press. Ormel, J., Koeter, W., Van den Brink, G. and Van de Willige, G. (1991) Recognition, management, and course of anxiety and depression in general practice. Archives of General Psychiatry. 48 (8). Papakostas, G.I., Petersen, T., Pava, J. et al (2003) Hopelessness and suicidal ideation in outpatients with treatment-resistant Depression: prevalence and impact on treatment outcome The Journal of Nervous and Mental Disease 191(7) 444-449 Paykel, E.S., Scott, J., Cornwall, P.L. et al (2005) Duration of relapse prevention after cognitive therapy in residual depression: follow-up of controlled trial. Psychological Medicine 35 59-68. Peplau, H. (1989) Interpersonal constructs for nursing practice in: O’Toole, A.,Welt, S. 9eds) )1989) Interpersonal Theory in Nursing Practice. New York: Springer. Perkins, R. Repper, J. (2004). Rehabilitation and recovery. In: Norman, I. Ryrie, I. (eds.) (2004) The Art and Science of Mental Health Nursing: A Textbook of Principles and Practice Maidenhead: Open University Press. Price, J.L., Hilsenroth, M.J., Petretic-Jackson, P.A. and Bone, D. (2001)A review of individual psychotherapy outcomes for adult survivors of childhood sexual abuse. Clinical Psychology Review 21 (7) 1095-1121 Puentes, W.J. (2004) Cognitive therapy integrated with life review techniques: an eclectic treatment approach for affective symptoms in older adults. Journal of Clinical Nursing 13 (1) 84-89. Putnam, F. (2003) Ten-Year Research Update Review: Child Sexual Abuse. Journal of the American Academy of Child Adolescent Psychiatry. 42 (3) 269-278. RCP (2007) CBT. Available from http://www.rcpsych.ac.uk/mentalhealthinformation/therapies/cognitivebehaviouraltherapy.aspx Accessed 5-1-09 Revicki, D.A., Siddique, J., Chung, J.Y. et al (2005) Cost-effectiveness of evidence based pharmacotherapy or cognitive behaviour therapy combined with community referral for major depression in predominantly low-income minority women. Archives of General Psychiatry. 62 868-875. Rollman, B., Shear, M.K, (2003) Depression and Medical Comorbidity: Red Flags for Current Suicidal Ideation in Primary Care. Psychosomatic Medicine 65(4) 506-507 Salkovskis, P.M. (1995) Cognitive factors in depression, obsessive-compulsive disorder and hypochondriasis. Current Opinion in Psychiatry 8(2) 80-84. Sensky, T., Turkington, D., Kingdon, D. et al (2000). A Randomized Controlled Trial of Cognitive-Behavioral Therapy for Persistent Symptoms in Schizophrenia Resistant to Medication. Arch Gen Psychiatry.57 165-172. Tschudin, V. (1995) Counselling skills for nurses. London: Elsevier.

Finding out the affect of different concentrations of sucrose solution

Finding out the affect of different concentrations of sucrose solution on the mass of potato chips Introduction The aim of this investigation is to see when osmosis occurs in potato cells and whether anything happens to them when they are put in different concentrations of sucrose solution. I have to apply my background knowledge to devise an experiment which will tell me whether if different concentrations of water molecules in a solution will affect the mass of plant cell when they are put into it. Background knowledge Osmosis is like diffusion but only of water molecules and it only happens when there are different concentrations of water molecules on either side of a selectively permeable membrane. The selectively permeable membrane "gaps" are only small enough to let water molecules pass through and not big molecules such as sucrose molecules. Water molecules from each side of the membrane always pass to the other side. When one side of the selectively permeable membrane has a higher concentration of water molecules than the other, more water molecules from the side containing a higher concentration of water molecules will pass through to the side with a lower concentration of water molecules. Less water molecules from the side with a lower water molecule concentration will pass to the other side because there are less of them. If the concentration of water molecules on either side of the selectively membrane is the same then the net flow of water in either direction will be the same. This results in no net flow of water-osmosis. An example of osmosis happening in a plant cell is when a potato chip is put into distilled water. The cell membrane of the potato cells is the selectively permeable membrane between the concentration of water molecules inside the potato cells and the distilled water that is outside of the potato cells. As the concentration of water molecules is of a higher concentration in the distilled water than inside the potato, there are more water molecules going through the potato membrane into the cell than water molecules from the inside of the potato going through to the other side. This is because there are more water molecules in the distilled water. Therefore the net flow of water by osmosis is into the potato cells. As more water molecules pass into the potato cells, the va... ...Maybe next time I could roll each potato chip down the paper towel once and blot the ends of them two times on the paper towel. To prove that my prediction is correct in any osmosis experiment, I could do another experiment, which shows osmosis happening and why it happens-different concentrations between a selectively permeable membrane. The experiment is shown below: Apparatus * 20cm in length visking tubing. * 20cm3 water * 10cm3 plastic syringe * testing tube Method Tie a knot at the end of 20cm length visking tube that has been soaked in water. Put 3cm3 of strong sugar solution in the plastic syringe and use that to partly fill the visking tube-it should be floppy. Place the visking tubing into a test tube containing water 20cm3 . Leave the visking tubing in the test tube for about 30-45 minutes. You should record your observations of the visking tubing before it was put into the test tube of water and after it had been left in the water. Look for any changes in how it looks and feels. Is it turgid or flaccid? References Collins GCSE total revision Science by Mike Smith and Chris Sunley GCSE Biology second edition by D.G. Mackean

Total Effect of The Tragedy of Macbeth :: essays research papers

The Shadow   Ã‚  Ã‚  Ã‚  Ã‚  Ã¢â‚¬Å"The Tragedy of Macbeth†, written by William Shakespeare, gives the reader an impact of the horror at the darkness in humans. In the story, the most dominant literary element is the theme. The theme brings out the impact of horror, while the other literary elements support it. One of the most evident quotes that made me think of the horror of darkness in humans was said by Macbeth, â€Å"Stars, hide your fires; Let not light see my black and deep desires†¦Ã¢â‚¬  This quote showed that Macbeth was heavily influenced by his ambitions.   Ã‚  Ã‚  Ã‚  Ã‚  The theme, being the most dominant literary element, shows how the darkness in people has been drawn out. Themes such as appearance versus reality, attempts to control the future, human responses to supernatural powers and loyalty show how we can be easily taken over by the evil in us. After the death of King Duncan, Macbeth tries to convince himself that he did the right thing. He murdered his king in cold blood and regained his consciousness for a brief moment. â€Å"Will all great Neptune’s ocean wash this blood clean from my hand?† this quote, also spoken by Macbeth, gives the reader a sense that he regained his ego and was exposed with extreme guilt. It also gives a sense that he was possessed by a demon. This can be backed up by the theme of human responses to supernatural powers. Although the witches contribute greatly here, I would want to talk about hallucinations first. (In psychology, hallucinations are a form of supernatural powers.) The soliloquy in Act II Scene I show Macbeth hallucinating of an imaginary, bloody dagger. â€Å"Is this a dagger which I see before me, the handle towards my hand?† This was his illusion of what was upcoming, the murdering of King Duncan. This illusion gives the reader a sense that he is possessed by his alter-ego that he is going to kill the king. The witches foretold the future, and that their prophecies of Macbeth let his own â€Å"shadow† take over himself. Being that Macbeth went crazy from murdering his king, he also became aware that this murdering might also happen to him. This he decided to try and control his future – well, at least in several attempts, but always ended up half done. â€Å"To be thus is nothing, but to be safely thus†¦Ã¢â‚¬  this quote shows that Macbeth is in fear, and he tries to overcome this fear by eliminating anyone that was a threat to him.

Dr. Martin Luther King :: essays research papers

My impression of Dr. Martin Luther King was always and still is that he was a great leader for the African American people. He was a big leader in the civil rights movement. He was also very involved in the community. Even though I have much respect for Dr. King, I felt he was a â€Å"house† or â€Å"yard† negro leader, the term Malcom X used, and was only interested with civil rights issues.   Ã‚  Ã‚  Ã‚  Ã‚  The term â€Å"house† and â€Å"yard† negroes was what Malcom X called black leaders who were just puppets for the white man. They were there just to keep peace among African American people. Like I stated early I have much respect for Dr. King but I still felt he was like the rest of the black leaders who just preached about nonviolence. The ones who always say, look have far we come from the old days, but in actuality we were no better then, than we were back in the old days. I just felt hat violence was never an option when it came to Dr. King and his beliefs. Until I read his comments and he states, â€Å"we still have a choice today; nonviolent coexistence or violent co annihilation.†   Ã‚  Ã‚  Ã‚  Ã‚  I also thought Dr. King was more interested in civil rights than he was human rights. â€Å"How is the black man going to get â€Å"civil right† before first he wins his human right?†(Malcom X). But after reading his comments my views have changed. He stated, â€Å"The limited reforms we have won have been at bargain rates for the power of structure. There are no expenses involved, no taxes are required, for Negroes to share lunch counters, libraries, parks, hotels and other facilities. Even the more substantial reforms such as voting rights require neither monetary or psychological sacrifice. He was also quoted saying â€Å"it a crime for people to live in this rich nation and receive starvation wages.†   Ã‚  Ã‚  Ã‚  Ã‚     Ã‚  Ã‚  Ã‚  Ã‚  My opinions of Dr. Martin Luther King, has changed since reading his comments. I went from thinking violence was never a choice for Dr. King to learning that it was. Although I feel that he was still a 100 percent against violence. My main opinion of him has change a great deal. I thought Dr. King was only for the civil rights moment, meaning he would be happy with us just getting our voting rights and every thing else that represented the civil rights movement. Dr. Martin Luther King :: essays research papers My impression of Dr. Martin Luther King was always and still is that he was a great leader for the African American people. He was a big leader in the civil rights movement. He was also very involved in the community. Even though I have much respect for Dr. King, I felt he was a â€Å"house† or â€Å"yard† negro leader, the term Malcom X used, and was only interested with civil rights issues.   Ã‚  Ã‚  Ã‚  Ã‚  The term â€Å"house† and â€Å"yard† negroes was what Malcom X called black leaders who were just puppets for the white man. They were there just to keep peace among African American people. Like I stated early I have much respect for Dr. King but I still felt he was like the rest of the black leaders who just preached about nonviolence. The ones who always say, look have far we come from the old days, but in actuality we were no better then, than we were back in the old days. I just felt hat violence was never an option when it came to Dr. King and his beliefs. Until I read his comments and he states, â€Å"we still have a choice today; nonviolent coexistence or violent co annihilation.†   Ã‚  Ã‚  Ã‚  Ã‚  I also thought Dr. King was more interested in civil rights than he was human rights. â€Å"How is the black man going to get â€Å"civil right† before first he wins his human right?†(Malcom X). But after reading his comments my views have changed. He stated, â€Å"The limited reforms we have won have been at bargain rates for the power of structure. There are no expenses involved, no taxes are required, for Negroes to share lunch counters, libraries, parks, hotels and other facilities. Even the more substantial reforms such as voting rights require neither monetary or psychological sacrifice. He was also quoted saying â€Å"it a crime for people to live in this rich nation and receive starvation wages.†   Ã‚  Ã‚  Ã‚  Ã‚     Ã‚  Ã‚  Ã‚  Ã‚  My opinions of Dr. Martin Luther King, has changed since reading his comments. I went from thinking violence was never a choice for Dr. King to learning that it was. Although I feel that he was still a 100 percent against violence. My main opinion of him has change a great deal. I thought Dr. King was only for the civil rights moment, meaning he would be happy with us just getting our voting rights and every thing else that represented the civil rights movement.

Media Convergence Worksheet Essay

Questions Answers What is meant by the term media convergence with regard to technology, and how has it affected everyday life? Since I have been going to school I had never heard of the word â€Å"convergence† I first learned about this when I enrolled in my Humanity 176 course. Convergence by definition is the exchange of various digital media such as music, radios, pictures. Convergence used in a technical sense is the exchange and sharing of digital media through computers and other mobile devices. Over the years Media has expanded and excelled across the world to bring the people all sorts of media attention and the ability to be able to converge onto there devices allows an assortment of options such as Internet TV whether it is free or on demand, voice telephone options such as Skype and other simple internet services which include Facebook and Windows Live Messenger. †¦ I believe that our technology has an extreme affect on everyday life, most of us would not know how to function without it, including myself. What is meant by the term media convergence with regard to business, and how has it affected everyday life? Media convergence gives businesses an opportunity to share information regarding any topic within and to others outside of the business like costumers with easy methods. This is really appropriate to meet consumer’s desires for instant and easily practicable and easy to acquire any information from any business. Media convergence regarding to business is used to offer media more professionally or efficiently and in an on demand way. In other words media convergence brings the opportunity to provide information to be acquired when a customer wants to and regarding any topic. Media convergence’s cons embrace less serviceable performance or fewer personnel to reach more people daily. Some elements are acquired from medi a devices or procedures in order to add on stipulate material. Thanks to  today’s technology, people can receive information regarding any services provided by any business or company. Through sources like the internet, customers can browse and purchase products through websites and other business providers. With this technology it makes it very easy for the customers to be able to find many different products for fair prices on what the business needs. Of course, business convergence also deals with far more than buying and selling from a store front. People are also able to set up their business through their own home via the internet. Business goes hand in hand with technology also, as they are able to advertise through television, radio and internet sites with their ads and commercials. Business convergence has become a big source in today’s media, and will continue to grow with technology as they work together to provide people with better and easier ways to conduct business. What are some of the issues that result from depe ndency on modern media? Describe at least three issues. They are things like ethical Issues. We depend on the media to tell us that what we are doing is wrong while we still do what we know is wrong. More and more people who depend on media and need the media is that much closer to being constantly influenced by the media. Our society depends on media and without it we would fall apart. We tend to believe what the media says instead of formulating our own thoughts.With the media the way it is we tend to accept this as part of our lifestyle without question The public also has an insatiable curiosity to know everything, except what the world is really trying to tell us. Another topic of discussion is drugs. Everyday you see ads and commercials and people talking about not doing drugs and we depend on this to teach are kids but in reality we need to learn to teach our kids morals instead of constantly relying on the media.. Commercials that promote alcohol and drinking are abundant on television. While other media shows people doing drugs a nd getting money from the sale of them. The media also tends to butt heads between other countries due to mis-information that was released over the media sites. Terroism comes in all forms when it comes to the internet. Some examples are identity theft, hacking into databases, creation of viruses and other deliberate means to destroy or harm personal objectives are all forms of cyber-terrorism. People seem to have an addiction to technology and cling to it as the world would end without it. Dependency of modern media has taken over and does not allow society to  function thoroughly as it should. The issues it brings with it outweighs the benefits because it’s mostly used in negative ways instead for good. How does media literacy help with responsible media consumption? The literacy of the Media is out there to challenge people with the understanding the representation of the media, with how it influences our culture. Media is out there to give the students the ability to read and write and be more competitive in our media culture. It uses an inquiry-based instructional mold that encourages people to ask questions about what they watch, see and read. Media literacy can also aim to enable people to be skillful creators and producers of media messages, both to facilitate an understanding as to the strengths and limitations of each medium, as well as to create independent media. †¦ By transforming the process of media consumption into an active and critical process, people gain greater awareness of the potential for misrepresentation and manipulation (especially through commercials and public relations techniques), and understand the role of mass media and participatory media in constructing views of reality. †¦ Protectionist approaches to media literacy emphasize the need to be aware of the negative aspects of mass media and popular culture, including the dangers and risks of online social media.

Essay Essay

THE MOST MEMORIABLE VACATION My most memorable vacation was when I went to NHA TRANG with my family last summer. When my father told me I was excited because NHA TRANG famous for beautiful beaches and delicious foods. After four hours on the train, finally we arrived. Although I felt tired after long hours, I am happy when I was standing in front of a beautiful beach. Firstly, we arranged our bags and after that, we quickly swim in the blue sea. Next, my younger brother and I were building sandcastles while my parents were sunbathing on the sand. For a few hours, we felt hungry so we went to a nearby restaurant to enjoy tasty foods. In the afternoon, we visited some beautiful and famous places such as THAP BA PONAGAR; HON CHONG then went to NHA TRANG center to buy some souvenirs. The day went by so fast. The trip was short but it had a strong impression on me and my family and I have many memories of that day. QUALITY OF A GOOD TEACHER The good teacher has three important qualities. The first quality of a good teacher is that having strong knowledge of his or her subject matter. For instance, teachers have to provide students with specific content knowledge. A good teacher will know how to explain the content that he or she is teaching in a way easy to the most understand for students. Another quality of a good teacher is enthusiastic and caring. For example, he or she always cares academic status of the students and help them more advance in learning. Moreover, they also learn about the family circumstances of the individual students and find ways to help the poor students. The last quality is that confidence. Standing in front of a class, he or she has to the voice clear and full of confidence to their student pay attention to his or her lectures. To sum up, a good teacher need to have three qualities above and ethic good quality. DISADVANTAGES OF LIVING IN THE DOMITORY Living in a college dormitory has several disadvantages. The first disadvantage is narrow space. For example, dormitory in PHU YEN University, there are eight students sharing the room, it becomes crowded and narrow. You do not have much space to learn within a dorm. In addition, your  roommates can be messy, upset, or talkative so you will feel uncomfortable when living together with them. Another disadvantage is food. You are not allowed to cook in the dormitory so you have to eat rice at the canteen or at the restaurant. The amount you have to pay for meals in the dorm expensive than in the motel. In addition, you will feel tired of when you have to eat the same foods every day. Finally, living in a dormitory is noisy. Sometime you cannot concentrate for learn if your roommate opens music loudly. To sum up, you must find the best accommodation for you to convenient for your learning but you should think before deciding to live in the dormitory. A BEAUTIFUL BEACH AT DAWN Beyond a shadow of doubt, NHA TRANG beach is one of the most beautiful beaches in Vietnam, particularly at dawn. Every day, at 5.30pm, the sunrise slowly, it is like yolk rise from the bottom of the sea. At that time, the beach always crowded. Many people get together here very early to do the exercise and bathe in the sea. The beach scenery at dawn is fantastic, with a neglected beauty. The silence covers the whole beach; there is no sound but the sound of breaking waves. If you stand on the sandbank and stare into the distance, in the sun direction, you will have a strange feeling; have something peaceful in the deep of your soul. The atmosphere is so great by the winds, which come from. When the sun has risen completely, you can see some light rays of sunlight; they signal to you that the dawn-time nearly ended. I think words cannot describe how nice this beach is at dawn. If you have a chance to visit somewhere, why do not you try visiting NHA TRANG to enjoy the beach landscape at dawn in the true sense of the word? A BEAUTIFUL BEACH AT DUSK Sitting on the fine sand, I can see the amazing beauty of the beach at dusk. The sun like a fiery orb looks like it is gradually receding into the waters below. The setting sun’s red rays lit up the sky above the western horizon. At the time, the sky consisted of an assortment of shades, a blend of reds, oranges, and yellows. The waters below mirror this effect. The waves are tinted vermilion; the sand under my feet is the same color, the vivid color mix highlights the beauty of the beach at dusk like a perfect picture. I can  hear is the sound of the waves as they crash against the shore, and seagulls, which I cannot see, squawking in the distance. Sometime I can smell the fishy smell of fish. It smells warm and salty, as I breathe in the cold, salty. I just stand there, eyes closed, and feel the moment until the dusk and the warm feeling fades. I wish time could stop to enjoy this wonderful moment longer. HOW TO MAKE CHICKEN RICE You can make a tasty chicken rice dish if you follow these easy steps. The first step is to prepare the necessary ingredient such as haft chicken, rice, three slices ginger, salt, coriander onions, cucumbers, tomatoes, and chilly sauce. Next, cook the rice in the rice cooker. The third step is to cut the chicken into bite-sized pieces, and then combine all the other ingredients and mix well in a bowl. After that, pour the mixture over the chicken, cover with foil and bake until the rice is cooked. When the rice is cooked, season to taste with salt, if needed. Finally, scoop a bowl of chicken rice on plate. Place cooked chicken over the rice. Garnish with sliced cucumbers, tomatoes, coriander, and spring onions. Now sit down and enjoy your delicious chicken rice plate with ginger sauce and chilly sauce on the side. HOW TO PREPARE FOR A JOB INTERVIEW Before a job interview, you can be stressful, but you can reduce your stress by following these skills. The first skill is picking out what you are going to wear to your job interview. The first choice an interviewer makes is going to base on how you look and what you are wearing. That is why it is always important to dress appropriately for a job interview. The second skill is that practiced greeting before your interviewer. You should always greet your interviewer with a friendly smile and a firm handshake. It will create a good impression about you to the interviewer. Next, you should prepare some typical interview questions you will probably be asked during a job interview. If you prepare well the answers of the interviewers can ask, you will not be surprised with questions about them. Practice interviewing  with a friend or family member ahead of time and it will be much easier when you are actually in a job interview. To sum up, the interviewers will appreciate what you did and can choice if you have a good preparation. AUSTRALIAN AND VIETNAMESE EDUCATION SYSTEM Australian and Vietnamese have similarities and differences in the education system. We can see that both education systems of Australian and Vietnam are quite similar that they have twelve grades, from one to twelve. In addition, schooling is compulsory for students until the age of fifteen. Despite the similarities, the two educations have some very important differences in system division, school-time. The first major difference between Vietnamese and Australian education is the system division. In Australia, primary school goes from grade one to six and secondary school from grade seven to twelve. In Vietnam, we have primary school (from grade one to five), middle school (from grade six to nine), and high school (from grade ten to twelve). Another obvious difference that we can see from these two educations is school-time. In Australian, the academic year begins in early February for school students and late February/early March for vocational and university students. However, in Vietnamese, the academic year begins in middle August for students and late August/ early September for university students. Although both education systems of Australian and Vietnamese have a lot of differences and similarities, they are good education systems for students. AMERICAN AND VIETNAMESE MEALS American and Vietnamese meals are quite different. One difference is Americans have one big dinner per day but Vietnamese have three meals a day with some snacking on fruits and cakes. Americans always think to take advantage of that time to be effective, breakfast and lunch only eating briefly, in the evening with more spare time, so comfortable chatting happily, and eating dinner together. Another difference is that the Vietnamese have breakfast with soup â€Å"pho,† rice or rice noodles; bean sprouts; greens; boiled eggs; and crusty bread and drink green tea or coffee. The Vietnamese have lunch and dinner with rice, fish, or meat;  vegetable dish with fish sauce then snacks with fruits or cakes. In contrast, Americans eat many foods that are high in calories and fat, such as hamburger, fried chicken, sandwiches. They do not spend much time in preparing food so they choose fast foods or going to the restaurant to eat. All in all, though there are differences between American meal and Vietnamese meal, they are typical culturally in the world.