Evidence-Based Treatment of Post-Traumatic Stress Disorder

Evidence-Based Treatment of Post-Traumatic Stress Disorder

  

Luke Fullagar 

RMIT University

 

 

This paper outlines the evidence base for the treatment of post-traumatic stress disorder (PTSD) in adults. Due to its Australian-context, this paper primarily relies on the meta-analysis completed by the Australian Centre for Posttraumatic Mental Health (ACPMH ) in 2007 (ACPMH, 2007), which includes and transcends the prior seminal systematic meta-analysis undertaken by United Kingdom National Institute for Clinical Excellence (NICE) in 2005 (NICE, 2005). Given word restrictions, for brevity, study references in this paper will generally refer to additional studies included in the expanded evidence-base reviewed by the ACPMH, and should be taken as extending rather than ignoring the NICE evidence base (as is the spirit of the ACPMH report).

Currently, the strongest-evidence base for psychological treatment of adults with PTSD is in respect of two trauma-focussed interventions: trauma-focussed cognitive behavioural therapy (TF-CBT) and eye movement desensitization (EMDR) and reprocessing treatment together with in vivo exposure therapy (ACPMH, 2007).  Over 30 controlled studies support these broad conclusions and demonstrate effectiveness in both PTSD symptoms and with comorbid depression and anxiety (ACPMH, 2007).  The following expands on this evidence, and concludes with a comparison of these treatments, and their recommended application in clinical settings.

Randomised controlled trials comparing TF-CBT in a range of contexts (e.g. earthquake victims, partner abuse), have demonstrated consistent, statistically-significant clinical superiority to waitlist conditions in reducing PTSD symptom severity and post-treatment diagnosis (both self-reported and clinician-rated) (ACPMH, 2007; Ehlers et al., 2005; Kubany et al., 2004; Basoglu et al., 2005; Lindauer et al., 2005; McDonagh et al., 2005; Rothbaum et al., 2005).  Moreover, two studies have demonstrated statistically-significant improvements in functioning in people receiving FT-CBT when compared with waitlist-conditions (ACPMH, 2007; Ehlers et al., 2005; Basoglu et al., 2005).  While the NICE study found significant evidence favouring FT-CBT over waitlist-conditions in reducing anxiety-related symptoms, subsequent studies reviewed by the ACPMH found a variant, and overall lesser standard of evidence (ACPMH, 2007; McDonagh, 2005; Ehlers, 2005). The NICE study found limited evidence for clinical superiority of FT-CBT over waitlist conditions for depression symptoms (NICE, 2005), and while observing a range of studies with very low or no statistically-significant reductions in depressive-symptoms, the ACPMH study noted two studies which demonstrated this relationship in populations which were predominantly woman aged in their late 30s to 40s (ACPMH, 2007; Kubany 2004; Ehlers, 2005).  Currently, evidence is unclear on the efficacy or clinical importance of FT-CBT in increasing self-reported quality of life (ACPMH, 2007; McDonagh, 2005).

Similarly, there is limited, relevant evidence supporting EDMR over waitlist-conditions in reducing PTSD symptom severity and post-treatment diagnosis (both self-reported and clinician-rated), depressive symptoms, anxiety symptoms and in increasing self-reported quality of life (NICE, 2005).

When comparing these treatments, both the NICE and ACPMH meta-analyses revealed inconclusive evidence to determine whether TF-CBT and EDMR differ in clinical importance on reducing PTSD symptom severity, post-treatment diagnosis (both self-reported and clinician-rated), clinician-rated symptom severity at 3 month follow up, anxiety symptoms at treatment conclusion and at 2-5 month follow-up, and in increasing self-reported quality of life (ACPMH, 2007; NICE, 2005).  Evidence also suggests that there is unlikely to be a clinically important difference between these treatments in respect of self-reported PSTD symptoms at 3-month follow-up, self-reported depression symptoms at 2-5 month follow-up, and limited evidence favouring EDMR over TF-CBT in reducing self-reported depression symptoms at treatment cessation (ACPMH, 2007; NICE, 2005). 

However, despite these statistical results in meta-analyses, a close inspection of the cases making up these analyses reveals qualitative differences in follow-up outcomes (ACPMH, 2007). There is support for opposing views: two studies demonstrate exposure's superiority over EDMR (which demonstrated some return to baseline at follow-up) (Devilly & Spence, 1999; Taylor, 2003) and another with regard to depression and end-state functioning at follow-up (Rothbaum, 2005); while in the converse Ironson (2002) and Lee (2002) demonstrate EDMR's superiority at follow-up.  The ACPMH (2007) argue that alterations to contemporary EDMR which include in vivo exposure and CBT techniques such as cognitive interweaving, future templating, create confounds in this comparison, and that there is therefore a case for treating contemporary EDMR as a variant of TF-CBT (ACPMH, 2007).  This view is supported by evidence suggesting that the aforementioned elements of contemporary EDMR potentially contribute more than the eye-movements themselves (Foley & spates, 1995; Renfrey & Spates, 1994), and critically, the cognitive restructuring and exposure components. 

While some evidence exists suggesting that cognitive restructuring and exposure components are efficacious on their own and demonstrate no improved outcomes when combined (Bryant, 2005; Marks, 1998), the lack of independence between these two treatment variables confounds the current evidence, and accordingly, no conclusive position is yet available on this point (ACPMH, 2007).  On this point, it is also important to note that other treatments such as psychoeducation, anxiety management and stress-inoculation training – which have demonstrated better than wait-list effectiveness yet lower than trauma-focussed treatment effectiveness in reducing post-treatment diagnosis, on follow-up and in treating comorbidities – are all included as elements in the more efficacious trauma-focussed treatments described herein (ACPMH, 2007).

No current evidence base exists for recommending a number of treatment sessions, and studies included in meta-analyses have ranged from single sessions to treatment protocols of 4-14 sessions (ACPMH, 2007).

No current evidence exists demonstrating any superiority of pharmacotherapy over trauma-focussed psychotherapeutic interventions on any of the abovementioned measures, and importantly, on dealing with depression comorbidity (NICE, 2005). Accordingly, it is recommended by NICE and ACPMH that pharmacotherapy not form a routine non-selective first-line treatment for traumatised adults in preference to trauma-focussed psychotherapy (ACPMH, 2007). However, on the basis of a Cochrane Review (Stein et al, 2006), which demonstrates that the greatest number of trials demonstrating efficacy were in respect of SSRIs, ACPMH recommends that where medication is prescribed in the treatment of PTSD in traumatised adults, SSRI antidepressants should be the first-choice.

 

References

 

ACPMH (Australian Centre for Posttraumatic Mental Health). (2007). Australian Guidelines for Treatment of Adults with Acute Stress Disorder and Posttraumatic Stress Disorder. Melbourne: Australian Centre for Posttraumatic Mental Health.

Basoglu, M., Salcioglu, E., Livanou, M., Kalender, D., & Acar, G. (2005). Single-session behavioral treatment of earthquake-related posttraumatic stress disorder: A randomized waiting list controlled trial. Journal of Traumatic Stress, 18(1), 1–11.

Bryant, R. A., Moulds, M. L., Guthrie, R. M., & Nixon, R. D. V. (2005). The additive benefit of hypnosis and cognitive-behavioral therapy in treating acute stress disorder. Journal of Consulting and Clinical Psychology, 73(2), 334–340.

Devilly, G. J., & Spence, S. H. (1999). The relative efficacy and treatment distress of EMDR and a cognitive-behavior trauma treatment protocol in the amelioration of posttraumatic stress disorder. Journal of Anxiety Disorders, 13(1–2), 131–157.

Ehlers, A., Clark, D. M., Hackmann, A., McManus, F., & Fennell, M. (2005). Cognitive therapy for post-traumatic stress disorder: development and evaluation. Behaviour Research and Therapy, 43(4), 413–431.

Foley, T., & Spates, C. R. (1995). Eye movement desensitiation of public-speaking anxiety: A partial dismantling. Journal of Behavior Therapy and Experimental Psychiatry, 26, 321–329.

Ironson, G., Freund, B., Strauss, J. L., & Williams, J. (2002). Comparison of two treatments for traumatic stress: A community-based study of EMDR and prolonged exposure. Journal of Clinical Psychology, 58(1), 113–128.

Kubany, E. S., Hill, E. E., Owens, J. A., Iannce-Spencer, C., McCaig, M. A., Tremayne, K. J., & Williams, P. L. (2004). Cognitive Trauma Therapy for Battered Women With PTSD (CTT-BW). Journal of Consulting and Clinical Psychology, 72(1), 3–18.

Lee, C., Gavriel, H., Drummond, P., Richards, J., & Greenwald, R. (2002). Treatment of PTSD: Stress inoculation training with prolonged exposure compared to EMDR. Journal of Clinical Psychology, 58(9), 1071–1089.

Lindauer, R. J. L., Gersons, B. P. R., van Meijel, E. P. M., Blom, K., Carlier, I. V. E., Vrijlandt, I., & Olff, M. (2005). Effects of brief eclectic psychotherapy in patients with posttraumatic stress disorder: Randomized clinical trial. Journal of Traumatic Stress, 18(3), 205–212.

Marks, I., Lovell, K., Noshirvani, H., Livanou, M., & Thrasher, S. (1998). Treatment of posttraumatic stress disorder by exposure and/or cognitive restructuring: A controlled study. Archives of General Psychiatry, 55(4), 317–325.

McDonagh, A., Friedman, M., McHugo, G., Ford, J., Sengupta, A., Mueser, K., Demment, C. C., Fournier, D., Schnurr, P. P., & Descamps, M. (2005). Randomized trial of cognitive-behavioral therapy for chronic posttraumatic stress disorder in adult female survivors of childhood sexual abuse. Journal of Consulting and Clinical Psychology, 73(3), 515–524.

NICE (National Institute for Clinical Excellence) (2005). The Management of PTSD in Adults and Children in Primary and Secondary Care (Vol. 26). Wilshire: Cromwell Press Ltd.

Renfrey, G., & Spates, C. G. (1994). Eye movement desinsitization: A partial dismantling study. Journal of Behavior Therapy and Experimental Psychiatry, 25, 231–239.

Rothbaum, B. O., Astin, M. C., & Marsteller, F. (2005). Prolonged exposure versus eye movement desensitization and reprocessing (EMDR) for PTSD rape victims. Journal of Traumatic Stress, 18(6), 607–616.

Stein, D. J., Ipser, J. C., & Seedat, S. (2006). Pharmacotherapy for post traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews(1).

Taylor, S., Thordarson, D. S., Maxfield, L., Fedoroff, I. C., Lovell, K., & Ogrodniczuk, J. (2003). Comparative efficacy, speed, and adverse effects of three PTSD treatments: exposure therapy, EMDR, and relaxation training. Journal of Consulting and Clinical Psychology, 71(2), 330–338.

 

35!

35 spins around that shiner,

Happier, luckier, never wiser,

35 more to make it finer,

'til I will my days from a Jason Recliner.

- Enmore, 23 September 2012.

Reflections on the Aetiology, Pathogenesis and Diagnostic Reassignment of Gambling Dysfunctions in the DSM-V

Reflections on the Etiology, Pathogenesis and Diagnostic Reassignment of Gambling Dysfunctions in the DSM-V

Luke Fullagar

RMIT University

Academic debate has not reached a universally accepted conclusion on the etiology and pathology of dysfunctionalgambling. Current theory and empirical research remains uncertain on whether dysfunctional gambling should most parsimoniously be considered a behavioral addiction, an obsessive-compulsive or a disorder of impulse control (APA, 2010).  This poses difficulties for both treatment development and diagnosis.  Moreover, contemporary research has demonstrated that dysfunctional gambling may not form one disorder arising in a homogenous population, but may instead be more accurately explained as a heterogenous group of populations differentiated in etiology, pathogenesis and severity, despite the display of similar phenomenological features (Blaszczynski & Nower, 2002). 

The history of the Diagnostic and Statistical Manual's (DSM) treatment of dysfunctional gambling highlights both the uncertiainty which has pervaded classification, and the development over time in understanding its complex of contributory factors. Based on significantly limited research (Blaszcynski, 2005; Rodda, Lubman & Latage, 2012), a diagnosis of Pathological Gambling was originally included in the DSM-III as a disorder of impulse control. Remodeling of criteria in the DSM-III-R was similarly undertaken with minimal recourse to empirical research (Blaszcynski, 2005) and based on substance abuse characterisations which included items of preoccupation, tolerance, withdrawal and efforts to minimise or eliminate gambling (APS, 2010; Rodda, Lubman & Latage, 2012). This model largely endured in the DSM-IV and is currently the dominant theoretical paradigm (Blaszczynski & Nower, 2002; National Research Council, 1999). However, a line of developing research on gambling uses for mood regulation (e.g. dissociation) and not impulse control (Anderson & Brown, 1984; Jacobs, 1986) was recognised by the addition of a new item 'gambling as a means of escape'.  Important also was Rosenthal's (1989) suggestion in the DSM-IV review process that criteria should account for the progressive nature of dysfunctional gambling, and distinguish between pathological and non-pathological variants. 

Indeed, in the 30 years since the first inclusion of gambling in the DSM, myriad course identifiers and predictive risk factors associated with dysfunctional gambling have been demonstrated, including: access, impulsivity, biological vulnerabilities, behavioural conditioning, emotional-regulation issues, family history, peer group influences and pre-existing psychopathology (Blaszczynski & Nower, 2007; Brewer, Grant, & Potenza, 2008; Toneatto & Nguyen, 2007).   In recent times, a number of multifactorial integrated biopsychosocial models have been advanced in an attempt to coherently assimilate these research findings (APS, 2010). Chief among these is the Pathways Model (Blaszczynski & Nower, 2007) which advances three subtypes differentiated on pathogenesis and increasing severity: (1) behaviourally-conditioned gamblers affected primarily by access, conditioning and cognitive processes; (2) emotionally-vulnerable gamblers for whom behavioral conditioning and erroneous cognitions are intensified by extant psychopatholgy including prior emotional and family disturbances, poor coping skills, low-self esteem, and social isolation, and for whom gambling is also a strategy for mood regulation (e.g. dissociation) and induction (e.g. arousal); and  (3) impulsive anti-social problem gamblers for whom preexisting psychopatholgy, genetic and neurochemical factors interact to intensify impulsivity and need for stimulation (Blaszczynski & Nower, 2002; APA, 2010; Blaszczynski & Nower, 2007). 

However, despite this growing evidence of a complex heterogeneous set of circumstances, it is proposed that the DSM Pathological Gambling diagnosis be reclassified as a one-dimensional behavioral addiction labeled DisorderedGambling in the DSM-V.  Some support exists for an addiction model. Clinical and epidemiological studies demonstrate high comorbidity with substance abuse (Petry, 2005). Problem gamblers also present with excessive preoccupation and urges to gamble despite negative consequences, difficulty with reduction and cessation (cf. Blaszczynski & Nower, 2002), and symptoms of withdrawal and tolerance (XXX; APA, 2010). 

However, this model has also drawn significant critique.  Substances, unlike gambling, directly reinforce cognitive and neurological processes that adapt and develop dependence. Studies observing boredom in participants engaging in moneyless simulated gambling are used as evidence that the arousal to gamble is associated with anticipated wins not the consequence of the direct act itself (Blaszczynski, 2005).  Moreover, it is argued that the chasing behaviour witnessed in dysfunctional gamblers is wrongly paralleled with dose tolerance in substance abuse, and better understood as at attempt to recoup lost money (Blaszczynski & Nower, 2002).  Furthermore, evidence that dysfunctional gambling is often motivated by a range of persistent erroneous and irrational beliefs which disregard logical probability and mutual independence of chance events despite direct and experiential evidence to the contrary (APA, 2010), is used to mount the argument that symptoms of dependence in dysfunctional gambling are of a cognitive rather than addictive nature (Blaszczynski, 2005).

In light of the above, it appears that a one-dimensional behavioral addiction model suggested for the DSM-V is unreflective of the evidence for a heterogenous condition of varying etiology, pathogenesis and severity, and accordingly a premature conclusion on the matter of dysfunctional gambling. While some arguments have been leveled that an addictions model may result in a practical increase in treatment within a professional and lay culture acquainted with the structure of addictions-modelling for other disorders (e.g. Petry, 2006; Potenza, 2006), the potential risks of unwarranted and incorrect stigmatization, slippery-slope arguments for restriction of other social freedoms, and the evidence for variant forms of gambling dysfunction lead to a conclusion that these positives are not outweighed by their disadvantages.

References

Anderson, G., & Brown, R. I. F. (1984). Real and laboratory gambling: Sensation-seeking and arousal. British Journal of Psychology, 75, 401-410.

APS Australian Psychological Society - Gambling Working Group. (2010). Special Report: The Psychology of Gambling. InPsych, 6, 1-15.

Blaszczynski, A. (2005). To formulate gambling policies on the premise that problem gambling is an addiction may be premature. Addiction, 100(9), 1230-1232.

Blaszczynski, A., & Nower, L. (2002). A pathways model of problem and pathological gambling. Addiction, 97, 487-499.

Blaszczynski, A., & Nower, L. (2007). Etiological processes. In G. Smith, D. Hodgins, & R. Williams (Eds.), Research and measurement issues in gambling studies. Elsevier: Toronto. pp.317-338.

Brewer, J. A., Grant, J. E., & Potenza, M.N. (2008). The treatment of pathological gambling. Addictive Disorders Treatment, 7, 1-13.

Jacobs, D. F. (1986). A general theory of addictions: A new theoretical model. Journal of Gambling Behavior, 2, 15-31.

National Research Council (1999). Pathological gambling: A critical review. Washington D.C.: National Academy Press.

Rodda, S. N., Lubman, D. I., & Latage, K. (2012) Problem gambling; aetiology, identification and management. Australian Family Practice, in press.

Petry, N. M. (2005). Pathological gambling: Etiology, comorbidity and treatment. Washington D.C.: American Psychological Association.

Petry, N. (2006). Should the scope of addictive behaviors be broadened to include pathological gambling? Addiction, 101, 152-160.

Potenza, M. (2007). Should addictive disorders include non-substance-related conditions? Addiction, 101,142-151

Rosenthal, R. J. (1989). Pathological gambling and problem gambling. Problems of definition and

diagnosis. In H.J. Shaffer, S. Stein, B. Gambino, and T.N. Cummings, (Eds.), Compulsive gambling: theory, research, and practice. MA, England. Lexington. pp.101-125.

Toneatto, T., & Nguyen, L. (2007). Individual Characteristics and Problem Gambling Behavior. In G.

Smith, D. Hodgins & R. Williams (Eds). Research and measurement issues in gambling studies, Sydney: Elsevier. pp. 92-103. Toneatto, T. & Gunaratne, C. (2009). Does the treatment of cognitive distortions improve clinical outcomes for problem gambling? Journal of contemporary psychotherapy, 39, 221-229.

O'Brien, C. (2011). Addiction and dependence in DSM-V. Addiction. 106(5), 866-867.

The Evolving Role of Psychologists Diagnosis and Management of Alzheimer's Disease in light of Promising Developments in Research on Biomarkers for Brain Amyloid Deposition.

The Evolving Role of Psychologists Diagnosis and Management of Alzheimer's Disease in light of Promising Developments in Research on Biomarkers for Brain Amyloid Deposition.

Luke Fullagar

RMIT University

As biomarker research into Alzheimer's Disease (AD) develops, psychologists will play a critical role in evolving psychological research, assessment tools and interventions to better understand, diagnose, prevent and treat cognitive and behavioral factors at all stages of the disease (in particular, early and presymptomatic stages). Psychologists will also provide essential diagnostic and management services as part of interdisciplinary healthcare teams in allied health settings.

The success of neuropsychological, biomarker and neuroimaging research, and their correlations, demonstrates that AD is a complex disease expressed in both biological and psychological dimensions. Longitudinal findings demonstrate that AD risk factors are genetic, biological and behavioural (Schaie, 2005; Brooks & Loewenstein, 2010), and that there is significant heterogeneity in each factor's pathogenesis and in how each factor relates to the disease at its varying stages (Schaie, 2005; Brooks & Loewenstein, 2010). While significant advances have been made in the prediction of AD using biomarker and neuroimaging techniques, it is neuropsychological and cognitive assessments that will continue to enable these biological results to be linked to clinical symptoms (Rockwood, 2010; APA 2012) – a point highlighted by their almost ubiquitous use as an outcome measure in studies assessing the utility of biological measures (Blacker, et al., 2007; Gomar, et al., 2011; APA 2012).  It is impossible to provide diagnostic, prognostic and disease progression indications specifically related to the cognitive and behavioral aspects of the clinical syndrome with biomarkers alone (Rockwood, 2010).  Accordingly, efficacious developments involving biomarkers will concurrently demand enhancements in the sensitivity of neuropsychological testing and assessment techniques – particularly in early and presymptomatic stages of AD (APA, 2012).  Indeed, as biomarker research progresses, neuropsychological assessment and evaluation will be required in corroborating evidence of AD onset, functional expression, rate of decline, functional capacity and success in response to biomarker therapies (APA, 2012).

Biomarker research has demonstrated particularly successful results in predicting development to mild cognitive impairment and AD from healthy populations (Graff-Radford et al., 2007; Stomrud et al., 2010; Lo et al., 2011; Jack, Knopman & Jagust, 2010), and the possibility of using biomarkers in early detection, and in identifying at-risk people at a presymptomatic stage, holds considerable promise (Brooks & Loewenstein, 2010).  However, while biomarker research is impressively sensitive, specificity results are mixed – making uncertain whether biomarkers can yet accurately distinguish between etiologically distinct dementias (Rockwood, 2010). This is of particular importance given AD pathology often arises without manifest cognitive symptoms during life, and also given many MCI cases do not include AD pathology (Rowe et al., 2010; Brooks & Loewenstein, 2010). In contrast, neuropsychological testing has demonstrated better sensitivity in predicting conversion to AD than most biomarkers (Gomar et al., 2011; Heister et al., 2011; APA, 2012), and when coupled with serial functional assessment remains the 'gold standard' for differential diagnosis in discriminating between AD from age-related cognitive decline, cognitive difficulties related to psychiatric or medical morbidities, and other related disorders (APA, 2012; Brooks & Loewenstein, 2010).  As biomarker research develops, it is hoped that interdisciplinary assessments will evolve to fill the specificity gap and enhance diagnosis and prognosis. Indeed, given biological testing and psychological evaluation and assessment each provide unique information and variance, it is no surprise that recent studies have demonstrated that their combination across serial assessments predicts progression from MCI to AD better than either technique in isolation (Landau, 2010).

As interdisciplinary approaches evolve, there will be increased demand for psychologists to provide, exchange and integrate diagnostic, prognostic and disease progression information alongside other allied health providers, and specifically, the medical profession (APA, 2012).  Psychologists will not only be essential service providers in this model, but are also well poised to contribute to research on enhancing communication between health providers, patients and caregivers, and tailoring 'best-practice' interactions for these parties (APA, 2012).

Early detection on the basis of amyloid deposition raises the concern that people may suffer needless stress before any cognitive, behavioral or neurodegenerative symptoms are identified (APA, 2012). Psychologists will be required to develop counseling and support approaches for these patients and educational approaches which counter risks of avoidance and denial, and enhance proactive engagement with diagnosis (APA, 2012). Moreover, biomarker research will also not replace cognitive and behavioral prevention strategies, which will continue to be successfully administered to at-risk and early-diagnosed people by psychologists. Psychologists are well-poised to provide educational interventions to alert those at potential risk to empirically-validated modifiable risk factors for AD (midlife obesity, smoking, depression, cognitive and physical inactivity, low-educational attainment) (Barnes & Yaffe, 2011), as well as behavioral therapies to reduce the incidence of these risk factors (APA, 2012).  Lifestyle behavior research has shown promising results for prevention, both in linking cognition and exercise (Colcombe et al, 2003), and also in respect of cognitive training programs (Smith et al., 2009; Basak, Boot, Voss & Kramer, 2008) (APA, 2012). 

Where the disease does progress, psychologists are also essential in assisting patients, family and carers develop advanced care planning, and in administering psychotherapeutic interventions designed to manage patient and caregiver stress, adjustment and acceptance, and coping with difficult behavioral alterations (APA, 2012). Research has shown that multiple psychologist-led face-to-face educational sessions are the most effective way to develop advanced care plans (Bravo, Dubois & Wagneur, 2008; APA, 2012). This is no small concern given 40% do not pursue advance care planning even when medical practitioners and social workers are involved (Garand, Dew, Lingler & DeKosky, 2011; APA, 2012). 

At later stages of AD, behavioral interventions are also effective in addressing negative emotional and social outcomes (Teri, McCurry, Logsdon & Gibbons, 2005), and are of critical importance given the limited efficacy of medication treatment in these populations (Sink, Holden & Yaffe, 2005; AGS, 2011). Psychologists also assist in the provision of optimal stimulation and positive engagement for late-stage AD patients for whom apathy is a central behavioral and emotional challenge (Lin et al, 2009; APA 2012). 

Evidence-based interventions for the health and wellbeing of carers and family have also been successful addressing caregiver burdens (predominantly depression), and are an example of interdisciplinary programs which combine remote access medical treatment with integrated allied health teams to provide acute psychological and social supports (Eisdoerfer et al., 2003; Finkel et al., 2007; APA, 2012).  Across the spectrum of AD management services, psychologists will remain critical service providers, and will continue to develop and administer essential neuropsychological and cognitive tests and functional assessment protocols, assess decision making capacity, develop evidence-based interventions to address differentiated forms of age-related cognitive decline, and educate patients and families on the nature and progression of AD (APA, 2012).

AD is a multifaceted disorder which has expression and effects which are biological, psychological and social. Psychologists will be required to adapt and integrate with biomarker and neuroimaging evidence in an interdisciplinary future which reflects in this complexity.

 

References

 

AGS, American Geriatrics Society (2011). Guide to the Management of Psychotic Disorders and Neuropsychiatric symptoms of dementia in older adults. Retrieved September 3, 2012 from http://dementia.americangeriatrics.org/GeriPsych_index.php#1

APA, American Psychological Association. (2012). APA Comments on the Draft Framework for the National Plan to Address Alzheimer's Disease. Submission to the consultation on the National Plan to Address Alzheimer's Disease. Washington, DC, USA. Retreived September 3, 2012 from http://www.apa.org/pi/aging/resources/alzheimer-comments.pdf

Barnes, D.E. & Yaffe, K. (2011). The projected effect of risk factor reduction on Alzheimer's Disease prevalence. Lancet Neurology, 10, 819-828.

Basak, C., Boot, W.R., Voss, M., & Kramer, A.F. (2008). Can training in a real-time strategy videogame attenuate cognitive decline in older adults? Psychology and Aging, 23, 765-777.

Blacker, D., Lee, H., Muzikansky, A., Martin E., Tanzi, R., McArdle, J., Moss, M., & Albert, M. (2007). Neuropsychological measures in normal individuals that predict subsequent cognitive decline. Archives of Neurology, 64, 862-871.

Bravo, G. A., Dubois, M.-F., & Wagneur, S. (2008) Assessing the effectiveness of interventions to promote advance directives among older adults: A systematic review and multi-level analysis. Social Science & Medicine, 67, 1122–1132

Brooks, L.G. & Lowenstein, D.A. (2010). Assessing the progression of mild cognitive impairment to Alzheimer's disease: current trends and future directions. Alzheimer's Research and Therapy, 2(28), 1-9.

Colcombe, S. J., Erickson, K. I., Raz, N., Webb, A. G., Cohen, N. J., McAuley, E., & Kramer, A. F.  (2003). Aerobic fitness reduces brain tissue loss in aging humans. The Journals of Gerontology, Series A: Biological Sciences and Medical Sciences, 58, 176-180.

Garand, L. , Dew, M. A., Lingler, J. H.,  & DeKosky, S. T. (2011) Incidence and predictors of advance care planning among persons with cognitive impairment. American Journal of Geriatric Psychiatry, 19(8), 23-30.

Gomar J. J., Bobes-Bascaran, M. T., Conejero-Goldberg, C., Davies, P., & Goldberg, T. E. & Alzheimer's Disease Neuroimaging Initiative (2011). Utility of combinations of biomarkers, cognitive markers, and risk factors to predict conversion from mild cognitive impairment to Alzheimer disease in patients in the Alzheimer's Disease neuroimaging initiative. Archives of General Psychiatry, 68, 961-969.

Eisdorfer, C. E., Czaja, S. J., Loewenstein, D. L., Rubert, M. P., Arguelles, S., Mitrani, V., & Szapocznik, J. (2003). The effect of a family therapy and technology-based intervention on caregiver depression. The Gerontologist, 43, 521-531.

Finkel, S.I., Czaja, S.J., Schulz, R., Martinovich, Z., Harris, C., & Pezzuto, D. (2007). E-Care: A Telecommunications technology intervention for family caregivers of dementia patients. American Journal of Geriatric Psychiatry, 15, 443-448

Graff –Radford, N.R., Crook, J.E., Lucas, J., Boeve, B.F., Knopman, D.S., Ivnik, R.J., Smith, G.E., Younkin, L.H., Petersen, R.C., Younkin, S.G. (2007). Association of low plasma Aβ42/Aβ40 ratios with increased imminent risk for mild cognitive impairment and Alzheimer disease. Archives of Neurology, 64, 354-362.

Heister, D., Brewer, J., Magda, S., Blennow, K., McEvoy, L., & for the Alzheimer's Disease Neuroimaging Initiative. (2011). Predicting MCI outcome with clinically available MRI and CSF biomarkers. Neurology, 77, 1619-1628.

Jack, C.R., Knopman, D.S. & Jagust, W.J. (2010). Hypothetical Model of dynamic biomarkers of the Alzheimer's pathological cascade. Lancet Neurology, 9(1), 119-128.

Landau, S.M., Harvey, D., Madison, C.M., Reiman, E.M., Foster, N.L., Aisen, P.S., Petersen, R.C., Shaw L.M., Trojanowski, J.Q., et al. (2010) Comparing predictors of conversion and decline in mild cognitive impairment. Neurology, 75, 230-238.

Lin, L., Wu, S., Kao, C., Tzeng, Y., Watson, R., & Tang, S. (2009). Single ability among activities of daily living as a predictor of agitation. Journal of Clinical Nursing, 18, 117-123.

Lo, R.Y., Hubbard, A.E., Shaw, L.M. Trojanwski, M.D., Petersen, M.D., Aisen, P.S., Weiner, M, W, Jagust, W. J. (2011). Longitudinal change of biomarkers in cognitive decline. Archives of Neurology, 68(10), 1257-1266.

Rockwood, K. (2010). Con: Can biomarkers be gold standards in Alzheimer's disease? Alzheimer's Research and Theory, 2, 16-24.

Rowe, C.C., Ellis, K.A., Rimajova, M., Bourgeat, P., Pike, K.E., Jones, G., Fripp, J., Tochon-Danguy, H., Morandeau, L.,et al. (2010) Amyloid imaging results from the Australian Imaging, Biomarkers and Lifestyle (AIBL) study of aging. Neurobiology of Aging, 31.1275-1283.

Sink K. M., Holden, K. F., & Yaffe, K. (2005). Pharmacological treatment of neuropsychiatric symptoms of dementia: A review of the evidence. Journal of the American Medical Association, 293, 596-608.

Smith, G. E., Housen, P., Yaffe, K., Ruff, R., Kennison, R. F., Mahncke, H. W., & Zelinski, E. A. (2009). A cognitive training program based on principles of brain plasticity: Results from the improvement in memory with plasticity-based adaptive cognitive training (IMPACT) study. Journal of the American Geriatrics Society, 57, 594-603.

Schaie, K. W. (2005). Developmental influences on adult intelligence: The Seattle Longitudinal Study. New York, NY: Oxford University Press.

Stomrud, E., Hansson, O., Zetterberg, H., Blennow, K., Minthon, L., Londos, E. (2010). Correlation of longitudinal cerebrospinal fluid biomarkers with cognitive decline in healthy older adults. Archives of Neurology, 67, 217-223.

Teri, L., McCurry, S. M., Logsdon, R., & Gibbons, L. E. (2005). Training community consultants to help family members improve dementia care: a randomized controlled trial. The Gerontologist, 45, 802–811.

 

 

 

 

Rogers Sings Rogerstein

http://www.thepresentparticiple.blogspot.com

A Short Review of the Triple-P Parenting Support Program

Parent-child relationships unquestionably play a prominent role in the development and biopsychosocial wellbeing of children (Sanders, Markie-Dadds & Turner, 2003). Social learning models demonstrate the "reciprocal and bidirectional" character of these relationships (Patterson, 1982; Sanders, 1999), and emphasise how breakdown in personal or interpersonal aspects can result in suboptimal child development and negative mental health outcomes.  Risk factors for major behavioural and emotional concerns in children (e.g. antisocial disorders, juvenile crime, drug and alcohol abuse) eminently include many inadequacies in the parent-child relationship: rigid and disproportionate discipline; insufficient supervision and investment; and absence of warm, positive connections and secure attachments with parents (Sanders, Markie-Dadds & Turner, 2003). In addition to these interpersonal concerns, research in developmental psychopathology highlights parent-level risk factors, notably: poor self-regulation and parent distress (depression, anger, anxiety and stress) (Sanders, Markie-Dadds, & Turner, 1999; Sanders, Markie-Dadds & Turner, 2003), and marital conflict (Grych & Fincham, 1990; Rutter, 1985; Sanders, Markie-Dadds & Turner, 2003). 

 

In the absence of adequately-tailored parenting education, many parents typically receive little or no instruction in parenting skills, and base parenting choices on habituation from their own childhood experiences (Sanders, Markie-Dadds, Tully & Bor, 2000).  Family relationships may reach a reversible state of vulnerability where current skills lack sufficient complexity to meet present parenting demand. From a social cognitive perspective (Bandura, 1977) this vulnerability can generate and reinforce negative self-efficacy toward parenting, and a state of learned helplessness (Donovan, Leavitt, & Walsh, 1990) or demoralisation (Webster-Stratton & Herbert, 1994).  Moreover, unfamiliarity with the range of adaptive parenting choices may reinforce dysfunctional cognitions and false attributions about the source, locus of control, and nature of presenting problems (e.g. genetics, issues inherent in the child) (Sanders, Pidgeon, Gravestock, Connors, & Young, 2003). Parents may also not be aware of the role of unexplored mood reactions in cases where distressing parental mood is indicated in the clinical picture (Sanders, Markie-Dadds, & Turner, 1999).  Further, at the social systems level, stigmatisation of family problems and seeking specific mental health assistance can lead to unfortunate delay in seeking intervention (Webster-Stratton & Herbert, 1994; Sanders, Markie-Dadds & Turner, 2003).  These associations together suggest a role for multifaceted and integrated parental support interventions in preventing and managing antecedent risk factors for child development.

 

Both educational and therapeutic interventions can support parents in reaching and maintaining self-defined goals for positive parenting competence – both in terms of active skill acquisition and management of cognitive, behavioral and mood concerns (Sanders, Markie-Dadds & Turner, 2003).

 

The evidenced-based Triple-P Positive Parenting Program includes cognitive-behavioural methods in its structured suite of multi-level educational and psychosocial family interventions (Sanders, Markie-Dadds & Turner, 2003). In a number of randomised controlled trials, Triple-P's tiered-blend of compassionate support, goal-directed education and active skills training for variant severities of child problems, has demonstrated effectiveness in both management of extant child behavioural and emotional concerns, and early-intervention/prevention (Sanders, Markie-Dadds & Turner, 2003).  Central to this approach is development and maintenance of positive parental competence, typified by: (1) establishing adequate and independently-enacted self-regulatory processes capable of flexible deployment across a range of life contexts (e.g. home, shopping) (Sanders, Markie-Dadds & Turner, 2003; Karoly, 1993); together with (2) an orientation toward five core principles of positive parenting which address the specific risk and protective factors for child development and mental health mentioned above (Sanders, Markie-Dadds & Turner, 2003). These factors include: teaching parents how to create a safe, engaging, positive and comprehensible learning environments (Hart & Risley 1975; Risley, Clark, & Cataldo, 1976), replacement of coercive discipline with assertive practice (Sanders & Dadds, 1993), reorganisation of child expectations against realistic capabilities (Azar & Rohrbeck, 1986), and committing to personal self-care and wellbeing (Sanders, Markie-Dadds & Turner, 2003).

 

Stimulating competence in the core still of self-regulation addresses issues of self-efficacy by co-creating new positive options for parents, which in-turn reinforce an internal locus of control and capacity for effective personal agency in family matters (Sanders, Markie-Dadds & Turner, 1999). Self-sufficiency is also encouraged by Triple-'s co-creative cognitive behavioral intervention process in which professionals facilitate parents in setting their own self-determined goals, standards, performance criteria, evaluation, monitoring and change strategies (Sanders, Markie-Dadds & Turner, 2000).  This approach also effectively works within public health resource limitations, by providing parents with minimally sufficient guidance, feedback and compassionate support from health professionals while also providing a broader media-resource and self-directed learning strategy (Sanders, Markie-Dadds & Turner, 2000).  Cognitive-behavioural strategies for guided self-directed learning and homework are a key feature of Triple-P's educational component, and involve provision of accessible plain-language written, audio and visual media illustrating key prevention and management approaches to common problems and risk factors (Sanders, Markie-Dadds & Turner, 2003).

 

Randomised controlled effectiveness trials have repeatedly demonstrated significant decreases in disruptive child behaviour, dysfunctional parenting and parenting conflict, and higher levels of parenting efficacy, satisfaction, and relationship satisfaction, after Triple-P intervention (e.g. Sanders and McFarland, 2000; Sanders, Markie- Dadds, Tully and Bor, 2000).  Importantly, these results have been achieved in both therapist-supported, group-directed and self-directed formats (Sanders, Markie-Dadds & Turner, 2003; Leung, Sanders, Leung, Mak, and Lau, 2003; Ireland, Sanders and Markie-Dadds, 2003; Bor, Sanders and Markie-Dadds, 2002). Moreover, participant satisfaction has been evidenced for a range of levels and different structures of the program (Sanders, Markie-Dadds & Turner, 2003).

 

To this end, it is proposed that the tiered, multifaceted Triple-P approach represents a comprehensive, adaptable, responsive, preventatively-oriented, publicly accessible, affordable, and evidence-based parental support strategy for management and prevention of risk factors leading to child development and mental health issues.

 

 

 

 

 

 

Chilly Winter...

http://www.thepresentparticiple.blogspot.com

Story Of My Unlived Life!

http://www.thepresentparticiple.blogspot.com

50 Excellent Questions

1. Have you spent time in silence today, meditating, journaling, praying, or writing morning pages?

2. Have you in the last 10 days called or visited, a grandparent, parent, aunt or uncle?

3. Have you in the last month left an extra large tip for someone?

4. Have you spent time playing, laughing, and smiling in the last three days?

5. Have you planned a vacation or play date with the people closest to you in the last six months?

6. Have you sent a hand written note to someone you take for granted in the last 60 days?

7. Have you looked around and expressed deep gratitude for everything around you in the past week?

8. Have you forgiven yourself for making a mistake or the wrong choice in the last 10 days?

9. Have you forgiven your parents or other care takers for their poor choices in your life time?

10. Have you called an old friend to connect in the last 30 days? 

11. Have you sat with a trusted friend/coach/therapist in the last 90 days and poured your heart out?

12. Have you asked for what you want lately?

13. Have you read a book from cover to cover in the last two weeks?

14. Have you looked in someone's eyes and said, "I love you" in the last seven days?

15. Have you paid someone a compliment today?

16. Have you decided what your life will look like five years from now?

17. Have you praised a child or young adult in the last 24 hours?

18. Have you unexpectedly picked up the tab in the last month?

19. Have you stopped to smell a flower in a garden in the last year?

20. Have you been spontaneous in the last five days?

21. Have you spent an afternoon daydreaming in the last 7 days?

22. Have you helped out a neighbor in the last 2 months?

23. Have you sent someone flowers in the last 3 months?

24. Have you surprised someone with a visit in the last 30 days?

25. Have you saved any money since January 1st, 2011?

26. Have you asked for what you wanted today?

27. Have you eaten more vegetables and fruits in the last 24 hours?

28. Have you uncluttered your home in the last year?

29. Have you read a book to a child in the last four months?

30. Have you volunteered your time in the last 90 days?

31. Have you in the last 21 days changed a bad habit?

32. Have you in the last week recognized someone cooperating with you?

33. Have you spent quality time with your loved ones in the last 48 hours?

34. Have you told someone what you will do to improve your relationship in the last 14 days?

35. Have you donated money to a good cause in the last 2 months?

36. Have you made out your will yet?

37. Have you spent a weekend alone in the last year?

38. Have you in the last month really listened to someone?

39. Have you spent time in nature over the last week? 

40. Have you spent in the last year a full-day taking a personal inventory of your character defects?

41. Have you disconnected from all electronics for at least 24 hours in the last month?

42. Have you spent time creating something new that has nothing to do with work in the last 4 weeks?

43. Have you expressed your feelings honestly and appropriately to a loved one in the last 5 days?

44. Have you held self-love in your heart in the last 12 hours?

45. Have you released an unhealthy attachment to a person in the last 6 months?

46. Have you expressed compassion to someone in pain in the last 2 weeks?

47. Have you appreciated yourself in the last 24 hours?

48. Have you decided what you want to experience today?

49. Have you experienced joy in the last 24 hours?

50. Have you experienced inner peace in the last 24 hours?

From:

http://theboldlife.com/2011/02/50-questions-reflection-personal-growth/?utm_medium=fbshare.me-facebook-post&utm_source=facebook.com&awesm=fbshare.me_hR9&utm_content=fbshare-js-large&utm_campaign=

Mania. God.

"It is not a matter if indifference whether one calls something a 'mania' or a 'god'. To serve a mania is detestable and undignified, but to serve a god is full of meaning." 

- C.G. Jung

You Am I - How Much Is Enough (Live at the Metro 96)

http://www.thepresentparticiple.blogspot.com

Great Towers In The Sky Obstruct The Full Moon Above...

"It is the vice of a vulgar mind to be thrilled by bigness, to think that a thousand square miles are a thousand times more wonderful than one square mile.  That is not imagination.  No, it kills it..."

– E.M. Forster, Howards End

Seinfeld - Fathers

"All fathers are intimidating. They're intimidating because they are fathers. Once a man has children, for the rest of his life, his attitude is, "To hell with the world, I can make my own people. I'll eat whatever I want. I'll wear whatever I want, and I'll create whoever I want.""

http://www.thepresentparticiple.blogspot.com

A Treatise on Forgiveness by Robert Augustus Masters

Forgiveness is the heart's pardon. Sacred closure.

To forgive is not to excuse or condone, but rather to cease dehumanizing and excluding from our heart our offending other or others.

When we forgive, we neither bypass nor gloss over injury, but instead embrace and embody a perspective in which injury is not given the power to obscure or diminish our compassion.

Although forgiveness might seem to some to be an act of acquiescence or weakness, it is actually an act of great power, for it not only retrieves us from the past, where we are emotionally bound to those whom we won't forgive, but also from the future — where we're similarly bound — thereby bringing us present, undividedly and wholeheartedly present.

Forgiveness is a radical act of love not only for the offending other, but also for oneself. In forgiving someone, we are, in so many words, telling that person, "I no longer am interested or invested in having anything damaging happen to you. No longer am I going to turn the hurt you have done me into an excuse to dehumanize or violate you. Although I may never again have or make contact with you, no longer will I keep you out of my heart, however difficult that might be."

Thus do we disconnect in order to connect at a deeper level.

We then stop feeding our resentment, realizing as we do so that it was actually feeding on us, consuming our energy and attention. Our appetite for vengeance naturally shrinks, like any other shadow, in the light of our forgiveness. Then the courtrooms of our mind are not so readily populated by us — wanting to be right no longer so easily recruits and centers us. We may still get angry, but will be far less likely to infuse it with ill-will or hatred, or let it transmute into aggression. Caring for the other becomes more important than getting even, regardless of the consequences that may be deemed fitting for whatever harm may have been done.

"Love your enemies." This may be the most practical (and marginalized) of all of the teachings of Jesus. Rooted as it is in our capacity to forgive, it cuts through the rigidly dualistic "I" versus "you" or "us" versus "them" mentality that so easily infects and aberrates us. Loving — not necessarily liking, but loving — our enemies is a kind of radical sanity, for in loving them, in wholeheartedly wishing for their freedom from delusion, we are not only ceasing to demonize them, but are also aligning ourselves with their healing. Their healing — our healing.

If our enemies were to find and embody their innate happiness, if they were freed from their suffering, if they were to heal, then they would no longer be motivated or driven to harm us. Is there a more potent and user-friendly catalyst for disarmament than forgiveness?
   
Implicit in the practice of forgiveness is the willingness to place ourselves — and not just intellectually! — in our offending others' shoes and skin, to the point where they are no longer "other," but rather only us in our less appealing facets.

Forgiveness does not depend upon what the offending other does.

That is, we don't have to wait for that person to make amends. (And, at the same time, it is essential to realize that we do not have to forgive until we are truly ready to do so —  to forgive prematurely is of no more use than putting off the forgiveness of which we are capable.) Sometimes we may be so righteously caught up in waiting for and expecting our offending others to make amends or to say that they're sorry, that we don't notice that we are being held hostage by our expectations of them.

If I refuse to forgive you until you "deserve" it, then I am simply punishing you, keeping myself negatively bound to you, or to the storyline with which I associate you.

If I won't forgive you until you have "earned" it, then I am keeping myself, however subtly, a victim of what you've done to me. And, if I am getting something out of staying in my "wounded" role — such as having a "valid" reason for not taking more responsibility for where I'm at in my life — I am likely going to continue to postpone forgiving you.
 
In the process of forgiving, we may have to, at least some of the time, reframe the harm-doing we have suffered. Perhaps the pain inflicted on us by our offending others has actually been of genuine benefit to us; perhaps we needed to be hurt, disappointed, betrayed, or left; perhaps we needed to learn something that could not be learned without being treated as we were treated by our offending others. This, of course, does not mean that their actions should therefore be condoned or praised, but that they be viewed from a perspective that's not rooted in an eye-for-an-eye morality.

Then we can clearly recognize such harm-doing as part of us. What I condemn in you also exists in me (and in everyone else), and there's no way that it's going to be healed if I persist in treating it as something alien to me.

None of this is to say that forgiveness is an easy practice. For example, the path to forgiveness may initially be — and may need to be — paved with hatred. We may need to feel and fully express our hate for another before we can even approach forgiving that person (as is often the case with those who have been raped). This, however, doesn't mean that we have to literally act out, or even share, such dark feeling with our offending other or others. If we can give our hate sufficiently free rein and voice, and just the space to be, in a safe environment — like that of good psychotherapy — we're not only going to feel, through our rage-releasing, a much needed sense of empowerment, but we're also bound to get to what underlies our hate, so that we can fully feel our hurt and thereby move through it.

And at the heart of that hurt is not more hurt, but a love that cannot help but forgive.
 
This love is self-radiant, effortlessly ego-transcending, simultaneously innocent and wise. It forgives us our trespasses, our forgettings of the Sacred, our stupidities large and small, and it does so instantaneously. It does not make a problem out of our mistakes. When we allow ourselves to house — and ultimately to be — such love, we do not see errors, but only incarnation's fleshdance in sacred transparency. Which is but the shortest of steps to remembering with our whole being What-Matters-Most.

Sometimes the process of forgiveness may seem to break our heart, but it is only the armoring around our heart that breaks. Or melts. Forgiveness brings us in out of the cold, potently reminding us of who we really are.

When we choose to forgive, we are entering the morality of the Divine. When we choose to forgive, we deepen our intimacy with the Beloved.

Forgiveness is an act of real power. It is the essence of true kindness.

May we all embody it.

Ritual in Contemplation: Text and Tools in Tantric Buddhism

http://www.thepresentparticiple.blogspot.com

Abraham-Hicks. Yeah, I know...

... who'd have thought I'd dig something from their work. But this came up on my Facebook feed today and I thought it was pretty cool.

"Abraham-Hicks has come up with a series of emotions that will help you work from feeling bad to feeling better about what ever you are experiencing. If you find where you are emotionally on the scale, and then try and find thoughts that feel just a tad bit better about it. Small baby steps toward Joy.

This is the scale:

The Emotional Guidance Scale

1. Joy/Appreciation/Empowered/Freedom/Love
2. Passion
3. Enthusiasm/Eagerness/Happiness
4. Positive Expectation/Belief
5. Optimism
6. Hopefulness
7. Contentment
8. Boredom
9. Pessimism
10. Frustration/Irritation/Impatience
11. Overwhelment
12. Disappointment
13. Doubt
14. Worry
15. Blame
16. Discouragement
17. Anger
18. Revenge
19. Hatred/Rage
20. Jealousy
21. Insecurity/Guilt/Unworthiness
22. Fear/Grief/Depression/Despair/Powerlessness


From the book "Ask and It is Given", pg. 114"

Plato

‎"You can discover more about a person in an hour of play than in a year of conversation."

- Plato

Passion

"All the soarings of my mind begin in my blood." 

- Rilke

New Food Pyramid

http://www.thepresentparticiple.blogspot.com

Gil Hedley on Reich's Orgone Accumulator (also popularised by William Burroughs). Probably my favourite speculative project.

"Wilhelm Reich's "orgone accumulator" was a sort of mini box/closet in which you would sit and enjoy the energy which was passively concentrated within it from the atmosphere outside of it by virtue of its layers of insulative and conductive materials. I believe that the human body in its layers is itself the superlative example of an "orgone accumulator." Our sequenced conductive and insulative tissue layers concentrate energy in our bodies for our use. Whether we yield to or resist this capacity, there really is no end to the resources available to us".

- Gil Hedley.

Poetics of Prayer - Robert Augustus Masters

"Prayer is sacred conversation, even when it is absolutely silent.

In its beginning stages, prayer mostly asks. As it ripens, prayer may still ask, but its primary characteristic is deep, devotional receptivity. So prayer initially has a lot to say, but later on it mostly listens.

Ultimately, prayer becomes what it is requesting, through bringing us into such deep intimacy with what really matters that we're no longer significantly separated from the object of our prayer and are in fact aligned with it even though it hasn't yet physically manifested....

What real prayer seeks is recognized, at least to some degree, to be already found. There is actually no real gap between seeking and sought in bare awareness—it is only in time, only in the manifesting of prayer's requests, that there appears to be such a gap.

Prayer helps bridge the unmanifest and the manifest by creating fertile conditions for bringing potentialities to life. Prayer provides templates, sacred and otherwise, for intentionality. As it matures, prayer's context shifts from petitioning to gratitude. Then prayer does not end with a thank you but is a thank you. It is in the spirit of this that our prayer for our beloved will be most effective. The more we let go of having to have something happen here, the more likely it is to happen. No desperation, no rush, just making haste slowly....

Allow your prayer to expand, deepen, and awaken you. Let your voice, however soft, emanate from your core as much as possible. Let your whole body participate. Be bare-hearted".

- Robert Augustus Masters

Goethe

"Colors are the deeds and suffering of light." 

- Goethe

David Whyte - Crossing the Unknown Sea

"There is a lovely root to the word humiliation - from the latin word
humus, meaning soil or ground. When we are humiliated, we are in
effect returning to the ground of our being.

Shedding the carapace we have been building so assiduously on the
surface, we must by definition give up exactly what we thought was
necessary to protect us from further harm. The outlaw is the radical,
the one close to the roots of existence. The one who refuses to forget
their humanity and in remembering, helps everyone else remember too.

To die inside, is to rob our outside life of any sense of arrival from
that interior. Our work is to make ourselves visible in the world.
This is the soul's individual journey, and the soul would much rather
fail at its own life than succeed at someone else's."

David Whyte - Crossing the Unknown Sea

Finally

http://www.thepresentparticiple.blogspot.com

The Five Elements Practice with Tenzin Wangyal Rinpoche

Video streaming by Ustream

Tenzin Wangyal Rinpoche guides a simple meditation practice that can help you to connect intimately with the five natural elements of earth, water, fire, air and space. This webcast was broadcast live at the close of Tenzin Rinpoche's retreat "Connecting With the Living Universe," at the Serenity Ridge Retreat Center in the mountains of central Virginia.

http://www.thepresentparticiple.blogspot.com

Simply Put

"Harming anyone – yourself or others – to gain happiness is like eating poison to prolong life… you will not achieve what you seek".

- H.H 17th Karmapa, Ogyen Trinley Dorje

 

David Treleaven - Meditation and Trauma

David Treleaven presents his dissertation defense "Meditation and Trauma: A Hermeneutic Study of Somatic Experiencing and the Western Vipassana Movement."

What if, in following basic mediation instructions one was causing more harm than good? This question arises from the dialog between Buddhism and contemporary trauma theory. In a deceptive twist of evolutionary fate, sustained attention on the body can lead to a dissociative, or freeze response. To explore the impact of this dynamic on contemplative practice, this theoretical dissertation uses Somatic Experiencing (SE), a psychotherapeutic approach to healing trauma, as a hermeneutic lens to explore the merits and the shortcomings of meditation practice for individuals with a history of trauma.

David Treleaven - Meditation and Trauma from East-West Psychology on Vimeo.

http://www.thepresentparticiple.blogspot.com

"I never saved anything for the swim back"

http://www.thepresentparticiple.blogspot.com

Trust

"I prefer to work at the speed of trust".

- Philip Corkill

Mahabharat Episode 1- With English Subtitles

From the cover - "The Mahabharata is one of the longest epic poems in the world and B. R. Chopra's Mahabharat is one of India's most successful TV series in history and has been repeatedly telecast on TV networks worldwide to phenomenal response. B. R. Chopra's Mahabharat boasted a talented set of starcast including Mukesh Khanna, Nitish Bharadwaj, Roopa Ganguly, Puneet Issar, Gufi Paintal, Gufi Paintal, Pankaj Dheer, Dara Singh & many more. Here are the classic series. Click http://www.rajshri.com/TVShow/Mahabharat-English-Subtitles to watch more TV shows".

http://www.thepresentparticiple.blogspot.com

On Collecting Books

‎"Even those books that I have not yet opened—unread books are an essential element of a library—were acquired for the further cultivation of a particular admixture of interests and beliefs, and every one of them will have its hour."

- Leon Wieseltier

Masters on Spiritual Bypassing

"True spirituality is not a high, not a rush, not an altered state. It has been fine to romance it for a while, but our times call for something far more real, grounded, and responsible; something radically alive and naturally integral; something that shakes us to our very core until we stop treating spiritual deepening as something to dabble in here and there. Authentic spirituality is not some little flicker or buzz of knowingness, not a psychedelic blast-through or a mellow hanging-out on some exalted plane of consciousness, not a bubble of immunity, but a vast fire of liberation, an exquisitely fitting crucible and sanctuary, providing both heat and light for the healing and awakening we need.

Most of the time when we're immersed in spiritual bypassing, we like the light but not the heat. And when we're caught up in the grosser forms of spiritual bypassing, we'd usually much rather theorize about the frontiers of consciousness than actually go there, suppressing the fire rather than breathing it even more alive, espousing the ideal of unconditional love but not permitting love to show up in its more challenging, personal dimensions. To do so would be too hot, too scary, and too out-of-control, bringing things to the surface that we have long disowned or suppressed".

— Robert Augustus Masters, "Spiritual Bypassing" (2010)

Angelic Gold Lights

http://www.thepresentparticiple.blogspot.com

TAE

"One of Gendlin's primary insights has been to show how what gets explicated is not equal to the implying from which it came. The poem that you MUST soon write is an intricate implying, not the beautiful poem that it will soon help explicate. The poem will come from a very careful attention to the intricate implying you are holding. That intricacy will grow the poem. And that intricacy is also what will have Christopher Alexander say, "oh no…wait…….the way I wrote that somehow excludes so much of such and such…hmmm…." It is a place of great intelligence and place that needs to make new forms in order to come into being. It wants that! Mostly".

- Jeff Falzone, in the TAE portion of The Magellan Courses (http://biffnet.org/tae/)

Kimura on Freedom

"The real essence of freedom is more in what you are free NOT to do than in what you are free to do. It is the freewill-power to refrain, abstain, and withdraw from acting that bestows freedom with its ultimate power—the rational, moral, and spiritual power. Freedom is the state of inner attunement with the highest spiritual principle operative inside human consciousness, while freewill is the self-generative intention originating from the same highest spiritual source. Thus, freedom is a spiritual activity while freewill is a spiritual power. Therefore, the freedom to do without the freedom not to do, perverts freedom to impulsivity and debases autonomy to automaticity.

Freedom can be experienced and understood but cannot be explained or proved. An explanation or proof, to be valid, intrinsically requires an internal logical necessity and explicatory causality, which voids from the system of explanation the very substance of freedom which makes freedom actually freedom. For this reason, those philosophers and scientists who confuse explanations with reality deny the reality of freedom, calling it an illusion. The illusion, however, is their explanation, not freedom. Freedom is possible in reality and only when you are free, you can experience what it means to be human in its full existential potential and evolutionary possibility".

- Yasuhiko Genku Kimura