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By S. Finley. Westminster College, New Wilmington Pennsylvania.

These dimensions and specific were published in the early 1980s discount diarex 30 caps without a prescription diet gastritis kronik, the health care deliv- approaches to evaluation are covered in Chapter 17 cheap 30caps diarex overnight delivery gastritis symptoms wiki. Such emphasis on controlling costs has led to a shift aspects of this broader evaluation, teams of health care from hospital to outpatient care, growth in managed care, professionals were assembled to provide comprehensive and case management of frail older persons. A 1987 National Institutes of to these changes, many programs have attempted to Health Consensus Development Conference defined retain principles of CGA yet streamline the process of CGA as a "multidisciplinary evaluation in which the mul- care, frequently relying on postdischarge and community- tiple problems of older persons are uncovered, described, based assessment. Furthermore, most of the early and explained, if possible, and in which the resources and programs focused on restorative or rehabilitative goals strengths of the person are catalogued, need for services (tertiary prevention) whereas many newer programs are assessed, and a coordinated care plan developed to focus aimed at primary and secondary prevention. Simultaneously, the overall health care system sionals rather than by one solitary clinician. As a result, has evolved in response to financial, technologic, and most of today’s CGA programs bear little resemblance cultural forces. Nevertheless, comprehensive geriatric assessment and then traces the reviewing the basic principles of CGA provides an under- evolution of the next generation of health service deliv- standing of both the evolution of this method of health ery innovations that are derived from CGA. Finally, I care delivery and the framework for CGA-like interven- speculate on the future of CGA-like interventions. Such team care recommendations; and (3) implementation of recom- requires a set of operating principles and governance. First among these principles is an process is to be successful at achieving health and func- understanding of the roles of each member of the team tional benefits. Within this broad conceptualization, CGA and mutual respect among the different professions. The has been implemented using many different models in team must also establish rules for process of care includ- various health care settings. Although such teams have been embraced in Most CGA programs have used some type of identifica- principle by health care systems, in practice they often tion (targeting) of high risk parents as a criterion for run counter to the training of health professionals. The purpose of such selection ticular, physicians have had little training in working with is to match health care resources to patient need. For health care teams, and their basic training emphasizes a example, it would be wasteful to have multiple health medical model. Rather, the intensive (and expensive) members evaluate all patients; whereas extended team resources needed to conduct CGA should be reserved for members are enlisted to evaluate patients on an "as- those who are at high risk of incurring adverse outcomes. Most frequently, the core team consists of Such targeting criteria have included: a physician (usually a geriatrician), a nurse (nurse prac- titioner or nurse clinical specialist), and a social worker. Frequently, the constituency of the team failure) is determined more by the local availability of profes- • Expected high health care utilization sionals with interest in CGA than by programmatic Each of these criteria has been shown to be effective in needs. However, none of extended team is gradually yielding to a strategy that these criteria are effective in identifying patients who relies on flexibility in team composition so that patients would benefit from all geriatric assessment and manage- are assessed by only those providers who are likely to ment programs. In this model, the only consistent ria should be matched to the type of assessment and member of the team would be the primary care provider. For example, Brief screens, as described in Chapter 17, might identify a geriatric evaluation and case management program which providers need to conduct further assessment and might focus on persons at high risk of health care uti- therapy. Conversely, a preventive program might rely patient briefly to determine whether a more in-depth solely on age (e. The overriding approach of this strategy is that each patient receives the only the amount of assessment that is necessary. Assessment and Development Regardless of the composition of the team, a key of Recommendations element is the training of the team. Such training should Once patients have been identified as being appropriate serve several purposes: (1) to ensure that team members for CGA, the traditional model of CGA invokes a team have an adequate understanding of the CGA process; (2) approach to assessment. Such teams are intended to to raise the level of expertise of team members in their improve quality and efficiency of care of needy older specific contribution to the team; (3) to develop standard persons by delegating responsibility to the health profes- approaches to problems that are commonly identified sionals who are most appropriate to provide each aspect through CGA; (4) to define areas of responsibility of indi- 18. Comprehensive Geriatric Assessment and Systems Approaches to Geriatric Care 197 vidual team members; and (5) to learn to work effectively The process of management of clinical disorders can as a team. When new members of the team are added, tations of such protocols have frequently met with con- they should receive the basic components of the initial siderable resistance or have been ignored in clinical team training. Nevertheless, common approaches to these If CGA is to be effective, the following six components problems that span across providers participating in the of the process of care must be addressed: CGA team are important to ensure that a similar inter- vention is being rendered to all patients. Implementation of the treatment plan In inpatient settings where the assessment team has 5. Monitoring response to the treatment plan primary care of the patient, generally implementation of 6. Revising the treatment plan as necessary recommendations is not a problem, provided that there The approach to gathering clinical data is changing.

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The anti-libidinal object constellation attacks and secondarily re- presses the libidinal (desiring) constellation as it presses to be reconnected with the central ego buy 30 caps diarex fast delivery gastritis rectal bleeding. That means it is easier to hate someone than to long for them in a situation that will never give satisfaction order 30caps diarex fast delivery diet to help gastritis. They do so because their un- satisfiable libidinal longing for each other is further buried from awareness by an attack by the anti-libidinal or rejecting ego. Likewise, a sugary-sweet, cloying couple can leave therapists feeling annoyed when they use libidinal, exciting relationships to further disguise the rejecting anti-libidinal system. Object Relations Couple Therapy 143 Exciting Libidinal object ego Central Ideal ego object Anti-libidinal Rejecting ego object Figure 9. The central ego in relation to the ideal object is in conscious interaction with the caretaker (or spouse). The central ego represses the split-off libidinal and anti-libidinal aspects of its experience of others along with corresponding parts of the ego and accompanying affects that remain uncon- scious. Christie represents alternately both the exciting and fearful internal object for Dennis as he craves and then attacks her. She longs for him, but immediately experiences him as a persecutory object and rejects him. Their relationship reproduces in- dividual internal issues in their interaction, producing a joint personality that is fearfully dominated by their shared rejecting object relations. A THEORY OF UNCONSCIOUS COMMUNICATION To make an object relations theory of individual development applicable to conjoint therapy, we need a theory of unconscious communication. Melanie Klein (1946/1975), a London analyst born in Germany, coined the term pro- jective identification for the way a person evacuates part of his mind into an- other person’s mind in order to rid himself of excessive anger or other unacceptable, dangerous elements. We now believe that all persons in inti- mate relationships use projective identification not only to protect them- selves, but also to communicate in depth (J. An infant puts unthought feelings, needs, and fears into its mother through facial and bod- ily gestures, vocal intonation, and subtle eye movements. The mother takes in these communications through introjective identification—through reso- nance with her own internal object organization, thereby joining with the infant’s experience. Her past experience of distress, fear, or happiness lets 144 THEORETICAL PERSPECTIVES ON WORKING WITH COUPLES her understand the infant’s experience. The experience of getting to know each other occurs through endless iterations of these cycles of projective and introjective identification, which go on in both directions: The mother also puts her anxieties about being a mother into the infant, who identifies with them and if things are going well, projects back reassurance. In in- fancy, the quality of these interactions is the major component in determin- ing the security of the infant’s attachment to the parents (Fonagy, Gergely, Jurist, & Target, 2003). In adulthood, the mutuality of these cycles is equally important and more reciprocal. Couples engage continuously in cy- cles of projective and introjective identification that are by nature largely profoundly unconscious. Therapy makes these matters more conscious so that a couple has new choices about how to relate. The in- fant unconsciously seeks an exciting object identification with the mother, for example by crying for more to eat. In the figure, the mother shakes off the identification—identifying instead with the experience of rejection her refusal brings. Rejecting the infant’s excess neediness results in the infant’s enlarging the rejecting object constellation. CASE STUDY Dennis comes from a prominent family whose secret is his mother’s illegit- imacy. Dennis grew up longing for this exiled grandmother, because his mother rejected her mother-in-law, too. Dennis unconsciously experienced his mother’s ha- tred as reliving her repressed longings for her own mother. The unex- pressed longing hidden beneath her hatred came through as though it were his longing for the mother she could not be. Disinherited and banned socially, they escaped to Europe where their first child was born before they could get divorces. In a system of mutual projective identification, the couple replays both kinds of repressed bad objects described by Fairbairn, living out in their re- lationship both the longing and rejection they absorbed from their parents during painful childhoods, nourished in emotionally impoverished families.

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Initiating and maintaining a collabora- tive alliance in which each spouse experiences being sensitively listened to discount diarex 30 caps without prescription gastritis working out, understood generic 30caps diarex overnight delivery mild gastritis symptoms treatment, empathized with, and not blamed is essential. The therapist assesses positive and negative cycles of interaction, attachment insecuri- ties, longings, and needs, which often underlie intense negative cycles of interaction in initial sessions. The therapist also assesses for factors that preclude the use of EFT, such as ongoing abuse or violence. The assessment phase of EFT is discussed in detail in the literature (Johnson, 1996). Step 2: Identify the negative interactional cycle that maintains attach- ment insecurity and distress. In Step 2, the therapeutic focus narrows, and the therapist must help the couple slow down and recognize their interactional patterns. Like the struc- tural therapist, the EFT therapist allows the couple to reenter their negative cycle, often by focusing on a recent argument. The therapist persists in get- ting a blow-by-blow account, as if she were listening to a live event broad- cast on the radio. This is focused explicitly on who does what and when, EFT: An Integrative Contemporary Approach 185 thenwhodoeswhatandwhen,then... Aseachspousegives the reenactment, the therapist is often taking notes of the cycle and reflect- ing it back by checking in with each spouse. The therapist puts the cycle into an attachment context by reflecting how each spouse ends up in sepa- ration distress, becoming absorbed in angry protest, and feelings of help- lessness and isolation. Step 3: Access the primary/unacknowledged emotions underlying each partner’s interactional position. In Step 3, secondary reactive emotions such as anger, frustration, bitter- ness, feelings associated with depression, or distance, are reflected and validated as couples initially recount them, but they are not emphasized. The underlying primary, or more vulnerable emotions, such as sadness, fear, and shame, are emphasized in therapist reflections. The therapist must, however, often go through secondary emotions, such as frustration or helpless numbing, to elicit a more nuanced awareness of more primary emotions. As a husband, for example, tells of withdrawing from his wife, the therapist reflects his secondary anger. When he subsequently relates, however, that he moves away from her because he feels "overwhelmed" and there is "no way out"—this is reflected with emphasis. The therapist has a real sense of the problematic cycle now and repeat- edly reframes distress in terms of the cycle, thus removing the focus of blame from any one partner: "There just seem to be these arguments that you guys get into. To- gether, the couple now sees their cycle, which has the effect of externaliz- ing the problem (White & Epston, 1989). Feelings of loneliness, failure, and despair are pitted against what the couple really wants, which is safety, companionship, and connection. Couples who have de-escalated their cycle typically spend much less time in their more reac- tive secondary emotions, are more cheerful, helpful, and have a real under- standing of their cycle in its totality (behaviors, stances taken, reactive and underlying emotions). They still fight, but less often, and report being able to exit from the cycle and rediscovering activities they mutually enjoy. Part- ners will not take the emotional risks necessary for the emotional restruc- turing in the next stage of EFT unless there has been cycle de-escalation. The couple is then prepared to enter Stages 2 and 3 of the approach in which a new, positive cycle is created that promotes attachment security— a second-order change. STAGE 2: RESTRUCTURING INTERACTIONAL POSITIONS Step 5: Promote an experiential identification of disowned or marginal- ized attachment needs and fears and aspects of self. Step 7: Facilitate the expression of needs and wants to restructure the interaction, based on new understandings, and create bonding events. Steps 5 through 7 should be processed with the withdrawing and more- placating spouse before deeply engaging the more-attacking spouse in this process. If this is not done and the more-attacking partner is encouraged to take significant risks that the withdrawer cannot respond to, the couple may relapse and lose their ability to de-escalate negative interactions.

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