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Topic 4: Psychoeducation & Behavioral Activation {by 9/27}
There are three readings due this week (Beck – 1 chapter; Volungis – 2 chapters). For this discussion, share at least two main thoughts: (1) Why is psychoeducation considered a vital component for effective CBT (please go beyond saying it "educates" clients!). (2) There is much research that supports the effectiveness of behavioral activation as a specific factor for CBT. Share your thoughts on possible reasons why behavioral activation is effective at reducing client distress. Your original post should be posted by the beginning of class 9/27. Have your two replies posted no later than 9/29. *Please remember to click the "reply" button when posting a reply. This makes it easier for the reader to follow the blog postings.
33 Comments (+add yours?)
(1) Psychoeducation is a vital component to effective CBT for several reasons. Clients are encouraged to learn new skills through therapy including developing insight into their diagnosis and distress, identifying and modifying negative automatic thoughts and core beliefs, making changes to their maladaptive behavior patterns, and learning the necessary skills specific to their presenting issues. Psychoeducation provides client with the knowledge to accomplish all of these skill independently. Additionally, psychoeducation aids in fostering therapeutic rapport and act as a learning process for both the therapist and the client, as the process should be collaborative as opposed to a one-way lecture. Psychoeducation does not cease after the beginning of therapy, it does however become less formal as the expectations of therapy change. In the early phase of therapy, therapists need to discuss what clients should expect while using a cognitive model. Explaining anticipated case formulations and treatment plans should also be reviewed. In this phase, therapists can psychoeducation as a base for encouraging optimism and motivation. Clients need to understand how CBT has the likelihood of decreasing distress and improving quality of life. Clients need to understand the relationships between triggering events, automatic thoughts, emotional and psychological responses, behaviors, and related outcomes. Finally, this information (and future information) should be communicated in a way that clients can comprehend, as well as remain an active participant. In the later phases of therapy, clients will learn how to problem-solve. Therapists can use psychoeducation to facilitate autonomous problem solving by using real-life examples, therapy notebooks, self-report measures, whiteboard examples and diagrams, and homework in order to track progress and reinforce learning to skills specific to their diagnosis. Finally, self-help books or other resources related to the treatment plan can be an appropriate part of psychoeducation depending on the phase of therapy and readiness of the client.
(2) The main objective of behavioral activation is to reduce negative reinforcing behavior patterns and increase positive reinforcing behavior patterns, and can be used throughout all phases of therapy. In order to increase their source of reward, therapists need to work with clients to increase their activity by engaging in activities or tasks that have been avoided. Activity monitoring and scheduling and graded task assignments (GTAs) are the two most common and effective form of behavior activation. In order to initiate these tasks, therapists and clients must have a strong collaborative relationship and the client must be motivated and ready to move onto a new intervention. Using Weekly Activity Monitoring and Scheduling Log can help clients internalize progress and promote self-efficacy. Behavioral activation allows therapists and clients to work together in the building of client self-efficacy and autonomy in regards to controlling their own emotions and behaviors, and these logs are an efficient way to track progress. Additionally, many clients report enjoying activities more than they expected to, which will help them discover that some of their automatic thoughts or predictions may be inaccurate. The quality of the logs, and more importantly, the quality of the therapist's review of the logs will aid in further understanding and motivation from the client. GTAs help clients break down larger tasks into smaller ones in order to decrease anxiety and increase opportunities for success and satisfaction. Similar to session structure, clients need to understand and be comfortable with the idea that not all scheduled activities will go as planned and that flexibility is vital. By using behavioral activation, therapists are giving clients multiple opportunities to feel accomplished and improve several aspects of cognition and behavior. Building self-efficacy, challenging negative automatic thoughts, and increasing hope are all goals of this technique, and it is done effectively through completing these logs and promoting healthy out-of-session tasks in order to identify adaptive and maladaptive patterns.
I like that you mentioned in your post that information should be provided to clients in a way that they will understand. I forgot to mention that in my post, but I believe that is an important aspect to include. We discuss a lot in class and in these posts that in order to establish a therapeutic relationship the client has to find the therapist "attractive" i.e, competent. In this case, I believe it is important for a therapist to acknowledge that being competent does not necessarily mean you have to use complicated jargon that is not used in day to day life– at least not until these terms have been thoroughly explained and the client has learned them! Great post.
Psychoeducation is considered a vital component to effective CBT because it is important for clients to know what they are getting themselves into. They should be on the same page as their therapist since CBT is collaborative therapy. It is important for clients to know insight into their diagnosis and distress, identifying and modifying their automatic thoughts and core beliefs, making changes to their maladaptive behavior patterns, and learning any necessary skills specific to their presenting problems (Volungis, 2018). Once the clients learn these skills themselves, then they will be able to help themselves later on after therapy is over and this could prevent a relapse from occurring. They would be doing the same skills as their therapist would do and this could help them tremendously. Psychoeducation is also important for CBT because it establishes therapeutic rapport. Like I said previously, CBT is a collaborative process, so both the therapist and the client are learning through this process. The therapist learns things about the client and the client learns skills from the therapist. This process is a very active process, so it is important to ask questions of your client and have your client elicit feedback. This is helpful, so the session can improve as the weeks go on. Psychoeducation is also crucial for the first few sessions of therapy because it informs the clients what the therapy process is going to feel like. It gives the client a chance to warm up, rather than be put on the spot right away. All in all, psychoeducation is very beneficial for both the therapist and their client. Now learning about how important psychoeducation is for clients, I never thought about it in this way. Now understanding this, everything ties in together and makes sense.
Behavioral activation is effective at reducing client distress because the goal of behavioral activism is to reduce negative reinforcing behavior patterns while increasing positive reinforcing behavior patterns. Behavioral activation is effective because it is used to break the client's maladaptive cognitive-emotional-behavioral patterns. It is meant to move the individual into the "opposite" direction because the therapist is trying to help the client escape the vicious cycle that they are in. This process mainly takes the behavior into action, not the thoughts. In order for this process to be a success, therapeutic rapport needs to be established because this process can be challenging for some clients and it is important for the clients to trust the therapist with doing the behavioral activation. Also, effective behavioral activation can naturally reinforce the therapeutic expectation of the collaborative nature of CBT. If behavioral activation is effectively implemented, then maladaptive behavioral patterns are slowly transformed into a lifestyle where accomplishments and pleasure are experienced and self-efficacy is developed. According to Beck, helping clients become more active and giving themselves credit for their efforts are essential parts of treatment, not only to improve their mood, but also to strengthen their sense of self-efficacy by showing them that they can be in control of their mood. After reading and learning about behavioral activation, I find this process fascinating because it is interesting to see how this process works and helps clients break out of their negative cycle that they are in and cannot escape. So learning how clients can escape this cycle and improve is very rewarding.
I loved your line about how "the client is learning from the therapist and the therapist is learning from the client." It really proves the point of the collaborative process of CBT. I also agree with your point that psychoeducation gives both the client and therapist to warm up and develop their relationship, which will only help for a positive outcome. I find the more I delve into the different individual compnents of CBT the more I agree with its process because everything works and ties together.
I liked how your response focused in on developing a strong therapeutic relationship. In order for any type of therapy to be successful there needs to be good rapport between the counselor and client. Both psychoeducation and behavioral activation can aid in developing that strong relationship. Psychoeducation does it by giving the client a way to be more active in their session. Behavioral activation lowers the stress of the client to then be able to open up more.
The point of CBT, and one of the many reasons why it is considered the most effective form of therapy is that, although the client-therapist relationship must be strong, it is brief. Unlike, other forms for therapy where clients are looked at as incompetent individuals that need a professional for months or even years at a time to feel "normal", CBT believes that if professionals can conceptualize why a client is thinking/behaving a certain way and can aid in adapting those behaviors and thoughts, we can also teach them to do this on their own, so that they are autonomous individuals in society. The most important way of being able to accomplish this is through psychoeducation, and why it is a vital component to the therapy process. Educating clients on their specific condition, teaching them new skills to deal with the condition, and letting them know that they are not "crazy", and that the condition does not define who they are, gives them hope to stay in therapy and provides a better chance for positive outcomes when therapy ends. Psychoeducation does not mean though, that the therapist lectures the client, but, collaborates with the client about what they want, and conceptualizes a treatment plan together with the client. This lets the client feel valued and eases the ability to accomplish goals. Psychoeducation should be a slow process, so that the client does not feel overwhelmed but slowly learns the new "language" and develops new skills that they can master. Because of this, the early phases of psychoeducation should focus on therapy expectations, case conceptualization and treatment plans with clients, where they learn more about their diagnosis and how it will be treated, in order to reduce any distress and give hope for positive outcomes. In later phases of CBT, the client will be learning new skills, in session and then applying these skills out of session, along with, if appropriate, reading material that may aid in treatment. If successfully done the therapist will notice a natural progression of their client "taking the wheel" more in session, while they simultaneously feel better out of session, because of the implementation of different skills learned.
I believe that behavioral activation effectively reduces clients stress because it concurrently works with the CBT model in helping change negative thought and behavioral patterns by collaborating with the client through activity. Behavioral activation works with psychoeducation and aids both the therapist and client to figure out together the root of current problem. Behavior activation gives the therapist multiple tools to look toward in making positive outcomes with their client. These tools are effective because it gives the therapist more to work with to increase the likelihood of success. Weekly activity monitoring logs help to find clients' behavioral baseline in a non threatening way, that motivates them to continue with therapy. Once a baseline is discovered clients can use daily activity schedules and graded task assignments to asses thoughts and emotions associated with different activities. Graded task assignments are especially beneficial in reducing client distress because it takes larger, more overwhelming tasks and breaks it down into smaller components which are easier to "digest". The client can then celebrate the small victories while working toward completing the "scary" large task. Both activity schedules and graded task assignments also leaves room for modification and adjusting as the therapy process progresses, which aids in the refinement of addressing the core of clients' distress. I believe that behavioral activation is effective as a whole because it is thoughtful, organized and strategic. It also integrates with all other aspects of CBT seamlessly.
"CBT believes that if professionals can conceptualize why a client is thinking/behaving a certain way and can aid in adapting those behaviors and thoughts, we can also teach them to do this on their own, so that they are autonomous individuals in society. The most important way of being able to accomplish this is through psychoeducation, and why it is a vital component to the therapy process. "
Melissa, I wholeheartedly agree! I'm so happy you caught this as well. One of the major points of psychoeducation seems to be overlooked by many. (But thankfully not our classmates!) I couldn't help but think that one of the most important reasons for psychoeducation was teaching your client CBT skills and concepts in session, so that they may comprehend it and remember it later on when they need to use skills. Like birds leaving the nest, we nurture our clients for a limited time so that they can fly on their own. That is the cheesiest analogy ever but I think you guys get what I mean! Psychoeducation is crucial for our clients so they not only use the skills we teach them but understand why they should use those skills and which are effective for them in scenarios they encounter.
I like your focus on the graded tasks assignments being most beneficial, I also agree with that. The concept of taking a large idea and breaking it down is a strategy that is useful in many aspects in life so utilizing that into therapy interventions is absolutely needed. I liked the term of "thoughtful" to describe behavioral activation, since it is actively collaborating with your client with changes in their thoughts which is quite personal and could be hard for clients. Overall, love your discussion
Melissa, I really like how you went into depth about how psychoeducation is crucial for CBT and how it really does help the individual. It is important to keep in mind everything that you said because it will help us later in the long run when we are actually practicing these skills ourselves. I really liked how you said, "Psychoeducation does not mean though, that the therapist lectures the client, but, collaborates with the client about what they want, and conceptualizes a treatment plan together with the client." I find this extremely important because someone outside of this field may not view this in this way, but in fact, psychoeducation is beneficial for both the therapist and the client, not just the therapist. I also liked how you gave examples of different activity sheets the clients could do to relieve some of their distress. All in all, thank you for sharing your thoughts!
I liked your comment about how psychoeducation needs to be a slow process. If I put myself as the client's shoes, I would not want to be delivered so much information all at once. I would be overwhelmed like you said what would happen to the client. However, since every client has different experiences with therapy then maybe it depends on the client whether how much you give them information. If a client has experienced, then maybe it would be alright to speed up the process maybe just a little since they are well aware of how the therapy sessions are. Overall, I enjoyed your interpretation towards psychoeducation.
Melissa, I enjoyed your blog post! I like how in your discussion of psychoeducation, you included the idea of letting your client know they are not "crazy" or that what they are going through is not abnormal. I think this is so important. It can be easy for a client to take their diagnosis and label themselves, making them feel badly, or as if this diagnosis is a defining characteristic of who they are as a person. I think it is so important to normalize the diagnosis for the client, and educate them on the symptoms, and possibly even some statistics on the disorder, or find similar cases such as athletes or influential people with that same diagnosis that help the client to realize that they are not alone or different. This also ties into your comment on behavioral activation, and how it works with the CBT model in regards to negative thoughts or behaviors. I think that behavioral activation also serves as a form of psychoeducation, as the client learns or tracks their behavior patterns and begins to change these behaviors into more positive ones. As you said, this can be a small victory for a client, but one that will likely make them feel that they can get through this or that their diagnosis is not defining of who they are and what they are capable of doing!
Melissa, I like your use of language throughout the post. Words like "normal" and "crazy" are often words that I think clients can get caught up on and psychoeducation can help reduce that worry. I think it also helps to show that there is a standard of what normal means to them and how they can feel the most healthy and able to live their day to day life as you mentioned.
(1) Psychoeducation is considered a vital component to effective CBT because it allows clients to learn new skills and apply these skills. Psychoeducation is more than just helping clients gain CBT knowledge. It helps them gain insight on their distress, their negative cognitions and maladaptive behaviors, and learn and apply skills to help themselves. CBT psychoeducation can also help with rapport and collaboration, due to the fact that therapist and client are engaging in a leaning process together. The therapist can personalize psychoeducation for their client, whether that be by focus of content/skills, pacing, and lecture to collaboration ratios. One of the important factors of psychoeducation is making sure that the client is understanding what is being reviewed, as well as making sure they are active in their learning, by collaborating with you and practicing and giving feedback. If a client is involved in the psychoeducational process, they are more likely to continue the collaborative relationship and be involved in their own therapy. Being involved in this process makes it more likely that clients are motivated to continue treatment and apply the learned skills to decrease their distress.
Psychoeducation helps give clients an understanding of what can be expected in therapy of the therapist and the client themselves, along with the course of treatment, what CBT is, and how CBT can help treat their distress. Giving clients a clear-cut explanation of what they can expect from therapy can clear some of the mystery around therapy, help clients get a sense that there is a way to treat their distress, and learn that they can help themselves too. But psychoeducation can also assist with developing rapport early on in the therapeutic relationship by getting the client motivated and hopeful that they can work on their distress. Psychoeducation also allows for clients to move when they feel ready, as sometimes clients need more information before they feel comfortable trying skills. Considering the goal for CBT is to have clients eventually be their own therapists and effectively use their skills, psychoeducation is crucial. If they do not have a deep understanding of CBT related skills that apply to them and apply them appropriately, then this goal will not be attainable nor effective. If you do not properly educate your client on the process and how they can help themselves, then you are not satisfying one of the major purposes of your therapeutic relationship and therapy itself.
(2) Considering that the purpose for using behavioral activation is to reduce negative reinforcing behavior patterns and increase the negative patterns with positive reinforcing behavior patterns (and eventually replace the negative patterns with positive ones), it is clear why behavioral activation is effective at reducing client distress. If a client engages in more positively reinforcing behavior patterns (e.g. hanging out with friends, completing self-care tasks, engaging in fun and rewarding activities) then they are less likely to be depressed and distressed from a lack of positively rewarding/reinforcing behaviors. That is, the decrease in negatively reinforced behavior patterns and increase in positive behavior patterns allows for a decrease in the behaviors that are causing a cycle of continuous distress (i.e. client socially isolates themself and does not engage in rewarding social activities, client then does not feel the reward of social interaction and can develop low self-efficacy in social interactions, which can reinforce the isolation. It is a vicious cycle of depression and distress). Behavioral activation helps clients engage in the activities that will put them in a rewarding cycle and decrease distress. By increasing engagement in rewarding positive behavior patterns, most likely the negative behavior patterns will decrease and become less engrained, as the pleasure from the rewarding patterns will hopefully become learned. Meaning that, the more a client replaces negative behavior patterns with positive ones, the more likely they are to continue this positive cycle and help themselves with their distress. Behavioral activation seeks to move clients in the opposite direction of the vicious cycle, a "positively rewarding cycle" if you will. By focusing on changing behaviors first, therapists can consequentially help clients change the associated thoughts (e.g. engaging a client in completing a chore, negative automatic thoughts associated with not completing that chore can become positive (accomplishment, pride), the client can engage in that task more often/to completion and experience the pleasure of completing the task, client then experiences increased or improved self-efficacy at that task, which can later help to be generalized to other tasks and cognitions).
Getting the client to engage in the behaviors can be one of the hardest parts of behavioral activation techniques, considering that many of the clients that suffer from depression or distress have low energy accompanied with negative automatic thoughts that keep them from engaging. Therapists can help start behavioral activation techniques on smaller and easier scales and build up to more difficult or general tasks. One simple technique Beck suggests is using self-monitoring schedules where the client puts tasks on a schedule and tracks them to completion or not. In all, behavioral activation is effective at treating client distress as it gets to the core issue of their distress (negative behavioral patterns and negative cognitions then develop into a vicious continuing cycle) and teaches the client how to change their behaviors so that they can treat their distress. The recurring theme of CBT yet again surfaces in behavioral activation as this technique taps into both maladaptive behaviors and cognitions to decrease client distress.
I really like how you mentioned that psychoeducation helps the client gain insight into their distress. I failed to mention this and after reading yours, I am wishing I had thought to mention it. I also like how you mentioned psychoeducation can help the client move when they are ready. After reading that, it really made me think about how true that is. If a client is feeling ready to change and wants to be very educated about their distress and exactly how to reduce it, the therapist can give them a lot of information and work to do outside of therapy. On the contrary, if an individual is not feeling as ready to move, the therapist can either not give them much information until they are ready, or can give them some to help them feel more comfortable with the things the therapist has in mind. It ties back into the collaborative aspect of CBT, and allows the client to help run the show.
I like your mention of therapists being able to personalize psychoeducation for their clients. I never even realized how far this personalization can really go for the therapeutic relation and therapy as a whole. If you simply just conduct sample psychoeducation for all your clients, you're not really benefiting them since the information could somewhat be useless if it doesn't apply to them – great point!
I really enjoyed reading you response on psychoeducation and your ideas behind why it is important during sessions. The part that caught my attention the most was how the structure of paychoeducation can change for each client. Therapy is not a one size fits all type of practice, so why should learning about the information be? Changing up what is explained and taught will benefit each individual client in the best way possible.
Psychoeducation does what the name states and much more. Using psychoeducation in CBT provides clients with information on therapy in general, CBT specifics, the therapeutic alliance, diagnoses and symptoms, and assessments used. Going beyond the obvious importance of psychoeducation, this component of CBT helps build on the therapeutic relationship and gain a better understanding of your client. By providing information and asking questions you can see what your client already knows and keeps the client actively engaged in the therapeutic process. Psychoeducation also gives you the opportunity to show your expertness, as we read in chapter 2 of Dr. Volungis's text. This is important to help build rapport with the client and leads to trustworthiness. Because CBT goes beyond sharing feelings psychoeducation is also important part of the homework component of CBT. You need to teach the clients to use skills outside of counseling and through future crises or stressors.
After reading through the chapter on behavioral activation and seeing the activity logs I can see why behavioral activation is effective in reducing client distress. Often times it can be difficult for clients to see things objectively and rationally. As we know this isn't always the case but the times that clients have difficulty seeing things more rationally the techniques used in behavioral activation can be helpful. The activity logs have clients write down everything that they do throughout the day. This helps clients see patterns of behaviors that they may not have realized were a pattern previously. Working actively with a therapist after filling out the activity log can help clients go through the emotions and thoughts that were attached to the activities, or lack of activities. This helps the therapist notice the clients' automatic thoughts and core beliefs. The therapist is able to then push clients to see the negative automatic thoughts and help them to adjust these negative automatic thoughts to be more realistic or positive. It gives a physical representation of how clients are behaving and thinking about themselves which can help clients see what is most distressing them. After seeing what is most distressing clients can then move forward with the therapist to work on changing those negative automatic thoughts and behaviors.
"The activity logs have clients write down everything that they do throughout the day. This helps clients see patterns of behaviors that they may not have realized were a pattern previously. Working actively with a therapist after filling out the activity log can help clients go through the emotions and thoughts that were attached to the activities, or lack of activities"
Becca, I like how you pointed out the usefulness of activity logs. I agree that it must be helpful for clients to materialize their negative behaviors and cognitions on paper (and track them!). Sometimes we can get stuck inside our own heads and this must be especially true for some clients. The therapist can guide the client through the specific behaviors and thoughts, and they can both have a running record of the negative behaviors. This could be especially useful in tracking client progress and even helping a client to feel the reward of accomplishing something by allowing them to review their progress.
I really liked how you included that psychoeducation helps build rapport with the client. It is important to build rapport with our clients but it is interesting to know this could also be done through psychoeducation. I also agree with your statement about how clients doing homework outside of therapy sessions, so they can practice these skills on their own for whenever they are in a crisis. I find having homework is very beneficial for the clients because they are able to learn these skills they practice in therapy and put these skills to the test. Also, your statement about behavioral activation helped me have a better understanding because of the way you explained it. I find it fascinating that through these activities, therapists are able to identify these negative thoughts and help modify these thoughts, so the client's behavior can change and their stress will be relieved. This is what CBT is all about and how all these different elements we learn about each week come together.
1. I think psychoeducation is a crucial factor in therapy because it provides information that individuals need in order to fully grasp the components that mental health has. Psychoeducation is more than just a history lesson around the clients diagnoses, it provides insight on what they may not fully understand. Psychoeducation provides a variety of information; ranging from basics around therapy terminology and session structure, to in depth understanding around a clients diagnoses and functioning, to even research that could provide statistics around their disorder and effective treatment. Using psychoeducation within CBT is necessary, as it lays out everything that the client could expect to see, and experience throughout therapy. This also helps build rapport with the client, as therapists could use this to see what level of understanding their clients have, but also have the client feel secure with their therapists knowledge around CBT or "expertness" as the text mentioned. While building trust, you can kind of give your client a sense of accomplishment as they are actively involved within their therapy and giving them a chance to feel more in control as they build more skill. I feel that that is important since you want to have clients want to come to therapy, and providing more collaboration through psychoeducation could really help make that happen. Overall, psychoeducation can deepen understanding, provide affirmation for your client and even motivate them, overall benefitting the therapeutic alliance and therapy for your client(s).
2. For this question my first thought was "wow how simple yet so effective." Behavioral activation is pretty much a way for clients to track their behaviors and gain a better understanding of such behaviors. I think it also gives clients a sense of responsibility and ties back into the collaborative approach that therapy and CBT specifically promote. Not to mention it keeps clients engaged and active! I thought of behavioral activation as a clients way of altering their own negative thoughts/behaviors but not even realizing that they were. Think about it- with activity logs and through discussion the client themselves can identify the behavioral patterns, and start to change these behaviors considered negative, and replace them with the preferred behavior. I think its effective because it provides the clients effort with a sense of control, promoting self-efficacy. It could also be rewarding to individuals since they're identifying more positive behaviors and aiming to increase that. Like many mentioned in their responses, the clients are reinforcing the positive behavior, self-conditioning themselves to alter their negative behaviors into their desired behaviors (which just happen to be therapy goals). I think it helps reduce client distress since it's removing the triggers to what might be causing the distress on the clients in the first place. Replacing those triggers with the more positive behavior is bond to have a more positive outcome. Further, you're tackling these behaviors head on through activation, breaking the cycle that many clients tend to get stuck on within these thoughts.
Alyce, I agree with your initial thought at how behavioral activation is so simple, but effective due to the fact that it involves the client tracking their behaviors and the therapist working with the client to gain an understanding of what is going on or the situation at hand. A simple concept, but one that also keeps the client engaged in the therapeutic process. I think for someone beginning therapy, they might think that change is not something that will begin early on. However, I think that behavioral activation puts the client in a more "in-charge" or active role in therapy and requires them to put in effort through activity logs and discussion, which allows them to notice the problems going on, and work towards changing these behaviors. It provides them with the ability to track their behaviors, identify patterns of behaviors, and have the support to begin to change these behaviors. Behavioral activation is effective too because as you said, it gives clients a sense of control and it also can provide them with a sense of accomplishment in the early stages of therapy and for many clients, I imagine that is extremely rewarding!
Alyce, i really liked your emphasis on the client feeling accomplished during psychoeducation. Giving clients an opportunity to first learn something new, and then use that information to build a better understanding of themselves is so important. As we all understand, a goal of CBT is to have our clients use the skills we collaboratively work on in session outside of session and throughout their everyday life. By using psychoeducation, we provide clients with knowledge that they can apply when attempting to use skills worked on in session. I think that this provides a potentially powerful opportunity for clients to make their own connections and feel successful about their understanding and progress of their therapy.
1)Psychoeducation teaches the client how to apply CBT skills to their life. Additionally, being able to use the skills on their own reduces the risk of future relapse. An important piece to psychoeducation is active participation for not only the therapist, but the client as well. Providing psychoeducation gives the therapist an opportunity to show that the relationship between them is very collaborative. Psychoeducation can actually be helpful in further establishing rapport with the client. In the early phase, it can be used to help build up the client's optimism and motivation in the process. The therapist usually begins the psychoeducation process by giving a detailed description of what therapy will look like, and expectations the client can have of CBT. This is a good opportunity to get questions and concerns from clients. Eventually, the therapist can introduce information and begin educating them about their diagnosis, and things associated with it. Throughout therapy, the therapist will teach them "mini-lessons" for new skills, which allows the client to receive direct feedback about the skill.
2) The main goal of behavioral activation is to decrease negative reinforcing behavior patterns while increasing positive reinforcing behavior patterns. Behavioral activation is used with patients who are depressed, but can be used with people who are not depressed but may have difficulty completing tasks. Behavioral activation is something that can be used very early in therapy, as long as there is good rapport between the therapist and client. The goal is to reduce distress and improve their mood and motivation for change. Activity monitoring and scheduling can be used, as form of behavioral activation. It involves having clients track their activities over the course of a week, while also giving them a place to record their thoughts or emotions throughout the week as well. The therapist may also decide to do a Daily Activity Schedule, which is similar to the activity log, but focuses on one specific day. Both of these recorded schedules visually shows the client that they can complete tasks and potentially even enjoy doing them (using the rating scale). They will also show the client that they are improving and feeling better than the might be giving themselves credit for. Reviewing these schedules allows the client to recognize and praise the client for their efforts, while also teaching the client to give themselves praise and credit for the work they do. This builds the client's self-efficacy and their motivation to change. Both schedules focus more on the client's thoughts and emotions while doing the activities, not just the actual activities themselves. This also helps the therapist be able to uncover any additional roadblocks that come up for the client.
I liked how you mentioned that behavioral activation can be used for several of reasons. Usually when behavioral activation is discussed, it only seems to target towards depressed people. However, as you mentioned as we have talked about in class, it is important to know that behavioral activation can be used for individuals who are not depressed too. It can be used to help anyone with distress and try to convince them to find motivation so he or she can have the encouragement to decide they want to change. Overall, I really liked how you briefly mentioned that statement.
I completely agree and love how you pointed out that Behavior Activation can be started early in therapy as long as there is good rapport between client and therapist. I feel strongly about the foundation that needs to be built in therapy from day one. It allows what is to happen next to go so much smoother and increase better outcome. I also enjoy how you touched on the importance of the visual component of the daily activity schedule and activity moinitoring worksheet. I am personally a visual person i agree that these worksheets help aid the client in being cognizant of their feelings and for the therapist to praise the client for efforts. Great reply Mikala
Mikala, I really enjoyed your comments on behavior activation! Specifically. I loved your comments on praise, both from the therapist and the client. Like you stated, these logs provide and opportunity for the therapist to point out successes and provide positive feedback in regards to client progress. However, I think what is more important is the praise client are able to give themselves and the sense of accomplishment they will feel. That intrinsic praise and boost of self-efficacy is exactly what therapists and clients should be mutually working towards.
Psychoeducation is important in producing effective CBT. Most people think psychoeducation only means that the therapist is educating the client in terms of providing information to the client about: their diagnoses, treatment plans, potential homework assignments, teaching new skills, explaining the cognitive model, and simply giving the client a brief overview of what the therapy sessions will be like so the client will know what to expect, but psychoeducation offers a little more. Besides educating the client about various concepts about what therapy holds, psychoeducation is very helpful in establishing an effective therapeutic relationship with the client. As said repeatedly, the CBT therapy sessions are a collaborative process with the therapist and client both working together. As the client is concentrating on listening to the therapist discuss new information about the sessions, the client gets the chance to see how competent and attractive the therapist is which the client will be able to rely, trust, and become aware he or she is in capable hands. Psychoeducation allows the client to learn the ability to become independent as whatever the therapist has said to the client, it benefits and supports the client to learn to be more autonomous.
From what I understood, behavioral activation is used in the beginning of the CBT sessions so the client can learn that he or she is in control of their behaviors by being able to succeed at performing tasks that they did not think they were capable of doing. In other words, it is removing the negative patterns of thinking and behaving and changing that into the individual gaining motivation to perform distressing tasks to improve their mood/distress. It is usually used for depressed clients because most of them do not have any pleasure or motivation to do anything. The simplest task for them can easily be seen to them as a difficult task such as taking a shower in the morning. With the help of the therapist, the therapist can help reduce the client's distress by motivating the client by behavioral activation. The therapist may not want to take big steps if the client is not ready to do it or it just causes too much distress. For instance, a task the client wants to do is to take a shower, however maybe actually getting in the shower may be seen to the client as really distressing. Therefore, the therapist convinces the client to take like baby steps to accomplish the task and a baby step the client can do is simply to get in the bathroom. The therapist will validate the client's baby step actions and the client will feel less distress knowing they accomplish something.
In regards to behavioral activation, I appreciate that you mentioned that this can be used for even the simplest of tasks (or the tasks that non-distressed individuals view as simple) such as taking a shower. From my perspective, if I had entered a therapy session where I would be recording a daily activity sheet, I would automatically think: "Oh great I'm going to have to think of something fun to do everyday". Yet, you made it clear that this is not the case– that often these logs are to help clients, especially depressed clients to motivate themselves to do small "activities" like taking a shower, or getting out of bed, or even eating a nutritious meal. I enjoyed your post!
1. For CBT to be effective, it is crucial that psychoeducation is incorporate within treatment. In CBT, psychoeducation works to provide clients with necessary skills to cope with specific problems they are presenting, inform the clients about their symptoms, diagnoses, and how CBT will work to help them and changing negative cognitions and maladaptive behavior patterns. In learning these skills, a client can play an integral part in their therapy by working collaboratively with the therapist. Providing psychoeducation allows for an opportunity to establish a positive therapeutic relationship, as it allows for the client to become actively involved and extends the therapists knowledge about the problems a client is presenting. Moreover, psychoeducation can build a positive rapport as it presents an opportunity for the client to trust the therapist. By this I mean that, when psychoeducation is provided about a specific diagnosis, this may help the client understand the facts versus the fears of their symptoms, ultimately allowing them to build hope that their symptoms can be reduced through and evidenced based practice like CBT. Additionally, rapport is established when the client views their therapist as competent. Therefore, when a therapist is able to provide psychoeducation to a client about why their symptoms are present, they may learn to understand their disorder better, resulting in more motivation to work with the therapist toward treatment goals. Without psychoeducation, it would be impossible for therapy to progress as new skills must be continuously taught and practiced throughout therapy. This is because, the ultimate goal of CBT is to teach clients to independently solve their problems after therapy. If psychoeducation is not provided, a client may be at high risk for future relapse, resulting in a poor quality of life.
2. Behavioral activation essentially focuses on the way that behaviors and feelings influence each other. Specifically, for depressed clients, behavioral activation works to gradually decrease negative behavior patterns they have acquired, such as avoidance or isolation through lack of positive reinforcements from the environment. However, behavioral activism is not specifically tailored to depressed clients. In general, behavioral activism works to improve the levels of energy and automatic thoughts in any distressed client. I believe that behavioral activism is effective in reducing a client's distress for this exact reason. Behavioral activism is essential in my opinion, especially when treating depressed clients, as it increases their engagement in activities that provide positive consequences or in activities they enjoyed before becoming depressed/distressed. To analyze how an individual's activities effect their mood, clients may be asked to keep weekly activity monitoring logs where they write down activities that have been completed throughout the week and rate their moods during each activity. In completing these activity logs, a therapist can identify behavior patterns such as avoidance, and provide them with the necessary skills to increase engagement in activities that boost their mood. In this case, a therapist may utilize activity scheduling, where enjoyable and meaningful activities are purposely scheduled allowing for motivation and energy to build. Finally, I believe behavioral activation to be crucial because the therapist and client work as a team to make gradual systematic changes through setting goals that are centered in a client's values, pleasures, and essentially, what they are good at. I feel that this is important as it helps a client in distress to feel more consistently engaged and happy in the world.
Sam, I really like how you mentioned therapists can identify patterns of behavior within a client's activity log. I do not think I thought of that or mentioned it in my blog post. Reviewing an activity log will allow the therapist to look for any pattern of behavior. I guess I never really thought about it as looking for patterns of behavior specifically and thought of it more just as inquiring about what they do no a daily basis. It sounds silly now that I say it, but I guess I never thought of it in that exact way before. Therapists could notice patterns such as the client not doing enough things to please themselves, or the client spending too much time sleeping, etc.
Psychoeducation is an extremely important, or vital component to effective CBT. As we know, the goal of CBT is for clients to eventually become their own therapists and be able to practice the learned CBT skills independently. Clients should not remain in therapy forever, or become dependent upon a therapist. Instead, CBT therapists work in a collaborative approach with the client to educate clients and encouraging practicing of CBT skills that will allow the client to resolve problems on their own, outside of therapy. However, this outcome cannot be possible without psychoeducation. This is more than just simply educating clients on CBT; it involves much more than that. In Dr. Volungis' book (chapter 6), he talks about how psychoeducation plays an important role in the therapeutic relationship. It may seem like these two concepts are completely unrelated, but they are actually critical to the overall therapeutic dynamic. We have previously discussed how the therapeutic relationship can greatly affect the outcome and overall success of treatment for clients. Therefore, when a therapist does not establish therapeutic rapport with a client, it can result in a poor or unstable therapeutic relationship. Psychoeducation helps with establishing this rapport, as both the client and therapist are involved in this educative part of therapy. Therapy is a continuous learning process, but begins with psychoeducation, where the client and therapist discuss expectations for therapy, and can also gain information regarding the client's presenting problems and previous experiences, if any, in therapy. It is a learning process for both the client and therapist. As therapists learn more about the client's problems, diagnosis, and experiences, the client is also learning about the expectations of therapy, the overall therapeutic approach and model of CBT, their diagnosis, and treatment approaches. Without this psychoeducation, CBT is simply just therapy. Clients should be familiar with the therapy they are taking part in, similar to the way therapists should be familiar with their client and their specific problems, diagnosis, and personal experiences, thoughts, and emotions. Without receiving psychoeducation, the client may struggle to understand their diagnosis or problems, as well as how therapy will help them resolve these problems. Psychoeducation is not intended to be a PowerPoint lecture or long, informative lecture filled with difficult to understand words or jargon. Instead, it should be introduced in a way that clients can understand what it is and how it is important to their treatment. Clients should be able to gain an understanding of how CBT will help resolve their problems, as well as how their thoughts, emotions, and behaviors are related to the problems, events, or automatic thoughts that they are experiencing. In my opinion, I can see how this may be a difficult or confusing concept, as some clients may not be aware of how these thoughts or events relate to the symptoms or problems they are experiencing. Therefore, psychoeducation must be a collaborative process where both client and therapist can work to educate and understand what it is that is going on without being overwhelmed. Not only can psychoeducation be a verbal, in session component, it can also be done through homework assignments where clients independently work and build upon therapeutic, or CBT skills outside of therapy sessions. Overall, I like to think of psychoeducation is the concept of meeting in the middle, or clients and therapists meeting in the middle. The client is experiencing their own problems which has led them to therapy, and the therapist is a trained, expert individual in the field of CBT. Together, the client and therapist can meet in the middle to work together to gain a better understanding of what is going on, and how CBT can help. Psychoeducation is not just the therapist talking, but instead it is a two-way conversation, where the client and therapist can work together in a collaborative approach to understand and work together to develop CBT skills.
Behavioral activation is effective at reducing client distress because it is based on the idea of reducing negative reinforcing behavior patterns such as avoidance or reduction of daily activities and routines, and increasing positive reinforcing behaviors such as participating in activities that bring pleasure. For clients who are experiencing significant distress, it may be difficult to accomplish daily tasks or routines. It can be understood as a significant cycle of distress in which the client presents with low energy, negative automatic thoughts, and therefore struggles to complete or even begin daily activities, which prevents them from successfully completing something or gaining a feeling of satisfaction or accomplishment, and then the cycle continues on. Behavioral activation begins by specifically targeting behaviors as opposed to focusing on automatic thoughts. The goal is for clients to begin behavioral activation in the beginning of therapy, as it allows clients to quickly begin working towards managing their distress and move forward. The use of activity logs to track and monitor weekly activities that are completed throughout each day, are helpful tools in behavioral activation as it provides a written out, visual, of what is going on in a day for that client. It can provide a new way of looking at the situation for the client as they fill this log out. Although it is likely the client is aware of how little they are accomplishing, or the difficulties associated with accomplishing tasks, a visual log may be more helpful in working to change these behaviors. The written log will allow both the client and therapist to see patterns of behaviors or trends across each week, therefore guiding further therapy as both the client and therapist work to target specific automatic thoughts. Behavioral activation encourages the shift of these negative thoughts to more positive thoughts, as they work toward alleviating the client's distress and negative reinforcing behaviors. I think behavioral activation is effective at reducing client distress because it is collaborative, but also allows the client to utilize take-homes such as these activity logs, and take a look at the bigger picture of what their behaviors or thoughts are resulting in and what shifts can be made to resolve this.
Hi Marissa! I liked your point with behavioral activation and how it can help guide therapy. It really can be a tool to see where the cognitive and the behavior may match or may not be adding up with each other. By this I mean if a client is saying they do one or think one thing but then do something to show the opposite then that may be something that needs to be talked about within session. I didn't specifically tie that together until now!
(1) It is clear at face value what psychoeducation does, it is educating a client about the terminology that is being used during sessions. However, the effect of psychoeducation is much greater than just learning new vocabulary. When used during CBT, the client can become more involved in their sessions because they will be more confident in what is actually occurring. With the client feeling more comfortable due to the psychoeducation the therapeutic relationship between the counselor and client can begin to grow stronger. The client should be able to more accurately describe what they are going through and feeling if the can fully understand what you are saying. With these more accurate conversations a counselor will better understand what their client is feeling or trying to express, which helps create more appropriate and effective goals. The counselor is the expert in this type of situation and sharing you knowledge with the client will help you show them that you are fully capable of helping them through this process. It also, in some ways levels the playing field so that a client won't feel as intimidated due to the information you have that they might not have.
(2) Behavioral activation is where the client is asked to participate in different activities in order for them to try stop isolating themselves. During CBT, these types of activities would be a great idea for a counselor to assign as homework and have a client do outside of the session. This type of strategy at first seems like it could be intimidating to client's, however has shown to have the reverse effect. During this time a client would be asked to write down everything they do throughout the day. If a client is depressed and thinks that they don't a productive or "fun" life, they can look back on their activity log and see everything they have done successfully throughout the week. Having a visual representation of everything positive or everything that might be hard but they accomplished could lead to more positive ways of thinking. Especially with depressed or anxious client's, this strategy could give them the motivation they need to keep going and that they are capable of living a "normal" life. On the opposite side, if you are working with a client who doesn't realize the negative actions or patterns that are happening repetitively during their day to day life, this give them visual proof that something is wrong. After the realization from a client their goals can be adjusted to meet the most successful outcomes for themselves. This can help decrease stress because it shows how they can make adjustments and help fix the issues they are dealing with.


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FishHawk Ranch has grown over the past 20 years, but its small neighborhood charm has always remained. New traditions are taking hold in each of the neighborhoods and throughout the community as residents come together at a myriad of social events and recreational activities.
With 17 model homes and 10 homebuilders, FishHawk Ranch's neighborhoods offer a variety of designs and floorplans to fit virtually any lifestyle. With 55+ and low-maintenance living options available in FishHawk Ranch, residents can enjoy a variety of amenities and activities and maybe pick up a new interest or two.
FishHawk Ranch has received national and statewide environmental and planning awards for its efforts to save and preserve trees during design, development and construction. These honors include a Grand Award from the National Arbor Day Foundation as the nation's top master-planned community, a Community Design Award of Excellence in Environmental Projects from the Hillsborough County Planning Commission, and a Future of the Region Development Award from the Tampa Bay Regional Planning Council.
One-third of the community will remain conservation and open space. Moreover, the community is bordered by 2,000 acres of county-owned nature preserve. Request More Information now!

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Born in Stockton, CA on June 17, 1939 to the late Alvin and Edna Jensen, Dorothy was the beloved wife of Walter Emil Hebel, Jr; loving mother to Joanne Hebel Weeton and Walter "Butch" Hebel; mother-in-law to John Marquez, Randy Weeton and Lydia Acu Hebel; and grandmother to Rebecca Marquez and Douglas Hebel.
Dorothy moved to Alameda when she married Walter Hebel in 1961. Dorothy enjoyed bowling, crafting gift tags, greeting cards and Christmas décor. She was a member of the Salvation Army's Women's Auxiliary and The Sons of Norway, San Francisco Lodge. She will be missed by all who knew her.
Family and friends are invited to a Life Celebration on Thursday, March 28th at 11:00 AM at Greer Family Mortuary and Cremation Services, 2694 Blanding Ave., Alameda.


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The 36-year-old Irishman, who had more than his fair share of clashes with referees during his illustrious playing career, is a supporter of the drive to eradicate bad behaviour towards the men in black.
However, he is adamant that some of his colleagues need to set a better example and said: "A lot of it will come down to the managers and how the managers behave. You watch a lot of managers - and sometimes it is not the manager, it is their staff, which is worse because the manager is letting the staff carry on that way."
Copyright (c) PA Sport 2008, All Rights Reserved.


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We are seeking males and females, ages 25 to 54, to participate in a paid online focus group about car shopping.
The focus group will take place on July 7th.
Those who participate will receive a $75 prepaid Visa card for their time and opinions.
Dave Mitchell is the author of The Paid Focus Group Network and Paid Focus Groups Live


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Dead or Alive VI (6) (Xbox One)
Dead or Alive VI (6) (Xbox One)
After a sinister incident in a village...
Kasumi, a successor of the legendary Mugen Tenshin ninja clan, abandoned her clan and became a "runaway ninja," secretly living in a hermitage in a mountain village.
Meanwhile, Helena Douglas, president of the new DOATEC, is involved in an incident...
The sudden ----- of an individual with special powers sent shivers down her spine...
And yet another....
A so-called genius chuckles at a mysterious light emitting an aura...
Behind a quiet time, a sinister plan is set in motion.
The passing days are about to be unduly overturned due to an open desire.
As Kasumi writes to her mother, her pen overflows with hesitation.
...It's not over yet.
Fights in Dead or Alive are based on a triangle system: strikes beat throws, throws beat holds, and holds beat strikes. When you land an attack of one type that beats another type, like landing a strike when an opponent tries to throw, that attack becomes a Hi Counter attack and does even more damage.
A special attack meter new to the series. Use the Break Gauge to execute new tactics such as a Break Blow or a Break Hold.
A Break Blow is a special skill which has a powerful smash while parrying an enemy strike
A Break Hold is the ultra hold which returns upper, middle, and lower attacks.
Fatal Rush is a powerful combo attack of up to four neatly animated punches and kicks making a first time player look like an expert


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Over the last several months I have been in conversation with Kim Malm from Gritman about developing a lay chaplaincy program. The purpose of the program would be to train lay people from different churches and faith communities throughout Moscow (and surrounding areas) to provide emotional and spiritual support to patients, families and staff at Gritman.
We know medical situations, particularly those that are critical and urgent, are often stressful. It can be scary to go through medical diagnosis and treatment alone. Often individuals feel isolated and need someone to talk to about what they are experiencing. Medical staff often need to be available to other patients and needs. We believe, and studies have shown, that having additional emotional and spiritual support while receiving care improves a patients attitude and recovery and that trained lay chaplains can provide this support.
We are pioneering this program here and so we have been doing a lot of "dancing" as we plan, dream, discuss, and work on logistics. We are ready to receive volunteer applications and work on training in the next couple of months. We see God at work in opening doors for this to happen and in bringing faithful volunteers who want to offer compassion and care.
In Christ,
Pastor Debbie
Sunday morning parking at the church is available in the high school parking lot on Third Street across from the church and in the city lots west of the church. These lots are available only on Sunday mornings. A small lot for handicapped parking is available just off of Adams Street on the north side of the church, with an accessible entrance directly into the sanctuary. A lift operates between the Fellowship Hall (3rd Street level) and the Sanctuary. William Sound System Receivers and Headsets are available to assist with hearing problems.
322 East Third Street
Moscow, ID 83843
The First United Methodist Church of Moscow, Idaho takes as our mission to be the body of Jesus Christ, ministering to a community which draws strength from its diversity. Our mission centers on the worship of God, expressed through varied forms of prayer, preaching, music, and ritual. See more...


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Knitting 101 - My First Hat Class
Level: Absolute Beginner
Duration: 2 hours
Location: Loopy Mango store at 500 Main St., Beacon, NY 12508 (accessible by Metro North Train from Grand Central station in NYC - approximately 1 hr 20 min).
Materials for My First Hat Kit (all materials included in class fee - $76):
- 1 ball of Loopy Mango Merino No. 5 (150g/74 yd) - 100% merino wool (you will get to choose your own color)
- Size 19 (15 mm) 20'' (50 cm) Circular Knitting Needles
- Box with pattern
You will learn the knit stitch, how to cast on, how to knit in the round, and make a pom pom, all with an experienced instructor to help guide you.
You will receive an email confirmation after purchase, listing details and instructions for everything you will need to do/bring before the start of class.
Select "Open Date" if you are purchasing this class as a gift or you aren't sure what date you are available to take the class. Once you are ready, please contact us to sign up for any available My First Hat class.


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Brand new, fully furnished and serviced apartment for rent in Tay Ho-West lake area, Hanoi, Vietnam. The apartment with the living space of 100 sq m, it has a spacious and open lay-out living room with big glass window thus brings lots of light into the apartment. This apartment has a modern kitchen with lots of storage space, there are 02 bedrooms with 02 bathrooms, nice walk-in shower,
The building is 24h guarded, elevator,
Please view Update properties at our main Website: Villas, House, Apartment for rent in Hanoi
Trang Tiếng Việt: Cho thuê nhà tại Hà Nội
For reference only


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Call Us 1300 790 197
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Will Never Use TID Again
Used TID on a number of occasions but never had to make a claim until recently. Thought the process would be easy but they just flick you off to their insurer, Cererbus, and thats when the problems start. It has been 4 mths since i submitted my claim but still no word from them. Every time i try to follow them up i get an automated message saying that "Unfortunately we are experiencing higher than normal volumes of claims", this has been the case with every email for the last 4 mths. I provided all the information that was requested on the form but they are still contacting my wifes medical providers trying to dig deeper to find something that will prevent them paying out. The medical providers are just furious with TID / Cererbus and having to provide the same information over again. Despite persistent follow ups it has been a month since i have heard from them and its been the worst experience ever. I have travelled several times since submitting my claim and have found cheaper insurers than TID and appear to provide a better level of cover. All TID want to do is sell you a policy and if anything goes wrong then you are on your own, they do not want to know you.
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Hi Bruce,
Thank you for taking the time to share that frank and honest feedback about your experience with TID. I'm sorry to hear how disappointed and frustrated you have been with our claims process.
We generally turn claims around in under 10 working days, which is why I'm concerned to hear how long your claim has been dragged out to.
Could you kindly provide me with your claim number? This way I can look into it and escalate it with Management in our Claims department as a matter of priority.
[email protected]
Ash - TID Customer Experience Manager


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Blind Foundation for India raises $13,000
CHICAGO: The Blind Foundation for India (BFI) organized a musical evening program at the Avery Coonley School's Performing Arts Center, Downers Grove, a southwest suburb of Chicago.
Over 180 people enjoyed the musical evening with melodious songs by Dr Dipak Shah and Dr Sheela Shah. Young artists from the Soorya Dance School of Northbrook gave enchanting performances to enthrall the audience. Dr Rajendra Dave and Dr Kumar Moolayil served as Emcees for the evening.
Through the musical Evening, BFI raised over $13,000 which will be used to fund a medical van in India. Dr Manu Vora, President of BFI, highlighted the plight of over 15 million blind people in India which translates to 1 out of every 3 blind people in the world. In India it costs only $20 per cataract operation in India compared to $4,000 in the US, a multiplier of 200.
BFI was established in 1989 with a mission to prevent and cure blindness and educate and rehabilitate permanently blind people in India. Over the years, the BFI team has raised over $3.5 million to examine eyesight of over a million people. So far, BFI has conducted over 110,000 free cataract operations, donated 104 medical vans to transport doctors and patients, and distributed over 10,000 Braille Kits to blind children for their education.
The current BFI focus is on prevention of blindness through Child Sight Projects. Over 500,000 children in government schools are examined for their eyesight and given necessary glasses, eye drops, Vitamin A, and given cataract surgeries in rare cases.
Surendra Ullal


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The famous Italian fashion brand TRU TRUSSARDI held a two-anniversary anniversary celebration event in Xiji Century Plaza and a 2008 autumn/winter show to share the Italian luxury lifestyle with a host of VIP guests and elites.
Singapore's popular icon, Mr. Lie William, was invited to attend and share the fashion experience with the guests. The addition of stars has added Starlight to the conference. The support of many trends has made the feast in the city even more dazzling.
TRU TRUSSARDI is a luxury urban series under the umbrella of the Italian first-line brand TRUSSARDI, adhering to its low-key and elegant brand spirit, combining innovative fabrics with extraordinary creativity, demonstrating the fusion of classic and modern, performing the autumn/winter 08 series with exquisite and unique. Togetherness.
TRU TRUSSARDI 2008 Fall Winter Women's Collection
The TRU TRUSSARDI Fall/Winter 2008 women's collection featuring the theme of urban chic reflects the essence of modern design in a vibrant and practical style. The extraordinary creative features since the birth of the brand have continued to this day, and are by no means exaggerated or overly dramatic. Instead, they are fluent and attractive designs that are suitable for various occasions.
The outline of the garment is designed through elegant and creative methods, and with a gentle sense of femininity, the essence of Art Deco Art or the spirit of the new century art has been vividly displayed on the superposition of geometric shapes. The selection of raw materials is full of energy and luxury, and it is in line with the pure pedigree of high-end casual wear. All this has been highlighted by the clear visual effects of the labels. The wool fabrics are the first and foremost, they are twisted slightly to bring a lustrous cavalry material effect. The unique patterns of men's clothing are matched with smooth satin, rainbow colored nylon and shiny micro-textured fabrics. The fusion of different cultural styles and styles brings a touch of style, while the contrast between vintage detail design and urban feel reminds us of the important moments of our century: embosses, folds and folds return you to the 1930s , and in stark contrast to loose silk; large chunks of wool fabric design coexist with complete Milanese knitwear, with the most important shape and microscopic design of carded wool garments; the effect of knitwear is to enhance the appearance of the subject, soft, The gentle, hairy appearance contrasts with twisting, glowing, and smooth lines.
This new futuristic classic style is emphasised by various colors, which relive each wonderful moment within a strong and confident color range, and combines dark colors and bright details to make the outline of the dress more daily and concurrent. Wear a sportswear atmosphere or use a sophisticated grey tone to preserve the softness of the new women. Therefore, camel and coffee combined with peony's gorgeous and deep blue strokes brought new life to the Art Deco world, which made Jeans wear more weight; Black climbed into the center of the stage, through the intensive use of ivory carving Accessories and feathers. People return to the world of knights.
This constant change reflects the diversification of dual styles/colors: purple-red for various occasions and all kinds of cobalt blue bring a strong impact on the urban sense, while the vinca designs and alabaster with a blurred gray tone Color expands the luxury latitude of smoke gray.
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Fashion Accessories,Man Belt,Cotton Webbing Belt
Hongmioo Trading Company Limited , http://www.hzleatherbelt.com


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Their are several things to consider when choosing a dog trainer in Trivoli Illinois. Whether you are choosing one to train your dog or considering becoming one yourself, you must consider several key factors. When finding a dog trainer, you must know what to look for, the basics of certification and licensing, the types of training, and how one becomes a trainer. Different breeds require different training styles. While positive reinforcement will work for every breed, for example, some more independent breeds, like spaniels or terriers, will need more reinforcement and training time. A trainer who has worked with various breeds, will be able to work with certain temperaments.
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Doggie Daycare Trivoli Illinois 61569
Play All Day Doggie Daycare: Levels Dog Training
Working out your canine is truly one of the best rewards you possibly can award your loved companion. Play All Day supplies one of the most versatile set training classes readily available, often known as "Levels Training". Levels training is an organization process featuring limitless guidance sessions during the period you may be registered. With a Levels membership, you can also visit our drop-in courses as frequently as you like for as long as you need. Pick up as much or as little lessons as you may wish dependent on your special expectations for your dog. Another benefit from Levels training is there is little or no wait for the next class to get started. You simply move up to the following stage the moment your dog has achieved the requirements.
Get Directions and Contact Info.,Play All Day Doggie Daycare
Petco Dog or Puppy Obedience Training Courses
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Peoria Obedience Training Club – Peoria, IL
Peoria Obedience Training Club supplies you along with your canine one of the finest obedience training establishments in the Midwest with a weather regulated dog obedience training area available for individuals with disabilities. They provide a well-lighted parking lot as well as acres of mowed lawn at which the dogs may be exercised.
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Trivoli IL. Doggie Daycare
Nu-Dog Professional Canine Training
Nu-dog highly regarded k9 training facility, located in Mapleton, Illinois. Is supervised successful expert instructor Roy E, Mashaney. With over 30 years experience we are outfitted to make use of virtually all levels of experience in addition to attainment objectives. We contain 1-on-1 coaching for yourself together with your canine to satisfy your desires. Our solutions come with:
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Canine Solutions: Peoria Illinois
Canine Solutions: Licensed Dog Training
Located about twenty-five miles east of Peoria Ill. is focused upon furthering the connections between dogs or puppies and their owners.
Canine Solutions steps involved in dog training focuses on the dog's individual nature, experience, understanding ability and sociable advancement in addition to the goals of the family.
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Heartland Dog Training & Education Foundation
Heartland Dog Training is a non-profit dog training facility as well as a education foundation on Peoria Ill. Northeast section. There education service is located back in the trees away from any kind of high-way and provides loads of trim, frequently mowed, outside grassy locations for dog training.
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Dog Training, Dog Trainers and Obedience Schools In and Around Peoria IL.
Bark Busters Home Dog Training
Dog or Puppy Training Occurs In Your Residence Whenever Bark Busters dog training teachers provide mature dog and puppy instruction at your house, they are able to evaluate your existing personal qualities together with which way they affect your dog's behavioral patterns.
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How to Find Dog and Puppy Obedience Training in Elmwood Illinois 61529


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User ID: 548499
Country: Ukraine
City: Kiev
Marital status: single
Children: none
Height: 5'6" - 167 cm
Weight: 121 lb - 55 kg
Eye color: blue
Hair color: blonde
Body type: average
Religion: Christian
Education: college
Smoke: no
Drink: no
English level: fluent
Occupation: business owner
About myselfI am a very active lady who has. a big variety of interests. I really love what i do. I think my work helps people to understand each other better and open world of love in new colors. I am very curious and interesting woman, i read a lot. I am very passionate, tender and loyal woman. I want to please a true man and be pleased by him.
About my partnerI'm not looking for someone ideal here. I just need someone special with own opinion and unique point of view on the world and values. I want to find a hot, passionate, laid back man who isn't shy to express his feelings in many ways. I do want to find a strong and dominant guy who never give up and who know what he wants from the life
Age criteriasearching for man aged 50 to 79
Dating goal


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Face reading, based in the Five Elements principles of Chinese medicine, is a system of recognizing and understanding the patterns in our facial features that correspond to certain aspects of our inner natures.
Our faces reveal valuable information about our personal history, our emotional struggles, and our personal strengths.
Understanding the Five Elements of Face Reading allows us to better understand ourselves and the people in our lives – family, friends, clients, colleagues.
Every relationship functions best when each person's strengths & challenges are understood, whether at home or in the work place. Face Reading offers us valuable information for enriching our relationships.
Let go of limiting patterns of self-judgment so you can be the person you were made to be.
Create deeper connections with the people you love.
Understand and appreciate the needs of each member of your community.
Find your hidden strengths and achieve your full potential.
Live in alignment with who you are.
Learn Five Elements Face Reading!
This course will introduce you to:
Face reading according to the Five Elements system
The major patterns of facial features that correspond to particular ways of being
Characterstics of particular facial features & their meanings
The Five Elements system of understanding our inner natures
One-day Introductory Course: $145
Sunday, March 24th
Space limited - register now to reserve your spot!


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Teach Primary magazine subscription
In each issue products are tested in real classrooms by real teachers to judge their effectiveness in helping children to learn. Articles not only assess how resources perform in practice but also provide inspirational ideas on how they can be used in lessons. If you're looking to make the most of your budget and bring the curriculum to life Primary Choice will help you make the right decisions.


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All council websites and online services will be unavailable from 5:30pm today for essential maintenance
Australia Day in the Gong is our city's biggest community event.
We're looking for up to six new community representatives from across our diverse community, including young people aged under 26, to join our Australia Day Committee.
As a member of the committee, you'll have the chance to have input into our Australia Day activities on 26 January, as well as associated events.
This group is a formal committee of Council. You can read more about what they do in the Australia Day Committee Charter.
Nominations close on Wednesday 8 May 2019.
Use our online form to apply.
If you'd like more information, please email our events team.


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Krystal Boerschinger
Hanceville High Class of 2003
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- 2003
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- 1Azad-Khaneghah, Peyman
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The Effects of Audience Response Systems on Learning Outcomes in Health Professions Education: a Best Evidence Medical Education (BEME) Systematic Review
The Effects of Audience Response Systems on Learning Outcomes in Health Professions Education: a Best Evidence Medical Education (BEME) Systematic ReviewDownload
Hartling, Lisa, Campbell, Sandy, Oswald, Anna E., Nelson, Cody
This review demonstrates that audience response systems have a positive impact on knowledge based learning outcomes with the most significant impact being observed when compared to non-interactive teaching methods. Learner reaction to the ARS was nearly all positive. A formal meta-analysis is...
Teaching Musculoskeletal Clinical Skills: A Best Evidence in Medical Education (BEME) Systematic Review of Techniques and Their Efficacy
Teaching Musculoskeletal Clinical Skills: A Best Evidence in Medical Education (BEME) Systematic Review of Techniques and Their EfficacyDownload
Campbell, Sandy, Hartling, Lisa, Oswald, Anna E., O'Dunn-Orto, Alexandra
This review provides supportive evidence for the use of several instructional methods to teach MSK skills with most studies supporting patient educator, interactive small group teaching and computer assisted learning. As class sizes grow, interest in the use of alternate instructional methods is...
Research and Clinical Application of the Menopause-specific Quality of Life (MENQOL) Questionnaire: a comprehensive systematic reviewDownload
Hegadoren, Kathleen, Lewis, Jacqueline, Ross, Sue J., Shandro, Tami, Campbell, Sandy, Sydora, Beate C., Yuksel, Nese, Fast, Hilary
This study reviews the literature surrounding the use of the Meonpause-specific Quality of Life questionnaire (MENQOL). One hundred sixty-six articles were included in the qualitative and quantitiative analyses for this study. The study revealed that the tool has been used extensively and...
A meta-synthesis was conducted to explore the effect of bridging programs in internationally educated nurses (IENs). This meta-synthesis used a grounded theory design. Of the initial1,372 papers retrieved from CINAHL, Medline, ERIC, Scopus and Web of Science, eight papers were selected that...
Brettle, Alison, Koufogiannakis. Denise
Poster at 8th International Evidence Based Library and Information Practice Conference
Azad-Khaneghah, Peyman, Neubauer, Noelannah, Stroulia, Eleni, Liu, Lili
Objectives: 1. To identify items used in peer reviewed mobile app rating scales. 2. To identify factors important to patients, clinicians, and app developers in evaluating the quality of mental health apps.


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"Spring is nature's way of saying, 'Let's party!'" ~ Robin Williams
Out in the country, you can see these guys about every 5 miles. They usually sell locally grown fruit at a small discount. They also prepackage some yummy fresh fruit with lemon juice and hot sauce, good on a hot day – you can see them right in front of the vendor's hands if you click on the photo to enlarge it. It's spring time here in CA.


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Axa InsuranceJune 2012 x100 pax Corinthia Hotel, St. George's Bay
This incentive group from AXA Ouest comprised of 70 people, all keen to have a memorable time in Malta, and so they did!
On arrival, the group was taken to the Saluting Battery at the Upper Barrakka in Valletta, where they could enjoy an open bar as well as the breath taking view of the Grand Harbour. Following that, the group was split into teams and given riddle books and cameras for their first activity, a Valletta Photo Safari. In the evening, the group was accompanied to Mdina, where they were greeted by torchbearers at Mdina Gate, who walked them through the Silent City, ending at Xara Palace for a mouthwatering dinner.
The following day, the group enjoyed a speedboat ride to Gozo, and on arrival they found self drive Jeeps waiting for them, so as to kick off their Gozo Discovery. A quick coffee stop at the Salt Pans, which was set up exclusively for the group, and then back to off-roading. The succulent BBQ lunch was set up at Dwejra, with the Azure Window as an astounding backdrop. In the afternoon, the group boarded the Fernandez gullet and following a surprise visit from James Bond, made their way to the amazing Blue Lagoon for a swim and some snorkeling. With the house DJ playing the best tunes, and an open bar to complement, the group sailed back to the hotel, to prepare for the unforgettable farewell dinner at the Mediterranean Conference Centre (MCC). The group arrived at MCC on vintage coaches, and found torch bearers, lance bearers, trumpeteers, drummers and a Master of Ceremonies to greet them and direct them to the historical hall where they shall spend the evening. After a delectable meal, the hall was transformed into a lounge bar for a night of dancing and partying.
The following morning, the group checked out, and left their hotel by luzzu boats, typical Maltese fishing boats. They were taken to the Three Cities area in the south of Malta, where they had brunch on the terrace at Casino di Venezia, with a spectacular view of the harbor.
The group, were then taken to the airport a couple of hours later, determined to explore Malta again.


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MY Newest Skin Care Obsession
Ive been using the same skin care system for almost 10 years. …. But my skin was a lot younger 10 years ago. So i've been exploring new options for my skin. Well a good friend of mine has been a Rodan & Fields consultant for a few years, and she is a firm believer in this company. The Drs. behind Proactive created this company and it's kind of taken over the world, or at least is on its way! So i got the "redefine" regiment and have been using it for a good 3-4 months. It's amazing. It's kind of an anti-aging line. They of course have other options, but this was the one i chose for me. It's a Regimen for the Appearance of Lines, Pores and Loss of Firmness. And as i'm getting more mature:), i want to be proactive for my skin!!!! I'm also obsessed with the macro exfoliator! it takes off a weeks worth of dead skin cells. you will NOT believe it.
I am such a believer in this, i too became a consultant and it's been great! If you have any questions, visit the site! Or hit me up! i'd love to help you!
visit my site here: https://amoore4.myrandf.com


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Roger Vivier Mini Diadem Thong Sandals Black
Condition: New
Availability: Warning: Last items in stock!
Availability date:
More info
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Inspired by a princess tiara, the Diadem buckle sparkles on these thong sandals in leather with elegant cross-over straps, heel with mirror-effect insert and leather outsole. Footwear with urban and modern taste that adds a touch of elegance to your outfit.
- Women's Roger Vivier Mini Diadem Sandals
- Leather upper
- Diadem rhinestone buckle
- Heel with mirror-effect insert
- Leather outsole
- Maintenance and care cards included
- Branded dustbag


text: Make it the tomorrow 5/7 at 1020 UTC, pass. I've had some things come up today. On Mon, May 6, 2013 at 8:32 AM, Lizeth Norman <normanlizeth at gmail.com>wrote: > Hi all, > Will attempt the AO-7 mode b pass this afternoon. The cavity I brought > really makes operating fun. > See here for some pictures of the RF hell I operate in. > http://www.flickr.com/photos/n3ykf/ > The elevated structure in the pics is a an electric railway. > The good news is that I'll be operating from the Morrow Solar. It's got a > view to the horizon. There are a few pics of that location on flickr too.. > 73 de Norm n3ykf/oa4 >


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LAREDO,Texas(KGNS)- A local dentist delivers much needed dental care to children and families in Ghana, West Africa.
Kool Smiles dentist Dr. Abrefi Asare recently returned from a mission trip in the Accra and Kumasi regions of Ghana.
Dr. Asare and a team of dentists from Kool Smiles and clinical staff spent a week providing dental care to nearly 200 children and adults.
The team spent days doing restorative dental work and educating children and adults about the importance of oral hygiene.
The trip was extra special for Asare since she's was born in Ghana.
She says being able to serve her native land and community was an honor and privilege.
Dr. Asare says she's grateful to her company Kool Smiles and their partners 'Touch A Life' for allowing her the chance to give back.