Industrial Marketing Saudi Telecommunication Company

Executive Summary This report evaluates the problems experienced by firms in undertaking B2B marketing activities. In an effort to develop a better understanding of the B2B marketing challenges experienced by organizations in the real business environment, the report has taken into account the Saudi Telecommunication Company which is the leading firm within the Saudi Arabian telecommunication industry.Advertising We will write a custom report sample on Industrial Marketing: Saudi Telecommunication Company specifically for you for only $16.05 $11/page Learn More The report is organized in a number of sections. The first section gives background information with regard to the changes in B2B marketing and the challenges experienced by firms in their B2B marketing. Considering the fact that there are numerous B2B marketing challenges faced by firms, the report has focused on the challenge emanating from the large number of individuals who are involved in org anizational buying process. A comprehensive analysis of challenges arising from a large number of individuals in the buying process is evaluated in the second part. The third part entails an analysis of the organization’s customer, competitive and organizational environments. In the conclusion, a summary of the main points considered in the report is given. Additionally, a number of recommendations to deal with the challenge evaluated in the report are outlined. Introduction Background of the study Marketing is one of the most important aspects that businesses have to incorporate in their operation in order to survive in the long run. Blythe and Zimmerman (17) assert that marketing incorporates a number of issues such as conception of product idea, formulating the pricing, promotion and distribution strategies and creating customer relationships in order to satisfy both individual and organizational objectives. The concept of marketing has undergone significant changes over t he past few years. One of these changes is related to increment in the intensity of competition. One of the factors that have stimulated growth in competition relates to the technological innovation. The emergence of different technologies has significantly impacted the concept of marketing. In their operation, management teams appreciate the fact that attracting and retaining customers can significantly enhance their ability to attain their organizational goals such as increasing their sales revenue and profit levels. To achieve this, businesses appreciate the fact that it is important to attain an effective market position. There are different aspects that businesses incorporate in an effort to achieve this. One of the market positioning methods that businesses incorporate relates to their target customer. For example, some businesses may position themselves to be selling to individual customers while others may position themselves to be selling to other businesses such as wholesa lers and retailers. However, some businesses have integrated both B2B and B2C marketing in their effort to enhance their competitive advantage by improving their sales revenue.Advertising Looking for report on business economics? Let's see if we can help you! Get your first paper with 15% OFF Learn More In their operation, B2B firms are experiencing unique challenges. However, in an effort to attract and retain customers most businesses which have adopted the concept of B2B are integrating emerging marketing technologies. One of the technologies that have been widely utilized is the information communication technology. Most businesses are increasingly automating their operations in an effort to enhance the level of customer engagement and optimize their sales. Additionally, automation of business processes is also aimed at minimizing the cost of operation. One of the ways through which organizations are achieving this is by incorporating new marketing software. One o f the factors that have stimulated businesses to increasingly consider minimizing the cost of their operation is associated with the effects of the 2008/2009 global economic recession. Companies are also considering automating their marketing processes due to growth in customer empowerment. Over the past decade, customers have become very empowered as a result of growth in social media. In an effort to take advantage of this phenomenon, organizations are increasingly integrating social media in their marketing processes. Automating the marketing processes plays a significant role in enhancing the effectiveness which helps the firms’ management teams accomplish organizational goals. For example, social media has enabled organizations to establish strong relationships with their customers. This is due to the fact that social media is creating room for a two-way conversation which enables organizations to push their brand message to the customers. Therefore, social media has sig nificantly transformed marketing into a two-way conversation. Integration of the social media platform into organization’s marketing activities has empowered customers by giving them an opportunity to share information regarding brands. For example, they have an opportunity to share information about their experiences with a certain brand. Through this process, consumers are able to influence others in their decision making process. Despite their efforts in automating their marketing processes, most B2B firms are increasingly facing new challenges. For example, in their B2B marketing, firms’ management teams are not only being challenged to ensure high volume of leads but also ensure that the leads culminate in sales opportunities.Advertising We will write a custom report sample on Industrial Marketing: Saudi Telecommunication Company specifically for you for only $16.05 $11/page Learn More Additionally, firms are also facing a challenge w hich arises from lengthening of the sales cycle. Firms which have incorporated the concept of B2B marketing are also required to involve themselves in comprehensive buying processes which are adopted by different customers. Organizations are also expected to ensure that they deliver their products that results in attainment of the perceived value. To attract and retain a large number of clients, B2B firms are required to ensure that they generate a public relations buzz. Considering a high rate at which firms are adopting emerging media in undertaking their marketing activities, B2B firms are required to ensure that they develop an edge across the multiple marketing mediums. These are some of the major marketing problems that B2B firms are experiencing. Saudi Telecommunication Company is the largest provider of telecommunication products in the Saudi Arabian Wireless Communication industry. In its operation, STC specializes in the provision of fixed and mobile telecommunication prod ucts to residential and institutional customers. STC’s two main brands include inVOICE which entails provision of bundle of voice and QUICKnet which specializes in the provision of mobile internet services. Additionally, STC also offers data and internet services to its customers. In an effort to attain its profit maximization objective, STC has ventured into the international market through global collaboration. The firm has attained this by establishing an undersea communication cable system which connects more than 35 countries most of which are located in North America, South East Asia, Middle East Asia, Europe and North Africa (Yahoo Finance para. 1). In its operation, STC’s main clients include the government, non-governmental organizations and other business institutions. In an effort to align itself with the prevailing market trend, STC has incorporated the concept of B2B marketing. The firm has attained this by automating some of its marketing processes. Aim T he objective of this report is to evaluate a B2 marketing issue faced by the Saudi Telecommunication Company in its operation. Considering the fact that there are a wide range of problems that firms are facing in undertaking B2B marketing activities, the report specifically focuses on the buying process. Scope The report is organized in a number of sections; the first section entails an analysis of the B2B marketing problem facing STC in its operation and its importance. The second section entails an evaluation of the customer, competitive and organizational environments.Advertising Looking for report on business economics? Let's see if we can help you! Get your first paper with 15% OFF Learn More Finally, a conclusion and a set of recommendations are outlined. Despite the fact that there are numerous challenges associated with B2B marketing, the report only takes into account the challenge emanating from dealing with a large number of individuals in the decision making process. Analysis of the problem faced by STC in its B2B marketing: Marketing to an large number of individuals involved in the decision making process STC is ranked as one of the most advanced telecommunication companies within the Gulf region. In an effort to attain its profit maximization objective, the company’s management team has been committed towards ensuring that its services are accessed by a large number of customers within Saudi Arabia. As a result, STC has established its operations in all corners of Saudi Arabia (Ayed Al-Allak 78). Since its inception, STC has been committed towards increasing its customer base. In its operation, the firm deals with a wide range of clients. Some of its ma jor clients include both local and regional wholesalers who deal with provision of telecommunication services, Internet Service Providers, regional enterprises, and other content providers. STC also provides telecommunication services to different institutions such as hospitals, government agencies and educational institutions. Business buying is one of the most important aspects that organizations should consider. This arises from the fact that their volume of purchase is relatively high compared to individual customers. Therefore, business customers can enable an organization to attain its profit maximization goals through increased sales. In their buying process, consumers have to undertake a comprehensive decision making process. One of the issues that STC’s management team is concerned with relates to developing of a strong relationship with its organizational customers. In an effort to understand how STC markets its products to institutional/ organizational customers, I talked to the company’s Chief Marketing Officer [hereafter referred to as the CMO] who revealed a number of issues that are taken into account in its B2B marketing process. The CMO asserted that the B2B marketing process is increasingly becoming very challenging. When asked why, he was of the opinion that there were numerous formal steps which were involved in the company’s industrial marketing process. Additionally, the CMO asserted that the firm was required to influence a large number of individuals before it could close a sales contract. According to Blythe and Zimmerman (16), organizational buying process is more intensive compared to individual buying process. Additionally, institutional buying process is more rational compared to consumer buying process which is sometimes characterized by a high degree of emotions. According to the CMO, organizational buying decisions are undertaken by the Decision Making Unit (DMU). The DMU is composed of different individuals from different departments. However, members of the DMU share responsibilities. One of the major challenges that STC’s marketing department faces in its industrial marketing process arises from the fact that it is difficult to identify the DMU within a particular organizational customer. Blythe and Zimmerman (17) assert that it is difficult to identify the DMU or the buying center within an organization’s organizational chart. In order to close a sale contract with a particular institutional customer, STC’s marketing department has to ensure that it influences the various parties within the DMU. This is one of the major problems that STC experiences in its B2B marketing. According to the CMO, Organizations’ decision making units are composed of different categories of individuals. Some of these categories include; Initiators Gatekeepers Buyers Deciders Users Influencers The initiators include individuals who are the 1st to identify a particular problem that a particular organization is facing. On the other hand, the gatekeepers control the flow of information within the organization. For example, the gatekeepers can be proactive in collecting or filtering information that can be utilized by an organization. An example of gatekeepers within an organization may include the junior staff members who are given the opportunity to attend trade fairs and exhibitions, or personal assistants who may perceive their main role within an organization to include preventing sales personnel from interrupting the operation of the organization’s decision makers. The buyers include the individuals who are charged with the responsibility of seeking and negotiating with potential suppliers. In most cases, buyers mainly include the purchasing agents who are charged with various administrative tasks which are critical in the buying process. Despite the fact that buyers have a limited autonomy in the decision making unit, they may be the only link that a particular organization may have in closing a sales contract. The deciders include individuals who have the final mandate regarding the purchase decision. According to Blythe and Zimmerman (17), deciders mainly include the organization’s senior managers. One of the issues that make B2B marketing to be challenging arises from the fact the deciders may not give the suppliers’ markets an opportunity to meet in order to explain the product or service that the firm intends to supply. However, deciders mainly rely on advice from other company representatives within the decision making unit. Users include the individuals who will be utilizing the product or service being supplied. In most cases, users include various work groups, for example, the technicians, accountants and engineers within the organization. The influencers mainly include the advisers who have the ability to influence the decision made by the deciders (Ayed Al-Allak 78). According to STC’s CM O, it is very difficult to identify influencers within an organization’s DMU. The Chief Marketing Officer further asserted that in some situations, an organization’s influencers may include the various categories of consultants such as the engineers. Alternatively, the influencers may include the deciders’ friends or golf partners. Despite the above categorization, members of the DMU are mutually exclusive. For example, the user may also play the role of an influencer while the gatekeeper may also act as the initiator. Considering the fact that members of the DMU are mainly organizational employees, they are more risk averse compared to individual customers. The risk-averse characteristic of the DMU members arises from the fact that they may lose their job if they make a wrong purchase decision. For example, the purchase decision may result in financial loss of the company. Additionally, making a wrong purchase decision may adversely affect the employees’ promotional opportunities (Blythe Zimmerman18). The company’s CMO asserted that STC is facing a challenge in its B2B marketing due to the complicated sales process. The firm’s sales personnel are required to convince a large number of individuals to close a deal. The large number of individuals involved in the purchasing process results in creation of obstacles which are hard to deal with. This is due to the fact that the sales personnel have to ensure that they connect and convert the various members within the DMU. One of the most important aspects associated with B2B marketing entails ensuring that the organization has an ability to influence their customers’ DMU. This arises from the fact that influencing the organizational DMU’s can contribute to development of a strong long-term relationship with organizational buyers. According to Blythe and Zimmerman (17), influencing the DMU can enable a firm to nurture repeat purchase behavior amongst the orga nizational customers. One of the ways through which an organization can influence its institutional customer relationship is by developing a personal relationship with members of the DMU. The customer environment In its operation, STC deals with different categories of business customers. Blythe and Zimmerman (21) define business customer as the individual who purchases products or services on behalf of a particular organization. The large number of business customers has played a critical role in the success of STC. The company’s customers can be categorized into four main groups. These include business and commercial customers, institutional organizations and reseller organizations. The business and commercial customers mainly include the users and aftermarket customers. With regard to users, STC supplies its telecommunication products and services to these customers so that they can improve their operational efficiency. For example, the firm provides telecommunication serv ices such as Data Services, Landline Services and Mobile Services to organizational customers so as to ensure that they have an effective communication network. Additionally, the products and services provided to this customer’s category are not for resale purposes. On the other hand, aftermarket customers include customers who are involved in activities associated with overhauling, repairing and maintaining of the products developed by another organization. This means that these customers are not directly involved in the original development of the product. In most cases, aftermarket customers include contractors who operate within the same industry as the main company. In its operation, STC markets its products and services to various contractors within the Saudi telecommunication industry. The telecommunication contractors within the Saudi Telecommunication industry are well established organizations. As a result, their purchase decision making is undertaken through a DMU. The objective of targeting this customer category is to influence them so that they can purchase the various components and supplies necessary for their operation from the organization. To achieve this, STC has to ensure that it influences the DMU. On the other hand, reseller organizations include the retailers and wholesalers. Wholesalers and retailers are some of the major reseller organizations that STC markets its products to. According to Ayed and Al-Allak (83), STC has different categories of wholesale customers. Some of these customers include Internet Service Providers, wireless service providers, content providers, regional carriers and operators and regional enterprises. In most cases, reseller customers stock products if they are sure that they will have a ready market. Reseller customers are not concerned with the technical characteristics of the product being supplied. However, to ensure that reseller organizations hold a particular company’s products, it is cri tical for the supplier to ensure that the reseller firms are confident that the final consumer will demand the product. Another category of STC’s customers includes the government. In most cases, STC is awarded contracts to provide telecommunication services to various government agencies and institutions. According to Blythe and Zimmerman (23), the decision making process and the government purchasing process are very strict. The purchasing process within government involves the tendering system. Product and service providers are required to bid for contracts. The lowest bidder is usually awarded the contract. Additionally, different parties are involved in the process of making a purchase decision. As a result, it is very important for suppliers to take into account special measures in order to successfully negotiate a deal. Considering the fact that the core objective of establishing business entities is to maximize profits, most suppliers consider the tendering system to be counterproductive. To influence the outcome of the tendering system, Blythe and Zimmerman (23) assert that it is important for organizations to proactively involve themselves in the tendering process before the winner is announced. One of the ways through which an organization can achieve this is by ensuring that the competing firms do not bid or place a bid that is too high. This arises from the fact that the probability of influencing the outcome of the tendering process is increased. Competitive and organizational environment According to Ayed and Al-Allak (80), there is a high growth potential for companies within the Saudi Arabian telecommunication industry. In an effort to exploit the presented market opportunity, firms within the industry are constantly improving their operational strategies. For example, telecommunication companies in Saudi Arabia are increasingly incorporating different expansion strategies in an effort to attain a high market share. Additionally, the fi rms are also reformulating their marketing strategies in an effort to enhance their competitive advantage (Ayed Al-Allak 82). In its operation, STC is facing a threat arising from an increment in the intensity of competition. Currently, the firm faces intense competition from three main companies which include Emirates Telecommunication Corporation, Orascom Telecom Holding and Qatar Telecom (Yahoo Finance para. 1). The firm is also facing threat of competition emanating from an increment in the number of new entrants. The new companies which might venture into the Saudi telecommunication industry may either be domestically or foreign based. Entry of new firms into the industry may result in reduction of STC’s market share. New entrants may also result in reduction in the company’s level of profitability. The intensity of competition within the Saudi telecommunication industry is also associated with the increment in the number of substitute products which have arisen from the high rate of technological innovation. The high rate of technological innovation has resulted in availability of a wide range of options for business consumers to select from. This presents a threat to STC with regard to its sales revenue. For example, if business consumers switch to mobile phone communication technology, STC’s sales revenue would be adversely affected. This is due to the fact that the company generates a significant proportion of its sales revenue from landline phones (Ayed Al-Allak 83). The Saudi telecommunication industry is characterized by moderate supplier bargaining power. The moderate supplier bargaining power arises from the fact that there are a large number of suppliers who supply various telecommunication products such as hardware, infrastructure parts and other supplies to customers. To attain a competitive advantage, suppliers within the Saudi telecommunication industry are committed to ensuring that the products are of a high quality (Ayed Al-Allak 78). The large number of suppliers within the Saudi telecommunication industry has culminated into an increment in the consumers’ bargaining power. The switching cost for firms within the telecommunication industry varies across customer segments. For example, residential customers have a relatively low switching cost. However, the switching cost is high for organizational/business customers. This is due to the fact that costly telecommunication infrastructure may be implemented (Ayed Al-Allak 82). To survive in the long term in such an environment, it is critical for firms within the Saudi telecommunication industry to ensure that they influence the consumers in their decision making process. This can only be possible if the firm has formulated comprehensive B2B marketing strategies which will enable the firm to have an influence on the various individuals within the organizations’ buying process. In its operation, STC management has ensured that its organizational environment is stable. The firm has attained this by integrating an effective organizational structure. Conclusion In their operation, businesses deal with a large number of customers. Some of these customers include the individual and institutional customers. To be successful in their operation, businesses are required to ensure that they incorporate effective operational strategies. One of the most important elements that businesses take into account relates to ensuring that effective marketing is undertaken. To improve their competitive edge with regard to marketing, most B2B firms have incorporated the concept of e-commerce. One of the ways through which these firms are attaining this is by automating their marketing activities, for example, by incorporating emerging marketing software. Additionally, B2B firms are also integrating the concept of social marketing in an effort to attract and retain a large number of customers. Despite this, the analysis provided abo ve has made it evident that B2B firms experience numerous challenges in their marketing activities. In order to develop a comprehensive understanding of the problems associated with B2B marketing within the Gulf region, the report has taken into account the Saudi Telecommunication Company. Additionally, the report has focused on one of the major B2B marketing problems which are associated with the organizational buying process. In their operation, buying decisions within businesses or organizations are made by the decision making unit which is composed of different individuals. To close as sales contract, B2B marketers are required to ensure that they influence the DMU. This is a challenging task because most of the members within the DMU are risk averse. Additionally, it is not easy to identify the DMU within a particular organization. The report also indicates that STC has diverse customer categories. To increase its sales revenue, it is imperative for STC to influence the decisio n making process of these customer groups. An analysis of the business environment reveals that the Saudi telecommunication industry is increasingly becoming competitive. Recommendation In its operation, STC should take into account the following recommendations. The firm’s management team should formulate effective B2B marketing strategies. The marketing strategies should enable the firm to survive in a business environment that is increasingly being characterized by intense competition. In the process of formulating its B2B marketing strategies, it is critical for STC to take into account the various B2B marketing challenges that the firms face today. This means that the firm should not only focus on the challenges associated with the buying process. To deal with the challenge arising from the growing number of individuals involved in the organization buying process, it is important for STC to identify the various parties involved in the decision making process. One of the ways through which the firm can attain this is by integrating the concept of direct marketing. Direct marketing will enable STC to develop a strong relationship with the various customer groups. The firm should also ensure that its relationship with the various customer groups is continuous. This will play a critical role in developing a high competitive edge with regard to influencing business customers in their decision making process. Works Cited Ayed, Shafi and Basheer Al-Allak. Saudi Telecommunication Company: Strategy  for sustainable competitive advantage. Tenaga: University of Malaysia, 2011. Print. Blythe, Jim and Alan Zimmerman. Business to business marketing management: A global perspective, London: Thomson Learning, 2005. Print. Yahoo Finance. Industry center: Wireless communications. 2012. Web. https://finance.yahoo.com/ This report on Industrial Marketing: Saudi Telecommunication Company was written and submitted by user Megan Tate to help you with your own studies. You are free to use it for research and reference purposes in order to write your own paper; however, you must cite it accordingly. You can donate your paper here.

How To Say Lets in Spanish

How To Say Let's in Spanish Spanish has two main ways of making suggestions or commands to a group that includes the person speaking. Both of them can be used as the equivalent of the English lets in a sentence such as Lets leave. Imperative Mood The most straightforward way is to use the first-person plural imperative mood, which takes the same form as the first-person plural form of the subjunctive mood. In regular -ar verbs, the ending is replaced by -emos, and in -er and -ir verbs, the ending is replaced by -amos: Bailemos un vals. Lets dance a waltz. Compremos una casa en Espaà ±a. Lets buy a house in Spain. Hagamos un trato. Lets make a deal. Tratemos de ser felices. Lets try to be happy. If youre using the imperative form of a reflexive verb, the -emos ending becomes -à ©monos, and the -amos ending becomes -monos. In other words, the -nos ending is added to the verb, but the -s is dropped before the pronoun: Levantà ©monos a las seis de la maà ±ana. Lets get up at 6 a.m. Lavà ©monos las manos. Lets wash our hands. Rimonos un ratito. Lets laugh a little bit. (Rà ©irse is an irregular verb.) In the negative form, however, the pronoun comes before the verb: No nos mejoremos. Lets not improve ourselves. Using Vamos A Probably more common than the imperative mood, and even easier to learn, is to use the first-person plural form of ir followed by a, i.e., vamos a, followed by the infinitive: Vamos a nadar. Lets go swimming. Vamos a casarnos. Lets get married. Vamos a estudiar. Lets study. Vamos a viajar a Italia. Lets go to Italy. You may note that vamos a infinitive can also mean we are going to infinitive, so the first sample sentence above could also mean We are going to swim. Indeed, ir a infinitive is a very common substitute for the future tense in Spanish. In the first-person plural, then, context will determine what is meant. It is not uncommon when meaning lets to replace vamos a with simply a. For example, a ver is a very common way of saying lets see. Another Meaning for Let Us When translating from English, do not confuse lets as a suggestion to the group with let us as a way of asking for permission. For example, one way you might say let us help you would be Permà ­tenos ayudarte, where the verb permitir is used in the third person (the person being addressed) rather than the first person (the people who want to help).

Personal statement Essay Example | Topics and Well Written Essays - 500 words - 2

Personal statement - Essay Example Through my Canadian experiences, and beyond I have acquired the ability to be able to suffer through the more difficult times and come out stronger and more determined as well. This has taught me independence and the learning skills necessary to overcome many adversities, which undoubtedly an abundant amount of foreign exchange college students must deal with if they are going to make it in their lives in a foreign land. Traveling to the United States had to be the scariest for me because I had heard so many stories about the country but was not sure if they were true. After I moved past my initial fears I soon devised ways to work past the obstacles that were in my path such as with language barriers and cultural disorientation, etc. However, after moving past the language barriers I found that I had a hard time trying to fit into what Americans considered to be the â€Å"norm† for the youth population in society. I definitely became rather defensive because I realized then that I was a minority and did not clearly fit in to the whole puzzle. Nevertheless, I have come to realize over time that a person’s attitude can make all the difference and that ethnicity is not necessarily what holds people back. A positive attitude and good communication skills are two of the most pertinent interpersonal skills that an individual needs to have in a country like America. This is due to the fact t hat I have come to learn with there being so many different ethnicities there has to be an open communication network to avoid misunderstandings and to get past the confusion of it all. This can be very difficult but again, with effort from both sides of the cultural boundaries it can be done. Perhaps if I had realized this earlier on one of my good friends would not have lost his life due to racial violence and stereotyping. However, even

Explain three (3) world arguments for birth control and two (2) world Essay - 2

Explain three (3) world arguments for birth control and two (2) world arguments against birth control - Essay Example The pills further prevent ectopic pregnancies due to the fact that they are able to suppress ovulation which makes them the most preferred contraceptive alternative for women especially those who are at the risk of having ectopic pregnancies which is a great threat to life (Sanger, 2013). The birth control methods reduces the risk of contracting ovarian cysts which is a fluid-filled growth developing in the ovary. This is possible because the pills prevent ovulation. The methods further prevent pelvic inflammation diseases which are caused by bacteria that infect the fallopian tubes as well as the uterus and can cause infertility under extreme conditions. They also reduce the spread of acne which cannot be cured by other forms of medications. Birth control methods such as the use of pills lead to blood clots or venous thromboembolism especially in the legs and lungs. Recent studies have indicated that the chances of blood clot are six times high in women who use oral contraceptives in comparison to nonusers. The use of pills may not require the use of other drugs such as antibiotics, anticonvulsants, antifungals as well as herbal medicines which can affect the amount of contraceptive hormones that the can be absorbed by the stomach and other metabolic processes. It has been established that women who use birth control pills have increased systolic as well as diastolic blood pressure hence they need to keenly monitor their blood pressure so that they do not exceed the expected limit. Closely linked to blood pressure problems is heart attack condition which arises due to birth control pills and is more prevalent among those women who smoke cigarettes. This is highly witnessed among women who are 35 years and above hence those who use birth control pills at this age bracket should not smoke as that will increase chances of developing

The Great Economic Depression Term Paper Example | Topics and Well Written Essays - 1250 words

The Great Economic Depression - Term Paper Example The Great Economic Depression Indeed, the stock market crashed, the economy eventually collapsed and the U.S was marred by a long spell of economic depression. This paper analyzes the major causes of the Great Depression, and the reasons why it lasted so long. The Great Economic Depression Introduction The Great depression of the 1930 is one of the darkest moments in the economic history of the United States. It was characterized by a crash of the stock market, collapse of the economy, which eventually escalated into a prolonged period of economic depression. The Great Depression caused enormous of hardships to millions of people and resulted to the collapse of a large fraction of the country’s banks, farms and businesses. Besides many other long-term causes which developed prior to the depression such as bank failures, decline in spending and the drought conditions, the stock market crash of October 1929 is perceived as the immediate cause of the Great Depression. The crash of the stock market The crash o f the stock market in October 1929 has been believed to be the major spark that marked the onset of the Great Depression. Initially, the stock market thrived through the 1920’s. The more it grew, the more people invested their money into it. Nonetheless, on Tuesday October 29, 1929, otherwise known as the Black Tuesday, the stock market crashed (Bernanke 16). Within two month after the crash of the stock market, stockholders had lost over $40 billion.... Bank failures The other major factor that contributed to the onset of Great Depression is the bank failures. Prior to the depression, many banks, especially in the rural areas had overextended their loans to farmers, most of who could not repay. Conversely, most big banks had overextended their credit to foreign countries in the aftermath of the First World War. As times became tougher, most of the banks halted their lending and many debtors defaulted on their outstanding loans. Consequently, many banks went bankrupt. Be that as it may, more than 9000 banks in the United States had collapsed by the end of the 1930’s (McConnell, Brue and Flynn 28). As a result many people lost their savings as most of the bank deposits were uninsured. As the Great Depression continued to hit even harder, more and more banks were forced out of business due to bankruptcy. In addition, the few surviving banks were worried and became more concerned with their ability to continue running. As a resul t, most of them became reluctant to offer new loans. This aggravated the situation as it led to less expenditure. Thus, the increased closing of banks and the panics by the surviving banks almost completely shut down the banking system of the United States. Decline in spending Scores of economists have attributed the onset of the Great Depression to a decline in spending. This is based on huge decline in output and prices during the Great Depression. An adverse demand shock leads to a reduction in aggregate demand for goods and services at a given price. As a result of the stock market crash and increased fears regarding the future economic problems, many people stopped purchasing goods and services. This

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Cognitive Behavior Therapy: Palliative Care Individuals that have been deemed by their medical team to have serious diseases that are resistant, nonresponsive or have failed reasonable treatments are often referred to specialists for comfort measures only. According to the World Health Organization, Palliative care is the active total care of patients whose disease is not responsive to curative treatment. Control of pain, of other symptoms, and of psychological, social and spiritual problems is paramount. The goal of palliative care is the achievement of the best possible quality of life for patients and their families (WHO, 1990). The National Center for Health Statistics (1996) estimated that 20% of all deaths and 30% of the deaths of elderly individuals occurred in extended care facilities. Extended care facilities are but one place where end-of-life issues are a common fact of daily life. However, regardless of the setting, each individual faces the end of life with his or her own view of life, death and the dying process. The estimated number of patients in palliative care varies due to the difficulty in capturing the actual numbers from hospitals, primary care practitioners, families and emergency rooms. The estimate of patients receiving the Medicare benefit for hospice and palliative care is approximately  ½ million, and it is estimated that, in 2000, approximately 20% of patients dying in the United States received hospice or palliative care services. It should be noted that although many, if not most, individuals in hospice/palliative care settings are age 85 or older, this level of care is not limited to older adults. Motor vehicle accidents, post-traumatic incidents, drug overdoses and other physiologically devastating disorders may result in permanent damage to the younger body as well as the older body. Mortality rates at a young age for those with mental illnesses is decreasing therefore it is estimated that by 2030 there will be 15 million individuals with mental illness residing in long term care facilities (SAMHSA, 2004). This chapter will focus on the reduction or modification of autonomic, psychiatric, or sensory symptom experience of these individuals through use of cognitive behavioral therapy. Cognitive behavior therapy (CBT) uses a structured and collaborative approach while helping individuals to recognize, evaluate and restructure the relationships between their thoughts, feelings and behaviors. Through a process of targeted interventions, the therapist assists individuals to identify, monitor and cognitively restructure the dysfunctional thoughts and/or to modify behaviors that are maladaptive, useless or even harmful (Beck, 1976; Turk, Meichenbaum, Genest, 1987; Freeman Freeman, 2005). CBT includes a range of both cognitive and behavioral techniques such as relaxation, guided imagery/visualization, biofeedback, behavioral experiments, guided discovery, stress management, training in pain or stress management strategies, and cognitive restructuring for dysfunctional thinking and many others . Although there is a paucity of research on the use of CBT in palliative care settings, CBT is effective for many of the psychological issues that are prevalent in palliative care including, depression, anxiety, pain management, and insomnia. The purpose of this chapter is to provide an overview on the use of CBT for assessment and treatment of psychological distress in palliative care settings. Assessment of Emotional Functioning in Palliative Care There are many challenges to the assessment of mood disorders in palliative care settings. An initial challenge is the myth that psychological distress is a normal reaction to end of life. Despite expectations, most individuals in palliative care settings do not have symptoms of anxiety, depression or dementia. Many individuals arrive at this stage of their lives or illnesses with a sense of calm resignation, if not expectations of relief and of going home to God, heaven or family members waiting for them in the hereafter. Therefore those individuals that are experiencing symptoms that require intervention may achieve significant benefit from the interventions. The most common presentations are those of depression, anxiety, pain management failures with exhaustion and anguish, and sleep disorders. The healthcare provider requires tools necessary to differentiate major depression from anger, sadness, and anxiety associated with the symptoms of an untreatable or chronic illness. Assessment of preparatory grief and depression. Another obstacle to the assessment process is simply overcoming the challenges of differentiating symptoms from normal grief of the illness itself. Differentiating between preparatory grief and depression is a key component to the proper assessment of depression in palliative care and has important treatment implications. Preparatory grief can be defined as what an individual must undergo in order to prepare himself for his final separation from this world (Kubler-Ross, 1997). Symptoms of preparatory grief include 1) Mood waxes and wanes with time, 2) Normal self-esteem, 3) Occasional fleeting thoughts of suicide, and 4) Worries about separations from loved ones (Periyakoil and Hallenbeck, 2002). Preparatory grief is a normal, not pathological, life cycle event (Axtell, 2008; Periyakoil and Hallenbeck, 2002). Major depression is defined as five or more of the following symptoms during the same two week period: depressed mood, marked diminish in pleasure, weight loss or gain, insomnia or hypersomnia, psychomotor agitation/retardation, fatigue/loss of energy, feelings of worthlessness or inappropriate guilt, lack of concentration/indecisiveness, and recurrent thoughts of death and suicidal thoughts or plans (APA, 1994). Table 1 provides a symptom list. The list is not intended to be all inclusive however it gives the clinician an overall view of symptoms that may be observed in the individual dealing with depression in a palliative care setting. Although some symptoms of grief and depression overlap, there are ways to distinguish between grief and depression. Table 2 summarizes the ways to differentiate symptoms of grief versus depression according to temporal variation, self-image, hope, anheonia, response to support, and active desire for an early death (Periyakoil Hallenbeck, 2002). The first step to proper recognition of depression involves the identification of possible risk factors (Wilson, Chochinov, de Faye, and Breitbart, 2000). Certain demographic characteristics, such as younger age, poor social support, limited financial resources and family history of a mood disorder, as well as a personal history of previous mood disorders place individuals at a greater risk for developing depression or anxiety in end of life situations. Risk for developing a mood disorder also is elevated with certain types of diagnoses, including pancreatic cancer and brain tumors, and particular medical interventions such as radiation therapy (Hirschfeld, 2000). Symptoms of the illness, including poor symptom control, physical disability, and malnutrition also place individuals at higher risk. The second step to the proper assessment of depression includes utilization of appropriate assessment tools. Many times it is the degree and persistence of symptoms that provide the information necessary when considering major depression. Major depression, which is estimated to occur in fewer than 25% of patients in end of life care, may be best screened with targeted questions such as: How much of the time do you feel depressed? In addition, for those individuals that have a difficult time describing their symptoms or history, asking family members to provide information about a previous history of depression or a family history can be very useful. Although studies validating assessment tools vary greatly, many of the self-report measures have been shown to be effective in palliative care patients. The most common utilized tools in palliative care settings frequently omit physical symptoms of depression. Many symptoms of depression overlap with the terminal disease process (Noorani Montagnini, 2007). Examples of self-report measures that omit somatic symptoms include the Beck Depression Inventory II (Beck, Steer, and Brown, 1996), Hospital Anxiety and Depression Inventory (Zigmond Snaith, 1983), and the Geriatric Depression Scale (Yesavage et al., 1983). The Hayes and Lohse Non-Verbal Depression Scale (Hayes, Lohse, and Bernstein, 1991) is a third party observational measure that can be completed by staff, family, or friends to assist with the diagnostic process. Terminally Ill Grief or Depression Scale (TIGDS), comprising of grief and depression subscales, is the first self-report measure designed and validated to differenti ate between preparatory grief and depression in adult inpatients (Periyakoil et al., 2005). Assessment of anxiety. The symptoms of anxiety may differ in individuals in the palliative care environment. Many times symptoms of anxiety have a physiologic component. For example in those individuals with chronic obstructive pulmonary diseases difficulty breathing, low oxygen levels and overall compromised respiratory function causes air hunger which is experienced as anxiety and even panic. Table 3 lists some of the common anxiety symptoms seen in this population. Family members are often at a loss as to what they can do to assist their loved one that is experiencing anxiety, and especially fearfulness. It is often useful to provide significant others with a checklist of items that are important to report to the healthcare provider. Involving the family has the benefit of giving them a structured guide for response which reduces their own anxiety in response to the patient. In addition the patient may relax more knowing that a family member is involved with their care in an approved, helpful manner. An example of a list of items for family members to watch for and report to the healthcare team is listed in Appendix 1. Cognitive Behavioral Interventions in Palliative Care Psychological intervention in the palliative care setting includes those aspects of treatment that would provide relief from emotional distress while an individual is dying. Often this time period includes depression, anxiety, grief and organic brain dysfunctions such as dementia and/or cerebral vascular diseases. Individuals and their family members are both considered the patient during these times. Many of these individuals are suffering from chronic, unremitting pain conditions which negatively impact their emotional health. Treatments for pain and chronic conditions also play a part in the individuals mental status. The use of Cognitive Behavior Therapy (CBT) is extremely useful for these individuals. Cognitive Behavioral Therapy has the strongest empirical support of any psychological intervention for the management of symptoms typically seen in a palliative care setting. The most common presentations of psychological distress in the dying patient include anxiety, depression, hopelessness, guilt over perceived life failures and remorse. Persistence of these thoughts and feelings interfere with functioning, makes the person generally miserable as well as those around them and can severely affect his/her quality of life. Medical treatments, such as antidepressants, anxiolytics and cholinesterase inhibitors, exist for these problems however supportive psychotherapy such as relaxation training, imagery, distraction, skill training, and negative thought restructuring improves the possibility of remission. CBT can also improve the symptoms of spiritual distress that may include feelings of disappointment, guilt, loss of hope, remorse, and loss of identity. CBT for depression. Symptoms of depression are common in end of life care. It can be one of the most distressing groups of symptoms an individual can experience and may interfere significantly with daily tasks of life. Some experts have estimated that up to 75% of patients with terminal illnesses experience symptoms of depression. Amelioration of some of the symptoms of depression can increase the amount of pleasure and meaning in life, as well as add hope and peace. Treatment for depression can reduce the experience of physical pain as well as general misery and suffering. In addition, reduction of the symptoms of depression may improve the treatment of coexisting illnesses more effective. Most importantly, given that one of the most serious symptoms of depression is suicidal ideation, it makes sense to treat depression in order to prevent successful suicidal outcomes. There is a paucity of literature in the area of the use of CBT with depression in Palliative Care, due to the high attrition rate resulting from physical morbidity and mortality (Moorey et al., 2009). Therefore, these factors pose significant barriers to conducting randomized clinical trials in Palliative Care to address these components. The following is a review of the sparse literature on CBT in Palliative Care with depression. In an attempt to address this problem, Moorey et al., conducted a cluster randomized controlled trial in order to determine if it was possible to teach nurses CBT techniques in order to reduce anxiety and depression symptoms in patients with advanced cancer (2009). Eight nurses were trained in CBT by attending several 1- and 2-day workshops and then were rated on the Cognitive Therapy First Aid Rating Scale (CTFARS) for CBT competence. Seven nurses did not receive training and served in the control group. A total of 80 home care patients entered the trial; however most of these participants were excluded due to being too ill to participate. A total of 16 patients were in the CBT group and 18 patients were in the control group. The participants received home care nursing visits in which assessments were conducted at 6-, 10-, and 16-week intervals. The individuals who received CBT reported lower anxiety scores over time, but no effect of the training was found regarding depression. It was noted that both groups experienced lower rates of depression over the course of the study. The authors noted the heterogeneity of the sample and the high attrition rate due to physical morbidity and mortality presented several barriers to conducting the study and may have played in a role in the findings (Moorey et al., 2009). Cole and Vaughan (2005), in their review on the feasibility of using CBT for depression associated with Parkinsons disease (PD), found that it is a promising option. The authors noted that depressed inviduals with comorbid PD experienced a significant reduction in depressive symptoms and negative cognitions. In addition they experienced an increased perception of social support over the course of treatment (Cole Vaughan, 2005). The recommended course of action for individuals in this setting included: stress management training, relaxation training, behavioral modification techniques for sleep hygiene, and cognitive restructuring. Modification of life stressors contributing to depressed mood should be identified and plans made to minimize stress and maximize quality of life. The use of thought restructuring is recommended in order to maintain a sense of purpose and fulfillment through meaningful activity and to adjust expectations of self and others. Individuals are also encouraged to return to previously enjoyed activities in order to maximize feelings of pleasure and happiness. Through systematic defocusing on physical conditions the person is able to experience more pleasant activities, which are also encouraged. Similarly, Dobkin et al, conducted a study which explored the effects of modified CBT for depressed patients with PD, in conjunction with a separate social support intervention for caregivers (2007). The patients received 10-14 sessions of modified CBT, while caregivers attended three to four separate psychoeducational classes. The modified CBT sessions were comprised of the same components of the previous Cole Vaughan, (2005) study, such as, stress management training, behavioral modification techniques for sleep hygiene, relaxation training, cognitive restructuring, modification of life stressors, and increasing engagement in pleasurable activities. The classes were targeted at providing caregivers with ways to respond to the patients negative thoughts and beliefs, as well as, strategies to offer appropriate support. As in the previous study, the modified CBT sessions were comprised of training in stress management, behavioral modification, sleep hygiene, relaxation techniques, an d cognitive restructuring. Participants reported a significant reduction in their depressive symptoms and cognitions and increased perception of social support at treatment termination and one-month post-treatment. CBT for anxiety. Along with depression, anxiety is a common mental health problem in palliative care settings and also appears to be alleviated with CBT interventions. In a small feasibility study examining the use of cognitive behavioral therapy techniques for mild to moderate anxiety and depression in hospice patients, four sessions of CBT techniques was found to significantly reduce anxiety and depression in a majority of patients (Anderson, Watson, Davidson, and Davidson, 2008). Overall, participants in the study found the CBT techniques acceptable, helpful, and qualitatively reported improved mood. A significant reduction in anxiety symptoms also was seen in a randomized controlled trial of CBT administered by home care nurses in patients with advanced cancer (Moorey et al., 2009). CBT techniques are particularly effective to assist with the management of anxiety related to breathing difficulties commonly seen with pulmonary diseases, such as chronic obstructive pulmonary disease (COPD). In a group of individuals with COPD, six sessions of guided imagery, a CBT relaxation technique, was found to significantly increase the partial percentage of oxygen saturation, which is a physiological indicator signaling more effective breathing (Louie, 2004). In another study, as little as 2 hours of CBT group therapy yielded a decrease in depression and anxiety among older patients with COPD, but there was no change in physical functioning (Kunik et al., 2001). CBT for pain management. Pain is not simply a biological response to unpleasant stimuli. It is a complex phenomenon that includes biological, psychological, behavioral and social factors that interact in complex ways to influence the pain experience. Some of the factors that can influence a persons experience of pain include: a) previous pain experiences, b) biologic and genetic predispositions, c) mood disorders such as anxiety and depression d) their beliefs about pain, e) fear about the pain experience, f) their individual pain threshold and pain tolerance level, and f) their skill with coping methods. Cognitive-Behavioral Therapy has the most empirical support for the management of chronic pain, especially when used as part of an interdisciplinary treatment approach to manage pain symptoms (Turk, Swanson, Tunks, 2008). Cognitive behavioral techniques can be used independently to assist with pain management or integrated into a comprehensive cognitive-behavioral case conceptualization framework to address pain (Turk, Swanson, Tunks, 2008). The three components to CBT for pain management are 1) Education and rationale for the use of CBT, 2) Coping skills training, and 3) Application and maintenance of CBT skills (Keefe, 1996). Useful behavioral interventions to assist with pain management include goal setting, relaxation strategies, such as deep breathing and guided imagery, and activities scheduling. Cognitive interventions would include increasing problem-solving skills and addressing an individuals maladaptive thoughts related to pain management. Examples of maladaptive thoughts include: 1) Ive tried every pain management intervention with no success, 2) I cannot do any of the things that I used to do, 3) nothing will help manage my pain, and 4) no one can help me feel better. CBT for pain manage ment has demonstrated efficacy in various diagnoses often addressed in palliative care. CBT has been found to be efficacious in the management of cancer-related pain in single studies (Syrjala, Donaldson, Davis, et al., 1995) as well as in systematic reviews (Abernethy, Keefe, McCrory, Scipio, Matchar, 2006). CBT for sleep hygeine. Insomnia, sleep duration and quality are major concerns for people with pain disorders such as osteoarthritis (Vitiello, 2009). Approximately 60 percent of individuals with chronic pain disorders report frequent nighttime awakening due to pain during the night. Disrupted sleep patterns exacerbate chronic pain intensity and experience which in turn causes more disturbance of the sleep/wake cycle. Successful treatment of interrupted sleep may reduce the pain experience as well as improve the overall quality of life for these individuals. Psychotherapeutic techniques that target sleep disturbances are easily incorporated within behavioral and cognitive management of other co-occurring disorders as well. Sleep disorders are common in patients who suffer from Parkinsons disease (PD) (Stocchi, Barbato, Nordera, Berardelli and Ruggieri, (1998). Specifically, insomnia, nightmares, REM sleep behavior disorder, sleep attacks, sleep apnea syndrome, excessive daytime sleepiness, and periodic limb movement in sleep result from changes in sleep structure, movement disturbances in sleep, disturbances in neurotransmission and medications. Individuals who are sleep deprived are at risk to develop infections, cardiovascular disease, hypertension, diabetes, depression, and require increased time to recover from stress (Schutte-Rodin, Broch, Buysse, Dorsey, and Sateia, 2008). CBT improves sleep by addressing unhelpful beliefs regarding sleep and misperceptions about the amount of sleep that one obtains. Many misperceive the amount of time they are actually asleep. People who suffer from insomnia actually sleep more than they are aware of because they are only attentive of when they are awake. Furthe rmore, many people believe they require 8 hours of sleep in order to be able to function during the day and any amount of sleep that is less is insufficient and will result in reduced ability to function during the day. Therefore, these beliefs and misperceptions can increase ones stress level about sleep and a stress response may result when one thinks about going to sleep. Clearly, a heightened stress response is not conducive to sleeping. CBT increases ones control over their unhelpful and inaccurate beliefs and enables them to replace them with more helpful and accurate beliefs (Whitworth, Crownover, and Nichols, 2007). CBT also addresses the behavioral components of ones sleep routine or patterns that interfere with ones ability to obtain restful sleep. Exercising, smoking, or drinking caffeinated drinks just prior to bedtime can interfere with ones sleep. All of these activities are stimulants that energize the body. Also, not having a bedtime routine, a regular sleep-wake pattern, or taking naps may interfere with ones ability to get restful sleep. Increasing ones sleep hygiene by developing positive habits that influence sleep such as, having a bedtime routine to prepare ones mind and body for sleep, regular exercise several hours before one intends to prepare for sleep, and avoiding coffee, alcohol, and smoking in the evening, as well as, increasing activities that produce relaxation (e.g., taking a hot bath one to two hours before going to bed, meditation, deep breathing, or muscle relaxation) can increase the likelihood of obtaining restful sleep. Another behavioral strategy utilized in CBT i s sleep restriction. This technique attempts to match ones actual sleep requirement with the amount of time one spends in his/her bed. The theory behind this approach is that reducing the amount of time spent in bed without sleep will increase ones desire to sleep (Harvey, Ree, Sharpley, Stinson, and Clark, 2007). Results of a study by Vitiello showed that treatment improves both immediate and long-term self-reported sleep and pain in older patients with osteoarthritis and comorbid insomnia without directly addressing pain control (2009). This study included 23 patients with a mean age of 69 years were randomly assigned to CBT, while 28 patients with a mean age of 66.5 years were assigned to a stress management and wellness control group. Participants in the control group reported no significant improvements in any measure while Individuals treated with CBT reported significantly decreased sleep latency (onset of sleep) by an average of 16.9 minutes and 11 minutes a year after treatment. Interruptions in sleep after sleep onset decreased from an average of 47 minutes initially to an average of 21 minutes after one year. Pain symptoms improved by 9.7 points initially to 4.7 points. Sleep efficacy (how rested does the person feel upon awakening) initially increased by 13 percent and 8 percent a year after treatment. The improvements remained robust in 19 of 23 individuals at a one-year follow-up visit. Furthermore, while many older adults experience insomnia, it is reported that up to two-thirds of those who experience these symptoms have limited knowledge regarding available treatment options. Sivertsen (2006), conducted a randomized controlled trial to compare the efficacy of non-benzodiazepine sleep medications with CBT. This study included 46 patients with a mean age of 60.8 years who were diagnosed with chronic primary insomnia. Participants were randomly assigned to either the CBT intervention (information on sleep hygiene, sleep restriction, stimulus control, cognitive therapy, and progressive relaxation), sleep medication (7.5 mg zopiclone each night), or placebo medication. Treatment lasted 6 weeks, and the CBT intervention and sleep medication treatments were followed up at 6 months. Data regarding total wake time, total sleep time, sleep efficiency, and slow-wave sleep was collected utilizing sleep diaries, and polysomnography (PSG; monitors physiological activity during sleep). Results revealed that total time spent awake improved significantly more for those in the CBT group compared to the placebo group at 6 weeks and the zopiclone group at both 6 weeks and 6 months. In comparison, the zopiclone group did not reveal significant results from the placebo group (Sivertsen, 2006). The CBT group experienced a 52 percent reduction in total wake time at 6 weeks compared with 4 percent and 16 percent in the zopiclone and placebo groups respectively. A statistically and clinically significant finding was that participants receiving CBT improved their PSG-registered sleep efficiency by 9 percent at posttreatment, opposed to a decline of 1 percent in the zopiclone group. Total sleep time increased significantly between 6 weeks and 6 months for the CBT group. The zopiclone group showed improvements at 6 weeks and maintained these improvements at 6 months, but did not show further improvements. The CBT group showed significant improvements compared to the zo piclone group in total wake time, sleep efficiency, and slow-wave sleep; total sleep was the only area that did not yield a significant difference (Sivertsen, 2006). ADAPTING CBT TO THE PALLIATIVE CARE SETTING Overview of CBT in Palliative Care Cognitive-behavioral therapy is effective for many of common mental health issues seen in palliative care and often augments the success of pharmacological interventions. In addition to the individual with the terminal illness, their family members, as well as multiple health providers are considered integral members to the success of the collaborative relationship. Use of a CBT case conceptualization framework and various components offer flexibility, which makes the CBT approach feasible to implement within a palliative care setting. The following section provides an overview of the components of cognitive-behavioral therapy and necessary adaptations to palliative care settings. Collaborative Relationship As mentioned in previous chapters in this book, a collaborative relationship is a core component of an effective cognitive-behavioral intervention. In a palliative care setting, the collaborative relationship often involves more than just the client and the therapist. The interdisciplinary treatment team works with the individual to develop an individualized treatment plan that is central to the case conceptualization and goal setting of CBT. A variety of disciplines, such as nursing and social work, use CBT techniques in palliative care settings. Individuals receiving palliative care often need assistance with CBT interventions as their illness progresses. Individuals receiving palliative care often need assistance from the treatment team with practicing skills, such as relaxation techniques, and adapting CBT interventions as goals of care change. Some individuals in the Palliative Care setting may not be facing death in the near future, and if they are facing impending death, they may not be aware of it. In these cases the primary patient may be the family member or significant other. It is also common practice for most individuals to seek help for mental health problems from their family practitioner even though the typical family practitioner has very little training in psychiatric/mental health assessment, diagnosis and treatment. In cases where the family is relying on an under-trained health care provider it may be incumbent upon the mental health provider to negotiate the gap between family and medical care. Case Conceptualization and Goal Setting Therapy with the dying person should begin with having the person identify, explore and determine outcome goals regarding the issues at hand. Similarly to the primary care setting, case conceptualization and goal setting need to occur almost immediately. The therapist uses the Socratic Dialogue to explore the persons concerns and worries. This gives the individual more of a sense of control over what will be happening in the therapy session. Once this sense of control is established it becomes easier to explore other, more emotion laden topics. Goals should be small, obtainable and proximal to the session to be most effective. For example, Mrs. Jones I will be back to see you tomorrow. One of the things you have decided to practice is your deep breathing at least twice tonight and again in the morning. When I return I will check with you to see how you are doing with the practice. In palliative care setting, it may be necessary to discuss how other people involved in care can assist with reaching goals. For example, nurses might remind individuals to practice relaxation strategies during wakeful periods, as well as talk an individual through the relaxation technique when experiencing a high level of pain. Behavioral Interventions Pleasant Events Scheduling. Activities scheduling is a useful intervention to assist with mood disorders, pain management, and sleep hygiene issues seen in a palliative care setting. Engaging in pleasant events distracts an individual from negative thoughts and provides experimental evidence to support more adaptive thinking styles. Often times in palliative care the first barrier to overcome is identifying pleasant events that can occur in a palliative care setting due to health limitations. Pleasant events need to be person-centered, meaningful, and feasible activities that can be built into a daily routine. Meaningful pleasant events can be identified through both clinical interview and self-report methods. Clinical interview queries should include taking a history of an individuals daily schedule and identify activities the individual enjoyed engaging in on a routine basis prior to their illness. From the generated list of previously enjoyed pleasant events it needs to be determined which activities the individual can continue to enga

Emily Brontes Wuthering Heights - Class Struggles :: Wuthering Heights Essays

Wuthering Heights   - Class Struggles   Conflict is a basic foundation for Emily Bronte's Wuthering Heights. Much of this conflict results from a distinct division of classes and is portrayed through such ways as personal relationships, appearance of characters, and even the setting. The division of classes is based on cultural, economic, and social differences, and it greatly affects the general behavior and actions of each character. The setting of the story at Wuthering Heights and Thrushcross Grange provides a clear example of social contrast. While the Heights is depicted as simply typical and "domestic," the Grange is described as a "scene of unprecedented richness" (80). Each house is associated with behavior fitting the description. For example, when Catherine is taken into the Grange, she experiences drastic changes, thus going from a "savage" to a "lady" (80). While at this house, she rises in status, learns manners, and receives great privileges such as not having to work. Heathcliff, on the other hand, learns to classify himself as a member of the lower class, as he does not possess the qualities of those at the Grange. The critical essay explains a main point in Wuthering Heights, Catherine's decision to marry Edgar Linton rather than Heathcliff, and this decision widens the gap between social classes. Edgar Linton is a wealthy man of high status, and Heathcliff is poor and possesses no assets. Catherine does not consider personal feelings, but instead, she focuses on her outward appearance to society. "Edgar Linton will be rich and I shall like to be the greatest woman of the neighborhood whereas if Heathcliff and I married, we should be beggars (81). It is obvious that wealth justifies social class, and Catherine strives to achieve high status. The struggle between social classes roughly resembles a real-life conflict during this time. The book was published during the Industrial Revolution, a time of great economic change in which laborers fought for fair conditions in the workplace, and employers fought to defend themselves. People formed groups to work for their own benefit, thus, causing the separation of classes.

It Is Much Better to Die with Dignity Than to Live with Pain Essay

I believe to die with dignity is better than to live with pain, because of euthanasia, seppuku, and organ donation. Euthanasia is from the Greek word which means â€Å"good death†. It refers to end someone’s life without pain and agony. Seppuku is a form of Japanese convention suicide of honour, it is a way of dying with dignity. Organ donation is after the death of terminally ill people to donate their organs to those in need. To begin with euthanasia, euthanasia is a different way of die with dignity. In present-day society, it is considered by a vast majority of the population â€Å"right† when it serves human dignity, or a larger cause. (â€Å"Euthanasia Essay – Right to Die With Dignity†,n. d. ). Euthanasia is responsible for the patient, family responsibility, socially responsible, sensible, rather than immoral. For example, people with senile dementia can’t do anything. Even how they feel brings too much pressure to their family. Life like this, they can’t feel any happiness. Why can’t choose die with dignity? Secondly, it’s a prize of death which literally means† stomach cutting†is a particularly painful method of self-destruction, and prior to the emergence of the samurai as a professional warrior class, was totally foreign to the Japanese( â€Å"Seppuku – Ritual†,n. d. ). To the samurai, seppuku is not only a way to die, it stands for honour, courage, loyalty, and moral character. This is a way to die with dignity, although they were defeated. They don’t want to live with humiliation, so they rather prefer to die. Living in society is not just sleeping,eating,playing. This kind of thing, is a way to give expression to personal value. Further more, organ donation is very sacred way for a person to die. If they live with only pain and there is no way to save them, why they can’t choose medically assisted dying? Increasing number of people choose donate their organs after their death in present-day society. This is a helpful way for others who needed it. To some of people who accept donaor’s organs they can survive. According to the U. S. government, 77 people receive transplanted organs each day. That’s the good news. The bad news is that 19 people in the United States die each day waiting for an organ that never becomes available. Trisha(2011) Organ donation is not only an end of life decision, it can be used to help someone else live longer. On the other hand, organ donation isn’t legal in some of any other countries. There are some poor people or people who need money, they like to donate there blood, kidney, liver to hospital, then they can get substantial revenues. This is not good for people’s health, they can’t for money to organ donation. Organ donation is only for people who will be die, people should respect organs, rather than to make money then they only have to donate their organs. For government, they should control it in a better way. In conclusion, one person if he can’t do the best then choose seppuku, it not reflect he has failure. It is a other way to die with honor. One person if he rather chooses to be medically assisted dying in order to help others. Stand on a good chance, his death can rescue any other patients. One person if he live with only pain, why he can’t choose die with dignity? Life is only left pain, death for them is a better way. Death is not to end of someone’s life, it’s better to die with dignity rather than live with pain.

Hemp - The Truth About The Earths Greatest Plant

Hemp - The Truth About The Earths Greatest Plant Persuasive Essay on the benifits of hemp Exclellent - A-In a perfect world there would be a product that could serve as a fuel source, a food source, a paper source, a textile source, and this product would be easy to produce in any of its forms. Believe it or not such a product does exist; it is the plant known as hemp. No tree or plant species on earth has the commercial, economic, and environmental potential of hemp. Over 30,000 known products can be manufactured from hemp.Hemp was a common crop grown in the U.S. until 1937 when it was unjustly banned. A common misconception about hemp is that it was banned because it was a widely abused, harmful drug. Hemp was banned because it was a competitive threat to the wood industry. Corporations that profited from the demise of hemp spread rumors that marijuana was a major drug problem, which it was not at the time.English: Cultivation of industrial hemp for fiber ...They also propagated a campaign that it was a drug that induced uncontro llable violence, another complete falsehood.Hemp is the plant scientifically known as cannabis sativa. It is referred to as hemp when it is grown for its fibers, stem, and seeds. Its leaves and flowers produce the drugs marijuana and hashish. However, sterile breeds of the plant are still illegal to grow in the U.S. Literally millions of wild hemp plants grow throughout the entire Midwest today. Wild hemp, like hemp used for industry purposes, is useless as an intoxicant. Yet U.S. drug law states that one acre of this can result in the owner being sentenced to death. The death penalty exists for growing one acre of perfectly harmless, non-intoxicating weeds!Hemp can produce any product that paper can produce. The difference is that one acre of hemp...

Do You Make Any Money Writing

Do You Make Any Money Writing If you havent been asked this question, you will. Family, especially, are noted for asking if the time you invest in your work is worth the money derived from it. Its as if you are choosing to make what you do. Its as if you are too stupid to walk away when its the last thing you want to do. So, lets empower you a bit. The next time someone brings this question up, turn it around. Ask what they make in their job. Then ask if its the best they can make. Ask if they feel shortchanged. And when they say they deserve to make more, ask them why they arent hunting for another job. Then ask if the time they spend on their job is worth the money derived from it. Why are they working that job if they arent being compensated properly? Chances are, theyll tell you they have no choice. They need the work. They need the money. They hope to make more. They havent been able to find other work. Theyd leave if they could. Whatever the excuse, they will say the last thing they can do is quit. So, chances are theyll also add that they sure wish they could leave because they hate their situation, hate the boss, hate the grind. How do I know? Because 80 percent of people in the world hate their job. Thats when you say that you dont make what youd like to make either, but heaven forbid you have to quit because you love it so much. As a matter of fact, you are thrilled to be doing something you intensely enjoy, and it helps compensate for not making more money. On those days you feel you havent been paid enough, you still smile because thank goodness you are working in a profession you adore. That alone makes it all worthwhile. And then you add . . . you hope you never have to retire from it. Thatll shut them up.

Greek City-States Research Paper Example | Topics and Well Written Essays - 2500 words

Greek City-States - Research Paper Example The size of the city states varied. While some consisted of few square miles, there are some consisting of over 100 square miles. The large city states formed through the consolidation of several cities. For example, the territory of Attica which earlier had 12 city-states became a single city state of Athens. By fifth century BC, it had a population of 250000. But most city states had population of few thousands only. The word politics is derived from the Greek word Polis. For the Greeks, the polis was not only a political institution, but it was a community of persons in which all political, economic, social, cultural and religious activities are focused (Spielvogel). The people in the city state consisted of citizens with political rights, citizens without political rights and non citizens. In the city state, women and children had no political rights. Slaves were not considered as citizens. All citizens of the polis had rights and responsibilities. According to Aristotle, the fat her of Political Science, every citizen must consider himself as belonging to the state. He emphasised on the unity of the people and believed that the state should take the initiative to direct the life of the community. This patriotism however brought distrust among the various city states that ultimate resulted in its ruin. In fact, Greece was not a politically united country. There was no central government in ancient Greece. It mainly denotes the geographical location only (Ancient Greek City-States ). War was an integral part of Greek way of life. According to the great Greek philosopher Plato, war exists by nature between every Greek city state. The tradition of warfare developed by Greeks became part of western civilisation. They possessed excellent weapons and made use of technological advancements. A large number of citizens were solders. They were interested in discipline and receiving training. This gave the Greek army an edge over the opponents’ larger armies. Th ey had a willingness to engage the enemy directly and thus the battle ends quickly with fewer casualties. They also demonstrated the effectiveness of heavy infantry. Colonisation Another major development during 750 BC and 550 BC was the expansion of Greece and growth of trade. Over population, hunger, poverty, growth of trade etc. forced many Greeks to leave their homeland and settle in distant parts. Most of them settled inn fertile agricultural lad taken from native population. Each colony was established as a polis and was independent of the mother polis (metropolis). The Greek settlements in Western part of Mediterranean included cities of Tarentum (Taranto) and Neapolis (Naples). Many Greek communities established in Italy who were later called Magna Graecia by the Romans. Syracuse, another city found by the Corinth was important. Greeks also established in southern France, Northern Africa and Western Egypt. The Greeks also established on the banks of black sea, most important being Byzantium. By establishing a trading post in Egypt, Greeks also got access to the culture and goods from the East. Results of colonisation Greek settlements in different places resulted in spreading Greek culture throughout Mediterranean region. The Romans had first contacts with Greece through settlements in south Italy. It also helped in developing a Greek identity. The Greek communities before the 8 century had isolated life. When they went abroad and confronted people

Comparing Consumer and Organizational Buyer Behaviour in the UK Essay

Comparing Consumer and Organizational Buyer Behaviour in the UK Desktop Printer Market - Essay Example It is for this reason that companies have to continue investing in research and development in order to produce more innovative products that competitors. The printers industry is experiencing the same challenges, especially in the desktop printer market; innovation is driving firms into developing new products with sophisticated level of technology and performance. In the UK, the desktop printer market is witnessing competition from the digital media market, thanks to advancement in technology. Indeed, statistics show that growth in the UK’s printer market has been in decline compared to other Western Europe countries like France and Germany. However, firms have continued to invest heavily in diversification of their product lines, with competition now shifting from all-purpose printers to 3D printers. Generally, there are two main buyers for desktop printers including consumers for home use and organizations for office use. Here, firms are concentrating on building positioni ng strategies that make them more attractive to the customers. Despite facing competition from digital media, firms have top compete among themselves, with major manufacturers such as HP, Samsung, Canon, and Epson among others investing heavily in advertising and other forms of promotion. This paper will examine and discuss the desktop printer market in the UK. ... n on decline; indeed, the downward trend is expected to continue in the current year, despite the industry being one of the largest in the UK, employing over 77,000 people (Ibis World, 2013). For quite a long time, the inkjet printers have dominated the printer market; however, other types of printers have taken the market by storm and have claimed a sizeable market share, among them being the laser printers and the recently introduced 3D printers. As a result, consumers and organizations have a variety of options from which to choose. With the technology shifting from analogue to digital, it means that new products have also to be digital in order to be relevant. It is for this reason that most recent printers are digital, making them more efficient and convenient to use. Indeed, it is now easy to buy a digital inkjet printer or a laser printer from the market. Importantly, technology has allowed the printer market to diversify further by introducing the 3D printers, which have been received warmly by consumers, thanks to their affordable prices and high quality printing capability. Indeed, almost every company is going for the 3D desktop printers due to the rising demand, especially from architects and home users, as well as from education institutions. It is no wonder that the UK government has established a program to sponsor teaching of 3D technology in schools. The UK market of desktop printers is highly competitive, as almost every large manufacturer of printers is available in the UK. These firms include HP, Canon, Epson, Samsung, and Kodak among others, all of which tend to outdo each other in terms of product differentiation and marketing strategy. The presence of such a big array of operators in the market means that entry to the market is very easy –