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By D. Potros. Corcoran College of Art + Design. 2018.

She learned how much of his identity was caught up in his job title and earning power—to the exclusion of other important aspects of himself cheap chloroquine 250 mg with amex treatment plans for substance abuse. She conveyed her understanding to him and let him know that she welcomed his becoming a more involved family member order chloroquine 250 mg otc symptoms for hiv. Martin realized how bright and ambitious Martha really was and how frustrating it had been for her to follow her stereotyped stay-at-home-mom script. He understood how as a young person, she was also discouraged from questioning the traditional roles that she had been taught. He felt her excitement at discovering she had something to offer the business world, where she was appreciated for her talents and accomplishments. With increased understanding, Martin and Martha were better able to appreciate their individual backgrounds and needs. They were able to negotiate a win-win solution to their current struggle by moving the family into a suburb of their current city, which had enough of a small town feel to allow Martin to open his hard- ware store but was still commutable for Martha. Their children were also able to commute to their familiar schools and stay connected with their friends. Martin and Martha bought Alison a car so she could help with the carpooling for Andrew. DIVERSITY ISSUES Additional layers of analysis of socialization and family transmission of val- ues would have been necessary if this couple had come from a different eth- nic background or if they had been a lesbian or gay couple. The additional messages related to their ethnic group, their acculturation, the meaning of family, their family-of-origin socioeconomic status, and homophobia would have increased the complexity of the gender-role messages (Carter, 1995; Comas-Diaz, 2000; Falicov, 1998; Fischer et al. For example, in an Hispanic couple, the gender-role messages might have been even more rigid because of machismo for men (Arcaya, 1999; Lazur & 238 THEORETICAL PERSPECTIVES ON WORKING WITH COUPLES Majors, 1995; Niemann, 2001) and marianisma for women. The couple might have had even greater difficulty examining their gender roles because of additional feelings of being disloyal to their families and culture. In an African American family, it would have been less likely that Martha had dreamed of staying home with her children. Typically, African American women do not suffer from the home-career conflict that afflicts many white middle-class women because they have always expected both to work and rear children (Collins, 1994; Lazur & Majors, 1995; Leonard, Lee, & Kiselica, 1999; Sparks, 1996). In a lesbian or gay couple, there are two persons who may have similar gender-role socialization. It is crucial to examine this similarity carefully, however, and not assume similarity that is not there. In lesbian couples, there may be two persons socialized to seek and nurture relationships. If stereo- typically socialized, both could give too much to the detriment of self- development (Clunis & Green, 1988; Falco, 1991; Slater, 1995). A gay couple in which both men have been traditionally socialized may struggle with inti- macy and commitment (Harrison, 1995). Both types of couples would have the additional layers of cultural discrimination and homophobia complicat- ing their relational issues. Ethnic diversity would add further complexity (Greene, 2000; Lowe & Mascher, 2001). Worell and Remer (1992, 2003) have extrapolated from counseling and psychotherapy outcome studies in general to feminist therapy results by noting common successful characteristics. Process variables that have been found to be effective in ther- apy (Beutler et al. Other variables related to successful outcomes (Beutler, Crago, & Arizmendi, 1986; Beutler et al. Beutler and colleagues (2004) reviewed literature that suggested good outcomes were related to positive therapist behaviors (p. There also ap- pears to be a clinically weak but significant positive effect of therapist’s self-disclosure on therapy outcome. Feminist and Contextual Work 239 Specific research "into the process of marital therapy and its relationship to outcomes [was termed] still in its infancy" by Alexander, Holtzworth- Munroe, and Jameson in 1994 (p. Research in marital and couples therapy has grown significantly in recent years, and literature reviews in- cluding meta-analyses have demonstrated that couples therapy in general is an effective treatment. However, research comparing specific approaches and models has been sparse (Sexton et al. In addition, there are questions concerning the long-term effect of some couples therapies.

Although the RCTs of breast cancer screening had some shortcomings buy chloroquine 250mg free shipping treatment leukemia, there is widespread agreement that they have pro- vided solid and valid evidence regarding the efficacy of early breast cancer detection with mammography (42) buy 250mg chloroquine overnight delivery medications side effects. As noted above, while the breast cancer screening RCTs demonstrated the efficacy of screening, they provide a less clear measure of the effec- tiveness of screening. There has been increasing interest in evaluating the impact of screening in the community setting, also referred to as service screening, and to measure the effectiveness of screening among women who participate in screening. The evaluation of screening outside of research studies poses a set of unique methodologic challenges, including identify- ing when screening is introduced, the duration of time required to invite the eligible population to screening, the rate of screening uptake in a pop- ulation, and finally the importance of distinguishing between screened and unscreened cohorts in mortality analysis since deaths resulting from cases diagnosed before the introduction of screening may predominate for 10 years or longer (62). In three recent reports evaluating Swedish data, inves- tigators were able to classify breast cancer cases before and after the intro- duction to screening on the basis of exposure to screening in order to measure the benefit of screening among those women who attended screening (37,40,62). In a recent report that expanded an earlier analysis of two Swedish counties to seven counties in the Uppsala region, Duffy and colleagues (62) compared breast cancer mortality in the prescreening and postscreening periods among women aged 40 to 69 in six counties, and 50 to 69 in one county. Overall, they observed a 44% mortality reduction in women who actually underwent screening, and a 39% reduction in overall breast cancer mortality after adjustment for selection bias, associated with the policy of offering screening to the population. Greater breast cancer mortality reductions were observed in those counties that had offered screening longer than 10 years (-32%) compared with counties that had Chapter 3 Breast Imaging 35 offered screening less than 10 years (-18%). Finally, in a separate analysis the investigators examined the effectiveness of mammography based on age at diagnosis, comparing mortality reductions in women diagnosed between ages 40 and 49 with women diagnosed after age 50 (37). They observed a 48% mortality reduction in women ages 40 to 49 at diagnosis based on an 18-month screening interval, and a 44% mortality reduction in women aged 50 to 69 at diagnosis based on a 24-month screening inter- val. These data demonstrate that organized screening with high rates of attendance in a setting that achieves a high degree of programmatic quality assurance can achieve breast cancer mortality reductions equal to or greater than observed in the randomized trials. Summary of Evidence: It is generally accepted that women should begin regular screening mammography in their 40s, and continue regular screen- ing as long as they are in good health (39,52). Supporting Evidence: There is widespread acceptance of the value of regular breast cancer screening with mammography as the single most important public health strategy to reduce mortality from breast cancer. For many years, breast cancer screening in women aged 40 to 49 was controversial based on the absence of a statistically significant mortality breast cancer reduction compared with women aged 50+ (63–66). Further, the benefit that was evident appeared much later in younger women, leading some to argue that the appearance of benefit was attributable to cases diagnosed after age 50 in the women who were randomized in their 40s (67). This argument persisted despite contrary evidence (40), and the eventual obser- vation of statistically significant mortality reductions for this age group in two individual trials (Malmo II and Gothenburg) (44,47) and favorable meta-analysis results (32). Further, Tabar and colleagues (68,69) showed that the 24- to 33-month interval between screening exams in the Two County Study had been sufficient to reduce the incidence rate of advanced ductal grade 3 cancers in women aged 50+, but not in women aged 40 to 49. The appearance of a delayed benefit was due to the similar performance of mammography in younger and older women to reduce breast cancer deaths among women diagnosed with less aggressive tumors. These and other findings showing higher interval cancer rates in younger women (70) led the Swedish Board of Health and Welfare to set shorter screening inter- vals for younger women (18 months) compared with older women (24 months). As noted above, when the screening interval is tailored to women’s age, similar benefits are evident. Recent analysis of service screening data also has shown similar mortality reductions in women aged 40 to 49 at diagnosis compared with women aged 50 years and older (37). Setting an age to begin and end screening is admittedly arbitrary, although the HIP investigators were led to include women in their 40s because they observed that more than a third of all premature mortality associated with breast cancer deaths was attributable to women diagnosed between age 35 and 50 (30). This is less of an issue for guidelines today than the fact that the evidence base from RCTs is for average-risk women aged 39 and older. The American Cancer Society recommends that women at higher risk for diagnosis of breast cancer at a younger age due to family 36 L. An age at which screening could be stopped, for instance age 70, based on risk or potential benefit also has been proposed (71), although several observa- tions argue against setting an specific age at which all women would no longer be invited to screening. First, risk of developing and dying of breast cancer is significant in older women. The age-specific incidence of breast cancer rises until age 70 to 74, and then declines somewhat, but not below the average risk of women aged 60 to 64 (72,73). Approximately 45% of new breast cancer cases and deaths occur in women aged 65 and older (1,46).

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We realize generic 250 mg chloroquine fast delivery rust treatment, all unconsciously buy generic chloroquine 250mg online medications drugs prescription drugs, that anger is often inappropriate, springing from irritants which ought not make us angry, and so we repress. Instinctively we feel that anger is demeaning, and perhaps even more powerful, we feel a loss of control when we are angry, and that is something the TMS personality finds hard to take. All of this is unconscious and thus we are unaware of our need to repress the anger. Instead we may experience a physical symptom, TMS or something gastrointestinal, for example. I have learned that heartburn means that I’m angry about something and don’t know it. So I think about what might be causing the condition, and when I come up with the answer the heartburn disappears. Generally for me it is something about which I am annoyed but have no idea how much it has angered me. Sometimes it is something that is so loaded emotionally, I don’t come up with the answer for a long time. After a seventeen-year experience working with TMS it seems clear that, in our culture at least, we all generate anxiety and anger and that, in any culture, human beings repress potentially problematic emotions. Put another way, the psychological conditions that lead to psychophysiologic reactions like TMS, stomach ulcers and colitis are universal; they only vary in degree. Those at the upper end of 46 Healing Back Pain the severity spectrum, with more intense symptoms, we call neurotic, but in fact we are all more or less neurotic, making the term meaningless. There is a wonderful metaphor of the unconscious in Peter Gay’s excellent biography of Freud, Freud: A Life for Our Time (New York: Norton, 1988), p. The emotional phenomena that have been described in this chapter are the “anti-social inmates” of the unconscious. We seem to have a built-in mechanism for avoiding what is emotionally unpleasant, which is the reason for repression. But there appears to be an equally strong force in the mind working to bring those feelings to consciousness (“forever attempting to escape”) and that is the reason for reinforcements, for what psychoanalysts call a defense. After I had examined her and told her she had TMS and what it meant, she said that the pain had begun after she invited an older sister to take a trip to Europe, at her expense. She began to worry about whether the sister would have a good time, felt that it was her responsibility to see that she did, and then got angry and resentful about having to feel that way. She further reported that she began to dream about her mother and sister and to recall her teenage resentments against them, based on the feeling (no doubt unjustified) that they “ganged up on her—to be good,” and that she was excluded from their close relationship. All of this was enhanced by the fact that she felt her father, with whom she had been very close, had abandoned her—he died when she was eleven. The Psychology of TMS 47 This is the kind of thing from which TMS often arises: anxiety, anger, resentment, with roots that go all the way back to childhood. I thought it remarkable of her to have come up with all that important psychological material with just a hint from me. The universality of these psychological phenomena is supported by the strangely ignored fact that over 80 percent of the U. Back and neck pain syndromes are the first cause of worker absenteeism in this country. It is estimated that somewhere around $56 billion are expended annually in the United States on the ravages of back pain. This virtual epidemic of pain syndromes can only be properly explained on the basis of a universal psychophysiological process. PHYSICAL DEFENSES AGAINST REPRESSED EMOTIONS For many years I was under the impression that TMS was a kind of physical expression or discharge of the repressed emotions just described. I had been aware since the early 1970s that these common back and neck pain syndromes were due to repressed emotions. Eighty-eight percent of a large group of patients with TMS had a history of other tension-related disorders, like stomach ulcers, colitis, tension headache and migraine headache. But the idea of TMS as a physical manifestation of nervous tension was somehow unsatisfactory and incomplete. Most important, it did not explain the repeated observation that making a patient aware of the role of the pain as participant in a psychological process would lead to cessation of pain, to a “cure. Stanley Coen, who 48 Healing Back Pain suggested in the course of our working on a medical paper together that the role of the pain syndrome was not to express the hidden emotions but to prevent them from becoming conscious.

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