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CME Disclosure
Priyanthy Weerasekera, M.D., M.Ed., Department of Psychiatry and Behavioural Neurosciences, McMaster University Hamilton, ON, Canada
Reports no competing interests.
Address correspondence to Dr. Priyanthy Weerasekera, Associate Professor, Postgraduate Psychotherapy Coordinator, Department of Psychiatry and Behavioural Neurosciences, McMaster University, St. Joseph's Hospital, Fontbonne, F442, 310 James St. South, Hamilton, ON, Canada L8P 3B6; e-mail: email@example.com.
The last three decades have witnessed significant advances in psychotherapy. Numerous scholarly articles and books have been devoted to pertinent topics in the field, making it difficult for the practicing clinician to keep up with this rapidly growing area. The purpose of this article is to provide some guidelines on how to evaluate the empirical literature in psychotherapy and then to explore three key areas: evidence-based psychotherapies for patients with psychiatric disorders, individual variables that predict differential outcome to treatment, and the therapeutic alliance. Finally, two case examples will be presented to illustrate how knowledge of the empirical literature can facilitate an evidence-based approach to the daily practice of psychotherapy in general psychiatry.
The early 1990s witnessed a significant paradigm shift in the practice of clinical medicine and medical education, with greater emphasis given to the individual scientist practitioner's critical appraisal skills and his or her ability to deliver "evidence-based" treatments. For the practicing psychiatrist this poses significant challenges as it requires maintaining a connection with advances in pharmacological and psychological treatments. For many psychiatrists keeping up with the former is much easier than the latter, given the availability of psychiatry online resources, courses, and conferences dedicated to this area. Remaining abreast of developments in psychotherapy seems to be more challenging, perhaps because of the narrow exposure to psychotherapy during training, greater emphasis on pharmacology, and unfamiliarity with resources dedicated to this area, the majority of which are located outside the discipline of psychiatry.
The purpose of this article is to assist the practicing clinician with the difficult task of keeping up with the empirical psychotherapy literature. First and foremost a discussion on how to evaluate the extensive research in this area will be presented with an emphasis on meta-analyses. Second, a brief review of the empirical psychotherapy literature will be presented with a focus on evidence-based psychotherapies for patients with psychiatric disorders. Third, individual variables that predict differential outcomes to treatment will also be discussed as this is an emerging area of research. Fourth, the therapeutic alliance will be briefly discussed as it has remained a robust variable in psychotherapy outcome. Finally, two case examples will be presented to help illustrate how knowledge of the empirical literature can guide evidence-based practice.
The gold standard in evidence-based medicine is the randomized controlled trial (RCT). In the RCT one treatment is compared with a placebo or a waiting list or an active comparison is performed under well-controlled conditions. In psychotherapy research this involves the use of well-defined treatment manuals that operationalize specific psychotherapies and reliable and valid instruments that assess therapist adherence, therapist competence, treatment process (i.e., therapeutic alliance), and treatment outcome (i.e., depression) variables.
There is an extensive body of literature examining RCTs for many types of psychotherapies, making it challenging for the practicing psychiatrist to remain current with the field. Reading reviews that provide guidelines can be an efficient method of keeping in touch with the literature. Two types of reviews are available: narrative reviews or systematic reviews. Although narrative reviews are helpful in providing an introduction to the area, systematic reviews or meta-analyses are more rigorous in that they use explicit search strategies, have clear standards for the studies they include, and arrive at an "effect size" that provides a quantitative analysis of how beneficial a treatment is compared with no treatment or an alternate treatment. Effect sizes (ES) are described as small (0.20–0.49), moderate (0.50–0.79), or large (0.80 and larger). The larger the effect size is, the greater the indication that a specific treatment is effective. The excellent article by Lam and Kennedy (1) included in this issue describes meta-analyses in detail so that treatment decisions can be made and follow an evidence-based approach.
Although the notion of levels of evidence has been discussed for some time (2), Lam and Kennedy provide an easy-to-follow step-by-step approach so that one is able to appraise a meta-analysis. Rigorous meta-analyses and RCTs carried out in several sites provide the highest level of evidence (level 1) for a particular treatment (1). Meta-analyses have been criticized for including poorly carried out RCTs and heterogeneous samples and for being subject to interpreter bias (3). However, more recent meta-analyses, including the Cochrane Database of Systematic Reviews, have taken many of these criticisms into account.
It is not the purpose of this article to present an exhaustive review of the psychotherapy outcome literature but rather to present a focused review that examines the most recent research. Several narrative reviews that appraise the empirical psychotherapy outcome literature are available (4). For the purpose of this article, PsycINFO and PubMed were searched using the MESH terms "meta-analyses," "meta-analysis," and "review" for the most common psychiatric disorders treated by psychiatrists (i.e., depression, anxiety disorders, and others), and the specific psychotherapies that have recently been associated with successful outcomes with these disorders (i.e., cognitive behavior therapy, interpersonal therapy, psychodynamic therapy, and so on). Only the most recent meta-analyses conducted over the past decade (2000–2009) were included as these reviews adhere to more rigorous standards, and earlier studies have been systematically reviewed elsewhere (5). In total, 67 meta-analyses were found for a variety of psychotherapies across the major psychiatric disorders. Duplicates of meta-analyses by the same author reported in several journals were not included, but rather the most recent one was selected for discussion. All meta-analytic reviews referred to in this article reviewed studies that made comparisons between various control groups such as waiting lists, no treatment groups, and other active forms of treatments. In addition, RCTs that support the use of new emerging therapies (e.g., mindfulness-based cognitive therapy), are also discussed as some of these therapies hold promise for the future if level 1 evidence can be established. Some of these therapies are discussed at length in separate articles in this issue of Focus.
Tables 1 through 6 list the meta-analyses for the common psychiatric disorders for which psychotherapies have been investigated. Each table lists the specific disorder studied, the author(s), search years, number of studies included in the meta-analyses and subjects included if this information is given, and the results reported in effect sizes : either the exact figures or described as small, moderate, or large or percentage improved. If information was missing, authors were contacted by E-mail to provide it, but not all responded. Acronyms are used in the tables, and these are explained in a footnote to the table.
Several meta-analyses have been performed for unipolar depression and other mood-related disorders. The National Institute of Mental Health (NIMH) Treatment of Depression Collaborative Study set the gold standard for psychotherapy research in the late 1980s (6). Results revealed positive outcomes for medications (imipramine), cognitive behavior therapy (CBT), interpersonal therapy (IPT), and case management for mild to moderate depression, and superior effects for medication in severe depression and for IPT in the nonfunctionally impaired severely depressed patient. Since the publication of this well-known study, numerous RCTs and several meta-analyses have continued to show positive results for several psychotherapies in the treatment of depression. In the past decade alone, at least 24 meta-analyses demonstrated moderate to large effect sizes for many psychotherapies for depression.
Table 1 shows a range of effect sizes for a variety of psychotherapies for the treatment of depression with large effect sizes noted for CBT whether delivered in individual or group formats (7–14). CBT is an integrated therapy in that it incorporates both cognitive and behavioral components in the conceptualization of patient problems and in the delivery of treatment. The fundamental premise of CBT is that psychological distress, whether it is manifested in mood, anxiety, or other problematic symptoms, is a result of specific maladaptive thought processes, which in turn lead to difficulties in emotions and behavior. Treatment includes challenging these distortions in the context of a collaborative relationship and a positive therapeutic alliance. Self-monitoring and behavioral techniques that incorporate specific homework exercises expose the patient to alternate interpretations of events and help change behavior in a positive direction. Helping patients to increase positive events in depression and decrease avoidance in anxiety (i.e., exposure) reduces maladaptive symptoms.
Meta-Analyses for Mood Disorders
Large effect sizes have also been reported for IPT especially for patients with certain psychosocial stressors and "obsessional" personality traits (15). IPT is a brief, structured, integrative therapy originally developed for patients with depression. The fundamental assumption in IPT, is that the onset of, maintenance of, and recovery from depression is determined by four key interpersonal events: losses, role transitions, interpersonal conflicts, and interpersonal deficit. Therapy focuses on integrating a medical model of depression as well as understanding and working through these key interpersonal areas.
Newer therapies such as behavioral activation and emotion-focused therapy (EFT) also demonstrate large effect sizes (11–12, 14). Behavioral activation is based on behavior theory and involves activity scheduling and the introduction of positive reinforcing events. Behavioral activation can be integrated with medications and other psychotherapies and is an easy-to-administer treatment requiring much less therapist training than the other psychotherapies. However, given the demand for participation in activities, patient compliance is crucial. EFT is an experiential therapy that integrates client-centered and gestalt techniques and is extensively described in a separate article in this issue. This therapy has been studied in RCTS as well as in a meta-analysis (11) and has been found to be helpful in the treatment of depression, with improvements in self-esteem and interpersonal problems noted in the long term.
A recent meta-analysis also showed moderate to large effect sizes for short-term psychodynamic therapy (STPP), better known as brief psychodynamic therapy, which incorporates the active ingredients of change of long-term psychodynamic therapy but in a briefer format. Short-term psychodynamic psychotherapy involves a heterogeneous group of treatments that focus on transference, defenses, or other intrapsychic conflicts. Interventions in STPP can focus on either supportive or expressive dimensions, with evidence supporting both as active ingredients of change in the outcome of treatment (13, 16).
Problem-solving therapy and the coping with depression (CWD) psychoeducation package have also been investigated in the treatment of depression. Both therapies are brief and active and engage the patient in working through difficulties in a systematic manner to learn specific skills that can be used when dealing with depressive symptoms. Both treatments show small effect sizes as a treatment for depression, although CWD appears to be effective as a preventative measure for future episodes (13, 17–19). However, a component analysis has revealed that the problem orientation package of problem-solving therapy has a much higher effect size than the complete package, raising issues as to which ingredients act as mechanisms of change in this form of treatment.
Of significance is a recent comparative meta-analysis by Cuijpers et al. (13), who found that although CBT, IPT, behavioral activation, short-term psychodynamic therapy, nondirective supportive therapy, problem-solving therapy, and social skills training were all effective for mild to moderate depression, IPT had a slight advantage and problem-solving therapy showed the fewest dropouts. Cuijpers et al. (20) also found that individual treatment produced better outcomes than group treatment at the end of treatment, but no significant difference was noted at follow-up. In a recent article in which highly stringent criteria were applied to the selection of studies, resulting in only 11 RCTs, a lower effect size was found for psychotherapies for the treatment of depression (21). Although this result requires replication, it is important to note that the use of highly stringent criteria excludes many well performed RCTs that have clearly established effectiveness.
The above meta-analyses have focused primarily on unipolar mild to moderate depression and have essentially established what was concluded in the early NIMH trials: most psychotherapies seem to be generally effective in the treatment of mild to moderate depression. Three meta-analyses have looked at chronic severe depression or dysthymia and have generally all found the same results: combined treatments that include medication and psychotherapy fare better than psychotherapy or medication delivered alone (22, 23, 25). This result probably comes as no surprise to the clinician who finds that these patients are more resistant to medications as well as to psychotherapy, thereby requiring an integration of both treatments. An additional meta-analysis showed superior outcomes with combined treatment than with medication alone, and patients remained in treatment longer if psychotherapy was integrated into the treatment plan (24).
Meta-analyses have also been conducted for childhood and adolescent depression, late-life depression, pregnancy and postpartum depression, and bipolar depression. In childhood depression effect sizes have been small at best, but recent studies showed moderate effect sizes in adolescent depression with greater than half of patients improving with CBT (26, 27). In the late-life period CBT and other "psychotherapies" grouped together showed high effect sizes (28). These psychotherapies included supportive, psychodynamic, and other treatments. Bledsoe and Grote (29) conducted a meta-analysis comparing several psychotherapies in the pregnancy and postpartum period and found large effect sizes for medication plus CBT, group therapy, and IPT, with moderate effect sizes for CBT and psychodynamic therapy, and small effect sizes for counseling and psychoeducation. The poorest results were found for bipolar depression for which large effect sizes have been found for psychoeducation and moderate effect sizes for CBT for enhancing medication compliance. Nonsignificant results have been found for interpersonal social rhythms therapy, a form of IPT (30).
Although many therapies have been found to be effective for depression post-treatment, many patients continue to have residual symptoms and tend to relapse. Therefore, neither psychotherapy nor medication provides a cure, but both treatments can be integrated in an evidence-based, patient-directed manner to provide the best outcome. Several psychotherapies such as CBT and IPT have focused on relapse prevention by increasing sessions, providing "booster" sessions, and focusing on prevention techniques. Because of the limitations of traditional cognitive therapy, new variants of CBT have emerged over the last two decades. Mindfulness-based cognitive therapy has recently been investigated for those patients with three or more episodes of depression and shows promise in four recent clinical trials (31). Mindfulness is not a specific form of therapy but an ancient Buddhist meditative technique. When practiced frequently, mindfulness produces a state of nonreactivity and detachment from disturbing thoughts and feelings that lead to depression, anxiety, and emotional dysregulation. There are many exercises that are considered "mindfulness" based. Some of these involve paying attention to the breath, attending to the moment, or focusing on an object. Mindfulness is an intriguing approach not only for chronic depression but also for other psychiatric disorders and its application in psychiatry is discussed in detail in a separate article in this issue.
Unlike for depression, there are few comparative trials of psychotherapy in the treatment of anxiety disorders. The majority of studies have compared medications, CBT, components of CBT (e.g., exposure, exposure and response prevention, and behavior therapy), relaxation, and eye movement desensitization reprocessing (EMDR) with wait list controls. There is heavy emphasis on the behavioral component of CBT in the treatment of anxiety disorders as patients are encouraged to "expose" themselves to the feared situation and not engage in avoidance. In EMDR patients are asked to recall a traumatic memory, and lateral sets of eye movements are induced by the therapist who moves his or her finger across the patient's field of vision. The patient is then asked to report any feelings, thoughts, or images that arise, which then become the focus of the next set of eye movements. This process continues until the distress evoked by the memory diminishes.
Table 2 shows 27 meta-analyses over the past decade for all anxiety disorders across the lifespan. When all anxiety disorders are combined, moderate to large effect sizes are evident for the treatment of all adult anxiety disorders with some studies showing large effect sizes for the treatment of obsessive-compulsive disorder (OCD), generalized anxiety disorder (GAD), and posttraumatic stress disorder (PTSD) and lower effect sizes for social phobia (32–35).
Meta-Analyses for Anxiety Disorders
Large effect sizes have also been found for the treatment of childhood anxiety disorders with CBT, with individual treatments equaling family treatment or group treatments, university clinics producing moderate effect sizes, and community clinics showing small effect sizes (36–38). These findings could indicate that CBT performed in the "real-world" community clinic is less effective, possibly due to several factors such as severity of illness, decreased therapist competency, or decreased therapist adherence to CBT interventions and poor patient compliance with treatment. Separate meta-analyses have been conducted for childhood OCD and social phobia, again showing large effect sizes with CBT treatments (39–41). Moderate effect sizes have also been found for CBT for late-life anxiety disorders (42).
With respect to specific adult anxiety disorders two recent meta-analyses showed very large effect sizes for exposure and response prevention and medications for OCD; however, symptoms do persist at moderate levels after treatment (43, 44). The treatment of GAD with CBT, behavior therapy, or medications also demonstrates high effect sizes, with small to moderate effect sizes for supportive and psychodynamic treatments (8, 45, 46). Moderate to large effect sizes have also been found for CBT and medications in the treatment of panic disorder with or without agoraphobia, but this effect seems to decrease with increasing comorbidity and longer duration of illness (8, 47, 48). Trauma-focused CBT and EMDR seem to have larger effect sizes as indicated in more recent meta-analyses, although controversy regarding EMDR as a treatment for PTSD still exists (49–52).
In social phobia moderate to large effect sizes have been found for both CBT and medications (53, 54). In addition, dismantling studies have shown that exposure alone is superior to exposure combined with cognitive reconstruction and social skills training (53). The treatment of specific phobias with in vivo exposure interventions also indicates large effect sizes (55). Therefore, at the present time CBT remains the mainstay of treatment for patients with anxiety disorders with moderate to large effect sizes demonstrated for different anxiety disorders across the lifespan. However, residual symptoms are prominent with increasing symptom severity and comorbidity, once again suggesting longer treatment and possibly combined treatment with medication for optimal response in the long term (49)
CBT has recently been investigated for psychotic disorders with two meta-analyses showing moderate to large effect sizes for decreasing patient distress associated with psychotic symptoms such as hallucinations and delusions (Table 3 Gould et al.) (56) found a moderate effect size in decreasing distress associated with psychotic symptoms after treatment with CBT compared with supportive therapy. However, a much larger effect size was found for CBT at follow-up. Pilling et al. (57) also found large effect sizes for CBT compared with usual care in decreasing relapse and dropouts, and increasing medication and treatment compliance in patients with schizophrenia. Zimmerman et al. (59) found a moderate effect size for CBT for acute psychotic symptoms and a small effect size for chronic psychosis. However, a recent Cochrane review did not find any difference between CBT and supportive therapy in the long term, indicating that more work may be needed in this area (58).
Meta-Analyses for Psychotic Disorders
Few meta-analyses have been conducted for personality disorders, given the limited research in this area, with the exception of borderline personality disorder (BPD) (Table 4). Leichsenring and Leibing (60) found large effect sizes for both psychodynamic therapy and CBT for the treatment of a variety of personality disorders. Two meta-analyses were conducted for BPD with comparisons being made between dialectical behavior therapy (DBT) and psychoanalytic day hospital treatment. DBT is an integrated treatment that incorporates techniques from CBT and mindfulness to promote emotion regulation and to decrease impulsivity leading to self-injurious behavior. Binks et al. (61) found moderate effect sizes for both DBT and psychodynamic therapy with only a few studies in their analyses. Psychoanalytically oriented partial hospitalization treatment was found to be helpful in patients with BPD, with an advantage noted over DBT in decreasing parasuicidal behavior and hospital admissions (61). A more recent meta-analysis found a moderate effect size for DBT; however, the sample consisted of patients from mixed diagnostic groups (i.e., substance abuse and others) (62).
Meta-Analyses for Personality Disorders
Meta-analyses have also been reported for other psychiatric conditions (Table 5). Moderate effect sizes have been reported for CBT and behavior therapy with individual and group treatment of bulimia (63). Abbass et al. (64) found a moderate effect size for short-term psychodynamic therapy for the treatment of somatoform disorders, whereas Malouff et al. (65) found a small to moderate effect size for treating chronic pain with CBT, which has been reported in other studies (66). Moderate to large effect sizes have also been reported for motivational interviewing (MI) for patients with substance abuse, although these effects seem to decrease over time (67), suggesting the need for "booster sessions," which are essential in many chronic conditions. MI is a specific interviewing technique with the aim of assessing a patient's readiness to change and engage in treatment. MI uses an open dialogue to explore whether a patient is ready to commit to treatment. The therapist is nonjudgmental, empathic, and respectful of the patient's current status. An interesting finding is that this intervention appears to have a greater effect on certain minority populations and may be considered a suitable "match" in such cases.
Meta-Analyses for Other Disorders
Leichsenring and colleagues (68, 69) reported two meta-analyses for a range of disorders and complex disorders treated with psychodynamic therapy and found large effect sizes compared with wait list or treatment as usual. When only RCTs were included, the effect size remained significant and large (69). In addition to this finding, effectiveness research supports the use of long-term psychodynamic therapies in decreasing symptomatic distress and improving interpersonal problems, social adjustment, and self-esteem (69). The last decade has witnessed an emergence of research in psychodynamic therapy, suggesting that this therapy is a viable option for interpersonal and characterological difficulties that cannot be treated by other briefer treatments focusing on symptomatic improvement. Further research may also establish brief dynamic therapies as beneficial alternative treatments in some axis I disorders when other treatments fail.
A group of treatments known as the "third-wave cognitive behavior therapies" have also been investigated for many conditions. Therapies under this umbrella include acceptance and commitment therapy (ACT) (which incorporates acceptance and mindfulness strategies, together with commitment and behavior change strategies to increase psychological flexibility) for the treatment of depression, anxiety, stress, and addictions; DBT for patients with BPD as discussed above; the cognitive behavior analysis system of psychotherapy (which integrates components of cognitive and psychodynamic therapy) for chronic depression; functional analytic psychotherapy (which incorporates radical behaviorism to in-session verbal behavior) for depression; and integrative behavioral couple therapy (which integrates behavioral couple therapy with emotional acceptance) for couple problems. A recent meta-analysis demonstrated moderate effect sizes for both ACT and DBT, but because of the small number of studies conclusions regarding the other therapies cannot be made at this time (62).
Although not incorporated in recent meta-analyses, two new therapies show promise in the treatment of patients with BPD: systems training for emotional predictability and problem solving (STEPPS) and schema-focused therapy. STEPPS is a brief therapy that incorporates CBT, skills training, and systems theory and has been found to be effective in RCTs in the treatment of BPD (70). Schema-focused therapy, a form of CBT that focuses on core beliefs and schemas developed in childhood, has also been found to be helpful in treating patients with BPD (71). Meta-analyses of the future will no doubt include these new forms of treatments and it is hoped that they will offer patients with BDT a wide range of psychotherapeutic options to choose from.
Systemic therapies have also been investigated for patients with psychiatric problems (Table 6). There is strong support for couples therapy as an intervention for couples experiencing relationship distress, with large effect sizes being reported (72). Behavioral marital therapy shows a moderate effect size in the treatment of marital distress (73). Couples therapy has always demonstrated consistently higher effect sizes than family interventions, and this has been attributed to family problems being more intractable and involving more patients. Whether this explains the lower effect sizes seen in family therapy is unclear. Moderate effect sizes have been reported for family therapy as an adjunct in child and adult disorders and in specific family problems (72, 74). However, one meta-analysis has indicated that, based on the few studies, recommendations at this time are difficult to make (75).
Meta-Analyses for Systemic Therapies
Group interventions minimize the use of resources and offer patients additional benefits such as increased social support and the perception that there are others who struggle with the same illness. Moderate to large effect sizes support the use of many types of group-based interventions in the treatment of several psychiatric disorders (76).
Although psychotherapies are effective treatments for many patients with psychiatric disorders, not all patients benefit from all treatments. There are probably many reasons for this outcome. First, there is great variability among therapists in their level of skill and expertise in delivering a specific treatment. Therapist competence is an important variable in outcome as it determines the integrity of treatment delivered (77). Although most studies control for this factor, they tend to use novice therapists such as psychology graduate students or psychiatry residents who have yet to develop finely tuned skills in a particular form of therapy. Novice therapists are also known to have more difficulty with more severely ill patients, particularly those who are struggling with developing an alliance with their therapists.
Second, there may be diagnostic issues in that a patient may be receiving a treatment for an illness he or she does not have. For example, treating a patient with dysthymia with a brief course of CBT may not produce the best results (66). Such patients require longer treatment and booster sessions after therapy. Third, there could be significant comorbidity that makes it difficult to focus on a target problem. As discussed above, patients with panic disorder and significant comorbidity have a poorer outcome than those who do not present with comorbidity (48). These patients may require more careful integration of several types of treatment and longer duration of delivery of each treatment. For the practicing psychiatrist "real-world" patients present with extensive comorbidity, longer duration of illness, and prior failures to many forms of treatment. Rarely do patients present with one axis I diagnosis.
Fourth, the patient may be unable to form a therapeutic alliance with the therapist, essential for successful psychotherapy outcome regardless of treatment type. This important variable is discussed at length below. And finally there may be individual factors that are specific to the patient that make him or her unlikely to respond to one form of psychotherapy but more responsive to another. A similar analogy would be depressed patients' differential response to various antidepressants. For whatever reason, some patients may be suitable for one form of psychotherapy and not another, based on multiple factors. Some patients may be more action oriented, preferring homework and behavioral exercises, whereas others may be noncompliant in this area, preferring to talk about their issues and explore their feelings. Identifying these individual variables early may help us match the patient to the treatment and be more efficient in our outcomes.
To explore significant patient variables that predict psychotherapy outcome, PsycINFO and PubMed were searched for the past 20 years using the search terms "patient variables (factors)," "client variables (factors)," predictors," and "psychotherapy outcome." Thirteen articles and/or chapters discussing specific patient variables that predicted differential response to psychotherapy were identified. The earliest research identified the patient's readiness to change as a predictor of engagement and outcome in therapy. Four stages of readiness to change have been described, including precontemplative, contemplative, action, and maintenance, with the majority of patients being in the first two stages, either not ready or contemplating change (78). MI assists in identifying the patient's stage and then helps prepare him or her for treatment (79). Patients in the precontemplative and contemplative stages need time to explore the risks and benefits of choosing a course of treatment and benefit from exploratory interventions such as MI, experiential or psychodynamic therapy. Patients in the action stage are more receptive to therapy and are probably good candidates for a specific form of treatment requiring action such as CBT (which involves exposure, cognitive restructuring, and specific exercises) or IPT, which also involves some problem-solving techniques to increase social support (80). Evidence to date indicates that this is an important variable, particularly in the treatment of addictive behaviors such as substance abuse (80). Therefore, readiness to change has been found to be an important variable in determining where to start with a patient. This may also encourage a better therapeutic alliance and increase the probability that a patient will remain in treatment. Additional treatments can be considered after patients have engaged in the initial treatment.
Other individual variables have been found to predict differential response to psychotherapy. Beutler et al. (81) found that patient resistance and reactance level predicted specific responses to certain therapeutic approaches. Patients low on the resistance/reactance variable were described as accepting of interpretations, homework, direction, and authority and generally being open and nondefensive in treatment. These patients generally did well in most treatments. Patients high in resistance and reactance, however, were described as being more resistant to treatment suggestions such as interpretations and prescription of homework. These patients generally valued autonomy, were described as dominant, and had a history of poor response to previous treatment. Patients with this response style did better with nondirective, exploratory therapies, emphasizing self-change (psychodynamic and experiential) and also benefitted from paradoxical interventions if carried out by an expert therapist in a timely fashion (82).
Degree of relatedness has also been found to predict differential response to treatment. Patients found to have a sociotropic style of relating (investment in long-term relationships) did well in supportive-expressive, long-term psychodynamic, and interpersonal therapy (83), whereas those patients with an introjective/autonomous style (values independence and autonomy) did better with psychodynamic and cognitive behavior therapies (83). Likewise, McBride et al. (84) found that attachment styles predicted response to treatment with those insecurely attached responding preferentially to psychodynamic and interpersonal therapies and those avoidantly attached faring better with cognitive therapies. Similarly, personality variables have also been studied with respect to differential outcome to treatment in specific psychiatric disorders with avoidant patients responding better to CBT and obsessional patients faring better with IPT in the treatment of depression (85). Patients with cluster B personality traits show a preferential response to those therapies that are highly structured and provide very clear, rigid boundaries (86).
Other patient variables that have been explored include functional impairment, religion and spirituality, and gender matching. Research to date indicates that severely functionally impaired patients do well with medications first, followed by psychotherapy. However severity of illness does not preclude the use of psychotherapy, although one should proceed with the idea that more time and effort will be required to attain a good outcome. There is no evidence to suggest that matching the patient's religion or gender to those of the therapist is essential for a positive outcome in therapy unless this is specifically requested by the patient (87).
Finally and perhaps new to the field is the contribution of neuroscience in predicting differential outcome to treatment. Imaging studies have shown that patients with OCD who show a decrease in pretreatment orbital-frontal cortical metabolism have a better response to medications, whereas those who show an increase have a better response to CBT (88). Imaging studies have also shown that medications, CBT, and IPT, when effective, all reverse pretreatment abnormalities in the prefrontal cortex of the brain, the area identified in depression (89). However, different regional effects were observed specific to each treatment. In an intriguing study, Goldapple et al. (90) found that depressed patients who responded to CBT showed a decrease in glucose metabolism in the frontal and parietal regions but an increase in glucose metabolism in the hippocampal region, whereas those depressed patients who responded to paroxetine showed the reverse pattern. Although in its infancy, these studies offer the hope of isolating a neural signature in predicting differential outcome to treatment (89), which is an exciting possibility for the future!
Once diagnosis has been established and an evidence-based psychotherapy has been selected with the consideration of individual patient factors, it is important to consider one of the most important variables in psychotherapy outcome: the therapeutic alliance. There is general agreement among therapists of divergent orientations that the therapeutic relationship is fundamental to treatment outcome. Although Freud gave more emphasis to the aspects of the therapeutic relationship that were developmental in origin and transferred to the therapist in the transference relationship, he did describe a collaborative component in the "positive transference," that permitted the patient to engage in treatment and participate in the work of therapy (91). Zetzel (92) and Greenson (93) further clarified this relationship, pointing to its reality-based components rather than those considered transferential in origin. The notion that the relationship was in itself therapeutic was also advocated by Frank (94). However, it was Bordin (95) who furthered the concept of the therapeutic alliance by emphasizing its importance in all therapies and offering a pantheoretical definition that could be adopted by all theoretical orientations.
Since these original reports, research on the therapeutic alliance has flourished with numerous instruments currently available for assessment. Four decades of research now demonstrate that regardless of the type of psychotherapy, reliably observable aspects of the nature of the therapeutic alliance predict outcome early in treatment (96). Ackerman and Hilsenroth (97) in a recent meta-analysis found that specific therapist attributes and techniques predict a positive therapeutic alliance. Therapists' attributes such as being empathic, warm, genuine, respectful, flexible, experienced, honest, confident, interested, and trustworthy and not authoritarian, controlling, or hostile all promote a positive alliance. Specific therapist techniques such as setting goals, being active, reflective, exploratory, supportive, empathic, and focused, as well as staying on task, are all important in maintaining a strong alliance. In addition, it is critical for the therapist to pay attention to ruptures in the alliance as this too predicts a positive outcome in psychotherapy (97). A positive alliance has also been shown to be important in maintaining medication compliance in pharmacological treatment (98).
Although the ability to form a positive therapeutic alliance is a fundamental skill, there are specific psychotherapies in which more attention is paid to alliance building factors as discussed above. These include the experiential or client-centered therapies (99), Luborsky's (100) supportive-expressive therapy and EFT (101), which integrates client-centered and gestalt techniques. Therefore, before implementing specific therapies or techniques, it is essential to ensure that sufficient attention has been given to the therapeutic alliance with the delivery of these alliance-building skills. Early dropouts or treatment failures could be due to a poor patient-therapist alliance, rather than to the intervention being delivered, whether this is an interpretation, challenging cognitive distortions, encouraging medication compliance, or other therapy-specific intervention. In summary, it is important that that therapist pay special attention to the therapeutic alliance especially early in treatment, as it is crucial to a successful outcome in any form of treatment and most importantly in psychotherapy.
After this brief review of the empirical psychotherapy literature, it is prudent to consider how this information can be applied to clinical practice. To assist in this process let us consider two clinical case examples.
A 42-year-old married father with three young children, who is practicing as a full-time lawyer presents with symptoms of chronic social anxiety and acute moderate depression with no suicidal ideation after a recent occupational stressor. His only significant relationship is with his wife. He is very independent in his approach to his work and his life and somewhat avoidant in his relational style. He has taken a variety of medications, none of which he has tolerated well and he would prefer to look at other alternatives. He is sent to you for a psychotherapy consultation. Which psychotherapy would you consider for this man based on the empirical literature?
First, we need to look at the clinical diagnoses. He is presenting with moderate depression for which many psychotherapies have been found to be effective as discussed above. CBT is effective for social anxiety disorder. This man presents with a high degree of autonomy and an avoidant attachment style. Therefore, CBT would certainly be indicated for depression and the social phobia; however, given his autonomy it would need to be delivered in a very slow, cautious manner without the therapist presenting as highly directive. Time will be required for an alliance to develop so the patient can consider CBT. It would be important to present him with all alternatives to treatment such as IPT, short-term psychodynamic therapy, and others, as well as the possibility of reviewing medication if there is no success with psychotherapy. IPT may be helpful, given that his depression may have been precipitated by a role transition or conflict at work. However, CBT will still be needed for the social anxiety disorder.
A 55-year-old widow presents with unremitting depression since the loss of her husband 2 years previously. She is currently a retired school teacher with two older sons who she sees infrequently. She has friends but she is reluctant to "burden" them with her problems. She has many regrets regarding issues relating to her deceased husband and has not discussed these with anyone. She also presents with long-standing symptoms of OCD, which have also gotten worse. She has medical problems that have made it difficult for her to tolerate antidepressants. She has been sent by her family doctor for a consultation regarding other treatment options.
A diagnosis of chronic depression and OCD suggests several treatments; however, both conditions are more resistant to treatment and require combined treatments. Chronic depression does suggest the need for combination treatments such as medication and psychotherapy. Perhaps medication could be revisited once she has established a positive alliance with a therapist. Given that her depression occurred in the context of grief and possible unfinished business issues, IPT, EFT, and psychodynamic therapy are all possible treatments to consider. These treatments will help her explore her unfinished business issues with her deceased husband, her distant relationship with both her sons, and her difficulties accessing social support. CBT or specifically exposure and response prevention will be needed to treat her OCD after her depression is addressed as she may be more motivated to deal with this as she gains the necessary energy required to engage in this form of treatment. It will also be important to use a group intervention at some point to help her access social support and look at her bereavement issues in this context. Other considerations are behavioral activation, which will help with scheduling positive activities and exercise.
The last decade has witnessed an explosion of research in psychotherapy for patients with psychiatric disorders. As outlined above numerous meta-analyses (or level 1 evidence) have demonstrated moderate to large effect sizes for many forms of psychotherapy such as CBT, IPT, EFT, behavioral activation, DBT, exposure and response prevention, EMDR, STPP, and psychodynamic therapy for psychiatric patients across the lifespan, representing a significant shift in the literature from decades ago. Numerous psychotherapies have been studied for depression, whereas CBT has been studied mainly for patients suffering from anxiety disorders and other conditions. Despite these promising findings, it is well known that not all therapies help all patients. Recent efforts to identify patient variables that can be matched to specific treatments have pointed to personality variables, attachment styles, and patient reactance and resistance in treatment. Although preliminary, it is intriguing to consider various individual variables when one is making treatment decisions.
Although specific therapies for specific disorders and individual variables that predict differential response to treatment dominate the literature, the therapeutic alliance formed between the patient and the psychiatrist continues to be a robust indicator of treatment outcome, indicating yet again that without a sound therapeutic relationship one cannot engage in any form of psychotherapy or other form of treatment with any success at any time. Although this information is well known to the practicing psychiatrist, it is important to know that it is supported by at least three decades of empirical research.
In summary, as clinical psychiatrists we frequently see patients struggle through a particular form of psychotherapy, unable to move forward and unable to use the sessions as we had hoped. This failure may not always be resistance, defense, transference, or homework noncompliance. In such cases it is important to consider several factors:
What is the patient's diagnosis or problem?
Are you delivering an evidence-based treatment specific for that diagnosis or problem?
Are there patient variables that might suggest an alternate treatment?
Are there therapeutic alliance issues?
Since the last issue of Focus dedicated to psychotherapy, much has changed. There have been numerous RCTs for several different psychotherapies, with more than 60 meta-analyses in the past decade alone. Several new psychotherapies have been identified for patients with psychiatric disorders and unique patient characteristics have been investigated to help match patients to specific treatments. Neuroscience also offers exciting possibilities of predicting differential response to treatment. In addition, as already established, the therapeutic relationship continues to be a robust predictor of outcome.
I look forward to the next issue of Focus dedicated to psychotherapy. One wonders what new discoveries will be made by then. It is hoped that empirical research will continue to support new therapies for patients with psychiatric disorders, identify additional patient variables that predict differential response to treatment, and explore therapist variables important in how we deliver psychotherapy, so that we can be more competent general psychiatrists and psychotherapists. Research aimed in this direction will continue to promote the evidence-based practice of psychotherapy and benefit patients struggling with complex psychiatric problems.
Online Resources : PsycINFO (this will yield the greater number of publications in psychotherapy research), PubMed, and the Cochrane Database of Systematic Reviews (key words: meta-analysis, meta-analyses, review)
Journals: There are key journals that publish empirical reviews and regular scholarly articles in psychotherapy. This is not a complete list.
Clinical Psychology Review (publishes excellent reviews on topics in psychotherapy)
Journal of Consulting and Clinical Psychology (publishes randomized control trials and reviews on topics in psychotherapy)
Psychotherapy Research (publishes specific research articles in psychotherapy, does not tend to publish review papers)
Journal of the Society for Psychotherapy Integration (focused publications on topics concerning psychotherapy integration)
British Journal of Psychiatry (general psychiatric publications that include papers in psychotherapy)
Canadian Journal of Psychiatry (publishes general topics in psychiatry and on occasion psychotherapy)
American Journal of Psychiatry (publishes wide variety of topics in psychiatry and some in psychotherapy)
Psychotherapy: Research, Training and Practice (publishes on general topics in psychotherapy with focus on research, training and clinical practice issues)
Focus: A Journal of Lifelong Learning in Psychiatry (dedicates special issues to psychotherapy)
Annual Meetings: There are many professional meetings that are devoted to psychotherapy. Some of these are the following:
Society for Psychotherapy Research (SPR) (offers an annual international meeting, which is excellent for keeping current with the research; the North American and Canadian chapters also have annual meetings): http://www.psychotherapyresearch.org/
Society for Exploration of Psychotherapy Integration (SEPI) (offers annual meeting, focus is on integrating psychotherapies): http://sepiweb.com/
Association for Behavior and Cognitive Therapy (ABCT) (offers annual meeting on topics in cognitive and behavioral therapies): http://www.abct.org/dHome/
American Psychiatric Association (APA) (offers workshops and meetings in psychotherapy topics): http://www.psych.org/
Canadian Psychiatric Association (CPA) (offers workshops and meetings in topics in psychotherapy): http://www.cpa-apc.org/
American Psychological Association (APA) (offers workshops in wide variety of topics in psychology including psychotherapy): http://my.apa.org/login
Training Institutions: There are many ways to obtain clinical supervision in a specific form of therapy. Distance supervision through webcams now offers a much convenient option. Online searches today yield an abundance of training opportunities. A few examples appear below.
The Beck Institute for Cognitive Therapy and Research (training in cognitive therapy): http://www.beckinstitute.org/
International Society for Interpersonal Psychotherapy (ISIPT) (training in IPT); http://www.interpersonalpsychotherapy.org/
Motivational Interviewing: http://motivationalinterview.org/training/index.html#training
Family Therapy: http://www.aamft.org/
Psychoanalysis: http://www.apsa.org/
Psychodynamic Therapy: http://www.psychodynamiccanada.org/
Group Psychotherapy: http://www.groupsinc.org/
Emotion-Focused Therapy: http://www.emotionfocusedtherapy.org/
Dialectical Behavior Therapy Training: http://behavioraltech.org/training/
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HOME Denver Broncos Gear Denver Broncos Kids Denver Broncos Kids Youth Sale Items (17 items) Product ID: 910480
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Your young Broncos fan wouldn't let poor weather stop him from supporting the team. When the mercury starts to drop, give him this Micro Polar fleece jacket so he can warm up and rock his Denver pride. This quarter zip jacket sports team colors, an embroidered team logo on the left chest and "Broncos" lettering across the back yoke to show the world where his loyalties lie. You'll never have to worry about him coming home from the game with a cold as long as he's wearing this warm and spirited jacket.
- 100% Polyester fabric
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This quote is about inheritance.
Record how this quote makes you feel.
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Search on Google Books to find citations of this quotation.
Andrew Carnegie (November 25, 1835 August 11, 1919) was a Scottish-American businessman and major philanthropist and the founder of the Carnegie Steel Company which later became U. S. Steel. He is known for having, later in his life, given away most of his riches to fund the establishment of many libraries, schools, and universities in America and worldwide.
I'm male, say nothing


text:
Former Speaker of the House Nancy Pelosi, the same woman who said we needed to pass ObamaCare to see what's in it, doesn't have a fan in Sarah Palin. The former Alaska governor and vice presidential nominee called Pelosi a "ding-bat" last night on Hannity.
Palin also responded to the ObamaTax ruling on her Facebook page.
Thank you, SCOTUS. This Obamacare ruling fires up the troops as America's eyes are opened! Thank God.
This proves to...


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New In Box. Part Number:013129813
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Browning Citori Lightning 28 Ga w/28" Blue Barrel w/Invector Choke
The Citori Lightning over and under is the only one to feature a transverse
mounted full width tapered locking bolt. The tapered locking bolt engages a
full width tapered recess in the rear barrel lugs that allows the bolt to
seat deeper over years of wear. A deeply blued steel receiver with high
relief, sculpted engraving, classic rounded pistol grip and lightning style
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From per adult
With the benefit of over 40 years' Club Med experience behind it, our Resort proposes innovative clubs for children and teenagers:
● Dedicated areas specifically designed for their needs, and equipment designed with a view to comfort and safety
● G.O®s with a passion for their job(1)
● Numerous activities for all ages: sport, creative activities and games for the different age groups
● Opening hours that allow parents to make the most of their stay, and respect the children's desires and sleeping patterns
For information: the children's clubs are open all week, except Saturday.
(1)In France, G.O®s with a BAFA (State diploma for youth group leaders) or childcare qualification, depending on the age of the children; in other countries, an equivalent local diploma or relevant experience.
A gentle haven for little ones, safe in the experienced hands of their dedicated G.O®s. Focus on early learning activities and motor skills:
Fun and spacious premises with plenty of outdoor space. Your toddlers will have a great time with their friends, and explore a wide range of activities designed to introduce them to new experiences:
We've thought of everything possible to ensure your children have a unique, adventure-packed holiday, with discovery, sports and activities for each age group:
Teenagers can meet up and take part in the activities that interest them, in the company of their G.O®:
Open 24 hours a day, it provides all the equipment necessary for preparing babies' meals: steriliser (provided only on request), microwave, fridge, bottle warmer (systematically provided in the room for G.Ms® who have reserved the Baby Club Med® or Club Med Baby Welcome®) and additional products such as mineral water, fruit, yoghourt, biscuits, cereals and long-life milk (baby formula milk not provided).
You'll find two baby feeding and equipment rooms in this Resort.
This Baby corner, located in the main restaurant, has savoury and sweet baby foods and all the equipment necessary for preparing babies' meals.
To enjoy a moment of total freedom, take advantage of the babysitting service.
Information and booking at Reception on request: Club Med provides a list of babysitting services but has no responsibility for the service provided.
We've done everything in our power to ensure the comfort and well-being of parents and babies.
Personal welcome, baby-care material available in your room and/or in the baby feeding room (cot, changing mat, baby bath, high chair on request, bottle-warmer), sweet and savoury baby foods, Baby Zone equipped to prepare babies' meals, high chairs in the restaurant.
Spare pushchairs are also available if required.
The playgrounds independent of the children's club facilities are open to children accompanied by their parents to the Baby, Petit® and Mini Club Med®.
Club Med Spa by DECLEOR now proposes specific beauty treatments for teenagers at set times in the day, to introduce them to the World of Wellness. An experience to try on your own, with Mum or with your friends.
Booking on site only.
** For information:
The term "massage" implies a superficial manipulation of the face or body, solely for aesthetic purposes, sometimes to ensure optimal penetration of a cosmetic product, or for comfort. The massage referred to is an external massage of the skin, with no medical or therapeutic aim. It may be done manually or with mechanical aids, exclusively by qualified, trained professionals.
Access conditions :
Minimum age : 11 year(s)
Maximum age : 17 year(s)
Babies explore movement - crawling, climbing and sliding - on fun circuits created especially for them.
The activity is run by G.O®, as part of the children's club activities proposed. Parents may also take part in this learning activity when the G.O® organise specific events.
For information, this activity is open to children enrolled at Baby Club Med® and Petit Club Med® only.
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Minimum age : 4 months
Maximum age : 3 year(s)
Clean Art Planet raises children's awareness of the environment. This original activity focuses on the objects that find their way into the sea and are then rejected by the waves: plastic bags, bottles, flip flops, and so on are used in a series of workshops that focus on art and colour, putting emotion in the limelight rather than right and wrong!
Once the objects have been collected from the beaches by adults, sorted according to object and colour and washed, the Mini Club Med® can get on with the creative side of the activity, during which the children invent objects and stories, do photography, create large-scale works of art and put on exhibitions.
The activity is run by G.O®s.
Access conditions :
Minimum age : 4 year(s)
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At Mini Club Med®, "Happy Nature Box" invites children aged 4 to 10 to discover nature through three fun activities:
Children aged 4 to 6 discover golf at Mini Club Med®, with one or two sessions a week.
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Through role play, children aged 3 to 6 get to learn tennis the easy way, from Petit Club Med®*.
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text: Group Career Assessment at the Collier Campus Career Services Office located in J-125 from 2-4PM The Career Assessment will help students gain a competitive edge and can lead to success in completing your degree and finding a satisfying job. You will learn about your personality type, interest, and values. Learning about yourself with others is fun and increases your understanding of differences and similarities with others. The Tuesday group is limited to 10 participants so you will want to pre-register to hold your seat and arrive about 10 minutes early.


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saw some 2012 bows on this australian site. The Bengal looks bad
saw some 2012 bows on this australian site. The Bengal looks bad
Last edited by Hutch~n~Son Archery; 11-21-2011 at 04:34 PM. Reason: language
anyone have any fav's yet in the new line up?
2003 Martin Prowler SE
2011 Hoyt Rampage XT
Easton Arrows
Trophy Ridge Sights
QAD Rest
Crimson Talon XT broadheads
Bengal is my choice
Bow String Depot Custom String Builders
Need a string set pm or email me @ email@example.com
or check us out @ http://bowstringdepot.com
Martin should send me the Scepter for the summer, you know to check for quality control.
A little common sense goes a long way, unfortunately it's in short supply!
I dont think they will do that just to get one persons view so when it arrives call me so I can come out and give a second opinion.
Bengal is looking like a clear front runner for me if I were in a position for a new Martin. The Onza still strikes my fancy and I'm still very much interested in the Ryteras. Hoping to get over to Cabelas near me this afternoon and see if they have an Onza in store that I could shoot, haven't seen one first hand yet and would like to check it out.
2014 Lithium :: 2007 Cheetah :: Jaguar Take-down
REAL AVID Field Staff / Bucks and Beards Scents Field Staff
2011 Martin Firecat 400/NAP Apache Dropaway/Truglo Xtreme Sight/Custom 8" Stabilizer/Victory V6 Arrows
2007 Martin Jaguar /Trophy Taker Dropaway/Extreme Sight/Custom 21" Stabilizer/Victory V6 Arrows
Bow String Depot, Custom String Builders email us @ firstname.lastname@example.com


text:
Verner: Finding our place in the sun (or shade)
Our friends Sam and Marilyn recently moved to Florida.
Signed on for new jobs. Sold the house in Salisbury. Packed their bags, put the beagle in the backseat and headed south. That's the Cliff Notes version; things are never that seamless where real estate transactions, lawyers and potted plants are involved. But still, they just did it, a life transformation that has left some of us as awe-struck as if they'd up and moved to the moon (which, given interstate highway traffic these days, would probably be a more relaxing journey).
"I cannot imagine ever moving again," my wife said.
Me either. In fact, plant me on the deck with a good book, a mug of coffee and a spot of shade, and I can do a convincing imitation of a dead stump. Heightening the effect is the fact that patches of my beard started mysteriously disappearing months ago. Now, it looks like I'm cultivating random splotches of lichen on my chin rather than facial hair. Personally, I think it's a good look — especially after I've been sitting outside in the rain for a few hours.
Life hasn't always been this ... settled. In my youth, I careened from place to place like a gyrating top. In the first 10 years after I graduated from college, I moved at least 10 times, not simply from cheap apartment to cheap apartment but from one city to another, one job to another. sometimes even circling back to the town and job I'd left a year or so previously. In psychological terms, I suppose I was trying to find myself. Or I had developed a strange obsession with borrowed pickups and rental vans.
One of those moves even took me to Florida. I was in my late 20s and wanted to see more of the world, so I took a newspaper job in Jacksonville. The world, I quickly discovered, was absurdly hot, flat as a waffle iron and full of roaches the size of Humvees. Plus, there was all that sand, which had the irritating habit of showing up where it shouldn't, like in shoes and underwear. Other than that, however, Florida was a perfectly lovely place to live, as I assured Sam when he first told me about their plans. I stayed there just long enough to meet my wife and get a bad sunburn while Christmas shopping. Then it was back to Georgia and, eventually, North Carolina.
That was almost 14 years ago. Some boxes from that last move are still sitting in the garage, unpacked — an accusatory symbol of how much stuff we can live without, as well as a reminder of how physically and emotionally exhausting it can be to pull up stakes, sort your accumulated life into boxes and heave yourself into the unknown.
It's good to do that occasionally, we're told — to uproot ourselves, shake off the old dirt, replant ourselves and encourage new growth. As a whole, Americans do a lot of repotting: The average American family moves every five years, or about 16 times, according to Census studies. (Those statistics seem high to me. Maybe they're skewed by people in witness protection programs.) Many moves, obviously, are work related or reflect families upsizing or downsizing. Juxtaposed against this rampant mobility, however, is this: Nearly 4 in 10 Americans — or almost 40 percent — have never left the community where they were born, according to a 2008 Pew study. Even among the restless and the career driven, I suspect most people reach a point in life where, even if the grass looks greener on the other side, it's way too much bother to get to it.
Hence my astonishment at people like Sam and Marilyn who, snugly perched in the "empty nest" stage of life, suddenly take wing. Sometimes, it involves a move to sunny Florida or — if you're already in Florida — perhaps to rugged Maine, remote Alaska or North Carolina. A couple of years ago, I met a couple who were selling their home near Charleston and moving to Argentina. Why Argentina? They had friends who'd relocated there, and they enjoyed mountain horseback riding.
There are even those so afflicted with wanderlust they can't stop moving. They sell their houses, divest themselves of furniture and appliances, buy a motorhome or camper and hit the road, with no final stopping place in mind. That's fully embracing the philosophy that life's a journey, not a destination — although given fuel prices, you might want to consider a Prius and a pup tent.
Whether we're nomads or homebodies, globe trotters or armchair travelers, we're all seeking our place in the sun, even as we cling to the comfort and stability of familiar ground. To departing friends, we wish safe travels and happiness at journey's end. To quote that great philosopher, Lemony Snicket: "It is always sad when someone leaves home, unless they are simply going around the corner and will return in a few minutes with ice-cream sandwiches."
Chris Verner is editorial page editor of the Salisbury Post.


text:
Photo by Nina Subin
The City of Devi, an apocalyptic sex comedy and love story, is the third book in Manil Suri's trilogy centered on Mumbai. [26:08]
Photo by Allie Maki Maya
Teaching Portland's children core curriculum through the arts. [30:06]
Photo courtesy of the Honolulu Museum of Art
Stephan Jost discusses how the Honolulu Museum of Art works to serve its military community. [25:56]
Photo by Daniel Schwartz
Toward the end of his life, Robert Ward discussed his remarkable career in music. [29:15]
Photo by Louis Gakumba
In her latest book, When Women Were Birds, Terry Tempest Williams explores the legacy of her mother's journals. [28:11]
Photo courtesy of Penguin Classics
The team behind the new app Poems by Heart discuss how they combine great gaming with classic poetry. [28:20]


text:
Main Content
If you have plans to head somewhere, nothing's getting in your way. You'll get what you want no matter what, and that's it. In the meantime, make sure your gear is safely secure in this Red Eye backpack from Metal Mulisha. This backpack features an eye-catching Metal Mulisha design with a printed MM skull on the front, faux leather panels, a large main compartment with accessory slots, a padded laptop sleeve, a tricot-lined media pocket with a headphone portal and multiple other pockets for all your stuff.
- 100% Heavy-duty polyester
- Faux leather panels
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- Front organizer pocket
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- Padded adjustable straps
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- Top carry handle
- Zippered laptop compartment
- Zippered side pockets
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From Crack To Christ!


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Slim straight. A streamlined straight leg jean with a slightly higher rise. A long, slender leg in pure white makes this a sexy jean for any occasion. Classic 5-pocket styling, tonal stitching, and zip fly with button closure.
FINAL SALE - cannot be returned or exchanged. No price adjustments.
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Sadly it didn't really snow much in Portland today (but there were flakes falling for maybe 10 minutes!). The photo above is from a snowshoe trip Tim and I took this afternoon. We chose a short 5-6 mile trail that passes two lakes. This is Upper Twin Lake. We enjoyed complete solitude until the last mile of the trail. It was freezing, but worth every step! We were visited by several Gray Jays, one who happily perched on a branch for at least 15 minutes while I snapped his photo (with ever-increasing numb fingers):
I love how you can see his little feet poking out from under his fluffed-up feathers. So sweet!
After snowshoeing, we drove back to Portland so we could head over to Herbivore to meet Melisser, the author of The Vegan Girl's Guide to Life. I filled my pockets with crackers (it's a terrible addiction, me and the cracker) from the snack table and chatted briefly with Melisser and Kittee. Kittee made some incredible cookies for the book signing event:
Carrot Cake Cookies with Candied Ginger and Cream Cheese Frosting! Oooooh yeah. The recipe is adapted from a great little cookbook called Cookies for Everyone. Check out Kittee's post on the cookies because her photos are much better and super close-up so you can experience cookie envy.


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Saturday Science Links: October 25, 2014
In science news this week, read about magical nose cells, 45,000 year old thigh bones, and the weirdest looking dinosaur ever.
The Resource Finder has powerful filtering features — check out the tutorial to learn more.
In science news this week, read about magical nose cells, 45,000 year old thigh bones, and the weirdest looking dinosaur ever.
The former chair of the Harvard University physics department muses on how faith gives meaning to his scientific work.
The story of the Genesis Rock reminds us of how biblical and scientific accounts, despite their different purviews and purposes, remain inexorably linked in our understanding of origins.
If discussions of science and religion sometimes get bogged down in Genesis, perhaps that is because they have not made the preparatory journey through the rich material of the Wisdom books.
Are black holes in trouble? Could life have come from space? What do we know about the religious lives of Indian scientists? Find the answers to these questions and more.
Written by BioLogos Fellow of Biology Dennis Venema, this series of posts is intended as a basic introduction to the science of evolution for non-specialists.
This week's news features volcanoes, skeletons, and stars, as well as a thought-provoking new book from InterVarsity press.
Stephen Meyer and the Discovery Institute seek to make the case for the designer in a purely scientific context, without specifying who the designer is. At BioLogos, we take the approach that science is not equipped to provide a full Christian apologetic.
From science and religion blogs: quantum uncertainty and God, the remarkable fact that we have come to understand our place in the created order, and the role of theology in making wise choices about the use of technology.
But what I heard on Sundays did not seem to fit with what I experienced of the world the rest of the week. Growing up in New Mexico in the cottonwood bosque of the Rio Grande valley provided everything for a kid to become a biologist. I roamed along the river, cooked over cottonwood fires, ate wild asparagus, watched clouds form thunderheads over the distant peaks of the Sangre de Cristo Mountains.
This week in origins news, a great collection of articles by key players in the conversation about theology and science, a surprising science fair discovery, and the Apollo 11 anniversary!
We don't have all the answers and never will. And when God says that he is revealed in his creation, I think that means we need to take care of what we have and understand where we came from. The more I understand how things work, the bigger God gets. When he was just a magician pulling things out of a hat, that doesn't even compare to how I see him now!
Last year I introduced readers to one of the leading voices about Christianity and science, John Polkinghorne. I also helped BioLogos bring in another leading voice, Robert Russell. This new series introduces a third prominent Christian thinker, Lutheran theologian Ted Peters, Research Professor Emeritus in Systematic Theology and Ethics at Pacific Lutheran Theological Seminary, the Center for Theology and the Natural Sciences (http://www.ctns.org/), and the Graduate Theological Union in Berkeley, California.
We should celebrate the many times that our churches and colleges encourage scholarship. I saw several delegates at Synod stand up and speak directly about the importance of supporting scholars who engage the science and religion dialogue. The recent Synod decision was a move in the right direction.
God could have created a fertile planet miraculously in an instant, but when we look carefully at the physical evidence, it appears that the earth has a longer history as part of the universe.
God could have created a fertile planet miraculously in an instant, but when we look carefully at the physical evidence, it appears that the earth has a longer history as part of the universe.
We are interactive human beings with a capability and a need to connect with others. Those connections can be through electronic or written means but nothing can replace the need for direct personal engagement. Our annual meetings continue to provide that interaction in an environment of open discussion and often vigorous debates.


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HD 24 race pits saver against spender
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News from WTOP
News from the AP
Mike Causey
Shows & Panels
Shows & Panels
- The 2014 Big Picture on Cyber Security
- AFCEA Answers
- American Readiness: Renewable Power and Efficiency Technologies
- Ask the CIO
- Building the Hybrid Cloud
- CDWG/NetApp
- Connected Government: How to Build and Procure Network Services for the Future
- Continuing Diagnostics and Mitigation: Discussion of Progress and Next Steps
- Delivering the Digital Government Mission
- Federal Executive Forum
- Federal News Radio's National Cyber Security Awareness Month Special Panel Discussion
- Federal Tech Talk
- The Future of Government Data Centers
- The Future of IT: How CIOs Can Enable the Service-Oriented Enterprise
- Government Perspectives on Mobility and the Cloud
- The Intersection: Where Technology Meets Transformation
- Maximizing ROI Through Data Center Consolidation
- Mitigating Insider Threats in Virtual & Cloud Environments
- Modern Mission Critical Series
- The New Generation of Database
- Reimagining the Next Generation of Government
- Targeting Advanced Threats: Proven Methods from Detection through Remediation
- Transformative Technology: Desktop Virtualization in Government
- The Truth About IT Opex and Software Defined Networking
- Air Traffic Management Transformation Report
- Cloud First Report
- General Dynamics IT Enterprise Center
- Gov Cloud Minute
- Government in Technology Series
- Homeland Security Cybersecurity Market Report
- National Cybersecurity Awareness Month
- Technology Insights
- The Cyber Security Report
- The Next Generation Cyber Security Experts
Shows & Panels
Open season, Medicare part B, Petraeus, & sequestration
Wednesday - 11/14/2012, 6:09pm EST
November 14, 2012 — This week on "Your Turn" , Walton Francis, the expert on the federal health-insurance program, joined host Mike Cause to talk about Open Season and whether Medicare part B is right plan for federal retirees.
Francis is the author of Checkbook Guide to Federal Health Plans. Both the online and print version have become the Bible for federal and postal workers and retirees looking for the best coverage.
Also, Federal Times reporter Sean Reilly talked about the fall from grace of former CIA Director David Petraeus, the next step toward the fiscal cliff, and the Postal Service's battle to survive.


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Visit NBCNews.com for breaking news, world news, and news about the economy
- ***** White House Free Gaza Vigil
- Home
- The (Israeli) General's Son
- If Americans Knew
- Peace, Propaganda, Promised Land
- Israeli Myths and Propaganda
- Israel and Palestine
- vid. SAID TO ME, AN ARAB, "PEACE" MEANS 'DIE QUIETLY.'
- Princeton's Dr. Falk: Winning the Legitimacy War
- Desmond Tutu: Israel - Liberate Yourselves
- The Gatekeepers
- vid. Torah EXPRESSLY FORBIDS ISRAEL'S BEHAVIOR
- Bishop Tutu: IT IS APARTHEID
- Ha'aretz: Israeli teens, Racist and Proud
- Young Jews Against Occupation
- 327 Holocaust Condemn Elie Weizel, Israel, for Gaza Massacre, Demand Boycott
- Dr. Meyer, Holocaust Survivor, "Israel like the Nazis."
- "Loving, you're filled with Hate?!?!"
- NYMag: Cornell West and the Obama-Blaming Left
- Jews Against Genocide letter to Chief Rabbis of the World.
- Israel's Death Grip on US Politics
- Rabbi Siegman - Slaughtering of Innocents
- The Price of US Ignorance of the SCHOLARSHIP
- Life in Palestine
- The Zionist Story
- vid. Palestine, [The Middle East], and US Policy. Scholar, Intellectual Edward Said
- The Iron Wall. 'MUST Watch,' Pr. Carter
- Oxford U: IS ISLAM VIOLENT?
- Yale's, Oxford's, Harvard's Rashid Khalidi... US HAS NEVER, EVER, BEEN AN HONEST BROKER...
- Russel Tribunal on Palestine
- Press Club DC: Reassessing US Israel
- IF YOU'VE A SHRED OF HUMANITY... WATCH THIS...Jewish Israeli Professor Nurit Peled: Gaza concentration Camp
- vid. Netanyahu: "America is easily moved.'
I strongly suspect that there is only one true Revolution possible for the human species - past, present, future. And the only time it ever has been tried, to my knowledge, is for several decades during and after the life of Jesus. That Revolution? Lived, total, solidarity with the Global Neediest (human and non-human species). "The Golden Rule is to steadfastly refuse to have what millions cannot have," is how Gandhi said it. "Do unto others ALL that you would have them do unto you," is how Jesus Lived it, and how He or his followers, said it.
***** Dangerous Ignorance: MSNBC - Just 6% Know Deficit Ration Declining under Pr. Obama
Labels: *****, DEMcowards, DEMhypocrites, DEMzombies, Devil, Evil, G.reedy O.ld P.igs, Insanity, Satan
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Copernicus and the Quantity Theory of Money
The audio version of the Mises Daily article for March 12, 2010. [5:39]
This audio version of the Mises Daily was read by Jeff Riggenbach. Murray N. Rothbard (1926–1995) was dean of the Austrian School. He was an economist, economic historian, and libertarian political philosopher.
From: Audio Mises Daily , Friday, March 12, 2010 by Murray N. Rothbard


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Handsome foliage & flowers make this an ideal groundcover for shade.
Lungworts look best grown in masses as a shady groundcover or combined with hostas, hellebores and ferns in a shady garden. Grown as much for their attractive leaves as for their flowers, lungwort's foliage remains attractive all season as long as the soil isn't allowed to dry out. The genus name Pulmonaria and common name lungwort allude to its historic usage as a remedy for respiratory problems. Lungworts form low-growing clumps that slowly spreads to form a groundcover without being aggressive and overtaking other plants.
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You're known for your fashion sense and your Miami fanaticism. This School Tribute V-neck tee from Nike ensures you show off both! Featuring printed Miami graphics, this shirt has an abundance of team spirit. It's also made with soft tri-blend material and has a flattering fit so you can show off your stylish Hurricanes pride in comfort!
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School officials showed cautious optimism this week when the district's CAP scores for the 1986-87 school year showed steady improvement.
The Chamber of Commerce has greeted two new businesses. Ribbon cuttings were held for Curtiss Group, the new Ford dealer, and for Affordable Lock and Key.
The Patterson High wrestling team — 39-1 in dual meets during the past five seasons — opened defense of its league title with a convincing win over a strong Riverbank team.
50 years ago — Jan. 10, 1963
A vista point overlook has been proposed for the new Interstate 5 freeway, in the area of Oak Flat Road.
To no one's surprise, the county Committee on School District Organization has voted 11-1 favoring the unification of the Patterson area's four school districts –— Patterson High and Patterson Elementary, as well as Grayson and Rising Sun elementary districts. The final decision will be by public vote, probably next fall.
75 years ago — Jan. 14, 1938
A flock of wild geese visited Patterson several nights this past week, feeding in vacant lots in the area of North Fourth Street and possibly lost in the foggy weather.
The varsity football team has selected Tony Azevedo as its most valuable player during the fall campaign. Official letter sweaters have been adopted by the Block P Club at the high school.
Hot lunches being prepared by the Del Puerto yearbook staff are meeting with acceptance at the high school.
100 years ago — Jan. 9, 1913
The fledgling Evans Telephone Co. has received shipment of its new switchboard, which has a capacity of 150 light drops and 40 magneto lines. Owner J.H. Evans is still awaiting arrival of additional parts before providing phone service to Patterson customers.
Nurseryman G.A. Mertes has provided 8,000 Burbank crimson winter rhubarb plants to M. Miller, while Mr. Heflinger has purchased 1,500 Burbank spineless cactus plants from him. Hez Jones has ordered Himalayan and Mammoth blackberry plants. Apple, peach, apricot, cherry, plum and pear trees are also being purchased for local orchards.
Pioneer resident Polly Rolston Hammonds has died here at age 80. She leaves 10 children, five of them Patterson-area residents, including a daughter, Mrs. Edwin Brown, with whom she lived on a ranch a few miles west of Patterson. The deceased had lived in this area since 1868.
The newly organized Methodist Episcopal Church plans to erect a house of worship at a cost of no less than $2,500. On the committee to solicit funds are Charles G. Hamilton, Hattie Lee and the Rev. W.H. Mumper.
—Irrigator archives


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square flair. Deep boxy bowl dishes soup, pasta, salad in matte black stoneware that makes everything pop high drama. Super tall sides angle modern interest.
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bento matte black square bowl. 9"Wx9"Dx3.25"H
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History of Horror
WTOP Film Critic Jason Fraley challenges you to see how many clips you can name in this monster mash-up of scary movie moments.
Do you have a favorite scary movie? Or do you have a real-life spooky story that still haunts you? You can join the conversation on our Facebook page or tweet your thoughts using #WTOP.
We're counting down the Top 50 Scary Movies of All Time.
The list is based on four criteria: (1) Fear Factor, (2) Historical Influence, (3) Filmmaking Skill, and (4) Pop Culture Impact.
Which movie will land at No. 1?
Check out the gallery to the right.
Also, check out the audio mash-up to the right to see how many clips you recognize from our "History of Horror."
Follow WTOP Film Critic Jason Fraley on Twitter @JFrayWTOP, read his blog The Film Spectrum or listen Friday mornings on 103.5 FM.
© 2013 WTOP. All Rights Reserved.


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This week marked another interesting milestone in the ongoing evolution of Catholicism. Since Tuesday, media outlets across the globe have been abuzz with headlines like: Pope Francis declares evolution and Big Bang theory are real and God is not 'a…
Welcome to the Theocratic States of America
by F. Andy Seidl • • 0 Comments
If you like the idea of living in the "Theocratic States of America," you may be pleased with today's Supreme Court decision. Today, the Supreme Court ruled 5-4 that the Christian-owned Hobby Lobby chain store is exempt from certain provisions of the…
Going to Work for CNN
by F. Andy Seidl • • 2 Comments
I have long been critical of CNN for becoming a "news show" network rather than a news network, which is why it comes as a surprise, even to me, that at the end of this month, I will be taking…
Religion, Science and Technology
Response to 22 Creationists
by F. Andy Seidl • • 1 Comment
Last Tuesday, Bill Nye (the science guy) debated Ken Ham (founder and CEO of Kentucky's Creation Museum) on the question of whether a young-earth creation model is compatible with the theory of evolution. NPR posted a nice summary of the debate,…
by F. Andy Seidl • • 0 Comments
For some reason, I remember a lot of dates and times. Not necessarily of upcoming events, but rather, of past events that, for whatever reason, just seem to stick in my mind. January 2, 2009, shortly after 3 AM is…
Black Friday at Walmart–Commercialization of Everything
by F. Andy Seidl • • 0 Comments
Black Friday scenes like this make it hard not to worry about our society. Well, sure, they're willing to sacrifice a chunk of their holiday time, and most of their self respect, but they did get that thing that's not…


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