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Christie represents alternately both the exciting and fearful internal object for Dennis as he craves and then attacks her gastritis symptoms and diet discount 500 mg clarithromycin with amex. She longs for him gastritis uptodate order genuine clarithromycin line, but immediately experiences him as a persecutory object and rejects him gastritis diet discount clarithromycin 500 mg. Their relationship reproduces in- dividual internal issues in their interaction, producing a joint personality that is fearfully dominated by their shared rejecting object relations. A THEORY OF UNCONSCIOUS COMMUNICATION To make an object relations theory of individual development applicable to conjoint therapy, we need a theory of unconscious communication. Melanie Klein (1946/1975), a London analyst born in Germany, coined the term pro- jective identification for the way a person evacuates part of his mind into an- other person’s mind in order to rid himself of excessive anger or other unacceptable, dangerous elements. We now believe that all persons in inti- mate relationships use projective identification not only to protect them- selves, but also to communicate in depth (J. An infant puts unthought feelings, needs, and fears into its mother through facial and bod- ily gestures, vocal intonation, and subtle eye movements. The mother takes in these communications through introjective identification—through reso- nance with her own internal object organization, thereby joining with the infant’s experience. Her past experience of distress, fear, or happiness lets 144 THEORETICAL PERSPECTIVES ON WORKING WITH COUPLES her understand the infant’s experience. The experience of getting to know each other occurs through endless iterations of these cycles of projective and introjective identification, which go on in both directions: The mother also puts her anxieties about being a mother into the infant, who identifies with them and if things are going well, projects back reassurance. In in- fancy, the quality of these interactions is the major component in determin- ing the security of the infant’s attachment to the parents (Fonagy, Gergely, Jurist, & Target, 2003). In adulthood, the mutuality of these cycles is equally important and more reciprocal. Couples engage continuously in cy- cles of projective and introjective identification that are by nature largely profoundly unconscious. Therapy makes these matters more conscious so that a couple has new choices about how to relate. The in- fant unconsciously seeks an exciting object identification with the mother, for example by crying for more to eat. In the figure, the mother shakes off the identification—identifying instead with the experience of rejection her refusal brings. Rejecting the infant’s excess neediness results in the infant’s enlarging the rejecting object constellation. CASE STUDY Dennis comes from a prominent family whose secret is his mother’s illegit- imacy. Dennis grew up longing for this exiled grandmother, because his mother rejected her mother-in-law, too. Dennis unconsciously experienced his mother’s ha- tred as reliving her repressed longings for her own mother. The unex- pressed longing hidden beneath her hatred came through as though it were his longing for the mother she could not be. Disinherited and banned socially, they escaped to Europe where their first child was born before they could get divorces. In a system of mutual projective identification, the couple replays both kinds of repressed bad objects described by Fairbairn, living out in their re- lationship both the longing and rejection they absorbed from their parents during painful childhoods, nourished in emotionally impoverished families. HOLDING AND CONTAINMENT The mother-infant relationship is marked by two processes central to cou- ple therapy. The first, psychological holding, is analogous to the way a par- ent holds a child in an "arms around" attitude to provide for safety, growth, and development. Within this enve- lope of safety, the parent offers herself in a focused eye-to-eye relationship 145 146 THEORETICAL PERSPECTIVES ON WORKING WITH COUPLES that is subjectively I-to-I, that is, a direct communication of the intimate couple’s inner feelings and inner worlds.
Sometimes adult children live at a great distance from their parents in another part of the state or the country chronic gastritis gastric cancer generic clarithromycin 500mg free shipping. No matter where the children live gastritis diet purchase clarithromycin 500 mg line, it’s important for them to communicate regularly gastritis recipes generic clarithromycin 250mg with mastercard, to visit, and to have their parents as guests if possible. Letters, phone calls, and little gifts help to keep up morale and help to maintain the good attitude that is so important to the well-being of a person with Parkinson’s. Children can look through a medical supply store for little things that will make the parent’s life easier. One busy man was surprised and delighted, for example, when his daughter gave him a small pocket pillbox with relationships with our adult children 129 a built-in timer. This thoughtful little gift enables him to take his medications on time as he moves from activity to activity. The person with Parkinson’s will experience a quicker emo- tional recovery if a sense of caring and support is extended by the children. At the same time, it’s important for adult children to refrain from pushing their advice too assertively on the parent who has Parkinson’s. Gayle Dakof of California, family members can best help a patient by showing concern and affection. But advice is taken better when it comes from doctors, other medical personnel, or other patients going through the same circumstances (see The Journal of Person- ality and Social Psychology, February 1990). Tay- lor, there is also a delicate balance between showing too much and too little concern about a patient’s condition. Be attentive, caring, and supportive of each other; keep the lines of communi- cation open; and educate yourselves as much as possible about Parkinson’s disease. In 1980, the first two of my grandchil- dren were born, and in the same year, my Parkinson’s manifested itself. The arrival of grandchildren brought pure delight; the arrival of Parkinson’s brought frustration and sorrow. When the time came to share the news, I received two very different mes- sages: Shout from the rooftops that you are a grandmother; keep quiet about the Parkinson’s. Everyone knew how much I had looked forward to being a grandmother, and soon they knew that I had attained that status. It’s about the grandpar- ent’s need to develop and enjoy that relationship, as well as to be open and honest with the grandchildren about Parkinson’s. Many people avoid discussing serious problems with children, problems such as an illness, a death in the family, or a change in family circumstances. They fear upsetting the children and, in a mistaken desire to protect them, delay such discussions "until the children are older. Today most psychologists support my position that children need to be told the truth (in an appropriate way) about circum- stances that arise. It’s easier to teach children positive attitudes in their early years than to change their attitudes when they are older. And it’s better to prevent the misinterpretations that develop when discussion is avoided. Children sense when something is being kept from them, and they are likely to build up in their minds whatever they imagine. In a recent instance, a seven-year-old whom we know was found crying while the adults in his family mourned the loss of a relative. When asked why he was crying, he said that he didn’t like to see everybody so sad.
How can they fulfill the mandate of being both a good provider and a nurturing father? The former requires long hours away from home dr weil gastritis diet purchase clarithromycin 500mg with amex, and the latter requires long hours at home gastritis bloating cheap clarithromycin master card. Rose gave up overfunctioning at home in an attempt to be the perfect wife and mother gastritis breathing cheap clarithromycin 250mg otc. However, they each created a more authentic self, de- creased their chronic anxiety, and lessened their marital conflict. I want to underscore the point that working on self from a feminist (or profeminist in the case of men) perspective can create the opportunity for the other to change, but does not guarantee that he or she will. I have also seen a few couples in which it has been the wife who refused to change. However, in most couples when the man makes progress in defining a more authentic self, the woman uses that opportunity to do the same, and the conflict in the couple decreases. THE UNFAVORABLE MARRIAGE MARKET Before discussing the next case example, I present the cultural context for African American families. During slavery, White slave owners routinely disrupted African American families by raping and impregnating slave women and by selling members of the same family separately. Similarly, during Reconstruction and continuing to the present, White middle-class men have controlled local economic and labor systems, severely limiting employment opportunities for African American men (Burton & Snyder, 1998). Contemporary under investment in inner city neighborhoods has resulted in impoverished cultural institutions, poor educational and job opportunities, especially for men, and social problems such as the drug culture with its ensuing high rates of incarceration and homicide. Given the under investment in these neighborhoods, large numbers of African American men have difficulty finding and maintaining jobs (Jarrett, Roy, & Burton, 2002). All kinds of economic studies, including time series and cross-sectional and longitudinal analyses find that poor male job opportunities are associ- ated with low marriage and high nonmarital fertility (Sigle-Rushton & Garfinkel, 2002). Employment for African American women has remained Bowen Family Systems Theory as Feminist Therapy 115 stable because low-paying domestic positions, such as babysitter or house- hold worker, have remained plentiful. From a woman’s perspective, this gender difference in economic viability renders the available pool of African American men unattractive as marriage partners. Other factors contributing to the low numbers of marriageable men are the high rates of incarceration and death among young African American men. Without an adequate education, many African American men have few employment choices. Many ultimately become involved in the alterna- tive economy of drugs or gambling. Thus, the ratio of desir- able men to women gives African American men a decided advantage. The operational sex ratio (OSR) influences the bargaining position of each sex, and thus the mating (marriage) market (Marlowe, 2002). With many attrac- tive women to choose from, many men refuse to make the long-term com- mitment of marriage, preferring serial cohabitation. Within relationships, this unfavorable ratio provides men with a significant degree of power, be- cause both partners know that if he is dissatisfied, he has many available al- ternatives, whereas she has few. CASE STUDY Linda and Lance are an example of how these socioeconomic forces play out in the context of personal relationships. She was "rescued" by Richard, who married her and accepted responsibility for her son. Richard was frequently unemployed, used cocaine, was involved with other women, and was abusive to Linda.
Just as "cases" are assigned as examples of specific "diseases" the "diseases" are members of the large category "disease gastritis quimica 250mg clarithromycin free shipping. In this broad radial category our understanding of what is in the category gastritis diet quality 500 mg clarithromycin, and why chronic gastritis diet guide cheap clarithromycin 250mg line, proceeds from the center out, just as it does with the smaller categories of the individual diseases. We do not begin with a scattergram of peripheral examples and then figure out where the center is. I claim, subject to empirical confirmation, that the prototypical, central "diseases," at least in Anglo-American folk culture and scientific medicine, are such entities as "pneumonia," "colds," "bladder infections," and "gastroenteritis" ("stomach flu"). Close to , but slightly off-center are "heart attacks," "appendicitis," "strokes," and "cancer. To confirm or reject this hypothesis it would be necessary to study both lay people and medical professionals to discover what names come to their minds most readily as representative examples of disease, how they think and reason about diseases, and how quickly and easily they assent to the inclusion of any given 58 CHAPTER 2 entity in the "disease" category. Also, if category membership in "diseases" were presented to an experimental group as a matter of degree this should result in some informative rankings. CENTRAL MEMBERS OF THE DISEASE CATEGORY "Pneumonia" and other central members share a number of features which give them their central place and vividness for identification as diseases. I have come up with a list of 13 features which characterize disease in contrast to health. These features may not be the only significant ones, but I think they are sufficient for picking out the most readily accepted examples of disease. The central, prototypical ensemble of these features makes the sharpest possible distinction of a disease from health. Clinical entities manifesting the features of core diseases stand out to be grasped readily and are blatant, as opposed to the less overt and more subtle features of less exemplary "diseases. Furthermore, they are readily suited to at least one or more of the important ideal cognitive models of disease, such as Being Under Attack. Parenthetically, note that the worst diseases, such as rabies, pancreatic cancer and AIDS are not necessarily the most prototypical. I suggest the following preliminary list of features for a central prototype such as "pneumonia," without claiming that it is definitive, and will later identify how these features are systematically diluted, modified and stretched in the characterization of other, less prototypical groups of diseases. Because pneumonia is one of the most representative diseases, its typical features are assumed to be present. Thus it makes sense to say, "She has pneumonia on an x-ray, but without symptoms," whereas we have no need to hear, "She has pneumonia with symptoms. There is a single primary cause, typically an infectious agent, which is far and away the leading cause generally coming to mind. Susceptibility factors in the environment or immune system are viewed as secondary and minor causes compared to the etiologic agent, even though upon reflection they may turn out not to be at all minor and could actually be equally necessary and decisive, although not sufficient without the infectious agent. A person is not conventionally regarded as having contracted pneumonia for psychological reasons. Social and psychological effects may not be trivial, but they are distinctly secondary. There are distressing symptoms such as cough, chest pain and fever with losses of function manifested by fatigue, weakness and shortness of breath. There are signs upon examining the body, which are abnormal concomitants of the disease. Complications are adverse events which make the illness more serious or prolonged than expected (something unusual goes wrong). In pneumonia these include pneumothorax, abscess formation, pleural effusion, septicemia, shock and respiratory failure. The victim is a person, not a cell, a fetus, an animal, a plant, a building or an organization.
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Since swimming requires substantial use of the upper limbs chronic gastritis x ray buy clarithromycin toronto, care must be taken to avoid excessive strain on the sternal bone gastritis symptoms weakness order 500 mg clarithromycin free shipping, which may cause discomfort or aggravate existing wound pain gastritis celiac discount clarithromycin 500mg online. Partici- pants may also need to modify their technique to ensure exercise prescription is adhered to . Most data regarding the energy requirements of swimming strokes are based on competitive swimmers and may not be relevant for cardiac patients (McArdle, et al. Of all the strokes, backstroke and breaststroke can be most easily modified to ensure the training intensity for each individual is attained. Conversely, the energy cost of front crawl can vary enormously, depending on the tech- nique used (Fardy, et al. The front crawl may achieve an intensity level of 80–85% of HRmax, which is a 118 Exercise Leadership in Cardiac Rehabilitation higher intensity than the recommended 60–75% HRmax for cardiac patients. Aqua-fit exercise, aerobic exercise performed in water, can be an alterna- tive way to exercise in water. This can be a good method for patients with lower limb arthritis and for obese subjects. Other issues that need to be considered when pre- scribing water-based activities are: Position The positions swimmers adopt have an effect on the myocardial workload. The horizontal position one adopts when swimming will increase the return of blood to the heart. This in turn will increase preload (the tension exerted on the heart wall at the end of the diastolic phase), and it will also increase the force of the subsequent contraction. Increases in preload and in the force of contraction are two of the physiological parameters necessary to determine myocardial O2 uptake (MVO2). Capability The individual’s capability must be taken into consideration prior to pre- scribing swimming as an exercise modality. By using HR or MET data from the results of the patients ETT or SWT the prescriber can assess whether swimming is an appropriate activity for their client. Swimming may be an inappro- priate exercise if this level of activity has not been achieved in most recent fitness tests. Breaststroke is estimated at 8 to10 METS and the front crawl at 9 to 10 METS (ACPICR, 2003). Temperature The recommended pool temperature is between 26 and 33°C (89–92°F) (Koszota, 1989). Lower temperatures will allow for heat dissipation during exercise, but patients with joint problems or peripheral vascular disease (PVD) may prefer and benefit from warmer water. There are no studies on cardiac patients with chronic obstructive pulmonary disease (COPD) and their response to pool temperature. However, COPD clients may dislike being sub- merged to chest height, due to the baropressure exerted by the water; this may decrease chest expansion and lead to breathing difficulties. RPE is not invalid during water- based activity, but it requires the target RPE to be about two points lower in water, compared to land-based exercise. In addition, there should be good communication between phases III and IV, regarding changes in the medical or exercise status of the class members (see Chapter 6). Exercise prescription in phase IV Phase IV exercise should see a maintenance of individualised exercise using the same FITT principles as in previous phases. Participants graduating to phase IV after phase III should be more independent exercisers and more responsible for self-monitoring. During an exercise consultation, the phase IV participant may wish to try different activities, for example dancing, hill walking, etc. The exercise consultant should help participants select activity and exercise that will help maintain their health, interest and fitness.