# Lexapro

By A. Vatras. Hardin-Simmons University.

In 194 Strategic and Solution-Focused Couples Therapy 195 this zeitgeist order lexapro 10 mg otc anxiety quizzes, this chapter presents strategic and solution-focused couples therapy (SSCT) and discusses how SSCT can be beneficially applied to couples order 5mg lexapro otc anxiety out of nowhere. SSCT selectively integrates principles from two therapy ap- proaches: namely, strategic couples therapy (SCT) and solution-focused therapy (SFT). A brief review of the existing theoretical and clinical literature on SCT is first described. Next comes a brief review of the existing theoretical and clinical literature on SFT. The methodology of SSCT that selectively inte- grates principles of SCT and techniques of SFT is then presented. After that, the methodology of SSCT is applied to a specific case to illustrate how it is utilized to address problems presenting in a couple. Last, the chapter explores how cultural and ethnic sensitivity in the application of SSCT can lead to beneficial results. REVIEW OF THEORETICAL AND CLINICAL LITERATURE SCT is based on Milton Erickson’s Strategic Therapy. Underlying Assumptions and Key Concepts Haley and Madanes concur with Erickson’s emphasis on tolerance of the idiosyncrasies of the indi- vidual. They also agree that it is the therapist’s responsibility to initiate what happens during therapy and to design a particular approach for solving each of the client’s problems (Haley, 1973, 1987, 1990, 1996; Madanes, 1981, 1991). Being highly practical, they deem it appropriate for the thera- pist to borrow any useful technique from other therapy models to address the presenting problem. They moreover espouse the epistemology of structuralism and a systemic perspective. The epistemology of structural- ism attempts to identify the objective truth of universals and structures and principles underlying and governing human behavior; it holds that symptoms result from some underlying psychic or structural problem, such as an enmeshed family boundary, incongruous family hierarchies, or psychotic family games (Haley, 1987, 1990; Madanes, 1981, 1990; Minuchin, 1974; Minuchin & Fishman, 1981; Selvini-Palazzoli, 1986; Selvini-Palazzoli, Boscolo, Cecchin, & Prata, 1978). A systemic perspec- tive assumes recursiveness or circular causality that views people and events in the context of mutual interaction and mutual influence. Instead of examining individuals and events in isolation, a systemic perspective examines the relationships between individuals and events, how each in- teracts with and influences the other. In other words, according to the systemic perspective, meaning is derived from the relationship between individuals and events, where each defines the other. There must be great tolerance of all the different ways cou- ples find to live together or apart. A more sensible focus would seem to be on the particular problem a couple is having within their type of marriage. The nature of the marriage might not be changed at the end of therapy, but ideally there will be a change in the problems they came in with that were distressing them. SYMPTOMS AS PRESENTING PROBLEMS Haley (1987) posits that it is more expedient to bring in the spouse when an individual presents with a severe symptom because a directive given to a couple is more likely followed than one given only to the individual. Like other systemic therapists, Haley assumes that a symptom can serve some interpersonal function in a couple’s relationship. While some therapists prefer to convince the couple that their real problem is their mar- riage, Haley proposes that the therapist focus on the presenting symp- tom/problem when dealing with the marital problem. That is, the therapist helps the couple improve the presenting symptom while attempting to in- directly improve the marital relationship. When there is an obvious im- provement in the presenting symptom, the couple is more likely to trust the therapist to help them work together on their marriage. A CHILD AS THE PRESENTING PROBLEM Some couples can fight with each other without involving their children, while others center their marital struggle on the child. Rather than dealing with their particular difficulties with each other, they disagree with each other on how to parent. Consequently, their child may cooperate by devel- oping symptoms to distract the parents from their marital conflict, unite them to focus on the child’s problems, and so hold the family together. One of the treatment strategies is to unite the parents as a parental team to deal with the child’s problems, and at the same time improve the marital Strategic and Solution-Focused Couples Therapy 197 relationship.

Sim ilarly discount lexapro 20 mg mastercard anxiety 60 mg cymbalta 90 mg prozac, if you play coin toss with som eone purchase lexapro 5mg with amex anxiety disorders in children, no m atter how far you fall behind, there will com e a tim e when you are one ahead. M ost people would agree that to stop the gam e then would not be a fair way to play. If you m ake it inevitable that you will (eventually) get an apparently positive result you will also m ake it inevitable that you will be m isleading yourself about the justice of your case. This and other exam ples are given in a paper by Oxm an and G uyatt, "A consum er’s guide to subgroup analysis", which reproduces a useful checklist for deciding whether apparent differences in subgroup response are real. Students often find it difficult to decide whether to use a paired or unpaired statistical test to analyse their data. If you m easure som ething twice on each subject (for exam ple, lying and standing blood pressure), you will probably be interested not just in the average difference in lying versus standing blood pressure in the entire sam ple, but in how m uch each individual’s blood pressure changes with position. In this situation, you have what is called "paired" data, because each m easurem ent beforehand is paired with a m easurem ent afterwards. In this exam ple, it is having the sam e person on both occasions which m akes the pairings but there are other possibilities (for exam ple, any two m easurem ents of bed occupancy m ade of the sam e hospital ward). In these situations, it is likely that the two sets of values will be significantly correlated (for exam ple, m y blood pressure next week is likely to be closer to m y blood pressure last week than to the blood pressure of a random ly selected adult last week). In other words, we would expect two random ly selected "paired" values to be closer to each other than two random ly selected "unpaired" values. U nless we allow for this, by carrying out the appropriate "paired" sam ple tests, we can end up with a biased estim ate of the significance of our results. Was a two tailed test performed whenever the effect of an intervention could conceivably be a negative one? The concept of a test with tails always has m e thinking of devils or snakes, which I guess just reflects m y aversion to statistics. In fact, the term "tail" refers to the extrem es of the distribution – the 83 H OW TO READ A PAPER dark areas in Figure 5. Let’s say that that graph represents the diastolic blood pressures of a group of individuals of which a random sam ple are about to be put on a low sodium diet. If a low sodium diet has a significant lowering effect on blood pressure, subsequent blood pressure m easurem ents on these subjects would be m ore likely to lie within the left hand "tail" of the graph. H ence we would analyse the data with statistical tests designed to show whether unusually low readings in this patient sam ple were likely to have arisen by chance. But on what grounds m ay we assum e that a low sodium diet could only conceivably put blood pressure down, but could never put it up? Even if there are valid physiological reasons why that m ight be the case in this particular exam ple, it is certainly not good science always to assum e that you know the direction of the effect which your intervention will have. A new drug intended to relieve nausea m ight actually exacerbate it and an educational leaflet intended to reduce anxiety m ight increase it. H ence, your statistical analysis should, in general, test the hypothesis that either high or low values in your dataset have arisen by chance. In the language of the statisticians, this m eans you need a two tailed test unless you have very convincing evidence that the difference can only be in one direction. Were "outliers" analysed with both common sense and appropriate statistical adjustments? Unexpected results m ay reflect idiosyncrasies in the subject (for exam ple, unusual m etabolism ), errors in m easurem ent (for exam ple, faulty equipm ent), errors in interpretation (for exam ple, m isreading a m eter reading), or errors in calculation (for exam ple, m isplaced decim al points). Only the first of these is a "real" result which deserves to be included in the analysis. A result which is m any orders of m agnitude away from the others is less likely to be genuine, but it m ay be. A few years ago, while doing a research project, I m easured a num ber of different horm one levels in about 30 subjects. One subject’s growth horm one levels cam e back about 100 tim es higher than everyone else’s. I assum ed this was a transcription error, so I m oved the decim al point two places to the left. Som e weeks later, I m et the technician who had analysed the specim ens and he asked "W hatever happened to that chap with acrom egaly? Statistically correcting for outliers (for exam ple, to m odify their 84 STATISTICS FOR TH E N ON -STATISTICIAN effect on the overall result) is quite a sophisticated statistical m anoeuvre. For m any non-statisticians, the term s "correlation" and "regression" are synonym ous, and refer vaguely to a m ental im age of a scatter graph with dots sprinkled m essily along a diagonal line sprouting from the intercept of the axes.

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