Health Insurance and Managed Care Essay Example for Free

Health Insurance and Managed Care Essay There are a myriad of issues that concern current federal health policies. These new issues emerged from a number of health policy agendas. Several issues are emerging as of late due to the notion that health care is usually perceived as prelude to issues concerning physical health problems. Federal health policies range from mental illnesses and physical therapy issues. The four central issues concerning federal health issues are: Health Insurance Access, Primary Care for Patients, Quality Management in Hospitals, and the Advancement of Healthcare Organizations. These issues constitute a broader set of issues, which concerns federal health policies. The advancement of new medical techonology has generated many opportunities for managed care spcecially in hospitals. These advances in the field of medical health allows medical practitioners to be more adept in handling patients. Furthermore, advanced technology has made precise diagnosis and apt treatment for complex illnesses. With this in mind, human diseases are given remedies in order to treat patients. However, a bevy of issues have emerged regarding managed care. This makes the issue of medical technology complicated in many ways. Healthcare providers are affected by such issue. Medical technologies that reduce costs and present high cost benefit ratio are eventually reimbursed. Such issues are taken into consideration by major health sectors. Wireless Devices and Applications The global proliferation of wireless devices and applications has been surpising. Wireless communications has seen an upscale growth due to the clamor for fast-paced business communications nowadays. Trends like carries and Bluetooth techonology are one of the most discussed issues whenever wireless applications come into mind. The issues of carriers are still similar since they wireless communication first emerged. However, wireless carries demand extra payments for consumers. Carriers are supposed to augment the services of telecommunication companies, though they are also responsible for revenue-sharing arrangements of telecom companies. Emerging trends of wireless communication include: †¢ Integration with native phone Apps (Camera, Media Gallery etc) †¢ Rich and more engaging user experience †¢ Faster access †¢ Reduced clicks †¢ Low latency †¢ Lower bandwidth requirement Nowadays, the use of mobile web is increasing. Wireless devices are being used people ranging from students to company executives. The proliferation of Wi-Fi hotspots have been evident. The use of 3G mobile broadband increased as well. These and other issues indicate that the wireless telecommunications industry is sustaining a sporadic growth and progress.

Typhoid Fever Signs, Symptoms and Treatments

Typhoid Fever Signs, Symptoms and Treatments Name of disease: Typhoid Fever 1. Aetiology: Typhoid fever, otherwise known as enteric fever, is a potentially fatal multisystemic illness caused primarily by Salmonella typhi. S typhi has been a major human pathogen for thousands of years, thriving in conditions of poor sanitation, crowding, and social chaos. It might have been responsible for the Great Plague of Athens at the end of the Peloponnesian War. The name S typhi is derived from the ancient Greek typhos, an ethereal smoke or cloud that was believed to cause disease and madness. In the advanced stages of typhoid fever, the patients level of consciousness is truly clouded. Although antibiotics have markedly reduced the frequency of typhoid fever in the developed world, it remains endemic in developing countries. This large genus of gram-negative bacilli within the family Enterobacteriaceae consists of two species: S. enterica, which contains six subspecies, and S. bongori. S. enterica subspecies I includes almost all the serotypes pathogenic for humans. According to the current Salmonella nomenclature system, the full taxonomic designation S. enterica subspecies enterica serotype typhimurium can be shortened to Salmonella serotype typhimurium or simply S. typhimurium. Salmonellae are gram-negative, non-spore-forming, facultatively-anaerobic bacilli that measure 2–3 by 0.4–0.6 Â µm. The initial identification of salmonellae in the clinical microbiology laboratory was based on growth characteristics. Salmonellae produce acid on glucose fermentation, reduce nitrates, and do not produce cytochrome oxidase. In addition, all salmonellae except S. gallinarum-pullorum are motile by means of peritrichous flagella, and all but S. typhi produce gas (H2S) on sugar fermentation. Notably, only 1% of clinical isolates ferment lactose, and a high level of suspicion must be maintained to detect these rare clinical lactose-fermenters. 2. Incidence: Typhoid fever occurs worldwide, primarily in developing nations whose sanitary conditions are poor. Typhoid fever is endemic in Asia, Africa, Latin America, the Caribbean, and Oceania, but 80% of cases come from Bangladesh, China, India, Indonesia, Laos, Nepal, Pakistan, or Vietnam. Within those countries, typhoid fever is most common in underdeveloped areas. Typhoid fever infects roughly 21.6 million people (incidence of 3.6 per 1,000 population) and kills an estimated 200,000 people every year. In the United States and other developed nations, most cases of typhoid fever arise in international travelers. 3. Pathogenesis : All Salmonella infections begin with ingestion of organisms, most commonly in contaminated food or water. The infectious dose is 103–106 colony-forming units. Conditions that decrease either stomach acidity or intestinal integrity increase susceptibility to Salmonella infection. Once S. typhi and S. paratyphi reach the small intestine, they penetrate the mucus layer of the gut and traverse the intestinal layer through phagocytic microfold (M) cells that reside within Peyer patches. After crossing the epithelial layer of the small intestine, S. typhi and S. paratyphi, which cause enteric (typhoid) fever, are phagocytosed by macrophages. These salmonellae survive the antimicrobial environment of the macrophage by sensing environmental signals that trigger alterations in regulatory systems of the phagocytosed bacteria. In addition, salmonellae encode a second type III secretion system that directly delivers bacterial proteins across the phagosome membrane into the macrophage cytoplasm. This secretion system functions to remodel the Salmonella-containing vacuole, promoting bacterial survival and replication. Once phagocytosed, typhoidal salmonellae disseminate throughout the body in macrophages via the lymphatics, and colonize reticuloendothelial tissues (liver, spleen, lymph nodes, and bone marrow). Patients have relatively few or no signs and symptoms during this initial incubation stage. Signs and symptoms, including fever and abdominal pain, probably result from secretion of cytokines by macrophages and epithelial cells in response to bacterial products that are recognized by innate immune receptors when a critical number of organisms have replicated. Over time, the development of hepatosplenomegaly is likely to be related to the recruitment of mononuclear cells and the development of a specific acquired cell-mediated immune response to S. typhi colonization. The recruitment of additional mononuclear cells and lymphocytes to Peyer patches during the several weeks after initial colonization/infection can result in marked enlargement and necrosis of the Peyer patches, which may be medi ated by bacterial products that promote cell death as well as the inflammatory response. 4. Clinical features : Typhoid fever begins 7-14 days after ingestion ofS typhi.The fever pattern is stepwise, characterized by a rising temperature over the course of each day that drops by the subsequent morning. The peaks and troughs rise progressively over time. Over the course of the first week of illness, the gastrointestinal manifestations of the disease develop. These include diffuse abdominal pain and tenderness and, in some cases, fierce colicky right upper quadrant pain and also constipation. The individual then develops a dry cough, dull frontal headache, delirium, and an increasingly stuporous malaise. At approximately the end of the first week of illness, the fever plateaus at 39-40Â °C. The patient develops rose spots, which are salmon-colored, blanching, truncal, maculopapules usually 1-4 cm wide and fewer than 5 in number; these generally resolve within 2-5 days. During the second week of illness, the signs and symptoms listed above progress. The abdomen becomes distended, and soft splenomegaly is common. Relative bradycardia and dicrotic pulse (double beat, the second beat weaker than the first) may develop. In the third week, the still febrile individual grows more toxic and anorexic with significant weight loss. The conjunctivae are infected, and the patient is tachypneic with a thready pulse and crackles over the lung bases. Abdominal distension is severe. Some patients experience foul, green-yellow, liquid diarrhea (pea soup diarrhea). The individual may descend into the typhoid state, which is characterized by apathy, confusion, and even psychosis. Necrotic Peyer patches may cause bowel perforation and peritonitis. This complication is often unheralded and may be masked by corticosteroids. At this point, overwhelming toxemia,myocarditis[C1], or intestinal hemorrhage may cause death. If the individual survives to the fourth week, the fever, mental state, and abdominal distension slowly improve over a few days. Intestinal and neurologic complications may still occur in surviving untreated individuals. Weight loss and debilitating weakness last months. Some survivors become asymptomaticS typhicarriers and have the potential to transmit the bacteria indefinitely. However, there are some atypical presentations of classical typhoid fever and the clinical course of a given individual with typhoid fever may deviate from the above description of classic disease. The timing of the symptoms and host response may vary based on geographic region, race factors, and the infecting bacterial strain. The stepladder fever pattern that was once the hallmark of typhoid fever now occurs in as few as 12% of cases. In most contemporary presentations of typhoid fever, the fever has a steady insidious onset[C2]. Young children, individuals with AIDS, and one third of immunocompetent adults who develop typhoid fever develop diarrhea rather than constipation[C3]. In addition, in some localities, typhoid fever is generally more apt to cause diarrhea than constipation. Atypical manifestations of typhoid fever include isolated severe headaches that may mimic meningitis, acute lobar pneumonia, isolated arthralgias, urinary symptoms, severe jaundice, or fever alone. 5. Complications: These include the following: Gastrointestinal bleeding (10–20%of patients), intestinal perforation (1–3% of patients).Others are neurologic manifestations which occur in 2–40% of patients, including: meningitis, Guillain-Barre syndrome, neuritis, and neuropsychiatric symptoms usually described as muttering delirium or coma vigil, with picking at bedclothes or imaginary objects. Rare complications include: Disseminated intravascular coagulation, haematophagocytic syndrome, pancreatitis, hepatic and splenic abscesses and granulomas, endocarditis, pericarditis, myocarditis, orchitis, hepatitis, glomerulonephritis, pyelonephritis and hemolytic-uremic syndrome, severe pneumonia, arthritis, osteomyelitis, and parotitis. Fewer than 10% of patients develop mild relapse, usually within 2–3 weeks of fever resolution and in association with the same strain type and susceptibility profile.About 10% of untreated patients with typhoid fever excrete S. typhi in their feces for up to 3 months, and 1–4% develop chronic asymptomatic carriage, shedding S. typhi in either urine or stool for greater than one year. Chronic carriage is more common among women, infants, and persons who have biliary abnormalities or concurrent bladder infection with Schistosoma haematobium. 6. Examination and tests: The diagnosis of typhoid fever (enteric fever) is primarily clinical. However there are series of tests which could confirm the diagnosis . These tests are : Cultures: Blood, bone marrow, stool and urine specimens. Blood Cultures are widely considered 100% specific while culture of bone marrow aspirate is 90% sensitive until at least 5 days after commencement of antibiotics. The technique is extremely painful, which may outweigh its benefit. Blood, intestinal secretions (vomitus or duodenal aspirate), and stool culture results are positive for S typhi in approximately 85%-90% of patients with typhoid fever who present within the first week of onset. They decline to 20%-30% later in the disease course. In particular, stool culture may be positive for S typhi several days after ingestion of the bacteria secondary to inflammation of the intraluminal dendritic cells. Bone marrow aspiration and blood are cultured in a selective medium (eg, 10% aqueous oxgall) or a nutritious medium (eg, tryptic soy broth) and are incubated at 37Â °C for at least 7 days. Subcultures are made daily to one selective medium (eg, MacConkey agar) and one inhibitory medium (eg, Salmonella-Shigella agar). Identification of the organism with these conventional culture techniques usually takes 48-72 hours from acquisition. Molecular Method: Polymerase chain reaction (PCR) has been used for the diagnosis of typhoid fever with varying success. Nested PCR, which involves two rounds of PCR using two primers with different sequences within the H1-d flagellin gene of S typhi, offers the best sensitivity and specificity. Combining assays of blood and urine, this technique has achieved a sensitivity of 82.7% and reported specificity of 100%. Serologic tests : These are assays that identify Salmonella antibodies or antigens, supporting the diagnosis of typhoid fever, but these results should be confirmed with cultures or DNA evidence. The Widal test was the mainstay of typhoid fever diagnosis for decades. It is used to measure agglutinating antibodies against H and O antigens of S typhi. Neither sensitive nor specific, the Widal test is no longer an acceptable clinical method. Indirect hemagglutination, indirect fluorescent Vi antibody, and indirect enzyme-linked immunosorbent assay (ELISA) for immunoglobulin M (IgM) and IgG antibodies to S typhi polysaccharide, as well as monoclonal antibodies against S typhi flagellin are promising, but the success rates of these assays vary greatly in the literature. Other non-specific laboratory studies Most patients with typhoid fever are moderately anemic, have an elevated erythrocyte sedimentation rate (ESR), thrombocytopenia, and relative lymphopenia. Most also have a slightly elevated prothrombin time (PT) and activated partial thromboplastin time (aPTT), and decreased fibrinogen levels. Circulating fibrin degradation products commonly rise to levels seen in subclinical disseminated intravascular coagulation (DIC). Liver transaminase and serum bilirubin values usually rise to twice the reference range. Mild hyponatremia and hypokalemia are common. A serum alanine amino transferase (ALT)–to–lactate dehydrogenase (LDH) ratio of more than 9:1 appears to be helpful in distinguishing typhoid from viral hepatitis. A ratio of greater than 9:1 supports a diagnosis of acute viral hepatitis, while ratio of less than 9:1 supports typhoid hepatitis Differential diagnosis: This includes include Malaria, Hepatitis, Bacterial enteritis, dengue fever, rickettsial infections, leptospirosis, amebic liver abscesses, and acute HIV infection. 7. Risk factors: a Gastric Factors : Antacids, histamine-2 receptor antagonists (H2 blockers), proton pump inhibitors, gastrostomy, and achlorhydria decrease stomach acidity and facilitate S typhi infection. b. Genetic and host factors: Genetic polymorphisms. c. Environmental and behavioural risk factors that are independently associated with typhoid fever include: 1. Eating food from street vendors, Living in the same household with someone who has new case of typhoid fever, Washing the hands inadequately, Sharing food from the same plate, Drinking unpurified water, and Living in a household that does not have a toilet 8. Treatment: The proper treatment approach to typhoid fever depends on whether the illness is complicated or uncomplicated. Complicated typhoid fever is characterized by melena (3% of all hospitalized patients with typhoid fever), serious abdominal discomfort, intestinal perforation, marked neuropsychiatric symptoms, or other severe manifestations. Depending on the adequacy of diagnosis and treatment, complicated disease may develop in up to 10% of treated patients. Medical Care: If a patient presents with unexplained symptoms suggestive of typhoid fever (enteric fever), broad-spectrum empiric antibiotics should be started immediately. Treatment should not be delayed for confirmatory tests since prompt treatment drastically reduces the risk of complications and fatalities. Antibiotic therapy should be narrowed once more information concerning the definitive diagnosis is available. Recommended antibiotic therapies are Cefixime, Azithromycin and Ciprofloxacin per oral for uncomplicated cases, while Ceftriazone, Azstereonam, Cefotaxime and Imipenem could be administered intravenously for complicated cases . Patients with uncomplicated disease may be treated on an outpatient basis. They must be advised to use strict hand washing techniques and to avoid preparing food for others during the illness course. Hospitalized patients should be placed in contact isolation during the acute phase of the infection. Feces and urine must be disposed of safely. Surgical care: Surgery is usually indicated in cases of intestinal perforation. Most surgeons prefer simple closure of the perforation with drainage of the peritoneum. Small-bowel resection is indicated for patients with multiple perforations. If antibiotic treatment fails to eradicate the hepatobiliary carriage, the gallbladder should be resected. Cholecystectomy is not always successful in eradicating the carrier state because of persisting hepatic infection. 9. Home treatment of First Aid (where applicable): No home treatment for typhoid fever. 10. Prevention. This involves the following measures: Protect and chlorinatepublic water supplies. Provide safe water supplies and avoid possible back flow connections between sewers and water supplies. Dispose of human faecesin a sanitary manner and maintain fly-proof latrines. Use scrupulouscleanliness in food preparationand handling. Educate the public regarding theimportance of handwashing: this is important for food handlers and attendants involved in the care of patients and/or children. Immunization for typhoid fever is recommended for international travellers to endemic areas, especially if travel will involve exposure to unsafe food and water or close contact in rural areas and with indigenous populations 11. Local names in Nigeria: Akom in Igbo,; Zazabi chiwo nkpanyo in Hausa and iba jeefun jeefun in Yoruba.. 12. Endemic areas Typhoid fever usually occurs in developing nations whose sanitary conditions are poor. Typhoid fever is endemic in Asia, Africa, Latin America, the Caribbean, and Oceania, but 80% of cases come from Bangladesh, China, India, Indonesia, Laos, Nepal, Pakistan, or Vietnam. Within those countries, typhoid fever is most common in underdeveloped areas. 13. Disease images Rose spots on the chest of a patient with typhoid fever due to the bacteriumSalmonella Lizzie van Zylwas a child inmate in a British-run concentration camp in South Africa who died from typhoid fever during theBoer War(1899–1902) References http://emedicine.medscape.com/article/231135-overview#3 http://www.who.int/topics/typhoid_fever/en/ http://www.nlm.nih.gov/medlineplus/ency/article/001332.htm http://www.infectionlandscapes.org/2011/11/typhoid-fever.html http://www.cdc.gov/nczved/divisions/dfbmd/diseases/typhoid_fever/ http://textbookofbacteriology.net/salmonella.htm Anthony S. Fauci et al, Harrisons’s Principles of Internal Medicine 17th edition 2008. Gerald L. Mandell et al, Mandell, Douglas and Bennett’s Principles and Practice of Infectious Disease 7th edition,2010. [C1]Shows link from Medscape. Article shows several similarities to Medscape article. [C2]Highlight [C3]Highlight

The Six Pillars Of Public Administrations Politics Essay

The Six Pillars Of Public Administrations Politics Essay The dichotomy of politics and administration is a model representing the idea that a division is required between the political realm and the field of public administration. As explained by Waldo (1984), there are two early public administration scholars that are credited with the dichotomy: Woodrow Wilson and Frank Goodnow. Although Wilson and Goodnows work was not identical, they both advocated for a strict explanation of the dichotomy. Wilson and Goodnows ideologies regarding the relationship between politics and public administration have served as fundamentally important for developing this essay. This brief discussion about the dichotomy of politics and public administration will include why scholars like Wilson and Goodnow believed it was necessary to separate politics and administration and treat them as two separate fields of study. Wilsons theory evolved during a time when politics was associated with corrupt behavior. Many citizens wanted a more professionally based bureaucracy that would be held to higher levels of accountability versus being controlled by politics. These ideas were clearly communicated in Madisons Federalist No. 10. Madison (1787) described the relationship between politics and administration by explaining that a factious spirit had tainted Americas public administration. Wilson reinforced the ideas of the founding fathers in The Study of Administration. Wilson (1886) expanded on Madisons ideas explaining that the bureaucracy needed to be more businesslike with civil servants providing services that were nonpartisan. In The Study of Administration, Wilson (1886) states that, Administrative questions are not political questions. Although politics sets the tasks for administration, it should not be suffered to manipulate its offices (210). With the latter quote being stated by Wilson, public administration should be considered a science irrelevant from any type of political coercion when it comes to things like decision making, policy, and public service. Bureaucracies all share a common goal and this is to provide services that benefit the overall public good; however, it is nearly impossible to completely separate politics from administration. For example, policies are often designed and implemented due to public sentiment. The number goal of a politician is to get re-elected; therefore, elected officials cannot ignore public opinion. Policies are written and passed by elected officials and then implemented by public agencies. Programs created by policies often die at the implementation phase because bureaucrats hold the power with providing optimal levels of implementation. One of the reasons programs are not properly implemented can be attributed to the fact that many bureaucrats may deliberately administer poor im plementation due to a program being contradictive to their political beliefs. Goodnow (1900) took a realistic approach to the dichotomy explaining that politics and administration needed to be two separate functions but, simultaneously, politics would never be completely separate from administration. Goodnows beliefs are demonstrated in the policy and implementation synopsis provided in the previous paragraph. Americas bureaucracies today are not as corrupt as they were during the time Madison vocalized his views in the Federalist Papers. Thanks to extensive empirical research and social science theories, the field of public administration is based on efficiency, accountability to the public, and effectiveness. It would be unreasonable to assume that political coercion does not still plague public administrators on occasion because politics will also play a role in public administration. Responsible public administrator When researching the topic of Responsibility in the realm of Public Administration, one encounters a very extensive literature base regarding the importance and reasons for responsible civil servants. Exploring the topic of responsibility and its significance in the field of public service reveals a strong connection between all of the pillars of public administration. Public administrators are held accountable by the public and they cannot act on their own accord because they are held responsible to the officials who have been elected by the public. Elected officials determine the course of action of public servants and this fact is highly relevant to the dichotomy of politics and public administration (Finer, 1941, p. 335). In order for public servants to be responsible, they must adhere to certain values and principles which make them efficient, legitimate, and representative of social equity. Svara(2007) has stated the highest duty of public administrators is to embrace a broad s et of obligations and responsibilities that promote the public interest, demonstrate character, advance justice, and seek the greatest good. Gaus (1953) explained the relationship that is created for the responsible public servant between the other pillars by stating that, The contribution of the United States to the idea of responsibility in administration was made by requiring the chief executive-and later many minor executives-to submit directly or indirectly to popular vote (432). The general public elects officials to represent them and protect them to a certain extent. As explained in the dichotomy, there are two sides to public administration. In regards to responsibility, legislators and politicians have the responsibility of designing policies to address social issues in an attempt of solving issues. The administrative side of the responsibility has to do with implementation of the policies designed by elected officials. The relationship between chief executives and other elected officials and the bureaucracy is clearly demonstrated in the nature of punitive policies. For example, legislators designed policies that place restrictions on speed limits. In order to keep roads and highways safe, reckless driving behaviors must be curtailed and this is done through punitive policies. Drivers that violate the speed limit know they are at risk to be cited and subject to fines and jail time; therefore, it may be tempting to speed but policies are enforced by public administrators to deter this behavior. In this case scenario, street-level bureaucrats are the primary civil servants that are responsible for the implementation of punitive policies. This is a perfect example to illustrate how the decisions made by elected officials, impact the daily work operations of public service. Administrators are responsible for carrying out proper implementation of polices. Finer (1941) made it clear that there is a distinction between policy design and policy execution. This is where public administrators have the most power in their responsibilities. They are the ones responsible for policy execution and it is clearly stated in the literature that implementation is the most importance stage of the policy process. A policy is only as strong as its implementation and many die at this level because of irresponsible public administrators. Ethical issues can arise in this area because administrators may neglect to implement a policy or a program created by an elected official because they do not agree with it or have a hidden agenda. In regards to the link between public administration and the pillars, administration is not less important to democratic government than administrative efficiency; it is even a contributor to efficiency in the long run (Finer, 1941, p. 335). When a public administrator acts responsibly, they have a higher chance of exhibiting ethical behavior and ultimately producing efficiency. Legitimacy Legitimacy of the administrative state is contingent upon several factors. In the event that administrative agencies provide ample, equitable opportunities for public involvement, legitimacy is being carried out. There must also be opportunities for empirical research and decision making in order to accomplish legitimacy in the state. All of the pillars are intertwined with legitimacy. In order for a state to be considered legitimate, their power has to be accepted by the general public; therefore, in order to achieve this broad scope of power a state must be efficient, ethical, serve the public good, be representative, accountable to the public, effective, and responsible to elected officials. According to Dr. Beaumaster, the person who has the authority and power is legitimate (2010). Legitimacy Power is derived from authority; authority is derived from legitimacy; legitimacy is a moral or normative standing. So whenever that person makes an unethical decision, this will reflect in his power and he may lose it. Public organizations can often be affected by their internal and external environments, especially new organizations. It is not uncommon for a new organization to become vulnerable when resources are lost or they have not successfully obtained strong support from their environment (Rainey, 2003, p. 359). Consumer preferences and public sentiment always affect business and this is applicable in both the public and private sectors; however, public agencies face bigger issues with legitimacy because they are held highly accountable to the public. For example, the issue of raising taxes is always a contentious decision for elected officials because the public can show adamant opposition to paying higher taxes. Rainey (2003) explains that when voters resist taxes, governments face analogous problems (359). Public and oversight authorities often impose stricter criteria on public organizations for honest, legitimate behaviors (Rainey, 2003, p. 359). Expanding on the last quote, an example of illegitimate behavior in a bureaucracy would be an elected official using coercive power on a public servant in order to get something accomplished. Abuse of power is an age-old problem in bureaucracies. In the event an individual were granted a prestigious position in government based solely on being from a prominent family, their appointment to the position would constitute as illegitimate. There were accusations of coercive power and bureaucratic appointments that were not legitimate during the George W. Bush administration (Maitland, 1989, p.11). To increase and ensure legitimate practices in government and to secure a legitimate administrative state, Peffer (2008) suggests that public servants must be recruited that possess expertise, values, virtue, leadership, and vision. Government agencies should focus on recruiting the best and the brightest managers and employees but public servants must develop a direct relationship with citizens in order to be completely legitimate. Research shows that the bureaucracy has to be legitimate in practice not just in theory (Peffer, 2008, p. 1). When all of the pillars of public administration are combined, they are likely to produce legitimacy which creates stability within the state. There are four sources to gain legitimacy; constitution, legal, public perception, and professionalism The legal is the primary source because it is the thing that can prove that you have something such as school diploma verifies that you earn a degree from that school. The secondary legal source of legitimacy is constitution because the constitution is used to determine the legitimacy of anybody that has an authority position. Third is public perception. The perception of someone regardless their position in society makes them legitimate in some level (Beaumaster, 2009). Accountability The goal of public service is to provide the greatest amount of public good for the least amount of money. The public depends on governments to provide high quality services; therefore, public servants are held highly accountable by the constituents they serve. Accountability is a fundamental element of public administration is linked with the other pillars. Accountability requires ethical decision making, equal representation, legitimacy, efficiency, effectiveness, responsibility, and accountability is intertwined with the dichotomy of politics and public administration, as well. Public servants are held accountable by both the public and the elected officials. A rational civilization can only be organized and achieved through accountable behaviors carried out legislatively, judicially, and administratively (Ashworth, 2001, p. 163). Accountability in the public sector is a bigger issue than in private sectors of business. It is a fact that public managers and organizations remain accountable to various authorities and interests and to the rule of law in general (Rainey, 2003, p. 96). Private sector industries have one goal and that is usually monetary profit. The goals of public agencies are typically quite different. Providing the public good and carrying out the will of the public is a very vague goal and one that is an ambitious endeavor, as well. With this being stated, public agencies are held accountable to a wider range of people than private sector businesses. Representativeness is highly related to accountability because it refers to the multitude of ways elected officials must represent their citizens (Rainey, 2003, p. 97). Through being chosen to represent a locality or a state government or even national government, public officials are held accountable. The dichotomy of politics and public administr ation should be highly transparent here. According to the literature, there are different types of accountability. The types of accountability are: Hierarchical, legal, professional, and political. Rainey (2003) defined hierarchical and legal accountability as having increased levels of control. With hierarchical and legal accountability, it is less likely that a bureaucrat would be granted large levels of discretionary decision making power. Decision making would likely evolve from top-level executives within the organizations. One will find decreased levels of control with professional and political accountability. Administrators may be granted the discretionary decision making power to decide whether or not a response is wise to an external influence (Rainey, 2003, p. 96). Accountability is a serious element of Public Administration. For example, many researchers believe that the episode with the Space Shuttle Challenger explosion in 1986 can be attributed to group think (Forest, 1995, p. 1). Group think falls under the category of professional accountability. In the situation of the Challenger explosion, accountability issues resulted in taking the lives of seven people. Public administrators are often confronted with unethical situations where they are forced to make the right decisions in order to abide by their accountability standards for carrying out the good of the public. It is important to remain accountable to the public and to the elected officials one serves without compromising integrity in order to achieve career advancement or to not hinder career advancement (Ashworth, 2001, p. 153). Public organizations do not have the luxury that private businesses enjoy because their daily operations and files are open to the public. The public must be promised accessibility in order to garner trust from constituents. Accountability is a large realm of public administration that encompasses many aspects of public service. Representation According to Dr. Beaumaster (2010), representation deals with who is going to represent the will of the people. Are they those who are elected by the people themselves? Representation is not the cornerstone of public administration but it is the cornerstone of our entire government system. So the people chose who is going to be responsible and accountable for the country and them. According to Jefferson, power came from the land and from the people (cited in Kettl, 2002). So without people, the government has no power. The jobs of public administrators often require the pursuit of consistency in order to achieve stability. But the role of the elected official can be somewhat different because the politician is the person that has been chosen to represent the public. Ashworth (2001) explains that politicians tend to seek change and new accommodations in an attempt to impress their constituents for the purpose of gaining re-election. Politicians often want to sweep out the old and bring in the new, whereas public administrators want to tinker with existing programs and make incremental changes in an attempt to improve public service, (Ashworth, 2001, p.11). It should be evident that the goals of politicians and public administrators are different in nature. Those innate differences are what create the issue with representation in public administration. Representation is a classic issue in government and public administration and more recently is has garnered significant attention because of affirmative action programs, equal employment opportunity policies, and a growing trend towards increased representation on diverse populations (Rainey, 2003, p. 97). Representativeness is the pillar of public administration that refers to the ways elected officials can represent their citizens and these different ways are what mold and shape the responsibilities of a public servant. Elected officials tend to determine the way the needs of their citizens are represented and this illustration of how the dichotomy of politics and public administration works. In regards to the pillars of public administration, they are all interconnected with representativeness. In order to be adequately representative of a targeted population, a public servant must exhibit ethical behaviors, be responsive to needs, produce efficient results, and obtain high levels of legitimacy. Rainey (2003) explains that there are two types of representation: passive and active. Rainey explains that active representation occurs when members of a group actually serve as advocates for the group in decisions about programs and policies (97). Passive representation simply refers to situations where members of a group are simply present in a government entity or agency. The difference between the two types of representation was imperative to explain because the type often determines the values, goals, and mission of an agency. The type of representation that is decided upon has potential to create contention. Conflicting values and criteria often present challenges for public managers. Furthermore, external authorities and political actors intervene in management decisions in pursuit of responsiveness and accountability, and impose structures and constraints on the pursuit of equity, efficiency, and effectiveness. Rainey (2003) made it known that sharp conflicts over which values should predominate-professional effectiveness or political accountability, for example-lead to major transformations of organizational operations and culture (98). Anytime an agency is influenced by external sources to change or alter their value system, for example, issues are likely to arise. All of the information presented in this essay explains the issue with representation. Efficiency and effectiveness In the early days of public administration, government was corrupt. Politicians exercised coercive powers in order to get tasks accomplished. In an attempt to deter corruption in government, an emphasis on efficiency and effectiveness evolved. Efficiency and effectiveness are considered as criterion to measure performance in government. Performance measures are proof of successes and failures in social programs. Public administration researcher, Fried (1976) considered efficiency to be one of the major performance criteria for public bureaucracy in America today. James Madison discussed in the Federalist Papers that dividing government into three branches was a way to place a checks and balances system on powers (Rainey, 2003, p. 94). Madisons ideologies explain how demands for efficiency and effectiveness started. Performance criteria deter corruptive, unethical behaviors in government. Too much political control would not enable public administrations to operate effectively and eff iciently; therefore, agencies would not be able to accomplish the objectives associated with the other pillars of administration. The overall goal of public agencies is rooted in the definition of efficiency. Efficiency has been defined in the literature as producing a good or service at the lowest cost possible while maintaining a constant level of quality (Rainey, 2003, p. 95). The general public holds public servants accountable and responsible for bringing this goal to fruition. Public servants are expected to illustrate competency in their work and incompetent values do not play a role in efficiency and effectiveness. Former United States President, Bill Clinton, launched the National Performance Review in response to inefficient government. Clintons attempt to streamline government resulted in 324,000 government jobs being eliminated (Rainey, 2003, p. 95). Efficiency and effectiveness can be hindered by unethical behavior. Public administrators play the most important role in program and policy implementation. Efficient implementation is imperative for producing effectiveness. If efficient, competent behaviors have not been engaged in, a program or policy evaluation is likely to reveal incompetence. Law enforcement agents, commonly referred to street-level bureaucrats, are granted massive levels of discretionary decision making power. In the event they chose to not implement a policy handed down from a high-level executive, they are not being accountable, responsive, efficient, legitimate, or effective. Hypothetically speaking, if a police officer pulls someone over for speeding and makes the decision to let the driver go and not write a citation they are exhibiting incompetent behaviors. Incompetency leads to inefficient policies that are not effective. If a policy is not enforced by the bureaucracy, it may be deemed as useless. Measuring effectiveness often presents obstacles for public agencies. Bureaucracies are often burdened with the choice of whether to measure effectiveness using subjective measures or objective measures (Rainey, 2003, p. 136). This poses a problem because agencies do not always produce measurements that are tangible; therefore, many agencies may measure effectiveness through profits and productivity (Rainey, 2003, p. 136). Mott (1972) studied effectiveness in public agencies by requesting that managers rate the quantity, quality, efficiency, adaptability, and flexibility of their departmental units. Motts study is representative of how organizations may combine both a qualitative and quantitative approach to measuring effectiveness. If an agency proves effectiveness, it is highly likely that public administrators have engaged in efficient strategies to implement programs and policies.

Are Zoos Inhumane? Essays -- Animal Cruelty

In the film, Madagascar, zoos are depicted as a sanctuary in which all the exotic animals are kept safe and are open for the public to view. But many would argue that zoos are inhumane, the caging of animals for our personal entertainment is unjustifiable. Those who believe that zoos are wrong and should be destroyed are animal rights activist; they believe that animals should be allowed to choose their own destiny. Those that believe that zoos are an important part of our lives are scientist and zoologist. This debate has gone on for generations and average folk are stuck in the middle, not knowing which side to stand on. The animals being kept in captivity could not be interviewed; their side of the story will be based on interpretation on their movement and interaction with animals in the zoo and in the wild. Are animals better suited to live in the harsh conditions of the wild or are they better suited to live their lives safely in captivity? Many animal rights activist argue that animals should be allowed to live their lives in the wild instead of captivity. That we as humans have no right to neither alter the fate of other species nor use them for our personal benefits. PETA who is well known for their animal rights view argue that â€Å"Captive animals are deprived of everything that is natural and important to them and as a result, they become bored and lonely and many even suffer from a condition called zoochosis.† (PETA 1) Zoochosis is a condition in which the animal wonders back and forth usually in the same position for hours on end. This condition is only seen in the zoos as a result of the animal’s captivity. As a result zoos provide these animals with Prozac, which is a mood-altering drug to help prevent public atte... ... in todays society. But one thing is for sure many would argue that zoos have brought humans and animals closer together for the good and the bad. Works Cited "Zoos." Animal Cruelty -. N.p., n.d. Web. 12 May 2015. Lin, Doris. "Emaciated Asian Elephant Started Life at Busch Gardens." N.p., n.d. Web. 12 May 2015. Kaufman, Leslie. "To Save Some Species, Zoos Must Let Others Die." The New York Times. The New York Times, 27 May 2012. Web. 12 May 2015. "Do We Need Zoos?" : An All Creatures Animal Rights Article. N.p., n.d. Web. 03 May 2015. "CSA - Are Zoos Necessary." CSA - Are Zoos Necessary. N.p., n.d. Web. 03 May 2015. Hone, Dave. "Why Zoos Are Good." Thegauardian. N.p., n.d. Web. Tuesday 19 August 2014 "How Zoos Are Saving Our Animals." – Features – ABC Environment (Australian Broadcasting Corporation). N.p., n.d. Web. 03 May 2015.

Joy Luck Club :: essays research papers

  Ã‚  Ã‚  Ã‚  Ã‚  Amy Tan’s The Joy Luck Club brings forth many characteristics of new world and old world traditions into the reader’s sight. Old world traditions are the customs and beliefs practiced in one’s native country. The novel introduces the reader to the hardships that one encounters when the environment and the neighbors change. The American customs, or new world traditions, seem to prevail in the thoughts of the Chinese-American daughters; thus, encouraging the mothers to stress the old world traditions onto their children. The mothers also try to bring the best of both worlds to their children to make their children’s lives better. As the children mature, they realize the true worth of their Chinese heritage and try to retain to the Chinese characteristics that they have. In The Joy Luck Club, old world and new world traits are gained and lost by the characters in the novel to benefit themselves and make their strength of mind stronger.   Ã‚  Ã‚  Ã‚  Ã‚  The children in The Joy Luck Club gain many characteristics of the old world and the new world that compose new people. The novel introduces us to characters that have lost their inner soul spirits that contain their Chinese heritage. The mothers know that their Chinese traditions and language are a necessary factor in dealing with their everyday life. The mothers also know that the new American traditions are needed to succeed in their new home. The mothers encourage English speaking, but also want to preserve their Chinese language. The major new thought that is gained by the children, and the mothers is the â€Å"American Dream.† They believe that anything is possible in America, and their dreams can be fulfilled trough their children. â€Å"My mother believed you could be anything you wanted in America†¦You could be instantly famous.†(Tan 141). The children gain pride for their native country also; raising their self-esteem and bringing abou t new strength in them. People cannot be accepted in society without accepting themselves. One has to accept their heritage and have pride for their heritage for other people to respect them. The mothers in the novel try to teach this lesson to their children. The minute our train leaves the Hong Kong border and enters Shenzhen, China, I feel different. I can feel the skin on my forehead tingling, my blood rushing through a new course, my bones aching with familiar old pain. And I think, My mother was right.

Reconstruction after the civil war

After much trial and tribulation that our exasperated country has faced, we all still gather here today in order to follow a long tradition of George Washington, a founding father and cherished president who gave and set precedent to all the new leaders who soon will follow the same path of presidency. A path followed by great accomplishments of the Grant administration, has helped to set a rolling future for the united States and now we will Improve upon the Grant administration using It as a stepping stone to once again unite the country.Now that the sure wind of war thin our country has prevailed we must continue to rebuild upon the accomplishments of the Grant Administration. We must rebuild within our trust with other human beings and rebuild within the large battered roads of this nation. Though much has been done in the last presidency, there is still ton more to accomplish. Likewise the efforts of before have helped me gain a foot on the task to better our united nation. Look ing back the last few years, already have we recovered from the tribulation of Civil War.We have started the healing process between the different races that were pitted against each other but now stand as brothers. The recent Call Rights Acts and the passing of the 1 5th Amendment have helped to guarantee and ensure the equal Civil Rights that all men will share and all able to be comprised under the glorious Constitution. Yet throughout the years we have also placed ourselves in the continued process of reconstruction in which we have rid the terrors of extremists groups but also have accomplished the first steps of reunion with the Southern states.Likewise, these efforts to heal the previous tension have been done to almost a full recovery. Many former rebels have been pardoned and owe the first steps to a unified country have put under way by the removal of many federal soldiers. The vanquishing of the post war tensions has been successful but now we must continue and move forwa rd. The reality is that all races much make the effort to live harmoniously with sympathy and empathy through the eyes of each individual.And through the government will the Constitutional rights of all men be upheld as shall the eradication of prejudice of others In order to keep this nation prosperous. In order to end the final lasting tensions of this era, we will make sure to eve the well waited autonomy of the last few southern states. We will make sure to relieve them of the pressure that federal troops have brought in the states of Louisiana and South Carolina. Through this progress we must also put in an investment to Americas' future in education.With support of the government it will be a priority to make sure education is available to everyone, for with this we can move forward and develop a bright future through the youth at the moment. Universal education and improvements in the intellectual and moral conductivity is the root to all prosperity. The interest to better so ciety Is In equality of both colored and white people, for the perseverance of everyone Is needed to make these new Improvements In equality and education. Again we have been In depression within our manufacturing and commercial Industries.For sure this will come to an end. In need we must comply that a papered currency Is unreliable and accustomed to fluctuate. Likewise the best way to back this is with a coin based currency where that I will keep as my honored predecessor, President Grant, who made sure to preserve the peace between us and foreign powers. If those countries that require aid need it, without disposition we will help in a peaceful and honorable way so we can create mutual understandings to the entire world[K] .Grieving once again to bring forward this nation I ask all of you: Farmers, lawyers, doctors, politicians, judges, and citizens to Join me in this movement to restore our country to the divine rights that we all share. To help in earnest efforts to rekindle th e unity we all share in order for every man no matter color to achieve the pursuit of happiness and without fail grasp the happiness that we all will share together.

A Format for Case Conceptualisation

Many professional and personal challenges confront practicum students as they work with clients. For example, students must establish a counseling relationship, listen attentively, express themselves clearly, probe for information, and implement technical skills in an ethical manner. Those counseling performance skills (Borders & Leddick, 1987) center on what counselors do during sessions.At a cognitive level, students must master factual knowledge, think integratively, generate and test clinical hypotheses, plan and apply interventions, and evaluate the effectiveness of treatment. Those conceptualizing skills, within the cognitive operations used to construct models that represent experience (Mahoney & Lyddon, 1988), show how counselors think about clients and how they choose interventions. It is highly desirable for instructors of practica to have pedagogical methods to promote the development both of counseling performance skills and conceptualizing skills.Such methods should be d iverse and flexible to accommodate students at different levels of professional development and with distinct styles of learning (Biggs, 1988; Borders & Leddick, 1987; Ellis, 1988; Fuqua, Johnson, Anderson, & Newman, 1984; Holloway, 1988; Ronnestad & Skovholt, 1993; Stoltenberg & Delworth, 1987). RATIONALE FOR THE FORMAT In this article, we present a format for case conceptualization that we developed to fill gaps in the literature on the preparation of counselors (Borders & Leddick, 1987; Hoshmand, 1991).Although many existing methods promote counseling performance skills, there are few established methods for teaching students the conceptualizing skills needed to understand and treat clients (Biggs, 1988; Hulse & Jennings, 1984; Kanfer & Schefft, 1988; Loganbill & Stoltenberg, 1983; Turk & Salovey, 1988). We do not discount the importance of counseling performance skills, but we believe that they can be applied effectively only within a meaningful conceptual framework. That is, wh at counselors do depends on their evolving conceptualization of clients; training in that conceptualization matters.Given the large quantity of information that clients disclose, students have the task of selecting and processing relevant clinical data to arrive at a working model of their clients. Graduate programs need to assist students in understanding how to collect, organize, and integrate information; how to form and test clinical inferences; and how to plan, implement, and evaluate interventions (Dumont, 1993; Dumont & Lecomte, 1987; Fuqua et al. , 1984; Hoshmand, 1991; Kanfer & Schefft, 1988; Turk & Salovey, 1988).Although systematic approaches to collecting and processing clinical information are not new, the case conceptualization format presented here, as follows, has several distinguishing features: 1. The format is comprehensive, serving both to organize clinical data (see Hulse & Jennings, 1984; Loganbill & Stoltenberg, 1983) and to make conceptual tasks operational ( see Biggs, 1988). The components of the format integrate and expand on two useful approaches to presenting cases that are cited often and that are linked to related literature on supervision: (a) Loganbill and Stoltenberg's (1983) six content areas of clients' functioning (i. . , identifying data, presenting problem, relevant history, interpersonal style, environmental factors, and personality dynamics), and (b) Biggs's (1988) three tasks of case conceptualization (i. e. , identifying observable and inferential clinical evidence; articulating dimensions of the counseling relationship; and describing assumptions about presenting concerns, personality, and treatment). In addition, the format makes explicit the crucial distinction between observation and inference, by separating facts from hypotheses.It advances the notion that observations provide the basis for constructing and testing inferences. Thus, the format fosters development of critical thinking that is more deliberate and le ss automatic than the ordinary formation of impressions. The approach is compatible with recommendations that counselors receive training in rational hypothesis testing to reduce inferential errors (Dumont 1993; Dumont & Lecomte, 1987; Hoshmand, 1991; Kanfer & Schefft, 1988; Turk & Salovey, 1988). 2.The format can be adapted to the developmental stage of students by its focus on stage-appropriate components and implementing those components in stage-appropriate ways (Ellis, 1988; Glickauf-Hughes & Campbell, 1991; Ronnestad & Skovholt, 1993; Stoltenberg & Delworth, 1987). As an example, beginning students use the format to organize information and to learn the distinction between observation and inference, whereas more experienced students focus on using the format to generate and test hypotheses. 3. The format is atheoretical, thereby permitting students to ncorporate constructs from any paradigm into their case conceptualizations. In this sense, the format resembles the cognitive s caffolding described in the constructivist perspective (Mahoney & Lyddon, 1988). Rather than being an explicit template through which observations are filtered to conform to an imposed representational model, the format provides an abstract set of cognitive schemas. With the schemas, the student actively fashions a conceptual framework from which to order and assign meaning to observations.Simply put, the format is a generic structure that the student uses to construct his or her â€Å"reality† of the case. COMPONENTS OF THE FORMAT The format has 14 components, sequenced from observational to inferential as follows: background data, presenting concerns, verbal content, verbal style, nonverbal behavior, client's emotional experience, counselor's experience of the client, client-counselor interaction, test data and supporting materials, diagnosis, inferences and assumptions, goals of treatment, interventions, and evaluation of outcomes. Background data includes sex, age, race, ethnicity, physical appearance (e. . , attractiveness, dress, grooming, height, and weight), socioeconomic status, marital status, family constellation and background, educational and occupational status, medical and mental health history, use of prescribed or illicit substances, prior treatment, legal status, living arrangements, religious affiliation, sexual preference, social network, current functioning, and self-perceptions. Initially, students are overwhelmed by the data that they assume need to be collected. Guidance must be provided on how students are to differentiate meaningful from inconsequential information.In our program, for example, we ask students to evaluate the relevance of background data, for understanding clients' presenting concerns and for developing treatment plans. We advise students to strive for relevance rather than comprehensiveness. Presenting concerns consist of a thorough account of each of the client's problems as viewed by that client. This task mi ght begin with information contained on an intake form. We assist students in developing concrete and detailed definitions of clients' concerns by showing them how to help clients identify specific affective, behavioral, cognitive, and interpersonal features of their problems.For example, the poor academic performance of a client who is a college student might involve maladaptive behavior (e. g. , procrastination), cognitive deficits (e. g. , difficulty in concentrating), negative moods (e. g. , anxiety), and interpersonal problems (e. g. , conflict with instructors). Counseling students should also explore the parameters of presenting concerns, including prior occurrence, onset, duration, frequency, severity, and relative importance.We further suggest that students explore how clients have attempted to cope with their concerns and that they examine what clients expect from treatment, in terms of assistance as well as their commitment to change. In addition, students should assess i mmediate or impending dangers and crises that their clients may face. Finally, we instruct students in identifying environmental stressors and supports that are linked to presenting concerns. Verbal content can be organized in two ways. A concise summary of each session is appropriate for cases of limited duration.Alternatively, verbal content can include summaries of identified themes that have emerged across sessions. Occasionally, those themes are interdependent or hierarchically arranged. For example, a client may enter treatment to deal with anger toward a supervisor who is perceived as unfair and, in later sessions, disclose having been chronically demeaned by an older sibling. We teach students to discriminate central data from peripheral data through feedback, modeling, and probing questions. Students need to focus their sessions on areas that are keyed to treatment.For instance, we point out that clients' focal concerns, along with the goals of treatment, can serve as ancho rs, preventing the content of sessions from drifting. Verbal style refers to qualitative elements of clients' verbal presentation (i. e. , how something is said rather than what is said) that students deem significant because they reflect clients' personality characteristics, emotional states, or both. Those elements can include tone of voice and volume, changes in modulation at critical junctures, fluency, quantity and rate of verbalization, vividness, syntactic complexity, and vocal characterizations (e. g. , sighing).Nonverbal behavior includes clients' eye contact, facial expression, body movements, idiosyncratic mannerisms (e. g. , hand gestures), posture, seating arrangements, and change in any of these behaviors over time and circumstances. Instructors can assist students in distinguishing relevant from unimportant information by modeling and providing feedback on how these data bear on the case. As an example, neglected hygiene and a listless expression are important nonverb al behaviors when they coincide with other data, such as self-reports of despair and hopelessness. Clients' emotional experience includes data that are more inferential.On the basis of their observations, students attempt to infer what their clients feel during sessions and to relate those feelings to verbal content (e. g. , sadness linked to memories of loss). The observations provide insights into clients' emotional lives outside of treatment. We caution students that clients' self-reports are an important but not entirely reliable source of information about their emotional experience. At times clients deny, ignore, mislabel, or misrepresent their emotional experience. Students should note the duration, intensity, and range of emotion expressed over the course of treatment.Blunted or excessive affect as well as affect that is discrepant with verbal content also merit attention. To illustrate, a client may report, without any apparent anger, a history of physical abuse. Initially, students can be assisted in labeling their clients' affect by using a checklist of emotional states. We have found it helpful to suggest possible affect and support our perceptions with observation and logic. Empathic role taking can also help students to gain access to clients' experience. Instructors may need to sensitize students to emotional states outside of their own experience or that they avoid.Counselor's experience of the client involves his or her personal reactions to the client (e. g. , attraction, boredom, confusion, frustration, and sympathy). We strive to establish a supportive learning environment in which students can disclose their genuine experiences, negative as well as positive. Students often struggle to accept that they might not like every client. But students should be helped to recognize that their experience of clients is a rich source of hypotheses about feelings that those clients may engender in others and, thus, about the interpersonal world that the clients partially create for themselves.The â€Å"feel† of clients often provides valuable diagnostic clues (e. g. , wanting to take care of a client may suggest features of dependent personality disorder). Sometimes students need assistance in determining whether their reactions to clients reflect countertransferential issues or involve â€Å"normative† responses. We draw on parallel process and use-of-self as an instrument to help clarify students' feelings and to form accurate attributions about the origins of those feelings (Glickauf-Hughes & Campbell, 1991; Ronnestad & Skovholt, 1993).Client-counselor interaction summarizes patterns in the exchanges between client and counselor as well as significant interpersonal events that occur within sessions. Such events are, for example, how trust is tested, how resistance is overcome, how sensitive matters are explored, how the counseling relationship is processed, and how termination is handled. Thus, this component of t he format involves a characterization of the counseling process. Students should attempt to characterize the structure of the typical session–specifically, what counselors and clients do in relation to one another during the therapy hour.They may do any of the following: answer questions, ask questions; cathart, support; learn, teach; seek advice, give advice; tell stories, listen; collude to avoid sensitive topics. Taxonomies of counselor (Elliott et al. , 1987) and client (Hill, 1992) modes of response are resources with which to characterize the structure of sessions. At a more abstract level, students should try to describe the evolving roles they and their clients play vis-a-vis one another. It is essential to assess the quality of the counseling relationship and the contributions of the student and the client to the relationship.We ask students to speculate on what they mean to a given client and to generate a metaphor for their relationship with that client (e. g. , do ctor, friend, mentor, or parent). Client-counselor interactions yield clues about clients' interpersonal style, revealing both assets and liabilities. Furthermore, the counseling relationship provides revealing data about clients' self-perceptions. We encourage students to present segments of audiotaped or videotaped interviews that illustrate patterns of client-counselor interaction.Test data and supporting materials include educational, legal, medical, and psychological records; mental status exam results; behavioral assessment data, including self-monitoring; questionnaire data, the results of psychological testing, artwork, excerpts from diaries or journals, personal correspondence, poetry, and recordings. When students assess clients, a rationale for testing is warranted that links the method of testing to the purpose of assessment. We assist students in identifying significant test data and supporting materials by examining how such information converges with or departs from o ther clinical data e. g. , reports of family turmoil and an elevated score on Scale 4, Psychopathic Deviate, of the Minnesota Multiphasic Personality Inventory-2 [MMPI-2; Hathaway & McKinley, 1989]). Assessment, as well as diagnosis and treatment, must be conducted with sensitivity toward issues that affect women, minorities, disadvantaged clients, and disabled clients, because those persons are not necessarily understood by students, perhaps due to limited experience of students or the â€Å"homogenized† focus of their professional preparation.Diagnosis includes students' impression of clients' diagnoses on all five axes of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV, American Psychiatric Association, 1994). We guide students' efforts to support their diagnostic thinking with clinical evidence and to consider competing diagnoses. Students can apply taxonomies other than those in the DSM-IV when appropriate (e. g. , DeNelsky and Boat's [1 986] coping skills model).Instructors demonstrate the function of diagnosis in organizing scattered and diverse clinical data and in generating tentative hypotheses about clients' functioning. Inferences and assumptions involve configuring clinical hypotheses, derived from observations, into meaningful and useful working models of clients (Mahoney & Lyddon, 1988). A working model consists of a clear definition of the client's problems and formulations of how hypothesized psychological mechanisms produce those problems.For instance, a client's primary complaints might be frequent bouts of depression, pervasive feelings of isolation, and unfulfilled longing for intimacy. An account of those problems might establish the cause as an alienation schema, early childhood loss, interpersonal rejection, negative self-schemas, or social skills deficits. We help students to elaborate on and refine incompletely formed inferences by identifying related clinical data and relevant theoretical const ructs (Dumont, 1993; Mahoney & Lyddon, 1988).We also assist students in integrating inferences and assumptions with formal patterns of' understanding drawn from theories of personality, psychopathology, and counseling (Hoshmand, 1991). As with their instructors, students are not immune from making faulty inferences that can be traced to logical errors, such as single-cause etiologies, the representative heuristic, the availability heuristic, confirmatory bias, the fundamental attribution error, and illusory correlations; (Dumont, 1993;Dumont & Lecomte, 1987). As an example, counselors tend to seek data that support their preexisting notions about clients, thus restricting the development of a more complete understanding of their clients. We alert students to the likelihood of bias in data gathering, particularly when they seek to confirm existing hypotheses. Furthermore, we demonstrate how to generate and evaluate competing hypotheses to counteract biased information ]processing (Du mont & Lecomte, 1987; Kanfer & Schefft, 1988).Instructors, therefore, must teach students to think logically, sensitizing them to indicators of faulty inferences and providing them with strategies for validating clinical hypotheses as well as disconfirming them (Dumont & Lecomte, 1987; Hoshmand, 1991). The proposed format can accomplish this task because it separates inferences from the clinical data used to test inferences and thus â€Å"deautomatizes† cognitive operations by which inferences are formed (Kanfer & Schefft, 1988; Mahoney & Lyddon, 1988).We have found it beneficial to have students compare their impressions of clients with impressions that are independently revealed by test data (e. g. , MMPI-2); this exercise permits the correction of perceptual distortions and logical errors that lead to faulty inferences. Although students' intuition is an invaluable source of hypotheses, instructors need to caution them that intuition must be evaluated by empirical testing and against grounded patterns of understanding (Hoshmand, 1991). We also model caution and support for competing formulations and continued observation.This approach fosters appreciation of the inexactitude and richness of case conceptualization and helps students to manage such uncertainty without fear of negative evaluation. With the development of their conceptualizing skills, students can appreciate the viability of alternative and hybrid inferences. Moreover, they become more aware of the occasional coexistence and interdependence of clinical and inferential contradictions (e. g. , the simultaneous experience of sorrow and joy and holistic concepts such as life and death).The increasingly elaborate conceptual fabric created from the sustained application of conceptualizing skills also enables students to predict the effect of interventions more accurately. Goals of treatment must be linked to clients' problems as they come to be understood after presenting concerns have been ex plored. Goals include short-term objectives along with long-term outcomes of treatment that have been negotiated by the client and trainee. Typically, goals involve changing how clients feel, think, and act. Putting goals in order is important because their priorities will influence treatment decisions.Goals need to be integrated with students' inferences or established theories and techniques of counseling. In their zeal, students often overestimate the probable long-term aims of treatment. To help students avoid disappointment, we remind them that certain factors influence the formulation of goals, including constraints of time and resources, students' own competencies, and clients' capacity for motivation for change. Interventions comprise techniques that students implement to achieve agreed-on goals of treatment.Techniques are ideally compatible with inferences and assumptions derived earlier; targets of treatment consist of hypothesized psychological structures, processes, and conditions that produce clients' problems (e. g. , self-esteem, information processing, family environment). Difficulties in technical implementation should be discussed candidly. We provide opportunities for students to observe and rehearse pragmatic applications of all strategies. Techniques derived from any theory of counseling can be reframed in concepts and processes that are more congruent with students' cognitive style.To illustrate, some students are able to understand how a learned fear response can be counterconditioned by the counseling relationship when this phenomenon is defined as a consequence of providing unconditional positive regard. In addition, we teach students to apply techniques with sensitivity as well as to fashion a personal style of counseling. Finally, legal and ethical issues pertaining to the conduct of specific interventions must be made explicit. Evaluation of outcomes requires that students establish criteria and methods toward evaluating the outcome s of treatment.Methods can include objective criteria (e. g. , grades), reports of others, self-reports (e. g. , behavioral logs), test data, and students' own judgments. Instructors must assist students in developing efficient ways to evaluate progress over the course of treatment given the presenting concerns, clients' motivation, and available resources. USES OF THE FORMAT We developed the :format for use in a year-long practicum in a master's degree program in counseling psychology. Instructors describe the format early in the first semester and demonstrate its use by presenting a erminated case; a discussion of the format and conceptualization follows. The first half of the format is particularly helpful when students struggle to organize clinical data into meaningful categories and to distinguish their observations from their inferences. The focus at that point should be on components of the format that incorporate descriptive data about the client. Later in their development, when students are prepared to confront issues that influence the counseling relationship, components involving personal and interpersonal aspects of treatment can be explored.As students mature further, components that incorporate descriptive data are abbreviated so that students can concentrate on the conceptualizing skills of diagnosis, inferences and assumptions, treatment planning and intervention, and evaluation. When conceptualizing skills have been established, the format need not be applied comprehensively to each case. Rather, it can be condensed without losing its capacity to organize clinical data and to derive interventions. The format can be used to present cases in practicum seminar as well as in individual supervision sessions. It can also be used by students to manage their caseloads.Also, the format can be used in oral and written forms to organize and integrate clinical data and to suggest options for treatment (cf. Biggs, 1988; Hulse & Jennings, 1984; Loganbill & Stoltenberg, 1983). For example, practicum seminar can feature presentations of cases organized according to the format. As a student presents the data of the case, participants can construct alternative working models. Moreover, the format compels participants to test their models by referencing clinical data. Written details that accompany a presentation are also fashioned by a student presenter according to the format.The student presenter can distribute such material before the presentation so that members of the class have time to prepare. During the presentation, participants assume responsibility for sustaining the process of case conceptualization in a manner that suits the class (e. g. , discussion, interpersonal process recall, media aids, or role play). Supervision and case notes can also be structured more flexibly with the use of the case conceptualization format to give students opportunities to relate observation to inference, inference to treatment, and treatment to outcome (Presser & Pfost, 1985).In fact, supervision is an ideal setting to tailor the format to the cognitive and personal attributes of the students. In supervision, there are also more opportunities to observe students' sessions directly, which permits instruction of what clinical information to seek, how to seek it, how to extract inferences from it, and to evaluate the veracity of students' inferences by direct observation (Holloway, 1988). FUTURE APPLICATIONS AND RESEARCH The format is a potentially valuable resource for counselors to make the collection and integration of data systematic when they intervene with populations other than individual clients.Application of the format to counseling with couples and families might seem to make an already conceptually demanding task more complex. Yet counselors can shift the focus from individuals to a couple or a family unit, and apply components of the format to that entity. By targeting relationships and systems in this way, the format can also be used to enhance understanding of and improve interventions in supervision and with distressed units or organizations.Although research has been conducted on how counselors collect data, few studies have investigated how counselors process information when testing hypotheses (e. g. , Strohmer, Shivy, & Chiodo, 1990). Empirical evidence of the effectiveness of various approaches to the conceptual training of counselors is long overdue. Avenues of inquiry include determining whether the format contributes to the acquisition of conceptualizing skills and to facilitative conditions and techniques thai: may be mediated by such skills (e. . , empathy and clear communication). There are several written measures available with which to evaluate students' conceptualizing skills. Examples of those measures are the Clinical Assessment Questionnaire (Holloway & Wolleat, 1980); Intentions List (Hill & O'Grady, 1985); and Written Treatment Planning Simulation (Butcher, Scofield, & Baker, 1985). Interpersonal process recall of audiotaped and videotaped sessions, case notes (Presser & Pfost, 1985), and direct observation can also be used.Other promising directions for research include comparing the effect of the format with other approaches to training, isolating components of the format that produce the greatest gains in conceptualizing skills, and determining the outcomes when the format is implemented with the use of different instructional strategies and with students at varying levels of development. Finally, investigation into how the format produces cognitive and performance gains would be valuable, particularly if integrated with literature on cognitive development and effective learning strategies.Nonetheless, the format has several limitations. Although students will eventually learn to apply the format more efficiently in their professional practice, it remains cumbersome and time consuming. Explicit and comprehensive application of the format in supervision and in the routine management of individual caseloads is particularly awkward. In those contexts, the format must be applied tacitly as a heuristic, with specific components used more deliberately when obstacles to progress are encountered.For example, focus on a client's affective experience can promote accurate empathy in the student and lead to more helpful interventions. Moreover, given the differences in the cognitive development of students (Biggs, 1988; Borders & Leddick, 1987; Ellis, 1988; Fuqua et al. , 1984; Ronnestad & Skovholt, 1993; Stoltenberg & Delworth, 1987), the format cannot be applied rigidly or uniformly as a pedagogical tool. Beginning students and those who think in simple, concrete terms seem to profit most from learning environments in which instructors provide direction, expertise, feedback, structure, and support.Conversely, more experienced students and those who think in complex, abstract terms learn more readily when instructors fashion auto nomous, collegial, flexible, and interactive environments (Ellis, 1988; Glickauf-Hughes & Campbell, 1991; Ronnestad & Skovholt, 1993; Stoltenberg & Delworth, 1987). Hence, the format must be applied creatively and tailored to students' capabilities, to avoid needless discouragement, boredom, or threats to personal integrity (Fuqua et al. , 1984; Glickauf-Hughes & Campbell, 1991; Ronnestad & Skovholt, 1993; Stoltenberg & Delworth, 1987)