Effective methods of understanding and treating PTSD

Effective methods of understanding and treating PTSD The treatment related publications of the last twenty years places a large amount of attention on determining the most useful psychological therapy for clients with a diagnosis of posttraumatic stress disorder, PTSD. The overall aim of this paper is to critically evaluate current cognitive models of PTSD and literature on the effectiveness of cognitive behavioural therapies to treat this disorder based on these models. Definitions of PTSD The 4th edition of the Diagnostic and Statistical Manual of Mental Disorders, DSM-IV (APA, 1994) defines trauma as: (a) The individual experienced, witnessed or was confronted with an event that involved actual or perceived threat to life or physical integrity; and (b) the individuals emotional response to this event included horror, helplessness or intense fear, Foa and Meadows (1997, p. 450). The psychological symptoms connected with PTSD are categorised into three groups of symptoms in DSM-IV: The main characteristics include re-experiencing (in the form of flashbacks, intrusive thoughts, and distressing dreams), avoidance/numbing and heightened arousal, after the person is subjected to a traumatic incident. (Foa Rothbaurn, 1992). The next group includes avoidance of stimuli trauma-reminding stimuli and symptoms of emotional numbing (Foa, Hearst-Ikeda, Perry, 1995; Litz, 1993). The final symptom group includes heightened arousal e.g. hypervigilance, exaggerated startle response, difficulty sleeping and irritability (APA, 1994). Current Government Guidelines on the treatment of PTSD Determining effective and efficient treatments for PTSD has come to be seen as important due to the conditions prevalence and the many techniques and interventions available. The National Institute for Clinical Excellence, NICE, reviewed the most robust outcome research and produced guidelines, to provide information and direction for the psychological management of PTSD in adult sufferers (NICE, 2005). The guidelines were developed from an independent, methodical, rigorous and multistage procedure of selecting, examining and assessing evidence for the successful treatment of PTSD. These guidelines conclude that individuals with PTSD should receive either trauma focused Cognitive Behavioural Therapy (TFCBT) or Eye Movement Desensitisation and Reprocessing (EMDR). However, a distinction is made between single incident trauma and more complex presentations, and the guidelines suggest increasing the total number of sessions accordingly. Although the guidelines appear helpful for the tre atment of single incident PTSD, they are arguably not as informative for treatment approaches for a large group of individuals with complex PTSD. This presents difficulties for the clinician and patient in deciding the most effective therapeutic options. Cognitive Behavioural Therapy (CBT) is the most extensively studied therapy for individuals with PTSD (Foa Meadows, 1997) and many studies support its efficacy in reducing symptom severity (e.g. Resick Schnicke, 1992; Foa, Rothbaurn, 1992; Foa et al., 1995; Foa Jaycox, 1996; Riggs, Murdock, 1991; Richards, Lovell, Marks, 1994; Thompson, Charlton, Kerry, Lee, Turner, 1995). However, CBT for PTSD encompasses diverse techniques. These include exposure procedures, cognitive restructuring procedures, and combinations of both these techniques. Exposure Therapy Exposure therapy is derived from the idea that imaginal exposure (IE) to the trauma or feared situation, leads to a decrease in symptoms. The theory argues enduring activation of traumatic memories result in processing of the emotional information, lessening of anxiety and assimilation of accurate memories (Foa et al., 1995). Much research has shown that treatment involving exposure therapy is effective in decreasing PTSD symptoms (e.g. Foa et al., 1999; Frueh, Turner, Beidel, Mirabella, Jones, 1996; Keane, Fairbank, Cadell, Zimmering, 1989). Foa, Rothbaum, Riggs, and Murdoch (1991) investigated exposure therapy, stress inoculation (a type of Anxity Management Treatment, AMT), supportive counselling, and a non-treatment group in the management of rape-related PTSD. Clinical measures of symptoms and standardized psychometric tests were examined before and after treatment as well as at a three month follow-up. The stress inoculation intervention showed superior results to the counselling and non-treatment conditions at post-test. However, at the follow-up, the individuals participating in exposure therapy showed more improvements of PTSD symptoms than individuals in the other groups. Research has investigated the efficiency of exposure therapy compared to different methods of treatment. For instance, exposure therapy and cognitive therapy were investigated by Tarrier et al. (1999) for the management of individuals with PTSD arising from various traumatic incidents. Although both approaches demonstrated a noteworthy decrease in PTSD symptoms that was still present at 6-months follow up there was no non-treatment control against which these two treatments could be evaluated. Similarly, Foa et al. (1999) compared exposure therapy to AMT and then combined the two treatments. These three groups were compared to a non-treatment control group. All three of these treatments successfully decreased symptoms of rape-related PTSD and improved more than the non-treatment control group. However there was no significant variation among the treatment groups on outcome measures. In a study that once again compared exposure therapy to cognitive therapy, Marks, Lovell, Noshirvani, Livanou, and Thrasher (1998) examined these two treatments alone and in combination in outpatients with PTSD secondary to a wide range of traumatic events. A relaxation therapy condition was employed as the comparison group. The three active treatment groups demonstrated significant reduction in symptoms compared to the relaxation sample. These intervention groups were not markedly different from on another on the main treatment outcome measures. Several investigations have advanced the field of PTSD treatment, even though the methodology utilized in the outcome study limited the conclusions that could be drawn. Frank and Stewart (1983) reported the effects of systematic desensitization on women who had been raped and who developed significant psychological symptomatology. Compared to an untreated comparison group, those women treated with graduated exposure improved most on a range of anxiety and depression symptom measures. Imaginal and in-vivo exposure was compared in a randomized study of survivors of varying traumatic events (Richards, Lovell, and Marks,1994). At the 12-month follow-up, patients reported consistent reductions in PTSD symptoms and improved social adjustment. This data further substantiates the efficiency of exposure treatment for some individuals, and also suggest that improvements in symptoms are also reflected in critical domains of life functioning. In conclusion, the existing data advocates the use of exposure therapy in the treatment of PTSD. In a previous review of this literature, Solomon, Gerrity, and Muff, (1992), (Sited in Shapiro, 1995) derived the same conclusion from data available at that time. Similar conclusions were drawn by Otto, Penava, Pollack, and Smoller (1996) in a more recent review of the literature. In what may prove to be an important lesson for the treatment of individuals exposed to traumatic events, Foa, Hearst-Ikeda, and Perry (1995) investigated the effectiveness of a short-term intervention to prevent the development of chronic PTSD in females who had been recently raped. The program was based upon that which worked well in earlier trials with chronic PTSD. Exposure therapy figured prominently in the package of treatment and also included elements of education, breathing retraining, and cognitive restructuring. When individuals receiving the package were compared to a control group, this study found that at 2 months post-treatment only ten percent of the treatment sample met the diagnosis for PTSD, while seventy percent of the untreated comparison group did. As information continues to grow on exposure therapy, there is a clear requirement for research to investigate combinations of psychological treatment, to utilize screening measures that consider occupational and social performance, and to access the outcome of interventions on co-morbid psychological difficulties. Unmistakably, the existing empirical research reveals the importance of extending the application of exposure approaches to PTSD patients. However future studies assessing the generalization of exposure therapy from laboratory trials to clinical settings would be particularly useful. When exposure therapy has been compared to other forms of cognitive therapy, such as cognitive restructuring (see below), it has proved to be more successful in reducing PTSD. Tarrier et al., (1999) assigned 72 people with chronic PTSD to either a Cognitive Therapy (CT) group or an imaginal exposure (IE) therapy group, and concluded that there was no noteworthy differentiation between the two treatment conditions initially or at 12 months post treatment. Participants recruited were obtained from a sample of referrals to primary and secondary mental health services and voluntary services, indicating that they were representative of a genuine clinical sample. However, 50% of the sample remained above clinical significance for PTSD symptoms after treatment was completed, although this dropped to 25% at six-month follow-up. This lack of improvement may have been influenced by participants failure to attend sessions regularly. Furthermore, those who did not show improvement rated the trea tment as less convincing and were rated as not as motivated by the clinician. Therefore, it is argued that motivation for therapy and regular attendance plays an important role in outcome of therapy regardless of treatment model. A further limitation of this study was that no control group was used and non-specific treatment factors and spontaneous remission could also account for the improvements in reported symptoms. Cognitive Restructuring Cognitive restructuring is derived from the theory that discovering and altering catastrophic and inaccurate interpretation of the trauma leads to a decrease in symptoms. Some of the latest models have emphasised the significance of altering thinking distortions in the rehabilitation of individuals who have experienced trauma (Ehlers Clarke, 2000). Ehlers, Clark, Hackmann, McManus, and Fennell (2005) utilized cognitive therapy based on the cognitive model of PTSD (see figure 1. Ehlers Clarke, 2000). From this model, the aim of therapy is to alter overly negative interpretations, amend the disturbance in autobiographical recollection and to eliminate the unhelpful behavioural and cognitive strategies (see figure 2, Ehlers et al., 2005). In a randomised controlled trial of twenty-eight participants diagnosed with PTSD. Fourteen participants were assigned at random to cognitive therapy treatment or a 13-week waiting-list condition. Those receiving cognitive therapy had 12 weekly treatment sessions, based on the Ehlers and Clarke (2000) model of trauma focused CBT. Participants completed self-report screenings of anxiety, mood and PTSD symptoms, and the Sheehan Disability Scale (APA, 2000). Measures were administered before and after treatment and at 6-months follow up. Findings revealed that cognitive therapy for PTSD was signifi cantly better than a three month waiting-list group on symptoms of PTSD, disability and symptoms of anxiety and affect. This study had no dropouts, which is a significant improvement on other studies, which yielded high dropout rates, (e.g. Tarrier et al., 1999). Participants displayed a positive change in cognitive appraisals. The Ehlers and Clarke (2000) model suggest that two additional paths of change; alteration in the autobiographical recollection of the trauma, and the discontinuation of maintenance behaviours and cognitive strategies are integral in reducing symptoms of PTSD. While the treatment incorporated these other aspects, these have not been measured systematically, so it is difficult to conclude whether clients experienced a change in these two areas. Further analysis indicated that demographic, trauma and diagnostic variable did not predict intervention results, signifying that the approach is pertinent to a broad scope of individual who have experienced trauma. Conversely, the extent of discrepancy of trauma and small sample numbers suggests that this finding would not be present in a larger sample. Co-morbid depression and previous trauma history, which was present in over half the sample, did not negatively affect outcome. Combinations of therapy Resick and Schnicke (1992) have proffered a multidimensional behavioural treatment for females who have PTSD associated with sexual assault. This treatment, known as cognitive processing therapy (CPT), includes components of exposure therapy, AMT, and cognitive restructuring. The cognitive therapy element of CPT involves tackling central thinking distortions found among females who have been assaulted. These authors have developed interventions which particularly deal with concerns of trust, self-confidence, safety and intimacy in the lives of trauma victims. In a preliminary evaluation of CPT, the authors compared outcomes at pre-treatment, post-treatment, 3 months follow-up, and 6 months follow-up for an intervention group and a non-treatment group (no random assignment was used). On clinician ratings and psychometric inventories of PTSD, the individuals receiving CPT improved significantly. Impressively at the post-treatment assessment, none of the treated patients met criteria fo r PTSD. In another study, Resick, Nishith, and Astin (2000) evaluated CPT and exposure therapy in the management of sexual assault-related PTSD. Both approaches proved successful in general and were more successful than a non-treatment control group. CPT did also seem to reduce comorbid symptoms of depression, as well as those of PTSD. Combination therapy that incorporates a number of cognitive-behavioural techniques have the advantage of addressing various difficulties that individuals with PTSD may experience, in addition to integrating methods that have a considerable scientific evidence base in the clinical literature. An intervention incorporating exposure therapy, AMT, and cognitive restructuring as the main elements for treating PTSD was proposed by Keane, Fisher, Krinsley, and Niles (1994). This treatment utilizes six stages as a means of treating severe and chronic PTSD, it incorporates the following: (1) behavioural stabilization; (2) trauma psycho-education; (3) AMT; (4) trauma focus work; (5) relapse prevention skills; and (6) aftercare procedures. Although this approach has clinical appeal, it wasnt until psychologists Fecteau and Nicki (1999) examined such a package in a randomized clinical trial for PTSD resulting from automobile accidents that the impact of a combination package such as that proposed by Keane et al. (1994) was assessed. Their intervention consisted of psycho-education, relaxation, exposure, cognitive restructuring, and guided behavioural exercises. Patients were randomly assigned to the treatment group or non-treatment comparison group and received some 8-10 sessions of individualized treatment. The outcome of the treatment was effective as assessed by clinical ratings, self-report questionnaires, and lab-based psycho-physiological evaluation methods. Described by the authors as clinically and statistically significant, these treatment outcomes were sustained at the 6-month post treatment evaluation. Bryant, Moulds, Guthrie, Dang, and Nixon (2003) studied the effects of IE alone or IE with CR in the treatment of PTSD. They hypothesised a CR and IE treatment combination would lead to significantly better decrease in PTSD symptoms than exposure on its own, which would be more beneficial than a supportive counselling condition. Fifty-eight civilian trauma victims, diagnosed with PTSD as measured by the Clinician Administered PTSD Scale, version II, CAPS-2, (Blake et al., 1995) were randomly allocated to one of the 3 conditions. Each participant received eight weekly 90-minute sessions of either IE, CR and IE or supportive counselling. Participants completed assessments at pre and post intervention and six months following. These measured PTSD symptoms and psychopathology. Forty-five participants completed treatment and analysis indicated that dropouts had higher scores for depression, avoidance and higher catastrophic cognitions than those who completed. Results indicated that parti cipants receiving both IE and IE/CR had a siginifcantly better decrease in PTSD symptoms and anxiety than supportive counselling (SC). The main revelation of this investigation was that treatment comprising of IE and CR leads to significantly better reductions in CAPS-II scores compared to treatment involving IE alone. Furthermore, those receiving IE/CR, but not IE on its own, gave accounts of less avoidance, depression and catastrophic thoughts than individuals in receipt SC. The findings from this research indicated that the combination of IE and CR are successful in decreasing symptoms of PTSD. It can be argued that the reasons why IE/CR may have been more effective than augmented treatments in the past (e.g. Foa et al., 1999) was that the research prudently controlled for the duration of time spent on every section of treatment. Furthermore, participants were instructed on CR before commencing IE so they understood the rationale behind the techniques prior to addressing the strong emotional components of IE. This may have increased their understanding and belief that it was a credible treatment approach. The outcome that CR improved the benefits of IE treatment could have been a result of a number of likely mechanisms. IE and CR may consist of similar aspects, such as processing of emotional memories, amalgamation of corrective information and acomplishment of self-mastery (Marks, 2000). Combining the two approaches may give the patient more chances to achieve treatment gains. CR may have lead to greater decrease in symptoms as it explicitly attended to identifying and changing unhelpful thoughts that may add to the maintenance of PTSD and related difficulties (Ehlers Clarke, 2000). Paunovic and Ost (2001), compared treatment outcome data for CBT and exposure therapy for sixteen refugees with PTSD. The authors excluded those who became too distressed in the initial interview, expressed a lack of confidence in the therapist or were misusing alcohol or drugs. Results indicated there was no significant difference between participants completing CBT or exposure therapy, being similar to Tarrier et als (1999) findings. Criticisms of Paunovic and Ost (2001)s study are that participants did not use a self-report trauma measure, so although results are positive, there is no clear analysis of whether participants felt their trauma symptoms decreased as a result of the treatment. Further, it is not possible to generalise these findings to traumatised refugees in general, as this work is unique. Working with the use of an interpreter raises several ethical and sensitive issues, as the participant must be able to develop a therapeutic alliance with the therapist and trust the interpreter (Tribe, 2007). It could be argued that participants may have been experiencing a greater degree of trauma, not least because they had not yet learned the native language. Discussion The most successful CBT treatments seem to be those that involve repeated exposure to the traumatic memory (Foa et al., 1991; Foa et al., 1999; Foa Rothbaum, 1992) on cognitive restructuring of the interpretation of the traumatic event, (Ehlers Clarke, 2000) or a combination of these approaches, (Resick Schnicke, 1992). Importantly, studies have concluded that trauma focused CBT is more successful than supportive counselling (Blanchard et al., 2003; Bryant et al., 2003). Whilst the studies reviewed have helpfully added to our understanding of PTSD there are numerous limitations of the applications of the findings. One in particular is an over-reliance on non-clinical samples of participants such that many claims of clinically effective therapy have been made from research with participants who were not within mental health systems, and despite having PTSD symptoms had not actively sought treatment. In addition, dropout rates in studies are high, particularly for those studies that did not use a clinical sample. This might have skewed the evidence particularly with approaches that used exposure-based therapy. Furthermore, most of the studies reviewed screened out those individuals experiencing the greatest amount of distress, avoidance and co-morbidity. Therefore results are biased towards those clients who were able to tolerate treatment and whose symptoms were not as chronic. Indeed, inclusion and exclusion criteria appear to have a great impact on outcome of treatment. For example, studies with a strict inclusion criteria (e.g. no co-morbidity, substance misuse, self harm) appear to have significant improvements, whilst other studies i.e. Kubany et al., (2003), allowed participants to continue with other therapy while embarking on their therapy. This makes it methodologically difficult to ascertain exactly what has been effective in reducing PTSD symptoms. As inclusion and exclusion criteria are idiosyncratic across studies, it makes it difficult to draw general conclusions regarding treatment effectiveness with a clinical population across studies. Studies often chose to focus therapy on identified groups, e.g. police officers. However, clients who experience PTSD do not form a homogeneous group and further, the symptoms experienced may be diverse even within a sample of individuals who have experienced the same trauma. Treatment studies often do not control for other factors that may be important contributing factors in outcome such as the role of education, quality of the therapeutic relationship, therapeutic alliance and other nonspecific factors. The literature was generally from American, British or European sources although clearly trauma is intercultural. This raises issues about how different cultures interpret PTSD, an essentially Western concept, and also whether the treatments advocated would be effective cross-culturally. Previous research has strongly indicated that PTSD is not an appropriate term to use in non-western situations (Summerfield, 1997), hence therapeutic approaches need to account for this. It is not clear in the majority of studies when the participant experienced the trauma, and at what point therapy started. Frequently these characteristics are omitted from studies, therefore making it difficult to compare effectiveness of studies. It is essential to think about the types of individuals that have been represented in the research and to look at whether it is representative of those who seek treatment. Finally, very little has been reported on the impact of other difficulties an individual is experiencing as PTSD can have a broad ranging effect on an individuals quality of life and functioning and most often clients have more complex presentations. Only very few studies reviewed controlled for this variable (see Ehlers et al., 2005). This is an inherent difficulty when completing resea rch with a trauma population as within research it is important to obtain a sample that have a similar degree of difficulties in order to assess treatment efficacy. Several papers have evaluated different types of therapy according to particular groups. However, it appears that one size does not fit all in relation to PTSID. In particular the issues of culture and gender are of importance (see Liebling Ojiambo-Ochieng, 2000; Sheppard, 2000). Individual formulations of presenting problems and contexts, which informs therapy that is adapted to suit individual clients needs, may in fact be more helpful. It remains important to consider individual differences and client choice when offering trauma therapy. Trauma therapy outcome studies are limited by the fact that sufferers usually have other mental health problems alongside PTSD such as depression or social anxiety. Evaluation of effective treatment of trauma survivors therefore might need to go beyond medical diagnostic categories as most of the research excludes clients with co-morbid problems. A multifaceted intervention, based on clients own views, which addressed these other difficulties, could assist in decreasing relapse and greaten the long-lasting effectiveness of any PTSD intervention. As outlined in the methodological limitations section, much of the research reviewed has not used a genuine clinical sample, there are high dropout rates, widely variable inclusion and exclusion criteria, and the heterogeneity of PTSD has perhaps not yet been accounted for. It is therefore difficult to ascertain what is specifically helpful or effective within the treatment components. This seems to be the next area for consideration in resea rch. Further research into the optimal length of treatment and timing of therapy, the effect of co-morbidity and the differing effects of individual and group therapy approaches for traumatised clients are required. Further controlled research is needed to ascertain if the types of therapies reviewed can provide long term lasting effects in reducing PTSD symptomatology. At present the scientific evidence is mainly restricted to the evaluation of short term, focused treatment approaches, and it would be helpful to have controlled studies on longer-term interventions for more complex cases of trauma. Further research would benefit from considering the clients views and experiences of therapy, this perspective was lacking in the literature reviewed. Service user and carer perspectives are beyond the scope of this review, however they have been highlighted as an important consideration within the NICE guidelines and therefore require further consideration in future research. Conclusion There appear to be at least three approaches with exceptional empirical evidence for treating PTSD; exposure therapy, cognitive therapy or a combination of these methods. These three interventions have empirical validation in well-controlled clinical trials, demonstrate strong treatment effect sizes, and seem to work well across varied populations of trauma sufferers. However future research to examine the efficacy of these methods in clinical environments is necessary. There is much to be learned about the treatment of PTSD. It is certain there will be no simple answers for treating people who have experienced the most horrific events life offers. Undoubtedly, combinations of treatments as proposed by Keane et al. (1994) and Resick and Schnicke (1992) may prove to be the most powerful interventions. PTSD research in this area is only in the earliest stages of its development. Finally, an assumption about the uniformity of traumatic events has been made in the literature in general. Although it is reasonable to speculate that fundamental similarities exist among patients who have experienced diverse traumatic events and then develop PTSD, whether these patients will respond to clinical interventions in the same way is an empirical question that has yet to be addressed. Studies posing a question such as this would be a welcome addition to the clinical literature: Will people with PTSD resulting from combat, torture, genocide, and natural disasters all improve as well as those treated successfully following rape, motor vehicle accidents, and assaults? This is a crucial issue that requires additional scientific study in order to provide clinicians with the requisite evidence supporting the use of available techniques. Research on the prevalence of exposure to traumatic events and the prevalence of PTSD has mainly been carried out in the United States. Yet there are fundamental errors in assuming that these prevalence rates apply even to other Western, developed countries. Studies that examine the prevalence of PTSD and other disorders internationally are clearly warranted. Implicit in this recommendation is the need to examine the extent to which current assessment instrumentation is culturally sensitive to the ways in which traumatic reactions are expressed internationally. Much work on this topic will be required before definitive conclusions regarding prevalence rates of PTSD internationally can be drawn. Studies of the effectiveness of the psychological treatments across cultures and ethnic groups are also needed. What may be effective for Western populations may be inadequate or possibly even unacceptable treatment for people who reside in other areas of the world and who have different world views, beliefs, and perspectives. This issue will need to be more closely examined before we can draw definitive conclusions. It is suggested that despite the type of treatment provided to individuals with trauma there is ultimately a necessity for a flexible, integrative approach to treatment in order to address the multifaceted and changing requirements of individual trauma survivors. A range of outcomes has been revealed with the types of treatments outlined in this review, it is uncertain which individuals will respond greatest to various treatment approaches. Nevertheless, what is important in determining the effectiveness of any psychological treatment of PTSD is that it is reliant upon forming and upholding a therapeutic alliance that is strong enough for the client to experience as safe and trusting for positive emotional modifications to take place.

Machiavelli - The Prince :: essays research papers

The Prince, one of the most popular and well known doctrines of political thought was also one of the greatest works of Niccolà ³ Machiavelli. First published in 1513, The Prince was written in response to the failure of the Greek-based Italian city-states. Machiavelli wrote The Prince because, despite being a firm Republican, he was also well-documented as a strong patriot. He wanted that his people live under a free but effective government, but he decided that if his nation has to be ruled by a despotic form of government that he would rather have it be a strong yet merciful tyranny. He wasn’t paid for writing The Prince, it wasn’t even originally a book, but a series of letters to the Prince Lorenzo de Medici. He wrote it during exile, after he had been arrested and tortured by Medici’s people, so it is doubtful that they had a bountiful relationship. Machiavelli’s intent, it would seem to the naked eye, was not to taunt the Prince, but to give him advice about how to survive on the throne and to also keep the dynasty in his family after his death. It appeared that he wanted to help the Prince to keep the nation free from invasion and occupation and also how to handle internal problems; such as when to bribe, oppress, cajole etc… Machiavelli’s real objective in writing The Prince was far different from the words that are found composed by him. The letters from Machiavelli to the Prince of Florence were not messages of suggestion as much as they were a job application for a place in his dynasty. The actual ambition of Machiavelli was to use this political hypocrisy to promote his own good. He was a firm believer that one should give the people what they want in order to earn their support and respect. Then, once in the public’s good graces, to use your authority, position and support to promote and complete your own agenda, political or otherwise, as long as it would eventually benefit the good of the people. He was a believer that anything can be justified as long as the results in for the common good. Machiavelli used this idea to coin his most well known phrase, “the end justifies the means.'; He explains that is it necessary to appear to be a lovely moral person, but in reality, to act “as necessity dictates'; and this allows lying, perjury and other immoral acts as long as the overall intent and final product is for the Common Benefit.

Fool Chapter 5

FIVE PITY THE FOOL Kent banished, Cordelia disinherited, the king having given away his property and power, but most important, my home, the White Tower; the two older sisters insulted by Kent, the dukes ready to cut my throat, well – getting a laugh might be a challenge. Royal succession, it seemed, would not be a prudent subject to broach, and I was lost for a transition to slapstick or pantomime after Lear's high drama, so Drool was but a millstone on comedy's neck. I juggled apples and sang a little song about monkeys while I pondered the problem. The king was, of late, leaning decidedly pagan, while the elder sisters favored the Church. Gloucester and Edgar were devout to the Roman pantheon, and Cordelia, well, she thought the whole lot was shit and England should have her own church with women in the clergy. Quaint. So the high-minded comedy of religious satire it would be†¦ I tossed my apples around the table and said, â€Å"Two popes are shagging a camel behind a mosque, when this Saracen comes up – â€Å" â€Å"There is only one, true pope!† shouted Cornwall, great tower of malignant smegma that he is. â€Å"It's a jest, you wanker,† said I. â€Å"Suspend fucking disbelief for a bit, would you?† He was right, in a way (although not for the purpose of the camel bit). For the last year there had only been one pope, in the holy city of Amsterdam. But for the prior fifty years there had been two popes, the Retail Pope and the Discount Pope. After the Thirteenth Holy Crusade, when it was decided that to avoid future strife, the birthplace of Jesus would be moved to a different city every four years, holy shrines lost their geographical importance. There arose a great price war in the Church, with shrines offering pilgrims dispensation at varying competitive rates. Now there didn't need to be a miracle declared on the spot; anywhere could basically be declared a holy site, and often was. Lourdes would still sell dispensation coupons with the healing waters – but also some bloke in Puddinghoe could plant some pansies and hawk, â€Å"Jesus had a wee right on this very spot when he was a lad – two pennies and a spliff of Cardiff chronic ‘ill get you out o' purgat ory for an eon, mate.† Soon a whole guild of low-priced shrine keepers around Europe named their own Pope – Boldface the Relatively Shameless, Discount Pope of Prague. The price war was on. If the Dutch pope would give you a hundred years out of purgatory for a shilling and a ferryman's ticket, the Discount Pope would let you out for two hundred years and send you home with the femur of a minor saint and a splinter of the True Cross. The Retail Pope would offer cheesy bacon toppings on the Host with communion and the Discount Pope would counter with topless-nun night for midnight mass. It came to a head, though, when St. Matthew appeared in a vision to the Retail Pope, telling him that the faithful were more interested in the quality of their religious experience, not just the quantity. Thus inspired, the Retail Pope moved Christmas to June when the weather wasn't so shit for shopping, and the Discount Pope, not realizing the game had changed, responded by forgiving hell altogether for anyone who gave a priest a hand job. Without hell, there was no fear, and without fear, there was no further need for the Church to supply redemption, and more important, no means for the Church to modify behavior. The Discount faithful defected in droves, either to the Retail branch of the Church, or to a dozen different pagan sects. Why not get pissed and dance naked around a pole all Sabbath if the worst of it was a rash on the naughty bits and the dropping of the odd bastard now and then? Pope Boldface was burned in a wicker man the next Beltane and cats shat in his ashes. So, yes, a two-pope joke was untimely, but fuck all, it was dire times, and I sallied forth, for a bit: â€Å"So the second pope says, ‘Your sister? I thought she was kosher?'† And no one laughed. Cordelia rolled her eyes and made a raspberry sound. The pathetic one-trumpet fanfare dribbled, the great doors were thrown open, and France and Burgundy ponced[20] into the hall followed by the bastard Edmund. â€Å"Silence, fool,† commanded Lear, with great superfluity. â€Å"Hail, Burgundy, hail, France.† â€Å"Hail, Edmund the bloody bastard!† said I. Lear ignored me and motioned for France and Burgundy to come before him. They were both fit, taller than me but not tall, a few years south of thirty. Burgundy had dark hair and the sharp features of a Roman. France, sandy hair and softer features. Each wore sword and dagger that I doubted had been ever drawn but for ceremony. Fucking frogs. â€Å"Lord Burgundy,† said Lear, â€Å"you have rivaled for the hand of our youngest daughter. What dowry do you require for her?† â€Å"No less than your highness has offered,† said the dark poofter. â€Å"Alas, that is no more, good Burgundy. What we offered, was offered when she was dear to us. Now she has roused our anger and betrayed our love and her dowry is nothing. If you want her as she is there, take her, but there will be no dowry.† Burgundy was stunned. He backed away, nearly stepping on France's feet. â€Å"I'm sorry, then, sir, but I must tend to property and power in my choice of duchess.† â€Å"She shall have neither,† said Lear. â€Å"So be it,† said Burgundy. He nodded, bowed, and stepped back. â€Å"I am sorry, Cordelia.† â€Å"No worry, sir,† said the princess. â€Å"If Burgundy's heart is wed only to property and power, then it could never be to me truly. Peace be with you.† I breathed half a sigh of relief. We might be driven from our home, but if Cordelia was driven out with us – â€Å"I'll take her!† said Edgar. â€Å"You will not, you blubbering, beetle-browed, dog-buggering dolt!† I may have accidentally exclaimed. â€Å"You will not,† said Gloucester, pushing his son back into his seat. â€Å"Well, I will have her,† said the Prince of France. â€Å"For she is a dowry in herself.† â€Å"Oh for fuck's sake!† â€Å"Pocket, that's enough,† said the king. â€Å"Guard, take him outside and hold him until our will is done.† Two yeomen stepped up behind me and seized me under the armpits. I heard Drool moan and looked over to see him cowering behind a column. This had never happened before – nothing like it. I was the all-licensed fool! I of all people could speak truth to power – I am chief cheeky monkey to the King of Bloody Britain! â€Å"You don't know what you're getting into, France. Have you seen her feet? Or perhaps that is your game, put her to work in the vineyards crushing wine grapes. Majesty, the poofter means to force servitude on her, mark my words.† But no one heard the last of it, the yeomen had dragged me from the room and held me in the hall outside. I sought to brain one with Jones but he caught the puppet stick and tucked him in his belt at the small of his back. â€Å"Sorry, Pocket,† said Curan, the captain of the guard, a grizzled bear in chain mail who held me by my right arm. â€Å"‘Twas a direct order, and you were fast cutting your throat with your own tongue.† â€Å"Not me,† said I. â€Å"He wouldn't hurt me.† â€Å"I'd have said he'd not banish his best friend or disown his favorite daughter before this night. Hanging a fool's an easy leap, lad.† â€Å"Aye,† said I. â€Å"You're right. Let me go, then.† â€Å"Not until the king's business is done,† said the old yeoman. The doors came open, fanfare trickled anemic through the portal, and out came the Prince of France, on his arm, Cordelia, radiant and wearing a grim smile. I could see her jaw clenched, but she relaxed when she saw me and some of the fire of anger left her eyes. â€Å"So, you're off with the frog Prince?† said I. France laughed at that, bloody buggering French fuck that he is. Is there anything so irritating as a noble who actually behaves nobly? â€Å"Yes, I am leaving, Pocket, but there is one thing you must always remember and never forget – â€Å" â€Å"Both at once?† â€Å"Shut up!† â€Å"Aye, milady.† â€Å"You must always remember, and you must never forget, that while you are the Black Fool, the dark fool, the Royal Fool, the all-licensed fool, and the King's Fool, you were not brought here to be those things. You were brought here to please me. Me! So when you put your titles aside, a fool still shall there reside, and now and forever, you are my fool.† â€Å"Oh my, you are going to do well in France – they hold unpleasantness to be a virtue.† â€Å"Mine!† â€Å"Now and forever, milady.† â€Å"You may kiss my hand, fool.† The yeoman released me and I bent to take her hand. She pulled it away, and turned, her gown fanning out around her as she walked away. â€Å"Sorry, having you on.† I smiled into the floor. â€Å"You bitch.† â€Å"I'll miss you, Pocket,† she said over her shoulder, and she hurried down the corridor. â€Å"Take me with you. Take us both with you. France, you could use a brilliant fool and a great lumbering bag of flatulence like Drool, couldn't you?† The prince shook his head, entirely too much pity in his eyes for my tastes. â€Å"You are Lear's fool, with Lear you shall stay.† â€Å"That's not what your wife just said.† â€Å"She will learn,† said the prince. He turned on his heel and followed Cordelia down the corridor. I started after them but the captain yanked me back by the arm. â€Å"Let her go, lad.† Next out of the hall came the sisters and their husbands. Before I could say anything the captain had clamped his hand over my mouth and was lifting me off my feet as I kicked. Cornwall made as to draw his dagger, but Regan pulled him away. â€Å"You've just won a kingdom, my duke, killing vermin is a servant's task. Leave the bitter fool stew in his own bile.† She wanted me. It was clear. Goneril would not look me in the eye, but hurried past, and her husband, Albany, just shook his head as he walked by. A hundred brilliant witticisms died suffocating on the captain's heavy glove. Thus muted, I pumped my codpiece at the duke and tried to force a fart, but my bum trumpet could find no note. As if the gods had sent down a dim and gaseous avatar to help me, Drool came next through the door, walking rather more straight than was his habit. Then I saw that someone had looped a rope around his neck, the noose fixed to a spear whose point was almost piercing Drool's throat. Edmund stepped into the corridor holding the other end of the spear, two men at arms flanking him. â€Å"The captain havin' a laugh with you, then, Pocket?† said Drool, innocent of his peril. The captain dropped me to my feet then, but held my shoulder to keep me from going at Edmund, whose father and brother passed behind him. â€Å"You were right, Pocket,† said Edmund, poking Drool a bit with the spear for emphasis. â€Å"Killing you would be enough to cement my unfavorable position forever, but a hostage – there's a mute I can use. I so enjoyed your performance in there that I prevailed upon the king to provide me with a fool of my own, and look at his gift. He'll be coming to Gloucester with us to assure that you don't forget your promise.† â€Å"You don't need the spear, bastard. He'll go if I ask him.† â€Å"Are we going on holiday, Pocket?† asked Drool, blood beginning to trickle down his neck then. I approached the giant. â€Å"No, lad,† said I. â€Å"You're going to go with the bastard here. Do as he says.† I turned to the captain. â€Å"Give me your knife.† The captain eyed Edmund and the men at arms beside him, who had hands on hilts. â€Å"I don't know, Pocket – â€Å" â€Å"Give me your bloody knife!† I whirled, pulled the knife from the captain's belt, and before the men at arms could draw I'd cut the rope around Drool's neck and pushed Edmund's spear aside. â€Å"You don't need the spear, bastard.† I handed the captain his knife and motioned for Drool to bend down so we were eye-to-eye. â€Å"I want you to go with Edmund and don't give him any trouble, you understand?† â€Å"Aye. You ain't comin'?† â€Å"I'll be along, I'll be along. I've business at the White Tower first.† â€Å"Shagging to be done?† Drool nodded so enthusiastically you could nearly hear his tiny brain rattling around his gourd. â€Å"I'll be helping, right?† â€Å"No, lad, but you'll have your own castle. You'll be the proper fool, won't you? There'll be all kinds of hiding and listening, Drool, do you understand what I'm saying, lad?† I winked, hoping against hope that the git would get my meaning. â€Å"Will there be heinous fuckery, Pocket?† â€Å"Aye, I think you can count on it.† â€Å"Smashing!† Drool clapped his hands and danced a little jig then, chanting, â€Å"Heinous fuckery most foul, heinous fuckery most foul – â€Å" I looked to Edmund. â€Å"You've my word, bastard. But you've also my word that if any harm comes to the Natural, I'll see to it that ghosts ride you into your grave.† A flash of fear showed in Edmund's eye then, but he fought it down and affected his usual swaggering smirk. â€Å"His life is on your word, little man.† The bastard turned and strutted down the corridor. Drool looked back, a big tear welling in his eye as he realized what was happening. I waved him on. â€Å"I'd have taken the other two if you'd dirked him,† said Curan. The other guard nodded in agreement. â€Å"Evil bastard was asking for it.† â€Å"Well, now you fucking tell me,† said I. Another guard hurried out of the hall then, and seeing it was only the fool with his captain, reported, â€Å"Captain, the king's food taster. He's dead, sir.† Three friends had I.

My Little Bit Of Country Essay Essays

My Little Bit Of Country Essay Essays My Little Bit Of Country Essay Essay My Little Bit Of Country Essay Essay My Little Bit of Country As humans we are always haunting the feeling of belonging. Not only the feeling of belonging to someone we love, but also figuring out the place where we feel home and safe. The feeling of belonging clarifies the ideal lifestyle for every individual. Some people find the feeling of belonging in a small suburb surrounded by an untamed nature. Others belong to a life surrounded by millions of people and skyscrapers. Once again, the feeling of belonging is a mindset that makes us value different kinds of lifestyles a feeling that makes us diverge from each other. In the essay My Little of Country (2012) written by Susan Cheaper, the thoughts about living and belonging to the city-life are being divulged to the reader. The essayist is arguing from her point of view of living her ideal life in the big city. Throughout, the essay is composed from a strict personal point of view. The personal point view and form of argumentation is being clarified from the beginning by the title My Little Bit of Country. The essay is following a chronological structure and is composed of two sections. The first section is representing the past where Cheaper is recalling old memories from her holding in New York City. The old memories of New York City are loaded with positive feelings, which appeals to the readers emotions. My earliest memories are of summer mornings in Central Park with my father after he came home from fighting World War II (P. L -l. 1-4). By the use of this as an opening line, and the mentioning of her father fighting in World War II it clarifies her feelings, and the strong importance of the memories from the big city creates sympathy from the beginning. Susan Cheaper starts off in the first section by comparing herself with a yak rapped in the Central park Zoo. Something about him suggested a great acceptance of the world in which he found himself so far from his snowy native mountains and bubbling brooks (p 1. I. 24-27). By using the yak as an example to amplify her feelings and the situation when she is forced to go living on the country with her parents her feeling of belonging in the city gets clarified. The use of an animal that is locked up in a place it does not belong to, appeals again to the readers emotions. Susan Achievers argumentation is build up with a unilateral positive opinion f the city-life supported by the use of negatively and positively loaded contrasts. The contrasts illustrate her strong opinion of her ideal life in the city and the differences between the life in the country and in the city. The city is stated as a place Of dreams -? a safe place to be a place where pieces Of nature also exist. Later in my life I heard Andy Warhol say that it was better to live in the city than the country because in the city he could find a little bit of country, but in the country there was no little bit of city (p. 3 -? l. 40 -149). Susan Cheaper arguments that the city contains the best of both sides, and by that she refers to Central park and The Central Park Zoo as the pieces of nature. In the same time this quotation also amplifies the meaning of the essays title, and how she feels that the city contains everything she needs to contain a successful life. People often associate the nature with an idyllic and peaceful place where people escape to when things get rough, but in Susan Cheaper s essay nature and country are depicted with an ironic attitude. When we went to visit my parents friends who had already made the move to Westchester or New Jersey, the so-called idyll of suburbia seemed a shabby comedown from Central Park (p. 2- l. 105-110). In the same way Cheaper uses negatively loaded adjectives to depict the country as a dangerous and rough place to be contrasting to the city. Why would want to scrape around the rough, dangerous ice of a country lake when I could glide around the smooth ice (p. 2- I. 115-117). The last section is representing the present. The use of both memories from the past and experiences from the present, amplifies her strong opinions and feelings toward the life on the country and in the city. In the last section Susan Cheaper mentions how great an importance Central Park has had during her life, and how the park has turned into a tradition for special and memorable occasions. For the past fifteen years, on New Years Eve we have we have gone to the Central park Our summer traditions happens on or around my birthday at the end of July (p. 4- l. 142-44 / 159-161). Her use of contrast, her unilateral opinions and experience-argumentation that appeals to the readers feelings, depicts the mindset Of most modern people who lives their lives in the big city. In todays socio most modern people no longer associate the country and the nature with a place where the human being belong. Still belonging to either the lifestyle in the city or on the country is an individual feeling and choice. Furthermore it is a statement that the modern society a result of the arbitration has made great changes to the human mindset and values in life. The modern people have now adapted to the life in the big cities surrounded by millions of people and grey skyscrapers that either makes us feel more powerful and successful or small, alienated and alone in a big city as New York.

The Difference Between a Phase and State of Matter

The Difference Between a Phase and State of Matter The matter is anything that has mass and occupies space. States of matter are the physical form taken by the phases of matter. Although the state and phase dont mean quite the same thing, youll often  hear the two terms used interchangeably. The States of Matter States of matter are solids, liquids, gases, and plasma. Under extreme conditions, other states exist, such as  s  Bose–Einstein condensates  and  neutron-degenerate matter.  The state is the form taken by matter at a given temperature and pressure. Phases of Matter A phase of matter is uniform with respect to its physical and chemical  properties. Matter undergoes phase transitions to change from one phase to another.  The primary phases of matter are solids, liquids, gases, and plasma.   Examples At room temperature and pressure, the state of a piece of dry ice (carbon dioxide) would be solid and gas phases. At 0  °C, the state of water can be the solid, liquid, and/or  gas phase. The state of water in a glass is the liquid phase. Learn More Diagram of Phase ChangesPhases of Matter and Phase Diagrams4 The Main States of Matter

Critical review of Nokia case support Essay Example | Topics and Well Written Essays - 1000 words

Critical review of Nokia case support - Essay Example The project, which covers the aspect of elderly population in Finland, primarily, focuses on the rural areas, since the country’s population is more rural oriented (89% of the territory dominated by the rural areas in Finland). Besides, decreasing the dependency ratios of the elderly people within the rural municipalities, the project also aims to facilitate in the delivery of better health services and assuring a sustained economic growth. The project, which includes both a literature review on the issue, and an evaluation of the present conditions through discussions, questionnaires, and interviews, will help us to understand the subject matter better by giving us a clear insight into the Finnish health care system, and the use of the technological innovations within this sector. The research question, suitably framed, takes into account the elderly population and the medical services in rural Finland, examines the entire field of medicine and innovative technology. The basi c motivation behind this project is the viability of the Health book, is an â€Å"easy to use online medical networking service aimed at senior citizens, communities, hospitals and doctors† (Nokia Corporation Case for Support, 2011, 3). The elderly population living within rural communities will benefit from this online health service by getting direct access to medical and social support without having to go out of their houses. The hypotheses that says ‘quality performing telecommunication connections and broadband accessibility make it possible for people in rural areas to live and work despite long distances’ (ibid, 4) is measurable both qualitatively and quantitatively. Qualitatively the data can be collected through theoretical studies of books, journals, and articles on the relationship between improved health care facilities, and innovative technologies and communications. Quantitatively, it is possible to measure the outcomes and implications through the different performance indicators, assessment tests, patient surveys, discussions, interviews, and questionnaires with people in the medical sector and patients, which allows the reader to get a complete overview of their opinions and views, on the present situation and future implications of the issue. Thus, the proposed form of methodology that takes into account both qualitative and quantitative methods, is suitable for this project. The proposed form of data collection makes the project viable, as it aims to explore the variables where the structures will be related to the activities and digital platform of the HealthBook (online medical networking service). The results will then be referred to the â€Å"accessibility and user friendliness of the platform for both elders and medical professionals† (ibid, 11). Lastly, the results would be measured, based on Donabedian’s guidelines (1980), and compared with the results of the preceding health care, thus, providing a clear picture of the present results and the future implications. 2. a. What is the likelihood of the project making a substantial advance in our understanding and knowledge of the subject area?   b. How strong is the impact statement; how will impact be achieved?   The project has chances of making a substantial improvement in the comprehension of the subject are

Market research Essay Example | Topics and Well Written Essays - 1000 words

Market research - Essay Example Henneberg (13) explores the challenges that have been faced by the US during the past decade make it a vital responsibility of the voters to bring about positive change as believed by everyone in the states. Thus, in the research, all these factors among other political reasons will be looked into in the subsequent sections. In the US, the race has always been between two parties, democrats and republicans. The democrat, incumbent president barrack Obama has been on the spot for various reasons against the republican mitt Romney, a white. O n the other hand, mitt has suffered blows in some of the Obama reactions to his allegations that bring him out in a negative way. Considering the ongoing campaigns, Obama tries to defend his seat by convincing them to add him more time to realize his impact but the opposition accuses him of not having utilized his term in office as expected and that he is a disappointment. These impacts on a significant number of voters differently thereby influen cing their probable choice the elections that are yet to come. Some of the significant states have chosen Obama over mitt Romney although by a slight margin. Data results by union times indicate that Obama is still leading in Florida, Ohio and Washington which are key regions in determining the final outcome. The choice of words has been giving mitt a major blow while it works well with Obama who is a better orator and has better choice of words to counter his rival. Race comes in as one of the dictators of the winner of the forthcoming elections. There are slightly more non white voters as there are white voters in the US. This indicates on how tricky it maybe for mitt considering that he is white while Obama is not. However, race in this case may not come in as plane as it is but as a redefinition considered as stereotype (Lipstz 76). Whites are the most likely to be adversely affected by this as the non whites may want to use the opportunity to prove that America belongs to all. As such, they will vote for Obama not because they like him but because they would like to have an alternative race other than white. The whites, on the other hand, may not vote for Obama considering that he has served for one term, and all did not go well with them since non whites have infiltrated and dominated America. This can be supported by the current demonstrations by some whites labeled â€Å"take back America.† most whites feel that America belongs to them so should be the leadership positions. However, this will be outbalanced by the relatively large numbers of the non whites who reason along the same line but to the opposite direction. The economic factors have been a major concern for the Americans since the world’s major economic meltdown that negatively affected the Americans during president Obama’s term. Mitt has at some point picked this as a campaign basis where he blames the Obama administration for the bad situation that befell the Americans . Obama, on the other hand, gives defensive reasoning of the same in an attempt to win the trust that he already lost. The trick in this case for him is that the government has had the issues to do with taxation and payment of bills. The other policy that acts as an indicator of the most likely winner of the election is the foreign policy that has been linked with the history. Obama successfully ended the war in Afghanistan and Iraqi but