By K. Curtis. Winona State University. 2018.

Long-term psychological sequelae of child sexual abuse: The Los Angeles Epi- demiologic Catchment Area Study 100mg clomid visa women's health clinic varsity lakes. Childhood molestation: Vari- ables related to differential impact on psychosexual functioning in adult women buy 50 mg clomid fast delivery menstrual vomiting and diarrhea. CHAPTER 17 Working with Couples Who Have Experienced Physical Aggression Amy Holtzworth-Munroe, Kahni Clements, and Coreen Farris HE QUESTION OF whether or not conjoint couples therapy is an appro- priate intervention for couples experiencing physical aggression is a Tcontroversial one. For reasons outlined later in this chapter, some ex- perts believe that it is never appropriate to offer violent couples conjoint therapy. In contrast, other experts, including ourselves, are willing to try such interventions cautiously and have experienced some clinical advan- tages in doing so. First, although many couples seeking couples ther- apy have experienced physical aggression, most will not report this aggres- sion during the therapy intake unless they are explicitly asked about it; thus, therapists should assess every couple for the possible occurrence of physical aggression. In doing so, they should use methods likely to increase the reporting of aggression (e. Second, couples therapy is not recommended for all violent couples and should be denied to some (e. Third, even when a violent couple is offered conjoint treatment, that treatment should not be traditional couples therapy; instead, it must have the elimina- tion of violence as a major treatment goal and must include interventions to help the couple achieve this goal (e. Fourth, couples therapists should be aware of resources for violent couples in their commu- nities (e. Fifth, therapists working with couples should try to keep abreast of the rapidly burgeoning research literature on marital violence, as our understanding of relationship violence is constantly changing and 289 290 SPECIAL ISSUES FACED BY COUPLES expanding. This chapter is designed to address these issues, providing therapists with a brief overview of the research on violent couples and of the issues to be considered when assessing couples, deciding whether or not to offer conjoint therapy, and working with couples who have experi- enced physical aggression. DIFFERING LEVELS OF RELATIONSHIP AGGRESSION When considering marital violence, one often thinks of battery, assault, and severe male-to-female aggression. One imagines men arrested for domestic violence and women seeking refuge at shelters. Such violence has been called battering, severe physical aggression (O’Leary, 1993), and patriarchal terrorism (Johnson, 1995), and the types of men who perpetrate such vio- lence have been divided into subtypes such as generally violent/antisocial men and borderline/dysphoric batterers (Holtzworth-Munroe, Meehan, Herron, Rehman, & Stuart, 2000). Some experts have suggested that severe male-to- female violence is used by men to control and dominate women (Johnson, 1995). Wives who experience severe husband abuse are at risk for physical injury, health prob- lems, and psychological symptoms, including fear, lowered self-esteem, and symptoms of depression and posttraumatic stress disorder (PTSD). As dis- cussed below, most experts believe that conjoint couples treatment for cou- ples experiencing this level of husband violence is inappropriate. Thus, such couples will not be the focus of this chapter, and we will refrain from re- viewing research involving samples clearly experiencing more severe male partner violence (e. National surveys suggest that, each year, one in eight men will engage in physical aggression against his wife (Straus & Gelles, 1990). Approximately half of all newlywed couples experience physical aggression early in marriage (e. Studies of such sam- ples suggest that, in the majority of cases, both partners engage in physical aggression (e. Such aggression has been labeled mild physical aggression (O’Leary, 1993), common couple vio- lence (Johnson, 1995), or bidirectional aggression (Cascardi et al. In our experience, couples who have experienced lower levels of physical aggression are the most likely to seek help from a couples therapist. As reviewed next, existing research suggests that conjoint couples therapy with such couples may not be unsafe and may not differ in the level of effectiveness from other therapy ap- proaches (e. Thus, given the focus of this book, our chapter focuses on this type of physically aggressive couple. In doing so, we limit our research review to studies of samples that might experience lower levels of aggression (e. NEGATIVE CONSEQUENCES OF COUPLES’ PHYSICAL AGGRESSION Although the prevalence rates of male and female physical aggression against an intimate partner are comparable, the consequences of partner vi- olence differ for men and women (Archer, 2000).

Thus generic 100mg clomid with mastercard menstruation age 9, much of the challenge for the healthcare marketer is in the accommodation of marketing principles to the unique characteristics of the healthcare industry order clomid 100 mg with amex pregnancy 7 months. In its original premarketing form, a market referred to a real or virtual setting in which potential buyers and sellers of a good or service came together for the purpose of exchange. The notion of a market place has been mod- ified to refer to the individuals or organizations in that market that are potential customers. Thus, to marketers a market is the set of all people (or organizations) who have an actual or potential interest in a good or service or, according to Kotler (1999), the set of actual and potential buy- ers of a product. Alternatively, a market is defined as a group of consumers who share a particular characteristic that affects their needs or wants and makes them potential buyers of a product. Markets are often thought of in terms of a market area—a geo- graphic area containing the customers of a particular organization for spe- cific goods or services. Markets may also be defined in nongeographic terms and refer to segments within the population independent of geography. The market, however defined, is thought to be characterized by a meas- urable level of market demand—the total volume of a product or service likely to be consumed by specific groups of customers in a specified mar- ket area during a specified period. In actual practice, health profes- sionals are not likely to deal with marketing in the abstract but are involved with concrete marketing activities. These concepts will recur repeatedly throughout the text, and it is worthwhile to pin down their definitions at this point. Public Relations Public relations (PR) is a form of communication management that seeks to make use of publicity and other nonpaid forms of promotion and infor- 80 arketing Health Services mation to influence feelings, opinions, or beliefs about the organization and its offerings. PR includes press releases, press conferences, distribution of feature stories to the media, public-service announcements, and other publicity-oriented activities. In the past, healthcare organizations often used PR for crisis management, particularly for damage control, justifying questionable actions, explaining negative events, and so forth. Over time, however, PR has been cast in a more proactive light as healthcare organizations have come to appreciate the benefits of a strong PR program. Communications Large healthcare organizations typically establish mechanisms for commu- nicating with their various publics (both internal and external). Com- munications staff develop materials for dissemination to the public and employees of the organization. Separate communications departments may be established, or this func- tion may overlap with the PR or community-outreach functions. Indeed, marketers have expended a great deal of effort in the examination of various models of communication (see Box 4. Community Outreach Community outreach is a form of marketing that seeks to present the pro- grams of the organization to the community and establish relationships with community organizations. Community outreach may involve episodic activities such as health fairs or educational programs for community residents. This function may also include ongoing initiatives involving out- reach workers who are visible within the community on a recurring basis. This aspect of marketing emphasizes the organization’s commitment to the community and its support of community organizations. While the benefits of community-outreach activities are not as easily measured as some more direct marketing activities, the organization often gains cus- tomers as a result of its health-screening activities, follow-up from educa- tional seminars, or outreach-worker referrals. One objective of community-outreach initiatives is to generate word- of-mouth communication concerning the organization or its services. Word- of-mouth communication occurs when people share information about products or promotions with friends. Efforts to generate positive word-of- mouth support are important, as word-of-mouth communication often tends to be negative. Theories in Communication refers to the transmission or exchange of information Marketing and implies the sharing of meaning among those who are communi- cating. Communication in marketing may be directed at (1) initiating actions; (2) making known needs and requirements; (3) exchanging information, ideas, attitudes, and beliefs; (4) establishing understanding; or (5) establishing and maintain- ing relations. Face-to-face commu- nication can involve formal meetings, interviews, and informal contact.

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Even if you have made a Will buy cheap clomid 50 mg online women's health center vcu, you may need to ensure that the process of passing on resources is as tax efficient as possible buy clomid 100mg visa women's health usf. If you do not already have a solicitor, get advice first at Citizens Advice in your area. Another issue is whether it is sensible to transfer some of your assets at an earlier stage than your death to your child. On the other hand it may reduce the eligibility of your child for certain state benefits both currently and in the future. Also, another thing to consider is whether your child is likely to be able to manage his or her own finances if you die, and you might need some arrangement whereby someone can manage the financial affairs – in the child’s interests, of course. There are a number of formal ways in which this can be organized – through the setting up of a Trust with your child as a beneficiary, for example. These considerations are invariably complex and need a detailed knowledge of the relevant legal situation; you need sound judgement about the long-term as well as the short-term financial consequences of the chosen course of action. It would be unwise to make major decisions on these issues without impartial advice. This may be because funds to support your existing accommodation as you have become used to it become less through having to work part-time or indeed having to give up work altogether. Of course, other difficulties, especially related to decreasing mobility, may mean that your existing accommodation, or a significant part of it, could become harder and harder to manage without adaptation. Factors affecting any decisions to stay or move will include your income, how easy the home is to adapt, and what kinds of services are available from the local Social Services and Housing Departments. Getting help for housing adaptations One of the issues that may be a major consideration to someone with MS as well as those living with them, is the need – at some point – to consider adaptations to their home to ensure that everybody can live comfortably and easily in it. A variety of adaptations may prove necessary, although each individual person may well require a different pattern of such adaptations. They are likely to range from installation of stairlifts, to adaptations to living rooms, bedrooms, kitchens, bathrooms and toilets, to making access easier both within the property, as well as into and out of it. Obviously many possible adaptations will not only depend on your own disabilities, but also on the nature and state of the property that you are currently living in. If you consider that you cannot continue to live in your current house without changes to the accommodation, there is a grant called the Disabled Facilities Grant (DFG) for which you may be eligible. This is available for owner occupiers, private and housing association tenants, and landlords, and is given by the department of the local council 161 162 MANAGING YOUR MULTIPLE SCLEROSIS responsible for housing. The person with MS need not personally make an application, for others can do this for them, although they have to demonstrate their right to do so. The maximum mandatory amount that can be awarded is £20,000, although local authorities have discretion to award more than this. Mandatory grants can be used to: • facilitate access to and from the property concerned; • make the property safe for those living in it; • ensure the disabled person can access the principal family room; • adapt the kitchen to enable the cooking and preparation of food independently; • provide access to a room used for sleeping; • provide or improve access to the toilet, wash basin, bath (and/or shower); • improve or provide a heating system in the property for the disabled person; • adapt heating, lighting or power controls to make them easier to use; • improve access and movement around the home to enable a disabled occupant to care for another person who normally lives with them. Discretionary awards can be used to adapt the property to make it more suitable for the accommodation, welfare or employment of the disabled occupant. There is a means test – both of the disabled person and what are called ‘relevant persons’ – for this Disability Facilities Grant, and you might have to contribute to the cost, depending on your financial situation. For most people with MS, the relevant person will be their spouse/partner – in addition to themselves, or a parent(s) if the person is under 18. The financial assessments are quite complicated and take into account savings (above £5000), as well as weekly income, set against an assessment of needs as recognized by allowances that the person with MS may have. RADAR has produced an information pack entitled Meeting the Cost of Adaptations which you may find helpful. If you feel that you cannot afford what the local authority indicates you should contribute, then you can ask the Social Services department to make a ‘top up’ payment or loan. The department can also help with top-up funding for a DFG if the cost is above £20,000 and the council housing department is only giving a grant up to the £20,000 limit for mandatory Disability Facilities Grants. Such (albeit HOUSING AND HOME ADAPTATIONS 163 discretionary) support has been important to many disabled people who could not obtain full funding for adaptations through their Disability Facilities Grant. Such zero rating will normally include the construction of ramps, widening of doorways and passages to facilitate access by a disabled person; installation of a lift between floors to facilitate access, including maintenance, repair and restoration of decorations, and works to bathrooms and toilets to facilitate use and access by the disabled occupant and any goods supplied in connection with this. Overall, in deciding whether to make an award, the housing department of the local authority will consider, in consultation with social services, whether the works are necessary and appropriate to the needs of a disabled person. They will also consider whether the adaptations are reasonable and practicable taking into account the age and condition of the property. These might include urging the disabled occupant to seek a renovation grant to make the property fit, considering whether a reduced level of adaptations to the property would be feasible, and finally considering with the disabled person the option of re-housing.

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A program of hospice and use of cardiopulmonary resuscitation in seriously ill hospi- palliative care in a private clomid 25mg line womens health australia, nonprofit US teaching hospital buy clomid 50mg visa womens health specialists of dallas. A national survey ogy of do-not-resuscitate orders: disparity by age, diagnosis, of end-of-life care for critically ill patients. Changes in orders limiting ysis and withdrawal of mechanical ventilation at the end of care and the use of less aggressive care in a nursing home life. Medical decision-making in the last Costs and Use of Care in the Last Year of Life. Longevity and Medicare active euthanasia and assisted suicide in Dutch nursing expenditures. The President’s Commission for the Study of Ethical oxygen on dyspnea in hypoxemic terminal-cancer patients. Strength For Caring (888) ICARE80 Hotline, associated with Alzheimer disease: variation by level of www. Patterns of pre-death service use by nal illness in the advanced cancer patient: Pain and other dementia patients with a family caregiver. Management of symptoms in dying patients and their families in hospital pain in elderly patients with cancer. This page intentionally left blank 27 Sources of Suffering in the Elderly Maria Torroella Carney and Diane E. Meier The relief of suffering is one of the primary aims of med- chapter attempts to address both physical and psycho- icine. The nature of suffering and what physicians can do social sources of distress in elderly patients, as well as to prevent or relieve it is poorly understood. Suffering is other factors associated with suffering often found in the a global concept that must be distinguished from pain or elderly patient population. Although physicians, patients, and medical literature tend 1 to link pain with suffering, these are distinct phenomena. Personhood includes personality and character, the indi- As symptoms are often interrelated with multiple vidual’s past, the family’s past, associations and relation- concurrent medical problems, management can be chal- ships with family and others, work and social roles, body lenging. As with any illness, the approach to treating image, the unconscious mind, political affiliations, the symptoms requires a thorough history, physical examina- secret life, the perceived future, and the transcendent or tion, and laboratory or radiologic investigations appro- spiritual dimension. Suffering with sickness occurs when priate to gain the best understanding of etiology and the illness or its symptoms not only threaten interference underlying pathophysiology. Once the cause and patho- with some aspect of personhood, but when it destroys or physiology are known, intervention ideally includes is perceived to destroy the integrity of the person, as just therapy to relieve the symptoms as well as to treat under- define. The goals of care may involve weighing the benefits Identification of suffering requires a high index of sus- and risks of treatments aimed at relief of suffering versus picion in the presence of serious disease and distressing those aimed at prolongation of life. Ask directly,"Are either cause (or are perceived to cause) a higher risk of you suffering? Intervening analgesics given at doses sufficient to relieve pain to to try to relieve distress or suffering can only be accom- simultaneously lead to respiratory depression. For most patients, physical pain is only one of Nebulized morphine or hydromorphone: several sources of distress. Physical aspects of pain cannot be effectively Plus or minus treated in isolation from the emotional and spiritual com- Albuterol 0. The various components of suffering Dexamethasone 16 mg initial, then must be addressed simultaneously. Many sources of dis- 8 mg bid ¥ 2 days, then 4 mg bid ¥ 2 days, then 2 mg bid tress and suffering are not visible and frequently are not Prednisone pulse spontaneously reported by patients. Formal and regular 40 mg po bid ¥ 5–7 days assessment is therefore critical to identification and Oxygen appropriate treatment of diverse symptoms. Physical and psychologic symptoms have been assessed most frequently using simple, validated measures, often in the form of symptom checklists. The Edmonton signs of respiratory function,9 and its management can Symptom Assessment Scale (ESAS) evaluates eight symptoms on visual analogue scales and has been exten- be challenging. It is important to diagnose and treat the sively used in palliative care research. Symptom Assessment Scale (MSAS) is a validated When therapy specific to the underlying cause is unavail- patient-rated measure that provides multidimensional able or ineffective, several techniques may alleviate information about a diverse group of common breathlessness. Simple techniques include pursed-lip 8 breathing and diaphragmatic breathing, leaning forward symptoms. It characterizes 32 physical and psych- ologic symptoms in terms of intensity, frequency, with arms on a table, cool air ventilation (fan or open 8 window), and nasal oxygen.

The daily use of bulk formers is necessary for maximal Medications for the Management of Constipation Medication Indications for Use Bulk formers Inadequate bulk in the diet and stool Stool softeners Hard stool causes constipation Laxative Difficulty expelling stool (oral stimulant) Suppositories and In combination with other other rectal medications if necessary stimulants Therevac® When lubricating stimulation is mini-enemas helpful Enemas For occasional use only buy discount clomid 100 mg line women's health clinic riverside campus, to avoid dependency 83 PART II • Managing MS Symptoms effectiveness clomid 25 mg amex women's health issues 2012. Common bulk formers include • Metamucil®, taken in a dose of one to two teaspoons daily mixed in a glass of water or juice and followed by an extra glass of fluid. This may be increased to one teaspoon taken two or three times per day if necessary; • P erdiem® fiber (brown container), taken in a dose of one to two rounded teaspoons daily; it should be placed in the mouth (not chewed) and swallowed with at least eight (preferably more) ounces of cool beverage; • FiberCon®, two tablets, one to four times a day; each dose should be followed by eight ounces of liquid; • Citrucel®, one tablespoon, one to three times daily, mixed in eight ounces of juice or water; • Fiberall®, available in chewable tablets, wafers, or powder, may be taken one to three times a day with eight ounces of liquid. Stool Softeners If the cause of constipation is hard stool, stool softeners are used to draw increased amounts of water from body tissues into the bowel, thereby decreasing hardness and facilitating elimination. Consistent use is recommended to obtain maximal benefit; as with bulk formers, stool softeners are not habit-forming. They include • Colace® (also known as DSS); take one pill every morning and evening; • Surfak®; take one pill every morning; and • Chronulac® syrup; take one ounce every evening, increasing to one ounce each morning and evening if necessary. Laxatives (Oral Stimulants) If difficulty in expelling stool is the cause of constipation, it may be corrected with laxatives, also referred to as oral stimulants. Although a 84 CHAPTER 11 • Bowel Symptoms number of over-the-counter laxatives are available, care should be taken to avoid the use of harsh laxatives, which may be highly habit-forming. The same results may be obtained by using the fol- Care should be taken to avoid the use of harsh laxatives, which may be highly habit-forming. Suppositories and Other Rectal Stimulants Rectal stimulants provide both chemical stimulation and localized mechanical stimulation combined with lubrication to promote stool elimination. They may be used either occasionally when nec- essary or on a routine daily or every-other-day basis in conjunction with other medications already listed. They include • lycerin suppositories, which contain no medication and provide rectal stimulation and lubrication for easier passage of stool. Glycerin suppositories are milder and less habit- 85 PART II • Managing MS Symptoms forming than Dulcolax® and are used to help develop a bowel routine; • Dulcolax® suppositories, which contain a medication that is absorbed by the lining of the large bowel and stimulates a strong wavelike movement of the rectal muscles that facili- tates elimination; and • Therevac® mini-enemas, which are not traditional enemas but rather lubricating stimulants in a easy-to-administer shell. This preparation is a clean way of administering a helpful medication to stimulate a bowel movement. Enemas may be considered an occasional treatment for consti- pation, but the frequent use of enemas should be avoided because the bowel may become dependent on them when they are used routinely. In summary, many medications are available without a pre- scription for the treatment of constipation, but their indiscriminate use should be avoided. A professional should be consulted to determine which medication or combination of medications is best suited to a specific problem. In attempting to control constipation, it may be necessary to begin a bowel program that includes a num- ber of medications. This may seem rather overwhelming in the beginning, but some medications may be eliminated as a routine is established and bowel movements become more regular. DIARRHEA AND INCONTINENCE Diarrhea is much less common than constipation in people with MS. However, it may be a significant problem because there may not be adequate warning of an impending attack and incontinence may therefore occur. The probable cause of such diarrhea is a reflex-like activity that results from the short-circuiting in MS, caus- ing frequent emptying even though the bowel is not full. The key to controlling diarrhea is to make the stool bulkier with- out producing constipation. Bulk formers such as Metamucil® or 86 CHAPTER 11 • Bowel Symptoms Perdiem Plus® may be helpful because they absorb water and there- fore make the stool firmer. When it is used to treat diarrhea, a bulk former should be taken no more than once a day, and it should not be followed by the recommended extra fluid that is needed when a bulk former is used to treat constipation. In extreme cases, medica- tions that slow the movement of the bowel muscles may be needed to control diarrhea, such as Kaopectate®, Imodium®, or Lomotil®. A loose stool in a person with MS most often is caused by something other than MS! Depending on the location of demyelinated areas, many alterations of normal speech patterns may occur as the result of MS. Most such alterations affect speech production, resulting in dysarthria, or slurred speech, ranging from mild difficulties to severe problems that make comprehension impossible. Demyelination in the cerebellum, the area of the brain involved with balance, is the primary cause of speech difficulties. If the tongue, lips, teeth, cheeks, palate, or respiratory muscles become involved, the speech pattern becomes even more slurred (dysarthric). Although exercises are sometimes advocated, they usually are not successful for this type of speech problem.

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