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Based on clinical experience discount 200mg acivir pills fast delivery early stages of hiv infection symptoms, others have suggested guidelines for deter- mining when conjoint therapy is inappropriate for violent couples (e buy 200 mg acivir pills otc natural antiviral supplements. Most agree that conjoint treatment is only appropriate for low to moderate levels of ag- gression and only if the wife is not perceived to be in danger of imminent physical harm. Related to this, the wife must not fear the husband, must feel comfortable in therapy with him, and must not feel so intimidated by him that she can’t be honest in therapy. A conjoint format is inappropriate if one spouse Working with Couples Who Have Experienced Physical Aggression 295 does not acknowledge the existence or problematic nature of violence in the relationship or is not willing to take steps to reduce the violence. DATA REGARDING THE EFFICACY OF CONJOINT COUPLES TREATMENT It is standard to review the research data regarding treatment efficacy at the end of a chapter. However, given the strong political controversy concerning the question of whether conjoint treatment is ever appropriate for physically aggressive couples, we believe that a review of the research should be pre- sented before discussing possible conjoint interventions. Thus, we here re- view the only three published studies we know of that have examined the effectiveness of conjoint therapy with couples experiencing husband vio- lence. All three compared conjoint treatment with gender-specific treatment (GST—in which men are seen in a men’s treatment group and women are seen in a women’s support group). In the earliest study, Harris and colleagues (1988) recruited over 70 cou- ples who had experienced husband violence and were requesting therapy at a family service agency. Using random assignment, some couples were as- signed to a couples counseling program that explicitly addressed violence as the primary relationship problem. The other treatment condition involved a combination of gender-specific and couples groups (i. A large number of couples who began treatment did not complete it, particularly among the couples counseling condition (i. Nonetheless, the follow-up data indicated that the two treatment con- ditions were equally effective in reducing the husbands’ physical violence (based on wife report) and in improving the subjects’ sense of psychological well-being. Brannen and Rubin (1996) recruited a sample of couples who were re- ferred to batterer treatment by the court system and who indicated a desire to remain in their current relationship. The conjoint therapy was designed to address husband violence as a primary problem. In contrast to the study conducted by Harris and colleagues (1988), six of the seven batterers who dropped out of treatment were in the gender-specific intervention condition. Follow-up data, collected six months after the completion of treatment, showed no sig- nificant differences between the two groups in levels of recidivism; in both 301 basic goal of therapy—violence desistance—will remain the same for cou- ples of all ethnic backgrounds, as all individuals have the right to live in a violence-free relationship. To our knowledge no studies of physical aggression in same-sex relationships have included randomly selected, representative samples of gay or lesbian couples. Thus, although our understanding of this phenomenon is limited, research examining convenience samples suggests that rates of physical aggression are very similar to those in heterosexual re- lationships (Turell, 2000; Waldner-Haugrud & Gratch, 1997; West, 2002). For example, some same-sex couples have described one partners’ threats of outing the other partner as a means of psychological abuse or to prevent an abused partner from leaving the relationship (Freedner, Freed, Yang, & Austin, 2002). As another example, some abused partners describe the lack of police response to their pleas for help, given the incorrect assumption that two same-sex partners must have equal power and physical strength and thus one cannot abuse the other (Renzetti, 1992). Although the clinician must be sensitive to such issues, we again believe that the therapy goal (i. Joan was staying home with their children, having quit her job when pregnant with their second child. He had a house painting business and was also in the process of establishing a karaoke business on weekends. The couple reported that they were seeking therapy because they "just couldn’t talk anymore," couldn’t "solve their problems without fighting," and "argued about everything. They fought about almost any issue, but frequent topics were fi- nances, household responsibilities, and how much time to spend with their families (both of whom lived in town). On several oc- casions, Joan had tried to storm out of the room but Michael had grabbed her, to prevent her from leaving. On one occasion, she had slapped and pushed him, to get him to let go of her, and both had sustained scratches or 307 third occasion, the therapist simply said, "You both are becoming noncol- laborative, so this might be a good time to. Following these in-session experiences, they began to take time-outs at home when their arguments were escalating. Although many methods of managing anger are covered in the time-out procedure, it is often necessary to de- velop these skills further.

We have used McGoldrick’s life cycle stages (loosely construed) to guide us in our choices purchase acivir pills 200 mg otc main symptoms hiv infection. Gordon purchase acivir pills 200mg visa anti virus warning, Temple, and Adams describe PAIRS, a premarital counseling curriculum, extensively de- signed to include a multiplicity of interventions to assist couples as they enter a committed relationship. He includes a discussion of the nature of mar- riage, cohabitation, and commitment; an overview of the tasks of the family cycle; and issues related to psychotherapy with couples in the early stages of the life cycle. Lower (Chapter 4) considers the difficult life transition to par- enthood and the adjustments that confront couples with young children. In Chapter 5, Mas and Alexander explore the four essential features of treat- ment based on clinical, research, and theoretical literature as applied to fam- ilies with adolescents. Highlighting the multiplicity of differences that such families may bring into the therapy room, these authors focus on cultural di- versity issues. Completing the part on life cycle stages, Peake and Steep (Chapter 6) examine novel ways to intervene with older couples capitalizing on their lived experience and using popular films and other resources as ad- juncts to psychotherapy. Section II of the book focuses on different theoretical approaches to work- ing with couples. Silverstein (Chapter 7) considers the application of Bowen family systems theory to work with couples and provides a supportive femi- nist critique of the theory. In Chapter 8, Patterson argues that common con- ceptualizations of cognitive-behavioral approaches to couples therapy do not always provide an adequate integration of these two traditions. Focusing on the separate foundations of behavioral approaches on the one hand, and cog- nitive theories on the other, Patterson provides an understanding of the Setting the Stage for Working with Couples 3 melding of these two traditions into cognitive-behavioral couples therapy. Scharff and de Varela (Chapter 9) describe how object relations therapy would be applied to couples. Shifting from more traditional approaches of working with couples to postmodern thinking, Rosen and Lang (Chapter 10) introduce key aspects of doing narrative therapy with couples. In the first of several integrative approaches to working with couples, Bradley and Johnson (Chapter 11) present emotionally-focused therapy, an inte- gration of collaborative client-centered, gestalt, systems approaches, con- structivist thinking, and understandings derived from attachment theory and the empirical literature. Cheung (Chapter 12) proposes the integration of strategic family therapy and solution-focused approaches to working with couples. In Chapter 13, Pitta describes integrative healing couples therapy that uses psychodynamic, behavioral, communication, and sys- temic theories in understanding the couple’s functioning. Concluding this part, Nutt (Chapter 14) describes feminist and contextual approaches to working with couples. Section III approaches couples’ interventions from the perspective of common presentations in therapy. Thus, Watson and McDaniel (Chapter 15) describe the work with couples who are confronting medical concerns. The interface of the biological and the emotional provide the framework for their work in medical settings. In Chapter 16, Harway and Faulk consider how a history of sexual abuse in one member of the couple may affect the overall couple’s functioning and may lead to difficult therapeutic concerns. Holtzworth-Munroe, Clements, and Farris (Chapter 17) discuss the implica- tions of intervening with these types of couples. Stanton (Chapter 18) reviews key elements of couples therapy for the treatment of addictive be- haviors. Infidelity is said to affect a large number of couples and presents particular challenges. In Chapter 19, Lusterman explores issues related to working with couples who have been touched by infidelity and proposes an effective model for intervention. Psychotherapists are often uncomfortable with exploring spiritual issues in therapy. Yet, spiritual and religious differ- ences, like other forms of cultural difference, contribute to some couples’ dissatisfaction with their relationship. Serlin (Chapter 20) considers how to interweave spiritual concerns in the course of psychotherapy. While couples comprised of two same-sex partners share many of the same issues as het- erosexual partners, Alonzo (Chapter 21) describes some unique issues for gay or lesbian couples. Kaslow (Chapter 22) examines the impact of socio- economic factors on couples’ functioning and describes some approaches to working with money issues in therapy. Not all couples presenting for psychotherapy are there to improve the couple’s bond. Some couples initiate therapy to provide a smoother transi- tion to divorce, while other couples initiate therapy in the hopes of sav- ing their relationship but ultimately decide instead to focus on marital 4 S ETTING THE STAGE FOR WORKING WITH COUPLES dissolution.

When the oscillations of the rod around the vertical axis is small (sin f > f) the solution for Eqn 200mg acivir pills free shipping hiv transmission statistics female to male. If we let f 5 p/6 and (df/dt) 5 0 at t 5 0 we obtain f 5 (p/6) cos [(3g/2L)1/2 t] for t $ 0 (4 buy cheap acivir pills 200mg antiviral rx. For a simple pendulum composed of a slender rod of length L and a bob of mass m, the period of oscillation is equal to 2p(L/g)1/2. Therefore, the rod with uniform mass distribution rotates around point O much like a classical pendulum with effective length equal to 2L/3. Thus, in using the lumped-mass approach, we would have achieved an exact solution if we had placed the lumped mass at a distance 2L/3 from the fixed point O. Next, let us turn our attention to the forces exerted by the hinge on the rod at point O. These forces are the gravitational force 2mg e2 acting at the center of the rod and the force (F1 e1 1 F2 e2 ) exerted by the pin at point O. According to the equation of motion of the center of mass, the net resultant force acting on an object must be equal to the mass of the object times the acceleration of the center of mass. The position, ve- locity, and acceleration of the center of mass are given by the following expressions: r 5 (L/2) [sin f e1 2 cos f e2] (4. Note that when the pendulum is at rest in the vertical position we have F1 5 0 and F2 52mg. However, because the distance be- tween any two points in a rigid body remains constant, this integral can be reduced to a simple algebraic form. The point C is the center of mass, and P and Q are two arbitrary points of the rigid body B undergoing pla- nar motion parallel to the (e1, e2) plane (Fig. General e2 j (a) F plane motion of a rigid object B parallel to the (e , B 1 P e2) plane (a). Also, because the motion occurs parallel to the (e ,e ) 1 2 plane, the angle u remains constant; therefore, du/dt 5 0. Note that in a plane parallel to the (e1, e2) plane, angle f can be any angle, taken counterclockwise from a line element 90 4. This is true because all such angles differ from each other by a constant and there- fore have the same time derivative. If (df/dt) , 0, then the object B rotates clockwise and it is said to have a negative angular velocity. Note also that angular velocity may vary with time but does not vary from point to point in a rigid body. Thus, knowing the velocity of a single point in a rigid body and its angular velocity, we can determine the velocity of any other point in the rigid body. In this example we seek to understand the contributions of segmental rotations of body parts to the vertical ve- locity of the body’s mass center during vertical jumping. The dimensions of the athlete are given as follows: Lf (length of the foot) 5 27 cm, Ll (length from ankle to knee) 5 48 cm, Lt (length from knee to hip) 5 50 cm, and Lc (length from hip to center of mass) 5 28 cm. Angles between body segments and the horizontal in the fixed refer- ence frame E are indicated by ff, fl, ft, and fc. As usual, the segment orientation angle is positive when taken counterclockwise from horizon- tal. The counter movement begins at t 5 0 when the body segments make the following angles with the horizontal: ff 5 0, fl 5 66°, ft 5243°, and fc 5 23°. Thus, at this instant, the feet are flat on the ground, the knee bent, and the upper body bent forward. Employing the inverse dynam- ics approach and using a videocamera and a computer, these body seg- ment angles were measured as a function of time for t. The rate of rotation R φ Q of a rigid body in planar motion E φ is equal to the time rate of P change of angle f. The angle f need not be uniquely defined O e because the rate of rotation is 1 the time derivative of angle f. The figure shows two angles whose time derivatives give the same value for the angular ve- e3 locity. The symbols F, A, K, H, and C denote the tip of the foot, ankle, knee, hip, and the center of mass of the athlete, respectively.

Potential physicians need to know first hand what patients experience in the halls while waiting for procedures order acivir pills 200mg hiv infection mode of transmission, in the emergency department while waiting for help acivir pills 200 mg hiv infection europe, and in their rooms after ringing the buzzer in distress. They need to see close up from the patients’ and families’ eye view what a hospitalization or outpatient experience means. This process of staying close to the patient should continue in the pre-clinical years. There should be chances for medical and nursing students to listen to the unstructured narratives of patients: to the stories of their illnesses and their efforts to cope; to their accounts of encounters with doctors and medical institutions; to their stories of seeking care and trying to find ways to pay for it. We need, in fact, a whole course in the preclinical years which is supplemental to the courses given on medical histories and physical diagnosis – a course on patient experiences. FULL SPECTRUM MEANS AND ENDS REASONING 163 Medical students by and large arrive at school with the idea that they should become skillful in order to serve patients. Unfortunately, the four years of medical school often communicate another idea: That students are learning to serve an ideal called "health" (assumed to be precise without having ever been precisely articulated), and that their job will be to foist this ideal on patients. We should not inculcate an ideal which has an abstract existence outside of actual patients. Such an agenda leads to the view that patients are obstacles to the external ideal, and not the very parties who ultimately determine what ideal goals should be in play. The perception that patients are difficult, stubborn, and foolish increases when ideals are anchored outside of those patients. This perception, whatever real justification it might sometimes have, becomes exaggerated and gets in the way of accomplishing anything. It would be well to replace the concept of ideal health with the concept of the possible, relative to particular patients. To facilitate wise decision making, the medical curriculum needs to focus on functioning with uncertainty, not arriving at premature certainty as though it was required for functioning. Professors should reveal the well-kept secret that not everything can be diagnosed to fit our existing categories of illness. They should admit that "illness" is not a univocal concept, but a vague one with borderline cases. They should acknowledge that triage is not something that happens only after a train wreck or a bomb explosion, but that it happens all day long every day, because not all concerns can be met at once – they have to be prioritized. Instead of teaching students that they have to do everything, and that anything less than absolute adherence to the ideal is total failure, the educational system needs to get real and teach how to prioritize – how to do the most necessary, the most practical, and the most important items for and with the patient first. Clinical teaching needs to emphasize that there are many ways to the promised land. The gold standard of care in Massachusetts is, surprise, looked down upon in Texas and California. The "mandatory" prophylactic colonoscopy enjoined by the American College of Surgeons is, wonder of wonders, an air contrast barium enema when ordered by the radiologists. Schools need to teach that recommendations which are at odds with one another can in some circumstances, far from being a scandal, be beneficial to medicine as a whole. Teachers need to be more tentative and less dogmatic, more skeptical and less religious about their current recommended practices. For one thing, as noted previously, they often have many diagnoses, uniquely mixed. For another, the importance of their diagnoses is for their lives, not the other way around. Patients do not and never will do everything their doctors tell them This lack of compliance is not, as medical education traditionally has let young doctors think, pure irrationality. If physicians were to ask why patients fail to come in for follow up, for example, or fail to get their prescriptions filled, or fail to take medications or comply with dietary and lifestyle advice, the patients would offer many sound reasons. Instead, we are taught an "all or nothing" approach to good 164 CHAPTER 6 care which too often results in patients going AWOL. Medical schools need to teach students how real patients act and how to deal with those realities, not send them out furnished only with rigid agendas which fail to interface with actual lives. Finally, let us take a critical look at hierarchies in medicine and the ordeal theory of medical education. Medical training is difficult enough without unnecessary shaming and humiliation for the trainees, and without subjecting them to impossible hours and patient loads, especially, at times, without adequate supervision and help from attending physicians. With the entry of women into medicine and a little help from the nascent efforts of medical residents to bargain on their contracts, some earlier abuses have been mitigated. And of course, there are vast differences between the various programs, with some being collegial and others completely authoritarian.