Characteristics of a Human Service Professional Essay

Individuals working in hospice are a great example of chronic bereavement. â€Å"Chronic Bereavement refers to multiple losses and include the effects of chronic anticipatory, and unresolved grief, as well as the compounding effects of experiencing several episodes of grief concurrently† (Hooyman p 349). While meeting the emotional needs of the dying and their families health services professionals don’t have always have time to deal with their own grief appropriately. Compassion Fatigue â€Å"Compassion fatigue describes the convergence of secondary traumatic stress and cumulative stress or burnout, which is most prevalent among professionals, family members, and associates of trauma survivors (Hooyman p350). Many human service workers have had some kind of early-life trauma that influenced their career choice which makes them more vulnerable to compassion fatigue. The symptoms of compassion fatigue are similar to those of primary traumatic stress disorder. They differ in that compassion fatigue doesn’t affect the health care provider. Vicarious Traumatization Vicarious traumatization (VT) is defined as â€Å"the negative transformation in a helper’s inner experience that takes place as a result of deep empathic engagement with traumatized clients couples with a sense of professional responsibility to help.† (Hooyman p350). There are many considerations when treating vicarious traumatization, especially during self-care such as awareness, balance, and connection. Awareness is to recognize signs and symptoms of vicarious traumatization, avoid substances that numb your feelings and awareness and listen to those who have noticed changes in you and discuss those changes. Balance is setting limits to availability to therapeutic work and setting realistic expectations. Then you need to know to apply what you have learned in the workplace and your personal life. Burnout Burnout is one of the main reasons for the quick turnaround in the health care profession. â€Å"Burnout refers to physical, emotional, and psychological exhaustion accompanied by a sense of demoralization and diminishing caring and creativity and personal accomplishments†. (Hooyman p352) To avoid burnout to quickly, health professionals may need to take long weekends or vacations to rejuvenate themselves. Countertransference â€Å"Countertransference is broadly defined as the personal reactions elicited in the professional relationship, directed toward the client and stemming from the professional’s previous experiences.† (Hooyman p 355) Countertransference occurs when a health care provider has unresolved issues and those issues affect the patient. Countertransference reactions include but are not limited to: being overprotective, rejecting a client, needing constant approval or reinforcement. Self-awareness is necessary to avoid countertransference.

Obesity and Calories Essay

But you also know that most diets and quick weight-loss plans have about as much substance as a politician’s campaign pledges. You’re better off finding several simple things you can do on a daily basis — along with following the cardinal rules of eating more vegetables and less fat and getting more physical activity. Together, they should send the scale numbers in the right direction: down. 1. Once a week, indulge in a high-calorie-tasting, but low-calorie, treat. This should help keep you from feeling deprived and binging on higher-calorie foods. For instance: †¢ Lobster. Just 83 calories in 3 ounces. †¢ Shrimp. Just 60 calories in 12 large. †¢ Smoked salmon. Just 66 calories in two ounces. Sprinkle with capers for an even more elegant treat. †¢ Whipped cream. Just 8 calories in one tablespoon. Drop a dollop over a bowl of fresh fruit for dessert. 2. Treat high-calorie foods as jewels in the crown. Make a spoonful of ice cream the jewel and a bowl of fruit the crown. Cut down on the chips by pairing each bite with lots of chunky, filling fresh salsa, suggests Jeff Novick, director of nutrition at the Pritikin Longevity Center & Spa in Florida. Balance a little cheese with a lot of salad. 3. After breakfast, make water your primary drink. At breakfast, go ahead and drink orange juice. But throughout the rest of the day, focus on water instead of juice or soda. The average American consumes an extra 245 calories a day from soft drinks. That’s nearly 90,000 calories a year — or 25 pounds! And research shows that despite the calories, sugary drinks don’t trigger a sense of fullness the way that food does. . Carry a palm-size notebook everywhere you go for one week. Write down every single morsel that enters your lips — even water. Studies have found that people who maintain food diaries wind up eating about 15 percent less food than those who don’t. Plus: 8 Kitchen Cabinet Makeovers for Weight Loss 5. Buy a pedomete r, clip it to your belt, and aim for an extra 1,000 steps a day. On average, sedentary people take only 2,000 to 3,000 steps a day. Adding 2,000 steps will help you maintain your current weight and stop gaining weight; adding more than that will help you lose weight. 6. Add 10 percent to the amount of daily calories you think you’re eating, then adjust your eating habits accordingly. If you think you’re consuming 1,700 calories a day and don’t understand why you’re not losing weight, add another 170 calories to your guesstimate. Chances are, the new number is more accurate. 7. Eat five or six small meals or snacks a day instead of three large meals. A 1999 South African study found that when men ate parts of their morning meal at intervals over five hours, they consumed almost 30 percent fewer calories at lunch than when they ate a single breakfast. Other studies show that even if you eat the same number of calories distributed this way, your body releases less insulin, which keeps blood sugar steady and helps control hunger. 8. Walk for 45 minutes a day. The reason we’re suggesting 45 minutes instead of the typical 30 is that a Duke University study found that while 30 minutes of daily walking is enough to prevent weight gain in most relatively sedentary people, exercise beyond 30 minutes results in weight and fat loss. Burning an additional 300 calories a day with three miles of brisk walking (45 minutes should do it) could help you lose 30 pounds in a year without even changing how much you’re eating. 9. Find an online weight-loss buddy. A University of Vermont study found that online weight-loss buddies help you keep the weight off. The researchers followed volunteers for 18 months. Those assigned to an Internet-based weight maintenance program sustained their weight loss better than those who met face-to-face in a support group. Plus: 15 Foods You Should Never Buy Again 0. Bring the color blue into your life more often. There’s a good reason you won’t see many fast-food restaurants decorated in blue: Believe it or not, the color blue functions as an appetite suppressant. So serve up dinner on blue plates, dress in blue while you eat, and cover your table with a blue tablecloth. Conversely, avoid red, yellow, and orange in your dining areas. Studies find they encourage eating . 11. Clean your closet of the â€Å"fat† clothes. Once you’ve reached your target weight, throw out or give away every piece of clothing that doesn’t fit. The idea of having to buy a whole new wardrobe if you gain the weight back will serve as a strong incentive to maintain your new figure. 12. Downsize your dinner plates. Studies find that the less food put in front of you, the less food you’ll eat. Conversely, the more food in front of you, the more you’ll eat — regardless of how hungry you are. So instead of using regular dinner plates that range these days from 10-14 inches (making them look forlornly empty if they’re not heaped with food), serve your main course on salad plates (about 7-9 inches wide).

Regulation of Physiological Process by Thyroid Hormones Essay

Regulation of Physiological Process by Thyroid Hormones - Essay Example On the other hand, each function may be controlled by several hormones, which act in concert. The secretion of the hormones in a normal human being is mainly based on negative feedback control, most of which involves the hypothalamic-pituitary axis that detects changes in the concentration of hormones secreted by peripheral endocrine glands. The hormones may also be secreted in response to changes in a controlled variable (Nussey & Whitehead 2001). The following examples illustrate as to how hormones regulate physiological function. The thyroid hormones, namely, thyroxine (T3) and tri-iodothyronine (T4) are secreted by the thyroid gland. They stimulate the oxygen consumption of most of the cells of the body, help in the regulation of lipid and carbohydrate metabolism, and are essential for normal growth and maturation. The thyroid hormones enter the cells after which T3 binds to the thyroid receptors in the nuclei. T4 binds, but not avidly. The thus formed hormone-receptor complex then binds to DNA via zinc fingers and affects the variety of different of different genes that code for enzymes which regulate cell function. The main physiological effect of thyroid hormones is calorigenic action (Ganong 2003). The hormones increase oxygen consumption of most of the tissues in the body except brain, testes, uterus, lymph nodes, spleen and anterior pituitary. The hormones also increase the metabolism of fatty acids. Due to increased calorigenic action, nitrogen excretion is increased and endogenous protein and fat st ores are metabolized, which may lead to weight loss. The hormones also cause hepatic conversion of carotene to vitamin A. Other functions include an increase in cardiac output by direct action on the heart and also by activating heat dissipation mechanisms. The pulse pressure and heart rate are also increased, thus shortening circulation time. In the central nervous system, the thyroid hormones increase the responsiveness of the brain tissue to catecholamines, thus activating the reticular activating system. The hormones also affect brain development and reflexes. They increase the rate of absorption of carbohydrate from the gastrointestinal tract.

Aldi supermarket Essay Example | Topics and Well Written Essays - 1000 words

Aldi supermarket - Essay Example In Aldi product innovation could be related to the introduction of products that do not currently exist in the UK supermarket industry, even if their differentiation from the industry’s existing products would be small: for example, an energy drink of different ingredients depending on the status of health and the age of consumers would be a product that meets the terms of product differentiation. Through product differentiation Aldi could manage to acquire a sustainable competitive advantage, i.e. an advantage that ‘cannot be copied by competition’ (Lamb et al. 2011, p.42). For developing a sustainable competitive advantage Aldi should try to ensure that its products are aligned with the needs of the local market and that they could attract the interest of local consumers (West et al. 2010); this means that the advantage of the firm’s products towards them of its competitors should be clear to the consumers. Another approach that Aldi would use for acquiring a sustainable competitive advantage would be the following: the firm could use social marketing, which ‘promotes behaviours that provide well-being for individuals or for society’ (Kapoor and Kulshrestha 2013, p.10). For example, Aldi could use its marketing campaign for increasing the awareness of people on the health consequences of the consumption of milk-based products. Of course, other strategies, for acquiring a sustainable competitive advantage would be also available to Aldi: for example, by decreasing the price of a specific category of products would result to a sustainable competitive advantage for Aldi, even in the short term (Lamb 2012). In the context of marketing, a PEST analysis is a valuable tool for assessing the status of a particular market, i.e. to identify the market’s current performance in regard to one or more industries. In addition PEST analysis can help to check the prospects of a market, i.e. its potentials for growth in the future, as related to a series of

YouTube Video Sharing Essay Example | Topics and Well Written Essays - 1000 words

YouTube Video Sharing - Essay Example YouTube.com has been the leader in Internet video search. This video entertainment site has been in operation for only a year but it has already become the most favorite video-sharing site, dislodging News Corp.'s MySpace, Yahoo, Microsoft's MSN, Google and AOL. This is the very reason why the onset You Tube, the very processes and legal aspects related to video sharing through You Tube is worth studying. Youtube serves as a quick entertainment break especially for viewers who have broadband connections at work or home. Youtube, whose original creators were students, however, is mostly popular among teens. It is said that more 100 million videos-usually short, homemade, comic videos created by users--are being seen on Youtubue every day. The record high was reported in June when an estimated 2.5 billion videos were watched on this site. Next to video lovers, online video advertisers, for sure, are the ones who are excited about the popularity of Youtube and other online video sites nowadays. With Youtube, the potential for online video advertising has become bigger. It was reported that online advertisements were the fastest-growing part of the $521-billion advertising market last year. Hence, web articles and peer reviewed journals published written and published from the year 2000 to the present are the most useful resources that can be acquired when writing about this topic. This is because You Tube was established along with the booming information technology and widespread use of internet, hence the coming of the 21st century will be the best possible years to looks for. The Form and the Medium Since a single click to see a video on Youtube can easily be counted, it also has become easier for companies to exactly track how many people are interested in their product. This, plus the fact that content providers and marketers could get instant recognition around the globe when they advertise their products online, is what attracts advertisers to put their money on online video advertising. Seeing the potential for increasing its revenues in Internet ads, web search leader Google Inc. recently bought Youtube for $1.65 billion in stock. This is so far the biggest price paid for a consumer-generated media site. Analysts said the acquisition would help Google compete in video search, an area where it has been weak. US Internet search giant Yahoo Inc., meanwhile, recently launched a video-sharing service in a move to capitalize on the trend being blazed by YouTube. The new video service's design is similar to that of Youtube, only that it has the capability to stream video which users can link their favorite footage to personal Web pages. This paper would try to compare the different video sharing facilities presented in the internet - such as the You tube, the Google and the Yahoo movies/video sharing. This will try to analyze the different factors why these forms of media are now becoming one of the most popular channel to advertise and/or market a product or service and equally powerful in disseminating information to. More so, in lieu of my final essay related to advertising, I will try to conceptualize different video advertisements (ranging from 1-5) for a varied number of products and services. These video ad concepts will have to be align with the effective and affective advertisements concepts (which will also be studied). Relevance to the Discipline The success of Youtube has been mired with controversies. For one, Youtube and other

Women, marriage, and shame in the nineteenth century France Term Paper

Women, marriage, and shame in the nineteenth century France - Term Paper Example Flaubert relates the marriage and the shame Emma had to endure with the other ordinary women of France and the way French trends were followed by them. Emma, in the beginning of novel, is presented as a beautiful, sharp and happy girl but, after marriage is referred to as a troubled, unhappy and unsatisfied house wife and mother, while at the end of the novel, she portraits herself as a tragic heroine and kills herself. Emma Bovary (Madame Bovary): Madame Bovary, was the young and beautiful wife of a doctor named â€Å"Charles†. She lived in the world of imaginations and fantasy. For Emma, life was nothing but a bundle of excitements. She was not only beautiful, but was also very intelligent and sharp. But, unfortunately, she could not develop her mind as a cautious adult woman. She could not utilize her intelligence and be well-aware of the world and her surroundings. The world in which Emma would live was far more different from the actual world. Emma had a very extremely ro mantic view and imagination of the world. She strongly believed in romance and excitement related to romance. This opinion of her about a beautiful and romantic world differed from the real world. As Emma was in a habit of reading romantic books and novels, this habit drove her even more towards the heights of passion for romance. She grew even more desperate to experience it. After she met Charles, she felt that she was having a great compatibility with him as both of them enjoyed each other’s company. They would spend a lot of time meeting each other which would please not only Emma but also Charles. Soon with the consent of Emma’s father, they got married. But, unexpectedly Emma started getting bored after marriage and started losing interest in her husband. Therefore, Emma’s opinion about marriage and her excitement about romance in the married life perished away. She became quite disillusioned, dull and miserable about her married life as her husband Charle s was very good but a bit dull and boring and was not able to come up with the expectations of his wife, rather the imaginations of his wife. This dissatisfaction with her married life led Emma to two marital affairs. This was because she was trying to seek for more romantic pleasure and wanted to make her life risky and excited. Emma, after marriage, soon gave birth to a daughter who was named â€Å"Berthe†. This could prove to be a change and a reason to get excited fir Emma but even motherhood seemed boring to her and was again disappointed with her life Women in the 19th century France: Women in 19th century France, were quite different and far more responsible and loyal than the way Emma was described I the novel. They not only had to look after their home but also earn for their family. They would work in different fields performing different jobs in order to act as a helping hand for their husband. They would usually work outside their homes without their children, hus band and other members of the family being neglected. Working outside the home would make them face uncountable and unimaginable sorts of challenges which they would face readily and bravely and then would take good care of their family as well. Some women would work indoors as well, such as maids, laundry women, tailors etc. This would not only keep them safe from the challenges of the outer world but also provide them with the income to help their family. But, these kinds of indoor jobs were not always helpful and enough for their family, therefore, majority of them had to go out to

Ethnography interviewing Parents who encourage their children to play Research Paper

Ethnography interviewing Parents who encourage their children to play aggressive sports - Research Paper Example Several parents are in favor of having their children play aggressive sports. One mother that was interviewed gave her side of the story. According to parent Sandra Hemingway (personal communication, August 8, 2011), she allows her 12-year-old daughter to participate in kickboxing because she believes it not only allows her to â€Å"learn valuable self-defense techniques,† but also because she thinks it is wonderful exercise for a young, growing girl. Another parent felt that having his child play an aggressive sport was a rite of passage, and part of his cultural heritage. According to parent Mark Garcia (personal communication, August 8, 2011), he allows his 14-year-old son to participate in soccer because it is a team-oriented sport which has cultural ties to his native homeland of Mexico. It seems that parents are definitely models for how aggressively participants of certain sports can act. According to Dunlap (2005), â€Å"Parents, coaches, teammates, and sport heroes often model support for aggressive styles of play†¦Ideally, childrens participation in sports should be fun, contribute to physical development, teach skills, [and] help develop social skills†¦Ã¢â‚¬  (pp. 38). Social skills are important for younger children. Research seems to suggest that, the more aggressive a contact sport is, the weaker the moral fibers of the child participating in the sport. This also suggests that the parents of these children are also going to have scored lower on moral reasoning tests. According to Hughes (2009), â€Å"People who have the greatest interest in highly aggressive contact sports or have participated in them for the longest amounts of time tend to score lower on tests of moral reasoning†¦Ã¢â‚¬  (pp. 49). Parents have actually been proven to be more prone to ‘sports rage,’ especially because of their children being involved in aggressive sports events. According to â€Å"New Law Upgrades ‘Sports Rage’ Penalty† (2002), â€Å"[L]awmakers cited

Strategy management - culture Essay Example | Topics and Well Written Essays - 1250 words

Strategy management - culture - Essay Example When an organization merges its tangible and intangible resources, it keeps the resource-based view (RBV), allowing itself to move in the pool of competition (Abt, 2007). Management scholars view RBV in a slightly different context. They have signified certain gaps in RBV approach, which needs further critical identification. To verify these gaps in RBV, Google Inc. has been chosen to assess the discrepancies, which is a prominent and successful business organization in the contemporary period (Henry, 2008). There are many things besides the Resource-based view that brought Google into a success position. Innovation is the first key step that marked its way towards successful performance (Farnham, 2014). Similarly, it is Google’s top leadership, which had the vision and competitiveness to bring the organization to that successive phase. Above of all, it was Google’s mastery of knowledge management (KM) that brought the company in to such distinction of progression. Not to forget, Google’s reliance on innovative strategies to make it both cost and product effective (Barney, 2001). Google kept the Resource-Based view of its resources, but also enhanced its culture of innovation to gain competitive advantage (Burke, 2010). It was something more than just adaptation of RBV concept that brought Google to success. All this indicates that Resource-Based view is not the only thing required for competitive success, but there are other significant factors that bring competitiveness within organization. RBV approach is basically contributes lesser for competitiveness (Abt, 2007). Through contemporary business perspective, mergers and acquisitions are strategic dimensions for any emerging organization (Phillips & Gully, 2011). According to general perspective of organization’s leadership, mergers and acquisitions are sufficient to raise company’s horizontal knowledge, which is very important for bringing competitiveness in long

Australian Feminist Movement Essay Example | Topics and Well Written Essays - 2500 words

Australian Feminist Movement - Essay Example These works denounced marriage as slavery for women. Feminism started in America as a revolution. The Seneca Falls convention held in 1848 is considered a milestone in the history of the Feminist Movement. It put forth the demand for women's rights which included right for equal pay, right for property, right for divorcing the husband, right for taking guardianship of the children etc. the most important in this agenda was womens' right to vote. This was a declaration of demanding equality without sexual discrimination. Their voice slowly started getting people's attention. When the 19th amendment was made in the American Constitution to give women the right to vote, it looked like they had finally won the battle. On 14th December, 1961, the President's Commision was set up by the then President John F. Kennedy to review the status of women. Its purpose was to review the status of women and remove the obstacles that prevented women from enjoying equal status in the society. This Commission was aimed to combat the customs, notions and other factors prevalent in the society that were hindrance for the women. So the movement that was building up quietly in the 50's, gained momentum and became more visible and more audible. The 60's were the era of demonstrations, marches and processions. This time it saw the participation of school and college girls as well. Status in Australia Feminism has its presence in Australia also. Although Australia has always been conceived as a true democratic state with total egalitarian attitude.(Summers, Anne, 1994, Dmaned whores and God's Police, p.103) But the feminist movement in Australia has been raising the issue to provide the Australian women equal access to power. This movement started in the nineteenth century and its prime focus was to get the women their right to vote and also an equal opportunity to participate in the political activities and help them come to power. ( Oldfield, A., Woman Suffrage in Australia: A gift or a Struggle. 1992) Australian women got their right to vote much after the American women. In fact their neighboring country New Zealand got their right to vote before them. This gave them the status of citizens finally.(Summers, Anne 1994, Ibid, p.405) But even then the Aboriginal women were not given the same status. It was only in 1967 that they also got the right to vote.(Brenner,J.1996, p.20) 1960 was the beginning of the second wave of Australian Feminist movement. This was focused on the legal and social equality. Although women had got their right to vote but practically they were still considered the "second sex". They faced discrimination at the workplace and often got exploited. At home also they did not have equal status as men. They had no control over their sexual and reproductive lives. This second wave had some achievements as they succeeded in getting equal wages for the women. They also got the discrimination based on marital status eliminated from the work place. Simultaneously there was another movement coming up which was for the rights of the marginalized groups. This movement wanted equality for people regardless of their country of origin or their color or race or their sexual preferences like being gay or lesbian. The feminists got a ground as patriarchy, against which they were

Duke of Edinburg Adventurous Journey Report Essay Example for Free

Duke of Edinburg Adventurous Journey Report Essay The Duke of Edinburg Adventurous Journey Report It all started on the cool morning of July 31. After a delay of about 2 hrs, we finally got on the Volvo AC bus after having our modest breakfast in OIS. I felt great; the morning fresh air always suited me. The bus passed effortlessly through the jam less Dhaka streets. Once it got to Savar, I began to notice natural beauty of the highest quality. There were all kinds of plants and shrubs and delicately colored flowers. The green carpeted Savar Golf Course was the main attraction of our journey from Dhaka to Aricha. After an hours delay at the Aricha ferry ghat, it took us another hour to cross the river. The other half of our journey from ferry ghat to Khulna was torturous. Amid the sweltering heat of the shrouded sun, the AC of the AC bus kept breaking down and we were not in a position to actually appreciate the natural roadside beauty. Everyone was sweating and cursing inside the bus. And no one had the heart of taking pictures or tuning to a song. So the first emotion upon stepping out of the bus was one of relief; no one would want to repeat a bus journey like that! We reached the quarter where we would be saying for the better part of the next 2 days. Every one of us felt disappointed on seeing the small building surrounded by the wild. Compared to BARD, this place was like a jungle. We spent an hour for settling in our room and washing ourselves up. Then we took a 20 minute walk and our journey for the day was put to an end. The next day was full of adventures. We took a 2 hr walk before breakfast. The highlight of our adventurous journey came right after that. We took a bus to Bagerhat to visit the Sathgombhuj Mosque. The guide there told us some part of the history of the mosque and also gave us an insight on where the name of the mosque derived from. After a brief photo-session we went to Khan Jahan Ali Mazar; there we sat near the edge of the lake and took a little snack break of singara and Frutica. Some half an hour later another bus trip took us to Chadmahal. The place is a gem hidden deep in the heart of Bagerhat. It looked like a great place for family hangout. Apart from anything else there is a zoo, an astounding 3-storey marble-studded building and an underwater entrance to the building. After our short visit to Chandmahal, we took our survey of the local people, as instructed and then went back to our resting place. After a day full of work, it was a bliss to me to get a quick shower and nap before the grand camp fire. Although most of the awardees were reluctant, the campfire went fine. I was honored to be given the chance to light the fire. From there on, we sang and Akter sir danced and overall the camp-fire was a success. After that we went to sleep. The next day, everyone woke up early and prepared to leave. We loaded vans with our luggage and hurried to the train station. No sooner had we got on the train, it gave its final whistle and started to move. The train journey was itself an adventure with one of the bogies going off-track soon after we passed a small station. All in all the adventurous journey was a memorable one and a few glitches along the way will not make it any less enjoyable.

People Suffering Mental Disorder Auditory Hallucinations

People Suffering Mental Disorder Auditory Hallucinations Auditory hallucinations for some people suffering mental disorder are frequently experienced as alien and under the influence of some external force. These are often experienced as voices that are distressing to the individual and can cause social withdrawal and isolation. Although auditory hallucinations are associated with major mental illnesses such as schizophrenia, they also occur in the general population (Coffey and Hewitt 2008). The annual incidence is estimated between 4-5 percent (Tien 1991), with those experiencing voices at least once, estimated between 10-25 percent (Slade Bentall 1988).The standard professional response to voice hearing has been to label it as symptomatic of illness and to prescribe anti-psychotic medication (Leudar Thomas 2000). An alternative is suggested by Romme and Escher (1993), who view the hearing of voices as not simply an individuals psychological experience, but as an interaction, reflecting the nature of the individuals relationship with h is or her own social environment. In this way, voices are interpreted as being linked to past or present experiences and the emphasis is on accepting the existence of the voices. Romme and Escher (1993) see hallucinatory voices as responsive to enhanced coping and found that those who coped well with voices had more supportive social environments than those who found it difficult to cope. This dissertation will aim to discuss the experience and management of auditory hallucinations in schizophrenia looking into therapeutic relationship, helping approaches, and working towards the ending of a therapeutic relationship discussing discharge. First chapter will aim to explain what schizophrenia is, the cause of schizophrenia, its symptoms and types with particular focus on auditory hallucinations. The chapter will then discuss what auditory hallucinations are in the diagnosis. Therapeutic relationship between service user and the nurse is paramount in mental health nursing and is seen to prove long term outcome such as social functioning (Svensson and Hansson 1999). Chapter two will aim to discuss the building of therapeutic relationship in the management of auditory hallucinations using Peplaus interpersonal relations model (1952). The importance of holistic assessment using a variety of tools, scales and questionnaires that will identify symptoms, risks, management of risk and address the service users needs will be discuss in chapter three. Chapter four of this dissertation will discuss helping approaches. Gray et al (2003) states that pharmacological and psychosocial interventions have been heavily researched to find the most up to date literature and recommendations for the management of auditory hallucinations in schizophrenia with medication and Cognitive Behavioural Therapy (CBT).. The final chapter will aim to discuss the ending of the therapeutic relationship between the nurse and the service user looking into discharge planning process and conclusion. Chapter one What is Schizophrenia and Auditory Hallucinations? Introduction to chosen topic Schizophrenia is one of the terms used to describe a major psychiatric disorder (or cluster of disorders) that alters an individuals perception, thoughts, affect and behaviour. Individuals who develop schizophrenia will each have their own unique combination of symptoms and experiences, the precise pattern of which will be influenced by their particular circumstances (NICE 2010). Allen et al (2010) define schizophrenia as a chronic and seriously disabling brain disorder that produces significant residual cognitive, functional and social deficits. Schizophrenia is considered the most disabling of all mental disorders (Mueser and McGurk, 2004), it occurs in about 1% of the world population, or more than 20 million people worldwide (Silverstein et al., 2006). The DSM -IV TR (APA 2000) defines schizophrenia as a persistent, often chronic and usually serious mental disorder affecting a variety of aspects of behaviour, thinking, and emotion. Patients with delusions or hallucinations may be described as psychotic. However, Tucker (1998) argues that the system of classification developed by the DSM-IV does not actually fit many patients as a whole; the syndromes outlined in DSM-IV are free standing descriptions of symptoms. He said unlike diagnoses of diseases in the rest of medicine, psychiatric diagnoses still have no proven link to causes and cures; Tucker argues that there is no identified etiological agents for psychiatric disorders. Schizophrenia is characterized by clusters of positive symptoms (e.g. hallucinations, delusions, and/or catatonia), negative symptoms (e.g. apathy, flat feet, social withdrawal, loss of feelings, lack of motivation and/or poverty of speech), and disorganized symptoms (e.g. formal thought disorder and/or bizarre behaviours). In addition, individuals with schizophrenia often experience substantial cognitive deficits including loss of executive function, as well as social dysfunction (Allen et al., 2010). It is estimated that nearly 75% of people with schizophrenia suffer with auditory hallucinations (Ford et al., 2009). Positive and negative symptoms are mentioned briefly because the dissertation is primarily focused on auditory hallucinations. Auditory hallucinations in diagnosis Auditory hallucinations are often considered symptomatic of people diagnosed as suffering from schizophrenia (Millham and Easton, 1998). APA (1994, p.767) defines hallucinations as a sensory perception that has the compelling sense of reality of a true perception but that occurs without external stimulation of the relevant sensory organ. Auditory hallucinations range from muffled sounds to complete conversations and can be experienced as coming either from within or from outside ones self (Nayani David, 1996). However, Stanghellini and Cutting (2003) argue that APA definition of hallucinations is false, they believe an auditory hallucination is not a false perception of sound but is a disorder of self consciousness that becomes conscious. Hearing voices is not only linked to a persons inner experience but can reflect a persons relationship with their own past and present experiences (Romme and Escher, 1996). Beyerstein (1996) suggests that voices are anything that prompts a move fro m word based thinking to imagistic or pictorial thinking predisposes a person to hallucinating. Auditory hallucinations, or hearing sounds or voices are the most common and occur in nearly 75 percent of individuals diagnosed with schizophrenia (Ford et al., 2009). Auditory hallucinations are often derogatory or persecutory in nature, and can be heard in the third person, as a running commentary, or as audible thoughts. Some individuals with schizophrenia also experience useful or positive voices that give advice, encourage, remind, and help make decisions, or assist the person in their daily activities (Jenner et al., 2008). Voice hearer can work with their voices and either choose what to listen to or can completely ignore them (Romme et al., 1992). Sorrell et al (2009) states that some individuals experience positive voices which do not affect the way they function or go about their daily living, these hearers also find that their voices may offer advice and guidance. The hearers voice can be reported as a little distressful or some go on to report no distress at all (Honig et al., 1998). However Nayani and David (1996) argues that individuals who experience a constant negative voice found them less difficult to control, they found the voice more powerful and attempt to ignore the voice. Chadwick et al (2005) said that those who resist voices or feel the need to argue or shout back are termed malevolent, those who think voices are good and engage with them are benevolent, they see voices are helping them so they tend to listen and follow advice. Swanson et al (2008) suggests that people who hear voices are more likely to be victims of violence than be violent themselves. However Soppitt and Birchwood (1997) argue that voices are more commonly linked to depression, voice hearers can also have a history of suicidal thoughts, paranoia and abuse. Not all auditory hallucinations are associated with mental illness, and studies show that 10 to 40 percent of people without a psychiatric illness report hallucinatory experiences in the auditory modality (Ohayon, 2000). A range of organic brain disorders is also associated with hallucinations, including temporal lobe epilepsy; delirium; dementia; focal brain lesions; neuro- infections, such as viral encephalitis; and cerebral tumours intoxication or withdrawal from substances such alcohol, cocaine, and amphetamines is also associated with auditory hallucinations (Fricchione et al., 1995) The phenomenological characteristics of auditory hallucinations differ on the basis of their etiology, and this can have diagnostic implications. People without mental illness tend to report a greater proportion of positive voices, a higher level of control over the voices, less frequent hallucinatory experiences, and less interference with activities than people who have a psychiatric illness (Lowe, 1973). There is also evidence that delusion formation may distinguish psychotic disorders from non clinical hallucinatory experiences. In other words, the development of delusions in people with auditory hallucinations significantly increases the risk of psychosis when compared with individuals who have hallucinations but not delusions. Auditory hallucinations may be experienced as coming through the ears, in the mind, on the surface of the body, or anywhere in external space. The frequency can range from low (once a month or less) to continuously all day long. Loudness also varies, from whispers to shouts. The intensity and frequency of symptoms fluctuate during the illness, but the factor that determines whether auditory hallucinations are a central feature of the clinical picture is the degree of interference with activities and mental functions (Waters, 2010) The most common type of auditory hallucinations in psychiatric illness consists of voices. Voices may be male or female, and with intonations and accents that typically differ from those of the patient. Persons who have auditory hallucinations usually hear more than one voice, and these are sometimes recognized as belonging to someone who is familiar (such as a neighbour, family member or TV personality) or to an imaginary character (God, the devil, an angel). Verbal hallucinations may comprise full sentences, but single words are more often reported. Voices that comment on or discuss the individuals behaviour and that refer to the patient in the third person were thought to be first-rank symptoms and of diagnostic significance for schizophrenia (Schneider, 1959). Studies show that approximately half of patients with schizophrenia experience these symptoms (Waters, 2010). Waters (2010) says a significant proportion of patients also experience non verbal hallucinations, such as music, tapping, or animal sounds, although these experiences are frequently overlooked in auditory hallucinations research. Another type of hallucination includes the experience of functional hallucinations, in which the person experiences auditory hallucinations simultaneously through another real noise (e.g., a person may perceive auditory hallucinations only when he hears a car engine). The content of voices varies between individuals. Often the voices have a negative and malicious content. They might speak to the patient in a derogatory or insulting manner or give commands to perform an unacceptable behaviour. The experience of negative voices causes considerable distress. However, a significant proportion of voices are pleasant and positive, and some individuals report feelings of loss when the treatment causes the voices to disappear (Copolov et al., 2004). The exact processes that underlie auditory hallucinations remain largely unknown. There are two principal avenues of research: one focuses on neuro anatomical networks using techniques such as positron emission tomography and functional Magnetic Resonance Imaging (MRI). The other focuses on cognitive and psychological processes and the exploration of mental events involved in auditory hallucinations. A common formulation suggests that auditory verbal hallucinations represent an impairment in language processing and, particularly, inner speech processes, whereby the internal and silent dialogue that healthy people engage in is no longer interpreted as coming from the self but instead as having an external alien origin. There is support for this language hypothesis of auditory hallucinations from neuro imaging studies. These show that the experience of auditory hallucinations engages brain regions, such as the primary auditory cortex and broca area, which are associated with language c omprehension and production. This suggests that hallucinatory experiences are associated with listening to external speech in the absence of external sounds (Waters, 2010) An explanation of why these experiences are not perceived as self-generated posits that auditory hallucinations arise because persons who have the hallucinations fail to distinguish between internal and external events. This arises because of deficits in internal self-monitoring mechanisms that compare the expected with the actual sensations that arise from the patients intentions. This abnormality also applies to inner speech processes and leads to the misclassification of internal events as external and misattribution to an external agent (Frith, 2005).However, Bentall and Slade (1985) suggest that individuals with hallucinations use a different set of judgment criteria from healthy people when deciding whether an event is real, and they are more willing to accept that a perceptual experience is true. This bias essentially involves a greater willingness to believe that an event is real on the basis of less evidence. According to the context memory hypothesis of auditory hallucinations, the failure to identify events as self-generated arises because of specific deficits in episodic memory for remembering the details associated with particular past memory events. These specific deficits in memory cause confusion about the origins of the experience (Nayani and David, 1996). Patients with auditory hallucinations tend to misidentify the origins and source of stimuli during ongoing events and during memory events (Waters et al., 2006). The lack of voluntary control over the experience is a key feature of auditory hallucinations, which might explain why self-generated inner speech is classified as external in origin (Copolov et al., 2003). Hallucinations are experienced when verbal thoughts are unintended and unwanted. Because deficits in cognitive processes, such as inhibitory control, are thought to render people more susceptible to intrusive and recurrent unwanted thoughts, studies have linked audit ory hallucinations with deficits in cognitive inhibition (Waters et al., 2006). Recent advances in the neurosciences provide clues to why patients report an auditory experience in the absence of any perceptual input. Spontaneous activity in the early sensory cortices may in fact form the basis for the original signal. Early neuronal computation systems are known to interpret this activity and engage in decision-making processes to determine whether a percept has been detected. A brain system that is abnormally tuned in to internal acoustic experiences may therefore report an auditory perception in the absence of any external sound (Deco and Romo, 2008). Ford et al., (2009) suggested that patients with auditory hallucinations may have excessive attentional focus toward internally generated events: the brains of persons who have auditory hallucinations may therefore be over interpreting spontaneous sensory activity that is largely ignored in healthy brains. Cognitive impairments are not the only factors responsible for auditory hallucinations. Psychological factors such as meta-cognitive biases, beliefs, and attributions concerning the origins and intent of voices also play a critical modulatory role in shaping the experience of hallucinations. The role of environmental cues and reinforcement factors through avoidance strategies must also be incorporated in any explanations of auditory hallucinations. These factors do not explain how hallucinations occur in the first place, but they have strong explanatory power when accounting for individual differences in how the voices are experienced (Baker and Morrison, 1998). Patients suffering from auditory hallucinations sometimes can not distinguish between what is real and what is not real, it is very important to build a trusting therapeutic relationship with the sufferer. This dissertation will go on to explore the importance of building a therapeutic relationship with a patient; To explore the extent of auditory hallucinations a patient may be experiencing it is important that an appropriate assessment and risk management are carried out, exploring the need for assessment and risk management in auditory hallucinations, It will also look into helping approaches discussing pharmacological and psychosocial approaches in the management of auditory hallucinations and how to end the therapeutic relationship between a service user and the nurse, looking into discharge planning. CHAPTER TWO DEVELOPMENT OF THERAPEUTIC RELATIONSHIP Development of the Therapeutic Relationship Peplaus theories laid the ground for ascendancy of the relationship as the key context for all subsequent interventions with patients (Ryan Brooks, 2000). Although the idea of the relationship endures as the paradigm for psychiatric nursing (Barker, Jackson, Stevenson, 1999a; 1999b; Krauss, 2000; Raingruber, 2003), it does not appear there is any universal consensus on exactly how to frame this relationship. The nurse-patient relationship can be defined as an ongoing, meaningful communication that fosters honesty, humility, and mutual respect and is based on a negotiated partnership between the patient and the practitioner (Krauss, 2000, p. 49). Peplau describes nursing as a therapeutic interpersonal process that aims to identify problems and how to relate to them (Peterson and Bredow 2009). Forster (2001) defines therapeutic relationship as a trusting relationship developed by two or more individuals. However, Jukes and Aldridge (2006) says at first sight therapeutic nursing and the therapeutic relationship may seem relatively easy to define, but once we scrape the surface we find a complex range of ideas and concepts that stem from philosophies, ideologies and individual therapies. Sometimes there are difficulties in applying these definitions to our own work. Not least of these difficulties is the relevance of the concept of therapy as healing to nursing. This begs the question of whether a therapeutic relationship always entails the use of a therapy, or whether there is something more universal and fundamental in therapeutic relationships. It seems important therefore to attempt a workable definition of the therapeutic r elationship that has currency within nursing as a whole. Additionally, it seems that therapeutic nursing has two facets. The first of these, and probably the most apparent, is the emotional and interpersonal aspect, which we might call therapeutic nursing as an art. The second is the more logical and objective aspect, which we might call The therapeutic nursing as a science. Arguably, there is a synergy between the two that leads to a gestalt, and therefore a need to address both aspects if our nursing is to be truly therapeutic in a holistic sense. Peplaus theory focuses on the nurse, the patient and the relationship between them and is aimed at using interpersonal skills to develop trust and security within the nurse-patient relationship. Therapeutic relationships are the corner stone of nursing practice with people who are experiencing threats to their health, including but not restricted to those people with mental illness (Reynolds 2003). The relationship of one to one of nurse patient has potential to influence positive outcome for patients. Hildegard Peplau interpersonal relations overlap over four phases namely: Orientation, Identification, Exploitation and Resolution. Peplau also identify that during the four overlapping phases nurses adopts many roles such as- Resource person: giving specific needed information that aids the patient to understand his/her problem and their new situation. A nurse may function in a counselling relationship, listening to the patient as he/she reviews events that led up to hospitalization and feeling connected with them. The patient may cast the nurse into roles such as surrogate for mother, father, sibling, in which the nurse aids the patient by permitting him/her to re-enact and examine generically older feelings generated in prior relationships. The nurse also functions as a technical expert who understands various professional devices and can manipulate them with skill and discrimination in the interest of the patient (Clay 1988). The orientation phase is the initial phase of the relationship where the nurse and the patient get to know each other. The patient begins to trust the nurse. This phase is sometimes called the stranger phase because the nurse and the patient are strangers to each other (Reynolds 2003). Peplaus (1952) suggest that during this phase early levels of trust are developed and roles and expectation begin to be understood. It is important that during this time that the nurse builds a relationship with the patient by gaining their trust, establishing a therapeutic environment, developing rapport and a level of communication expectable to both the patient and the nurse. During the orientation phase trust and security is supposed to be developed between the nurse and the patient. Co-ordination of care and treatment of patient while using an effective communication between the MDT is a nurse role. The nurse also acts as an advocate/surrogate for a patient and promotes recovery and self belief. Essential communication skills are deemed to be listening and attending, empathy, information giving and support in the context of a therapeutic relationship (Bach and Grant 2009). Building a therapeutic relationship needs to focus on patient -centred rather than nurse-task focus. Bach and Grant (2009) say interpersonal relationship describes the connection between two or more people or groups and their involvement with one another, especially as regards the way they behave towards and feels about one another. Communication is to exchange information between people by means of speaking, writing or using a common system of signs or behaviour. Faulkner (1998) suggested that Rogers (1961) client centred approach conditions can be seen as important factors that contributes to a therapeutic relationship. Rogers (1961) three core conditions are: congruence, empathy and unconditional positive regards. Congruence means that the nurse should be open and genuine about feelings towards their patient. Having the ability to empathise with the patient would show that the nurse has the ability to understand the patients thoughts and feelings about their current problem. Unconditional positive regards is viewing them as a person and focusing on positive attributes and behaviour (Forster 2001). The orientation phase also gives the nurse the chance to asses the patients current health and once the assessment has been carried out the can then move the relationship forward to the identification phase. The identification phase is where the patients needs are identified through various assessment tools. Assessment will be discussed in detail in the next chapter. Butterworth (1994; DH 1994a; DH 2006a) says that during the identification phase the nurse and the patient will both work together discussing the patients identified needs, needs that can be met and those that cannot be met. They will al so identify risks and how to manage the risks and aim to formulate a care plan. Butterworth said the care plan should focused on the patients individual needs, long and short term goals and their wishes, whilst being empowered at all times to make informed decisions and choices that matter in their care. Collaborative working between multi-agencies ensures the needs of the patient are being met through appropriate assessment and treatment under the Care and Treatment Plan (CTP). The Care and Treatment Plan is one of a number of new rights delivered by the Mental Health (Wales) Measure (2010). The Measure also gives people who have been discharged from secondary mental health services the right to make a self referral back for assessment and it extends the right to an Independent Mental Health Advocate to all in-patients. A care co-ordinator must ensure that a care and treatment plan which records all of the outcomes which the provision of mental health services are designed to achieve for a relevant patient is completed in writing in the form set out (Hafal, 2012). The Sainsbury Centre for Mental Health (Rose 2001) found that patients are often not involved in the care planning process and many service users were not even aware of having a care plan. The exploitation phase is where interventions are implemented from the needs and goals set out in the identification phase which enables the service user to move forward, these interventions will assist in managing auditory hallucinations, whilst educating the patient and family members about the illness. Helping approaches will be discussed in detail in the next chapter looking at various up to date interventions available for the management of auditory hallucinations. A trusting relationship can help with recovery and during these interlocking phases is what the nurse and the patient are aiming for (Hewitt and Coffey, 2005). Building of a trusting therapeutic relationship is essential for nursing interventions to work (Lynch and Trenoweth, 2008). Nurses need to be sensitive, show compassion at all times and understanding to a patients needs. Nursing interventions needs to address physical, psychological and social needs; this involves having holistic approach (Coleman and Jenkins, 1998). Nurses need to work with the best evidence based therapeutic treatment available, this then being a positive approach to care (NMC 2008). The Chief Nursing Officer (CNO) review of the Mental Health Nursing (2006) noted that to improve quality of life, service users risks need to be managed properly, whilst promoting health, physical care and well being. However, Hall et al., (2008) argues that the CNO review does not take into consideration the great pressure nurs es are under and also the complex needs of the service user. Therapeutic interventions are an important aspect of recovery (Gourney 2005). Recovery can be described as a set of values about the service users right to build a meaning life for themselves without the continuous presence of mental health symptoms (Shepherd et al., 2008). The purpose of recovery is to work towards self determination and self confidence (Rethink 2005). National Institute for Mental Health in England (NIMHE, 2005) described recovery as a state of wellness after period of illness. Nurse need to provide a holistic view of mental illness with a person centred approach that can work towards the identification of goals and offer the patient appropriate support through interventions like CBT, family therapy and coping skills, this will enable the patient to be at the centre of their own care, thus taking responsibility for their own illness and improve quality of life. Service user who have a full understanding and accept their illness can engage more with therapies and in terventions with the necessary support from professionals, this then leads to self determination and better quality of life (Cunningham et al., 2005). However, Took (2002) says it is important to remember that with a service user experiencing auditory hallucinations, their mood and engagement can fluctuate and also the side effect of prescribed medication can affect this which may slow down the recovery process. Early intervention is also recognised to improve long term outcomes of auditory hallucinations in schizophrenia (McGorry et al., 2005: NICE 2009). However, not all service users will seek advice when first experiencing symptoms, due to stigma attached to mental illness and fear of admission to hospital (French and Morrison 2004). Some service users have also complained that the hospital has a non therapeutic environment and that they also feel unsafe and in an orison like setting (SCMH 1998, 2005; DoH 2004b). Drury (2006) says that service users felt that some professionals lacked compassion. Mental health nurses are encouraged to adopt a client centre approach, some research suggests nurses lack empathy and have general uncaring attitude (Herdman 2004). The final phase of Peplaus theory is the resolution phase. This is where the nurse and the service user will end their professional relationship. The relationship can end either through discharge or death. For the purpose of this dissertation the ending of the relationship that will be discussed at a later chapter will be discharge. Therapeutic relationship is seen as paramount during these interlocking phases of peplaus interpersonal relations theory, nurses needs to promote the service users independence whilst treating them with respect, privacy and dignity. By identifying treatment goals, implementing and evaluating treatment plans the service user can move on to interventions that will help them manage and cope with auditory hallucinations. Chapter 3 Assessment of a patient with Auditory Hallucinations Assessment of Auditory Hallucinations Assessment is the decision making process, based upon the collection of relevant information, using a formal set of ethical criteria, that contributes to an overall estimation of a person and his circumstances (Barker 2004). Hall et al (2008) described assessment as one of the first steps to the nursing process; it is also part of care planning and a positive foundation for building a relationship and forming therapeutic alliance. It is an ongoing process that enables professional to gather information that allows them to understand a persons experience. Most assessments have similar aims. However, how assessments are conducted can vary enormously. Such differences are very important and can influence greatly the value of the information produced (Barker 2004). In Wales CTP was introduced under the Mental Health (Wales) Measures 2010. CTP means a plan prepared for the purpose of achieving the outcomes which the provision of mental health services for a relevant patient is design to achieve and ensures service users have a care plan, risk assessment and a care co-ordinator to monitor and review their care (see appendix one). NICE (2010) suggest that assessment should contain the service users psychiatric, psychological and physical health needs and also include current living arrangements, ethnicity, quality of life, social links, relevant risk and other significant factors that may affect the service users quality of life. Assessment of a patient relies upon the collection of information through interviewing: the patient, member of their family, direct observation of the nurse, questionnaire, rating scales, and previous history (Previous records). However, Barker (2004) argues that despite the importance of the history, if relied upon as the sole method of assessment, not only may the final picture of the patient be of a doubtful accuracy but it may also lack the fine detail necessary for the planning o