Royal Bank of Scotland Essay Example | Topics and Well Written Essays - 1500 words

Royal Bank of Scotland - Essay Example RBS is regarded as one of the largest and oldest banks in Europe and holds immense credibility within the banking sector. Recently, it featured in the top ten banks in the world, with total assets worth $2,342.66 billion (see Figure 1) and was ranked third in the UK with total assets worth $2,267.93 billion in the year 2010 (See Figure 2) (Relbanks, 2012). The group recorded an operating profit worth ?6.1bn for the financial year 2011-2012 up by 10% as compared to the previous year. The improvement in the bank's profitability was largely attributed to its excellent performance in the UK retail sector. Furthermore the improvement in performance could also be attributed to the bank’s 5 year improvement plan adopted in the year 2009, which entails improving customer service; restoring the bank to a sustainable enterprise and improving its risk profile; and rebuilding value for its shareholders. The customer driven strategy is the key competitive strength of the bank, and has help ed it in sustaining its performance in the midst of external challenges and threats. (RBS Annual Report, 2012). PEST Analysis: The political, economic, social and technological factors affecting RBS are discussed below: Political factors: One of the biggest setbacks faced by RBS during the financial crisis was taking over of its ownership by the UK government following a crash in the credit markets. The bank faced severe problems in raising new capital and failed in its attempt to revive its plunging profitability. In the year 2008, the UK government which was worried about the state of the financial markets sought to take up 58pc in RBS for ?15 billion (The Telegraph, 2011b). Furthermore, the collapse of the bank during the financial crisis is largely attributed... This essay mostly focuses on The Royal Bank of Scotland and aims to discuss, analyze and assess various key issues with regard to the performance of the bank, such as the external threats and challenges, that were faced by it and the strategies adopted by the same to counter them. The Royal Bank of Scotland (RBS) is an international banking and financial services company headquartered in Edinburg, United Kingdom, with various branches across Europe, the Middle East, Asia, and the Americas, catering to over 30 million customers worldwide. It offers a range of products and services to a wide range of customers including individual as well as corporate customers; through its subsidiaries such as Natwest, Ulster Bank, Direct Line, Charter One, Coutts, and Churchill. After nearly failing in a face of 2007-2008 crisis, the bank aimed to focus on improving its activities by focusing on risk management and aligning its business to suit the external environment. The three core principles of i ts strategy, that was used and discussed in the essay include sustainability, accountability and increased customer focus. According to its sustainability strategy, the bank proposes to actively engage in employee engagement to increase and improve their productivity. In conclusion, the researcher hopes that these strategies adopted by the Royal Bank of Scotland are likely not only to result in a positive impact on the bank’s performance, but also increase customer satisfaction and market confidence.

Hot Cross Bun Formulation

Hot Cross Bun Formulation The purpose of this study is to reflect on the package of care offered to a client and to critically evaluate the evidence base for the model which might be considered best practice for a specific client problem, or issue. This entails identifying a particular clients presenting issues while describing the evidence that is available for a suitable therapeutic approach, or model which would promote best practice. The study will reflect on a client who has been diagnosed with post- traumatic stress disorder (PTSD) as a result of a road traffic accident (RTI) and concentrates on the use of imaginal exposure therapy (IET) for the treatment of symptoms. Triggers and maintenance factors contributing to the clients deteriorating well-being will be explained using formulation as well as the protective and predisposing elements that were explored in therapy. Relevant literature will be cited throughout and appropriate research articles that have been critically reviewed will be discussed. Pre sentation, referencing and informed consent are consistent with the School of Health and Social Cares guidance and have been adhered to throughout this assignment. Introduction PTSD is an anxiety disorder that can develop after exposure to one or more terrifying events, in which grave physical harm occurred or was threatened. It is a severe and ongoing emotional reaction to an extreme psychological trauma. The trauma may involve someones actual death or a threat to the individuals or someone elses life. The PTSD sufferer is affected to a degree that usual psychological defenses are incapable of coping. Reports of battle-associated stress appear as early as the 6th century BC. PTSD-like symptoms have been recognised in many combat veterans in many conflicts since. These symptoms have been called shell shock, traumatic war neurosis, and Post-Traumatic Stress Syndrome (PTSS). The modern understanding of PTSD dates from the 1970s, largely as a result of the problems that were still being experienced by Vietnam veterans. The term Post Traumatic Stress Disorder was coined in the mid-1970s. Early in 1978, the term was used in a working group finding presented to the Committee of Reactive Disorders of the American Psychiatric Association. The term was formally recognised in 1980 in the third edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association. Although a controversial diagnosis when first introduced, PTSD has filled an important gap in psychiatric theory and practice. From an historical perspective, the significant change ushered in by the PTSD concept was the stipulation that the etiological agent was outside the individual him or herself (i.e., the traumatic event) rather than an inherent individual weakness (i.e., a traumatic neurosis). The key to understanding the scientific basis and clinical expression of PTSD is the concept of trauma. DSM-IV-TR criteria for PTSD In 2000, the American Psychiatric Association revised the PTSD diagnostic criteria in the fourth edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)(1). Diagnostic criteria for PTSD include a history of exposure to a traumatic event meeting two criteria and symptoms from each of three symptom clusters: intrusive recollections, avoidant/numbing symptoms, and hyper-arousal symptoms. A fifth criterion concerns duration of symptoms and a sixth assesses functioning. PTSD is unique among other psychiatric diagnoses because of the great importance placed upon the etiological agent, the traumatic stressor. In fact, one cannot make a PTSD diagnosis unless the patient has actually met the stressor criterion which means that he or she has been exposed to an historical event that is considered traumatic. Clinical experience with the PTSD diagnosis has shown, however, that there are individual differences regarding the capacity to cope with catastrophic stress so that while some people exposed to traumatic events do not develop PTSD, others go on to develop the full-blown syndrome. Such observations have prompted a recognition that trauma, like pain, is not an external phenomenon that can be completely objectified. Like pain, the traumatic experience is filtered through cognitive and emotional processes before it can be appraised as an extreme threat. Because of individual differences in this appraisal process, different people appear to have different trauma thresholds, some more protected and some more vulnerable to developing clinical symptoms after exposure to extremely stressful situations. Although there is a renewed interest in subjective aspects of traumatic exposure, it must be emphasised that exposure to events such as rape, torture, genocide, and severe war zone stress, are experienced as traumatic events by nearly everyone. The National Institute for Clinical Excellence (NICE) has published guidance to help the National Health Service (NHS) recognise and treat people who develop PTSD after traumatic events. Recommendations include psychological treatment in the form of trauma-focussed cognitive behavioural therapy (CBT) and/or a course of anti-depressant medication while receiving therapy. Trauma-focussed CBT focuses on a persons distressing feelings, thoughts (or cognitions) and behaviour and helps to bring about a positive change. In trauma-focused CBT, the treatment concentrates specifically on the memories, thoughts and feelings that a person has about the traumatic event. Imaginal exposure therapy (IET) is a component of trauma-focused CBT and involves revisiting the traumatic memory or memories in a safe and controlled environment so that the intensity of the individuals anxious and fearful reactions (thoughts, emotions, physical sensations and behaviours) is reduced. Clients are exposed to the trauma memory by repeatedly describing the events of the trauma aloud until the anxiety response is reduced. This process is referred to as habituation. The treatment aims to eventually eliminate the fearful responses so that the client can face a feared situation without experiencing anxiety or fear. The goal IET is to process the trauma memories and to reduce distress and avoidant behaviours that the traumatic memory evokes. CBT, as we know it today, is a result of a group of modern related therapies that have empirical psychological support. There have been two main influences to modern CBT and these are behaviour therapy (BT), as developed by Wolpe, Skinner and others in the 1950s and 1960s and cognitive therapy (CT) as developed by Beck and others in the 1960s and 1970s (Westbrook, et al. 2011, p2). Freudian psychoanalysis had dominated the psycho-therapeutic world since the late 1800s, but in the 1950s, Eysneck and others in the psychological community questioned the lack of empirical evidence to support psychoanalysis. As a result, BT developed within the academic and scientific psychology community, basing its methodology on observable events between stimuli and response. Despite the success of BT, there was still some dissatisfaction with what was seen as the limitations of a purely behavioural approach (Westbrook, et al. 2011, p3). Beck and others were developing ideas about CT as early as the 1950s; these ideas focussed on mental processes such as thoughts, beliefs and our interpretation of events, and continued to maintain an empirical approach to validate its theory to the psychological world (Westbrook, et al. 2011, p3). Although Beck was not the first to link faulty behaviour with irrational thought and unhealthy emotions, his work revolutionised the psychology world a nd continues to be used today. Background to the Client Throughout this assignment the client will be referred to as T. Protecting the clients identity complies with the British Association for Counselling and Psychotherapy (BACP) and the British Association of Cognitive and Behavioural Psychotherapies (BABCP) guidelines regarding client anonymity as described in the Ethical Framework for Good Practice and fulfils the requirements of the Universitys School of Health and Social Cares policy on confidentiality. T was seen in a primary care setting with a counselling service that offers short to medium term therapy for clients over the age of 16 years. She was referred to the service by her GP. She is a 25 year old female who is married with two boys aged 7 and 5 years. She is currently unemployed and lives in social housing with her husband who works in a local factory. T was raised and lived in an area where the 2007 Index of Deprivation (ID2007) indicates deprivation is 110.6% higher than the national average. There is a higher proportion of the working age population claiming incapacity benefit than the County average (Area Action Partnership). T first went to her GP shortly after being released from hospital after an RTA. She was a front seat passenger and received injuries to her face, arms and legs which included severe bruising, cuts and a temporal mandibular joint (TMJ) injury. Three months after the accident T continued to experience nightmares and flashbacks. The GPs letter to the service noted the clients deterioration and the original diagnosis of acute stress disorder (ASD) that had been diagnosed in the first month following the accident was amended to PTSD. Several studies have provided convincing evidence that early CBT treatment of ASD reduces the possibility of the development of PTSD (Moulds, et al. 2009, p16). ASD was introduced into the fourth edition of the diagnostic statistical manual (DSM) in 1994. The diagnostic criteria for ASD (Appendix A) are similar to those of PTSD, but differ in two fundamental areas. Firstly, ASD can only be diagnosed in the first month following the traumatic event and secondly, ASD includes a greater emphasis on dissociative symptoms (American Psychiatric Association, 1994). During their consultation, the GP noted that T had become withdrawn and distanced from her family and friends, she reported feeling like she was watching the world from inside a bell jar, this dissociative symptom is described as derealisation, and is common in ASD patients (Simeon and Abugel, 2006, p86). The GP assessed T using the Patient Health Questionnaire (PHQ 9) and the General Anxiety Disorder Assessment (GAD 7) which resulted in scores of 15 and 19 respectively. These scores indicate that T was suffering with moderate to severe anxiety with depression. T was seen over a period of 13 sessions. The duration of each session lasted between 1 hour and 90 minutes. Longer sessions were included to provide sufficient time for sharing the trauma history and allow time for anxiety levels to decrease (Leahy and Holland, 2000, p197). The contract between the counselling service and T was explained. This included informed consent to tape sessions, confidentiality and its limitations and an evaluation of risk. Evaluation of risk is an important part of the therapeutic process and is done throughout therapy. It involves assessing the client, the environment and also the therapists own personal and professional limitations (Mueller, et al. 2010, p 65). CORE OM was used to calculate a risk score and also to assess Ts suitability for therapy. The Cognitive Therapy Rating Scale as developed by Safran and Segal was not available to the therapist during the first session, but subsequent reviewing of the scale indicated that T was a suitable candidate for cognitive behavioural interventions. CORE OM score is shown below in figure 1. Prior to developing a treatment plan, the therapist socialised the client to CBT explaining the evidence that supported using CBT interventions for PTSD. (Bryant, et al. 1999) and (Westbrook, et al. 2011, p81-83). First session therapist notes detailed Ts past history, the development of problems and the protective factors in her life (Appendix B). T was clear about what she wanted from therapy. Her problems fell into three main areas: (1) Nightmares, poor sleep, anxiety around bedtime, which resulted in an increased irritability with others; (2) Avoiding travelling in any form of transport, which resulted in her relying on others to take her children to school and other social or sporting events; (3) Withdrawing from friends and family, which led to her isolating herself socially. She believed that if she avoided all forms of transport and stayed inside, she would reduce the chances of experiencing any flashbacks or getting very panicky which she found extremely distressing and frig htening. T and the therapist created a Problem and Goal form to capture this information (Appendix C) and agreed to discuss the problems and goals again when the treatment plan was formulated. The specific client issue selected is Post Traumatic Stress Disorder (PTSD). PTSD is defined as a common anxiety disorder that develops after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened (DSM-IV-TR: 463). The DSM-IV-TRs criteria are precisely written as: exposure to a traumatic event, persistent re-experience of the event, avoidance of the stimuli, persistent avoidance of increased arousal, duration of disturbance and impairment of social occupational or other important areas of functioning. Within the criteria there are subsets portraying greater detail of the types of symptoms that may be experienced by the client (Appendix A). T was seen over a period of 13 sessions. The duration of each session lasted between 1 hour and 90 minutes. Longer sessions were included to provide sufficient time for sharing the trauma history and allow time for anxiety levels to decrease (Leahy and Holland, 2000, p197). The contract between the counselling service and T was explained. This included informed consent to tape sessions, confidentiality and its limitations and an evaluation of risk. Evaluation of risk is an important part of the therapeutic process and is done throughout therapy. It involves assessing the client, the environment and also the therapists own personal and professional limitations (Mueller, et al. 2010, p 65). CORE OM was used to calculate a risk score and also to assess Ts suitability for therapy. The Cognitive Therapy Rating Scale as developed by Safran and Segal was not available to the therapist during the first session, but subsequent reviewing of the scale indicated that T was a suitable candidate for cognitive behavioural interventions. CORE OM score is shown below in figure 1. Prior to developing a treatment plan, the therapist socialised the client to CBT explaining the evidence that supported using CBT interventions for ASD. (Bryant, et al. 1999) and (Westbrook, et al. 2011, p81-83). First session therapist notes detailed Ts past history, the development of problems and the protective factors in her life (Appendix B). T was clear about what she wanted from therapy. Her problems fell into three main areas: (1) Nightmares, poor sleep, anxiety around bedtime, which resulted in an increased irritability with others; (2) Avoiding travelling in any form of transport, which resulted in her relying on others to take her children to school and other social or sporting events; (3) Withdrawing from friends and family, which led to her isolating herself socially. She believed that if she avoided all forms of transport and stayed inside, she would reduce the chances of experiencing any flashbacks or getting very panicky which she found extremely distressing and frigh tening. T and the therapist created a Problem and Goal form to capture this information (Appendix C) and agreed to discuss the problems and goals again when the treatment plan was formulated. The therapist asked T if she could recall her most recent experience of a flashback (Figure 2a). T reported that the pattern of events leading to feeling panicked or experiencing a flashback were the same. She would make an effort to do a certain activity, but flashbacks and panic were triggered by (in particular) smells or sounds that could not be avoided. The hot cross bun formulation in figure 2a tracks events from leaving the house, hearing cars and smelling petrol, which was the trigger point. On this occasion T reported having a clear memory of being trapped in the car (which was also her recurring nightmare), she could remember smelling petrol and hearing the screeching of brakes. Her brain misinterpreted these signs for an actual threat, creating distorted thinking: Ive got to get home something terrible is going to happen, hostile emotions; fear, anxiety and terror, unpleasant physiological reaction; heart pounding, shaking, feeling nauseous, which led to her avoidant behavi our to reduce her anxiety and escape her perceived fearful situation. Flashbacks are defined in DSM IV as a recurrence of a memory, feeling, or perceptual experience from the past (American Psychiatric Association,1994). Another example of a flashback involved T sitting in her garden when a neighbour was mowing the lawn with a petrol engine lawn mower. T could smell the petrol and this triggered a flashback to the events of the RTA. The therapist encouraged T to follow the formulation and create her own diagram based on her experience in the garden (Figure 2b). T and the therapist were able to look at both diagrams and see that the pattern was similar. A sound or smell was identified as the trigger in both examples. Her thought process, affect and physiology were similar, but crucially, this led again to her avoidant behaviour. Hot Cross Bun Formulation Event/Trigger: Walking to the shop to buy milk, hearing the cars and smelling petrol Flashback of being trapped in the car Thoughts: Im going to die, Ill never see me children again Ive got to get away from here Ive got to get home, something terrible is going to happen Behaviour: Emotions: Escape the situation Fear Tearful Terror Anxiety Physiology: Heart pounding, Nausea, Tense, Sweating, Shaking Based on Hot Cross Bun (Padesky, 1993) Hot Cross Bun Formulation (originally hand drawn by client) Event/Trigger: Sitting outside in the garden, having a cup of tea Hearing neighbour start up his lawn mower Smelling petrol from the lawn mower Flashback of fear of being burned alive Thoughts: Oh God! Its happening again Ive got to get inside the house. Ill be safe there Behaviour: Emotions: Tearful Fear Needing to get inside the house Terror Anxiety Physiology: Heart pounding, Nausea, Tense, Sweating, Shaking, Based on Hot Cross Bun (Padesky, 1993) T and the therapist discussed the process of recording details in this format and agreed that it gave them both a greater understanding of Ts situation. This collaborative approach is characteristic of CBT and was necessary when working towards a treatment plan for factors that needed to be targeted in therapy and homework setting. Padesky and Greenberger (1995, p6) explain the importance of the client and therapist working as a team, particularly as clients may have an expectation that the therapist is going to fix them. Milton (2009, p104) agrees adding that the therapist also plays the role of a trainer, encouraging the client to become an observer of themselves in order to challenge their thoughts, feelings and beliefs. Westbrook et al (2011, p238) cites Kazantzis et al (2002) in providing evidence of greater improvement in those clients who complete homework. T was keen to monitor any anxiety provoking scenarios at home using the hot cross bun model. She was aware that if her se cond goal was to be achieved (Appendix C) she needed to reduce and eventually eliminate her avoidant behaviour (Wells, 1997, p49-50). A treatment plan was discussed and agreed with T based on her problem list and goals for therapy (Appendix C). The treatment plan included the following elements: Pyscho-Education Grounding and Safety Work Imaginal Exposure Therapy Cognitive Restructuring Relapse Management The session on psycho-education gave T the opportunity to learn about her symptoms, and to recognise and anticipate them for effective management. Fisher, (1999) states that psycho-education is an essential element for stabilising a trauma client. Briere and Scott (2006, p87) agree, adding that psycho-education provides the client with accurate information about the nature of their trauma, which gives them a greater understanding of their situation. Psychoeducation involved justification of use of IET, a history of our learning experience and the fight or flight response. Regular reference was made to the clients formulation so that she could understand how and why her threat response had been activated. Once T understood her anxiety response in relation to her experiences, she felt ready to continue onto the next stage of therapy. Grounding and safety work was completed prior to IET. Herman (1997, p155) argues that the central task of the first phase of trauma therapy must be safety. The client needs to feel safe within themselves; learning grounding and safety skills gives the client the opportunity to manage potential uncontrolled flashbacks. This also formed part of Ts relapse management in the later stages of therapy. Once safety and grounding work was completed, the therapeutic process moved onto the trauma itself using IET. Throughout therapy there were opportunities to explore Ts present situation and past events. This information was initially written down in a mind map format and shared with T during the session. As additional information was gathered in subsequent sessions this was written in longitudinal format (Figure 3). From the information gathered, the client recognised how and why she had always been the rescuer in the family. This included an age inappropriate responsibility when her father had left the family home and T had taken on the role of carer to her distraught mother and siblings. She suffered an emotional breakdown at the age of 14, over whelmed by the pressure of doing well at school so that she could get a good job and support the family. T recognised how this belief system developed after her father left and how it was effecting how she saw herself in the present. During therapy T and the therapist discussed the importance of this belief and how it had allowed her to cope during those years growing up. The therapist asked what purpose this belief served in her life now when she was happy with her family and well supported by her husband. She no longer needed to be the rescuer. T and the therapist explored how this belief may be affecting what was happening to her when she was fearful of having a flashback. T concluded that she needed to add I must always cope to her beliefs in Figure 3 and I cant cope to her thought process. T recognised the contradiction between this thought and her rescuer belief. Longitudinal Formulation Early Experiences 5 years old, Dad leaves family home Oldest of four children, Takes on a helping role Later supports mother through depression Breakdown at school aged 14 years due to self- imposed pressure Met future husband aged 16,Pregnant at 17 years and married at 18 years old Beliefs Its my responsibility to take care of everyone and make things right I must always cope Assumptions and Rules I must be perfect and do everything right, otherwise I will let everyone down If something goes wrong it will be my fault Critical Incident Car Accident Activation of Beliefs Its my responsibility to save everyone Automatic Thoughts I should have got B out of the car. I didnt do everything I could have I failed. I cant cope with this Behavioural Emotions: Avoidance Fear Social withdrawal Anxiety Fearful to go outside Guilt Fearful to travel in any transportation Worry Physiology Poor Sleep Tense Heart Pounding Sweating The goal of IET is to expose the client to the memory of the trauma rather than to relive the trauma itself. Ts therapy involved her retelling the story initially in the past tense and then in the present tense. An important part of the healing process was encouraging T to bring those traumatic memories to mind, in a safe and trusting environment, while remaining in the present. The client learns through repetitive description, that the memory of the event is not dangerous and will also allow habituation to take place (Zayfert and Becker, 2008, p127). T decided that she would record the sessions on the voice recorder section of her mobile phone and listen to the recordings at home as part of her homework. Zayfert and Becker (2008, p130) emphasise how critical listening to the tapes at home is as the repetition is vital if the exposure is going to be successful. The therapist explained that T would be asked to close her eyes and describe the events of that day. Leahy and Holland (2000, p 198) suggest breaking the clients story down into smaller parts if there are a series of traumatic events. T was asked to recall the events of that day in terms of chapters; several chapters were listed (Appendix D). Ts experienced anticipatory anxiety at the thought of retelling the story and this was discussed. The therapist reassured her she would be experiencing the memory, that the RTA was not happening right now and that she was safe in the room and could open her eyes at any time. T began at a point in time when she felt safe and ended the narration at a point in time when again she felt out of danger. The therapist explained the Subjective Units of Distress (SUDS) Rating Scale and then T began narrating her story in the past tense and was allowed to do this uninterrupted; the therapist only intervening to check on Ts anxiety. Ts SUDS score was noted for each chapter (Appendix D col A). At the end of each session, T was given time to process her experience before leaving. T gave the therapist feedback on how she felt sessions had gone, and what, if anything she had learned. The next session involved the client narrating the story, but this time in the present tense. T found this difficult at first and often resumed the past tense. T and the therapist had discussed the likelihood of this happening and T agreed that the therapist would prompt her to return to the present tense. SUDS scores were again noted (Appendix D col B). T reported being surprised at the change in scores from the previous week. There were certain sections of the story that T found very difficult to narrate; these sections were narrated without much detail. After discussing this briefly, T and the therapist listened to the recording of the present tense narration. T recorded SUDS levels herself (Appendix D col C) and once complete, the three SUDS scores were examined and discussed. T noted how scores had both increased and decreased from first narration to second narration, but that all scores had reduced on her first listening to the tape. T was then asked to grade the chapters and chose five (the most anxiety provoking) to work on. The five chapters were listed chronologically (figure 4) and then in order of their anxiety rating (figure 5). For the next five sessions each chapter was narrated and listened to repeatedly until Ts SUDS rating had dropped; starting with the least and working towards the most anxiety provoking. The therapist asked questions relating to the clients senses and emotions and physiology so that her memories were fully activated (Leahy and Holland, 2000, p197). To Ts surprise, narrating in the present tense and sensory questioning produced additional memories that T had not remembered in the previous narrations. Figure 4 Chronological Order 1Â  Car flips over upside down smell of petrol 2Â  Wood coming towards the car 3Â  The car door wont open (Ts recurring nightmare) 4Â  B is not moving 5Â  G is screaming at T to get them out of the car Figure 5 Order of Severity Least to Worst 5 4 3 2 1 Wood coming towards the car Car flips over upside down smell of petrol G is screaming at T to get them out of the car The car door wont open (Ts recurring nightmare) B is not moving The therapist noted the five chapters as hot spots (Figure 6) and asked T what her thoughts were when she brought the scene to mind. These were also noted together with the emotion that went with them. The therapist was able to challenge Ts distorted thoughts through cognitive restructuring which included her rescuer belief that she was somehow responsible for getting everyone out of the car that day. Once SUDS levels had been reduced for all five chapters Appendix E), T was able to say out loud her re-evaluation statement for each chapter accepting and believing it. Fig 6 Re-Evaluation of Peak Experiences Hot Spot Thought Belief Emotion Re-Evaluation The car has flipped Ive survived the crash Fear I did not burn to death. Over onto its top; there but now Im going to burn I did not die, I did survive Is a smell of petrol to death the experience and I am safe now. Its over. THIS IS A FACT Wood from a fence is The wood is going to hit Fear The wood did not hit me or anyone else. Flying towards the car me. Ill never see my boys I did survive the experience. I am safe. again. My children are safe. Its over. THIS IS A FACT The car door wont open. Its not going to open, Terror I was not trapped. I did get out of the car. It just wont budge at all Im trapped. I am not trapped now, I am safe now. Its over. THIS IS A FACT B goes limp and his head Oh my God! B is dead Terror B did not die. He did survive the accident Falls forward He is safe now. Its over. THIS IS A FACT Sister G screams to T to I must break the window. Fear We all got out of the car. We did not die. Get them all out of the car I have to get us all out. We are all safe now and its over. If I dont break the window THIS IS A FACT Were all going to die Outcomes and Personal Reflection Ts post therapy CORE score of 31 (figure 7) represents a mean score of 0.912 (9.12) and falls within the healthy range of the Core measure. As there is a mean difference of over 5, this, according to CORE measurement indicates a clinical and reliable change (CORE ims). Fig. 7 Core OM Results Pre and Post therapy Pre Post Well Being 14 06 Functioning 21 05 Risk 02 00 Problems 42 20 Total 79 31 Ts presentation improved in the finals stages of therapy. Her cuts and bruises had healed well and she was no longer suffering with TMJ. T reported healthier sleeping patterns, but still with occasional dreams. She believed that she had spent so much time listening to her chapter on being trapped in the car that she became fed up of listening to it, rather than it provoking any anxiety. She was able to travel as a passenger in a car, and also to drive the car herself, but did not feel ready to drive on her own in the car. As a result understanding her an

Thomas Jefferson :: essays research papers

Thomas Jefferson   Ã‚  Ã‚  Ã‚  Ã‚  The book that I choose to read and analyze was Jefferson The Virginian, written by Dumas Malone. This book was the first volume and it was written in 1948. I choose this book because I have always been interested in Thomas Jefferson and his life. I found this book to be extremely informative about Jefferson. It included growing up on the fringe of western settlement in Virginia, the college of William and Mary in Williamsburg, to the years he served in the Virginia House of Burgesses, to helping write the Declaration of Independence, and to his years as president of the United States.   Ã‚  Ã‚  Ã‚  Ã‚  Thomas Jefferson was born April 2nd 1743 in Albemarle County, Virginia. His parents were Peter Jefferson and Jane Randolph, the House they live in was called Shadwell, it was named after the parish in London where his mother was from. Jefferson’s father died in the summer of 1757. In Peter Jefferson’s will he said not until his son turned twenty-one would he be able to receive what had been left to him, which included lands on either the Rivanna or the Fluvanna, a proper share of the livestock, half of the slaves not disposed of, and the residue of the estate. After his father’s death he had no true father figure in his early life. The man who had the greatest impact early in his life was while he was studying under the Reverend James Maury. This partnership probably did little to influence Jefferson’s political views in future years, but Maury did encourage him to study the classics like the Greeks and Italians. After leaving from Maur y’s school he attended William and Mary in Williamsburg, Virginia. The most   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   influential professor that he had here was William Small who taught philosophy. Another Influence that Small had on his life was that he got Jefferson work in the law office of George Wythe. He studied law for five years under Wythe. While under Wythe’s leadership Jefferson became friend’s with the governor of the time Francis Fauquier, he was able to meet him through Wythe’s service on the general court. In 1767 he was elected to the Virginia House of Burgess at the age of twenty-five, and five years later he married Martha Wayles Skelton.   Ã‚  Ã‚  Ã‚  Ã‚  When it came to time for the revolution against the British Empire, Thomas Jefferson was more than ready. Before he wrote his chief literary contribution to the revolutionary cause, he wrote Summary View.

“Forgiving my father” by Lucille Clifton Essay

As a person treads through life, he or she will realize at one point or another that the existence of complex relationships will often have an affect on the actions of those involved. The nature of these relationships can have either a positive or negative effect on a person depending on the nature of it, or how severe its elements are. It is human nature to hold emotions inward and uphold a proud countenance; however, those who go against this natural tendency will exert a rebellion of sorts to any and every falsehood. In the poem â€Å"forgiving my father† by Lucille Clifton, the speaker describes a daughter is haunted by recollections of strife between her and her father. The speaker in the poem actually seeks to hold her father accountable for his shortcomings instead of forgiving him for his deficiencies. In the poem â€Å"My papa’s waltz† by Theodore Roethke, it is clear that the papa and the child have a relationship sprinkled with fear, joy and love. Both fathers in the poems are dangerous to their child in many ways. In Clifton’s poem, the speaker is in danger because of the mental distress and financial instability caused by her father. In Roethke’s poem, the speaker is in danger mainly due to his father’s abusive behavior. In Clifton’s poem, the speaker is using a monetary debt to symbolize a debt of love and affection. The father in this poem is unable to provide the necessary care for his family which leads to the early death of the speaker’s mother, and causes mental distress to the speaker. The speaker is haunted by her father even in sleeping. â€Å"all week you have stood in my dreams/like a ghost, asking for more time†(Clifton, Lucile â€Å"forgiving my father†, line 3-4) How can a ghost pay debts and asking for more time? It cannot. The word â€Å"ghost† symbolizes the worriment that the speaker has over the unpaid debts and lacks of care. While on the other hand, the father in Roethke’s poem, comes home drunk after a long day just in time for his son’s bedtime.†The whiskey on your breath/Could make a small boy dizzy/We romped until the pans/Slid from the kitchen shelf;/My mother’s countenance/Could not unfrown itself.† (Roethk e, Theodore â€Å"My Papa’s Waltz†, line 5-8) Envisioning a heavy-drunk man romping through the house with his small son, it is easy to see why a mother may frown at the spectacle. It is nearly time for bed, and the father is doing everything to get the son riles up rather than calm down for sleep. The fact that the romping dance is even disrupting  the order of the mother’s â€Å"kitchen shelf† surely contributes to her frowning countenance. Instead of bringing joy and love to their home, neither one of the fathers cares about his family. They bring danger to their family and leave unhealed wounds on their children. The father in Clifton’s poem is dangerous to the speaker. The relationship between the speaker and her father is marked by resentment and abandonment. In the second stanza of the poem, the speaker states that her grandfather is also a needy man just like her father.†but you were the son of a needy father,/the father of a needy son,† (Clifton, line 12-13) With neediness flowing through the family, the speaker is worried about her own destiny. The father in this poem sets a miserable path for the speaker to follow. In comparison to the father in Clifton’s poem, the father in Roethke’s poem abuses his child physically. The speaker depicts a harsh father-son relationship is that the description of the dancing is violent with systematic child-abuse. â€Å"The hand that held my wrist/Was battered on one knuckle;/At every step you missed/My right ear scraped a buckle./You beat time on my head† (Roethke, line 9-13) The father â€Å"beat time† on the child’s head and crashes around the room so much that â€Å"the pans/slid from the kitchen shelf.† The word â€Å"beat† is a clear indication of abuse, and the fact that the child is held still by a hand that is itself â€Å"battered† strengthened the sense that manual violence is the subject of the poem. A child doesn’t voluntarily use the word â€Å"beat† in the context of an adult’s relationship to the child unless intending to suggest child-abuse. The image of the father’s belt buckle scraping the child’s ear in the third stanza confirms the father uses whatever tools are available to accomplish this beating. Furthermore, the child doesn’t appear to be enjoying himself. â€Å"But I hung on like death./Such waltzing was not easy.† (Roethke, line 3-4) The child describes the â€Å"waltz† as requiring him to hang on â€Å"like death† is hardly a positive description of something a little boy would welcome. The word â€Å"death† raises the threatening reminder that child-abuse all too often has fatal consequences. In conclusion, both fathers are dangerous to their children. The father in  Clifton’s poem possesses an invisible danger to the speaker; while the other father possesses a visible danger to the speaker. However, I learn an important lesson from both poems also, which is to appreciate my parents even more. It is because my parents always love me unconditionally. I also learn to forgive others who may have hurt me either physically or emotionally. Often, forgiving someone can be a hard task. It can even be a crime for those who wish never to forgive. Forgiveness must come from the heart, and can be the solution to both parties.

Annotated Bibliography on Teen Pregnancy

Annotated Bibliography on Teen Pregnancy B. T HCS/465 October 23, 2011 Annotated Bibliography on Teen Pregnancy Clinical Digest. (2009). Aggression is a predictor of rapid repeat teen pregnancy: pubertal onset age and conflict management key considerations in prevention strategies. Nursing Standard, 23(24), [16]. Retrieved from http://www. cinahl. com/cgi-bin/refsvc? jid= 530&accno=2010217733 This article provides data from actual interviews with teens that have has rapid repeat pregnancies within 24 months of the last pregnancy experienced and those individuals who did not. The study shows significant differences in aggression behaviors and how recognizing these behaviors early on could help prevent teen rapid repeat pregnancies in the future. This is a peer-reviewed article and was researched by clicking the peer-review box during the search process. Kelly, L. , Sheeder, J. , & Stevens-Simon, C. (2004). Teen Home Pregnancy Test Takers: more Worried or more wishful? Pediatrics, 113(3 Part 1), 581-584. Retrieved from http:// www. cinahl. com/cgi-bin/refsvc? jid=783&accno=2005077833 This article provides insight from a study of teens that used home pregnancy Tests. Were these individuals more concerned with contraception mishaps? or the affects that child rearing would have on their futures? The study included 340 individuals who were racially and ethnically diverse who were sought out because of visiting three different teen clinics for various reasons. The reasons included pregnancy testing, sexually transmitted disease testing, obtaining contraceptives and general health visits. This is a peer-reviewed article and was researched by clicking the peer-review box during the search process. McKay, A. , & Barrett, M. 2010). Trends in teen pregnancy rates from 1996-2006: a comparison of Canada, Sweden, U. S. A. , and England/Wales. Canadian Journal of Human Sexuality, 19(1-2), 43-52. Retrieved from http://www. cinahl. com/cgi-bin/refsvc? jid=1558&accno= 2010691048 This article provides statistical data concerning teen pregnancy and abortion rates covering a ten year time period. Research concerning teen pregnancy and abortion is important t o understanding socioeconomic factors and trends in teen sexual and reproductive health. Trends have decreased in teen pregnancy meaning ither a stronger support system for teens to encourage control over sexual activity is available or there is an increase in contraceptive usage. This is a peer- reviewed article and was found by clicking the peer-review box during the search process. Medoff, M. (2010). The Impact of State Abortion Policies on Teen Pregnancy Rates. Social Indicators Research, 97(2), 177-189. Retrieved from http://dx. doi. org. ezproxy. apollolibrary. com/10. 1007/s11205-009-9495-9 This article provides research from state-level data for the years of 1982, 1992, nd 2000 concerning teen pregnancy rates, abortion rates, and new laws and policies affecting the pricing of abortions and how these new laws and policies are deterring unwanted pregnancies. This is a peer-reviewed article and was found by clicking the peer-review box during the search process. Monahan, D. J. (2002). Teen pregnancy prevention outcomes: Implications for social work practice. Families in Society, 83(4), 431-431-439. Retrieved from http://search. proquest. com/docview/230165951? accountid=35812 This article provides detailed information concerning study group demographics, nowledge and dating behaviors, and adolescent attitudes and how these details affect teen pregnancy and intervention programs. Are prevention programs helping decrease the amount of teen pregnancy seen each year? What are these programs offering teens to help them make more beneficial life choices? This is a peer-reviewed article and was found by clicking the peer-review box during the search process. Sen, B. (2003). Can Beer Taxes Affect Teen Pregnancy? Evidence Based on Teen Abortion Rates and Birth Rates. Southern Economic Journal, 70(2), 328-343. Retrieved from http://www. utc. du/Outreach/SouthernEconomicAssociation/southern-economic- journal. html Data from the years of 1985, 1988, 1992, and 1996 we re used in this interesting article on beer taxes and teen pregnancy and how they are related. The article provided statistical data showing that higher tax rates on beer have shown to negatively affect teen pregnancy and abortion rates. This is a peer-reviewed article and was found by clicking the peer-review box during the search process. Witte, K. (1997). Preventing teen pregnancy through persuasive communications: Realities, Myths and the hard-fact truths. Journal of Community Health, 22(2), 137-137-54. Retrieved from http://search. proquest. com/docview/224047307? accountid=35812 This article provides interesting data concerning the use of pregnancy prevention campaigns and what they communicate to teens and adolescents. Campaigns according to the study should provide more negative and hard-fact truths to communicate teen pregnancy, sexual activity, and abortion in order to help combat future teen pregnancy and abortion rates. This is a peer-reviewed article and was found by clicking the peer-review box during the search process.