By R. Gorok. Sherman College of Straight Chiropractic.

Though it is not yet under intensive research by mainstream medicine order 20mg tadacip with mastercard, there have been many observations through the years that psychological and social factors may play a role in the cause and cure of cancer purchase tadacip 20mg otc. One of these was reported by Kenneth Pelletier buy tadacip 20 mg, a member of the faculty of the School of Medicine generic 20 mg tadacip free shipping, University of California, at the time. He was interested in “miracle cancer cures” that had occurred in seven people in the San Francisco area and wondered if they had anything in common. He found, in fact, that all seven people became more outgoing, more community oriented, interested in things outside of themselves; they all tried to change their lives so that there was more time for pleasurable activities; all seven became religious, in different ways, but all looked to something bigger than themselves; each spent a period of time each day meditating, sitting quietly and contemplating or praying; they all started a physical exercise program and they all changed their diets to include less red meat and more vegetables. It certainly looks as though social and emotional factors played a role in these “miracle cures. Carl Simonton, Stephanie Matthews-Simonton and James Creighton titled Getting Well Again (New York: J. Tarcher, 1978) that describes the Simontons’ therapeutic technique for treating cancer. Theirs is a psychological approach to the problem in which they seek to understand their patients and find ways of changing attitudes and concepts since they believe these are important to the eventual outcome. A very popular recent book on the subject is Love, Medicine, and Miracles by the Yale surgeon Bernie Siegel (New York: Harper & Row, 1986). Siegel began his career as a surgeon, became aware of the social and psychological dimensions of cancer and began to work with patients accordingly. His book is highly inspirational and, because of its popularity, has introduced many people to the idea that the mind can be mobilized to combat cancer. Siegel’s work, however, because of its lack of psychologic and physiologic specificity. He does not present a theoretical model of how emotions play a role in the cause and cure of cancer and where his work fits into that model. Lacking that it is unlikely that his work will have much impact on the traditional medical research community. This is a pity for there is a great need for more precise definition of what social and psychological factors are contributing to what illnesses and how. Acknowledging the important role of the emotions in health and illness, medicine must reexamine its concepts of disease causation. The attempt to bridge that mysterious gap between emotion and physiology will require the best minds in experimental medicine and the kind of interest and commitment that medicine now accords to such things as genetic research or the chemotherapy of cancer. But we won’t get those people and that kind of commitment if 160 Healing Back Pain we put “the power of love” into a medical context without carefully studying its specific psychological and physiologic effects. If that isn’t done, how do we distinguish between Bernie Siegel, Norman Vincent Peale and Mary Baker Eddy? These considerations aside, doctors like Siegel, Simonton, Pelletier and Locke (and a number of others I have not mentioned) are pioneers, and what they have to teach is of enormous importance to the future of medicine. THE IMMUNE SYSTEM AND INFECTIOUS DISEASES Here again, there is a long history of awareness that the emotions have something to do with our susceptibility to or ability to fight off infection, but none of it is generally accepted by medical doctors and rarely applied in everyday practice. Frequent colds and genitourinary infections are among the most common but it is likely that psychological factors play a role in all infectious processes. As with cancer, it is the efficiency of the immune system to do its job of eradicating the infectious agent that is at issue. Stressful emotions can reduce that effectiveness and allow the infection to flourish but there is ample anecdotal evidence that people have the capacity to enhance immunologic efficiency by improving their emotional states or employing other techniques, as the following story illustrates. The cover article of the Washington Post Health Journal for January 1985 was a piece written by Sally Squires titled “The Mind Fights Back. Having been previously exposed to the virus, she developed the usual positive immune reaction, a bump about one-half inch in diameter, which then disappeared in a few days. To confirm that an immune reaction was going on a blood test was done that demonstrated that her white blood cells were actively fighting the infection. After repeating the procedure twice with the same reaction she was instructed to try to stop the body’s normal reaction, which she did in her daily meditation, and for three weeks in a row the bump got smaller and smaller. Then she was asked to stop interfering with the normal immune reaction and with the last three injections of the virus she got the usual bump again.

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To "even a dragon that walks along the river has little fish biting its tail" he replied that the proverb said "that we’re all made alike buy tadacip 20mg cheap. In his early adulthood a screening measure used to identify persons fabricating psychological and physical symptoms found that he had a tendency to exaggerate symptoms generic tadacip 20 mg with mastercard, and the patient gets secondary gains from his delusions cheap 20mg tadacip visa. Tree: (1) The trunk of the tree was completed first in a clearly phallic shape (feeling of basic power and ego strength); (2) the client placed spe- cial emphasis on the apples and branches through erasures (anxiety purchase tadacip 20 mg amex, de- pendency, and oral needs); (3) the branches are one-dimensional (patho- formic) and drop toward the bottom of the picture (trauma with regard to contact in the environment); (4) the amount of detailing for the tree is in direct contrast to the detailing for the house and person. Person: (1) The hair was drawn first, erased, and then emphasized (vir- ility striving, freedom); (2) the shoulders are large and excessively squared (defended, preoccupied with need for strength); (3) the neck is nonexist- ent (body drives threaten to overwhelm); (4) the person is clothed in a trench coat (security and protection, defensiveness). Qualitative Analysis: Proportion House: The door is drawn excessively large (dependent). Tree: (1) The tree is small compared to the form page (feelings of in- feriority, insignificance); (2) the branches of the tree dwarf the size of the trunk (inadequacy coupled with striving for security and satisfaction within the environment). Person: The person is small compared to the form page (feelings of in- feriority, insignificance). Qualitative Analysis: Perspective Tree: (1) The tree is placed high on the page and toward the left corner (seeks satisfaction in fantasy, aloof, insecurity with environmental fac- tors); (2) it leans definitely toward the left (seeks immediate and emotional satisfaction, overconcern with self and past). Qualitative Analysis: Time House: (1) After completing the garage door and prior to beginning the upper story windows, the patient ceased drawing for many moments and spontaneously stated, "It’s hard to tell people about what bothers me.... I think there’s a time and destiny for everyone" (found solace and accept- ance in religion through the escape/withdrawal of his bedroom). Qualitative Analysis: Comments, Drawing Phase Tree: (1) After erasing and adding a second berry to the bottom right row of branches, he made a superfluous comment: "It’s a little bit detailed" (insecurity); (2) he then immediately made a series of unrelated comments ("I stay up late at night chewing tobacco or reading a book"), and at this point his speech became so rapid that I could ascertain only his general topics. These comments focused on his medication, his drug use (present and past), and confrontations by peers in his dorm. After this comment, he then added the rounded top to the trunk of the tree (regression as the tree took on a more phallic form). Person: (1) After completing the person’s hair he stated, "This was old- style long hair. I never grew my hair long" (virility strivings); (2) after com- pleting the trench coat he stated, "I was thinking, I know it looks like a warlock or something" (constant struggle between good and evil, God and devil, superego and id). Qualitative Analysis: Comments, Postdrawing Inquiry House: (1) The house is above the client, and while he was drawing it it reminded him of his mother’s house (personal relationships regarding home and family; feels insecure, insignificant); (2) he stated that it was a friendly house but then added, "I wish I had better memories of being there, but when I was there, I was mentally ill" (contradicts statement of happy 132 Interpreting the Art memories with unpleasant experiences); (3) he added that what the house needed most was "to be taken care of.... Tree: (1) The patient stated that the tree was feminine because "with her caring heart she shows her fruit," which was determined by "lots of nice apples" (sexual and maternal symbols combined); (2) the tree reminded him of "how a person should grow up and produce good fruit" (concern and obsession with his mental illness as a "defect," with resulting religious metaphor relating to fruit of her womb; sexual, maternal, and religious symbols combined). Person: (1) The male’s name is "Werewolf," and the patient is attempt- ing to convert him to Christianity by "talking about the Lord," but Were- wolf is thinking about "how good a feeling hard rock music gives him" (re- ligious delusional thoughts surrounding struggle to remain pious; good and evil thoughts comingling); (2) the person is "sick in the mind" because "he won’t stop using drugs and he’s into witchcraft" (projection of patient’s in- ternal struggle); (3) unlike in the drawings of the house and tree, the weather in this rendering is "cold and rainy. A light drizzle" (depression, external pressures); (4) in response to the question "what does this person need the most? Qualitative Analysis: Concepts House: His house should be built on a ranch, which is a frequent topic of this patient (i. Tree: The tree is a healthy apple tree because "you don’t see hardly any dead spots" (infantile dependency and oral needs ill disguised). Person: The person is a werewolf (sexually predatory symbol) who prefers drugs and witchcraft to religion and conventionality (powers that threaten to emerge from within the patient). Quantitative Analysis: Summary According to Buck’s scoring system the patient’s raw G IQ is 73 and his net weighted score IQ is 77, which places the patient in the Borderline In- tellectual Functioning range. His good IQ score correlates to an IQ of 83 and represents his ability to interact in his environment. An overview of his de- tail, proportion, and perspective scores basically yields difficulty surround- ing critical and analytical judgment regarding the more basic problems 133 Reading Between the Lines that are presented by the environment. The patient’s lowest overall scores appear in the drawing of the tree, where individuals generally attain their highest score. This expresses significant conflict in the patient’s basic feel- ing of ego strength. Evaluation of his HTP reveals the presence of the following character- istics: (1) feelings of insecurity and inferiority regarding masculinity, re- sulting in an attendant withdrawal into masculine symbols of power; (2) infantile and orally dependent traits that cause sexual symbols and mater- nal symbols to be united, creating possible Oedipal conflicts; (3) a ten- dency to retreat into a delusional or religious belief system to meet his dy- namic needs when body drives threaten to overwhelm. In the end, this patient is essentially immature, with infantile depend- ency needs and predominant feelings of shame and humiliation that im- pede his general functioning within the environment. Yet, in the fantasy of finding himself through his delusional belief system, he instead loses him- self.

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As stated by a site participant proven 20 mg tadacip, they are "given a dose of Motrin and told to go away cheap tadacip 20mg without a prescription. Thus purchase tadacip 20mg free shipping, while no effects of the guideline on practices might have been achieved at this MTF generic 20mg tadacip mastercard, there is some qualitative evi- dence that such changes may be needed. Conclusions Site B limited its strategy for implementing the low back pain guide- line to care for active duty personnel, and therefore, it limited inter- ventions to its TMCs. Even on this limited scale, however, implemen- tation of the guideline was approached with little support from the leadership and little guidance from the champion or the members of the implementation team. It has been particularly difficult to gauge the extent to which the guideline has actually been used. The MTF staff participating in the site visit consistently stated that they believe they were already practicing consistent with the guideline, and they were focused more on reporting the other priorities that compete with their ability to work on strengthening practices for low back pain patients. In the face of these statements, however, orthopedics providers report a continuing high incidence of inappropriate refer- rals for MRIs or for chronic care. Also, the MTF has not examined al- ternatives to strengthen the way it practices patient education: one- on-one at the discretion of providers and medics. While a majority of providers in the family and internal medicine clinics reportedly have been introduced to the low back pain guide- line, implementation has been left to the discretion of each provider within these clinics. Providers in these clinics tend to believe even more strongly than TMC providers that their practices already are consistent with the guideline. In the words of one of the MTF providers, they "recognize that the MTF is a long way from implementing the guideline. Given the contrasting reports we heard re- garding the appropriateness of and variations in practices for low back pain care, it will be important to track trends in key measures to assess the status of practice quantitatively. A change in MTF command as well as in staff leading the implementation team may have contributed to shift emphasis away from implementation of the low back pain guideline to other priori- ties. One issue that has hampered implementation has been the continuing inability to gain support of the nursing and ancillary staff to use the documentation form 695-R when they process low back pain patients for provider visits. Although many providers have found the guideline helpful, many others said they were already de- livering care as specified in the guideline. As a result, it has not been possible to substantiate providers’ claims that they are al- ready following the guideline. The Organizational Context The MTF had a 50 percent turnover in its staff during the summer of 1999, including many in leadership positions. As of our final visit, the new com- mander had not seen the low back pain guideline and had not yet been briefed about it. Since our first site visit, deep differences had arisen among providers about the usefulness of the low back pain guideline and about the likely effectiveness of promoting patient self- care. Attitudes Toward the Low Back Pain Guideline Attitudes toward the low back pain guideline varied broadly among providers at Site C. At one extreme, one provider who recently grad- uated from a residency program had read the entire guideline and felt he had learned something. At the other extreme, an experienced provider thought the low back pain guideline was not the best choice to implement first because it is "a disease that is hard to monitor. However, providers who had been in Reports from the Final Round of Site Visits 137 practice longer had more negative attitudes, stating that introducing the guideline did not improve care but only increased documenta- tion requirements and other inefficiencies resulting from more time spent in meetings and duplicating work. This attitude is in sharp contrast to the results of a small pilot test of the documentation form 695-R that Site C had conducted at a TMC, which concluded that the form was easy to follow and allowed the TMC to process clients faster. The overall strategy of Site C for imple- mentation of the low back pain guideline had not changed since our first site visit. Their strategy was to implement all components of the guideline in all clinics and TMCs for both active duty and other pa- tients. Documentation form 695-R was seen as the primary vehicle through which compliance with the guideline would be achieved. Monitoring of selected key metrics, using ADS data and review of medical records, would permit them to assess progress and provide feedback to providers on potential issues or needed improvements. Except for loss of its original facilitator, the implementation team had remained the same since our first visit. The team consisted of two representatives from quality management, a phar- macist, the head nurse, a physical therapist, a sports medicine physician, nursing staff, and ancillary staff. The team reportedly meets monthly as part of a broader effort to implement pathways at the MTF.

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