Free Persuasive Essay on Youth Sports

The Value and Problems Associated with Youth Sports Introduction The youth sport is a perfect way to spend leisure time with a beneficial effect on health and mind. However, there are various aspects, both positive and negative, influencing the expectations and preferences of young people, their parents, and coaches. The youths engaged in sports improve their fitness, develop physical skills and moral values. However, the injuries, insufficient financial support or misunderstanding of the real values can bring a negative effect. Although sport is valuable for the health and well-being of young people, there are numerous problems since it requires a personal approach and wise coordination of a young athlete.

Michael Collins, Astronaut of Apollo 11 Mission

Astronaut Michael Collins has often been called the forgotten astronaut. He flew to the Moon aboard Apollo 11 in July 1969, but never set foot there. During the mission, Collins orbited the Moon, doing photography and keeping the command module ready to receive moonwalkers Neil Armstrong  and Buzz Aldrin when they finished their surface mission. Fast Facts: Michael Collins Born: October 31, 1930, in Rome, ItalyParents: James Lawton Collins, Virginia Stewart CollinsSpouse: Patricia Mary FinneganChildren: Michael, Ann, and Kathleen Collins  Education: United States  Military Academy at West Point, Harvard UniversityMilitary Career: U.S. Air Force, Experimental Flight School, Edwards Air Force BaseNASA Accomplishments: Gemini astronaut, pilot of the Apollo 11 Command Module, flew to the Moon with Neil Armstrong and Buzz Armstrong.  Interesting Fact: Collins is a watercolor painter of Everglades scenes and aircraft.   Early Life Michael Collins was born on October 31, 1930, to James Lawton Collins and his wife Virginia Stewart Collins. His father was stationed in Rome, Italy, where Collins was born. The elder Collins was a career Army man, and the family moved quite often. Eventually, they settled in Washington, D.C., and Michael Collins attended St. Albans school before leaving to attend college at the United States Military Academy at West Point.   Collins graduated West Point on June 3, 1952, and immediately entered the United States Air Force to become a pilot. He took flight training in Texas. In 1960, he joined the USAF Experimental Test Pilot School at Edwards Air Force Base. Two years later, he applied to become an astronaut and was accepted into the program in 1963.   Collinss NASA Career Astronaut Michael Collins in his official NASA portrait. NASA   Michael Collins entered NASA in the third group of astronauts ever selected. By the time he joined the program, he had studied spaceflight basics as a graduate student, along with other future astronauts Joe Engle and Edward Givens. Astronaut Charlie Bassett (who died in a crash before he could fly in space) was also a classmate. During training, Collins specialized in extravehicular activity (EVA) planning for the Gemini program, as well as spacesuits for use during spacewalks.  He was assigned to the Gemini mission as the backup and flew aboard the Gemini 10 mission on July 18, 1966. It required Collins and his crewmate astronaut John Young to rendezvous with the Agena vehicles. They also performed other tests, and Collins did two spacewalks during their time on orbit.   Going to the Moon Upon his return to Earth, Collins began training for an Apollo mission. Eventually, he was assigned to Apollo 8. Due to some medical issues, Collins did not fly that mission but was instead assigned as the Capsule Communicator (known as Capcom) for that mission. His job was to handle all communications with Frank Borman, James Lovell, and William Anders on the flight. Following that mission, NASA announced the first team to go to the Moon: Neil Armstrong and Edwin Buzz Aldrin to land and explore, and Michael Collins to be Command Module pilot orbiting the Moon. Astronaut Michael Collins, command module pilot of the Apollo 11 lunar landing mission, studies flight plan during simulation training at the Kennedy Space Center in preparation for the mission. Bettmann Archive / Getty Images The three men lifted off from the Kennedy Space Center on the Apollo 11 mission on July 16, 1969.  Four days later, the Eagle lander separated from the command module, with Armstrong and Aldrin headed to the Moon. Collins job was to maintain the orbiter, follow the mission on the surface of the Moon, and photograph the Moon. Then, when the other two were ready, dock with their Eagle lander and bring the other two men back to safety. Collins performed his duties and in later years, admitted that he was very worried about Armstrong and Aldrin landing safely and getting back. The mission was a success, and upon their return, the three astronauts were heralded around the world as heroes.   Apollo 11 astronauts (L-R) Aldrin, Collins, Armstrong peering out window of quarantine room aboard recovery ship Hornet following splashdown fr. historic moon mission. The LIFE Picture Collection/Getty Images / Getty Images A New Career Path After the successful Apollo 11 flight, Michael Collins was tapped to join government service, where he was made the Assistant Secretary of State for Public Affairs late in 1969, serving under President Richard Nixon. He held that position until 1971, when he took over as Director of the National Air and Space Museum. Collins held that job until 1978 and then was appointed the undersecretary of the Smithsonian Institution (the parent body over the Air and Space Museum).   Since leaving the Smithsonian, Michael Collins has studied at Harvard Business School and served as vice president of LTV Aerospace. Hes also written several books, including his autobiography titled Carrying the Fire. He is also well-known as a watercolor painter, focusing on scenes in Florida and also on spacecraft and aircraft subjects.   Awards and Legacy Michael Collins is a retired USAF general  and belongs to a number of organizations, such as the Society of Experimental Test Pilots and the American Institute of Aeronautics and Astronautics. He was also inducted into the Astronaut Hall of Fame. Over the years, Collins has been given many awards and honors, including the Presidential Medal of Freedom, the NASA Exceptional Service Medal, Air Force Distinguished Service Medal, and NASAs Distinguished Service Medal. A lunar crater is named for him, as well as an asteroid. In a rare and unique honor, due to his involvement in several movies and TV, Collins and his fellow astronauts Armstrong and Aldrin have a star on the Hollywood Walk of Fame dedicated to the Apollo 11 astronauts. He also appeared in a documentary about his flight to the Moon.   Collins was married to Patricia Mary Finnegan until her death in 2014. He remains an active and sought-after public speaker and continues painting and writing. Sources Chandler, David L., and MIT News Office. â€Å"Michael Collins: ‘I Could Have Been the Last Person to Walk on the Moon.’† MIT News, 2 Apr. 2015, news.mit.edu/2015/michael-collins-speaks-about-first-moon-landing-0402.Dunbar, Brian. â€Å"NASA Honors Apollo Astronaut Michael Collins.† NASA, NASA, www.nasa.gov/home/hqnews/2006/jan/HQ_M06012_Collins.html.NASA, NASA, er.jsc.nasa.gov/seh/collinsm.htm.Nasa. â€Å"Michael Collins: The Lucky, Grumpy Astronaut - The Boston Globe.† BostonGlobe.com, 22 Oct. 2018, www.bostonglobe.com/opinion/2018/10/21/michael-collins-the-lucky-grumpy-astronaut/1U9cyEr7aRPidVuNbDDkfO/story.html.

Separation Of Church And State Essay - 1455 Words

Define Free: An Inside Look on Religion in the Workforce Is there moral truth? Where does it come from and who decides? Man? God? Do our beliefs truly matter in the face of society? Or is religion only to be kept silent in our own homes. Separation of Church and State. This statement has not only caused controversy in the â€Å"rights† a church has, but has also lessened the impact a person of faith can have on society. Separation of Church and State has been falsely identified as being a part of the first amendment, however it is directly stated in the US Constitution that Congress shall make no law prohibiting the practice of a religion or prohibiting the practice of this religion in the eyes of society. Not once is Separation of Church and State mentioned in the First Amendment. However due to this inaccurate assumption, those involved in a religious activities in public settings have been victims towards brutality and minor religious persecution. The rampant influx of religious brutality in society, especially towards employees of various professions, has brought the first amendment under flame as society is beginning to question the true validity in the idea of â€Å"freedom of religion†. Our Founding Fathers are mostly known for their pursuit towards life, liberty, and the pursuit of happiness. But what many Americans do not know is that our Founders were heavily religious and used their Christian ideology to form the Constitution. James Wilson, also known as â€Å"the lost Founder†Show MoreRelatedSeparation Of Church And State1446 Words   |  6 Pagesthe separation of church and state still necessary in the overall legal and social aspects of a modern society such as the United States? Research and history show that maintaining the church separate from the government is important for the ongoing success of a free and well functioning society. Separation of church and state is a political and legal doctrine which states that government and religious institutions are to be kept separate and independent from one another. Ideally, the church shouldRead MoreSeparation Of Church And State Essay1513 Words   |  7 PagesSeparation of church and state is a defined as, the understanding of the intent, and function of the Establishment Clause, and Free Exercise Clause. The Combination of church and state has been a topic that, many generations have struggled with for centuries. The first amendment of the constitution states that â€Å"Congress shall make no law about our religious beliefs, or prohibiting our free exercise of religion† If we put our faith in the constitution to define the founding father’s standpoint ofRead MoreThe Separation Of Church And State902 Words   |  4 PagesA Closer look at the Separation of Church and State in the United States Although â€Å"God† is mentioned in the Constitution, this country was built upon the principle of separation of church and state. Despite this ideal, those elected into office: propose, pass, and deny laws based on their religious beliefs, completely disregarding the previously mentioned principle. The problem with that is that the country is so ethnically and culturally diverse that one religion representing an entire nation ofRead MoreThe separation of church and state1200 Words   |  5 PagesThe separation of church and state has been a long debated topic in the history of America. Although founded upon Christian ideals, the framers of the Constitution explicitly outlined the government to function secularly, in what is commonly referred to as the â€Å"Establishment Clause†. When interpreting the Constitution in regards to religion, there are two primary philosophies. The first philosophy this paper will explore will be referred to as Positive Toleration. In gen eral, the idea of positiveRead MoreSeparation of Church and State701 Words   |  3 PagesSeparation of Church and State To understand Locke’s argument for the separation of church and state you first need to understand what the purpose of the government is. Locke stated that the government is supposed to support civil interest. These civil interests include property, life, and security. Therefore the government’s job is to protect the civil interests of the people using force lawfully. Once Locke institutes the power of the government he develops three important assumptions vitalRead MoreSeparation Of Church And State1095 Words   |  5 PagesThe separation of church and state has been encountered and challenged several times in the Supreme Court, which was first mentioned by Thomas Jefferson. However it is not solidly stated in the Constitution on what is right or wrong and good or bad. This theory was modified from various elements from the Constitution essentially the first and fourteenth amendments. In the first amendment it is written Congress shall make no law respecting an esta blishment of religion or prohibiting the free exerciseRead MoreThe Separation Of Church And State1632 Words   |  7 Pages We are currently living in a time where freedom of religion is guaranteed in the United States. It has been since the first amendment of the Declaration of Independence was adopted in 1791. The first amendment prohibits the making of any law respecting the establishment of religion or impeding the free exercise of religion ( (Rotunda, 2004). This amendment established the separation of church and government that our country was founded on and still practices today. We as Americans are freeRead MoreSeparation Of Church And State1825 Words   |  8 PagesSeparation of church and state refers to the division of the relationship between religion and government. Various laws apply to different countries around the world about the separation of church and state. Some involve religion so much into their daily lives; it controls how their country is run. In other places, where it is not mandated as much, it becomes a problem in disputing what is and what is not right. The United States of America faces this issue as they struggle deciding what the meaningRead MoreThe Separation Of Church And State1594 Words   |  7 Pagesdirection and control exercised over the actions of the members, citizens, and inhabitants of communities, societies, and states. While documents have been written to help the leaders of our country, there is constant debate over what changes need to be made. Some believe that the country is falling apart while others think minor adjustments need to be made. The separation of church and state is also a topic of debate. The question of what needs to be changed and where religion falls in all of this are alwaysRead MoreThe Separation Of Church And State Essay1641 Words   |  7 PagesThe separation between church and state is a debate that continues to grow with tension as the culture of America rapidly polarizes. A long-standing claim that America was founded on Christian doctrine is a common argument in favor of the church and state to remain tog ether, yet the most commonly used metaphor explaining what the â€Å"Separation of Church and State† contextually means in today’s terms is simply that government and religion should not coincide with one another in any capacity. Evidence

Management Skills - 2026 Words

Introduction Time is one of the most valuable resources for everyone. It should be managed properly by the managers of any organizations in order to run the organizations smoothly. And, Delegation is a process of assigning task by one person to the other. The purpose of this essay is to discuss how managers cannot function effectively without good Time Management and Delegation skills. It then discusses the benefits of time management and delegation, drawbacks of delegations and measures to improve time management and delegation skills. Time Management Managing time is very vital as time is very essential to everyone. Therefore, it should be used properly as it cannot be restored. It is a skill that anyone can develop if remain†¦show more content†¦It helps managers to become more productive which eventually helps the organization to gain more good reputation in outside world. Consequently, being productive means there is a chance of being promoted to next level as well. In addition, due to effective time management, there will be reduction in stress levels. The confidence level grows with the increase in the accomplishments as a result of proper time management. And by completing allocated tasks on time, you have plenty of time to relax and have fun that ultimately leads to having peace of mind. Having a peace of mind means more focused at what we do and therefore, as a result it will be helpful in being more creative and innovative at work than others. Another advantage of time management is that it helps to identify and eliminate time wasting actions. Furthermore, Delegation saves time and helps in increasing productivity. It benefits managers, as it will free up time for them. Delegations helps to priorities work as managers complete their more urgent tasks and delegate less important tasks to other subordinates. Weightman J described â€Å"Members of staff are valued when responsibility is delegated to them, but this involves delegating real responsibility, not just giving people jobs to do†(Pg. no. 100). Delegating task encourages and motivates subordinates, as they are given the responsibility to complete the task that willShow MoreRelatedManagement Skills1662 Words   |  7 Pagesmiddle managers and top managers. Each of the three managers has different specific ability required. This essay focuses on top-level managers and what are the skills necessary for top-level manager or Chief Executive Officers (CEOs). This thesis will also identifies the three types of managerial skill and compares Katz theory of Managerial S kills with Minzberg theory of Managerial Roles. Chief executives officers (CEOs) are certainly responsible enough for their position in the firm. â€Å"Top managersRead MoreManagement Skills And Leadership Skills1528 Words   |  7 PagesManagement Skill Builder Introduction Strong management and leadership is very crucial for business success. It helps in driving innovation, unlocking the potential of employees, as well as enabling the manager to drive growth and productivity. It is never fast, and it is not always simple to build up depth and strength in management or leadership capabilities. However, the possible benefits are vivid: increased performance and profitability, improved rates of survival, and better employee wellbeingRead MoreManagement Skills And People Skills1726 Words   |  7 Pagesleader? The attributes of effective leadership reside in two categories, management skills and people skills. Management skills, also known as the mechanics of leadership, are the core components to effectively managing a group of people. Though one may be quite effective at the people skills of leadership, if he cannot adequately delegate, communicate, and adapt, he will be disorganized and overwhelmed. Management skills take a well-meaning, but disorganized, individual and give him the power toRead MoreManagement Skills And Leadership Skills1528 Words   |  7 PagesManagement Skill Builder Introduction Strong management and leadership is very crucial for business success. It helps in driving innovation, unlocking the potential of employees, as well as enabling the manager to drive growth and productivity. It is never fast, and it is not always simple to build up depth and strength in management or leadership capabilities. However, the possible benefits are vivid: increased performance and profitability, improved rates of survival, and better employee wellbeingRead MoreCareer Management : Skills And Skills1482 Words   |  6 Pagesfollowing task, a skills audit has been introduced, highlighting current aptitudes and capabilities against professional standards. Moreover, advancement needs have been identified and the exercises required to meet them have been expressed with the audit. At long last, a duplicate of my CV has been displayed highlighting my improvement opportunities made evident from undertaking this unit. Skill Area Description of Specific Skill Evidence of skill How I’m doing Action Career management skills Taking onRead MoreThe Time Management Skills That Helped907 Words   |  4 Pagesweek, so having a planner allowed me to not confuse the idea that 2.1 is due on Thursday instead of Tuesday. This also helped me with thinking about how much time I have until the next project is due. Other time management skills that helped was goal setting and learning better study skills. The goal setting that helped was realizing what a SMART goal is; Specific, Measurable, Attainable, Realistic/Relevant, and Timely. For this semester, I was able to realize that unlike High School where I couldRead MoreGraduation Speech : Time Management, Memory Skills, And Study Skills1159 Words   |  5 Pagesclass has taught me how to succeed during my years in college. There are many things Student Success showed me that helped me during this first semester, but the four things that were most influential were Time Management, Memory Skills, Test Taking Skills, and Study Skills. Time Management was extremely helpful for me. Before college and before I took Student Success I never even thought about how I could arrange my day and time in order to be the most efficient I could. I would forget about my homeworkRead MoreThe Leadership And Management Skills1386 Words   |  6 PagesLeadership and Management Introduction   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Leadership management is one of the most essential facets in our current generation and those to come. Exceptional leadership and management skills have the capacity of successfully carrying a company from one stage of development to the next, which synchronizes aspects of technology and adequate research. The leadership and management skills exhibited by iconic leaders are worth emulating because their names are noted throughout history due toRead MoreGlobal Management Skills779 Words   |  4 PagesMINA MANAGEMENT INSTITUTE SHARING THE VISION OF EXCELLENCE GLOBAL MANAGEMENT SKILLS The collapse of international economic boundaries, rapid changes, workforce mobility and diversity, and the economic interdependence of countries is what is popularly known as Globalisation. This phenomena poses difficult challenges to everyone especially mangers to reassess their capabilities and get ready to manage internationally. The need arises from the fact that traditional management skills are designedRead MoreDeveloping Management Skills404131 Words   |  1617 Pagesan online assessment and preparation solution for courses in Principles of Management, Human Resources, Strategy, and Organizational Behavior that helps you actively study and prepare material for class. Chapter-by-chapter activities, including built-in pretests and posttests, focus on what you need to learn and to review in order to succeed. Visit www.mymanagementlab.com to learn more. DEVELOPING MANAGEMENT SKILLS EIGHTH EDITION David A. Whetten BRIGHAM YOUNG UNIVERSITY Kim S. Cameron

Asian Immigration And The United States - 2508 Words

Harmony Xu Asian Am 30W Final Paper Since immigration gates reopened in 1965 with the passing of the Taft-Hartley Act, Asian immigration has risen into the seven digits. Over the past few decades, Asians have established themselves amongst American society to the extent where Asian American Studies has become a subject of study amongst the most prestigious universities in the United States. Starting off as merely numbers, cheap numbers, that is, to plantation owners and railroad companies, the generations formed from these first migrants—the children and grandchildren of the first Asian settlers on American soil have fought for their rights in the Land Of The Free. These immigrants not only have achieved their right to be treated no†¦show more content†¦Liu grew up in Poughkeepsie, New York to Chinese immigrant parents from Taiwan. His Wikipedia page refers to him simply as an â€Å"American writer† as opposed to many Asian American figures who has their ethnic background noted before â€Å"Ame rican† in their description. Liu refers to himself as a â€Å"banana† where he is white by acclamation, and much like the claims of Takao Ozawa of the landmark court case in 1992—he does not physically look white. This clash would be the root of Liu’s struggle with his ethnic identity and race growing up. Liu did not grow up with a â€Å"tiger mom† in the likes of Amy Chua , but a relaxed father who spoke English better than typical Chinese immigrants and a mother who only wanted him to be a â€Å"good boy†. Eric Liu happily and completely assimilated into American culture, and it was not until after he was married in his late twenties did he begin to question his Chinese identity. For Eric Liu, his assimilation â€Å"began long before he was born†. For Eric Liu, he was completing his parents’ assimilation—parents whom immigrated to America with human and financial capital. In comparison to his peers, Eric Liu never knew how he was different aside from what he saw in the mirror because Eric Liu was raised in a middle class family. A mirror of the real life struggles of the Chinese fleeing China on the tail of a Japanese

Backpacking A Different Way Of Camping free essay sample

Backpacking: A Different Way Of Camping Essay, Research Paper Backpacking: A Different Way of Camping What is bivouacing? To most people, it is perceived as a clip to pack up the auto, thrust to local cantonment evidences, and spend the weekend in the great out-of-doorss. It is a clip to lark with household and friends around a campfire, singing vocals, playing games, and roasting marshmallows while listening to ghost narratives that can merely be heard while bivouacing. However, to the avid backpacker, bivouacing takes on a different position. While sing the great out-of-doorss is really similar to auto encampment, backpacking is really different in many respects. Preparation for backpacking and auto encampment and the venues where one can put up cantonment are really different. In either instance, sing the great out-of-doorss and its natural beauty can non be surpassed. With auto bivouacing the lone existent restriction is one # 8217 ; s vehicle. A individual is limited to the vehicle # 8217 ; s capacity to carry or tow. For illustration, a camper will convey a range, a 12 adult male collapsible shelter, two ice chests of meat and murphies, five gallons of H2O, and possibly tow a camper. On the other manus, when backpacking, the fortunes are really different. One is limited to his or her ain capablenesss: the sum of weight that can be carried, endurance degrees, merely to call a few. Commissariats must be carefully measured. If overloaded, it can impact public presentation while boosting to one # 8217 ; s finish, but if non adequate commissariats are carried it, will impact how long one can last out in the wilderness. The equipment must be minute in size and weight. Particular lightweight ranges, collapsible shelters, kiping bags, and apparels must be used when backpacking. The mean weight of a full back pack is about thirty- five lbs. A camper is wholly dependent on what is in his or her back pack to last in nature. Reaching one # 8217 ; s concluding finish for auto encampment and backpacking are besides really different. To acquire to the campground while auto encampment, one follows a Ro ad map to the park, drives to the Texas Ranger station, picks up a base on balls, and pulls in to the campground. Depending on the size of the park, there are normally 50 to one hundred campgrounds filled with weekend warriors. While backpacking, making the campground is a greater undertaking. First, the backpacker enters the park, gets a base on balls from the Texas Ranger station, and drives to the trail head. At the trail head one loads his or her cogwheel in the back pack and steadfastly attaches it to their waist and back. Finally, the backpackers hikes two to twelve stat mis to make their finish, following a topographical map and using a compass. If one is fortunate, there will be person bivouacing at the same site. Backpacking is normally done by oneself or in a group. Traveling to the public toilet is besides really different in both instances. For one, there are no portable public toilets while backpacking. A shovel and lavatory paper are a backpacker # 8217 ; s merely agencies. One picks a topographic point, digs a hole, and knee bends. It is a really peaceable experience with the birds chirping, the air current blowing, and trees rocking. While auto encampment, there is normally a communal public toilet that about ever odors of germicides or deodourants. Car encampment and backpacking are two signifiers of bivouacing that differ from each other in the regard that backpacking is a more independent signifier of bivouacing. If one feels like get awaying the metropolis merely for a few yearss, one can skip into a auto and thrust to a campsite. It is comparatively easy to fix for auto encampment, but backpacking is much more strict and requires much planning. Though more modification in what one can transport, backpacking allows a individual to see the out-of-doorss in a manner that auto encampment can non. The most beautiful sights are seen while backpacking, and this is because a auto can merely take one so far. Most backpackers experience something that most auto campers will neer see: the beauty of nature untouched by common adult male. Regardless of the manner of researching the great out-of-doorss, an exciting escapade awaits.

Cbt Case Study free essay sample

Case Study Identifying Information For the purposes of the case study the client will be called Jane. Jane is a 22 year old single white British female who lives with her parents in a house outside the city. She is heterosexual and has had a boyfriend for seven years. She feels unable to discuss her issues with her boyfriend. Her parents both have mental health issues and Jane does not feel able to talk to her mother about her problems. She has an older brother she has a good relationship who lives with his girlfriend, a four hour drive away. Jane is educated to degree level, having studied Criminology and is currently working part-time for her father managing his client accounts for a business he runs from home. A typical day involves organising all receipts and creating spreadsheets for each client’s accounts. Jane states she would like to get a full time job and be normal like her friends. Jane has a small circle of friends from university who she states have all gone onto full time employment. Jane also has a puppy she spends time looking after and taking for regular walks. Assessment Jane was referred following a health check at her GP surgery. She had been prescribed Citalopram 20mg by her GP for anxiety symptoms and panic attacks she had been having for two years. Jane has no previous contact with mental health services. Jane’s father had a diagnosis of Bi-Polar Disorder, her brother has Depression and her boyfriend has a diagnosis of Obsessive Compulsive Disorder which he is continuing treatment for. Jane’s anxiety/panic has increased over the past two years. She had read about Cognitive Behavioural Therapy on the Internet and was willing to see if it was help ease her anxiety symptoms. Jane stated that the problem started due to family issues in 2007. Her brother and father were estranged due to a financial disagreement and this resulted in Jane’s brother leaving the country with his girlfriend, causing Jane to become very distressed. Also during this time she was taking her final exams at University, Jane states this was when she experienced her first panic attack. She had spent the evening before her brother left the country, drinking alcohol with friends, she remembers feeling ‘hung-over’ the next day. While travelling in the car to the airport, with her brother and his girlfriend, Jane states she started to feel unwell, she found it difficult to breathe, felt hot, trapped and felt like she was going to faint. Jane stated she felt â€Å"embarrassed† and â€Å"stupid† and had since experienced other panic attacks and increased anxiety, anticipating panic attacks in social situations. Jane had reduced where she went to, finding herself unable to go anywhere she may have to meet new people. Her last panic attack happened when Jane visited her GP for a health check and fainted during the appointment, Jane has blood phobia and she stated she had not eaten since the day before and was extremely anxious about the any medical interventions. Jane believes it was a panic attack that caused her to faint. The GP prescribed her 20mg of Citalopram, a few weeks prior to her initial assessment with the therapist. When Jane and the therapist met for the initial session Jane described herself as feeling inadequate and as if she was trapped in a cycle of panic. Although Jane felt unhappy she had no suicidal ideation and she presented no risk to others. Jane stated she had become more anxious and that she had panic attacks at least twice a week. Prior to and during therapy, Jane was assessed using various measures. These enabled the therapist to formulate a hypothesis regarding the severity of the problem, also acting as a baseline, enabling the therapist and Jane to monitor progress throughout treatment. (Wells, 1997). The measures utilised in the initial assessment were a daily panic diary, Wells (1997) and a diary of obsessive- compulsive rituals, Wells (1997) a self rating scale completed by the client Jane. Other measures used were, The Panic Rating Scale (PRS) Wells (1997), the Social Phobia Scale, Wells (1997), used by the therapist to clarify which specific disorder was the main problem for Jane. Having collated information from the initial measures, a problem list was created so the therapist and Jane could decide what to focus on first. This list was based on Jane’s account of the worst problems which were given priority over those problems which were less distressing. Problem List 1. Anxiety/Panic attacks 2. Obsessive hand washing. 3. My relationship with my family. 4. Not having a full time job. 5. My relationship with my boyfriend Having collaboratively decided on the problem list, the therapist helped Jane reframe the problems into goals. As the problem list highlighted what was wrong, changing them into goals enabled Jane to approach her problems in a more focused way (Wells, 1997), the therapist discussed goals with Jane and she decided what she wanted to get from therapy. It was important for the therapist to ensure that any goals were realistic and achievable in the timeframe and this was conveyed to Jane (Padesky amp; Greenberger, 1995). Jane wanted to reduce her anxiety and expressed these goals:- 1. To understand why I have panic attacks. 2. To have an anxiety free day. 3. To reduce the amount of time worrying . To reduce obsessive hand washing at home. Case Formulation Jane stated that for about a year she had been repeating certain behaviours, which she believed prevented her from having panic attacks. This involved Jane washing her hands and any surrounding objects at least twice. Jane had a fear of consuming alcohol/drugs/caffeine/artificial sweeteners, she stated she had had her first panic attack the day after drinking alcohol and had read that all these substances could increase her anxiety. Jane had not drunk alcohol for 18 months as she felt this caused her anxiety and made her nable to control the panic attacks. Jane stated she feared that if any of these substances got on her hands and then into her mouth she would have a panic attack and faint. These beliefs increased Jane’s anxiety when Jane was exposed to any environment where these substances were present. This unfortunately was most of the time, Jane stated that every time she saw any of these substances consumed or even placed near her, she became anxious and had to wash her hands and any surrounding items which she may come into contact with again. These safety behaviours maintained the cycle of panic, Jane would always continue the routines that she believed prevented a panic attack. The worst case scenario for Jane was â€Å"the panic would never stop and I will go mad, causing my boyfriend to leave me†. Jane felt this would make everyone realise what she already knew, that she was worthless. Her last panic attack happened when Jane had visited her GP; this caused Jane feelings of shame. â€Å"There’s all these people achieving, doing great things and I can’t do the most basic things† The therapist used the Cognitive Model of Panic (Clark, 1986), initially developing the three key elements of the model to help socialise Jane to the thoughts, feelings and behaviour cycle (see diagram below) Cognitive Model of Panic Bodily sensations Emotional response Thought about sensation Clark (1986) Using a panic diary and a diary of obsessive-compulsive rituals, Jane was asked to keep a record of situations during the week where she felt anxious, and this was discussed in the next session. Jane stated she had not had any panic during the week, when discussing previous panic attacks during the session, Jane became anxious and the therapist used this incident to develop the following formulation. Heart beating fast/increase in body temperature Fear/dread I feel hot, I can’t control it Clark (1986) Jane stated she felt like she was sweating, she had difficulty breathing; felt faint, had feelings of not being here and felt like she was going crazy. All these symptoms suggested that Jane was experiencing a panic attack and Jane met the criteria for Panic Disorder, defined in the DSM IV and states that â€Å"panic attacks be recurrent and unexpected, at least one of the attacks be followed by at least one month of persistent concern about having additional attacks, worry about the implications or consequence of the attack, or a significant change in behaviour related to the attacks† (APA, 1994). During the sessions the therapist continued to socialise Jane to the model of panic (Clark, 1986); together Jane and the therapist looked at what kept the cycle going. The therapist continued to use the model formulation, with the addition of Jane’s catastrophic interpretation of bodily symptoms, to illustrate the connection between negative thoughts, emotion, physical symptoms. Social situation I will be unable to stay here Everyone will notice I am not coping I’m going to faint Sweating/breathing fast/dizzy Clark’s (1986) Cognitive Model of Panic. Progress of Treatment The therapist hypothesised that Jane’s symptoms continued due to Jane not understanding the physiological effects of anxiety. The results were a misinterpretation of what would happen to her while being anxious, and this maintained the panic cycle. Although Jane tried to avoid any anxiety by using safety behaviours, she eventually increased the anxiety she experienced. Session 1 After the initial assessment sessions, the therapist and Jane agreed to 8 sessions, with a review after 6 sessions. Jane and the therapist discussed that there may only be a small amount of progress or change during the sessions due to the complexity of Jane’s diagnosis and agreed to focus on understanding the cycle of panic (Clark, 1986) From the information gained from the formulation process, the therapist tried psycho education. The therapist was attempting to illicit a shift in Jane’s belief about what, how and why these symptoms were happening. The therapist discussed with Jane what she knew about anxiety and from this the therapist discovered that Jane was unsure of what anxiety was and the effects on the body. For the first few appointments the therapist knew it could be beneficial to concentrate on relaying information about anxiety, (Clark et al, 1989) focusing on Jane’s specific beliefs anxiety, the therapist wanted to try to reduce the problem by helping Jane recognise the connection between her symptoms. As Jane believed, â€Å"she was going mad†, the therapist was trying to help Jane understand the CBT model of anxiety and to alter Jane’s misunderstanding of the symptoms. The therapist and Jane discussed Jane’s belief that she would faint if she panicked, Jane had fixed beliefs about why she fainted. The therapist attempted to enable Jane to describe how her anxiety affected her during a ‘usual panic’. Instead Jane began to describe symptoms of social anxiety, this suggested to the therapist that the main problems could be a combination of /social phobia and obsessive behaviours; the following dialogue may help to illustrate this. T. When you begin to become anxious, what goes through your head? J. I need a backup plan; I need to know how to get out of there. Especially if it’s in an office, or a small room. T. What would happen if you did not get out? J. I would panic, and then pass out T. What would the reasons be for you to pass out? J. Because I was panicking. T. Have you passed out before when you have panicked? J. I have felt like it. T. So what sensations do you have when you’re panicking? J. The feeling rises up, I feel hot and I can’t see straight. I get red flashes in front of my eyes, like a warning. My vision goes hazy. I think everyone is looking at me. T. Do you think other people can see this? J. Yes. T. What do you think they see? J. That I’m struggling and I cannot cope or, I try to get out of the situation by pretending I feel ill before they notice. T. What would they notice, what would be different about you? J. I stick out like a beacon, I’m sweating, loads of sweat and my face is bright red. T. How red would your face be, as red as that â€Å"No Smoking† sign on the wall? J. Yes! I’m dripping with sweat and my eyes are really staring, feels like they stick out like in a cartoon, it’s ridiculous. T. How long before you would leave the situation? J. Sometimes the feeling goes, like I can control it. But I could not leave. There would be a stigma and then I could not go back, the anxiety would increase in that environment or somewhere similar. The therapist persisted with this example and tried to use guided discovery to help Jane get a more balanced view of the situation. (Padesky and Greenberger, 1995) T. So you would not go back? J. I would if I felt safe, like with my boyfriend or I could leave whenever I wanted to. It’s the last straw if I have to go. It makes it even harder. T. You say that sometimes it goes away. What’s different about then and times when you have to leave? J. It’s like I just know I have to leave. T. What do you think may happen if you stay with the feelings? J. That I will pass out. T. hat would that mean if you passed out? J. It would be the ultimate. It would mean that I could not cope with the situation. T. If you could not cope what would that mean? J. I can’t function, I can’t do anything. I‘m just no use. T. How much do you believe that? Can you rate it out of 100%? J. Now. About 60% if I did faint it would be about 100% T. Have you ever fainted due t o the sensations you have described to me? J. No. I have fainted because I’m squeamish. I don’t like blood. Or having any kind of tests at the GP. T. So do I understand you? You have never fainted due to the panic sensations? J. No. I’ve felt like it. T. So you’ve never passed out due to the symptoms? What do you make that? J. I don’t know, that would mean that what I believe is stupid. It’s hard to get my head around it. Session 2-3 The therapist used a social phobia/panic rating scale measures to ascertain the main problem; this was increasingly difficult as throughout each session the patient expanded on her symptoms. The therapist managed to understand that the patient avoided most social situations due to her beliefs about certain substances; this caused the obsessive hand-washing. This then had an impact on Jane’s ability to go anywhere in case she could not wash herself or objects around her. Jane also believed fainting from blood phobia had the same physical effects as panic, and she would faint if she panicked. It was complicated and the therapist attempted to draw out a formulation. I SEE A PERSON DRINKING ALCOHOL IT’S GOING TO GET ON MY HANDS AND INTO MY MOUTH I FEEL SICK, I’M GOING TO FAINT I FEEL DREAD, I FEEL ANXIOUS, SWEATING I MUST WASH MY HANDS TO STOP THE PANIC GETTING WORSE. Session 4 The formulation shows the extent of Jane’s panic and how her safety behaviours were impacting on all aspects of her life. The therapist attempted again to use information about the causes of anxiety and its effects on the body. The therapist explained what happens when you faint due to blood phobia, this was an attempt to supply Jane with counter evidence for her catastrophic interpretations of her panic. The therapist also used evidence to contrast the effects on the body when fainting and when panicking. After two sessions, the therapist continued to provide and attempted to relay the facts about the nature of anxiety/panic/fainting with the inclusion of behavioural experiments. Educational procedures are a valid part of overall cognitive restructuring strategies, incorporated with questioning evidence for misinterpretations and behavioural experiments (Wells, 1997) The therapist asked Jane to explain to the therapist the function/effects of adrenalin, to see if Jane was beginning to understand and if there had been any shift in her beliefs about panic. The following dialogue may help to illustrate the difficulties the therapist encountered; T. Over the last few sessions, we have been discussing anxiety and the function of adrenalin. Do you understand the physical changes we have looked at? Does it make sense to you? J. Yes. Something has clicked inside my head. I feel less insane now, I understand more about what’s going on. It makes things a little bit easier, but it takes time for it to sink in. T. Do you think you could explain to me what you understand about anxiety/adrenalin? J. As I interpret it is, I like to think of it as, â€Å"I’m not anxious it’s just my adrenalin, It’s just the effects of adrenalin effecting my body† but it’s hard to get from there, to accepting the adrenalin is not going to harm me. I know logically it’s not. But it’s still hard. T. That’s great you’re beginning to question what you have believed and are thinking there may be other explanations for your symptoms. J. Yes. But I still think it’s to do with luck. I have good or bad luck each day and that predicts whether I have a panic or not. I think I’ll be unlucky soon. Session 5-6 The therapist continued to try use behavioural experiments during the sessions to provide further evidence to try to alter Jane’s beliefs about anxiety. The therapist agreed with Jane that they would imitate all the symptoms of panic. Making the room hot, exercising to increase heart rate and body temperature, hyperventilation (ten minutes) Focusing on breathing/swallowing. This continued for most of session 5. As neither the therapist nor Jane fainted, they discussed this and Jane stated it was different in the session than when she with other people. Jane also stated she felt safe and trusted the therapist, she did not believe she could be strong enough to try the experiments alone, as it was â€Å"too scary† The therapist asked Jane to draw a picture of how she felt and put them on the diagram of a person, this then was used to compare with anxiety symptoms, while talking through them with the therapist. The therapist and Jane created a survey about fainting and Jane took this away as homework to gain further evidence. The survey included 6 different questions about fainting e. g. What people knew about fainting/how they would feel about seeing someone faint, etc. Treatment Outcome The treatment with Jane continues. The next session will be the 6th and there will be a review of progress and any improvements. There has been no improvement in measures as noted yet. The therapist intends to use a panic rating scale (PRS) Wells, (1997) during the next session. The therapist will continue to see Jane for two more sessions, lo oking at what Jane has found helpful/unhelpful. Discussion Overall the therapist found the therapy unsuccessful. Although Jane stated she found it helpful, it was difficult for the therapist to see the progress due to the many layers of complexity of Jane’s diagnosis. The therapist has grown more confident in the CBT process and understands that as a trainee, the therapist tried to incorporate all the new skills within each session. The therapist was disappointed that they were unable to guide Jane through the therapy process with a better result. The therapist would have like to have been able to fully establish an understanding of Jane’s complex symptoms earlier on in the therapy. The therapist believes that Jane’s symptoms were very complex and the therapist may have been more successful with a client with a less complicated diagnosis. The therapist would then be able to gain more information via the appropriate measures to enable the formulations in a concise manner. This has been a huge learning curve for the therapist and has encouraged them to seek out continuing CBT supervision within the therapist’s workplace. This is essential to continue the development of the therapist’s skills. The therapist feels that although this has not had the outcome that the therapist would have wanted, it has been a positive experience for Jane. There appeared to be a successful therapeutic relationship, Jane appeared comfortable and able to communicate what her problems were to the therapist from the beginning of therapy. The therapist hopes this will encourage Jane to engage with further CBT therapy in the future and the therapist over the final session hopes to be able to support Jane in creating a therapy blueprint, reviewing what Jane has found helpful. Certificate in CBT September – December 2009 CBT Case Study Panic/Social Phobia/OCD WORD COUNT 3,400 References APA (1994). Diagnostic Statistical Manual of Mental Disorders, Revised, 4th edn. Washington, DC: American Psychiatric Association Padesky, C. A amp; Greenberger, D. (1995). Clinicians Guide to Mind Over Mood. New York: Guilford Padesky, C. A amp; Greenberger, D. (1995). Mind Over Mood. New York: Guilford Wells, A (1997). Cognitive Therapy of Anxiety Disorders. Chichester, UK: Wiley