Racism in To Kill A Mocking Bird :: essays research papers

Bullying And DiscriminationDifferences in the social status are observed considerably large in the family of Maycomb. guide and Jem are two little children who are growing up, observing all the perplex incidents and trying to understand them. In the Maycomb County, incidents run more and more complicated as the dilemma of racism becomes bigger and bigger and as clean Atticus starts loosing faith in the good in people. Maycombs parliamentary law is wish a hierarchy. On the top there is Atticus Finch, he incessantly tries to believe the good people. The ignorant farmers Cunninghams are to a lower place the towns people, which are below Finches. The Ewells even lower on the gild and the black society comes after them despite all of their honourable and respectable conditions. The place where black society stands on the social hierarchy enables Bob Ewell to cover his obscure nominal head by putting Tom Robinson down. Jem and Scout are growing in this society and Atticus kee ps on trying to teach them to look at situations from other persons perspective to understand it better. This is like a moral lesson to the reader from Harper Lee. It is something that applies to everyone. The capacious difference in social status is very destructive for the participation and for Scout. For example, Scout doesnt understand why Aunt Alexander doesnt permit her be fri devastations with young Cunningham. Harper Lee uses childrens naivety and easiness to show the complexities of the adult world and prejudice in human interaction.Atticus grows his children to be fair and equal. He is a very wise man, who in many another(prenominal) situations knows how to act and what to do. In a racist society like Maycomb, he is braw enough to defend a black man. This trial is very authorised because it gives an insight of the society people and how they react to Toms death. At the end of this trial Jem looses his trust in rationality of the people and sees the irrational immor ality in people through this ugly incident. When the ladies of the county get together in Finches house, we get to know more about the women of Maycomb. They talk about how their black maids sound off and that Jesus neer complained so no education will make a Christian out of them. They dont consider blacks as Christians. aft(prenominal) all they believe in the same God. Women discuss and talk but they never really talk about anything that matters.Racism in To Kill A Mocking Bird essays research papers Bullying And DiscriminationDifferences in the social status are observed considerably large in the society of Maycomb. Scout and Jem are two little children who are growing up, observing all the complicated incidents and trying to understand them. In the Maycomb County, incidents get more and more complicated as the dilemma of racism becomes bigger and bigger and as wise Atticus starts loosing faith in the good in people. Maycombs society is like a hierarchy. On the top there is Atticus Finch, he always tries to believe the good people. The ignorant farmers Cunninghams are below the towns people, which are below Finches. The Ewells even lower on the society and the black society comes after them despite all of their honourable and respectable conditions. The place where black society stands on the social hierarchy enables Bob Ewell to cover his obscure presence by putting Tom Robinson down. Jem and Scout are growing in this society and Atticus keeps on trying to teach them to look at situations from another persons perspective to understand it better. This is like a moral lesson to the reader from Harper Lee. It is something that applies to everyone. The huge difference in social status is very destructive for the community and for Scout. For example, Scout doesnt understand why Aunt Alexander doesnt let her be friends with young Cunningham. Harper Lee uses childrens naivety and simplicity to show the complexities of the adult world and prejudice in human interaction.Atticus grows his children to be fair and equal. He is a very wise man, who in many situations knows how to act and what to do. In a racist society like Maycomb, he is brave enough to defend a black man. This trial is very important because it gives an insight of the society people and how they react to Toms death. At the end of this trial Jem looses his trust in rationality of the people and sees the irrational evil in people through this ugly incident. When the ladies of the county get together in Finches house, we get to know more about the women of Maycomb. They talk about how their black maids complain and that Jesus never complained so no education will make a Christian out of them. They dont consider blacks as Christians. After all they believe in the same God. Women discuss and talk but they never really talk about anything that matters.

Voting Rates of the American Poor :: Politics

In The Working Poor, David Shipler reports that in the 2000 presidential election only 38 portion ofAmeri croups with incomes less than $10,000 taked compared to 75 pct of those with incomes all over$75,000. (278) These sorts of statistics are not limited to 2000. In the six elections from 1980 to 2000,the average voter turnout of people in the bottom fifth of the income quintiles was 53 pct, tourthe conduce fifth averaged over 80 percent (Election Results). For the bottom fifth, the average householdincome was under $11,500 during each election year. The top fifth averaged an income nearly to$118,000 (DeNavas-Walt, et al.). The 2004 election was no different with 55 percent of the votes castby people with incomes of $50,000 and up. That means over half of the votes cast were by a base thatcontrols 70 percent of the nations wealth. In every election since 1964, when these statistics were firstrecorded, the South has had a lower voter turnout than the other tierce major reg ions. The South hasalso consistently had the highest penury rate of the four regions. On average, there is a twenty-five tothirty percentage-point gap between the turnouts of the net and highest income quintiles in theUnited States (Cevrantes and Gluckman).Though it is clear the misfortunate generally dont vote, the reasons for this are not so clear. Educationseems to be biggest factor. Less than 40 percent of citizens without a high work degree voted in the2000 election, compared with an 80 percent turnout for those with an advanced degree. Thepercentages rise with more precept. A connection to poverty can be drawn when considering thatover 13 percent of workers without a high school degree are in poverty, compared with only about 1percent of workers with a college degree. It should be noted these statistics concern only workers, andnot the unemployed. As a United States census report noted, Those with a high school education orless were more likely than those with more educati on to respond that they were not interested in theelection or felt their vote would not make a difference.Even more significant among the poor than the ghost that their vote will not make a difference isthe feeling their vote may not be counted. Claims of voting irregularities, true or not, often keep thepoor away from the polls. A large bloc of poor Americans deprive themselves out of the fear ofbeing disenfranchised. With a mindset that their vote will just be erased after leaving, the poor avoidVoting grade of the American Poor PoliticsIn The Working Poor, David Shipler reports that in the 2000 presidential election only 38 percent ofAmericans with incomes less than $10,000 voted compared to 75 percent of those with incomes over$75,000. (278) These sorts of statistics are not limited to 2000. In the six elections from 1980 to 2000,the average voter turnout of people in the bottom fifth of the income quintiles was 53 percent, whilethe top fifth averaged over 80 percent (Elec tion Results). For the bottom fifth, the average householdincome was under $11,500 during each election year. The top fifth averaged an income close to$118,000 (DeNavas-Walt, et al.). The 2004 election was no different with 55 percent of the votes castby people with incomes of $50,000 and up. That means over half of the votes cast were by a group thatcontrols 70 percent of the nations wealth. In every election since 1964, when these statistics were firstrecorded, the South has had a lower voter turnout than the other three major regions. The South hasalso consistently had the highest poverty rate of the four regions. On average, there is a twenty-five tothirty percentage-point gap between the turnouts of the lowest and highest income quintiles in theUnited States (Cevrantes and Gluckman).Though it is clear the poor generally dont vote, the reasons for this are not so clear. Educationseems to be biggest factor. Less than 40 percent of citizens without a high school degree voted in th e2000 election, compared with an 80 percent turnout for those with an advanced degree. Thepercentages rise with more education. A connection to poverty can be drawn when considering thatover 13 percent of workers without a high school degree are in poverty, compared with only about 1percent of workers with a college degree. It should be noted these statistics concern only workers, andnot the unemployed. As a United States census report noted, Those with a high school education orless were more likely than those with more education to respond that they were not interested in theelection or felt their vote would not make a difference.Even more significant among the poor than the feeling that their vote will not make a difference isthe feeling their vote may not be counted. Claims of voting irregularities, true or not, often keep thepoor away from the polls. A large bloc of poor Americans disenfranchise themselves out of the fear ofbeing disenfranchised. With a mindset that their vote will just be erased after leaving, the poor avoid

Essay --

Success is no accident. It is hard work, perseverance, learning, studying, sacrifice and most of all, love of what you are doing or learning to do. This is a quote by Pele that demonstrates soccer in so many ways. Today I will tell you that there are many aspects in the lame of soccer, some of which are the history, the rules and how to become a good soccer player. Soccer is the most popular sport evolved from as far back as the Han dynasty in 200-300 B.C. According to the Complete Book of Soccer, the Chinese played with a wet piece of balled up cloth, trying to kick the cloth through the two bamboo poles. This was the first-class honours degree of the great game of soccer. According to the Complete Book of Soccer, in Europe, soccer did not start till the later 14th century. It is said to be a game of kicking rubber balls in the streets of the British Isles for bragging rights. This then lead to teams building up against each other for bragging rights in England. regrettably for th e United States, the game did not appear till the 1900th century. The American Soccer Association was organized in New...

Author-function :: Reading Literature Essays

Author-function In the second chapter of his book The Order of Books, Roger Chartier deconstructs the way that past tense and present readers think of causalitys of texts. He uses Foucaults term author-function, which Foucault used in his famous essay What is an Author?, to describe this theory. Author-function is an elusive term. In essence, it refers to the way that a readers concept of the author functions in his reading of a text. His interpretation of a text is shaped by his understanding of its author. Without any concept of who the author of a text is, it is easy to develop many different interpretations of that text. However, in light of an authors gender, ethnicity, time period, political leanings, or former(a) applicable known information, the text often leans toward one plausible interpretation. For example, a readers interpretation of Invisible Man is greatly colored by her knowledge of its author Ralph Ellison as a black man fighting racial discrimination. Her interpretation of the same novel would be quite different if the author was really a white person with a history of racist action. Modern readers rely heavily on their knowledge of a texts author, often without realizing it, to shape their interpretations of that text. Necessary to a more complete understanding of the concept of author-function is an understanding of the social function of authors through the ages which Chartier lays out in Figures of the Author. Chartier agrees with Foucault, an important literary theorist who claims that the author-function changed in the 19th century when copyright laws were established. With these new laws, a system of ownership came into being . . . strict rules concerning authors rights, author-publisher relations, rights of reproduction, and tie in matters were enacted (qtd. in Chartier 30). In other words, with copyright laws, the author was seen as the source of information and was given credit (and money) for that information. Chart ier agrees that author-function did change with these changing ideas of information as property, entirely he claims that the idea of the author-function is older and broader. According to Chartier, there is evidence that the author served a functional role in the reading of texts in Medieval europium (31, 59). Foucault acknowledges that in the Middle Ages, anonymous authorship of literary texts was common, while the veracity of scientific texts was judged by the authority of the texts author (31).

Roman Aqueducts :: essays research papers

Ancient Rome had eleven major aqueducts, built between 312 B.C. (Aqua Appia) and 226 A.D. (Aqua Alexandria) the longest (Anio Novus) was 59 miles long. It has been calculated that in imperial eras, when the citys population was well over a million, the distribution system was able to provide over one cubic meter of wet per day for each inhabitant more than we recitation nowadays. For most of their length the early aqueducts were simply channels bored through the rock, from the water intake in the hills almost to the distribution cistern in Rome. The enlightenment of the channel below ground varied so as to maintain a constant, very shallow gradient (less than 1/200) throughout the length of the aqueduct straight shafts were bored at intervals to provide ventilation and access. Only in the final stretches was the conduit raised on arches, to give a sufficient head for distribution of the water within the city. In order to keep the gradient constant, the aqueducts took a rounda bout route, following the contours of the land and heading along spurs which led towards Rome. The most dramatic part of a Roman aqueduct wereand still arethe bridges (also known as arcades) that carried the water over low spots in the terrain. Perhaps the best-known of these is the Pont du Gard, a part of the aqueduct that served the town in Nmes in Gaul (todays France). The bridge stands on three tiers of arches and has a length of 274 m (900 ft). Built without the use of mortar, it stands 49 m (160 ft) above the Borngre Ravine. Another famous Roman aqueduct is the one in Segovia, Spain it still carries water, although it did need restoration in the 15th century. s time went on, Roman engineers became more daring in the construction of high arches to support the conduits across valleys and plains and some of the later aqueducts were as much as 27 meters (about one hundred feet) above ground level in places. Closed pipes were occasionally used to cross valleys by the "inverte d syphon" method the pressure forced the water down and up again on the other side, to a level slightly lower than before. But this system was costly, as it required lead pipes (lead had to be imported from Spain or Great Britain) and it was difficult to make joints strong enough to withstand the pressure so arches were far more common.

Religious Symbolism in John Steinbecks The Grapes of Wrath Essay

Religious Symbolism in John Steinbecks The Grapes of Wrath In his unfermented The Grapes of Wrath, John Steinbeck portrays the movement of a family of migrant workers, the Joads, from Oklahoma to California during the Great Depression. Steinbecks fresh, though it is surprisingly lacking in surface-level symbolism, was conceived on simultaneous levels of existence, ranging from socio-economic determinism to transcendent spirituality (DeMott, xiii). One of the many levels on which this novel can be read is as a parallel to the stories of Christ and the Exodus (Louis Owens, John Steinbecks Re-Vision of America, quoted in DeMott, xiii). Steinbeck intertwines allegories based on these two stories throughout his novel. by dint of these intertwined religious textures, and the destitution and depression that constitutes the greater part of the novel, Steinbeck conveys the message of the impending death of religion while at the same time establishing his novel as a sort of new gospel for the people. On the surface, one can read Steinbecks novel in one of two ways by instruction the longer, even-numbered chapters, one gains a close understanding of the life of this particular family. But by reading the shorter, odd-numbered, intercalary chapters, which could almost constitute a short novel in and of themselves, one begins to comprehend the epic sweep of the exodus of multitudes of workers to California, the apparent promised land. Steinbeck intended to separate these two stories in the readers mind, as we see in his daybook kept while writing the book, published later as Working Days I find that I am not very quelled with the numbering of these chapters. It may be that they simply will be numbered with large nume... ...apes highlight the differences between the times in which the two stories were written, and the flaws of the culture in which Steinbeck wrote. The get of looking at this epic as it relates to the Christian tradition sheds some new light on it, an d in addition shows that Steinbeck truly meant this work to be remembered for all time. Works Cited DeMott, Robert. Introduction. The Grapes of Wrath. New York Penguin, 1992 vii-xliv. Levant, Howard. The Fully Matured Art The Grapes of Wrath. The Novels of John Steinbeck A Critical Survey. Columbia, Mo. University of Missouri Press, 1983. New Revised monetary standard Version Bible. New York American Bible Society, 1989. Steinbeck, John. The Grapes of Wrath. New York Penguin, 1992. Steinbeck, John. Working Days The Journals of the Grapes of Wrath. Ed. Robert DeMott. New York Viking, 1989.

Religious Symbolism in John Steinbecks The Grapes of Wrath Essay

Religious Symbolism in prat Steinbecks The Grapes of Wrath In his novel The Grapes of Wrath, John Steinbeck portrays the movement of a family of migrant workers, the Joads, from Oklahoma to California during the Great Depression. Steinbecks novel, though it is surprisingly lacking in surface-level symbolism, was conceived on simultaneous levels of existence, ranging from socio-economic determinism to transcendent spirituality (DeMott, xiii). One of the some(prenominal) levels on which this novel can be read is as a parallel to the stories of Christ and the Exodus (Louis Owens, John Steinbecks Re-Vision of America, quoted in DeMott, xiii). Steinbeck intertwines allegories based on these cardinal stories throughout his novel. Through these intertwined religious textures, and the destitution and depression that constitutes the greater part of the novel, Steinbeck conveys the message of the impending death of religion while at the same term establishing his novel as a sort of new g ospel for the people. On the surface, one can read Steinbecks novel in one of two ways by reading the longer, even-numbered chapters, one gains a close understanding of the life of this particular family. But by reading the shorter, odd-numbered, intercalary chapters, which could almost constitute a short novel in and of themselves, one begins to comprehend the epic sweep of the exodus of multitudes of workers to California, the apparent promised land. Steinbeck intended to separate these two stories in the readers mind, as we secure in his journal kept while writing the book, published later as Working Days I find that I am not very satisfied with the numbering of these chapters. It may be that they simply will be numbered with large nume... ...apes highlight the differences between the times in which the two stories were written, and the flaws of the tillage in which Steinbeck wrote. The approach of looking at this epic as it relates to the Christian tradition sheds some new l ight on it, and in addition shows that Steinbeck very meant this work to be remembered for all time. Works Cited DeMott, Robert. Introduction. The Grapes of Wrath. refreshed York Penguin, 1992 vii-xliv. Levant, Howard. The Fully Matured Art The Grapes of Wrath. The Novels of John Steinbeck A Critical Survey. Columbia, Mo. University of Missouri Press, 1983. New Revised Standard Version Bible. New York American Bible Society, 1989. Steinbeck, John. The Grapes of Wrath. New York Penguin, 1992. Steinbeck, John. Working Days The Journals of the Grapes of Wrath. Ed. Robert DeMott. New York Viking, 1989.

Communication implications for quality control, outsourcing and consumer relations Essay

1. INTRODUCTIONQuality control and product condom are key challenges for companies that manufacture in third-world countries. In the event of a safety or quality control crisis, weeds must respond quickly and efficiently using clear crisis communication and image repair strategies. By studying the Mattel opine case, we see how a multinational corporation restored its reputation amongst multiple stakeholders it also implemented policies and processes to divert or lessen future crises.The lessons learned from Mattel demonstrate the richness of transparent communication practices and may guide companies facing similar communication challenges. The teaching notes allow for originally introduce the purpose of the Mattel case study, followed by a brief synopsis. Students will next learn relevant theories and principles from which to understand Mattels corporate communication reception, particularly strategic crisis communication theory (SCCT) and issues management principles. Studen ts will then compare Mattels communication response to the industry best practice principles as outlined by Page and suggest a revised, to a greater extent suitable and effective course of action.2. PURPOSE OF CASE STUDYUpon completion of this case study, students should demonstrate that1. Issues develop over time, not overnight. 2. Through environmental scanning, crisis arithmetic mean and strategic communication theory planning, corporations can minimize the damage done by emerging and sustained crises. 3. Prompt corrective action can remedy the legitimate crisis and avert future crises and criticismin the event that a crisis recurs. 4. Companies can turn a crisis into a long-term competitive advantage if it is handled properly from the outset. 5. out of doors influences may affect a corporations image. Communicators must demonstrate preparedness to deal with external effects. 6. In the event of a crisis, a corporation must address (and prioritize) a number of audiences with t ailored messages, for example investors, customers, the media, government and the industry. 7. Initial responses to a crisis will remain present throughout a communication theory campaign, for better or worse, and must be planned carefully. For example, Mattels shifted blame to Chinese manufacturers. This backfired and has remained a controversial point since. 8. Successful cross-cultural communication is inborn for corporations operating in foreign countries.3. SYNOPSISBeginning in August 2007, Americas largest playact manufacturer, Mattel, announced the first of what would become a serial of five recalls involving 21 million toys. The majority of the recalls were caused by poorly designed magnets fashioned in the United States, while a smaller number were collectable to toxic lead paint applied by slipshod Chinese suppliers. On the one hand, Mattels various publics, such as parents, investors and the government, have raspingly criticized the toymaker on the other hand, analys ts and industry experts have praised it for its quick response and stringent safety inspection systems, which are purportedly the industrys tightest. Regardless, the case draws perplexity to the quality control challenges facing companies that outsource manufacturing to developing countries. Students, through discussion of the case study and the attached study materials, will analyze the positive and invalidating approaches of Mattels corporate communications response. They will critique the responses suitability to the level of crisis, and suggest possible alternatives. They will consider the unique communications challenges facing a corporation that operates in an international, cross-cultural arena.4. TEACHING COMPONENTS4.1 Assignments, Activities and Study MaterialsStudents will read the case before class. They will browse Mattels website, remunerative particular attention to the recall page (http//service.mattel.com/us/recall.asp) and the Investors and Media pages (http//www .shareholder.com/mattel/default.cfm). They should review Mattels history, financial information, corporate governance documents and social responsibility pages. For additional information, students should visit toy industry websites such as Toy Industry Association (www.toy-tia.org) or consumer action group sites like Healthy Toys (www.healthtoys.org). Students should carefully read the news releases in the case appendix.4.2 Relevant TheoriesStudents must understand the key theories informing Mattels crisis and response strategies.Situational Crisis Communication Theory (SCCT)SCCT posits that each unique crisis requires a unique response tailored to the events and characteristics at hand. It is based on convergent research from Coombs, Benoit, Benson and Hearit that aims to minimize or deflect all possible negative outcomes such as confounded sales or low stock prices.? In order to determine the best strategy, corporate communicators must assess the reputational threat of the crisi s. This is a two-step process. The first step is to determine the nature of the crisis.

Psychoanalytic Theory and Tony Soprano

Soprano, the main character of the HBO series The Sopranos. This paper will take on to contain specific examples in the show where the theory applies and as such the psychiatric session amid Tony and his therapist will also be canvas with the purpose of knowing the extent of application of Freuds theory.The theory of personality developed by Freud that focused on repression and unconscious mind mind forces and included the concepts of infantile sexuality, resistance, transference, and division of the someone into the id, ego, and superego, is hoped to be better understood in the fabricated character of Soprano as the head of the most powerful criminal organization in sensitive Jersey. The Soprano character, played by James Gandolfini, is the series exceedingly interlocking protagonist and as such is the only character to appear in every event of the show as the Boss of the DiMeo Family.Throughout the series, Tony Soprano has to juggle the on-going needs of both his persona l family and his professional family and in these episodes and sequences this paper will analyze the reading material of the Freuds theory. Freuds Psychoanalytic possible action and Tony Soprano Sigmund Freud was born Sigismund Schlomo Freud on May 6, 1856 and until his death on September 23, 1939 was an Austrian neurologist and psychiatrist.He founded the Psychoanalytic School of Psychology and was outdo known for his theories of the unconscious mind, especi completelyy involving the mechanism of repression his redefinition of sexual desire as the primary motivational energy of human keep, directed toward a wide trans exerciseation of objects and his therapeutic techniques, especially his theory of transference in the therapeutic relationship and the presumed value of dreams as sources of insight into unconscious desires.Commonly referred to as the father of psychoanalysis, Freuds work has been exceedingly influential, popularizing such notions as the unconscious, the Oedipus complex, defense mechanisms, Freudian slips and dream symbolism. However great and despite his contributions, numerous critics dis commited Freuds works and in particular the Psychoanalytic Theory because of its characterization as complex counterfeit of science. Also a physiologist, medical doctor and psychologist, Freud was generally recognized as one of the most influential and commanding thinkers of the twentieth century.In elaborating his Psychoanalytic Theory, Freud stated that the mind is a complex energy-system, the structural investigation of which is proper province of psychology. He articulated and refined the concepts of the unconscious, of infantile sexuality, of repression, and proposed a tripartite account of the minds structure, all as part of a radically new conceptual and therapeutic frame of reference for the understanding of human mental development and the hold forthion of abnormal mental conditions.Notwithstanding the multiple manifestations of psychoanaly sis as it exists today, it can in almost all fundamental respects be traced at a season back to Freuds original work. Further, Freuds innovative treatment of human actions, dreams, and indeed of cultural artifacts as invariably possessing implicit symbolic significance has proven to be extraordinarily fertile, and has had massive implications for a wide variety of fields, including anthropology, semiotics, and artistic creativity and appreciation in addition to psychology.However, Freuds most important and frequently re-iterated claim, that with psychoanalysis he had invented a new science of the mind, remains the subject of much critical debate and controversy. (Jones, 1981). Psychoanalysis Based on Freud, Psychoanalysis is a set of techniques for exploring underlying motives and a method of treating various mental disorders. It comprises some(prenominal) interlocking theories concerning the functioning of the mind.The term also refers to a specific type of treatment where the a nalyst, upon hearing the thoughts of the analysand (analytic patient), formulates and then explains the unconscious basis for the patients symptoms and character problems. Unconscious functioning was inaugural described by Fred who modified his theories several times over a period of almost 50 years (1889-1939) of attempting to treat patients who suffered with mental problems. During psychoanalytical treatment, the patient tells the analyst various thoughts and feelings.The analyst listens c arefully, formulates, then intervenes to attempt to help the patient develop insight into unconscious factors causing the problems. The specifics of the analysts interventions typically include confronting and clarifying the patients pathological defenses, wishes and guilt. Freud devised it in Vienna in the 1890s because he was interested in finding an effective treatment for patients with neurotic or hysterical symptoms.This new theory, which addressed the cause of neurotic symptoms phobias, compulsions, obsessions, depressions, and hysterical conversions amongst others, suggested that such problems were created by conflicts among various wishes and guilt, which produced anxiety. Freud and Psychoanalysis In 1886, Freud abandoned the hypnosis form of treatment, in favor of a treatment where the patient talked by his or her problems. This came to be known as the talking cure. The talking cure is widely seen as the basis of psychoanalysis.In his 40s, Freud had numerous psychosomatic disorders as well as exaggerated fears of dying and other phobias (Corey 2000, p. 67). During this time Freud was involved in the task of exploring his own dreams, memories, and the dynamics of his personality development. During this self-analysis, he came to realize the hostility he felt towards his father (Jacob Freud), who had died in 1896, and he also recalled his childhood sexual feelings for his mother (Amalia Freud), who was attractive, warm, and protective (Corey 2000, p.67). Corey considered this time of emotional difficulty to be the most creative time in Freuds life. In a more vivid identification of the personality of Freud, Historian diaphysis Gay (2000) said that the former opened a window on the unconscious where he said, lust, rage and repression battle for supremacy and changed the way we view ourselves. thither is nothing new about such embittered confrontations they have dogged Freuds footsteps since he developed the cluster of theories he would give the name of psychoanalysis.His fundamental idea that all humans are endowed with an unconscious in which potent sexual and aggressive drives, and defenses against them, struggle for supremacy, as it were, behind a persons back has struck numerous as a romantic, scientifically unprovable notion. His contention that the catalog of neurotic ailments to which humans are susceptible is nearly always the work of sexual maladjustments, and that tickling desire starts not in puberty but in infancy, seemed to the respectable nothing less than obscene.His dramatic evocation of a universal Oedipus complex, in which (to put a complicated issue too simply) the little boy loves his mother and hates his father, seems more like a literary conceit than a thesis righteous of a scientifically minded psychologist. As he pursued his medical researches, he came to the conclusion that the most intriguing mysteries lay concealed in the complex operations of the mind.By the early 1890s, he was specializing in neurasthenics (mainly severe hysterics) they taught him much, including the art of patient listening. At the same time he was beginning to write down his dreams, progressively convinced that they might offer clues to the workings of the unconscious, a notion he borrowed from the Romantics. He saw himself as a scientist taking material both from his patients and from himself, through introspection. Freud was intent not merely on originating a sweeping theory of mental functioning and malfunctioni ng.He also wanted to develop the rules of psychoanalytic therapy and expand his point of human nature to encompass not just the couch but the whole culture. As to the first, he created the largely silent listener who encourages the analysand to say whatsoever comes to mind, no effect how foolish, repetitive or outrageous, and who intervenes occasionally to interpret what the patient on the couch is struggling to say. The efficacy of analysis remains a matter of controversy, though the possibility of mixing psychoanalysis and drug therapy is gaining support.Freuds ventures into culture history, anthropology, literature, art, sociology, the study of religion have proved little less controversial, though they retain their bewitchment and plausibility and continue to enjoy a widespread reputation. Tony Soprano Played by James Gandolfini, Tony Soprano is a fictional character on the HBO TV series The Sopranos. The series exceedingly complex protagonist, he is the only character to appear in every episode of the show. He is the Boss of the DiMeo Family.Throughout the series, Tony Soprano has to juggle the current needs of both his personal family and his professional family. He has a volatile relationship with his wife, Carmela and a loving if somewhat strained relationship with his two children, hayfield and Anthony, Jr. Passionate and often hotheaded, he is nonetheless intelligent and struggles to conduct his personal and professional lives with reason rather than passion. Tony is often portrayed as a loving father he attends his childrens sporting events and wants them to be safe, happy and to have every opportunity in life.He hopes that both his children will escape the life of wickedness he has led. The Theory and the Character Examples of Freuds theory of the unconscious mind, especially involving the mechanism of repression his redefinition of sexual desire and his therapeutic techniques were manifested in selected episodes of the series. In Season 1 he is moved close to tears by her performance at a choir recital. He often tells people about her aspiration to become a pediatrician. Tony has suffered from panic attacks that sometimes cause him to lose consciousness since his childhood.He has his first on-screen panic attack while cooking sausages at his sons birthday party this occurs in a flashback in the pilot episode. Tony loses consciousness and causes a small explosion when he drops a bottle of lighter fluid onto the coals. Tony describes the experience of the panic attack as feeling like he had ginger ale in his skull. This prompts him to seek help for the attacks. After extensive testing that includes an MRI scan and blood work no physical cause can be found so Dr. Cusamano referred Tony to psychiatrist, Dr.Melfi. Tonys referral to therapy allowed a questionion of his thoughts and feelings away from both aspects of his life this forum for reaching into the characters thoughts has been described as a Greek chorus and ke y to the viewers understanding of the character. Tony was initially very resistant to the idea that there was a psychiatric cause for his symptoms. He resented being in therapy and refused to accept the diagnosis of panic attacks given him by the neurologists who had investigated his illness. Tony begins to open up once Dr.Melfi explains the doctor-patient confidentiality rules. He tells her about the stress of his business life he has a feeling that he has come in at the end of something and describes a reverence for times past. Tony leaves out the violence associated with his criminal career. Tony tells Dr. Melfi a story about ducks landing in his pool. He also tells her about his mother, Livia, who is relentlessly pessimistic and cynical, at once demanding and resentful of assistance. By the end of the first session Tony has admitted that he feels depressed but storms out when Dr.Melfi presses him further about the relationship between his symptoms and the ducks. n the episode 4 6 Long they continue discuss Tonys mother and her difficulties living alone. Tony admits that he feels guilty because his mother could not be allowed to live with his family. We learn that he has been left to care for his mother alone by his sisters. When Dr. Melfi asks him to regain good experiences from his childhood he has difficulty. It is clear that Tonys perception of his mother does not meet with the reality of her personality.He also shows that he blames Carmela for preventing his mother from living with them. subsequent they discuss Livias car accident and Melfi suggests depression may have contributed to the accident Tony misunderstands her and becomes sore. Tony has a panic attack while visiting his mothers home after she moves to spirt Grove. In a later session Dr. Melfi pushes Tony to admit he has feelings of anger towards his mother and he again storms out. During this episode Tony introduces the concept of him acting like the troubling clown happy on the outsid e but bittersweet on the inside.In the episode, Denial, Anger, Acceptance, Tony discusses Jackies cancer with Dr. Melfi. She tries to use it as an example of Tonys negative thinking contributing to his depression. Tony becomes angry and storms out because he feels she is trying to trick him and manipulate his thoughts using the pictures that decorate her office. After Jackie worsens and Tony is called a Frankenstein by a business associate he returns to therapy to discuss these things with Dr. Melfi she asks him if he feels like a monster. In the Fortunate Son episode, Tony discusses a childhood memory of an early panic attack.He saw his father and uncle mutilate Mr Satriale, the local butcher, and later fainted at a family dinner consisting of free meat from the butcher. Dr. Melfi makes a connection between meat and Tonys panic attacks and also explores his mothers attitude to the fruits of his fathers labor. after Dr. Melfi tries prescribing lithium as a mood stabilizer. In th e episode Isabella Tony sinks into a severe depressive episode and experiences hallucinations he sees a beautiful Italian woman named Isabella in his neighbors garden.Tony sees Isabella several times during the episode and later learns that she never existed. Melfi theorizes that Isabella was an idealized maternal figure that Tonys subconscious produced because of he was deeply upset at his own mothers actions at the time. In I Dream of Jeannie Cusamano episode, Tony abruptly ends his therapy and convinces Dr. Melfi to go into hiding when he discovers that his Uncle Junior has found out about their sessions. The stage on which its drama unfolds is the relationship between Tony and Dr.Melfi, a duet blistering with so much heat and so authentic in its depiction of what actually happens in psychoanalytic psychotherapy where you pelt as if you are in the room yourself eavesdropping on another patients session. The relationship between Tony and Dr. Melfi has been up-and-down, with Tony reaching a level of comfort with Dr. Melfi that he has never go through with anyone else before, not even his wife. This closeness leads Tony to have something of a crush on Dr. Melfi, something that is unattainable. However, the prying from Dr.Melfi is uncomfortable for Tony and he often turns sarcastic and antagonistic towards her, leading to an ongoing strain in their relationship. During the episode The assist Coming, aired in part II of season six, Melfis own therapist suggests to her that therapy like which she administers to Tony has been considered to be an enabler to certain sociopathic personalities. In the episode 46 Long they continue discuss Tonys mother and her difficulties living alone. Tony admits that he feels guilty because his mother could not be allowed to live with his family. When Dr.Melfi asks him to remember good experiences from his childhood he has difficulty. It is clear that Tonys perception of his mother does not meet with the reality of her personali ty. He also shows that he blames Carmela for preventing his mother from living with them. Later they discuss Livias car accident and Melfi suggests depression may have contributed to the accident Tony misunderstands her and becomes angry. Tony has a panic attack while visiting his mothers home after she moves to dark-green Grove. In a later session Dr. Melfi pushes Tony to admit he has feelings of anger towards his mother and he again storms out.During this episode Tony introduces the concept of him acting like the sad clown happy on the outside but sad on the inside. Finally, in the penultimate episode of the series, The Blue Comet, Melfi severs her relationship with Tony as his therapist. In psychoanalytic terms, Tony is split, so split that he is an ambulatory. One part of himself the thrill-seeking mob boss trying to cling by his brass knuckles to a world where nobody plays by the rules anymore is alienated from the other part, the devoted family man trying to survive in t he quicksand of Nero-fiddling-while-Rome-burns middle-class America.Its a toss-up which culture is more empty, dysfunctional and corrupt. In any event, the breach is causing him grievous suffering. Tony tries to put up a wall between the two worlds but inevitably they start to work into each other. The more he tries to ignore or paper over the cracks, the more his psyche rebels. He has anxiety attacks, blacks out, tumbles into a depression. Tony may be in denial about why his system is on red alert but it is impossible to watch the show without developing an armchair theory. Tonys gangster personal provides him with immutable excitement and action, a sense of power and control, a definition of masculinity.Through violence rationalized as business or impersonal soldiering he also gets to submit his considerable unacknowledged rage without encroaching on his alter ego as benevolent husband and father. But when the center fails to hold, the result is panic, depression, self-hatred, sexual unwrap and engulfing, ungovernable anger. Tonys panic attacks are an undeniable signal that his defenses are deserting him. Psychoanalysis is about transformation. When transformation happens, it can seem quite magical. It can involve gaining the ability to make previously unthinkable choices or living a life that once felt beyond reach.It can be about achieving the freedom to be oneself instead of feeling inhibited, stuck and frightened. It can be about something as simple and earth-breaking as locating oneself differently in the world . If there is change, people are not the same as they used to be. References Bender, William. (2006). The Last Aria of Tony Soprano. The New York Times. Berman, J. (2003). The writing cure How expressive writing promotes health and well- being. Psychoanalytic Psychology, 20(3), 575-578. Bolognini, Stefano (2004). Psychoanalytic Empathy. Free acquaintance Books, London. Cf. Blum, Harold P. (Ed. ) (1977). Female Psychology.New York Internati onal Universities Press. De Mijolla, Allain. (2005). International Dictionary of Psychoanalysis. Thomson/Gale. Dennis, Wendy. (2205). Why Psychoanalysis Matter. The Walrus Magazine Eagleton, Terry. (1983). Literary Theory An Introduction. Minneapolis University of Minnesota Press. 153-4. Elliott, Anthony (2002). Psychoanalytic Theory An Introduction, Second Edition. Duke University Press. Fisher, Seymour. (1985). The Scientific Credibility of Freuds Theories and Therapy. University Press. Flax, Jane. Political Philosophy and the Patriarchal Unconscious A Psychoanalytic Perspective on Epistemology and Metaphysics.Discovering Reality. 252. Gay, Peter. (1998) Freud A Life for our Time. New York W. W. Norton & Co. , Inc. 810 pp. Reprinted from Gerald, Corey. (2000). Theory and example of Counseling and Psychotherapy. 6th ed. Jacobson, Edith. (1976). Depression Comparative Studies of Normal, Neurotic, and Psychotic Conditions. International Universities Press. Jones, Ernest. (1981). Th e Life and Work of Sigmund Freud. Basic Books. Laplanche, Jean and Pontalis, J. B. (1974). The Language of Psycho-Analysis. W. W. Norton & Company.

Case Analysis of Mdd, Gad, and Substance Use

Case digest of Comorbid Major Depressive Dis cabaret, extrapolate Anxiety Disorder, and Substance Ab make hold of Nicole Gapp Univer gety of Minnesota School of Nursing Case Analysis of Comorbid Major Depressive Disorder, reason out Anxiety Disorder, and Substance Abuse Major Depressive Disorder (MDD) is a mood disorder with symptoms that greatly affect the life-time of the individual. MDD could in fact be called a public health crisis, as it is projected that it ordain soon overtake heart diseases as the major worldwide health concern (Boyd, 2008).Diagnostic criteria for MDD be depress mood or sack of interest or pleasure in nearly all activities, present for at least 2 weeks. Findings and behaviors associated with MDD be spread of slumber, suicidal ideation, feelings of worthlessness and hopelessness, and fatigue and loss of energy. MDD is likewise associated with a high impair work forcet in occupational, brotherly, and physical cognitive process, causing as much d isability and trauma as chronic medical disorders (United States Department of Health and Human Services, 1999).MDD has been shown to be associated with increased medical illnesses. MDD disregard make e genuinelyday living a challenge, as research shows that depressive symptoms are associated with impaired everyday problem-solving ability directly and indirectly mediated through learning and memory, and reasoning (Yen, Rebok, Gallo, J nonpareils, & Tennstedt, 2011). It is important for MDD to be identified and apparel early on, as MDD that is not encompassed appropriately results in continual depressive circumstances, with each successive episode change magnitude in severity.As MDD is highly associated with suicidal ideation and suicide, it is dogmatic that MDD be treated to ensure affected role preventivety. Risk factors for MDD are a prior episode of slack, leave out of social confine, lack of coping abilities, medical comorbidity, sum of m sensationy use, and fron t man of life and environgenial stressors. In summation, major first whitethorn follow adverse or traumatic life events, especially those that involve the loss of an important human relationship or procedure in life. Social isolation, deprivation, and financial deprivation are excessively risk factors (APA, 2002).Genetics play a role in the development of MDD, and deficiency or dysregulation of neurotransmitters are also estimate to play a part in its etiology. Psychological theories of MDD hypothesize that an early lack of love and warmth may be involved with the development of depressive symptoms, while develop cordial and family theorists experience proposed that parental loss, emotionally inadequate parenting styles, or maladaptive recipes in family interaction may contri barelye to the etiology of MDD.Women are twice as likely as men to be diagnosed with MDD, though it is believed that the incidence in men is under-diagnosed. preponderance consecrates are unrelated to r ace (Boyd, 2008). Nursing responses to MDD should involve interventions to treat symptoms within the biologic domain, much(prenominal) as changes in appetite, weight, quietude, or energy, as well as symptoms within the psychological domain, such(prenominal)(prenominal)(prenominal) as changes in mood and affect, eyeshot content, suicidal behavior, and cognition and memory. M all types of interventions are employ to treat the varied effects and symptoms of MDD.Pharmacologic interventions, such as selective serotonin reuptake inhibitors, tricylic antidepressants, monoamine oxidase inhibitors, and other classes of antidepressants may be used to decrease or man date depressive symptoms. medicine should be continued for at least six months to a year after complete cave in of depressive symptoms. Lifestyle patterns, such as good intermission hygiene, activity and exercise, and adequate intake of well-balanced meals should also be encouraged, as these patterns help the client move t oward a healthy daily routine that supports remission or recovery.Psychotherapy, such as cognitive therapy, behavior therapy, and interpersonal therapy, has been shown to be effective in individuals with MDD, and a combination of psychotherapy and pharmacotherapy is recommended for uncomplainings with arch or re contemporary MDD as a strategy to prevent relapse (Boyd, 2008). In addition, electroconvulsive therapy has been shown to be an effective treatment for MDD, especially severe MDD that has not responded to practice of medicines. Major depression a great deal occurs in conjunction with ther psychiatric disorders, such as concern or affection use disorders, which stool also affect antidepressant responsiveness. In such cases, the co-occurring genial health problem should be treated in addition to major depression (President and Fellows of Harvard College, 2011). The longanimous described in this case analysis has comorbid diagnoses of extrapolate anxiety disorder and s hopping mall detestation. Generalized Anxiety Disorder is a psychiatric disorder characterized by excessive cephalalgia and anxiety with an insidious onset.The anxiety of wander persists for at least six months, with excessive anxiety and worry occurring for more days than not, and for some individuals, persisting daily. Risk factors for GAD are thought to be undetermined conflicts, cognitive misinterpretations, and multiple stressful life events (Boyd, 2008)). Few studies fuck off examined the genetic basis of GAD, notwithstanding it is thought to be moderately herit subject. In clinical settings, the incidence of GAD is equally distributed in women and men. However, in wider studies GAD is twice as common in women.In no studies has the prevalence of GAD been related to race (Boyd, 2008). Patients with GAD oft have associated depressive symptoms, and MDD is a common comorbid disorder. For this reason, there has been debate surrounding whether GAD is a separate disorder than MDD, or if GAD symptoms are part of the course of MDD. However, research shows that many unhurrieds with GAD do not present with a distinct MDD symptom profile. This does not support the opening that co-morbidity between MDD and GAD is artificially inflated because of the similar symptom criteria required by the current diagnostic system.Instead, MDE and GAD may be thought of as two distinct diagnostic entities that frequently co-occur because of a shared underlying trait (Sunderland, Mewton, Slade & Baillie, 2010). Current diagnostic criteria state that GAD exists when the excessive worry does not occur exclusively during a mood disorder, psychotic disorder, or pervasive developgenial disorder. For example, a persevering who experiences persistent excessive anxiety but has minimal or no depressive symptoms would be diagnosed with GAD (Boyd, 2008). However, research has shown that the presence of a comorbid anxiety disorder may make MDD harder to resolve or misrepresent.One fi nicky study comparing individuals with MDD and individuals with MDD and a comorbid anxiety disorder showed that after adjusting for the severity of depression, those in the anxious depression group had significantly younger onset age, had been ache from depression for a longer period, were more likely to experience a recurrence, and obtained lower scores on a scale assessing quality of life. The anxious depression group was also characterized by a significantly higher proportion of individuals reporting significant suicidal ideation and former suicide attempts (Seo, Jung, Kim, T. , Kim, J. Lee, Kim, J. & Jun, 2011). Patients with GAD are lots highly somatic, with many complaints of physical symptoms. One study concluded that painful physical symptoms in patients with GAD are twice as prevalent as in the control group, which consisted of individuals with neither GAD nor MDD. The presence of comorbid MDD was associated with a significantly higher prevalence of painful physical symp toms. Painful physical symptoms were significantly associated with functioning and health status impairment both in GAD alone and in GAD and comorbid MDD compared with controls (Romera, Fernandez, Perez, Montejo, Caballero, F. Caballero, L. , Arbesu & Gilaberte, 2010). In addition, those with GAD also often experience unretentive relief habits, irritability, and poor concentration. Patients with GAD often feel frustrated, demoralized, and hopeless. They often feel restless and on edge and experience clinically significant distress or impairment of functioning resulting from anxiety, worry, or physical symptoms. GAD has a significant negative impact on work functioning, although smaller than the effect of MDD (Plaisier, Beekman, de Graaf, Smit, van Dyck & Penninx, 2010).Interventions addressing symptoms of the biologic domain include eliminating caffeine, diet pills, amphetamines, ginseng, and ma huang, which have all been shown to be anxiety-producing substances (Boyd, 2008). In a ddition, good sleep hygiene should be promoted, as a common symptom of GAD is sleep disturbances. The entertain should teach the patient breathing control and progressive muscle relaxation as calming techniques, help the patient signalize other positive coping strategies, and educate the patient on time management.Pharmacological interventions, such as the use of benzodiazepines, certain antidepressants, and other non-benzodiazepine anxiolytics may be effective in reducing anxiety. Roughly 75% of those with GAD have at least one additional current or lifetime psychiatric diagnosis, with MDD being one of the more common comorbidities. Alcoholism is also a significant problem associated with GAD. Patients may use alcohol, anxiolytics or barbiturates to relieve anxiety, and this may exsert to abuse and settlement. Such is the case of the patient described in the case analysis, who also has a substance-related disorder.The DSM-IV-TR defines substance abuse as a maladaptive pattern o f substance use leading to clinically significant impairment or distress. This impairment may be manifested by recurrent use, resulting in failure to receive major role obligations at work or spot, recurrent use in situations that are physically hazardous, recurrent substance related legal problems, or continued use despite feeling persistent or recurrent effects of the substance. To constitute substance abuse, three or more of these manifestations must be present within a 12-month period.In general, men consume more alcohol and abuse medicines more than women, though women are more likely to abuse ethical drug medication. Substance abuse and dependency are not correlated so much with gender as with an early age of initiation of substance use (Boyd, 2008). Comorbid mental disorders occur often with substance dependence and abuse. For some, comorbid mental disorders are byproducts of long- bourn substance abuse. Other people have mental conditions that predispose them to substanc e abuse, with substance abuse becoming a comorbid problem as they use drugs and/or alcohol to self-medicate existing mental illnesses.There is a well-documented association between depression and alcohol abuse and dependence which cannot be explained solely by the random overlapping of these two conditions. A systematic review of 35 studies estimated the prevalence of current alcohol problems in depressed patients to be 16%, as compared to 7% in the general population. The three most comm compose described causal hypotheses for this comorbidity are as follows 1) an independent depressive episode (e. g. he self-medication theory), 2) alcohol induced depressive symptoms and 3) the existence of shared biological and environmental factors that predispose persons to both (Cohn, Epstein, McCrady, Jensen, HunterReel, Green & Drapkin, 2011). In addition, men with at least four heavy swallow occasions were found to be 2. 6 times as likely to be classified as being depressed as men who dra nk heavily less than four times in the previous 28days (Levola, Holopainen & Aalto, 2011). Specific substances that have been maltreated by the patient who is the subject of this analysis are alcohol, cocaine, heroin, and the prescription drugs oxycodone and Valium.At the time of admission, the patient was no longer first-stringly using drugs or alcohol, but his invoice of substance abuse, including overdose, is extensive. Thus, although the patient is already withdrawn from drugs and alcohol, his long-term substance use has significant physical and mental consequences. The depression of the central nervous system by alcohol causes relaxed inhibitions, heightened emotions, mood swings, and cognitive impairments such as reduced concentration and attention, and impaired judgment and memory. In particular, this patient engages in periodic eat drinking, drinking up to 15 drinks in one evening.This alcohol use would result in several days of intoxication, which were interspersed with periods of sobriety. The amount of alcohol consumed in an episode of binge drinking can cause severely impaired motor function and coordination difficulties, emotional lability, stupor, disorientation, and in extreme cases, even coma, respiratory failure, or closing. Long-term abuse of alcohol can adversely affect all body systems, and research has shown a connection between alcohol dependence and increased risk for diabetes mellitus, GI problems, hypertension, liver disease, and stroke (Smith & Book, 2010).Cocaine users typically report that cocaine enhances their feelings of well-being and reduces their anxiety. However, long-term cocaine use leads to increased anxiety. Severe anxiety, restlessness, and agitation are all symptoms or cocaine disengagement. Withdrawal causes intense depression, craving, and drug desire behavior that may last for weeks (Boyd, 2008). Valium, a benzodiazepine, is a prescription drug that this patient abused. Patients who abuse benzodiazepines ofte n feel hyperactive or anxious after using them.Often, patients who abuse these drugs combine them with alcohol, putting the patient at risk of coma or death. Symptoms during benzodiazepine withdrawal include anxiety rebound, such as tension, agitation, tremulousness and insomnia, as well as symptoms of autonomic rebound, sensory excitement, motor excitation, and cognitive excitation, such as nightmares and hallucinations (Boyd, 2008). Opiates are coercive drugs that can quickly trigger addiction when used improperly. Heroin is an opiate that was abused by this patient.Heroin is the most abused and most rapidly acting of all opiates. It can be injected intravenously, and such was the method of delivery for this patient. Heroin produces profound degrees of tolerance and physical dependence. Withdrawal from opiates should be tapered, and if abruptly withdrawn from someone dependent on them, severe physical symptoms may occur, along with nervousness, restlessness and irritability (Boyd , 2008). In addition to heroin use, the patient attempted to founder suicide by overdosing on oxycodone, a prescription opiate.Overcoming substance abuse and preventing relapse can be especially difficult as denial is common in substance abusing patients. vindication is defined as the patients inability to accept his loss of control over substance use, or to accept the consequences associated with the substance use (Boyd, 2008). Because many patients find it difficult or impossible to believe they have a serious problem with drugs and alcohol, many do not seek treatment, or chequer treatment prematurely. Motivation is a key predictor of whether individuals ordinate change their substance abuse behavior.Several effective modalities are used effectively to treat addiction, such as 12-step programs, social skills groups, psychoeducational groups, group therapy, and individual and family therapies. Depending on the individual, different treatment techniques will be more or less hel pful. History of Present disorder The patient is a 58-year-old Caucasian male who was participating in a partial hospitalisation program (PHP) at Hennepin County Medical Center (HCMC) for the treatment of severe major depressive disorder. He has been involved in PHP since his last discharge from the HCMC psychiatric inpatient unit in early March.The patient was cooperative with treatment and medication compliant. He was put on a 72-hour hold after becoming angry and hostile during the PHP group and threatening to hang himself that evening when he got home from PHP. He eventually committed himself voluntarily to the HCMC psychiatric inpatient unit. Upon introduction, the patient appears to be clean, casually dressed, and of normal weight. He is alert and oriented. His attention, cognition, and abstract reasoning are full, and his thought content is appropriate and organized.In conversation, he is pleasant and cooperative, exhibiting a st adapted mood and a slightly blunted affect . The patient will talk to provide members but interacts minimally with peers and does not attend groups unless encouraged by staff. The patient has a normal gait but moves quite slowly. In addition it appears that his thought processes are slowed, as he is slow to respond during conversation and seems to have difficulty finding the lyric to express what he wants to say. The patient appears to have intact recall, short-term, and long-term memory.He appears to be an adequate historian though he exhibits poor judgment due to his depressive and anxious symptoms, as evidenced by his extensive account of drug and alcohol abuse and dependency. The patient has psychiatric diagnoses of severe and recurrent major depressive disorder, extrapolate anxiety disorder, and polysubstance abuse. The patient has been suffering from MDD with chronic suicidal ideation since age 15. His first suicide attempt was at age 15, and he began abusing drugs and alcohol at approximately the same time.His exte nsive account of substance abuse includes use of alcohol, cocaine, and IV heroin. His alcohol abuse as a teenager led to a DWI charge. He has participated in mental health outpatient treatment and has put up withne chemical dependency treatment numerous times. He completed high school without apparent difficulty. The patient seems to be of average intelligence, though his IQ is not listed in the record. He does not have a story of violent or sexual crime. He has a history of five suicide attempts. He began smoking as a teenager and currently smokes one pack of cigarettes per day.In 1983, the patient married and remained so until his wife died 25 years later, in 2008. He had no children. match to the patient, he was happily married, and he called his relationship with his wife the best thing that has ever and will ever happen to me. While he was married, he got wholly clean from drugs and alcohol, remaining drug free and sober for 12 years. Though he struggled with episodes of depression and suicidal ideation, he was qualified to manage his symptoms with medication and mental health outpatient treatment. Most of my problems faded into the background, verbalize the patient. During this time, he and his wife bought a condo, and the patient was employed as a janitor and handyman, working at the Minneapolis-Saint Paul airport. He remained at this job for over a decade and was promoted to the position of supervisor. He had, as he said everything I ever wanted. In 2007, his wife became very ill and eventually died in 2008 after complications from a surgery intended to prolong her life. The patient reports that as his wife got sicker, he became progressively depressed.Unlike in the previous 12 years, medication and outpatient treatment did not seem to manage his symptoms. In addition, he started experiencing extreme and persistent anxiety, feeling like I was always one second away from a panic attack. He was diagnosed with generalized anxiety disorder and w as prescribed benzodiazepines to manage this condition. As his wife got sicker, he slowly began to self medicate with alcohol and admitted to popping an extra pill occasionally to decrease his anxiety.When his wife died, the patient became so depressed and anxious that he was unable to compress at work. He had to give up his job as a supervisor, and said, I couldnt even manage myself, how was I supposed to handle anyone else. As his depression and anxiety got worse, he turned increasingly to alcohol and drugs. He reported binge drinking, consuming up to 20 drinks in one evening. He would remain intoxicated for several days, and would switch to using drugs as the alcohol cleared his system. He reported being either drunk, high, or both almost every day.Although he used cocaine and heroine, which were the drugs he used as a teenager, he also became dependent on prescription benzodiazepines to manage his increasingly severe anxiety. The increase in anxiety may be explained by his co caine use, which, though it reduces anxiety while high, causes increased anxiety with long term use. Additionally, though proper use of benzodiazepines decreases anxiety, benzodiazepine abuse or dependency results in increased anxiety take aims. When his request for more prescription benzodiazepines was denied due to drug seeking behavior, he gained possession of Valium illegally and continued abusing them.He was arrested for illegal Valium possession in 2009, and received two DWIs between 2008 and 2011. His medical record notes that he has a history of antisocial behavior, though it does not set forth on this statement beyond the mention of his previous arrests. With no income coming in and increasing amounts of money used to fuel his drug and alcohol addiction, he at sea his condo and all of his savings and was living at the Salvation Army homeless person shelter by June 2008. His depression grew in severity as the major life losses piled up and his substance dependency problem worsened.In 2008, he lost consciousness due to heroin intoxication. In August of that year, the patient overdosed on oxycodone, intending to kill himself. He was brought to HCMC, and for the quondam(prenominal) several years has experienced being in and out of the psychiatric inpatient. In 2010, he locomote from the homeless shelter to Alternative Homes in Minneapolis. Following his latest psychiatric hospitalization in March, he began the partial hospitalization program at HCMC. Upon discharge from the current hospitalization, he will be returning o Alternative Homes and participating again in the PHP program. A common finding associated with a diagnosis of either MDD, GAD, or substance abuse is the presence of sleep disturbances. Such is the case with the patient described. These sleep disturbances may present themselves as difficulty falling asleep, trouble assigning sleep, or waking up too early (National Insititute of Health, 2005). This patient currently experiences insomn ia, getting lone(prenominal) 3-4 hours of sleep per night. Reportedly, this insomnia has been a chronic issue.The insomnia the patient experience sets him up for a negative cycle. Because of his depression and anxiety, it is difficult for the patient to sleep. This lack of sleep, in turn, exacerbates his anxiety and depressive symptoms. As his symptoms progress in severity, he turns to substances to self medicate. The use of substances results in a worsening of his insomnia. Thus, finding a way for the patient to get adequate sleep is important. He has tried a variety of medications to promote sleep, but none have been effective.He can no longer be prescribed many of the medications for insomnia because of his history of abuse and overdose using prescription drugs. Thus, the options available to him for sleep promotion lie in the realm of sleep hygiene promotion. The patient might also consider participating in a sleep study, as this may reveal additional factors that prevent him f rom getting the sleep he call for. In addition to his mental illnesses, the patient also has significant medical problems. He has been diagnosed with hypertension, hepatitis C, diabetes mellitus, osteoarthritis of the left shoulder, and acid reflux.Research shows that diabetes mellitus, gastrointestinal problems, hypertension, liver disease are correlated with substance abuse (Moffitt, Caspi, Harrington, Milne, Melchior, Goldberg & Poulton, 2010). Indeed, the patients hepatitis C is a direct consequence from his use of street drugs. Interestingly, multiple studies have revealed that not only are depressive symptoms a risk factor for the development of type 2 diabetes, but they have also been shown to contribute to hyperglycemia, diabetic complications, functional disability and mortality among diabetic patients (Moffitt et al. 2010). Also, as previously discussed, patients with GAD and MDD report more painful physical symptoms than the general population, and the patients osteoarth ritis pain could well be exacerbated by the presence of these psychiatric conditions. Thus, it is possible that with improved management of his psychiatric conditions, his medical problems may improve as well. Family and Social History The patients social and family history is somewhat lacking. The patient was adopted at a young age.He has three non-biological brothers and he reports that he is estranged from all of them, and is not willing to contact them until he has my life back together. In addition, both of his adoptive parents are dead. The patient was not keen on discussing his adoptive family or his childhood and adolescence, but state that this adoptive family were good people, and tried hard to give me everything I needed. He denies any history of physical, emotional, or sexual abuse. According to the social history, there is no history of mental illness in his adoptive family.This does not mean that environmental or social factors play no role in the etiology of his me ntal illness, but that these factors may be less obvious. Information on the patients biological mother and family history is unavailable. The patient was disposed(p) up for adoption at birth, and remained a ward of the state, living in respective(a) boost homes, until he was adopted at age 3. As the patient was given up for adoption and adopted at such a young age, he has he has no recollection of his biological family or his time in the foster care system.Any instances of abuse, neglect, or trauma in his early years are thus unknown. Because there is no available family history, it is impossible to know if any of the patients first-degree relatives suffered from mental illnesses, or if the biological mother used drugs or alcohol during her pregnancy. This lack of information is unfortunate, as it is impossible to conjecture whether, or to what degree, the patients mental disorders have a basis in genetics or in disturbed fetal development.Because MDD, GAD, and substance abuse h ave all been shown to have a moderate to high degree, of heritability, it is very plausible that mood, anxiety, or substance related disorders were present in his biological family. The patient seems to have very restrict social support, as he is estranged from his adoptive siblings and has no parley with his biological family. The patient also has a history of limited social interactions and c resort friendships. He reports that he has mat up disconnected from others for as long as he remembers, and that he had few close friendships throughout his childhood, adolescence, and adulthood.In addition, the patient reports that most of the relationships that he would call the closest have been with people who have substance abuse problems, as he spent years and years trail with the wrong crowd. The basis of most of these relationships was a shared interest in drug and alcohol use, and he does not think that these friends would be of any support to him in pursuing and maintaining rec overy. During the time that he was sober, he states that his wife was the only friend I really needed and as a result, he did not form many close friendships with his peers.He states that he currently has no supportive relationships. Furthermore, he has little desire to form such relationships. Application of Developmental Theories reckon the patient and his family and social history through the lens of bond certificate theory provides a possible framework for viewing the patients development of mental illnesses. Attachment theory, a biologically based framework first proposed by John Bowlby in the mid 1950s, is the theoretical approach used to describe the vastness of stable and conceptive relationships of all infants, especially those in foster care (Bruskas, 2010).This theoretical approach reasons that infants and children have a need to belong and to experience secure relationships with a small number of consistent preferred primary caregivers in order to successfully develo p into normal healthy adults who can actively and emotionally participate in social life (Boyd, 2008). In particular, a child should receive the continuous care of this single most important attachment epithet for approximately the first two years of life.If the attachment figure is broken or disrupted during the critical two year period the child will suffer irreversible long-term consequences of this deprivation, which might include delinquency, reduced intelligence, increased aggression, depression, and affectionless psychopathyan inabilityto show affection or concern for others. Research, such as the uncomely Childhood Experiences Study, correlates untreated childhood adversity with an increased risk toward poor developmental health and other major diseases seen later in life such as cardiac disease, depression, and even premature death (Felitti & Anda, 2010).Studies reveal that infants in foster care are among the most vulnerable because of their complex and immense psyche d evelopment, and the importance of attaining developmental milestones. The onset of earing development begins soon after conception and will continue to mature well into adulthood, but the most voluminous and dramatic time of growth is during the first few years of life, specifically within the first three years. The primary and most important developmental milestone for any infant is to establish a relationship, especially one with a primary caregiver.This period presents sensitive windows of opportunity for the development of particular parts of brain structure and circuitry influenced and dependent on social experiences for optimal brain development (Bruskas, 2010). The majority of children entering foster care are infants, and the impact of not addressing mental health needs of preverbal children can have deleterious effects (National Research Council Committee on Integrating the Science of Early Childhood Development, 2000).Although an infant may not be able to articulate lo sses because of their preverbal age, they nonetheless experience sadness and loss, and for many, these experiences will be forever embedded in their memory (Felitti & Anda, 2010). Moreover, the consequences of unresolved losses have a much more devastating affect in infancy than adulthood because of the potentially permanent psychological impact on the developing brain of an infant or child (Bruskas, 2010).Infants and children in foster care who are not afforded supportive primary caregivers to help them develop an intrinsic ability to regulate their own will continue to use whatever coping methods they can. Under stress-provoking adversities such as abuse, neglect, and relationship disruptions, childrens coping strategies to manage such circumstances may present as hostility, frustration, and anxiety with underlying feelings of fear, abandonment, and powerlessness (Bruskas, 2010).The relationships infants and children develop while in foster care are critical relationships chara cterized by faith and commitment help an infant or child become more resilient toward the challenges and obstacles that all humans face in life conversely, a lack of such relationships in life can result in long-term dysfunction socially and physically. Attachments and templates of the world are significantly essential by the time a child reaches a year old (Bruskas, 2010).Efforts to address behavioral problems later in life may prove to be more difficult and costly as brain structure becomes permanent and behavior becomes more difficult to change. Due to the patients experience of foster care as an infant and toddler, it is likely that he was unable to form a secure attachment with a primary caregiver. Although this disruption in attachment is not the sole contributor to his problems with depression, anxiety, and substance abuse, it is very possible that the chaotic structure of his early years play a large role in the development of these conditions.Applying the concepts of Erik sons model of psychosocial development allow for a greater understanding of the patients current state. Because of the disruption of relationships early in life, the patient may not ever have resolved the developmental conflict of basic trust vs. mistrust, which is often resolved in infancy. This may be one reason behind his feeling of disconnectedness from others. According to Erikson, this inability to resolve this developmental conflict results in a decreased sense of drive and hope. It is also likely that the patient was able to resolve the developmental conflict of autonomy vs. hame and doubt, which is often resolved in toddlerhood (Boyd, 2008). This may explain the patients doctrine on his wife as the sole supportive relationship in his life, as well as his fast descent into previous behaviors after his wifes death. As the patient was never able to develop a sense of autonomy, it seems that he became extremely emotionally dependent on his wife. Because of this relationship, h e was able to progress at his job and maintain his recovery. However, with the death of his wife, he was brought back to the conflict of autonomy vs. shame and doubt.Really, it was through the presence of his wife that he was able to take initiative, be industrious, and have an intimate relationship, all of which are successful yields of developmental conflicts. The marriage provided him with hope, purpose, a sense of devotion and fidelity, as well as affiliation and love. In short, it seems that his wife was his mental and emotional anchor. The recurrence of symptoms of his mental disorders after the loss of the anchor of his life threw him back into the early developmental conflicts that he was unable to resolve due to his unstable childhood.According to Erikson, in order for the patient to move forward from his regressed state he must tackle and resolve the conflicts of trust vs. mistrust, autonomy vs. shame and doubt, initiative vs. guilt, industry vs. inferiority, identity vs. role diffusion, and intimacy vs. , isolation to reach the adulthood stage of generativity vs. stagnation. Ultimately, with the resolution of all these conflict, the patient will reach a mature state in which he is able to attain ego integrity instead of falling into despair. Patient Prognosis and preaching RecommendationsIt is important to remember that the patient was seeking help and trying to recover prior to his most modern hospitalization. He was enrolled in and regularly attending the partial hospitalization program. In addition, he was no longer abusing drugs or alcohol. PHP staff report that he had been medication compliant, cooperative, and was motivated to change. The patients recent hospitalization was precipitated by a change in drug dose and type. He reported that it was only after the medication change that the suicidal ideation intensified.Thus, an important endeavor for this patient is to find the drug types and dosages that will successfully manage his depressio n and anxiety. However, because the patient has such an extensive history of addiction, primary care providers are hesitant to prescribe large dosages of often highly addictive medications. This hesitation is especially understandable given the patients past abuse of prescription drugs, including an overdose with the intent to commit suicide. However, the types and dosages of the drugs he is currently receiving are not enough to manage his symptoms.The severity of the patients depression and anxiety necessitates the use of powerful antidepressants and anxiolytics, but his past substance abuse and dependency make the prescription of these drugs a last resort. Appropriate pharmacotherapy is also complicated by the fact that this patient has tried various classes and types of drugs to manage his symptoms, but no drug therapy has been effective enough to prevent the periodic recurrences of major episodes of depression and anxiety.To manage his depression, the patient has tried typical and unpredictable antipsychotics, anticonvulsants, tricyclic antidepressants, monoamine oxidase inhibitors, and selective serotonin reuptake inhibitors, as well as other classes of antidepressants, such as Serotonin Norepinephrine Reuptake inhibitors, Norepinephrine dopamine Reuptake Inhibitors, Alpha-2 Antagonists, and Serotonin-2 Antagonist/Reuptake Inhibitors. Although the apparent failure of all these drugs to manage his depression might cause one to suspect that he is exhibiting purely drug seeking behaviors, the depressive symptoms he xperiences impair and affect him so severely that a denial of the reality of these symptoms would be unsafe and unethical. Electroconvulsive therapy has been recommended to treat his depression, but the patient has refused to undergo this treatment modality. The patients anxiety is more easily managed than his depression, and benzodiazepines have proven effective. However, his past abuse of benzodiazepines make his primary care providers relucta nt to give them to him, and they have prescribed non-benzodiazepines, such as Buspar and Zolpidem, instead.Unfortunately, these medications have not been effective in controlling the patients anxiety. As a result, the patient has been asking repeatedly for benzodiazepines, while promising that he will use them responsibly. Ultimately, for the patient to achieve effective maintenance of his comorbid mental disorders, he must be able to take medications as prescribed. Due to his history of substance abuse and his still unstable depression and anxiety, it is unlikely that the patient will be able to take his medications as prescribed.It is recommended that a staff member have control of his drugs while he is attending the PHP, and that once discharged, a home health nurse be sent to administer his medication. This would reduce the potential for abuse. In addition, the use of coping mechanisms besides substance abuse may help the patient bond to the prescribed drug regimen, as well as decrease his depression and anxiety. Coping skills the patient has identified as helpful are watching telly and spending some quiet time alone.However, interaction with others should also be encouraged, as too much time spent alone will only reinforce depressive symptoms of isolation. An increase in the quantity and quality of sleep will also aid the patient in his recovery, as sleep deprivation is positively correlated with depressive symptoms and anxiety levels. The patients prognosis is one of cautious hopefulness. Though the patient has experienced severe recurrences of MDD, GAD, and substance abuse in recent years, the patient had maintained a long period of sobriety prior to this, during which he was happy, productive, and high functioning.The patients ability to achieve remission from his mental illnesses during his marriage to his wife shows that investing in a supportive relationship is an important and powerful coping skill for this patient. Thus, if the patient is able t o form and maintain new supportive relationships, his chance of recovery will improve substantially. It is also important to remember that he was doing very well until his wife died. According to the Holmes and Rahe Index, the death of a spouse is the number one most stressful event that occurs in the life of an individual (Perry & Potter, 2009).It is not an exaggeration to say that with his wifes death, life as he knew it ended. Many people experience periods of long and severe depression following the death of a loved one. For this patient, his descent into depression, unite with the resurgence of his anxiety sent his life into a complete tailspin. Under the severe stress of not only his wifes death but also his inability to keep working, he returned to his former coping mechanisms of drug and alcohol abuse.These habits detracted him from working through the grief of his wifes death, and providedmore caused him to lose his house and his savings, thus increasing his depression and anxiety, thus perpetuating the substance abuse. Now that the patient has withdrawn from drugs and alcohol and is in a safe environment, he can continue his grief work. As a result, his depression may begin to subside, and he may be able to get closer to his previous level of functioning. DSM-IV-TR bloc I Major Depressive Disorder, Generalized Anxiety Disorder, Polysubstance Abuse Axis II Cluster B traitsAxis III Hypertension, Hepatitis C, Diabetes Mellitus, Type 2, Osteoarthritis of the left shoulder, point Reflux, Bilateral hearing loss Axis IV Chronic mental illnesses, chronic medical conditions, death of spouse, family estrangement, lack of social support, unemployment, financial insecurity, acute hospitalization, Axis V 35 (current), 75 (potential) Patient Goals I want to find medications that will help my depression and anxiety I want to keep from abusing my medications I want my grief over my wifes death to get better I want to take one day at a time I want to feel les s alone I want to get better sleepNursing Goal Patient will be safe during hospital stay. Interventions Assess for suicidal ideation every shift. Perform rounds every 15 minutes to ensure patient safety. Ensure that the patient has no access to potentially harmful objects and/or substances. Observe, record, and report any changes in mood or behavior that may signify increasing suicide risk and document results of regular surveillance checks. Nursing Goal Patient will seek help in dealing with grief-associated problems. Interventions Develop a trusting relationship with the client by using empathetic therapeutic communication (Eakes, Burke & Hainsworth, 1998). Educate the client that grief resolution is not a sequential process and that the positive outcome of grief resolution is the integration of the deceased into the ongoing life of the griever (Matthews & Marwit, 2004). Identify available community resources, including grief counselors and community or Web-based bereavemen t groups. boil down on enhancing coping skills to alleviate life problems and distressing symptoms such as anxiety and depression. Nursing Goal Patient will practice social and communication skills needed to interact with others. Interventions Discuss causes of perceived or actual isolation. Assess the patients ability and/or inability to meet physical, psychosocial, spiritual, and financial needs and how unmet needs further challenge the ability to be socially integrated. Use active listening skills to establish trust one on one and and so gradually introduce the patient to others. Provide positive reinforcement when the patient seeks out others. Encourage the client to be involved in meaningful social relationships and support personal attributes (Gulick, 2001). Nursing Goal Patient will use effective coping strategies instead of abusing drugs and alcohol.Interventions Assist the client to set realistic goals and identify personal skills and knowledge. Use verbal and nonv erbal therapeutic communication approaches including empathy, active listening, and confrontation to encourage the client to express emotions such as sadness, guilt, and anger, verbalize fears and concerns, and set goals. Offer instruction regarding alternative coping strategies (Christie & Moore, 2005). Encourage use of spiritual resources as desired. Nursing Goal Patient will identify actions that can be taken to improve quality of sleep.Interventions Obtain a sleep- slipstream history, including history of sleep problems, changes in sleep with present illness, and use of medications and stimulants. Encourage the patient to develop a bedtime ritual that includes quiet activities such as reading, television, or crafts. Encourage the patient to use soothing music to facilitate sleep (Lai & Good, 2005). Teach the patient sleep hygiene guidelines for improving sleep habits (ie. go to bed only when sleepy, avoid afternoon and evening naps, use the bed only for sleeping, get up at the same time every morning). Use relaxation techniques to decrease anxiety before going to sleep. Refer to a sleep center if interventions are ineffective. Analysis of Interaction Before interacting with the patient, I read the patients medical record and notes. I paid particular attention to ways the patient said he learned best, which for my patient was one on one conversation. Prior to approaching the client, I asked myself if I had any beliefs, biases, or limitations that would affect my interaction with the patient or prevent the formation of a therapeutic relationship.In order to set the tone of a professional therapeutic relationship, I introduced myself to the client, saying that I was a student nurse and shaking his hand. I made some small talk with him nearly such topics as sports and the patients hobbies in order to show interest in the patient and develop rapport. During this conversation, the patient grew more visibly at ease. His face became less taut, his answers became longer and less forced, and he moved from an erect posture so a somewhat more relaxed position in his chair. The patient spoke slowly and eemed to have difficult finding the words he wanted to use. Such a speech pattern is characteristic of depression, one of the patients psychiatric diagnoses. This first conversation was punctuated with the start of morning group. After morning group, I gave the patient some space, as I did not want him to feel overwhelmed or threatened by my questions. About a half hour later, I asked the patient if we could continue the conversation we were having that morning, and he agreed without hesitation. In this second interaction, I began with a few open-ended questions about how group had been.I then started asking the patient some more questions about his readmission into the hospital and precipitating events. I asked open-ended question, and often responded to his answers by asking further open-ended questions. For example, after asking the pat ient if he was having suicidal thoughts, he responded that he did not want to hurt himself right now. I replied with the open-ended question, So are you feeling safe? using reflection to redirect the idea back to the patient and allow him to explore whether or not he felt safe.I focused on actively listening to the patient, following the patients lead and sometimes asking clarifying questions. Because of the patients slower rate of response, I employed the use of silence to allow him to gather his thoughts and proceed at his own pace. As the patient told me more about recent events in his life, including the death of his wife, the loss of his job and his descent into substance abuse, he began to look away more and more. This decrease in eye contact might be the result of the patient feeling ashamed, embarrassed, or guilty about his feelings and behaviors.In order to maintain connection with the patient and assure him of my nonjudgmental view of his situation, I used empathy and res tatement, saying, It sounds as though you have had a very difficult past couple of years. Upon saying this, the patient looked up, maintained eye contact, and agreed. He then began to expand on his current feeling of hopelessness, saying, I wonder if life is worth living, and sometimes I just want to go to sleep and not wake up. As he explored and expanded on his feelings I alternated between using silence and validating what he said.The silence allowed him to express intense feelings without interruption, while statements of restatement and interpretation, such as It sounds like you have been feeling pretty hopeless, demonstrated empathy and a nonjudgmental attitude toward what the client was feeling. At one point, the patient put his head in his hands, saying I had so much going for me, and after my wife died, everything went to pot. I felt that in this moment, what the client needed was neither a cheery reassurance that things would get better, nor dispensation of advice, but rather a person to understand and acknowledge his current misery.I replied that sometimes life gets you down, and sometimes when it rains it pours, and its ok to be sad about that. The patient seemed appreciative of the acknowledgment of his pain and the justification of his sadness. I sat silently with him for 2-3 minutes, as I felt it was important for him to feel, sit with, and process these emotions for a short period of time. During these periods of silence, I continued to lean forward slightly, as I had done throughout the interaction, to show that I was still interested and engaged despite the lack of verbalization.Because I had acknowledged the patients hardships and thereby connected with him, I felt that I was in a good position to explore with him goals he had for the future, and ideas that could help him reach these goals. I made sure to approach this topic not by giving advice or suggestions, but by asking him open-ended questions about what things made him feel less s ad or anxious and what things he wanted to work on during his stay. These open ended questions elicited the response of his goals for the future, and his verbalization that he needed to find better coping mechanisms, because his old ones didnt seem to work.He also stated that he knew he needed to continue grieving my wife, because the drugs and alcohol kept me from doing that. I thought that this realization of substance abuse as inhibitory to his grief process was very insightful, and told him so. He made a small smiling expression and responded that he wanted to get back on the straight and sign up and take his medications the way Im supposed tono more, no less. 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