The DSM estimates that between two and three percent of the adult population in the United States are compulsive gamblers.  Male compulsive gamblers often begin during adolescence.  However, women tend to start to gamble later in life.  By the time a compulsive gambler seeks help, clients generally have an average debt running from $55,000 to $92,000.

For Factor #2 and #3 go to Pathological Gambling Course

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Make it a habit to glance at your expression in the resident’s dresser or bathroom mirror. You be the judge. Ask yourself, “What am I reflecting to this resident as they perform this ADL?” “What am I reflecting to the rest of the world, as far as that goes?” What do you see as you glance at your face?

So what can you do, if you feel that you need to change?

Here is technique, or how-to, number one. As you look in the mirror, divide your face into the upper brow region and the lower half, your mouth and cheeks. As you look at yourself in the mirror, first look at your upper face, your brow. Is it furrowed, perhaps indicating to your resident stress or displeasure? Or is it smooth? With age, unless we are movie stars who have had face lifts, we all have wrinkles, lines, and creases. I am not talking about natural aging or character lines. I am talking about the lines that you create yourself by tensing your brow ridge. Experiment with this, and note the dramatic difference in what you project by tensing up and pulling together your eyebrows.

Now, relax your eyebrows and concentrate on flattening or relaxing your brow ridge. Raise your eyebrows slightly. It almost feels like smiling with your forehead, because it reflects calmness in those muscles.

Furrowed, tense brows to your resident reflect an unfriendly, stressed person who seems unapproachable and unwilling to really help, no matter what their words say.

Question #2: To reflect calm in the upper portion of your face, concentrate on doing what with your brow ridge?

Now, let’s look at the lower half of your face, your mouth and cheeks. Have you ever received an insincere smile from someone? Yes, unfortunately we all have. Like the fast food clerk that hates his or her job and hands you your bag of food through the drive up window, smiling with an all too toothy smile, while blurting out, “Have a nice day!!” What’s wrong with their smile? The corners of his or her mouth are turned up, so doesn’t that qualify as a smile? Why does it come across as painfully insincere? Well, it’s because the smile is not reflected in their eyes.

Try another experiment with a mirror. Lower your lids to one-quarter or one-half of the way closed. Then smile. You look something like Bugs Bunny, don’t you? The top half of your face doesn’t match the bottom half. Think about how receiving this insincere Bugs Bunny-type smile feels to your resident as they are doing their best to put the button through the hole as they dress. If your eyes don’t match your smile, they know in their heart that you don’t really mean what you are saying.

Now look in the mirror and think of something wonderful, maybe a rainbow or a beautiful summer day. Or, think of someone or something that you really care about, maybe a car, a dog, or a significant other. Look in the mirror. Look straight into your eyes and smile. Do you see what your eyes are doing? They are open naturally, with a warm energy coming out. They match your smile.

That sincerity is what creates the kind of bonding relationship between a care giver and a resident. This helps the resident to see that you respect their efforts to risk trying and failing. They see that you really care. It’s easy to have someone do something for you, because you don’t have to risk failure. Obviously, none of us want to fail. We all want to succeed and have the feeling of being accepted just as much as our residents do.

Question #3: A Bugs Bunny insincere smile occurs when your what does not match your what?

In your ALF, it’s up to you to provide that feeling of acceptance and support for your resident. You have to encourage them to try, to cheer and root them on with a warm caring expression of support on your face.

Non-Verbal Prompt #2, #3, #4, #5 and #6 go to Geriatric & Aging Course

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During our weekly session, Allan stated, “I don’t know what went wrong. I was in my session with Betty, and she was mentioning her new boyfriend, and I just got really in sync with the discrepancies between her verbal and nonverbal communications. So, I brought them up, just like we learned how to do. All of a sudden, she’s hostile and defensive… she just shut down on me!”  Track 6 will outline four ways in which a therapist can respond to a client’s nonverbal behavior using Gestalt therapy.

I stated to Allan, “Well, your perceptions of her behaviors certainly seem accurate.  But there seem to be two factors that contributed to Betty’s being defensive.
— First, you had never responded to her nonverbal behavior in a session before. 
— Second, you didn’t introduce the approach you were using, so Betty did not know what to expect.
In the future, you might want to consider carefully introducing the ideas of Gestalt therapy, and starting by implementing only one or two approaches at a time.  Implementing complicated or multiple approaches early on might overload Betty.”

For Guideline #2, #3 and #4 go to Gestalt Course

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#1 Dissociation
As you are well aware, there are many kinds of dissociation.  However, I have found that, fundamentally, dissociation refers to a disconnection between experience and emotion, or between mind and body. See if any of these dissociative remarks sound familiar:

Here is grieving client observation
— Number One:
“It’s like I’m outside of my body looking in.”
– Number Two:
“I have no idea what I’m feeling”

Dave, age 17, made a third dissociative observation when he stated, “I knew I should have felt something, but I didn’t feel anything.”  Dave was referring to an accidental cut to his hand which happened several days after his best friend, Jeremy, died from a drug overdose.  Dave stated, “It was a deep cut.  The doctor gave me 9 stitches.  At first, I just watched the blood flowing out.  I didn’t feel any fear or pain.  I knew what was going on,  I just didn’t care.  Then my mom saw it and she freaked.  Her scream sort of woke me up, I guess.”   Later on this track, I will describe a technique I suggested Dave use to avoid similar dissociation.

For #2 and #3 ‘D’s of Grief go to Grief Course.

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Since it appeared that Perry was doing everything right physically, we discussed possible emotional conflicts, since he was looking for an answer in this area.  Perry began to come to the conclusion that the reason for his continued decline in T-cells was his addiction to having anonymous sexual encounters and how he felt about them.  Perry stated, “I know it’s not a good thing, but it’s like an addiction.  I want to stop sleeping around, but I can’t.”  Would you agree that Perry’s anonymous sexual encounters may have been a great source of distress?

I stated to Perry, “Identifying anonymous sexual encounters as a possible factor for emotional distress is only half the battle.  Knowing you are addicted is only the first step in healing the underlying reasons for that addiction.  Overcoming addiction can take time and effort.”  Because Perry clearly wanted to begin to acknowledge and accept his feelings, I recommended he attend a Sex and Love Addicts Anonymous meeting.  At Perry’s first meeting, he was more of an observer than a participant.  But gradually Perry began to share his feelings with the group.  Perry also began to share his experiences, distress, and his guilt.

After three months of this process, Perry stated, “My T-cell count has more than doubled!!  It went from 150 to over 300!  Those meetings are the only thing I’ve changed in the last three months!  Can you believe it?”  Subsequent tests showed that Perry’s T-cell count has now climbed to almost 400.  However, Perry’s situation is not unique.  A number of other HIV positive clients have experienced major improvements in T-cell counts through what they, like Perry, feel is solely through emotional growth.

Are you treating a client like Perry? Could he or she benefit from emotional growth?

For #2  Other Techniques for Emotional Healing go to HIV/AIDS Course

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#1 Preoccupation
The first stage of the addictive experience is preoccupation.  Pedophiles become hostages of their own obsession.  Do you agree?  Their obsessions about child pornography or other sexual acts which involve children become intrusive on their daily activities.  Jim, age 34, stated, “I couldn’t get these images out of my head.  They invaded my life.  I would start work, but then, all of a sudden, I would get flashes of my nephew in my mind, doing things I wish I hadn’t thought of.  Personally, I’ve never enacted them out with him, but I will go to websites and try to instant message kids, just so I can flirt with the ideas.”

I stated to Jim, “Because of your obsession, every introduction and meeting passes through your sexually obsessive filter.  Normally, these obsessions begin to interfere with daily life, and other areas are affected.  Does that ever happen with you?”  Jim stated, “Yeah, I couldn’t concentrate on work, all I could think about were these images and how to make them come about.  I can’t sleep, so I spend most of my time on the internet.  Sometimes, when I’m chatting with people I know are adults, I’ll fantasize that they’re really young teens.”

Clients like Jim are addicted to sexual behavior, and, in the case of pedophiles, become addicted and preoccupied with the thought of sexual acts with children.  I stated to Jim, “I’d like you to think of this preoccupation as a warning sign that’s telling you to watch your steps.  When you begin to feel the obsession taking over, be mindful of it and of your behaviors.”  Think of your Jim.  Is he experiencing this sexual preoccupation?  How would you address his preoccupation?

For #2, 3 and 4 Stages of a Pedophilic Addictive Experience go to Internet Course

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In our search, we found three examples for errors leading to opioid intoxication: inadvertently administering high-dose intrathecal tramadol instead of morphine leading to myoclonus, diaphoresis, and hypotension [10]; escalating the dosage of intravenous opioids too rapidly after withdrawal from the artificial respirator, followed by sedation and respiratory depression[12]; and mixing up basal rate and bolus dose in a pump of patient-controlled analgesia, leading to lethargy of the patient.[14] Although our literature search did not yield articles on errors in the management of symptoms other than pain, it seems plausible that errors occur just as well in treating nausea, vomiting, constipation, dyspnea, delirium, or any other frequent symptom in palliative patients.

Palliative care clinicians usually encounter patients who already have been diagnosed as suffering from a specific life-limiting disease. In some cases, previous preventive or diagnostic errors of colleagues may be retrospectively detected by palliative care clinicians. The example we found was a 48-year-old patient with metastatic cervical cancer, who had shown dysplasia in a Papanicolaou test 3 years prior, which had not been followed-up or prompted a colposcopy because the treating physician moved away and the communication to the new doctor was apparently insufficient.

For Relevance, Detection and Prevention of Medical Errors in Palliative Care go to Medical Errors Course

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Need #1: Preventing Humiliation
The first concept related to a narcissistic client’s need for power and control is preventing humiliation.  As stated earlier in the track, narcissistic clients often control the emotions of sadness and fear as a prevention against vulnerability.  This desire to remain seemingly powerful and in control often results as a defense mechanism developed in early childhood.  As children, I have found that these clients suffer a severe narcissistic injury or a blow to self-esteem that scars and shapes their personalities.

This injury most often entails humiliation, specifically the experience of being powerless while another person enjoys the exercise of power.  Often, this other person is a parent or guardian who uses physical strength to force the child into submission.  To regain their own sense of power, narcissistic clients will use their inability to feel in order to control others around them.

Holly, age 26, described many repeated instances of feeling powerless in her early childhood and adolescence.  She stated, “My parents were contemplating putting me in a mental hospital without telling me.  This was when I was seventeen.  On another occasion, when I was fourteen and away at camp, they changed my high school without asking me.”

When I asked about her parents, Holly stated, “My father is a bull!  He’s a person who controls people.  He always appears as a nice guy, and most people see him that way, but he causes so much disorder!  In business, he is ruthless.  His only trip is power—power and money.  He is rather handsome, but big and burly.  When he was angry, he was very frightening.”

From her description, I could deduce that Holly’s father was a narcissistic character who valued power and control.  Because of his own need for power, he took the control away from Holly in making decisions for her.  This left her feeling powerless and to regain that power, she suppressed her own feelings of sadness and fear.  Think of your Holly.  How has his or her own need for power affected his or her emotions and feelings?

For Need #2 & #3  and Technique : Rage Control go to Narcissism Course

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#1 Sensory Experiences
The first concept is sensory experiences.

Stacy, age 32, suffered from a fear of toilets and doorknobs.  To begin her imagined exposure therapy, I asked Stacy, “How would the external setting of this scene affect you if this were a real situation?  Think about all your senses.  For example, what are you seeing?  What can you smell?  What do you hear?  What do you feel or touch?  What do you taste?”

I asked Stacy to record her senses in her journal.  She stated, “I can see the toilet.  It’s white porcelain, stained slightly off white over the years.  The bathroom smells like my flowery soap, jasmine, which my grandmother gave me a long time ago.  The toilet is running.  I’ve just used the toilet and it needs to be flushed.  The handle is slightly cold to the touch.”

Think of your Stacy. Can you think of any other sense that he or she should be mindful of during his or her exposure?  How would you frame these questions differently?

For 2, 3 and 4  Concepts Regarding Behavioral Strategy go to OCD Course.

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#1 Anger Arising from Limitations
The first manifestation of anger is anger arising from limitations.  Clients who experience chronic pain find themselves constantly frustrated by the reduced scope of their abilities.  Because of their loss of independence, clients become angry at themselves for their lack of ability but also those who do not accept or recognize their limitations.  When another person asks a client to perform beyond their capabilities, the client becomes enraged at him or herself for not being able to accomplish it and also the other person for not recognizing and validating the client’s condition.

Carol, age 31, had an enflamed disc in her spine that caused her constant pain.  One day, a new manager at her office asked her to carry a box down to the warehouse.  Unable to carry the box, but also equally unable to explain her weakness to her manager, Carol instead asked one of her friends to do the task for her, but still complained about the ignorance of her new employer.  Carol stated, “He didn’t even ask me if I could carry that box, he just ordered me to!  He’s such an inconsiderate ass!  I bet if he expressed one ounce of concern for his employees, his head might implode.”

Carol’s unwarranted anger was quick in passing, but I still asked her to explain her condition to the manager the next day.  I stated, “I know that you know people cannot read minds.  If you do not explain to the people around you about your back pain, you will only find yourself becoming more and more angry at your situation.”  I asked Carol to make a list of people that should know about her condition to reduce the frequency of her angry outbursts.

Think of your Carol? Is he or she angry about his or her limitations?

For #2 and #3 Manifestations of Anger go to Pain Management Course

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