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Con- tract providers resisted participation for the low back pain guideline discount amitriptyline 10mg amex, and similar resistance was observed in other demon- strations. These attitudes are due in part to financial incentives created by their contracts, where they are paid based on the number of visits they complete, and time spent on any other ac- tivities is unpaid time. Individual MTFs are not likely to take the lead in communicating information or ideas with others because each of them has a full set of work commitments that tend to discourage it from looking beyond the MTF boundaries. Examples of issues that oc- curred in the low back pain demonstration (as well as later in the asthma and diabetes guideline demonstrations) include how to handle patients presenting with multiple concerns or diagnoses, placement of documentation forms in the medical chart, proce- dures for use of diagnostic codes for visits, and the reading level for patient education materials. Thus, consider replacing traditional utilization review functions with this more proactive approach to achieve appropriate and consistent practices. Resource limitations inevitably define the scope of implementation any given MTF can undertake. Priorities for action should be consis- tent with available resources, and in turn, the needed resources Lessons from the Low Back Pain Demonstration 105 should be provided to support the agreed-upon actions. Both the ac- tions defined and the allocation of resources should be time limited, so that the desired new practices can be successfully integrated into a clinic’s routine and then these resources can be reallocated to other priorities. Appendix A EVALUATION METHODOLOGY PROCESS EVALUATION To capture the full dynamics of a process as complex as practice guideline implementation, it is important to take into account the roles and interactions of the many aspects of the system in which the guidelines are being implemented. A variety of stakeholders need to be considered to ensure that indi- viduals involved in implementing new practices anticipate possible effects on the stakeholders and responses that might be expected from them. These groups include treatment program leadership, middle management, the clinical and administrative staff working with program residents, and the clients themselves. The implemen- tation team consists of important stakeholders who not only are serving as team members but also have other job responsibilities. Information was collected about the actions involved in practice guideline implementation for participating MTFs, the dynamics of the change process, and responses of participants to their experi- ences with the process.

More specifically this process entails the therapist ac- cepting and respecting the client’s cultural differences and then adapting one’s practice to become more relevant to the client trusted amitriptyline 25 mg. Furthermore, thera- pists need to develop a self-awareness of how they perceive others and of any judgments they may be making regarding their differences. In addi- tion, therapists need to make an extra effort to develop trust and coopera- tion with ethnically diverse clients who might come to therapy suspicious about the prominent culture. Cultural competence is especially critical in psychotherapy with couples and families, since culture influences all aspects of individual and family life and parent-child relationships (Samantrai, 2003). Couples with Adolescents 67 Children and adolescents from families of ethnic minorities are one of the largest growing segments of the U. A number of studies have shown a higher rate of dropping out from therapy than Anglo clients after the first session. The mental health system has often not responded to the needs of ethnic minorities. As therapists, we need to address what techniques and what conditions are most therapeutically effective with ethnically diverse populations. As mentioned in the beginning of this chapter, it is important not to overgeneralize regarding the relationship between the therapist and the ethnically diverse couple, but to tease apart the more specific factors that facilitate this therapeutic relationship. The degree of acculturation of the client, language fluency, diagnostic validity, symptom expression, and the client’s worldview have all been found to be significant influences on ther- apeutic effectiveness (Aponte et al. As therapists, we need to be sen- sitive to centicultural bias where criteria defined and validated in one culture are used to determine psychological disorder in another culture. The interaction between culture and symptom expression needs to be care- fully understood so as not to label a normative expression of a particular emotion in one culture as dysfunctional because of its current expression among professionals of a different culture (Falicov, 2003).

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Recipes for clinical care are supposed to dictate choices when doing so is really helpful 50 mg amitriptyline, but they always involve assumptions about narrative and descriptive context which need, at the proper time, to be examined. The fact that rigidity and automaticity work sometimes does not mean that they work all the time. Even in the greatest emergencies conditions may arise which demand that we not be creatures of protocol. The two great pitfalls around context which Dewey identifies are failing to consider context and its particularities, so that our actions become inappropriate in the light of it, and discounting central concerns and priorities because considerations are too diffuse. There is a time to discount and ignore and a time to pay attention to some individual fact; a time to accept the obvious and a time to question it. There is a time to concentrate and a time to look around; a time to make a judgment and a time to withhold one. Bayesian reasoning, with its controversial concept of prior probability is one attempt to assess, semi-formally, the importance of context. In a nutshell, it offers a method for weighting the significance of an individual piece of data given certain aspects of the context in which it occurs. Informally, we do this all the time, for example when we decide to double check a laboratory value which makes no sense in light of what we know already about a case. When studies come out "proving" that penicillin does not shorten the course of streptococcal pharyngitis, that antibiotics do not help cat scratch disease, that triglycerides do not affect heart disease, that ibuprofen is as safe as acetaminophen in children over six months and that post-menopausal estrogen causes breast cancer (or does not), that a high fiber diet can (or cannot) prevent colon cancer or that personality does or does not affect heart attack risk, we take all with "a grain of salt. No matter how compelling the statistical evidence internal to one study may be, it does not exist in a contextual vacuum. For example, suppose that a serologic test for HIV is positive in 95% of people actually infected with HIV and in 1% of people who are not infected. When such a test is used in a population "previously known" to have a low incidence of HIV infection, say "worried well college students" who havea1in1,000 chance of being infected, a positive test has much less predictive value than it does in a population of 1,000 prisoners whose "prior probability" of being infected is, say, 10%. When prior probabilities are actually applicable to the group being tested, and in this lies the controversy, the predictive value of the test comes out as follows: For the 1,000 college students 92 CHAPTER 3 there is one who will likely have a true positive test result and there are 10 who will have false positive tests. After the test, the probability of anyone testing positive actually being infected is about. The predictive value of a negative test only improves the odds that one is not infected in this group from.

Couples are able to make wonderful suggestions for the charac- ters in the movies generic 50mg amitriptyline amex, although that same couple or family may be too close to solve their own dilemma. A sampling of relevant movie options include: • The Trip to Bountiful (Geraldine Page and Rebecca De Mornay) • The Last of His Tribe (Graham Greene and John Voight) • Used People (Shirley MacLaine, Kathy Bates, and Marcello Mastroianni) • Fried Green Tomatoes (Kathy Bates, Jessica Tandy, and Mary Stuart Masterson) • Wrestling Ernest Hemingway (Robert Duvall, Richard Harris, and Piper Laurie) • Cocoon (Hume Cronyn, Wilford Brimley, Maureen Stapleton, and Jessica Tandy) • On Golden Pond (Henry Fonda, Jane Fonda, and Katharine Hepburn) • Nobody’s Fool (Paul Newman and Jessica Tandy) • Grumpy Old Men (Jack Lemmon, Walter Matthau, and Ann-Margret) • A Gathering of Old Men (Louis Gossett Jr. Gaines) • A Walk in the Clouds (Anthony Quinn, Keanu Reeves, and Aitana Sanchez-Gijon) • Steel Magnolias (Shirley MacLaine, Olympia Dukakis, Sally Fields, Dolly Parton, and Julia Roberts) • Parenthood (Steve Martin, Mary Steenbergen, Jason Robards, and Keanu Reeves) • Twilight Zone—Montage (excerpt on retirement home) • Driving Miss Daisy (Jessica Tandy and Morgan Freeman) • The Shadow Box (Joanne Woodward, Christopher Plummer, and Valerie Harper) • To Dance with the White Dog (Jessica Tandy and Hume Cronyn) • Nothing in Common (Tom Hanks and Jackie Gleason) • War of the Roses (Michael Douglas, Kathleen Turner, and Danny DeVito; a good one to scare people regarding divorce) • The Witches of Eastwick (Jack Nicholson, Cher, Susan Sarandon, and Michelle Pfeiffer) • Terms of Endearment (Shirley MacLaine, Jack Nicholson, and Debra Winger) • Home for the Holidays (Holly Hunter, Anne Bancroft, and Robert Downey Jr. The authors have used them in doctoral courses for psychologists and family therapists. Whenever the 86 LIFE CYCLE STAGES course is taught, the students regale us with additional movies they want to add. The format has also been effective with more experienced therapists as a vehicle to understand dynamics and plan therapeutic strategies. With older adults, it is not unusual that the partners have one or more previous marriages, following divorce or death of a spouse. We will con- sider some movie examples that portray challenges older couples may en- counter. These themes may include the couple themselves, with other tugs such as their children or their families of origin. Used People (1992) is a funny and memorable example to try out therapy options on families that would drive any therapist crazy. The main charac- ters include Shirley MacLaine, Marcello Mastroianni, Kathy Bates, and a cast of unforgettable family members. The Italians collide with the Jews after MacLaine’s first husband dies and Mastroianni’s character appears at the wake to pay his respects. He intimates that he met MacLaine’s husband at a time when the husband was about to leave his wife because she focused too much on her duties and grown children. MacLaine and her family were shocked that the charming Italian asked her to go out on a coffee date.