By A. Pedar. Delta State University.

Therefore the hair on end appearance secondary to marrow hyperplasia seen elsewhere on the skull vault order serpina 60 caps with mastercard blood pressure medication infertility, spares this region discount serpina 60caps amex arrhythmia young. The following give rise to lucencies within the skull vault on skull radiographs: (a) Sutures. The following give rise to calcifications within the vault on skull radiographs: (a) Vascular impressions. Regarding the meninges: (a) The three components are the outer fibrous dura, the avascular arachnoid and the inner vascular pia mater. Regarding the skull: (a) Wormian bones are small bony elements seen in suture lines and suture junctions. Regarding the meninges: (a) The falx cerebri consists of two layers and forms a complete partition between the cerebral hemispheres. Regarding meningeal blood supply and innervation: (a) The main blood supply to the meninges is from the middle meningeal artery. Regarding the normal development of the brain: (a) The neural tube expands to form the three primary vesicles during the twelfth week of intrauterine development. T1-weighted inversion recovery images are particularly sensitive to myelination in the first 6 months. Regarding the medulla: (a) It is closed superiorly where it is related to the lower part of the fourth ventricle. The pons: (a) is concave on the ventral aspect containing mainly transverse fibres which pass posterolaterally as the middle cerebellar peduncle. In the head: (a) The inferior sagittal sinus is usually identified at catheter angiography. Regarding the pituitary gland: (a) The pituitary gland is superior to the suprasellar cistern. Moreover, the jugular foramen of the corresponding side is under developed and these features are examined with CT. A line joining the anterior and posterior commissures on midline sagittal MR scans (the AC–BC line) is a standard reference in image guided stereotactic surgery. Regarding the motor pathways: (a) The upper motor neurons arise in the pre-central gyrus of the frontal lobe. Regarding the cerebral hemispheres: (a) The corpus callosum is the largest of the commissural tracts. Regarding the limbic system: (a) It includes the limbic lobe, olfactory apparatus and the septal areas. Regarding the cerebral ventricles: (a) They contain between 20 and 25 ml of cerebrospinal fluid in the young adult. Regarding the ventricles and basal cisterns: (a) The trigone of the lateral ventricle is the confluence of the body, occipital and temporal horns. Regarding the fourth ventricle: (a) In sagittal section it is triangular with an anterior floor and a roof directed to the apex. Regarding the subarachnoid cisterns: (a) The cisterna magna lies between the pons and the postero-inferior surface of the cerebellum. Regarding the subarachnoid cisterns: (a) The chiasmatic or suprasellar cistern contains the circle of Willis. Regarding the intracranial circulation: (a) When present, the trigeminal artery arises from the vertebral artery. It contains the posterior cerebral, posterior choroidal and superior cerebellar arteries and the trochlear nerve. Regarding the intracranial circulation: (a) The carotid siphon is the fusiform dilatation at the origin of the common carotid artery. Regarding the intracranial circulation: (a) The middle cerebral artery runs laterally through the Sylvian fissure. Regarding the anatomic variants of the intracranial circulation: (a) The commonest variation of the circle of Willis involves the posterior communicating artery. Regarding the intracranial venous anatomy: (a) The cortical veins are usually variable. The trigeminal artery, the commonest of these, arises from the internal carotid artery just before it enters the cavernous sinus and passes lateral to the dorsum sella to the upper basilar artery.

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The central ego in relation to the ideal object is in conscious interaction with the caretaker (or spouse) discount serpina 60caps on line arrhythmia only at night. The central ego represses the split-off libidinal and anti-libidinal aspects of its experience of others along with corresponding parts of the ego and accompanying affects that remain uncon- scious generic 60caps serpina overnight delivery arrhythmia of the stomach. Christie represents alternately both the exciting and fearful internal object for Dennis as he craves and then attacks her. She longs for him, but immediately experiences him as a persecutory object and rejects him. Their relationship reproduces in- dividual internal issues in their interaction, producing a joint personality that is fearfully dominated by their shared rejecting object relations. A THEORY OF UNCONSCIOUS COMMUNICATION To make an object relations theory of individual development applicable to conjoint therapy, we need a theory of unconscious communication. Melanie Klein (1946/1975), a London analyst born in Germany, coined the term pro- jective identification for the way a person evacuates part of his mind into an- other person’s mind in order to rid himself of excessive anger or other unacceptable, dangerous elements. We now believe that all persons in inti- mate relationships use projective identification not only to protect them- selves, but also to communicate in depth (J. An infant puts unthought feelings, needs, and fears into its mother through facial and bod- ily gestures, vocal intonation, and subtle eye movements. The mother takes in these communications through introjective identification—through reso- nance with her own internal object organization, thereby joining with the infant’s experience. Her past experience of distress, fear, or happiness lets 144 THEORETICAL PERSPECTIVES ON WORKING WITH COUPLES her understand the infant’s experience. The experience of getting to know each other occurs through endless iterations of these cycles of projective and introjective identification, which go on in both directions: The mother also puts her anxieties about being a mother into the infant, who identifies with them and if things are going well, projects back reassurance. In in- fancy, the quality of these interactions is the major component in determin- ing the security of the infant’s attachment to the parents (Fonagy, Gergely, Jurist, & Target, 2003). In adulthood, the mutuality of these cycles is equally important and more reciprocal. Couples engage continuously in cy- cles of projective and introjective identification that are by nature largely profoundly unconscious. Therapy makes these matters more conscious so that a couple has new choices about how to relate. The in- fant unconsciously seeks an exciting object identification with the mother, for example by crying for more to eat. In the figure, the mother shakes off the identification—identifying instead with the experience of rejection her refusal brings. Rejecting the infant’s excess neediness results in the infant’s enlarging the rejecting object constellation. CASE STUDY Dennis comes from a prominent family whose secret is his mother’s illegit- imacy. Dennis grew up longing for this exiled grandmother, because his mother rejected her mother-in-law, too. Dennis unconsciously experienced his mother’s ha- tred as reliving her repressed longings for her own mother. The unex- pressed longing hidden beneath her hatred came through as though it were his longing for the mother she could not be. Disinherited and banned socially, they escaped to Europe where their first child was born before they could get divorces. In a system of mutual projective identification, the couple replays both kinds of repressed bad objects described by Fairbairn, living out in their re- lationship both the longing and rejection they absorbed from their parents during painful childhoods, nourished in emotionally impoverished families. 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.

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Only when Cathy and David were comfortable with the therapist and thera- peutic processes 60 caps serpina otc arteria zabrze, did the therapist doggedly remain solution focused buy 60caps serpina prehypertension chest pain. The solution-focused approach focusing on strengths and possibilities brought about positive changes and growth, which could easily be attributed to David and Cathy’s efforts. CONSIDERATION OF ETHNIC DIVERSITY ISSUES As illustrated above, the integrated approach of SSCT can be applied to most situations that bring a couple in for therapy. The examination and discussion of how SSCT can be specifically tai- lored to suit the cultural expectations of an ethnic group is beyond the scope of this discussion (Cheung, 2001). Nevertheless, it is noted that the ef- ficacy of SSCT can be enhanced by ethnic and cultural sensitivity to and awareness of a couple’s background. For example, both approaches are relationship focused and are therefore congruent with most ethnically diverse client populations with a collective culture (i. Because these ethnic groups tend to look up to the Strategic and Solution-Focused Couples Therapy 207 therapist for some structure for treatment and expect to receive some kind of expert advice and directives, a strategic model will be consonant with the client’s cultural expectation of therapy. In other words, with couples whose cultural identity is with one of these ethnic groups, case conceptual- ization and interventions from a strategic model will expediently be em- ployed in the beginning stage of treatment. Not until the client is ready to explore his or her strengths and feels comfortable with a more egalitarian relationship with the therapist will a solution-focused approach be used (Cheung, 2001). It should also be noted that for some Asian American cultures, the pri- mary relationship in a family is not between a husband and a wife, but be- tween parents and their children. Therefore, therapists do not see a lot of direct requests for couples therapy; instead, they may encounter quite a lot of child referrals that require interventions in the parenting and par- ent-child relationship domains. In these referrals, the therapist often de- tects some marital discord that may contribute to the child problem, or parent-child relational problem. The best way to handle the referral is to stay with the presenting problem to help the parents deal with the issue without focusing on the marital issues directly. Only when the couple see improvement in the presenting problem and trust the therapist and the therapeutic process will they ask for help in their marriage. This is acceptable to the therapist if he or she truly respects the clients’ self-determination. Also, for the family that has had a good therapy expe- rience, there is a greater likelihood that they will return later for other problems including marital issues. SUMMARY As discussed, human suffering is ubiquitous, complex, multidimensional, and multidetermined; therefore, no one single therapy approach can be effec- tive with all people with all types of problems at all times. Ineffective cou- ples therapy likely results from a mismatch between a conglomerate of factors such as client factors (e. Therapists, who employ SSCT, enhance their treatment flexi- bility and efficacy by judiciously integrating and applying the theories and techniques from both SCT and SFT. On the one hand, SSCT utilizes SCT, which in- corporates Structuralism and Systems thinking. In the spirit of Structural- ism, SCT searches for the underlying causes of presenting problems, and uses the existing family developmental normative data from the human and medical sciences to understand, empathize, validate, and normalize the 208 THEORETICAL PERSPECTIVES ON WORKING WITH COUPLES person’s suffering. With recursiveness as a seminal part of its Systemic perspective, SCT accentuates the person’s family context and circular causality to conceptualize his or her life tasks and challenges. It also em- ploys the principles of change from SCT to effect rapid changes by giving directives or assigning between-session tasks. It emphasizes the person’s phenomenological field and his or her constructed reality through lan- guage. It provides a positive, empowering, and person-centered approach to help the clients focus less on the effects of the problems, but more on generating successful solutions. By employing SSCT, therapists increase their versatility and flexibility to conceptualize and intervene effectively with a wide variety of clientele burdened with a myriad of problems and challenges. Certainly, cultural competence in applying the SSCT model will only increase the therapist’s effectiveness. The expanded family life cycle: Individual, family, and social perspectives (3rd ed. Cognitive-behavioral ther- apy for binge eating and bulimia nervosa: A comprehensive treatment manual.

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