OBJECTIVE: To determine the feasibility and effectiveness of medical hypnosis and cognitive behavioral therapy (CBT) for relief of pain, improvement of psychological status, and quality of life in men with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS).
METHODS: Men with refractory chronic pelvic pain who were symptomatic for >3 months were assessed for hypnotic susceptibility after medical, mental health, and social history were obtained. Psychological data from healthy men with no evidence of pain disorders or genitourinary symptoms were used as a comparator group. In 7 weekly sessions, the psychologist/hypnotherapist utilized CBT to challenge and balance negative cognitions associated with symptoms, performed guided imagery and hypnotic intervention, and provided patient training in self-hypnosis for symptom management. Changes in symptom indices, psychometrics, and compliance with home exercises using audiotapes of hypnosis sessions and CBT workbooks were assessed after 3 and 6 months.
RESULTS: Sixteen men with median pain duration of 7 years and high symptomatic pain scores participated. All had moderate to high hypnotic ability. At 6 months after training, the median NIH-CPSI total score decreased 10.5 points (-7 to -27) relative to pretreatment in 57% of patients; McGill pain scores decreased a median of 6.5 points (-2 to -28). Both NIH-CPSI pain and quality of life domain scores significantly improved (P ≤ .02). Most (88%) patients reported continued self-hypnosis effective for symptomatic relief and improved coping.
CONCLUSION: CBT and self-hypnosis training for patients with CP/CPPS was feasible, resulted in decreased symptoms, and provided patient self-directed methods to improve sense of control, ability to cope, and dissociation from pain symptoms. Longer-term follow-up is required to determine the impact of these therapeutic approaches for selected men with this disorder.
KEYWORDS: Prostatitis; Chronic pelvic pain syndrome; Medical hypnosis; Cognitive behavioral therapy
CORRESPONDENCE: Rodney U Anderson, MD, FACS, Department of Urology, S287 Stanford University School of Medicine, Stanford, California 94305-5118, USA ().
CITATION: UroToday Int J. 2011 Aug;4(4):art46. doi:10.3834/uij.1944-5784.2011.08.02.
ABBREVIATIONS AND ACRONYMS: BSI, Brief Symptom Inventory; CAM, complementary and alternative medical; CBT, cognitive behavioral therapy; CNS, central nervous system; CP, chronic prostatitis; CPPS, chronic pelvic pain syndrome; CPSI, Chronic Prostatitis Symptom Index; DSM, Diagnostic and Statistical Manual; GRA, global response assessment; NIH, National Institutes of Health; PPSS, Pelvic Pain Symptom Scale
As with many chronic pain disorders, the etiology of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is poorly understood and poorly characterized; treatment is mostly empirical and unsatisfactory. Chronic pain is a complex phenomenon that may be affected by emotional, cognitive, behavioral, and physiological responses. Therefore, a multimodal treatment approach may be important for some patients. Despite decades of efforts to manage CP/CPPS symptoms using pharmacologic therapies, none have demonstrated proven effectiveness in placebo-controlled clinical trials. In comparison, several types of complementary and alternative medical (CAM) therapies including myofascial release physical therapy [1,2], paradoxical relaxation [1,3], acupuncture , electrical neuromodulation , and herbal quercitin and pollen extract (Cernilton N) [6,7] have demonstrated beneficial effects and patient compliance. The success of each of these CAM therapies is thought to be due to targeted neuromuscular, neuroendocrine, or neuropsychological systems.
A recently suggested clinical phenotypic classification of patients with urologic chronic pelvic pain includes psychosocial dysfunction as one of the domains that contributes to its multifactorial presentation . A protocol for cognitive behavioral therapy (CBT) based on psychosocial factors has been suggested for CPPS but remains untested . Hypnosis intervention also has been shown to consistently produce significant decreases in pain associated with a variety of chronic pain conditions including cancer pain, low back pain, vulvodynia, and irritable bowel syndrome [10,11,12,13,14]. It has been used for symptom management in patients with fibromyalgia; however, CBT in conjunction with hypnosis produces greater symptom benefits than conventional medical treatment only or CBT without hypnosis .
Recent evidence associating the experience of pain and brain state measured via electroencephalography has heightened interest in interventions that impact the cortical neuromodulation of pain, including behavioral treatments such as self-hypnosis training and biofeedback . To our knowledge, no clinical trial has evaluated therapy with hypnosis alone or in conjunction with CBT in helping patients with symptom management and reduction of the negative effects of CP/CPPS.
The present pilot study was designed to assess the feasibility of utilizing a protocol of combined CBT and hypnosis in men with refractory CP/CPPS. The protocol is designed to target neuro- and bio-psychosocial factors that may contribute to this complex disorder. The goals are to examine the short-term effectiveness of reducing pain and to provide patients with self-hypnosis training as a way of coping with pain and gaining greater self-control over it. This approach is based upon the premise that treating urologists understand the preeminence of psychological variables when managing refractory CP/CPPS. After evaluating a new patient, the urologist teams with a psychologist trained in pain management for the purpose of optimizing treatment outcomes. The patient undergoes a series of individual psychotherapy and hypnosis training sessions, while complying with between-session behavioral homework assignments. Patients may continue to use self-hypnosis after treatment, on an as-needed basis.
This prospective investigation was conducted at the Stanford University Urology Clinic between October 2009 and October 2010. The protocol was reviewed and approved by the Stanford University Human Subjects' Committee and participants gave signed informed consent. Patients were invited to participate in a 7-session protocol without monetary compensation. Treatments were provided without cost.
Experimental Group . The participants were 16 men with refractory, long-term CP/CPPS. All participants had failed several prior multimodal therapies. No differentiation was made between inflammatory and noninflammatory prostatitis (National Institutes of Health [NIH] categories IIIA/IIIB), or the specific location of pelvic pain. All participants had symptoms for 3 months within the last 6 months. They had a total NIH-Chronic Prostatitis Symptom Index (CPSI) score of at least 12 and a nonzero pain domain score.
Comparator Group. To further understand the psychological profiles of the men with CP/CPPS and how chronic pain may have affected them, we obtained psychological data from 26 age-matched and demographically similar healthy men with no evidence of pain disorders or genitourinary symptoms as a comparator group. They did not receive CBT or hypnosis therapy. The participants in the comparator population were healthy controls in a larger NIH-sponsored study from the Chronic Prostatitis Collaborative Research Network (CPCRN) that is designed to assess hypothalamic-pituitary-adrenal axis function in CP/CPPS .
After the urological examination, a licensed psychologist (TFN) with extensive experience in the application of hypnosis and CBT for pain management assessed the participants' hypnotic susceptibility and imaginative activity with the Tellegen Absorption Scale . This scale has 34 true-false items that correlate with the ability to maintain a state of attention involvement. The psychologist also administered the Hypnotic Ability Assessment and Training Scale, which was developed by the psychologist/hypnotherapist (TFN). A comprehensive pain, mental health, and social history were obtained.
Symptom and Outcome Assessments. Primary outcomes were compliance and trial feasibility, changes in symptom scores using the NIH-CPSI total and subdomain scores, changes in severity, frequency, and pain location with the Pelvic Pain Symptom Scale (PPSS) , and short-form McGill pain questionnaire (SF-MPQ) scores . Assessments were collected before treatment and at 1, 3, and 6 months after completion of therapy. The global response assessment (GRA), a 7-point Likert scale, was administered at each follow-up visit to evaluate patients' perceptions of the overall effect of the therapy: "How are you now in comparison to before CBT and hypnosis?" Responses were: markedly improved, moderately improved, slightly improved, no change, slightly worse, moderately worse, or markedly worse.
Psychological and Psychosocial Assessments. The following self-report instruments were used: 1) Beck Depression Inventory (BDI-II) ; 2) Beck Anxiety Inventory (BAI) ; and 3) Perceived Stress Scale (PSS) . A psychological profile of distress was evaluated with the Brief Symptom Inventory (BSI) of the Symptom Checklist (SCL-90R), a 53-item inventory measuring nine dimensions: depression, anxiety, somatization, obsessive-compulsive behavior, interpersonal sensitivity, hostility, phobic activity, paranoid ideation, psychoticism (social alienation), and the Global Severity Index (GSI), a composite measure of overall distress . Responses were scored on a 5-point Likert scale ranging from 0 (not at all) to 4 (extremely bothersome). Scores were converted to T scores based on adult male, nonpatient (ie, nonpsychiatric) profiles from a reference population. Detailed medical and psychosocial histories were obtained during sessions with the psychologist in an attempt to determine potential etiological factors associated with the onset and exacerbation of CP/CPPS symptoms.
Treatment Procedures. Participants attended 7 weekly treatment sessions with the psychologist consisting of: (1) teaching CBT (identifying negative cognitions associated with CP/CPPS symptoms generating negative feelings, and then countering them with more adaptive and realistic cognitions); (2) providing a hypnotic exploratory session about psychological factors that may be contributing to symptoms; (3) teaching hypnosis for symptom management (generalized relaxation, guided imagery of a pleasant scene, and glove-anesthesia); and (4) training in self-hypnosis by making an individualized digital recording of a hypnotic session to be used daily at home. The procedures for CBT and self-hypnosis training are shown in the Appendix. Audiotapes and CBT worksheets were provided and CBT and hypnosis compliance logs were collected at each session. Participants were not permitted to receive any additional therapy for CPPS during the course of the study and follow-up period.
Descriptive statistics were generated on all demographic, medical history, and physical examination findings including medians, means, and standard deviations (SD) for continuous variables and frequencies and percentages for categorical variables. Differences between pretreatment and posttreatment NIH-CPSI total and subdomain scores and psychometric profile scores were analyzed with the paired-sample t test. Comparisons of demographic continuous variables, psychometric, and BSI scores between the experimental and control groups were determined with the Mann-Whitney U test (2-tailed); demographic discrete variables were compared with the 2-tailed Fisher's exact test. Statistical significance was considered at P < .05. Statistical analyses were performed using R software, version 2.9 (R Foundation for Statistical Computing; Vienna, Austria).
Sixteen men with CP/CPPS were enrolled and completed all therapy sessions; 1 participant who failed to provide follow-up questionnaires was eliminated from evaluation. For the duration of study and in the preceding months, none of the patients reported the use of any psychotropic medications. The patients had moderate to high hypnotic engagement with a median (25th percentile, 75th percentile) Tellegen score of 15 (9.5, 23).
Table 1 contains the characteristics of the experimental and comparator groups and the probability of significant group differences. The men with CP/CPPS had a median age of 43 years (range, 29-53 years). There were no significant group differences in age. The patients had a median duration of CP/CPPS of 7 years (range, 1.25-30 years). The median pretreatment NIH-CPSI total score was 25 out of a 43 maximum (range, 15-38). There was a significant group difference for the total score and all domain scores (all with P < .001). There was also a significant group difference for all of the PPSS domain scores (all with P < .001). There were significantly more participants that were categorized as Hispanic/Pacific Islander ethnicity/race in the control group (P = .007); other ethnic/racial characteristics were similar between groups. Most participants in both groups were educated beyond high school; there were significantly more patients with CP/CPPS that were college graduates (P = .001), but there were significantly more participants in the control group that also had graduate or professional degrees (P = .008). There were significantly more participants in the control group that were married (P = .02); there were significantly more patients in the experimental group that were divorced (P = .01).
The mental health histories obtained by the psychologist prior to commencing the therapy protocol revealed that most patients reported a history of depression, anxiety, or dysthymic disorder. Eight of the 16 patients had received some counseling in college or had psychotherapy for a limited time as young adults. One patient was continuing sessions with a family therapist for depression, and 1 had completed 6 months of prior psychotherapy for depression and panic related to his pelvic pain. The remaining 8 patients had no previous contact with a mental health professional.
The psychologist provided a Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV  diagnosis for each patient after his initial assessments; DSM diagnoses were not available in the patients' urology clinic records. DSM-Axis I diagnoses for most patients included adjustment disorders with depressed mood (309), anxiety (309.24), mixed anxiety and depressed mood (309.28), or dysthymic disorder (300.4). All patients carried the Axis I pain disorder associated with psychological factors (307.80). Two patients were diagnosed with posttraumatic stress disorder, delayed onset (309.81). No patient had a DSM-Axis II diagnosis indicative of a personality disorder or mental retardation. Two patients carried an Axis IV diagnosis, indicating sufficiently severe pain symptoms that they were unable to continue working. The median Axis V (Global Assessment of Functioning Scale, range 1-100) score was 61 (range, 57-68). Scores of 61-70 indicate mild symptoms (eg, depressed mood and mild insomnia); scores of 51-60 indicate moderate symptoms (eg, flat affect, circumstantial speech, occasional panic attacks).
Table 2 presents the personal and medical history and major life stressors associated with onset of initial CP/CPPS symptoms. The results of these assessments call to attention the multiple psychosocial and biologic factors that might contribute to this disorder.
Table 3 shows median BSI scores, the interquartile range, and the centile rank for the experimental and comparator groups and the probability of significant group differences. The BSI scores for distress from physical symptoms were significantly elevated in all scales for men with CP/CPPS (all with P < .0001), with the exception of phobic anxiety. Men in the experimental group ranked in the 91st centile on the global severity index of the BSI, compared with the 46th centile for men in the control group (the 50th centile represents an average score for an adult male without a psychiatric disorder). The psychometric profile scores in the BSI for the men with CP/CPPS remained unchanged in the 6 months of follow-up.
Fifteen participants completed 3 months of follow-up; 14 participants completed 6 months. Table 4 shows the significant improvements in NIH-CPSI total scores evident within the first month after therapy (P = .001), which were either sustained or further improved through 6 months of follow-up. NIH-CPSI total scores decreased a median of 10.5 points (range, -7 to -27 points) in 8 out of 14 patients (57%) at month 1 and month 6. The scores represented a median decrease of 42% (range, 30% to 59%) from baseline. Pain domain scores decreased at month 6 relative to pretreatment; however, no durable changes in urinary symptoms were evident. Quality of life domain scores were significantly improved as early as within the first month and throughout 6 months after therapy (P = .001). The PPSS score decreases were commensurate with NIH-CPSI scores. McGill pain questionnaire scores were significantly decreased at months 3 and 6 (P ≤ .03). Most patients reported that they would continue to use the skills they learned in treatment; they reported that they experienced pain relief and improved coping when they continued the program. The global response assessments at month 1 indicated that 7 out of 15 patients (47%) reported moderate to marked improvements after therapy; at month 6, 36% of the patients indicated these levels of improvement.
Table 5 contains the psychometric scores of both participant groups at baseline and 6 months after treatment and the probability of significant differences. Results indicate that men with CP/CPPS had significantly elevated perceived stress and anxiety scores before CBT and self-hypnosis training when compared with participants in the control group (P < .001). Scores for depression and anxiety decreased significantly in the patients with CP/CPPS after therapy (P < .05).
The objective of CBT and self-hypnosis training was to provide tools for the participant to use for symptom management. Although a treatment schema was employed, the psychotherapy sessions were individualized to address each patient's specific issues that could be modulated by CBT and hypnosis methods. The guided imagery and hypnotic interventions also addressed areas uncovered in the hypnotic inquiry that may not have been identified in the medical and psychological history. These interventions targeted aspects believed to be involved in the development and maintenance of the CP/CPPS pain cycle.
Substantial individual differences can exist in the ability to be hypnotized or practice self-hypnosis; not all individuals are able to enter a hypnotic state. All participants in our study had moderate to high hypnotic ability, as identified with the Tellegen Absorption Scale. Because the number of participants was limited in this feasibility study, we had intended to exclude those with low hypnotic ability; we did not find it necessary to implement this exclusion criterion. Therefore, the study outcomes might be biased toward those who can achieve a hypnotic state. Reports indicate that high hypnotic ability is not necessary for successful hypnotic pain intervention. Although greater hypnotic pain relief is associated with high hypnotic suggestibility, those with medium suggestibility (representing about one-third of the general population) can also appreciate clinically significant hypnotic analgesia .
The experience of chronic pain is the result of complex interactions between multiple supraspinal central nervous system (CNS) sites. The involvement of CNS sites, structures, and processes contributing to pain gives the clinician a large variety of interventions from which to choose, including psychological interventions that affect cortical activity such as hypnosis. For patients whose pain experience is related to neurophysiological processes that can be influenced by hypnotic suggestions, a marked decrease in pain intensity can be expected.
The present clinical trial used therapeutic methods to alter the body-mind relationships in CP/CPPS by utilizing tools to deal with the psychosocial issues associated with chronic pain. Perceived stress and cognitive/behavioral variables such as catastrophizing have been related to greater pain intensity and disability in CP/CPPS [26,27]. We have consistently observed that the psychological profiles of men with CP/CPPS differ greatly from age-matched healthy men with no pain disorders . This was also confirmed in our participants with CPPS, who had significantly greater indices of overall distress than the comparator group with a history of no pelvic pain. This is in agreement with several earlier reports of psychological disturbances (eg, depression, catastrophic thinking, anxiety, elevated scores on somatic scales, anger-hostility) observed in conjunction with chronic CP/CPPS [27,28]. Psychosocial distress associated with chronic pain could be interpreted as a result of the pain or a contributory factor in the patient's distress regarding their perceived pain. The feed-forward relationship between chronic pain and psychopathology is described by the diathesis-stress model . This model illustrates how the stress of coping with chronic pain exacerbates an individual's semidormant but preexisting characteristics (diathesis), eventually resulting in psychopathology. Thus, individuals with a dysthymic disorder, major depression, or an anxiety disorder probably experience more pain or suffering when compared with the person who was in excellent mental health previously.
We cannot discern whether the elevated scores on almost all domains of the BSI for personality characteristics represent traits resulting from the stress effect of coping with chronic pain, a state phenomenon, or inherent personality characteristics that further contribute to the exacerbation and maintenance of CP/CPPS. Changes in trait have been observed with treatment of various pain conditions and associated with improved pain scores . In this study, the observation period was probably too short to appreciate any personality changes within the BSI survey that might possibly occur.
After CBT and self-hypnosis training, the participants experienced significant decreases in both McGill Pain Questionnaire scores and NIH-CPSI symptom scores. However, these improvements were not reflected in the GRAs at months 1 and 6 when only 47% and 36% of the patients, respectively, reported moderate to marked improvements after therapy. This could be interpreted as the patients having very high expectations for therapy outcome because these patients with refractory, chronic pelvic pain had previous therapy failures. However, it also highlights a disconnect that we have often observed in our clinical experience in that scores on validated questionnaires for outcome measures used in clinical trials such as the NIH-CPSI, which have supposedly clinically meaningful decreases do not coincide with patient satisfaction. The reverse of satisfaction with improved symptom scores is also often observed.
In consideration of our results, it is useful to highlight some of the methodological issues that may have impacted our findings. The uncontrolled study examined the feasibility of multimodal CBT, hypnotic intervention, and daily self-hypnosis in a small cohort of men with refractory CP/CPPS who were highly motivated to explore a new therapeutic modality. However, the number of sessions was limited and continued psychologist intervention would likely have been advantageous. This was not an instruction manual-based program of guided imagery; rather, therapy sessions were individualized for each patient and required a skilled practitioner. We could not objectively measure compliance, and longer-term follow-up is needed to determine duration of pain reduction in individuals who continue use of self-hypnosis. A prospective, randomized trial comparing intensive intervention with a therapist providing education, discussion, emotional venting, and empathy compared with CBT and self-hypnosis would have merit in discerning the most valuable alternative modality for men with CP/CPPPS.
Results indicate the feasibility of CBT intervention and self-hypnosis training for selected patients with refractory CP/CPPS. The self-directed methods improved the patient's sense of control and ability to cope with and dissociate from pain symptoms. Longer-term follow-up is required to determine the impact of this therapeutic modality for men with this disorder and its application in multimodal therapy. However, the therapeutic value of a cooperative relationship between the urologist and psychologist cannot be underestimated.
Supported by a grant from National Institutes of Health, NIDDK, DK065297
Conflict of Interest: None declared.
CBT and Hypnosis Procedures
Session 1. Extensive Case History Evaluation
- Psychosocial, educational, developmental, family, physical and mental health, marital, work, major losses, and life transitions history (~ 90 minutes)
Session 2. Introduction to CBT
- Overview: negative emotions (eg, sadness, resentment, guilt, hopelessness) are caused by negative cognitions about life events rather than the actual events, either external (situational) or internal (physical pain sensations)
- Guidance in use of CBT paradigm: identification of 10 cognitive distortions (all-or-nothing thinking, overgeneralization, dwelling on the negatives, discounting the positives, jumping to conclusions, magnification or minimization, reasoning from your feelings, should statements directed at self or others, labeling yourself according to your behavior, blaming); learning how to alter the distortions with the following paradigm:
- - Event: occurrence in patient's life that seemed to cause an emotional reaction
- - Automatic thought: self-talk that actually caused the patient's mood to change (eg, "I'll never get over this pain")
- - Emotion: a one-word feeling (eg, angry, sad, guilty, shameful, worried)
- - Behavior: action taken by the patient when feeling a negative emotion (eg, avoiding a social engagement, drinking alcohol or taking excessive medication, confiding in a close friend or family member)
- - Counter-arguments to the automatic thought (the lynchpin of the homework assignment): creating a counter argument that effectively negates the automatic thought generating the negative emotion
- Didactic information and instructions on pain management given to the patient:
- - Factors exacerbating pain perception: sleep deprivation, increased daytime pelvic muscle tension, dwelling on pain, having a negative mood (eg, anger or despair)
- - Factors mitigating pain perception: increasing amount of sleep, remembering to relax pelvic floor muscles, increasing fun or play activities daily, increasing social or normal activities rather than avoiding or cancelling them, and increasing physical exercise rather than avoiding or cancelling them
- Homework assignments:
- - Read Feeling Good: The New Mood Therapy and A Headache in the Pelvis
- - Keep a CBT log of negative cognitions, feelings, and counter-arguments to their negative cognitions
- List major life transitions: positive and negative life events (eg, divorce, death of family member, moving to a new house, changing jobs) that occurred before the onset of their chronic pain
Session 3. CBT and Introduction to Hypnosis
- Review CBT log: fine tune patient's understanding of the basic concepts and assist with development of counter-arguments to their negative cognitions
- Explain hypnosis and its use in treating pain conditions, including 4 aspects: relaxation, symptom management (pain management), investigation, and training in self-hypnosis
- Hypnosis training and evaluation session (20 minutes) including imaginative exercises and focus of attention on the most vivid sensory aspects (sight, hearing, smell, touch, or kinesthetic input)
- Homework assignments: continue with CBT log and reading of Feeling Good: The New Mood Therapy
Session 4. CBT and Hypnotic Intervention
- Review CBT log sheets for emphasis on aggressively developing counter arguments to their negative cognitions
- First hypnotic session (~ 25 minutes), including: generic relaxing imagery (eg, an ocean beach, meadow, another place in nature); awareness of altered physical sensations to be used as cues that they have achieved hypnotic trance (eg, subjective feelings of lightness, heaviness, warmth, coolness, paraesthesia, other sensations); remembering a pleasant, proud, or happy moment from their past in vivid detail
- Homework assignments: continue keeping CBT log with focus on specific negative emotions that recur and developing effective counter-arguments to them; read Feeling Good: The New Mood Therapy; practice some aspect of the relaxing imagery experienced in hypnosis
Session 5. CBT and Hypnotic Intervention
- Review CBT log sheets
- Hypnotic intervention (preparation of digital recording of ~ 25-minute session that is accompanied by a handout and used for homework): imagine a pleasant place in nature, remove a backpack filled with stressful events and negative thoughts, loosen and relax each muscle from head to toe, lie down in the sunshine and notice warmth in certain parts of the body, place one hand in warm water, let the hand grow numb (inducing glove anesthesia), move the hand to the pelvic area and transfer the numbness to areas in pain, and contemplate an important positive thought or goal about the patient's life or health
- Homework assignment: Continue keeping CBT log; use hypnosis recording at least once per day
Session 6. CBT and Hypnotic Intervention
- Review CBT log sheets
- Exploratory hypnotic session (~ 40 minutes): inquiry about psychological factors and traumatic events that might be contributing to or causing pelvic pain through ideomotor questioning; inquiry themes include history of family member with pelvic pain or chronic pain, having been told that they would suffer chronic or pelvic pain some day by someone in their past, any personal experience that caused or contributed to the pain (eg, childhood sexual molestation, other physical or psychological trauma), engaging in self-punishment for some perceived infraction (eg, an infidelity), having an ongoing negative emotion that causes or contributes to the pain (eg, anger, fear, sadness, guilt, shame), chronic pelvic pain as a reflection of the ongoing psychological stressor, secondary gain from retention of symptom(s) (eg, avoid sex with a difficult spouse, receive long-term disability insurance), visualize a calendar with a particular month and week when the symptoms could be significantly diminished or disappear completely
- Homework assignment: continue keeping CBT log; engage in two hypnotic sessions (~ 25 minutes) per day, once using the recording and once on their own
Session 7. CBT and Hypnotic Intervention
- Review CBT log sheets, assess success with self-hypnosis practice; evaluate mood and problem areas that arose in prior hypnotic inquiry session
- Hypnotic session (~ 25 minutes) and review imagery for relaxation and pain reduction
- Take-away instructions: continue using self-hypnosis in a preventive manner (eg, early in the day or before pain symptoms worsen or if anticipating a pain-inducing or stressful experience); practice CBT methods as a matter of course, until they become automatic
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My boss and I have weekly one-on-one meetings. During these meetings, he frequently takes phone calls from his family, gets up in the middle of a discussion to use his personal restroom, and allows workers to just barge in to talk to him. I’m very frustrated with these interactions but he is the owner of the company and I am a new manager. I’ve discussed it with my peers, but the general consensus is it’s always been this way and he will not change. What can I say to still remain respectful and professional, yet help him understand how devalued this makes me feel?
Dear New Guy,
Thanks for your question. As I see it, this may be a difficult situation to change. The owner has a lot of leeway, and you aren’t describing any overtly hostile behaviors. Begin by asking yourself whether you’re accurately reading your boss’s intent.
Examine your Story: You’re telling yourself a story about his behavior—that his actions are intended to disrespect you. As a result, you feel devalued. Ask yourself the following two questions:
• Do you have all the facts you need to be confident your story is true?
• Is there any other, more positive, story that could fit this same set of facts?
Here are two attempts at different stories:
Story #1: From your boss’s perspective, the company is an extension of his home, and his office is his living room. When he invites you in for your weekly chat, it’s as if you are a guest in his home. He’s not trying to make you feel bad. He’s treating you with the same respect he would any one who entered his home.
Story #2: Your boss wants his company to feel like family, where he is the patriarch. As a result, he downplays some of the professional, impersonal, sterile business practices you see in most organizations. Instead, he creates more personal, informal relationships. Meeting with him is like sharing a beer with your father-in-law, when your father-in-law is buying. He sets the agenda, you’re not exactly his equal, and he takes bathroom breaks and family calls when he feels like it. But none of his behavior is intended to offend.
You mention that your peers don’t think your boss will ever change. Do they want him to? Or do they see his behavior as inclusive and welcoming? Are you the only one who is taking offense?
Master Your Story: I will suggest some actions that may help you change your boss’s behavior. But they don’t come with a guarantee. You can’t control your boss. What you can control is your reaction to his behavior. If you can’t master your story—if you can’t find a way to accept your boss’s behavior and feel good about it—then your choice comes down to either convincing your boss to change or leaving his employment.
Get Your Heart Right: Before you take action, stop and ask yourself what you really want long term for yourself, your boss, and the organization. Your initial question focuses too narrowly on how the situation makes you feel. Ideally, the conversation you have with your boss shouldn’t be about you and your feelings. The conversation should be about how to further your boss’s and the company’s priorities as well as your own.
Detail Your Expectations: You are asking for a change in the way your weekly meetings are handled. What exactly do you want? Don’t ask for something vague, like respect. Instead, make your requests very specific, such as: fewer interruptions, shorter meetings, clear agendas, etc. Decide what it is you are asking for.
Make it Motivating: Write down the pluses and minuses of each request. And include your boss’s perspective. For example, what does your boss gain or lose if he stops taking phone calls during your meetings? How would this change help him achieve his goals? Do your best to anticipate the consequences he values, and to weigh them in your balance sheet. Again, focus on consequences to the business and the boss, instead of talking about how his behaviors makes you feel. Your feelings may be fairly low on his list of priorities.
Make it Easy: Do your part to make your meetings more professional. Make calendar appointments that have beginning and end times. Get him agendas in advance, and bring a copy with you. Stick to the agenda as much as possible. At the same time, take care to avoid offending your boss. He may interpret your actions as signaling that you want only a professional relationship, not a friendship.
During the Meeting: At the beginning of the meeting, let your boss know what you’re stepping away from in order to meet with him. This puts some urgency on keeping the meeting on track and ending it on time. Then, when he interrupts your meeting, consider saying, “Let me know when you’re ready to continue, or if you want to reschedule.” Then leave.
I hope there are nuggets within my answer that will help you move forward. Please let me know how you work it out.


KANDAHAR, Afghanistan — For most of their lives, Gul and Razziq slept under the same dusty blankets on the same dirt floors. They toiled side by side in the same potato fields and prayed in the same mosque, two poor brothers in a forgotten corner of the Afghanistan war.
Gul, the elder brother, was the first to choose. With no gun or money, he walked out of his home one summer day and into the ranks of the Taliban. Razziq soon followed, but down a different road: to the barracks of the U.S.-backed Afghan national police. The brothers’ decisions have transformed them into enemies and forced them to consider a day they had never imagined.
“I don’t know when I will face my brother on the battlefield, but it’s only a matter of time,” Gul said. And when it happens, Razziq said, “I will have no choice but to fight him back.”
In Afghanistan, personal choice is often all that separates America’s friends from its enemies. Combatants share the same religion, land, language, even blood. “Upset brothers” is how President Hamid Karzai describes the Taliban.
And so the war has become one prolonged appeal for allegiance: The United States relies on tens of thousands of troops and a gusher of development dollars to make its case; the Taliban offers a simpler mix of intimidation and kinship.
The safest territory in Afghanistan is the neutral middle, a space that the expanding war has eroded. Forced to take sides, Afghans have divided into factions, complicating any attempt to end the war — and chipping away at any hope of bringing warring brothers home to the same family again.
Gul and Razziq, who spoke on the condition that only their first names be used, grew up in Bazargan, a village in Zabul province, along the southeastern border with Pakistan. They are ethnic Pashtuns from the same tribe that produced Mohammad Omar, the leader of the Taliban. Since Razziq joined the police a year ago, the brothers have not spoken to each other. Separately, and without each other’s knowledge, they agreed to interviews in Kandahar city.
Neither looks the part of the warrior. Even with his grey turban, Gul, 23, stands barely over 5 feet tall. He has gentle brown eyes and delicate features: a finely crafted figurine of a fighter. He allowed no recordings or photographs but said he could move freely and without fear of arrest. Razziq, 20, arrived in civilian clothes — beige robes similar to his brother’s, his thick black hair spilling from under his notched Kandahari cap. He seemed more forlorn and introverted than Gul, and he told his story in a whisper.
The Northern Alliance, backed by the might of the United States, overthrew the Taliban when Gul was 13. He felt no allegiance to the Taliban regime, but he gradually developed an admiration for its interpretation of Islam. He spent more time at the mosque than Razziq. Gul objected to their younger sister taking classes in a neighbor’s home. His classmates called him “little mullah,” said Asadullah Nawabi, a friend and pharmacist in Zabul.
Gul’s views hardened when U.S. soldiers killed a cousin, Ismat, during a night raid in their village, according to both brothers. “The Americans had surrounded a compound. When he tried to leave it, he was shot,” Razziq recalled. Ismat was a bystander, they said, not an insurgent.
“That was the moment I realized the Americans were not here to build our country,” Gul said.
Not long after, he dropped out of high school and left home to find the Taliban.
“It’s every Muslim’s obligation to fight the invader and occupier,” he said. “I was nervous when I left. I didn’t know what would happen to me. But I was also happy because I was going to join a group of people who were fighting for God.”
Finding the insurgents was not difficult. “Anyone can join them,” Gul said. “They are not like government officials who don’t open the door even after you knock 20 times.”
A few days after leaving home, Gul returned with his new comrades. Razziq watched as three motorcycles came up to the family’s home, two turbaned Taliban fighters on each. He noticed that his brother, for the first time, was carrying a gun.
Razziq was disgusted. He had pleaded with Gul not to join the Taliban. It would put him in danger, the younger brother had argued, and would draw unwanted attention to the family. As the eldest son, Gul was responsible for tending the farm and supporting their parents and siblings. As it was, their meager harvests earned them barely enough to survive.
Razziq did not consider U.S. troops occupiers. They were in Afghanistan under a United Nations mandate, he noted, and have paid to build schools and hospitals and train Afghan soldiers and police. The Taliban insurgents “bomb bridges, they plant mines, and most of the time, civilians get killed,” Razziq said. “He joined the very people who burn down schools, who don’t let women go to school, who do all sorts of evil things.”
During the visit, Razziq brooded and refused to speak to his brother. While Gul’s Taliban companions lounged in the mosque eating an okra dish made by his mother, his father appealed to Gul to change his mind.
“He said, ‘Son, it’s not too late. You can still come back home and leave the Taliban,’ ” Razziq recalled. “But Gul wouldn’t listen.”
Gul pulled out a Koran and read his father a verse: For anyone who abandons his religion and dies an unbeliever, he read, “their deeds have become worthless in this world and the afterlife.”
Gul said he started as a driver for the Taliban, was promoted to bodyguard and now fights in a 10-man cell operating in Zabul province. As part of the organization’s military wing — separate from those involved in administering ad hoc village-level justice — he learned how to wire fertilizer bombs, fire a Kalashnikov rifle and ambush foreign troops. “The IED is our weapon of choice,” he said, referring to improvised explosive devices.
Since he joined in 2007, the Taliban’s area of operations has grown, he said, and he can move freely throughout southern Afghanistan. It has been a peripatetic life — traveling at night from village to village, camping outside — but a rewarding one, he said.
“The simplicity of their lives has really impressed me. The mujaheddin are people who left everything behind: their families, children, wives, property. They are fighting for God and freedom,” he said. “We feel sorry for every single American soldier who dies in Afghanistan. Our advice is to go home and live with your families and leave us in peace.”
Without Gul to help farm, money grew scarce. They had been a family of eight — parents, four brothers and two sisters — living in a three-bedroom mud hut in one of the poorest provinces in Afghanistan. They owned two sheep and a small garden but mostly farmed neighbors’ fields: potatoes, almonds, wheat and grapes. They sold their produce in the bazaar in the district capital, earning what they could.
On the radio, Gul said, he had heard about the millions of dollars the Americans had allocated for development projects in Zabul, but he saw no evidence of change. Afghan government officials, he concluded, had stolen the money. “The reason I don’t support the government is I think they are thieves,” he said. “They are heroin addicts and hash smokers. You can hardly find an honest man in the government.”
To help his family, Razziq needed to find work. Unlike Gul, who nearly finished high school, studied in a madrassa in Pakistan and could speak broken English, Razziq was illiterate — a condition he likened to blindness. The Afghan police paid $220 a month and required no education. “I wanted to serve the country,” he said. “And I wanted to be part of the team that makes it possible for children to go to school.”
His father hated the idea. Where they lived, the Taliban had more authority than the government: The group’s members spoke at the mosque and regularly passed by asking for food and shelter. Anyone who joined the police was asking for trouble. But Razziq refused to stay home. He joined an outpost in Taziq, an about 45-minute drive from his house. That was a year ago. He has not been home since.
“I cannot go back there,” he said. “The Taliban will cause problems.”
Each month, Razziq sends $130 — more than half his salary — to his family, usually with a friend acting as courier. When his father had errands in the provincial capital, Qalat, they would meet for a few minutes to catch up. But that has been rare. His connection to his family has been severed.
To Gul, his brother’s new job was a betrayal: a choice of money over freedom. “I know my brother made the wrong decision. I hope he quits his job and comes back home. Nobody will touch him,” Gul said. Until Razziq does, they will be enemies.
The centrifugal forces of war have pulled apart other Afghan families as well. In 2006, Yar Mohammad left Shahjoy — Gul and Razziq’s district — and moved to Iran, where he discovered clean neighborhoods, paved roads, young men in jeans and women without burqas. When he came home, he wanted nothing to do with Chino, his dusty village, or his brother, a Taliban leader who goes by the nom de guerre Commander Khanai. Without telling his family, Mohammad joined the police and was stationed in neighboring Ghazni province, leaving behind his wife and baby daughter.
When his family members found out that Mohammad had chosen to side with the government, they were enraged. His father called him a “servant of infidels” and vowed to disown him and never attend his funeral.
Mohammad is “dead to us,” said Commander Khanai, who has fought with the Taliban for five years. “He has betrayed us. He has made an unforgivable mistake. I will shoot him if I see him. Since he is serving the occupiers’ interests, for me, he is no different from an American.”
A few months ago, Mohammad called his brother and asked for permission to visit his wife and daughter in the village.
“He first started cursing me, and then he warned me that if I show up, he will kill me himself,” Mohammad recalled.
“I told him nobody wants to see him, including his wife,” Commander Khanai said. “He is an apostate, and the punishment for apostasy is death.”
The enmity between Gul and Razziq is more tempered. They miss each other and yearn for the day when the family can be reunited. Gul hopes his brother understands why he is fighting. Razziq hopes his brother realizes they are both Muslims.
“When you leave your loved ones, you miss them,” Gul said. “I’m trying my best to convince him to quit his job.”
“I want to see him again,” Razziq said. “Although I’m mad at him, I could forgive him.”
When the war is over, both want to return to their village, and both are willing to forgive. “Who doesn’t want to be with his family in his own home?” Razziq asked.
“We had a very good relationship once,” he said. “We were two good brothers.”
Special correspondent Habib Zahori contributed to this report.


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Background and Initial Formation
Nubia, or Kush, was a region along the river Nile in today’s southern Egypt and northern Sudan. It was one of earliest civilizations of north-eastern Africa whose history can be traced back to at least 3000 B.C. During the New Kingdom of Egypt (16th to 11th Centuries B.C.), Nubia was an Egyptian colony. When the New Kingdom came to an end, Kush became an independent kingdom centered at Napata in present-day Sudan. Between 780 and 755 B.C., King Alara established the Kushite Dynasty. Though Nubian culture predated that of the Egyptians, the Kushites were heavily influenced by Egypt with its rise. They worshiped many Egyptian gods, and the kings styled themselves as Pharaohs and even built pyramids.
Rise To Power And Accomplishments
The Kushite Kingdom grew in influence under Alara’s successor Kashta, who extended his hegemony over the Elephantine region of southern Egypt and Thebes. Kashta compelled Shepenupet I, the "God's Wife" (high priestess) of the Amun cult, to adopt his daughter as her successor after which Thebes practically became a Nubian province. The Kushites developed an independent script and were the first and only ancient civilization to have a succession of female sovereigns. Kushite power reached its climax under Kashta’s successor Piye. In the twentieth year of his reign, Piye conquered all of Egypt and formed its 25th Dynasty. This line lasted until a native Egyptian dynasty regained power for the last time in 653 B.C under Psamtek I. After the Assyrians invaded Egypt some years later, Kush became an independent kingdom.
Challenges and Controversies
When King Tantamani attempted to retake Egypt in 664 B.C., he was soundly defeated by the Assyrians. In 591, the Egyptians under Psamtik II invaded Kush under King Aspelta, and burnt down Napata. The Kushites reestablished their capital further south at Meroe, probably for the forest resources, which could provide the wood to heat iron furnaces and to trade with the growing number of Greek traders. There are differing theories on the move to Meroe. Since no royal residence has been found at Napata, one view is that Napata was only a religious center. Nubian kings were crowned and buried at Napata, though they lived and ruled from Meroe. The discovery of a royal burial site at Meroe suggests that the kings threw off the religious yokes of the priests, and ruled in their own right from their capital.
Decline and Demise
Kush flourished for many centuries, even under the Greek and Roman imperial hegemony to come. However, the royal tombs began to reduce in size and grandeur by the 2nd Century A.D., and the large-scale building projects came to an end. By the middle of the 4th Century, no royal burials continued to take place. Archaeological evidence suggests that the Kushite Kingdom was destroyed by an Ethiopian invasion around 350 A.D. By the Sixth Century, new states had formed in the regions of Nubia once ruled from Meroe. It seems certain that the Nubian culture morphed into a culture called the Ballana, which governed the known states of the time, including Makuria, Alodia, and Nobatia.
Historical Significance and Legacy
The name of Kush is given by the Old Testament. Cush was a son of Ham who settled in Northeast Africa, and gave his name to the region between northern Sudan and southern Egypt, extending into parts of Somalia, Eritrea, and Ethiopia along the Horn of Africa. Cush, to some, represented the Garden of Eden in the Hebrew Bible. The Kushites neglected to write much in the way of historical records, and therefore much of whatever we do know about them today comes from Egyptian texts and archaeological studies. Strong female rulers provided stability between kings, and mothers exercised a strong influence over their sons who became male rulers. Unlike Egypt, the Kushite kings also governed with some degree of popular consent, and Nubian law was largely independent from the use of royal decree.


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Bluffs High Class of 1953
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...then, before i left, i turned around and told the judge "i'm here to state who i am and be honest with you." i said "if they thought i was dangerous on the road like you're trying to accuse me of, wouldn't they have taken my license when i first got it? yes they would. and the judge says "yeah, you have a point," he goes "you don't need to get loud," i said "don't get loud?" i says "i've got every right to get loud." i says "you can't do a god damn thing about it, because i'm expressing myself in your court, and there is nothing you can do about it. you think you're god because you have a robe and you can put people up the god damn river for 20 years? well you're not."
and i left it at that...
did you walk away?
yes i did...i don't like the judicial system, i don't like the government system, i don't like the police, i don't like anything to do with this country's government. i just don't like it, because...they're sneaky, like i said - they're deceitful, they're lying, they're cheats, the rip people off. that's the american government for you. america is a third world country, and people don't recognise it...and i think that that's pretty god damn sad, that they don't recognise their own country as a third world, third rate, third class slum.
well...d'you have any weapons?
yes, i do. i own a high-powered assault rifle, i own a 12-gauge double barrel shotgun, i own a regular shotgun, i own a regular hunting rifle, i own a 9 milimetre, a 357, a 45 handgun, a 38 special, and, erm...i own an m-16 fully automatic ground assault rifle...
d'you think things are gonna get better before they get worse?
no way. things are just gonna get worse and keep on getting worse. like i said, america's a third world country as it is and...and we're just basically in a hopeless situation as it stands.
what d'you think this country's gonna look like in the year 2003?
y'know, i'll tell you the truth - nothing against you guys, but i don't wanna answer that question because...i haven't even got a mind that's that...that inhumane.
are you ready for what's coming?
ready as i'll ever be.
most people aren't.
there's a little saying...dates back for generations...
be prepared for anything at any time from anybody, don't take no shit, always stand your ground. people wanna come up to me and run their mouth - guess what? i'll throw them through the fucking window...i won't think a thing of it.
would you mind reciting your poem for us?
not at all, i don't see why...i don't see why i couldn't.
there's an evil virus that's threatening mankind
it's not state of the art, it's a serious state of the mind
the muggers, the backstabbers, the two faced elite
a menace to society, a social disease
to brainwash the mind is a social disorder
the cynics, the apathy one-upmanship order
watching beginnings of social decay
gloating and sneering at life's disarray
eating away at your own self esteem
pouncing on every word that you might be saying
to attack someones mind is a social disorder
the constitution, the government, martial law order
superficially smiling a shake of the hand
as soon as your back is turned treason is planned
when every good thing's laid to rest
by the governments hate, by the constitution and their lies
and every time you think you're safe
and when you go to turn away
you know they're sharpening all their knives
all in your mind
all in your head
try to relate it
all in your mind
all in your head
try to escape it
without a conscience they destroy
and that's a thing that they enjoy
they're a sickness that's in all of our minds
they want to sink the ship and leave
the way they laugh at you and me
you know it happens all the time
but it only happens in your mind
the rats in the cellar you know who you are...
or do you?
watching beginnings of social decay...
thank you for your time


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Colour coding in maths
So, this week in maths was all about multiplication. The majority of my maths group struggled with long multiplication from the get go. I went back to basics and we practised multiplying by a single digit and then tried to move onto 2-digits by 2-digits. It didn’t go well. Errors littered throughout. We worked through examples together, I went around to give feedback as usual, but it wasn’t sinking in. Obviously, at the end of that lesson, I knew we’d need to spend more time on it, but I was thinking about what exactly it was that was holding them back and it became quite clear: they were getting confused with the layout, what goes where and the relationship between it all. When multiplying by one digit, they were ok, but as soon as another digit was added into the mix, it threw them. Moving onto that second line, to multiply the tens column, was causing us a world of pain.
Then an idea about using colour coding to reinforce the layout and the calculations relating to the different columns hit me. This could well be down to the fact that we’d had a staff meeting on colourful semantics just this week – an approach that colour codes different types of words to help children develop their use of grammar. Anyway, here’s what we tried yesterday.
I stuck to multiplying 2-digit numbers, but I wrote the unit/ones digit at the bottom in red and the tens one in blue. Then I wrote the calculations relating the red digit in red and the calculations, on the second line, relating to the blue digit, in blue. I modelled it, we worked through an example together. When modelling, I asked questions like “what colour pen do I need now? Why?” Then I gave them questions set out in this way and blue and red pencils to try it out themselves. It was really interesting. It was almost like having to swap pencils forced them to think about swapping columns, slowed them down and made them pay more attention to each step of the calculation. By the end of the lesson, they were all multiplying 2-digits by 2-digits, with few errors. I had moved a couple on to using 3-digit numbers too.
At the beginning of today’s lesson, I gave out three more to recap and practice – with no input – and they did them. So then we moved onto long multiplication with decimals, which I’d promised them was not a big jump now they’d done the ground work, and they could all do it. In fact, they were multiplying decimals without the need for the colour coding.
Of course this is anecdotal and I’m not suggesting colour coding is some sort of miracle, but two lessons ago, they were really struggling with the steps of long multiplication and as soon as I colour coded it, they were able to practice it more independently and have been able to move on from using it quickly. I hadn’t expected them to be multiplying decimals accurately so quickly.
I think this may be something I explore a little further as the need arises. Division next week, so who knows…


Are You Ready to Update the Furnishings in Your Home?
It is time to make a change.
After 19 years in the same house, the furniture and the decorations are looking pretty dated. While some of your friends have redecorated and redesigned their most used spaces in their homes, you have been paying for college tuition and making car payments. Now that your children are out of college and have no student loan payments to make though. it is time to do something for yourself. With piles of catalogs with pictures of fashionable Italian sofas and various types of contemporary European furniture all over the house, you feel like you are finally ready to begin making choices. Although you have been leaning toward some of the more contemporary leather furniture choices, your husband is a fan of the more traditional pieces.
With the help of an interior designer, you feel like you have found some pieces that you both like and as soon as you give your final approval, the order will be placed. By the beginning of summer you hope to have a pair of fashionable Italian sofas as well as some comfortable leather recliners that your husband will enjoy. In the meantime, you have painters scheduled and an order in for new carpet. In some ways, it was less painful to make car and college tuition payments, but you know that when the entire process is finished you will be glad that you took the time to make the changes. The new interior will not only make your home more current looking, it will also be a great new space for entertaining.
Investing in Well Made and Well Designed Furniture Changes How Guests See Your Home
Whether you are considering chic Italian sofas or high end leather furniture, it is important to invest in well made pieces that will last, instead of simply buying the cheapest pieces that you can find. consider some of these facts and figures about the home furnishings industry:
- The two types of top grain leather include full grain and corrected grain.
- A full grain leather is left in its natural state, which means that nothing has been done to alter its grain.
- Corrected grain leather refers to a type that has been altered by buffing the surface to reduce scarring or embossing to develop a special effect
- Keeping the economy rolling, the U.S. home furnishings industry generates $44.36 billion in sales a year.
- A pair of fashionable Italian sofas can completely change the look and feel of your home.
- Sofas typically have a lifespan of seven to 15 years. High end pieces of furniture that are well cared for, however, can last for generations.
- Easy to care for, leather should be maintained by simply using a conditioner every six to 12 months and wiping up spills as they occur with a clean cloth.
- As the third most expensive purchase that anyone makes, furniture sales have grown steadily in the last 20 years. In 1992, for instance, furniture and home furnishing stores sales amounted to $52.34 billion. By the year 2013, however, those sales grew to $101.41 billion.
- The only two things that most people spend more on than furniture are a home and a car.
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Best diet books of all time
While a number of authors have written on “ayurvedic massage,” most of them have not truly integrated the massage techniques into the science of ayurveda with the background and depth of knowledge of the authors of this volume. Readers of this text will gain a background in ayurvedic theory, as well as applied therapy. Ayurvedic massage can be seen as a therapeutic tool in its own right as well as a predecessor to panchakarma treatment. For the first time the important concept of “marma massage” has been explained and described. This book can be considered to be the authoritative text on Ayurvedic Massage Therapy in the field and is sure to be a classic work referred to by ayurvedic massage practitioners around the world.
Dr Sabhash Ranade
More free books Reflexology – Beryl Crane
Reflexology is a gentle and extremely effective form of therapeutic foot massage. An ancient technique of treating the whole body by pressing reflex points in the foot, reflexology is rapidly becoming one of the most popular complementary therapies.Lavishly illustrated in full-color, An Illustrated Guide: Reflexology provides an authoritative introduction to the therapeutic powers of […] Qigong Massage : Fundamental Techniques for Health and Relaxation – Jwing-Ming Yang
Qigong Massage, one of the oldest methods of healing, is built upon five thousand years of progress and a highly refined, solid theoretical foundation. Used to improve health, slow down aging, and treat many types of illnesses, Qigong massage is a wide and deep healing science, and the root of many other popular forms of massage therapy. This comprehensive text by world renowned […] Tappan’s Handbook of Healing Massage Techniques : Classic, Holistic and Emerging Methods – Frances M. Tappan
This pioneering text in massage therapy provides basic information on the art and science of effective healing massage techniques in quick-learn, easy-to-understand terms. Whether you're a licensed massage therapy practitioner, health related professional, or just interested in basic massage therapy techniques, this is the book for you!
Author: Frances M. Tappan
ISBN: […] Tappan’s Handbook of Healing Massage Techniques : Classic, Holistic and Emerging Methods – Patricia J. Benjamin
For courses in Massage Therapy and Physical Therapy. This pioneering text in massage therapy provides basic information on the art and science of effective healing massage techniques in quick-to-learn, easy-to-understand terms. Whether you're a licensed massage therapy practitioner, another health-related professional, or just interested in basic massage therapy techniques, this is […] Anatomy Flashcards for Healing Massage Techniques – Rick Johnson
An essential, portable reference tool, this is a set of anatomy flashcards printed in a small, thin 8.5 x 11 booklet of 2 perforated cards per page. It contains 88 cards showing various labeled anatomical images applied to therapeutic bodywork. Each side of each card has self-contained information about muscles, origins, insertions, actions, and nerves. Multiple muscles per card […] Marma Therapy : The Healing Power of Ayurvedic Vital Point Massage – Ernst Schrott
The effective yet gentle 'Sukshma' technique, for working with the Marma points at the emotional as well as on the physical level, is fully described in this book. Marma Therapy - the art of treating specific vital points on the human body - is one of the greatest healing secrets of Ayurveda. It can be used to detoxify, strengthen and revitalize the body, for rejuvenation and […] Healing with Touch : Massage, Shiatsu, Reflexology and Reiki – Raje Airey
This is a concise guide to the therapeutic power of hands, shown in over 170 practical photographs. You can learn how to react positively to stress and illness with therapeutic self-massage techniques. You can use shiatsu and reflexology to strengthen your immune system and improve your sense of wellbeing. It clearly explains how to use the ancient therapy of reiki to channel […] Crystal Wands : For Healing, Massage Therapy and Reflexology – Ewald Kliegel
Supported by easy-to-understand descriptions and illustrations, this compendium demonstrates the effects and uses of crystal wands as a major therapeutic tool for well-being and good health. From simple-to-perform massages to specialized reflexology uses, the featured techniques depict the multitude of possibilities for using crystal wands in tandem with massage, including […]
Best diet books of all time


Sunday, 13 October 2013
E-Focus Akwa Ibom State
E-Focus or Election-Focus aims to study each state and understand what role the state will play in determining who becomes president in 2015. This article will focus on Akwa Ibom State.
Akwa Ibom State Governor
Obong (Barrister) Godswill Akpabio
Akwa Ibom state named after the Qua Iboe river and was created in 1987 from the former Cross River State and is currently the highest oil and gas producing state in the country. The state’s capital is Uyo. Akwa Ibom has an airport and two major sea ports on the Atlantic Ocean with the proposed construction of a world class seaport Ibaka Seaport at Oron. Dr. Godswill Akpabio currently governs the state.
Results of the 2011 Presidential Election in Akwa Ibom State
For anyone current in Nigerian politics it is safe to say that the Akwa Ibom State Governor is currently the most vocal and ardent supporter of president Goodluck Jonathan amongst the Nigerian governors, safe to say for Governor Seriake Dickson of Bayelsa State. This has earned Obong Akpabio the esteemed position of Chairman of the PDP Governor’s Forum and a seat on the PDP Mini Convention Special Committee.
Results of the 2011 Governorship Election in Akwa Ibom State
Looking at the two pie charts depicted on this page it is clear that the PDP has a huge and overhwleming control of the politics of Akwa Ibom state. There have been a plethora of media reports about the ‘uncommon transformation’ going on in Akwa Ibom State which would suggest that the Governor is a working and popular governor. This only portends good things to come for the PDP in 2015, while it is a serious challenge for the All Progressive’s Congress.
If president Jonathan wins the PDP nomination in 2015, it is very clear that he will receive maximum support from Governor Akpabio and the PDP will likely win the state by a similar margin to that of 2011.
The challenge for the APC in Akwa Ibom is to try to find a way to establish itself, probably by identifying and engaging disgrnuntled members of the PDP and key opposition figures. Even if this is done it is highly improbable that the APC can win upto 5% of the votes in Akwa Ibom.
Consequently, the PDP candidate will most probably win with at least 95% of the total votes cast in 2015, if not more.


How to hire the best cleaning services?
Cleaning services play an essential role in our lifestyle. Hiring cleaning services may seem a little bit difficult. It’s necessary that the facility of providing cleaning is in the right hand or not. Maintaining a clean and healthy environment is the key to the success of the business as well as for lives too. Cleaning services Dubai is very famous for this job. For hiring the cleaning servers, you should keep some question in your mind.
Tips for hiring the best cleaning company
For hiring any cleaning service, we should keep some points in mind to consider while hiring any cleaning services. Those points are:
- Understanding your business
They can’t understand what you want from them until you tell them your requirement. Now in order to make the cleaning process uncomplicated and effective, you should explain out your needs well in advance to the cleaners.
- Cleaning schedule
Schools always cleaned every afternoon; Sports ground always cleaned in the morning before starting the practice. So it’s mandatory that the cleaning servers should be very much supple about their schedule.
If you hire experienced cleaning services, then you can be confidents about the services. They will surely provide you the best as much as possible. Cleaning services Dubai is very much experienced and good at this job.
Cleaning services are very much helpful to maintain our lifestyle. These are few tips which will help you when you will go to hire any Cleaning services Dubai. I hope that you will surely consider these points while calling any cleaning services.


Embedded Software Engineer - £28,000 to £45,000
Following on from the introduction of a new CEO last year, this company's product line is taking a change!
Due to the introduction of more wireless technology and its advancement into the world of IoT, a Somerset based electronics house are looking to add to their existing team with another embedded engineer on a permanent basis.
A senior that can hit the ground running and implement immediate change or a junior who wants to take advantage of their expertise and resource and work up the ranks would both be considered.
This position will give you exposure to full code life cycle experience in a beautiful rural setting!
*Understanding of microcontroller hardware and architectures is essential.
*Experience of embedded software development in C.
*Able to understand / interpret circuit diagrams.
*Good development, documentation, release and revision management skills.
*I2C, SPI, Bluetooth, wireless protocols, PWM, AD, UART desirable.
Although this position requires a strong user of Embedded Linux, it's also a fantastic opportunity to truly immerse yourself within this technology and become a true expert within a changeable and dynamic field. To, apply, please send an up to date CV to Charles Hoskins at iO Associates for immediate consideration.


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The service has invested considerable resources in launching what is arguably the biggest competitor to Chaturbate in the tip-based cybersex niche.The service features a rather large membership from all over the world.You will have no problem meeting new friends from either across town, across the country or even from other continents.While many performers let you watch their live sex shows at no cost, relying on tips for compensation, more and more are now migrating to ticket based shows, where a nominal fee is required to enjoy the best part of their performances.Chaturbate is, without doubt, the most popular tip-based webcam sex site on the internet.And yes, you can also meet women for real-world sex encounters.Click here to visit Sex Play Cam Play Friends is for those of you seeking a webcam sex dating service with an international clientele.You’ll need a paid membership to search the user profiles for members seeking cybersex, but rest assured, your search will turn up a very large number of users looking for Skype sex encounters.What we really like about this service is that member profiles can also contain photos, audio, and video.Video feeds are fast with very decent framerates (performer equipment dependent of course).The service enjoys a high trust factor from both users and performers.


“Think about silver as a poker video game. The stakes are from the billions. JPMorgan is Keeping an ace, king substantial royal flush. It’s a lock so they can’t reduce. Most people else with the desk has 4 of a kind or an entire property. JPMorgan is in no hurry to earn the pot.”
Any usage of components needs to be accompanied by a reference to the resource. The Company shall not be answerable for any errors or delays in the information and its publication, or for just about any steps taken in reliance thereon.
Will buyers turn to gold in 2017? Regardless of unbridled optimism about President Donald J. Trump and increasing consumer confidence, the earth is surely an unpredictable location, and any range of functions could mail investors flocking back to gold in 2017.
Investor assurance does hold prices substantial, with high desire for equities. But traders must be mindful too: confidence is usually a fragile issue in the marketplaces, and Despite the fact that it would force a stock marketplace large, it can equally as very easily bring about it to swing another way.
Fascination costs might not contain the impact on gold you may think. Anyone looking at the record of your price of gold towards the history of curiosity premiums won't see a 1:one correlation.
I use a unique method of estimate the third component (the leap and dip part) from your 1 used by the authors, but still based on dummy variables:
"Among the list of backwinds for gold has was a headwind which is likely to remain a driving power for gold prices in 2017," Fertig explained, noting that the 30-yr pattern of declining bond yields has began reversing.
The shorter term marriage concerning the S&P and gold is much more unstable, at a charge of 0.121 %. This is often why gold results in these a strong effect as a secure haven against uncertainty inside the stock marketplace. There's a substantial brief-term effect, but very little to no outcome Eventually.
But there's a growing feeling of unease amongst buyers. Growing inflation normally convinces men and women the economic system is expanding unstable, which can urge buyers to sell their positions just before the marketplace usually takes a dive.
We previously know that the gold outlook for 2017 is going to be strongly afflicted by other moves on the market more than the short-term. We also know that the lengthier expression traits and predictions for gold in 2017 will have tiny to no correlation to how the remainder of the market is going to behave heading forward.
Nevertheless, Federal Reserve plan necessarily has an infinite impact on the economic climate. It’s essential to remember the context of latest fascination prices; they’re nevertheless incredibly considerably down on the size, reduced even than when rates are actually slashed in the course of crashes from the past.
Plot the Formal countrywide debt on a log scale each and every four a long time – presidential election many years. The exponential increase (about nine% per check here annum – on a yearly basis) is unmistakable. Doubling personal debt around just about every 8 yrs is not really a profitable tactic for the US economic climate. Acquire cover!
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Greetings fellow travelers,
I’ve got some nice gigs coming up and I wanted to share the info with you.
On Thursday, August 3 I’ll be in Hillsdale, NY playing the Lounge Stage at the Falcon Ridge Festival. Our set starts at 9:15 and that round is me, Heather Lloyd and Danielle Miraglia. I look forward to seeing you there!
And Monday, August 14 and Tuesday, August 15 I’ve got “Sister Kate’s Two Dates” at the Aquinnah Town Hall on Martha’s Vineyard.
You can get the tickets for the Vineyard shows at ticketsmv.com/kate or read about our betting service.
Here’s the poster:
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Unexpected PC crashes could damage or even delete your files, so you should back up everything. Some printers and other hardware might not work, and some software might not install or work correctly, including antivirus or security programs. You might also have trouble connecting to home or corporate networks.
Also, if your PC runs into problems, Microsoft will likely examine your system files. If the privacy of your system files is a concern, consider using a different PC. For info, read our privacy statement.
What does it work with?
Technical Preview should work with the same devices and programs that work with Windows 8.1, but you might need to update or reinstall some of them.
Drivers for basic functions like storage, networking, input, and display come with Windows. These drivers allow you to complete the Windows installation and connect to the Internet. You might be able to get drivers from Windows Update.
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Adult Instruction Class
The Adult Instruction Class covers the basic teachings of the Christian faith. This class may be taken for membership in the church, but membership is not required at the completion of the course. There is no cost to enroll. This class is offered several times throughout the year, and most scheduling needs can be accommodated.
Bible Class & Sunday School
The Second, Fourth & Fifth Sundays of the month at 12:00 p.m.
Sunday School is available these Sundays during the Bible Class.


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Also, my fellow followers, I love all your responses. I realize that they all do not end up on the blog, but on my email. I am trying to remedy that situation. In the meantime, thanks for reading and responding, it makes my solitary writing life a bit more enjoyable!
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