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Objectives: Critically appraise the therapy session

Objectives:

  1. Critically appraise the therapy session and determine if the applicable principles are applied throughout the shown session.
  2. Demonstrate your ability to evaluate your own reactions to the session.
  3. Analyze how you feel this therapeutic modality may affect, enhance or apply to your future PMHNP practice. 

Purpose:

  1. IS NOT to evaluate the acting in the portrayals.
  2. Is to demonstrate you can identify (include in your write-up) the principles of the applicable therapeutic modality.
  3. Is to include how you felt the principles of the modality is or is not included in the therapeutic exchange. 

Directions:

  1. Review the video clip and critique the psychotherapy counseling session using the assessment tools below.
  2. You can review the critique tool below and then click on the link below to download the MH708 Video Critique form-1.docx Download MH708 Video Critique form-1.docx. Complete the assignment and then upload completed assignment file for submission
  3. Please answer the questions directly on that form. Do not write long paragraphs
  4. For Question 2, use this handout from Module 2 to pick out the communication techniques: TherapeuticCommunication handout.pdfDownload TherapeuticCommunication handout.pdf

Video: https://youtu.be/W3hMmZQAdhw

MH708

COUNSELING INTERVIEW CRITIQUE

 

1. MSE – Perform a mental status exam on the patient. You should be able to complete most of the exam from the video, but if there is a section that you cannot complete, you may write “unable to assess.” If there is more than one patient in the video, you may choose one of the patients.

2. Communication skills – Use the handout from the Module 2 lecture to identify communication skills used by the therapist and give examples. Were these appropriate to the timing and issues being discussed?

3. Reaction to the session – Discuss your personal feelings about the session. This is not a commentary on whether the therapist did a good job, but rather, how did this session make you feel.

4. Therapy framework – Please list the principles of the framework of the applicable theory and which the counselor addressed and which he/she did not. Give examples.

5. What could the counselor have done differently and why – Within the currently used therapy, what are some different counseling skills, responses, and interventions that you might have used instead and why? If you cannot think of anything that should have been done differently, then what would be the next step in the therapeutic process?

6. Progression – Did the therapist and patient work on any goals? Did they make progress towards those goals? Please explain why you feel it did or did not progress how you anticipated.

7. Applicability – How might this psychotherapy approach relate to your future work as a PMHNP? In other words, how (cite examples) will you be able to use and apply the knowledge and/or skills of this psychotherapy in your further work? 

,

Therapeutic Communication Techniques To encourage the expression of feelings and ideas

Active Listening– Being attentive to what the client is saying, verbally and non-verbally. Sit facing the client, open posture, lean toward the client, eye contact, and relax. Sharing Observations– Making observations by commenting on how the other person looks, sounds, or acts. Example:” you look tired” or “I haven’t seen you eating anything today”. Sharing Empathy– The ability to understand and accept another person’s reality, to accurately perceive feelings, and to communicate understanding. Example “It must be very frustrating to know what you want and not be able to do it”. Sharing Hope– Communicating a “sense of possibility” to others. Encouragement when appropriate and positive feedback. Example “I believe you will find a way to face your situation, because I have seen your courage in the past”. Sharing Humor– Contributes to feelings of togetherness, closeness and friendliness. Promotes positive communication in the following ways; prevention, perception, perspective. Sharing Feelings– Nurses can help clients express emotions by making observations, acknowledging feelings, and encouraging communication, giving permission to express “negative” feelings and modeling healthy anger. Using Touch– Most potent form of communication. Comfort touch such as holding a hand, is especially important for vulnerable clients who are experiencing severe illness. Silence– Time for the nurse and client to observe one another, sort out feelings, think of how to say things, and consider what has been verbally communicated. The nurse should allow the client to break the silence.

Providing Information– Relevant information is important to make decisions, experience less anxiety, and feel safe and secure. Example “Susie is getting an echocardiogram right now which is a test that uses painless sound waves to create a moving picture of her heart structures and valves and should tell us what is causing her murmur”. Clarifying– To check whether understanding is accurate, or to better understand, the nurse restates an unclear or ambiguous message to clarify the sender’s meaning. “I’m not sure I understand what you mean by ‘sicker than usual’, what is different now?” Focusing– Taking notice of a single idea expressed or even a single word. An example is “On a scale of 0 to 10 tell me the level of the pain you are experiencing in your great toe right now.” Paraphrasing– Restating another’s message more briefly using one’s own words. It consists of repeating in fewer and fresher words the essential ideas of the client. For example the client says “I can’t focus. My mind keeps wandering.” The student nurse says,” You’re having difficulty concentrating?” Asking Relevant Questions– To seek information needed for decision making. Asking only one question at a time and fully exploring one topic before moving to another area. Open-ended questions allows for taking the conversational lead and introducing pertinent information about a topic. For example “What is your biggest problem at the moment?” or “How has your pain affected your life at home?” Summarizing– Pulls together information for documentation. Gives a client a sense you understand. It is a concise review of key aspects of an interaction. Summarizing brings a sense of closure. Example “It is my understanding that your arm pain is a level 1 since you’ve taken a Vicodin one hour ago. Taking your pain medication before physical therapy seems to help you complete the activities the doctor wants you to do for your rehabilitation. Is this correct?” Client responds “Yes It really helps to take the medicine before I do my physical therapy because it helps reduce the pain in my arm.”

Self-Disclosure– Subjectively true personal experiences about the self, are intentionally revealed to another person for the purpose of emphasizing both the similarities and the differences of experiences. These exchanges are offered as an expression of genuineness and honestly by the nurse and disclosures should be relevant and appropriate. They are used sparingly so the client is the focus of the interaction: “That happened to me once, too. It was devastating, and I had to face some things about myself that I didn’t like. I went to counseling and it really helped…..what are your thoughts about seeing a counselor?” Confrontation– Helping the client become more aware of inconsistencies in his or her feelings, attitudes, beliefs, and behaviors. Only to be used after trust has been established, & should be done gently, with sensitivity: “You say you’ve already decided what to do, yet you’re still talking a lot about your options.”

Non-therapeutic Communication Techniques

“Blocks” to communication of feelings and ideas Asking personal questions – Asking person questions that are not relevant to the situation, is not professional or appropriate. Don’t ask questions just to satisfy your curiosity. “Why aren’t you married to Mary?” is not appropriate. What might be asked is “How would you describe your relationship to Mary. Giving personal opinions– Giving personal opinions, takes away decision-making for the client. Remember the problem and the solution belongs to the patient and not the nurse. “If I were you I’d put your father in a nursing home” can be reframed to say,” Let’s talk about what options are available to your father.” Changing the subject– “Let’s not talk about your insurance problems it’s time for your walk” Changing the subject when someone is trying to communicate with you is rude and shows a lack of empathy. It ends to block further communication, and seems to say that you don’t really care about what they are sharing. “After your walk let’s talk some more about what’s going on with your insurance company.” Automatic responses– “Administration doesn’t care about the staff,” or “Older adults are always confused.” These are generalizations and stereotypes that reflect poor nursing judgment and threaten nurse-client or team relationships. False Reassurance– “Don’t worry, everything will be all right.” When a client is seriously ill or distressed, the nurse may be tempted to offer hope to the client with statements such as “you’ll be fine.” Or “there’s nothing to worry about.” When a patient is reaching for understanding these phrases that are not based on fact or based on reality can do more harm than good. The nurse may be trying to be kind and think he/she is helping, but these comments tend to block conversation and discourage further expressions of feelings. A better

response would be “It must be difficult not to know what the surgeon will find. What can I do to help?” Sympathy– Sympathy focuses on the nurse’s feelings rather than the client’s. Saying “I’m so sorry about your amputation, it must be terrible to lose a leg.” This shows concern but more sorrow and pity than trying to understand how the client feels. Sympathy is a subjective look at another person’s world that prevents a clear perspective of the issues confronting that person. A more empathetic approach would be “The loss of your leg is a major change, how do you think this will affect your life?” Asking for Explanations– “Why are you so upset?” A nurse may be tempted to ask the other person to explain why the person believes, feels or is acting in a certain way. Clients frequently interpret why questions as accusations. “Why” questions can cause resentment, insecurity and mistrust. It’s best to phrase a question to avoid using the word “why”. “You seem upset. What’s on your mind?” Approval or Disapproval–“You shouldn’t even think about assisted suicide, it’s just not right.” Nurses must not impose their own attitudes, values, beliefs, and moral standards on others, while in the professional helping role. Judgmental responses by the nurse often contain terms such as should, ought, good, bad, right or wrong. Agreeing or disagreeing sends the subtle message that nurses have the right to make value judgments about the client’s decisions. Approving implies that the behavior being praised is the only acceptable one. Disapproving implies that the client must meet the nurse’s expectations or standards. Instead the nurse should help clients explore their own beliefs and decisions. The nursing response “I’m surprised you are considering assisted suicide. Tell me more about it…” gives the client a chance to express ideas or feelings without fear of being judged. Defensive Responses– “No one here would intentionally lie to you.” When clients express criticism, nurses should listen to what they are saying. Listening does not imply agreement. To discover reasons for the client’s anger or dissatisfaction, the nurse must listen uncritically. By avoiding defensiveness the nurse can defuse anger and uncover

deeper concerns: “You believe people have been dishonest with you. It must be hard to trust anyone.” Passive or Aggressive Responses– “Things are bad and there is nothing you can do about it.” Or “Being is sick is bad and it’s all your fault.” Passive responses serve to avoid conflict or sidestep issues. They reflect feelings of sadness, depression, anxiety, powerlessness, and hopelessness. Aggressive responses provoke confrontation at the other person’s expense. They reflect feelings of anger, frustration, resentment and stress. Assertive communication is a far more professional approach for the nurse to take. Arguing– “How can you say you didn’t sleep a wink when I heard you snoring all night long!!” Challenging or arguing again perceptions denies that they are real and valid to the other person. They imply that the other person is lying, misinformed, or uneducated. The skillful nurse can provide information or present reality in a way that avoids argument: “You feel like you didn’t get any rest at all last night, even though I thought you slept well since I heard you snoring.” –Author Unknown

A 13 year old boy is accompanied by his parents into the community mental health clinic

 

Scenario: A 13 year old boy is accompanied by his parents into the community mental health clinic for the evaluation of Attention Deficit Hyperactivity Disorder (ADHD).  Both parents are impatient, demanding and requesting for you to start their child on a CNS stimulant medication. 

Based on this scenario, respond to the following prompts:

  1. Which neurotransmitter(s) are involved in ADHD?  How will you approach this clinical case? 
  2. According to the DSM V-TR, what is the criteria for this condition? What is the NICHQ Vanderbilt Assessment Scale and how will you apply it to this case study?
  3. If the child meets diagnostic criteria for ADHD, what diagnostic(s) or lab(s) will you order prior to prescribing a CNS stimulant drug? Why is it important to assess and monitor a child’s weight and height once you start treatment for ADHD?       

Assignment Guidelines

  • Format: Your response must be written in APA format.

    Ethical issues: Do not use adolescents using birthcontol and do not use

    See instructions; Do not use adolescents using birthcontol and do not use anything that has to do with parent refusal of life saving measure such as Jehovah witness. The topic is chosen already located at the top. 

    Current Ethical Issues in My APN Track Presentation- My track is Family Nurse practitioner

    Topic chosen

    Chronic opioid management in primary care

    Decision-Making Model

    You already chose: ✅ Beauchamp and Childress’ Principlism Approach

    · Focuses on autonomy, beneficence, nonmaleficence, justice

    · Well-suited to FNP and aligns with ANA Code of Ethics

    Chronic Opioid Therapy for Non-Cancer Pain

    Ethical conflict: Beneficence vs. Nonmaleficence

    · Risk of addiction vs. need for pain control

    · Stakeholders: Patients, FNPs, DEA, insurers, families

    · National crisis = lots of empirical data, EBP, policiesCDC guidelines, ANA & AANP statements available

    This assignment provides you with the opportunity to examine a healthcare or professional issue of interest in which ethical conflict is present.

    Overview

    Each of you will create a Kaltura Capture presentation in which you:

    1. Identify a health-related topic that contains ethical conflict related to your APN track (AGACNP, CNM, FNP, NNP, PMHNP, or PNP) that is different than the topic you used in your Ethics Case Analysis (Assignment 7.1).

    2. Select a decision-making model to use for your topic.

    3. Provide background information, including relevant historical, social/cultural, policy, and political contextual factors from all viewpoints about the topic.

    4. Supply empirical research that adds to the understanding of the topic.

    5. Describe why the issue is significant to individuals, society, health care, and/or nursing.

    6. Identify all alternative courses of action, identifying perspectives of relevant stakeholders.

    7. Analyze different ways of thinking about the issue utilizing the ethical principles, moral theories, and codes of ethics encountered in the course.

    8. Briefly summarize the ethical conflict and various courses of action open to stakeholders.

    Important

    You will not articulate the ethically correct course of action in the presentation or provide recommendations for APN practice, advocacy, or leadership. Your presentation should not convey what you think the ethically correct action should be for your topic.

    Make sure you present both sides of the argument equally. The person watching your presentation should not have any idea of what you think the ethically correct action should be. Think of a courtroom, with both sides presenting a strong case before the judge. Be thorough, as your classmates should not have to do any additional research on the topic.

    Remember to include strong supporting evidence and not just speak in generalizations, just like you would at a nursing conference. Be sure to include any position statements that our professional nursing or other organizations might have about supporting or opposing the issue. This topic should be well-researched.

    Step 1: Choose Your Topic

    You may choose a topic of your choice, but it must be related to your APN track (AGACNP, CNM, FNP, NNP, PMHNP, or PNP), and it must be a different topic than the one you used for the Ethics Case Analysis. A list of possible topics was listed in Week 7 and other possible topics were presented in your Week 11 readings.

    Step 2: Choose a Decision-Making Model

    Refer to Week 11’s readings and lesson for a list of decision-making models. Determine which model is best suited for your topic and presentation.

    Step 3: Create Your Presentation

    You must use  this PPT templateLinks to an external site. when creating your video presentation. The template is to ensure a degree of uniformity across the presentations. You may add pictures or change the background color to personalize your presentation, but this is not required.

    Tips to Create Uncluttered Slides

    · Do not use complete sentences on slides. Use bullet points and concise language.

    · Allow space around the text to enhance readability.

    · Place APA citations in a smaller font than the main text.

    · Group content under headings appropriate to your topic. For example, on background slides, you could use these headings (as appropriate to your topic): Federal & State Law; Cultural & Social Aspects

    The presentation should be 18–20 minutes in length. The instructor will only grade the first 20 minutes of the video presentation. Please ensure that your appearance is professional and that your setting (which will be visible to the instructor and the student reviewing your presentation) is not distracting to the viewer. Also, make sure your audio hardware is working properly and your headset volume is set sufficiently loud.

    Exemplar

    Select the following button to review an exemplar. Since this topic is discussed at length, you cannot use it for this assignment. Also remember, you cannot choose abortion [includes termination of any pregnancy, at any point, for any reason] for this course, as exemplars were provided in Week 7.

    Exemplar [PPT]Links to an external site.

    Step 4: Record Your Presentation

    You must use the Kaltura Capture Desktop Recorder to record your video presentation. Use a headset for the best quality audio, and test your recording for sound quality.

    Note: You will  not be able to upload a PPT or other files to this assignment. You must use Kaltura Capture.

    Step 5: Submit Your Presentation

    See the  Video Assignments for Students tutorialLinks to an external site. for Kaltura video assignment submission instructions.  Note: Do  not publish your videos to the Media Gallery, your instructor will only grade the videos uploaded and submitted to this assignment page.

    Note: You will  not be able to upload a PPT or other files to this assignment. You must use Kaltura Capture.

    Ethical Analysis Model

    I will utilize Beauchamp and Childress' Principlism Approach in my Current Topics Presentation. Due to the fact that the four basic principles of autonomy, beneficence, nonmaleficence, and justice are highlighted, the model of this ethical analysis is widely applied in the field of health care. These guidelines provide an informative and balanced framework for the analysis of moral dilemmas in the field of advanced practice as well as nursing.

    It is practical and flexible, thus my choice. It enables the APRN to be open to alternative views without being rigid in a given theory of ethics. Patient care by virtue of using the four principles can be compassionate yet ethically supportable in practical clinical practice even in controversial or complicated situations. For instance, this paradigm fosters reflective thinking that upholds patients' rights yet considers wider consequences in a given circumstance like in informed consent, in terminal care, or in the distribution of resources.

    It fosters steady, intentional decision-making and is highly compatible with the nursing process as well as the ANA Code of Ethics. To determine the best moral and patient-centered solution, the model also fosters collaboration with interdisciplinary groups. It is also advantageous that the model places a strong focus on justice, as this works exceptionally well in addressing issues that are often the center of modern-day healthcare issues, including disparities in health, health determinants based on socioeconomic status, as well as the delivery of fair care. In my view, the Principlism Approach is well-tailored to my topic based on its flexibility and lucidity, and it will aid in directing a good ethical analysis.

     

    References

    American Nurses Association. (2021).  Nursing: Scope and Standards of Practice (4th ed.).

    Beauchamp, T. L., & Childress, J. F. (2019).  Principles of Biomedical Ethics (8th ed.). Oxford University Press.

    Rubric

    NUR6272: Current Ethical Issues in My APN Track Presentation Grading Rubric

    Criteria

    Ratings

    Pts

    Identification of topic that contains ethical conflict (10 points)

    10 to >9.2 pts

    Noteworthy

    Describes clearly why topic meets the definition for a situation of ethical conflict. Identifies transgression of moral principles and undesirable outcomes for those who support and those who oppose the action.

    9.2 to >8 pts

    Meets Expectations

    Adequately describes why topic meets definition. Transgression of relevant moral principles and undesirable outcomes not entirely clear.

    8 to >0 pts

    Needs Improvement

    Description of topic does not meet the definition of a situation of ethical conflict. Moral principles and undesirable outcomes are omitted.

    / 10 pts

    Background (10 points)

    10 to >9.2 pts

    Noteworthy

    Conveys the historical development and relevant legal, social, and cultural aspects of the topic so that listeners have an adequate understanding of the topic. Includes position statements and EBP guidelines, as applicable.

    9.2 to >8 pts

    Meets Expectations

    Provides enough information so that listeners have a basic understanding of the topic, but some relevant background information is omitted.

    8 to >0 pts

    Needs Improvement

    Background information is not adequate for understanding the topic.

    / 10 pts

    Significance of ethical issue (10 points)

    10 to >9.2 pts

    Noteworthy

    Clearly demonstrates how the issue is significant to individuals, society, health care, and to nursing. Includes incidence, prevalence, and outcomes related to the topic.

    9.2 to >8 pts

    Meets Expectations

    Significance of issue to individuals, society, health care, and to nursing is not entirely clear.

    8 to >0 pts

    Needs Improvement

    Significance of issue to individuals, society, health care, or to nursing not addressed.

    / 10 pts

    Decision-making model and stakeholders (10 points)

    10 to >9.2 pts

    Noteworthy

    Discusses decision-making model. Identifies stakeholders and briefly addresses how they may view the situation and factors that may influence their views.

    9.2 to >8 pts

    Meets Expectations

    Identifies decision-making model. Stakeholders (1-2) missing. Analysis of stakeholders’ views is adequate but may omit a contextual factor.

    8 to >0 pts

    Needs Improvement

    Decision-making model missing. Multiple stakeholders are missing and/or how they may view the situation is not adequately addressed.

    / 10 pts

    Analysis 1 (15 points)

    15 to >13.94 pts

    Noteworthy

    Effectively utilizes all four moral theories, all four ethical principles, and the ANA Code of Ethics in a well-developed analysis of one perspective related to the situation of ethical conflict.

    13.94 to >12.15 pts

    Meets Expectations

    Moral theories and ethical principles, provisions of the Code of Ethics adequately used, but a theory, principle, or relevant provision is missing from analysis.

    12.15 to >0 pts

    Needs Improvement

    Moral theories, ethical principles, and relevant provisions of the Code of Ethics are missing from the analysis.

    / 15 pts

    Analysis 2 (15 points)

    15 to >13.94 pts

    Noteworthy

    Effectively utilizes all four moral theories, all four ethical principles, and the ANA Code of Ethics in a well-developed analysis of the alternative perspective related to the situation of ethical conflict.

    13.94 to >12.15 pts

    Meets Expectations

    Moral theories, ethical principles, provisions of the Code of Ethics adequately used, but a theory, principle, or relevant provision is missing from analysis.

    12.15 to >0 pts

    Needs Improvement

    Moral theories, ethical principles, and relevant provisions of the Code of Ethics are missing from the analysis.

    / 15 pts

    Summary (5 points)

    5 to >4.6 pts

    Noteworthy

    Briefly summarizes the ethical conflict and the various courses of action open to stakeholders.

    4.6 to >4 pts

    Meets Expectations

    Summarizes the ethical conflict, but various courses of action open to stakeholders are omitted.

    4 to >0 pts

    Needs Improvement

    Summary of the ethical conflict is inadequate, and various courses of action are not addressed.

    / 5 pts

    Supporting Evidence (5 points)

    5 to >4.6 pts

    Noteworthy

    References 10 or more relevant, current, peer-reviewed journals and/or professional nursing/healthcare organizations.

    4.6 to >4 pts

    Meets Expectations

    References 6-9 relevant, current, peer-reviewed journals and/or professional nursing/healthcare organizations.

    4 to >0 pts

    Needs Improvement

    References 5 or fewer relevant, current, peer-review journals and/or professional nursing/ healthcare organizations.

    / 5 pts

    Writing & APA format (10 points)

    10 to >9.2 pts

    Noteworthy

    No or minimal (1–2) errors in grammar, punctuation, spelling, or APA format for citations and references.

    9.2 to >8 pts

    Meets Expectations

    Some (3–5) errors in grammar, punctuation, spelling, or APA format for citations and references.

    8 to >0 pts

    Needs Improvement

    Numerous errors in grammar, punctuation, spelling, or APA format for citation and references. Reference slide is absent.

    / 10 pts

    Communication (10 points)

    10 to >9.2 pts

    Noteworthy

    Presented within timeframe and in logical order. Presented in a manner that is articulate, confident, and well-rehearsed. Personal appearance and setting are professional. Sound quality is consistent, and video of the presenter is clear (e.g., not blurry or shaky).

    9.2 to >8 pts

    Meets Expectations

    Meets Expectations Presented within timeframe. Disorganization hinders understanding. Some areas are not well-rehearsed. Some instances of “ums” and “ahs” or brief periods of silence. Personal appearance and setting are mostly professional. Brief sound quality or video issues.

    8 to >0 pts

    Needs Improvement

    Needs Improvement Not presented in timeframe or in logical order. Communication skills unsatisfactory. Numerous instances of “ums” and “ahs” or periods of silence. Personal appearance and setting not professional. Consistent issues with sound or video quality, or video of the presenter is missing.

    / 10 pts

    M6: Residents v. Board of Education Case Discussion Instructions

     

    M6: Residents v. Board of Education Case Discussion

    Instructions

    Navigate to The Heights and find the HPS Central Office. Complete the scenario about Residents v. Board of Education.

    After you have completed the scenario, participate in the following poll, then respond to the prompts below.

    Poll on Residents v. Board of Education Case

    What individual and collective strengths was the social worker able to help the task force draw on through the process of reaching a resolution?

    Next

    Responses are anonymous to students but not to faculty

    • How does the social worker's knowledge about the community and the connection developed with the community play out in this case? Why is this important?
    • How do issues of diversity (age, race, ethnicity, education, gender), oppression, and power differentials play out in this case? Using specifics from the case, provide examples of where one or more of these factors presented challenges here. What steps could you take to meet those challenges?
    • The task force was able to expand their base of support by reaching out to their communities of identification. What external supports might be available to you, in your community, or the community in which you practice?
    • What might you have done differently?
    • What is your overall takeaway from this virtual case? 

    Requirements

    • Submit your initial post by the due date.
      • Your initial post should be approximately 1,200 words.
    • Respond to at least two posts from your classmates by the end of the module.
      • Your responses should be thoughtful and well-considered. They should reflect a conscious effort to incorporate what we are learning into your work with your clients.
    • Review the Discussion Rubric Download Review the Discussion Rubricto ensure that you meet all of the grading criteria.

      SOAP 3: Chief Complaint: I need a contraceptive method to avoid pregnancies

      Chief Complaint: I need a contraceptive method to avoid pregnancies.

      DX: MUST BE A ICD-10 ACCORDING TO THE CHIEF COMPLAINTS

      PLEASE I ATTACHED THE TEMPLATE FOR YOU BE ABLE TO COMPLETE THE ACTIVITY ACCORDING THE  INFORMATION PROVIDED

      ALSO I ATTACHED AND EXAMPLE OF HOW EACH SECTION MUST BE COMPLETED IN FULL.

      THIS ASSIGNMENT WILL BE SUBMITTED VIA TURNIN IN, THEN NEED TO BE ORIGINAL WORK AND NOT COPY AND PAST OR SIMILAR TO OTHER STUDENTS ASSIGNMENTS

      PROFESSOR IS EXTREMELY DEMANDED IN REVIEWING PROCESS THAN PLEASE AS A UNIVERSITY LEVEL TRY TO COMPLETE THIS AS REQUIRED IN EACH SECTION

      REFERENCES 3-4 NO ODLER THAN THE PAST 5 YEARS AND FOLLOW STRICTLY THE TEMPLATE AND MY INSTRUCTIONS PLEASE.

      DUE DATE JULY  24, 2025 

      PLEASE AVOID ERROR TO AVOID UPDATES 

      CONPH NSG6020 Subjective, Objective, Assessment, Plan (SOAP) Notes

      Student Name:

      Course:

      Patient Name: B.N.

      Date:

      Time:

      Ethnicity: Caucasian

      Age: 41

      Sex: Male

      SUBJECTIVE (must complete this section)

      CC: “I have a heartburn and acid reflux that keeps waking me up at night”

      HPI: B.N. is a 45-year-old male patient with a history of gradually worsening gastroesophageal reflux symptoms. He presents with frequent typical episodes of heartburn following spicy or fatty meals and periodic regurgitation of sour-smelling fluid into his mouth. Onset was 3 months ago and have gradually worsened. Located in the epigastric region, with occasional radiation to the throat with a duration typically last 1–2 hours after meals or when lying down at night, with a character: A burning pain or pressure in the chest and upper abdomen. The aggravating factors have been consuming spicy, fatty, or acidic foods, as well as when bending over or lying flat and the relieving factors the use of over-the-counter antacids. Timing have been intermittently throughout the day but are most frequent post-meals and during nighttime, with a Severity of 6/10 on average, with occasional exacerbations to 8/10 during severe episodes.

      · Medications: Omeprazole 20 mg daily (started 2 weeks ago)

      · Previous Medical History: Hypertension (diagnosed 4 years ago) and GERD.

      Allergies: Penicillin , with dizziness and flushing sensation.

      Medication Intolerances: None reported

      Chronic Illnesses/Major traumas: Hypertension

      Hospitalizations/Surgeries: None reported

      FAMILY HISTORY

      · M: Alive and healthy

      · MGM: Late, asthma

      · MGF: Alive, GERD

      · F: Alive, obesity

      · PGM: died of road accident

      · PGF: Alive, healthy

      Social History: B.N. is an office employee with a 14-year history of reported cigarette smoking. He smokes a half pack per day and sporadic alcohol use, having two or more beers per week. He denies all illicit drug use. His food intake is fast food and coffee drinking, frequent enough to explain his gastrointestinal complaints. His habits of smoking and eating are addressed as possible aggravating factors in his illness.

      REVIEW OF SYSTEMS

      General: B.N is weight loss due to acid reflux during meals.

      Cardiovascular: No chest pain, palpitations, or edema

      Skin: No rashes, lesions, or itching

      Respiratory: No cough, shortness of breath, or wheezing

      Eyes: No reported vision changes, denies eye pain.

      Gastrointestinal: Heartburn, regurgitation, denies vomiting, diarrhea, or constipation

      Ears: No hearing loss, tinnitus, or ear pain

      Genitourinary/Gynecological:

      No urinary symptoms

      Nose/Mouth/Throat: No nasal congestion, or dental issues, sore throat due to acid reflux.

      Musculoskeletal: No joint pain, no falls.

      Breast: Denies any change.

      Neurological: No headaches, dizziness, or numbness

      Heme/Lymph/Endo: Denies anemia or any endocrine disorder.

      Psychiatric: Denies anxiety, or mood changes.

      OBJECTIVE (Document PERTINENT systems only. Minimum 3)

      Weight: 180lbs

      Height: 5’9”

      BMI: 25.9

      BP:138/88mmHg

      Temp: 99.2°F

      Pulse: 78bpm

      Resp:16/min

      General Appearance: Well-nourished, alert, and oriented x3. Appears comfortable.

      Skin: Smooth with no rashes, moles, red spots

      HEENT: Normocephalic, PERRLA, oral mucosa pink and moist, no pharyngeal erythema or tonsillar enlargement.

      Cardiovascular: Regular rhythm and rate. S1 and S2 present, no gallops or rubs were heard.

      Respiratory: Lung clear to auscultation bilaterally, no wheezes, crackles or rhonchi sounds

      Gastrointestinal: Bowel sound presents is 4 quadrants, Abdomen soft upon palpation.

      Breast: No lumps or tenderness noted.

      Genitourinary: No tenderness, no CVA pain.

      Musculoskeletal: Full range of motion in all extremities, no deformities were noted.

      Neurological: Alert and oriented X 4 , speech appropriated .

      Psychiatric: Patient calm and answers question appropriately , no anxiety or mood change were noted

      Lab Tests: CBC, CMP, and H. pylori test.

      Special Tests: None at this time

      DIAGNOSIS

      Differential Diagnoses

      1. 1- Diagnosis, (ICD 10 code): “Peptic Ulcer Disease (PUD) – K27.9”.

      Peptic Ulcer Disease is a disease in which ulcers or open sores occur in the stomach or duodenal lining, usually due to Helicobacter pylori infection or long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) (Srivastav, et al., 2023). The symptoms on presentation are epigastric burning pain, nausea, and vomiting at times. ICD-10 code K27.9 is for an unspecified peptic ulcer with hemorrhage or perforation not specified. Although patient symptoms are characteristic of GERD, PUD is not excluded since both can produce upper GI distress and have some of the same symptoms such as epigastric pain. Since there are no alarm symptoms (e.g., weight loss, hematemesis), PUD is unlikely now.

      2. 1- Diagnosis, (ICD 10 code): “Esophagitis – K20”

      Esophagitis is inflammation of the esophagus, usually caused by acid reflux, infection, or drug-induced inflammation (Tageldin, et al.,2021). Symptoms can be chest pain, dysphagia, and heartburn. Code K20 is the ICD-10 code that is specifically used to indicate this condition. Esophagitis is listed as a differential because chronic acid reflux (such as in GERD) will cause inflammation of the esophagus. GERD, if left untreated, can lead to esophagitis and therefore is still a consideration.

      Diagnosis

      1. 1- Presumptive Primary Diagnosis (ICD 10 code): “Gastroesophageal Reflux Disease (GERD) – K21.9” (Rogers, & Eastland, 2021)

      GERD happens when stomach acid chronically flows back into the esophagus, irritating and producing symptoms of heartburn, regurgitation, and epigastric pain. GERD is usually associated with lifestyle issues such as diet, smoking, and obesity. The ICD-10 code K21.9 is for GERD without esophagitis. The diagnosis fits the patient's presenting complaint of heartburn, regurgitation, and relief with antacids, and it is the highest presumptive diagnosis (Rogers & Eastland, 2021). The presumptive diagnosis is the most likely diagnosis given the patient's history, physical exam, and preliminary findings.

      Plan/Therapeutics:

      1. Lifestyle Modifications:

      · stop consuming those meals that cause this problem such as spicy food.

      · Avoid sleeping after consuming a full meal. Eat a minimum of three hours prior to sleeping in order to allow the stomach time to digest (Jallepalli, et al., 2022)

      · Refraining from taking large meals. Eating several small meals will assist the patient.

      · Avoid consuming alcohol or limit the amount and smoking (Jallepalli, et al., 2022).

      Medications

      · The patient should Continue taking Omeprazole 20 mg daily before breakfast (Rogers, & Eastland, 2021).

      · Add Famotidine 20 mg HS PRN breakthrough symptoms.

      1. Follow-Up: RTC in 4 weeks for re-assessment.

      Diagnostics:

      · If the symptoms persists, do an upper endoscopy.

      Education:

      · Discussed the significance of lifestyle modifications in managing GERD.

      · Discussed long-term risks of untreated GERD, including Barrett’s esophagus and esophageal cancer.

      · Provided smoking cessation resources and encouraged follow-through.

      References

      Jallepalli, V. R., Thalla, S., Gavini, S. B., Tella, J. D., Kanneganti, S., & Yemineni, G. (2022). Impact of patient education on quality of life in gastroesophageal reflux disease.  Int J Pharm Phytopharmacol Res12(1), 25-8.

      Rogers, J., & Eastland, T. (2021). Understanding the most commonly billed diagnoses in primary care: Gastroesophageal reflux disease.  The Nurse Practitioner46(4), 50-55.

      Srivastav, Y., Kumar, V., Srivastava, Y., & Kumar, M. (2023). Peptic ulcer disease (PUD), diagnosis, and current medication-based management options: schematic overview.  Journal of Advances in Medical and Pharmaceutical Sciences25(11), 14-27.

      Tageldin, O., Shah, V., Kalakota, N., Lee, H., Tadros, M., & Litynski, J. (2021). Esophagus. In  Management of Occult GI Bleeding: A Clinical Guide (pp. 65-86). Cham: Springer International Publishing.

      image1.png

      ,

      CONPH NSG6020 Subjective, Objective, Assessment, Plan (SOAP) Notes

      Student Name:

      Course:

      Patient Name: (Initials ONLY)

      Date:

      Time:

      Ethnicity:

      Age:

      Sex:

      SUBJECTIVE (must complete this section)

      CC:

      HPI:

      Medications:

      Previous Medical History:

      Allergies:

      Medication Intolerances:

      Chronic Illnesses/Major traumas:

      Hospitalizations/Surgeries:

      FAMILY HISTORY (must complete this section)

      M:

      MGM:

      MGF:

      F:

      PGM:

      PGF:

      Social History:

      REVIEW OF SYSTEMS (must complete this section)

      General:

      Cardiovascular:

      Skin:

      Respiratory:

      Eyes:

      Business Finance – Management Week 1 Assignment: Selection of Company and Problem

       

      Criteria

      Choose a company from the Fortune 500 list. Your choice must be below the top 100 (101-500) in the ranking at https://www.zyxware.com/articles/4344/list-of-fortune-500-companies-and-their-websites#rank-101-400 or you can utilize Google to find a list of Fortune 500 companies. Determine a business challenge this company faces that could be addressed through business analysis techniques, theories, and tools. Develop a general course of action using Chapter 1: Introduction of Your BABOK® Guide and lesson on PADIO on how you will go about making a decision and developing a solution to the problem you have identified. In an approximately 1000-word MS Word document, describe the company, the company’s history, the problem, the problem owner(s), the problem stakeholders, and your critical thinking and decision-making course of action for solving the problem. At a minimum, your course of action should move you through the five stages of decision-making and problem-solving: planning, analysis, designing and developing alternative solutions, implementation of the solution, and taking the solution operational (within the operational stage, address tasks of maintenance, training, and evaluation). Using Microsoft Excel, develop a Gantt schedule chart of the tasks you have outlined in your paper that will be necessary to move through in order to solve the company’s problem. Capture a screenshot of the task schedule and paste the image into the appendix of your paper (an appendix comes AFTER the reference page). Note: If you do not have the software installed on your computer, it is provided free from our KU Outlook 365 account. 

        Behaviorism provides a valuable framework for understanding human behavior across various domains

         

        Behaviorism provides a valuable framework for understanding human behavior across various domains, including education, health, and social policy. Drawing on the lessons and readings from Module 8 – 11, select a current event or societal issue (e.g., public health campaigns, educational reforms, or workplace dynamics) and explore how behavioral science can offer insights or solutions.

        In your response:

        1. Identify the current event or issue you selected.
        2. Explain how key concepts  of operant conditioning (e.g., stimulus control, reinforcement, extinction) apply to this issue.
        3. Discuss the ethical and practical implications of applying behavioral interventions to address this issue.
        4. Reflect on potential limitations or challenges in implementing these interventions.

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        Positive Reinforcement in Institutions

        n ose who pose threats to themselves or to society at large, we requently commit to institutions. There, we permit them only

        limited social relationships, deprive them of freedom of movement and ofopportunities for decision making, and forbid most of the amenities they could enjoy outside. We often justify these institutions as instruments for beneficial change. "Schools" for the handicapped are supposed to teach their pupils new skills to help them overcome their limitations. "Hospitals" for the mentally ill are supposed to cure them. "Correctional institutions" are supposed to rehabilitate lawbreakers.

        Institutionalized Coercion

        Locating these facilities in areas that are relatively unpopulated and difficult to get at (at least initially, before cities or suburbs grow up around them) indicates, however, what we really Lntend them for. They are supposed to keep people whom we have decided are retarded, insane, or criminal out of sight. We hand these "humane" facilities over to members of the helping professions-physicians, psychologists, nurses,behavior analysts, physical therapists, speech therapists, rehabilitation counselors, social workers, and correctional officers-and wash our own hands ofthe problems. "Out ofsight, out of mind" is a grand avoidance reaction by the community.

        Their geographic isolation, their walls , gates, and security towers, and the public tendency to ignore the very fact oftheir existence leave these institutions almost completelywithout control from the outside. Whatever humanitarian impulses might have led to their initial establishment, their freedom from public accountability turns most of them into little more than warehouses for those whom society judges to be misfits. The immediate priorities of staff and administrative convenience, inmate docility, and obedience to rules and regulations replace longer-term educational, therapeutic, or

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        Coercion and Its Fallout

        correctional goals. Coercion then becomes the technique of choice for getting the residents to ..behave."

        An institution that is operated mostly for the benefit of the staff attaches little significance to the deleterious side effects of coercion. And so we find coercion prevailing in the institutional management ofpeople with retardation or mental illness and ofthose incarcerated for committing crimes. When public or judicial pressure for reform does arise, it is short-lived and usually ineffective because it concentrates on physical facilities and administrative procedures. Rarely does an investigation evaluate the rationale and application ofbehavior management techniques. Through misunderstanding or incompetence, some institutional managers and members of the helping professions twist and alter the concept of reinforcement beyond recognition, attempting to transform even positive reinforcement into an instrument of coercion.

        The Misuse of Deprivation. Those whom we have placed in positions of control over ourselves and others-teachers and school administrators, military officers, prison guards and correctional officers, police, government officials-are so accustomed to coercion that they often can comprehend no other way. If they do try positive reinforcement, their first impulse is to take something away from their controllees so they can then give it back in return for "good behavior." That is exactly what happened in some infamous prison projects that claimed to be using positive reinforcement. They imposed solitary confinement on inmates and then let them out for short periods if they showed the proper contrition; deprived them of food and then handed them morsels if they acted subserviently; denied them privacyand then gave them a few moments by themselves ifthey had not been seen engaging in suspicious social interchanges with other prisoners; gave them menial jobs and switched them to more desirable work if they performed uncomplainingly and without resistance. And then, with any lapse, real orperceived, they reimposed the deprivations.

        Such techniques are, of course, completely coercive. They are based on socially imposed deprivation and on the escape and avoidance that such deprivation generates. Punishment by shocks or by deprivation makes escape reinforcing. Ifwe deprive prisoners, students, children, or others of their basic needs, rights, and privileges in order to create reinforcers, those reinforcers are negative,

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        not positive. They may serve temporarily to keep orderliness in cell blocks, barracks, and classrooms, but they will also generate the long-term side effects of coercive control.

        Deprivation, however, does contribute to the effectiveness of positive reinforcers: We have little interest in food right after a good meal, but food influences our actions powerfully as time passes since our last meal; the sexual appetite of sailors after a long sea voyage is legendary; although individuals vary widely, what we do to get money and what we do with money after we get it depend strongly on how much we already have. Nevertheless, even though deprivation makes positive reinforcers stronger, it is still not necessary to impose deprivations deliberately in order to make use of positive reinforcers. No one has enough ofeverything. It does not usually take much extra effort to discover reinforcers that are already effective without additional deprivation.

        My concern here is with the use of deprivation as an instrument of coercion. In certain extreme cases, deprivation for a brief time can produce desirable consequences that are unavailable any otherway. After everyone else has given up, you can still set a child with retardation on the road to effective learning. First make her hungry. Then use food as a reinforcer for some basic behavior like self-feeding and following simple instructions. Once the child has learned those, you can develop other reinforcers and discontinue food deprivation. In cases of extreme retardation, or when previous incompetent treatment has made a child unresponsive to standard methods of instruction, both the child and the communitywill find the temporary hardship beneficial.

        Even then, one uses deprivation only to enhance the attractiveness of a positive reinforcer, not to punish unsatisfactory behavior. Once the child learns some adaptive behavior, one quickly discontinues the deprivation, with no threat to impose it again. Taking away food, possessions, privileges, or rights just so that these can be given back in return for good behavior, and then taken away again to punish bad behavior, subverts the principle of positive reinforcement. Anyone who uses deprivation this way can expect the controllees to escape, fight back, and exert countercontrol, just as they would react to any coercive regimen.

        It is far more effective simply to take advantage of naturally occurring deprivations. Many exist even without social intervention; that is the way the world works. Food, sex, and other biologically

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        determined deprivations are built in. Without producing them ourselves or making them any more severe than they would be in the normal course of things, we can often put these deprivations to good use in teaching basic skills to beginners and to those with learning deficiencies.

        As mealtimes approach, for example, food becomes a stronger and stronger positive reinforcer. Some people with retardation or mental illness seem sensitive to only a small number ofreinforcers, but food is one ofthe most reliable. The use offood as a reinforcer at mealtimes is a proven and powerful way to teach basic skills to those with learning disabilities. It isjustas useful in teaching typically developing children. Such teaching does not require us to deprive our pupils of meals if they fail to learn. Teaching methods are now available that guarantee learning, so meals need not be missed because of unsuccessful teaching. Even if we have not yet worked out a completely effective instructional program, pupils who have trouble learning do not have to go hungry. While we are perfecting our instructional plan, we can always let them earn a full meal by practicing something they already know how to do.

        Eventually, the conduct learned at mealtimes enables pupils with retardation to function adaptively at other times, too. Their newfound abilities-carrying a tray from serving counter to table, using a fork and spoon, picking up spilled food, saying "please" and "thank you"-make it possible to take them to cafeterias and restaurants. There, new choices of food and drink become available to them and they experience new environments. While on route to their treat, they can be taught skills that make travel safe and enjoyable for them­ they can learn to read signs, interpret traffic signals, react to strangers, and so on. Their world begins to open up.

        And then new reinforcers become effective as they learn how to interact with different environments and with people who are important to them. They learn to recognize signs of approval as precursors of other reinforcers, so people's reactions take on significance, becoming reinforcers in their own right. When that happens, positive reinforcers like food need not always be forthcoming immediately; delay ofgratification becomes possible. Food, one ofthe few effective reinforcers at first gets these seemingly behaviorless inmates ofthe local institution started. Before long, we find ourselves able to use the newly learned reinforcers to teach them more advanced behavior. Mealtimes then no longer need to be used as

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        learning opportunities but can simply be enjoyed, both appetitively and as social occasions.

        Ti.me-out and Its Abuses. A controversial form of punishment, particularly in institutions but also at home, is the "time-out" procedure. As a means of social control, various forms of time out have long been part of society's arsenal ofcoercive techniques. What is time-out? What does it accomplish? Does it differ in any important way from other kinds of punishment?

        The basic feature of a time-out is the withdrawal of positive reinforcement. This usually means removing someone physically from an environment that has been making positive reinforcers available toanother environment thatmakes little orno reinforcement possible. It is a form of socially imposed deprivation. In practice, time-out may range from standing an obstreperous child in the comer to putting a violent patient into solitary confinement-the classical padded cell.

        Children do have to learn the meaning of "no." Indeed, as they continually experience opportunities to explore the unfamiliar, and having already learned that some such situations result in disaster, they come actually to welcome rules and limits that serve to protect them from unpleasant consequences. A "time-out chair" or some other special place where children are sent after misbehaving can be a relatively painless way of teaching them that "no" denotes such limits.

        As used in many institutions, however, and by parents who control largely by punishment, time-out-the withdrawal of positive reinforcement-is just as coercive as the application of a shock. Because time-aut inflicts no pain, it is oftenjustified as a benign kind of punishment. This reasoning is similar to justifying the use of drugs instead of straitjackets, ropes, or chains to immobilize an uncooperative patient. The cruelty lies less in the method than in the outcome. Isolation, physical restraint, and chemical restraint remove the victims from contact with all of the reinforcers that make life meaningful and worthwhile. Drugs can tum them into zombies, and padded cells can tum them into raving maniacs. Both kinds of punishment put an end to all learning except for various forms of escape and avoidance that serve as mechanisms of countercontrol. When the power of the authorities is too great for reprisal or deception, depression takes over.

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        It i often forgotten that even a relatively mild time-out cannot be an effective punisher unless the punishee is removed from a positively reiriforcing environment. That is what the name, "time-out," refers to; it means time away from reinforcement. Removing a disruptive child, inmate, or patient into a seeming time-out is not going to prevent future disturbances unless the original situation was reinforcing in the first place. If it was not, taking the child out of it may actually reinforce the disruptive behavior.

        And then, our interaction while removing a child, for example, may provide stronger positive reinforcement than anything the child was getting in the original situation. We talk to him and, especially ifhe resists, we pick him up and cany him, holding him close. When that happens, time-out itself becomes a positive reinforcer, making future disruptive behavior even more likely. We will strengthen the very conduct we intended to punish.

        A child whom we have to place repeatedly in time-out is sending us a message: "I do not like it here. It is not paying off for me. Rather than being unsuccessful and having you ignore me, I would prefer you to cany me, kicking and screaming, into the bare room next door where you will have to sit with me and hold me in order to keep me from banging my head against the wall." Our response to that message has to be an examination ofour own conduct. What were we doing­ or not doing-that made the child prefer the time out?

        If we were trying to teach, we will probably find that we were not being successful. Because our pupil was not learning, we were unable to reinforce, and the pupil found otherways to "succeed." The remedy in that situation is not to place the child in time-out, taking away further opportunities for either pupil or teacher to learn, but to revise our teaching. Go back to the last thing the child had learned successfully, so that positive reinforcement again becomes possible, and start over. Proceed more slowly this time, and take advantage of newly available methods for reducing and even eliminating errors from the learning process.* *A large technical literature shows that errors are not a necessary part of the learning process, but behavior analysts have not yet presented that material in easily available form for nonprofessionals. Behavior shaping-teaching new behavior by reinforcing gradually closer approximations to what is desired-can transform trial-and-error to trial-and-success in teaching motor skills like the production of tones on musical instruments or the pronunciation of words. Teaching long sequences of actions like shoe tying, spelling, or "top-down" computer programming can proceed errorlessly if the teacher starts from the end of the sequence and works backwards. With skillful environmental shaping-teaching new relations between behavior and environment

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        Arranging a teaching program so that almost all behavior that occurs is reinforceable is a powerful way to improve the learning of people who find learning especially difficult. Time after time, with careful programming and positive reinforcement, children who were supposed to be incapable oflearning have been turned into learners. More often than not, even children medically diagnosed as hyperactive will participate constructively in class for long periods of time, causing no disturbance or distraction as long as they are being reinforced for successful learning. Effective teaching will usually make it unnecessary to punish a child for misbehavior, or to drug a child out of hyperactivity.

        Prisons as Learning Environments. Most youths incarcerated in reformatories have impoverished repertoires of behavior. From the beginning, even before their imprisonment, they had only a limited armament ofadaptive skills. Many reinforcers were out oftheir reach and others were unknown to them. They were just as effectively deprived as if we had deliberately taken away their food, shelter, economic support, and all possibility of attaining the kinds of success thateducation and trainingmake possible. Such deprivations, not the results of biological processes, are socially imposed.

        This is not to suggest that criminality is confmed to the poor or to the socially rejected. Serious crime exists at all economic and social levels. But homes and neighborhoods that suffer the harshest social and economic deprivation, and at the same time lack a tradition of upward economic mobility, also spawn the most visible forms of youthful criminality. Such communities do not place great value on-do not provide reinforcers for-conversing about anything except basic needs, reading anything longer than billboard phrases and newspaper headlines, writing anything more than signatures and perhaps a few expletives suitable for graffiti, or calculating anything more than the simplestcash transactions. Young people in depressed areas, deprived of effective learning environments, grow up unable

        by changing the environment gradually from familiar to unfamiliar forms-children can learn errorlessly to copy, Wiite, and name letters ofthe alphabet; medical students can learn the basic structure of the nervous system so errorlessly that they find it difficult at first to believe they are actually learning anything. Procedures that establish equivalence relations among spoken words, Wiitten words, and pictures give children simple reading and speaking vocabularies that they were never explicitly taught and that they use even the very first time without error. Errorless teaching is an active field of research, with new methods and applications coming along rapidly.

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        to talk, read, write, or calculate numerically. Written applications and job interviews are out of the question. Ambitions are necessarily limited to the immediately foreseeable resolution of coercive contingencies imposed on the one hand by the Law and on the other by the deprivations incompetence brings on. Their lives revolve around reinforcers that are limited to food, shelter, alcohol, sex, drugs, and money to purchase these. What they do learn is the most reliable way-sometimes the only way open to them-for obtaining basic reinforcers: Take them from someone else.

        When the law catches up with youths whom the social system has failed to teach effectively, they are sent to "correctional" institutions that are supposed to "reform" them. After serving their term, they usually return to their old territory, having learned nothing that might help them get out of that environment, and even unaware of the desirability ofgetting out. If they have been reformed in any way, it has been by a sharpening of their ability to keep from getting caught.

        Many do get caught again. The threat of imprisonment failed to prevent their first lawless acts, and actual imprisonment fails to prevent their repetition. These failures are to be expected; coercive control provides no alternatives for the lawbreaker who lacks socially desirable kinds of competence. Deprivations imposed within prison walls are hardly more severe than the familiar realities outside. Thrown back into the same old scene with no new coping behavior and now labelled as criminals, subject to even greater restriction, why should they be expected to act any differently than before?

        Criminalityis a complexproblem-actually, manydifferent problems and with many roots. But in all its variations it is still behavior. Our everyday concern is not with an abstract concept, "criminality," but with criminal actions. To assume that criminal acts are subject to the same principles that control all kinds of behavior could prove incorrect. Yet, given the successful extensions ofbehavioral analysis to other kinds of complex human conduct, we cannot neglect this important class just because of preconceived notions that have little or no empirical support. Certainly, to reduce the incidence of criminality by redesigning the environments it springs from is an infinitely complex task. It is rarely possible to achieve the necessary control of the critical reinforcers, to eliminate the current negative reinforcers and replace them with positive. And so we dare not eliminate our prisons.

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        But however one feels about the desirability of imprisonment, its failure to deter repetitive crime represents lost opportunities, even tragedies. Prisons and reformatories control reinforcers to an extent that is not permltted on the outside. While offenders are temporarily unable to engage in the acts that brought them to prison, it is possible to use positive reinforcement to teach them more adaptable and acceptable forms ofconduct. Before leaving prison, the offender could be equipped with new options, ways ofsurviving within rather than outside the law. Reducing the number of multiple offenders would also reduce society's ever increasing need for new prisons.

        The use of imprisonment as an opportunity for education has met with so little success that law enforcement professionals view the notion with nearly complete skepticism; proponents are "ignorant do-gooders." The lack of success and the resulting skepticism, however, come from the mistaken notion that teaching can only be accomplished by coercion, particularly when the students are "criminals." Most educational programs within prisons have failed because they relied on coercive control. With positive reinforcement, it is possible to accomplish real corrections in misdirected life paths. Also, a well designed learning program with high levels of positive reinforcement, instituted before youths have become habitual offenders, costs considerably less in the long run than to prop up the standard system of coercive control.

        This is notjust impractical theory. Positive reinforcement has been used successfully to replace juvenile offenders' incompetence with constructive skills, making new reinforcers available to them for the first time. A superb demonstration project that showed the effectiveness ofa well-planned and competentlyadministered positive reinforcement system has been almost completely ignored by professionals in behavioral science and in law enforcement. In this project, new capabilities permltted youngsters, on leaving prison, to enter new environments and succeed there without coming into conflict with the law. The techniques for getting them there are not difficult in principle. All correctional officers should be trained to use them.*

        The project made courses available to youthful prisoners, starting with basic reading, writing, speaking, calculating, and remembering,

        • The final report of this federally funded project Is available as: H. L. Cohen and J . Filipczak. A New Leaming Environment. Boston. MA: Authors Cooperative, Inc.

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        and then going on to more advanced skills that made use of those prerequisites. The content and sequence of courses was carefully programmed. Guaranteeing that each course prepared students for the next one, and requiring high marks before they could move on, ensured success-continued reinforcement. No one was forced to take courses. Punishment did not follow if anyone preferred the usual prison routine rather than participating.

        Simply making courses available was not enough, though. After all, if they had never experienced the advantages that elementary skills can bring, why should the prisoners have been interested in participating? Contrived reinforcers for learning were therefore necessary at first, until the students' new skills brought them into contact with more natural consequences. That is where a critical feature of the system, positive reinforcement for learning, entered the picture.

        In order to get prisoners started, the project paid them for learning. That made it possible for those who did engage in the learning process to get things that would not otherwise have been available at all, regardless of how they acted in prison. High exam scores gained the learner a private space. Although sparsely furnished at first with a table, chair, bookshelf, and lamp-items that made continued studyfeasible-the space could be outfitted later according to the owner's personal tastes and resources. How were student prisoners supposed to obtain those resources? Having secured the space, they could then earn credits by continuing to show new learning in their courses. They could save and use the credits like money to purchase items in a store. The stock in the store was tailored to the preferences of those who were working for credits.

        Paying the students for learning simply set up school as another job that was available to the inmates. The credits, the store, the private space, and other privileges were actually part of the school program-the job-and were enjoyed only during school hours­ while the prisoners were on the job. That the reinforcers the participants enjoyed were actually earnings probably helped account for the relative absence of resentment and hostility on the part of prisoners who did not take part. They all had their choice of jobs. Nobody was shut out. The reinforcers were available to anybody who selected the school job as part of his prison duties.

        Private ownership created new reinforcers. Wall decorations, furnishings, furniture, music, and 1V became items worth working

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        for, and learning continued. New skills created the potential for still more reinforcers that the store made available. The ability to write letters turned stationeryandwrttingmaterials into useful possessions. The ability to handle a job interview made certain clothing desirable for students who would soon be completing their prison term. The ability to read created a new pleasure, and books became desirable possessions. Later, as students became capable of new and more complex behavior, they were allowed to begin using their credits to buy privileges they could not before have been trusted to handle: telephone calls, visits in privacy by friends and relatives, and, starting in conjunction with their courses, supervised trips outside the walls. As the value of learning, itself, became apparent, the students eventually came to use some of their credits to pay tuition for courses that they requested-a requirement they would also meet outside.

        When these students left, they were able to do things that made new reinforcers available. Their world had expanded. There was no guarantee, of course, that the old contingencies in their home environments would not take over again, but now they at least had a chance for something different. The evidence suggests that many capitalized on new opportunities that the nonpunitive approach had opened up to them. Fewer returned to prison.

        It is too bad thatwe waited until these youths had been imprisoned before we attended to their needs. We could have been investing in those at-riskyoungsters before they got into serious trouble. Positive reinforcement now can eliminate the need for punishment later. The best way to prevent juvenile crime and give young people the opportunity for satisfying, productive lives is not to lock them up but to steer them in the right direction before serious trouble starts.

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        This Coercive World

        W e live in a coercive world, bombarded by warning signals and threats. The governmentwarns, "Obey the law or go to jail." Law enforcement agencies pay attention to us only

        when we have done something punishable. In our churches we hear, "Sin not lest your souls be damned." The landlord never thanks us for the rent, but if we miss, tells us "Pay up or get out." When mortgage payments are delinquent, the usually unresponsive bank threatens to send the sheriff. Educators tell us, "Spare the rod and spoil the child," and bemoan the permissive society that forbids them the use of the rod and the switch. The boss orders, "Get here on time or be fired." Options like "Eat your vegetables or else no dessert" or "Say that again, and I'll wash your mouth with soap" teach children "what is good for them." Legal, business, and social institutions communicate with us most frequently by advising uswhatwe should do…or else. The common meaning of "Behave yourself' is "Do what I want you to do." Coercing us, pushing us around-threatening us with punishment or loss, or telling us what we have to do to escape or avoid punishment or loss-is the predominant technique for getting us to "behave."

        Sometimes people tell us what they are going to do to us if we fail to act as they would like. When the threatener is also going to administer the punishment, the coerciveness is quite open. At other times, people warn us of dire consequences that will come from someone else, perhaps even from an impersonal Nature; those warnings, although technically coercive, are just good advice. When we remind someone to carry an umbrella in order to keep from getting wet, we do not have to be concerned that we are coercing them. But even this benevolent warning illustrates in a minor way our general acceptance ofcoercion. Although we need not worry ourselves about this mild and unimporta

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