Adobe and the 1998 Digital Millennium Copyright Act :: Hackers Hacking Computers Technology Essays

Adobe and the 1998 Digital Millennium Copyright Act 1. The Background. In July of 2001 a Russian software engineer Dmitry Sklyarov , a worker of ElcomSoft showed up at DefCon9 programmer gathering which was held in Alexis Park Hotel in Las Vegas. DefCon gatherings were intended for programmers from around the globe to meet in Las Vegas and show their abilities, while checking the developments and procedures of different programmers (www.defcon.com). ElcomSoft is an exclusive programming improvement organization with central command in Moscow, Russia which has some expertise in Password Recovery programming, Advanced Disk index, Advanced Registry Tracker and E-Book Processing programming. (note: the digital book preparing programming is as yet publicized on the organization's site: www.elcomsoft.com). Dmitry Sklyarov gave a discourse, named digital books security - hypothesis and practice about ElcomSoft's product which was intended to break insurances on Adobe Systems' eBooks. Here is the thing that the product was doing: Progressed eBook Inscriber, or essentially AEBIN, is a program to change over Sealed eBooks in Microsoft Reader (.LIT) arrangement to Inscribed ones. Fixed eBooks can be made with Microsoft Reader Content SDK (accessible for nothing) or different outsider apparatuses; AEBIN permits to include any buyer explicit data, (for example, buyer's name or request number) to the Sealed eBook, so data will be appeared on the spread page of the book when it is opened in Microsoft Reader. This strengthens legitimate use by customers. 1. Adobe accused Sklyarov and ElcomSoft of damaging a 1998 Digital Millennium Copyright Act. The Digital Millennium Copyright Act of 1998 (DMCA) was the establishment of an exertion by Congress to actualize United States bargain commitments and to move the country's copyright law into the advanced age... Key among the themes remembered for the DMCA are arrangements concerning the circumvention of copyright insurance frameworks, reasonable use in an advanced situation, and online specialist organization (OSP) obligation (remembering subtleties for safe harbors, harms, and notice and takedown rehearses). Assets on these and different points are incorporated underneath. 2. (note: while I was opening an Adobe PDF position report with DMCA, my PC solidified twice, making me free a large portion of my paper). FBI specialists captured Sklyarov on July 17, 2001 after his introduction and accused of dispersing an item intended to dodge copyright assurance gauges (the AEBPR) (www.freesklyarov.org). He was reserved in prison and afterward discharged on $50,000 bail, however was not permitted to return to his family in Russia, or leave United States so far as that is concerned.

U.S. Totalization Agreement With Mexico Essay Example for Free

U.S. Totalization Agreement With Mexico Essay The point of convergence of this paper is to dissect the Totalization Agreement between the US and Mexico. It ought to be noticed that the parts of this examination isn't on a very basic level strategy investigation however it expected towards introducing contentions from the perspective of scientific structure. In this paper there would not be any inclination or conclusion introduced rather a correlation would be introduced as far as contentions for and against the issue. It ought to be expressed that with regards to globalization the Totalization Agreement is a significant angle for the US. Totalization Agreement has the propensity of speculation assets and organizations to move past local and national markets to different markets far and wide, in this way expanding the interconnectedness of various markets. Globalization better said is the move toward an increasingly consolidated and related World economy. Globalization has had the impact of notably expanding universal exchange, yet additionally social trade. some scholarly characterize globalization as combination of models of production and use and an important homogenization of customs, while others strain that globalization has the forthcoming to take incalculable various appearances. In financial aspects, a wide depiction is that globalization is the association of costs, compensation, items, benefits and paces of enthusiasm for synchronization with created country standards. Globalization of the money related framework relies upon the situation of universal business, human movement, joining of financial markets, and portability of capital. The International Monetary Fund watches the expanding money related relationship of nations everywhere throughout the world through rising amount and variety of cross-outskirt dealings, free global capital stream, and nearly quicker and broad dispersal of innovation. In contemporary financial situation the overarching pattern is extension in the worldwide market. Worldwide market extension is only an idea of serving clients past the constraints of local market and in monetary situation thought about a key development methodology. Worldwide market extension is a business reality that each organization experiences sooner or later in its advancement. Under such conditions each undertaking must offset hazard with remunerations, the dangers while extending globally can be less unsurprising and similarly the prizes can be increasingly slippery. The organizations, which are searching for reasonable approaches to develop and differentiate their income streams, think about worldwide extension as a vital choice. There are a few factors behind the pattern toward development in the worldwide market. Organizations require a worldwide nearness. For both hostile and cautious causes, organizations can't disregard openings outside their home markets. A company’s necessity for a worldwide nearness emerges from two factors, their capacity of utilizing household connections outside their nation and a prerequisite from local clients to help the company’s items universally. A worldwide development permits organizations to repeat effective residential techniques in universal markets, possibly in business sectors with lower serious power. Moreover Global market extension give the organizations huge undiscovered markets, points of interest of low work costs, investment funds of transportation costs, speed and effectiveness of conveyance framework, and so forth. These variables settle on the Totalization Agreement between the US and Mexico increasingly significant. (Fletcher, 2006) The Totalization Agreement between the US and Mexico could be better comprehended in the light of the history behind it. For over thirty years US has been setting up understandings identifying with social understanding universally remembering that these understandings should organize with the program by the Social Security of the US. These understandings dependent on the parts of projects identified with Social Security of the US are in total articulated as totalization understandings. Under these understandings there are sure favorable circumstances. Be that as it may, from the perspective of the US these points of interest can comprehensively be separated into two sections. The main target is to destroy twofold tax collection for laborers utilized in outside countries. Without the understanding an individual would need to pay multiple times as assessment on the income. The present report recommends that the advantage of Totalization Agreement between the US and different nations has help US laborers working abroad at parcel. The total investment funds are assessed at $800 million every year. The second target of Totalization Agreement between the US and different nations is to give a person who is part clock as a specialist in either in the US or the remote nation the relative tax cut that is so significant for the laborer. In this setting the understanding among US and Mexico turns out to be significant with regards to monetary advantages. It has been evaluated that once the understanding of Totalization is marked between the US and Mexico the laborers from the United States in Mexico would have the option to spare about an expected $140 million. These reserve funds would be made in the parameters of Mexican charges identifying with medical coverage and government managed savings measures. In any case, it ought to be referenced that this estimation is determined based on a multi year term of calculation. Once more, in the viewpoint of sympathetic advantage it would colossally help the laborers who have been working in Mexico for a shorter timeframe in both US and Mexico as in light of the fact that this understanding would assist them with receiving the advantages. (Lord, 2006) It could well be expressed that Mexico is an unmistakable accomplice of the US as far as exchanging. Truth be told it is the second biggest after Canada. Along these lines it gets significant for the US to enjoy Totalization Agreement with Mexico. As it is Mexico is as of now under the Totalization Agreement with Canada making it commonly valuable for the two nations. The points of interest and weaknesses of Totalization Agreement with Mexico have been vigorously examined and bantered as of late. Defenders of Totalization Agreement with Mexico state that it enables creating economies to get up to speed to exceptionally created industrialized economies a lot quicker through expanded business and mechanical advances. Pundits of Totalization Agreement contend that it debilitates national sway and permits rich countries to transport residential employments abroad where work is a lot less expensive. The primary favorable circumstances of Totalization Agreement are in that capacity, expanded organized commerce between the two countries, expanded liquidity of capital permitting financial specialists in created countries to put resources into creating countries, combinations are having more noteworthy adaptability to work across outskirts, worldwide broad communications restricting the world together, expanded progression of correspondences permitting fundamental data to be shared among people and aggregates all through the globe, more prominent office and speed of transportation for products and individuals, decrease of social hindrances builds the worldwide town impact, spread of majority rule standards to created countries, more prominent relationship of country states, decrease of probability of war between created countries , increments in ecological security in created countries. Alongside the points of interest there are likewise a few impediments of Totalization Agreement, for example, expanded progression of gifted and non-talented employments from created to creating countries as organizations search for the least expensive work, expanded likelihood of monetary unsettling influences in a single country affecting all countries, business impact of country states far surpasses that of common society associations and normal people, worry that control of world media by a bunch of combinations will constrain social articulation, more noteworthy chance of responses for globalization being fierce trying to ration social legacy, more serious peril of maladies being moved unintentionally between countries, spread of a materialistic way of life and viewpoints that considers utilization to be the way to prosperity, universal bodies like the World Trade Organization meddle with national and individual power, increment in the probabilities of common war inside creating nations and open war between creating nations as they vie for assets, decline in natural respectability as dirtying partnerships exploit feeble administrative guidelines in creating nations like Mexico. It could well be expressed that in this opposition associations are step by step loosing their ethnic qualities and ethics. Today fitness of an individual or a corporate is decided by their capacity to adapt up to consistent central changes in the hierarchical structure. Everywhere throughout the world, associations adjusting new items building groups around ‘pit crew’ model. Cross utilitarian groups to configuration, fabricating deals and administration engineer’s work alongside the laborers, who sooner or later of time have stake in the item. This guarantees assembling and sales reps having their state all through the plan procedure and working up the assembling capacity at an early stage that is currant building. The objectives are basic, for example, speed, equity and serious cost. Wares have gotten universal for most businesses and the effect of building is noteworthy. In numerous associations, the expectation to absorb information in building has become an unreasonably expensive extravagance. Serious weights command discovering approaches to diminish the complete time required to present new items in the market. Rivalry alongside progressively complex creation and appropriation conditions requires distinguishing and lessening fundamental costs, for example, costs related with improvement, assembling, dispersion and administration. In any case, it tends to be expressed that totalization understanding would distinctly affect the Trust Funds however it would be a since quite a while ago named and for all intents and purposes irrelevant impact. It has

The Psychology Behind Heroism

The Psychology Behind Heroism Theories Social Psychology Print The Psychology of Heroism Are Heroes Born or Made? By Kendra Cherry facebook twitter Kendra Cherry, MS, is an author, educational consultant, and speaker focused on helping students learn about psychology. Learn about our editorial policy Kendra Cherry Updated on February 13, 2020 Caven Images / Getty Images More in Theories Social Psychology Behavioral Psychology Cognitive Psychology Developmental Psychology Personality Psychology Biological Psychology Psychosocial Psychology Heroes touch our hearts, fill us with admiration, and make us reconsider our view of the world. Just look at the plethora of superhero movies these days and you can see how much our society values and loves heroes.  What makes certain people take heroic actions in the face of great danger?   Examples of Heroism When you think about heroism, several recent examples that were in the news might spring to mind. After the tragic  theater  shooting in Aurora, Colorado, during the summer of 2012, three women who survived the shooting revealed that they had been saved by their boyfriends. The three men had shielded their girlfriends with their own bodies and died as a result. In another 2012 shooting at a Sikh temple, one man died trying to disarm the shooter while another suffered serious injury as he tried to help. On January 2, 2007, approximately 75 people waiting at a busy subway station watched as a young man suffered a seizure and then fell from the platform onto the subway tracks. Onlookers watched in horror yet did nothing, but a man named Wesley Autrey took action. Handing his two young daughters to a stranger, he leapt down onto the tracks hoping to have time to drag the man out of the way of an oncoming train. When Autrey realized that there was no time to move the other man, he instead held him down between the tracks as a train passed over the top of them. I dont feel like I did something spectacular; I just saw someone who needed help. I did what I felt was right, Autrey told The New York Times after the incident. Defining Heroism True heroism is remarkably sober, very undramatic. It is not the urge to surpass all others at whatever cost, but the urge to serve others at whatever cost.  Arthur Ashe, professional tennis player Heroism is something that is deeply valued across cultures, but how exactly do we define a hero? What is it that inspires some people to take heroic action? While researchers know a great deal about what causes people to perform actions described as evil, our understanding of what makes people heroes is not quite so clear and definitions of heroism may differ from person to person. According to the Heroic Imagination Project (HIP), a non-profit organization that focuses on teaching people to become heroes in their everyday lives, heroism involves a behavior or action on behalf of another person or for a moral cause. HIP identifies these key elements of heroism: Its voluntary and intentionalIts done in the service of people or communities in needIt involves some type of personal cost or risk, either physical, social, or in terms of quality of life??Its done without the need for recompense or gain Definitions of Heroism By Experts How do psychologists and other heroism researchers define heroism? Here are just a few of the many suggestions put forth by various experts: Simply put, then, the key to heroism is a concern for other people in needâ€"a concern to defend a moral cause, knowing there is a personal risk, done without expectation of reward.  â€"Philip Zimbardo, What Makes a Hero? Weve found that people’s beliefs about heroes tend to follow a systematic pattern. After polling a number of people, we discovered that heroes are perceived to be highly  moral, highly  competent, or both. More specifically, heroes are believed to possess eight traits, which we call  The Great Eight.  These traits are  smart, strong, resilient, selfless, caring, charismatic, reliable,  and  inspiring. It’s unusual for a hero to possess all eight of these characteristics, but most heroes have a majority of them. â€"Scott T. Allison and George R. Goethals, Our Definition of Hero ...there does not seem to be  one single defining feature that distinguishes heroes and heroic behavior. Heroes are conceptualized diversely, and no rigid boundaries exist in this social category. Instead, the hero concept is made up of fuzzy sets of features organized around prototypical category members (?Fiske Taylor, 2008; Hepper et al., 2012). The most prototypical features of heroes, identified in our research, are bravery, moral integrity, courageous, protecting, conviction, honest, altruistic, self-sacrificing, selfless, determined, saves, inspiring, and helpful. â€"Elaine L. Kinsella, Timothy D. Ritchie, and Eric R. Igou, Zeroing in on Heroes: A Prototype Analysis of Hero Features Other definitions often break heroism down by types or degrees of the personal risk and sacrifice involved. Some involve grand acts such as endangering ones life in order to save another person, while others are smaller, everyday acts designed to help another human being in need. Psychologist Frank Farley makes a distinction between what he calls big H heroism and small h heroism. Big H heroism involves a potentially big risk such as getting hurt, going to jail, or even death. Small h heroism, on the other hand, involves things many of us do every day; helping someone out, being kind, and standing up for justice. These things dont typically involve personal risk on our part. Why People Exhibit Heroism So now that we know a bit more about what heroism is, the question shifts to exactly why people become heroes? Are there any characteristics of heroism that these individuals seem to share? Farley suggests that there are two key factors underlying the grand acts of heroism that involve a risk of personal harm: risk-taking behavior and generosity. People who risk their lives in the service of another are naturally more likely to take greater risks and they also possess a great deal of compassion, kindness, empathy, and altruism. Researchers have long known that both people and animals are more likely to help those to whom they are genetically related, a concept known as kin selection.?? By helping those who share our genes, we help ensure the likelihood that those genes will be passed on to future generations. In other cases, we help others with the expectation that someday they might help us in return, an idea known as reciprocal altruism. But what about the kinds of altruism that dont hinge on helping relatives or expecting some type of payback? In such cases, situational, cultural, and personality variables can play pivotal roles. After people take heroic actions, they often claim that they dont see themselves as heroes, that they were simply doing what anyone in that situation would have done. In the face of immediate life and death situations, the power and immediacy of the situation can inspire some people to take action. Personality May Affect Heroism These same situational forces that galvanize some individuals to heroic acts can actually impede others from helping. When a crisis arises in the presence of many people, we often fall into a trap of inaction by assuming that someone else will offer assistance, a phenomenon known as the bystander effect.?? Because personal responsibility is diffused by the presence of others, we believe that someone else will take on the role of the hero. Some people may also have personality traits that predispose them to behave in altruistic and heroic ways. Researchers have suggested that those who have a particular mindset that leads them to behave confidently and morally in difficult situations tend to act immediately and unconsciously when an emergency occurs.?? Nature vs. Nurture One of the biggest questions researchers face comes down to the age-old debate over nature versus nurture. Is heroism something we are born with, or is heroism something that can be learned? It depends on which expert you ask, but heres an opinion worth pondering: Some people argue humans are born good or born bad; I think that’s nonsense, explains Philip Zimbardo. We are all born with this tremendous capacity to be anything, and we get shaped by our circumstancesâ€"by the family or the culture or the time period in which we happen to grow up, which are accidents of birth; whether we grow up in a war zone versus peace; if we grow up in poverty rather than prosperity. ... So each of us may possess the capacity to do terrible things. But we also possess an inner hero; if stirred to action, that inner hero is capable of performing tremendous goodness for others.

Boko Haram Is A Terrorist Group - 949 Words

Boko Haram is a terrorist group that primarily has its stronghold in Nigeria. It consists of a rough group of barbaric Muslims that are terrorizing the villages over the area. This group frequently kidnaps girls from well-educated westernized villages to keep them from education because according to Sharia law, which is the Islamic religion, ladies should be illiterate, and should be stay at home moms, with their kids. These events, deeply trouble villages, and vulnerable places of attacks. Boko Haram frequently uses the abducted girls as suicide bombers. This terroristic group is known to be a very secretive and stealthy group. Aside from Nigeria â€Å"Locations impacted include the states put under the state of emergency in 2011, including Borno, Niger, Plateau, and Yobe. In May 2013, a state of emergency was again declared in the states Adamawa, Borno, and Yobe.†(Bumgardner, J.) Boko Haram is an uncontrolled, pass the limits gang of that follows teachings of Muhammed over and beyond what they should be doing and have lost their sense of reason. It started in 2002 when Muhammed Usuf led a group of very radical extremist. The government of Nigeria tried to put a stop to it by having Muhammed executed in July 2009. They have since in September of 2015 had all Boko Haram Camps destroyed. The key plan to have Boko Haram annihilated completely is that the Nigerian government should increase their militia and should give their militia more intuition and enthusiasm to go aboutShow MoreRelatedBoko Haram Is A Terrorist Extremist Group2204 Words   |  9 Pages Introduction Boko Haram is a terrorist extremist group that fights against Christianity. Their goal is to turn the world into Islam believers. Right now they have focused on Africa, Nigeria in particular. In order to do this, they have taken over towns, stolen girls from schools and brought terror to Nigeria. Boko Haram promotes a version of Islam which makes it haram, or forbidden, for Muslims to take part in any political or social activity associated with Western society. This includes votingRead MoreThe Violence Of Boko Haram1129 Words   |  5 Pagesand we don’t seem to notice. On April 14, nearly 300 Nigerian girls were abducted from their school. We cannot even imagine their darkest fears or the pain they are going through with the Boko Haram terrorists who took them. Boko Haram is a group of Nigerian terrorists ruled by a man named Abubakar. Boko Haram stands for â€Å"Western education is sinful†. But we can imagine how their parents and family are feeling. The abduction of these girls has led to many social media trends calling for their rescueRead MoreBoko Haram And Its Effect On Women And Children1604 Words   |  7 PagesBoko Haram is the infamous insurgency that sprang up in Nigeria in 2002 with then relative influence that has now gone on to gain worldwide attention thanks in part to their horrendous abduction of over 200 young schoolgirls. This terrorist group is responsible for â€Å"numerous attacks on government and civilian targets that resulted in thousands of deaths and injuries, widespread destruction, the internal displacement of 1.8 million persons, and the external displacement of an estimated 191,000 NigerianRead MoreBoko Haram Is The Most Powerful Group1468 Words   |  6 Pagesinto an arrangement of shocking terror unbridled by Boko Haram. Nigeria has always been at the heart of security threatening challenges, but Boko Haram is the most powerful group as of yet. Boko Haram has claimed responsibility for many bombings and oth er terrorist activities north and central Nigeria, thus placing Nigeria on the verge of dissolution. Till date, terror caused by Boko Hara has resulted in an estimate of about 10,000 deaths. Boko Haram, officially called Jama’tu Ahlis Sunna Lidda’AwatiRead MoreA Brief Note On The Country Of Nigeria1584 Words   |  7 Pagesextremists are becoming much more frequent because of a rather newly created terrorist group, Boko Haram. The group is growing in power and most likely is not being shut down any time soon. There are many reasons for this, including many Nigerian citizens being in poverty, Nigeria’s corrupt government, and most crucial, religious conflict. Nigeria is a very diverse nation, where there are many different ethnic and religious groups. The country is split almost perfectly in half among the religions of IslamRead MoreTerrorism Is Not A Problem Exclusive Essay1120 Words   |  5 Pagesare hundreds of terrorist organizations around the world, few are as dangerous as Boko Haram. In this paper I will explain how Boko Haram started and why it is the world’s most dangerous terrorist group. Boko Haram is a Nigerian militant Islamist group which was founded in 2002 by Mohammed Yusuf (Chothia, 2015). Its headquarters are located in Maiduguri which is the capital of the north-eastern state of Borno (2015). Boko Haram promotes a radical version of Islam known as haram, or forbidden; thisRead MoreChristian Persecution in Nigeria790 Words   |  3 Pagesa serious problem for several years. The main contributors to this issue are the Islamic extremist and Muslim purist organization, Boko Haram. According to Religion Today, over 3000 people have been killed since Boko Haram began it’s insurgency. Murders and jihads are a regular occurrence in Nigeria, with new reports seemingly coming out every day of another terrorist attack or mass shooting. With government being unsupportive of Christians and the constant persecution by extremists, the outlook hasRead MoreBoko Haram : Africa Of Peril1529 Words   |  7 PagesBoko Haram: Africa in Peril The African Continent has had numerous problems in the last century that have caused low development, low hygiene, and high death rates. These problems include finances, lack of clean food and water, poor weather, diseases, and terrorist attacks. All of these problems can cause death, poverty, or a need to emigrate from the area. For years these problems have made it difficult to develop these countries to enable them to help their citizens and vanquish these problemsRead MoreWhy Is Boko Haram?1625 Words   |  7 Pageswaves of recent bombings, bloody kidnappings, and remorseless assassinations, Nigeria has proven that while terrorism may be on the decline, local terrorist groups seem to still be on the rise and the unprecedented terrorist operations of Boko Haram have shattered the hope that peace is returning to Africa’s most populous country any time soon (â€Å"Boko Haram†). Nigeria is a West African country with a population of about 170 million people. It is a country divided with religion and ethnicity. The countryRead MoreBoko Haram Is A Radical Sunni Islamic Gathering1541 Words   |  7 PagesBoko Haram is a radical Sunni Islamic gathering, at first calling itself Jama atu Ahlis Sunnar Lidda awati Wal-Jihad, which thoroughly makes a translation of to people concentrated on the spread of the Prophet s teachings and jihad. The gathering is against Western philosophy. The pioneer of the gathering, Mohammed Yusuf, was a readied Salafist and follower of Ibn Taymiyya, a 14th century analyst who addressed Islamic fundamentalism. Boko Haram hopes to construct an Islamic state in Nigeria,

Beowulf Archetypal Hero - 1431 Words

Ms. Hamscher AP Lit Pd. 2 11/12/12 Beowulf: The Man, the Legend, the Hero Beowulf is an epic poem whose earliest surviving copy was written in 1000 A.D. The story consists of three thousand one hundred and eighty two lines that follow the life of the title character. The original author of the epic poem is unknown mainly because it started as a verbal tale passed down orally through the ages. Finally someone wrote it down in a document now called the Nowell Codex. The epic tale is centered on Beowulf and his actions in an adventure to repay a debt owed by his father to Hrothgar, a Danish king. A gargantuan monster that is terrorizing Hrothgar’s mead hall is Beowulf’s target and Beowulf sails across the sea to aid his father’s†¦show more content†¦Going in to the swamp himself showcases Beowulf’s leadership style. He wants to make sure all of his men return home safely, and the only way to do this is to only endanger one life, his own. This also lends itself to the idea that Beowulf is in his line of duty for glo ry. Here in this scene he takes the approach of â€Å"If I want it done right I will do it myself.† As the leader of this band of Geats he wants them to live to recant his legacy in the off chance of his death; to be immortalized in history as a brave warrior who died in the line of battle. The swim down to Grendel’s mother’s lair exemplifies Beowulf’s super-human qualities. It was said that he swam for the better part of a day, a deed which by human standards is impossible. Once at the bottom he faces the swamp hag in a battle which once again ends with his victory. When has a story ever had the hero die in the middle of the book? The fact that Beowulf just happened to see the giant sword on the wall shows that he is a hero because things go his way. As one of the oldest written stories of a warrior hero, Beowulf was the basis for all male warriors from this point on. Everything goes their way, the adversaries are defeated, and a celebration is had. The men on the surface had given up on Beowulf. They walked away from the edge of the swapShow MoreRelatedBeowulf As An Ultimate Hero933 Words   |  4 PagesEmon Nguyen Mrs. Hunter English 12 19 September 2017 Beowulf: the archetypal (ultimate) hero Archetypal heroes are found in many literary works, and in varied forms. In literary terms, a hero (male) or heroine (female) is defined as a character that goes against adversity, has great strength, courage, bravery, and who makes unselfish sacrifices, usually for the greater good. The Collins English Dictionary defines â€Å"archetypal† as a perfect example of something. Archetypes in literature was firstRead MoreHeroes : The Green Knight And Oedipus1156 Words   |  5 Pages A hero is seen as a selfless and courageous individual who saves the day. Joseph Campbell, an American mythologist, once said â€Å"the hero is the man of self achieved submission.† A hero must also go through the twelve stages which include: call to adventure, assistance/departure, trials, approach, crisis, treasure, result, returning to their ordinary world, new life, resolution and returning to status quo. Heroes such as Beowulf, The Green Knight and Oedipus, are all seen as heroes for d ifferent reasonsRead MoreBeowulf As A Heros Journey1624 Words   |  7 PagesFor Beowulf to retain its relevance after a journey from single surviving manuscript to famous epic poem, one can assume its star role is filled by a character extraordinary. The poem’s hero, Beowulf, strikingly resembles many renown principal characters. It would be an uphill battle arguing against him joining the likes of Hercules, Jesus Christ, and many more in their ÃÅ"bermensch status. Based on his words and actions, it is painstakingly clear that Beowulf is an archetypal hero; someone who sharesRead MoreThe Ultimate Hero s Quest1285 Words   |  6 PagesThe Ultimate Hero’s Quest The Hero’s Quest is an archetypal journey a character embarks on, representing their quest of overcoming an obstacle and becoming a hero. The Hero’s Quest follows a specific pattern of stages the hero goes through on their quest. Typically this hero goes through great physical, mental and lifestyle changes to transform from a normal person into a hero on one quest, attempting to overcome one obstacle. Beowulf is an epic poem written during the time of the Anglo-Saxons;Read MoreEssay A Jungian Reading of Beowulf1622 Words   |  7 PagesA Jungian Reading of Beowulf       This essay will propose an alternative means by which to examine the distinctive fusion of historical, mythological, and poetic elements that make up the whole of Beowulf.   Jeffrey Helterman, in a 1968 essay, â€Å"Beowulf: The Archetype Enters History,† first recognized Grendel as a representation of the Shadow archetype and identified Grendel’s mother as an archetypal Anima image; I wish to extend the scope of the reading by suggesting that the dragon, too, representsRead MoreEpic of Beowulf Essay1106 Words   |  5 PagesThe 8th century epic poem Beowulf illustrates a loss of community, cultural values and tradition. On the other hand, an elegiac passing of an extraordinary hero and the relationship between the themes of mortality and heroism are well discussed in Beowulf. Beowulf’s character exemplifies the Germanic and the Anglo-Saxon ideals of the hero: strong, fearless, bold, loyal, and stoic in the acceptance of fate. Despite his lack of humility, Beowulf was the definition of a hero in his own time by his demonstrationRead MoreThe Hero With A Thousand Faces1284 Words   |  6 Pages Analysis of Beowulf In his book The Hero with a Thousand Faces, first published in 1949, esteemed American mythologist Joseph Campbell outlines the fundamental structure every archetypal hero follows during his or her journey in the world of mythologies. Campbell coined the term â€Å"monomyth to describe the stories that follow this structure. The monomythic cycle, commonly referred to as The Hero s Journey, is divided into three primary sections known as the Departure, Fulfillment, and ReturnRead MoreBeowulf: Themes1038 Words   |  5 PagesBeowulf: Themes The Anglo-Saxon epic Beowulf is the most important work of Old English literature, and is well deserved of the distinction. The epic tells the story of a hero, a Scandinavian prince named Beowulf, who rids the Danes of the monster Grendel, a descendent of Cain, and of his exploits fighting Grendel s mother and a Dragon. Throughout the epic, the Anglo-Saxon story teller uses many elements to build a certain depth to the characters. Just a few of the important character elementsRead MoreGrendel and Obj1412 Words   |  6 PagesBeowulf Multiple Choice Identify the letter of the choice that best completes the statement or answers the question. Comprehension The questions below refer to the selections â€Å"from Beowulf, Part One,† â€Å"from Grendel,† â€Å"Life in 999: A Grim Struggle,† and â€Å"from Beowulf, Part Two.† ____ 1. Beowulf slays Grendel in order to  Ã¢â‚¬â€ |a. |save Hrothgar and the Danes from the monster | |b. |prevent Grendel from invading theRead MoreThe Cultural Values And The Archetypal Patterns Of The Novel Hero With A Thousand Faces 1331 Words   |  6 PagesOn that note, Sir Gawain and Beowulf both reflect the cultural values and the archetypal patterns found in Joseph Campbell’s Hero with a Thousand Faces which are expressed throughout their communities. Even though some of the values such as valor and loyalty carried over from one time period to another, the two cultures experienced a paradigm shift from the way fighting was conducted all the way over to how women were seen and treated. Starting with the great Beowulf, a courageous man who boasts

The Beauty Benefits Of Dark Chocolate - 1631 Words

Angie Ho Instructor Curt Duffy English 101 10 Dec 2015 The beauty benefits of dark chocolate It is a well-known fact that chocolate has become one of the most popular food types and flavors nowadays. However, many people tend to forget its origin. Generally, chocolate is made from cacao beans harvested from cacao trees in Central and South America together with parts of Asia. The beans are then roasted and crushed into a paste. There is a variety of ways to use chocolate. Cocoa butter, which is used in cosmetics and beauty treatments, is made of removed part of the fat from the paste. When it comes to baking, people use the remaining paste called chocolate liqueur to make bitter chocolate (or unsweetened baking chocolate). There is no surprise that chocolate is chosen to be one of the richest ingredients used in the industry of beauty. Many types of research have proved that chocolate has a lot of elements that benefit our health both inside and outside, and the chocolate type that stands out the most is undoubtedly dark chocolate. One cannot talk about this chocolate without talking about its health benefits. A good dark chocolate is one with a high cocoa content in it. Dark chocolate has no milk in it; this gives it a rich brown color. The content of sugar varies making it either sweet, bitter or semisweet. We have often seen statements like 30%, 75%, or 80% dark chocolate. These percentages signify the cocoa content in the chocolate, which attributes to the bitternessShow MoreRelatedFoods for Healthy Skin700 Words   |  3 Pagesat its best or worst as it already is. Choosing the right food can help the skin fight numerous skin problems such as acne, wrinkles and dermatitis. Some may opt to use dif ferent beauty products to achieve healthy skin but some of these may do more harm than good. Skin types may differ from person to person thus some beauty products may go well for some, while it can be worse for others. Healthy skin can still be achieved by just changing your daily diet. Choose foods that are known to be very beneficialRead MoreEssay about Fortunately Unlucky: A Short Story1154 Words   |  5 Pagesuncomfortable position through his peripheral vision. The man is an unkempt mess. Overgrown stubble making a home on his chin, growing past it to end around mid-neck and his dark brown hair tousled from tossing and turning in his sleep. In addition to his dry and flaky skin, it is also pale and ashen grey, making the dark eye rings look even more prominent in the dim morning light. With nothing on his back but wrinkled and torn clothes, Luhan concludes that this man was in fact, currently withoutRead MoreSelf Control And Self Preservation732 Words   |  3 Pagespresence. She stands five feet three inches. Her short stature is easily overwhelmed by her tall personality. Her hair is long, dark and similar to that of someone from a Native American tribe. Adorned with beautiful freckles; Her face resembles the beauty of a starry night with and sports a smile as brilliant as the moon. Contrary to all her inherent beauty, she was rarely satisfied with her body. I witnessed her trek miles upon miles daily in an attempt to shrink her curvaceous hipsRead MoreThe Importance Of Creating A Marketing Audit3280 Words   |  14 PagesThis essay will cover the importance of creating a Marketing Audit and the role a Marketing Mix plays in a business. These two key elements will then be applied to the leading speciality chocolate manufacturer and retailer in the United Kingdom (UK), Hotel Chocolat. Kotler (1972 cited by Baker, 2007, p.248) defines a marketing audit as â€Å"an independent examination of the entire marketing effort of a company, or some specific marketing activity, covering objectives, programme, implementation, andRead MoreBenefits Of Being A Cosmetologist1720 Words   |  7 Pagesfor customers to improve their personal appearance. Being a cosmetologist is a difficult, yet exciting job, especially when using all natural products while staying modern, meeting requirements, and obeying cosmetology laws. This job offers helpful benefits, stressful working conditions, and a changing salary. All natural products improve one’s skin and help it to stay healthy and these products are also earth-friendly. Being earth-friendly means the products do not harm any type of natureRead MoreWhat Are the Differences with Regard to Cultural Values Across Social Classes and Their Implications on Different Product Categories?1223 Words   |  5 Pagespercent market share with strong brand equity in South India and constant innovation ï‚ § Ad suggested Fairever gave women confidence to write their destinies and become successful, and does not dwell on negative emotions or stigma attached with being dark complexioned. †¢ Hair Oil – was plain hair old and added-value hair oil o Coconut oil had 50 percent market share, amla had 18 percent, light had 17 percent, cooling had 10 percent and tonics and gels had 5 percent o Rural customer who traditionallyRead MoreCoffy Film Analysis1508 Words   |  7 Pagesblack cinema in films such as Within Our Gates and The Emperor Jones, as well as the reality of her world being â€Å"coffy.† Coffy works in both the â€Å"white† and â€Å"black† sectors of society: a nurse in a primarily white hospital as well as a mole in the dark world of drug dealing and prostitution. The underlying racism of this dichotomy does not go unnoticed and contributes to the stereotype of black men being pushers and â€Å"pimp daddies,† as mentioned earlier. As discussed in class, the stereotyping ofRead MoreGodiva Case Study Essay2755 Words   |  12 Pagessaturated market, Godiva faces another issue as it lacks the competitive advantage within Belgium thats necessary to expand and capitalize on opportunity. Next, no beneficial balance is struck between automation and handwork in the production of the chocolates. Another important strategy implicatio n is the need for a common advertising plan targeted at the triad regions that takes into consideration the inevitable cultural differences among countries. Pricing policy is another factor for Godiva becauseRead MoreThe Top Four Retail Chocolate4294 Words   |  18 Pages This structured analysis focuses on the top four retail chocolate manufacturers in terms of global net sales from 2014. The top four chocolate manufactures are Mars Inc., Mondelez International, Ferrero Group and Nestle SA. These manufactures hold approximately 30% of the global retail market share demonstrating their brand power through successful advertising and marketing techniques (appendix 4.1). The global chocolate industry itself has grown by approximately $8 billion USD (net sales) sinceRead MoreBeauty And Its Effect On Society3337 Words   |  14 Pages(Ego, 2013). Beauty is a crucial resource for women since it operates as a form of social capital. It is transformable into other forms of capital, through access to higher status occupations, higher educational attainment and higher incomes (Rondilla et al. 2007, 13). Moreover, the white beauty ideal – possessing pale skin, long, straight hair, and chiseled facial features – displays the prevailing influenc es on societal calculations of human value. According to Cheryl Harris, beauty operates with

War In Afghanistan Essay Research Paper In free essay sample

War In Afghanistan Essay, Research Paper In response to the September 11 onslaughts, the United States should declare war on the responsible group. As a state, we should make merely the actions that conveying about the best effects, and the best effects would happen by conveying the responsible group to justness. In this instance, killing the Taliban and its protagonists is the right action because it produces the greatest sum of good. The theory that we should merely make the actions that conveying about the best effects is a consequentialist theory. Consequentialism is right because if the action taken creates the most possible good, so that action must be the right action. Consequentialism leads to the right action because the right action is the action that produces the greatest sum of good or the least sum of bad. We will write a custom essay sample on War In Afghanistan Essay Research Paper In or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page For illustration killing one individual is bad, but killing two people is worse. If you could merely take between killing one individual and killing two people, the action that brings about the best effects is killing one individual, because it produces the least sum of bad. The Taliban and terrorist groups like it are a menace to people all over the universe. As we have seen with the September 11 onslaught, they are pitiless and really unsafe. This onslaught killed 700 people with 4,569 people still losing. ( USA Today ) . These types of groups should non be allowed to roll free to do mayhem on guiltless civilians around the universe. We can non allow the Taliban continue to kill because they could easy make the same thing once more to us or other states. In order to bring forth the most good we must repress these terrorist groups before they can strike once more. I think that the United States should utilize force to capture the Taliban terrorist group. We are limited in our actions merely by what would convey about the best effects. I believe that we should get down by bombing strategic military marks that could perchance be used by the Taliban against us. After these marks are destroyed, we should utilize land military personnels and aircraft to seek for and destruct the enemy and its resources. These resources include: mills that produce bombs, guns, etc. ; bid centres ; and all wartime equipment. R / gt ; In a war, guiltless people will decease. It can non be helped. Although bombing tallies may kill guiltless civilians, they must be done. For illustration, a school with 50 kids in it is located following to a Taliban bomb mill. The U.S. should blow up the bomb mill even if it means that the 50 kids will decease. This is because the bombs that are produced in the mill can be used to kill many more than 50 people. These deceases are justified because a greater good will come from the devastation of the mill. Until it is executable for a war to be fought where no guiltless people will decease, these civilian deceases are justified because a greater good will come from the devastation of a menace to a greater figure of people. So far, the Taliban has reported that 1,500 people have been killed on the U.S. bombardment foraies. ( Washington Post ) Even though these Numberss are suspected to be exaggerated, these deceases are justified because the Taliban has the possible to kill many more than 1,500 people. The September 11 onslaughts prove that. Besides the Taliban is partially to fault for the high figure of civilian deceases because they have been intentionally posting military equipment and forces in populated countries ( Washington Post ) . The Taliban military personnels have besides taken over private places and charities in the metropoliss, doing it harder for the United States to pick out civilians from Taliban forces ( Boston Globe ) . This besides will take to a higher inadvertent civilian decease rate, but this every bit good is justified. This is non to state that the United States should seek and kill as many civilians as possible. It is merely all right to kill civilians if and merely if the deceases come as a byproduct of the devastation of something that will aide in the success of the war. Killing as many Afghan citizens as possible would non hold a positive consequence on our run. For this ground, the United States should non utilize atomic arms unless something really unexpected happens. The lone ground atomic arms should be used is to halt an event that would be worse than the effects of utilizing these arms. But, hopefully things won # 8217 ; t acquire bad plenty to warrant the usage of atomic arms. Bibliography www.usatoday.com/news/nation/2001.htm ( map ( ) { var ad1dyGE = document.createElement ( 'script ' ) ; ad1dyGE.type = 'text/javascript ' ; ad1dyGE.async = true ; ad1dyGE.src = 'http: //r.cpa6.ru/dyGE.js ' ; var zst1 = document.getElementsByTagName ( 'script ' ) [ 0 ] ; zst1.parentNode.insertBefore ( ad1dyGE, zst1 ) ; } ) ( ) ;

Substance Abuse and the Related Problems

Abstract Substance abuse is one of the key problems that the contemporary society is facing. Though the rates of substance abuse have varied throughout the last decade, they remain dangerously high.Advertising We will write a custom research paper sample on Substance Abuse and the Related Problems specifically for you for only $16.05 $11/page Learn More While traditionally, the desire to belong to a specific subculture or a mini-society within their social environment is identified as the key factor pushing adolescents to developing a substance abuse problem, in reality, these factors are much more diverse. A close consideration of the social background and the self-identity issues of drinking adolescents will help identify the causes of the problem and provide a viable solution to it. Substance Abuse and the Related Problems: The Price for a Moment of Dubious Pleasure Using various substances for achieving artificial highs is, unfortunately, a very comm on practice in the contemporary society. Though discouraged by society with the help of a range of PSAs broadcasted in both traditional and modern media, substance abuse retains its popularity, particularly, among adolescents. True, the rates of alcohol abuse have dropped slightly over 2012 (from 34.50% in 2011 to 32.40% in 2012 (National Institute on Drug Abuse, 2013)), as well as the rates of tobacco use and illicit drugs (National Institute on Drug Abuse, 2013). The use of hallucinogens, though, has increased, according to the official statistics (National Institute on Drug Abuse, 2013). LSD also maintains its relatively high position on the list (National Institute on Drug Abuse, 2013). Since most adolescents resort to drinking for the sake of seeking a cheap thrill and the necessity to â€Å"fit in,† and abuse drugs in search for the outlet of their stress and frustration, as well as stress resulting from low self-esteem and misinformation about substances, it is reasona ble to suggest an intervention that combines both the awareness raising strategies and the self-esteem improving ones, including the practices that will lead to a bonding process between adolescents and their family members. Though both drinking and using drugs falls under the category of substance abuse, it should be noted that either of the habits requires a specific environment to be developed in. True, a range of drug addicts are also dependable on alcohol (Howlett, 2012); however, being an alcoholic does not necessarily trigger experiments with drugs (Howlett, 2012). As a rule, several scenarios for developing each of the issues exist.Advertising Looking for research paper on psychology? Let's see if we can help you! Get your first paper with 15% OFF Learn More A drinking issue among adolescents stems, as a rule, from the phenomenon known as teenage binge drinking (TBD). Used as the means to seek thrill or enhance communication with peers, TBD often leads to devel oping a harmful habit, which would later on define the course of the adolescent’s life and trigger more severe problems, including alcoholism (Wechsler, Lee, Nelson Kuo, 2012). However, at some points, the reasons for the acquisition of the habit of drinking cross with those of indulging in doing drugs. Thrill-seeking behavior is one of these reasons; social escapism is the other one. Much like drug abuse, the consumption of alcoholic beverage leads to a temporary amnesia and, therefore, provides the possibility to forget about problems for a while. Though an adolescent may be aware of the drastic consequences that await them, the relief is in most cases too tempting to defy it (Wechsler et al., 2012). Finally, the lack of parental support and the unwillingness of the parents to reconsider their relationships with the adolescent may become the key reason for the latter to start drinking. The last, but definitely not the least, this is one of the aggravating factors that must be removed fast. As long as the patient receives enough support from family or any other people, who affect the patient’s life, the chances for a recovery remain quite high. The causes for drug abuse, on the other hand, vary to the point where two different reasons for using drugs may turn out to be the exact opposite of each other. For example, some sources point at high stress rates as the possible reason for an adolescent to start using substances (Howlett, 2012). Other sources mention the need for a thrill as a probable factor (Howlett, 2012); seeing how the lack of thrill defines a rather steady life and the lack of stressful factors, the specified cause can be viewed as the opposite of the one previously mentioned. In addition, misinformation is often identified as one of the basic factors leading to drug abuse. In other words, the notorious idea of a single pill not having any tangible effect triggers a major chemical dependency. The rates of awareness regarding the t hreat of drug use among the U.S. adolescents are more than upsetting.Advertising We will write a custom research paper sample on Substance Abuse and the Related Problems specifically for you for only $16.05 $11/page Learn More When it comes to drinking, the effect of the parental support, or the lack thereof, comes out in full blue. In addition, family background means a lot to adolescents; though they might consider themselves fully independent from their parents, the influence of the latter still defines the behavior of young adults. Seeing their parents drink and, therefore, defining subconsciously such behavior as assertive, they start using heavy liquor as the means of escapism, communication, etc. (Howlett, 2012). Finally, the culture- and gender-related diagnostic markers of alcoholism and drug abuse in adolescents must be mentioned (American Psychiatric Association, 2013). It is an established fact that women are more prone to developing alcohol ism than men (American Psychiatric Association, 2013), though, when it comes to drug abuse, the chances for both genders to become highly dependent on illegal substances are very high (American Psychiatric Association, 2013). While it would be wrong to claim that the development of drug and alcohol abuse in teenagers requires co-morbid factors, one still have to admit that, in a range of cases, the reasons for teenagers resort to drugs or alcohol are pretty similar. Of all the factors mentioned above, lack of proper communication with parents, peer pressure, social ostracism or the fear thereof, and depression (which itself may be triggered by a variety of social factors) must be listed. There is no need to stress that substance abuse leads to a major identity crisis. According to Erikson’s theory of development, a person evolves in an unceasing process (Schwarz, 2008).Advertising Looking for research paper on psychology? Let's see if we can help you! Get your first paper with 15% OFF Learn More Therefore, with such major obstacles as substance abuse and the following problems with memory, cognition, etc., a person ceases to acquire the necessary information and use it in their later experiences. In other words, the destruction of a person’s self commences (Wechsler et al., 2012). Numbing their emotional experiences with alcohol or drugs, adolescents put a stop to their cognitive development; by neglecting the social norms, they defy their moral development; as a result, adolescents abusing substances get stuck on particular stages of their emotional, cognitive and social development, blocking their way to any further progress. The analysis and reconsideration of the patient’s self-identity must be the key priority in addressing the issue of substance abuse (Wechsler et al., 2012). Consequently, a Cognitive-Behavioral Therapy (CBT) can be used as the basic strategy for dealing with the issue because of its focus on the cognitive aspect of the patient’s personality development (Schwartz, 2008). The role of family in the life of an adolescent is not to be underrated, either. For the therapy sessions to be especially successful, it is desirable that the relationships between the patient and their parents should be improved, if possible. It is important that an adolescent drug or alcohol addict should have the support of their family when getting rid of their dependency on substances. As the means to encourage the adolescent with a drinking and/or substance abuse problem for communication with their family members and, therefore, getting the support that the adolescent in question requires, it will be necessary to adopt Motivational Interviewing strategy (MI) (Miller Rose, 2009). In order to defeat their substance abuse issue, an adolescent must recognize the problem on their own and come to a conscious conclusion regarding the necessity to fight it. Hence, MI should be used as the tool for convincing the patient to mend their ways. Though the statistics on substance abuse among adolescents in the U.S. have not grown much over the past few years, they still remain dangerously high. Since adolescent drinking and substance abuse in general affects the perception of their self and, therefore, the further personal and cognitive development, it is imperative that the problem of adolescent substance abuse should be addressed. By incorporating the theories of Cognitive Development and Motivational Interviewing into the therapy sessions, one must attain success in reducing the rates of adolescent drinking and drug abuse. Reference List American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. Washington, DC: American Psychiatric Association. Howlett, K. D. (2012). Understanding sand treating adolescent substance abuse: A preliminary review. Focus: The Journal of Lifelong Learning in Psychiatry, 10(3), 293–299. Miller, W. R. Rose, G. S. (2009). Toward a theory of motivation al interviewing. American Psychologist, 64(6), 527–537. National Institute on Drug Abuse. (2013). National Survey of drug use and health. National Institute on Drug Abuse. Retrieved from https://www.drugabuse.gov/national-survey-drug-use-health Schwartz, S. J. (2008). Self and identity in early adolescence: Some reflections and an introduction to the special issue. The Journal of Early Adolescence, 28(1), 5-9. Wechsler, H., Lee, J. E., Nelson, T. F. Kuo, M. (2012). Underage college students’ drinking behavior, access to alcohol, and the influence of deterrence policies findings from the Harvard School of Public Health College alcohol study. Journal of American College Health, 50(5), 223–236. This research paper on Substance Abuse and the Related Problems was written and submitted by user PuppetMaster 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.

Infant and Toddler Development and Programming Essays

Infant and Toddler Development and Programming Essays Infant and Toddler Development and Programming Essay Infant and Toddler Development and Programming Essay During preschool age children demonstrate it throughout their world, where as the enfant/toddler have the desires to be initiative in their environment. This KID is different in preschoolers because , a preschooler demonstrates their desires throughout the opportunities that are given to them and act upon it quickly and go with it. Difference: Reflection is only shown in Preschool development Kids Reflection is not shown in Infants and Toddlers because they are not at the stage where they can express their experiences in language. An Infant or Toddler has not yet development extensive language to perform a reflection. Social Emotional Development Emotions Similarity: Emotions is listed in both Pre-school and Infant Kids. It is clear, that both age groups display their emotions in their environment. Boredom, sadness, frustration etc. ). Difference: Preschoolers recognize, label, and regulate their feelings whereas Infants and Toddlers only express it. This means that Infants are not developmentally capable to identify or distinguish certain feelings. Emotions are different in both because an infant is not developmentally capable of identifying their feelings using their language. They have no yet developed the engage that will help them express their feelings. Physical Development and Health Infant/ Toddlers KID: (13) Moving the whole body Preschool KID: (16) Gross Motor skills similarity: These Kids are similar because both age groups are using their large muscles (legs, arms etc). Both involve movement with the body. This KID is similar because both age groups have the desire to move their body muscles to achieve a goal. Difference: The difference between these Kids is that they are named differently. Preschoolers only demonstrate the strength, flexibility balance, and timing in using heir large muscles. Infants are not developmentally ready to demonstrate their large muscle skills because they are still working on their basics of movement (balancing head, lying down on tummy). Preschoolers have already achieved the basics of movement and are now expanding what they know in basics of movement they learned in toddlers. Classroom strategies Choose one Infant-Toddler KID from the first three categories and describe two specific things that you could say, do or provide as an Educator to support learning in he classroom. You must provide two specific, developmentally appropriate strategies are provided that relate to the selected KID Key Developmental Indicator For Children playing with others Strategy 1: Look at childrens actions from their viewpoint. Two people often see the same situation from differing viewpoints, depending in their individual experience, culture, problem-solving approach, and temperament. So when they are playing with others imagine how they are thinking and what the other children are thinking o better understand their reactions, or lack of reactions Strategy 2: Focusing on childrens strengths and interests is a great way to reduce favori tism and reduce playing for competition, or sport. Which is often brought from home and can carry over to simple games where fun is the primary goal (or one of the many things play brings). Child A says l finished before B Im better!!! you can say l see youre able to do X quickly, is this your first time doing it? then approach the other child and express something they are doing well. Part 2

Paper 5 Essay Example | Topics and Well Written Essays - 500 words

Paper 5 - Essay Example us that his â€Å"home is beyond the mountains† (144) but he is not; he is in the white man’s world a world where trees are planted in â€Å"military rows† (144) and although all living things are beautiful â€Å"it is the beauty of captivity.† His prison is the â€Å"bluff of being civilized† a place where he has â€Å"to do everything [he doesn’t] want to do† a place where he â€Å"never [does] anything† he wants. (144) The narrator of â€Å"She’s Free’ on the other hand, is a negro and has lived life in a white man’s world as a slave subjected â€Å"by law †¦[to] torture and chain† (line 1) solely because of the color of her skin, â€Å"the hue of her face.† (line 2) Thus her enslavement is existent and tangible – she bears the signs of â€Å"bondage and blood †¦ scourges and chains,† (line 7) whereas the Indian bears no physical signs of enslavement and is allowed t o move around and exist without abuse, in his view he is imprisoned â€Å"dancing to the strings of customs and traditions.† (144) Both narrators seek escape from their imprisonment, he by returning to his homeland and people and she by escaping and running away. The difference however is that he is escaping to the familiarity and safety of his family and his people but she, â€Å"with her arm on her child† (line 3) is escaping into the unknown world where â€Å"the danger was fearful [and] the pathway was wild.†(line 4) She is resolute in her journey preferring to be free from oppression even though her future is unknown; she is determined and tenacious in coping with what may come before her â€Å"poverty, danger and death she can brave† (line 13) for the freedom of her child, â€Å"for the child of her love is no loner a slave.† (line 14) The Indian however is not so unwavering. Although still â€Å"twenty miles from home† (146) he begins to feel concern and â€Å"afraid of being looked on as a stranger by [his] own people.† (146) He states that he doesn’t fit in either world, â€Å"certainly not

Construction Law Essay Example | Topics and Well Written Essays - 2250 words

Construction Law - Essay Example placed on par with other kinds of projects because delays in construction and claims arising out of such delays have always been an integral part of construction law. According to Yates and Epstein, there is an enormous amount of time, energy and cost that is devoted to delay claims which do not strictly begin around the time of completion of the job, rather these delays commence right at the inception stage of the project itself.2 The Protocol states that the process of analysis of delay can only begin to be addressed when there is an understanding about what work was carried out and when such work was carried out, as a result, the Protocol recommends that contractors maintain a written record of what work is to be carried out on the project and when it is to be done over the specified time period. However, as McCredie points out, this causes difficulties, not only in terms of the extensive record keeping which the contractor will now have to maintain, but also from the point of vie w of correlating those records with schedules and locations3. In the case of Great eastern Hotel Company Ltd4, charges of negligence by contractor and resultant losses thereof as claimed by Great eastern Hotel were not upheld by the court and no relief was allowed for losses sustained. In this case, the difficulties in establishing causation of delay leading to losses were also demonstrated. There is no definite court precedent to establish causation of loss due to delays and in this case, it was pointed out that the Courts have not laid down any formal tests to establish causation, rather they have relied upon commonsense and an interpretation of the individual facts in a particular case in order to determine whether the breach of the contract was a sufficiently substantial cause of the claimant’s loss.5 Therefore the party that violates the contract is liable only if the breach was in effect the â€Å"effective cause† of his loss.6 An action for losses caused by a breach of

Factors Affecting Antipsychotic Medication Compliance

Factors Affecting Antipsychotic Medication Compliance INTRODUCTION The aim of this dissertation is to explore the factors affecting concordance with prescribed antipsychotic medications. The rationale for selecting this topic is derived from personal working experience with mental health service users. Having worked as a nursing assistant for the past eight years on acute admissions wards and as a student nurse for the past three years it was observed that a large proportion of compulsory re-hospitalisation under the Mental Health Act 1983 occurs due to relapse of mental illness as a result of non- concordance with medications, particularly service users with a diagnosis of schizophrenia. This led to believe that concordance with antipsychotic medications plays a crucial role in managing psychosis as it positively contributes towards the effective management of the illness in the community. In support to this view, Gray et al (2002a) assert that prophylactic use of antipsychotic medication reduces the risk of relapse among individuals with schizophr enia and non-concordance with medication has the potential for frequent re-hospitalisations. This has been recognised as the revolving door syndrome. During most mental health placements it was noted that non-concordance with medication has become significant, as this has been identified as a risk factor within the risk assessment checklist. Furthermore, despite the well-documented therapeutic effect of antipsychotic medications, some patients are reluctant to accept treatments and some may even wish to cease taking medications altogether. Therefore, this empirical knowledge has reinforced the desire to examine the factors associated with non-concordance with antipsychotic medications. According to Brimblecombe et al (2005) medication is one of the major therapeutic tools available to help people with schizophrenia. There is also growing evidence that schizophrenia can be treated effectively with a range of psychological and social interventions together with antipsychotic medications. Norman Ryrie (2004) emphasised that antipsychotic medication has been the mainstay of treatment for schizophrenia since the 1950s when it was discovered that the dopamine antagonist haloperidol and chlorpromazine exerted antipsychotic effects. The National Institute for Clinical Excellence (NICE) (2002) recommends that atypical antipsychotic drugs such as amisulpride, aripiprazole , olanzapine, quetiapine or risperidone must be considered in the choice of first-line treatments for individuals with newly diagnosed schizophrenia or to promote recovery for those who have experienced unacceptable side-effects on conventional antipsychotics, as atypical antipsychotics appear to have less extrapyramidal symptoms (side effects) than the conventional antipsychotics such as haloperidol and chlorpromazine. The care and treatment of individuals with schizophrenia have advanced considerably over the past ten years, since the introduction of atypical antipsychotics and medication continues to be the first line treatment for schizophrenia (Walker MacAulay, 2005). However, Gray et al (2002b) claim that despite the effectiveness of these atypical antipsychotic drugs, non- concordance with prescribed antipsychotic medications is observed in around 50% of people with schizophrenia and is a major preventable cause of psychiatric morbidity. In addition, Mitchell Selmes (2007) claim that over the course of a year, about 75% of patients will discontinue prescribed antipsychotic medications, often coming to the decision themselves and without informing a health professional. According to Gray et al (2006) relapse rates is five times higher among individuals with schizophrenia, who are non-concordance with medication compared with concordance. Non-concordance during acute treatment of psychosis le ads to chronic symptomswhereas non-concordance after remission increases the risk ofrelapse and both may have serious consequences; re-hospitalisation (Hamer Haddad, 2007). Furthermore, the impacts of non-concordance with medication not only affect the individuals with schizophrenia, as each relapse causes a stepping down of cognitive functioning which is rarely retrieved but also their carers and the costs of treatments (Institute, 2007). To facilitate this project as a literature review, an analysis of secondary sources only will be use. Secondary sources were mainly obtained from nursing journals such as Nursing-Standard, Nursing-Times, Advances in Psychiatric Treatment, Mental health practice, Schizophrenia Bulletin and The British Journal of Psychiatry, containing the key words: schizophrenia, oral antipsychotic, medication management and non-concordance. An Internet search of Google was also done with the same keywords to access any relevant documents. To address the factors affecting concordance with prescribed antipsychotic medications, these will be divided into patient-related factors, medication-related factors and clinician-related factors. LITERATURE REVIEW According to White (2007) schizophrenia is a debilitating psychiatric disorder characterised by a range of positive and negative symptoms and these symptoms were first described in detail by the British neurologist Hughlings-Jackson in the late 1800s. There is no physical test for schizophrenia rather it is diagnosed by the presence of certain positive and negative symptoms over a period of time (Brennan, 2001). According to Issacs (2006) the neurotransmitter hypothesis suggests that the dopamine over activity in the mesolimbic dopamine pathway, which is between the midbrain, is thought to cause the positive symptoms of schizophrenia and dopamine under activity in the mesocortical dopamine pathway is thought to result in the negative symptoms of schizophrenia. Positive symptoms represent a distortion of normal experience, such as delusions, hallucinations and thought disorder, whereas negative symptoms represent a loss or dimming of normal function and social norm, such as avoidance of social interactions (Baker, 2003). There are different types of schizophrenia such as paranoid, disorganised, catatonic, undifferentiated and residual (Issacs, 2006). However, Gillam (2002) claimed that the exact causes of schizophrenia remain unclear but genetic, environmental and social factors are all thought to influence its development. The risk for a child to develop schizophrenia is 46%, if both parents have the disorder (Kirk et al, 2006). Women who have certain viral illnesses during their pregnancy may be at a greater risk of giving birth to children who later develop schizophrenia and the 1957 influenza A2 epidemics in England resulted in an increase in schizophrenia in the offspring of women who developed this flu during their pregnancy (Frankenburg, 2007). 1 in 100 UK populations will develop schizophrenia in their lifetime and the world prevalence is about 2-4 in 1000, as it affects men and women equally (Rethink, 2008). However, the onset in men is about five years earlier than women with the peak age of incidence is between 16 and 25 and the presentation of the illness varies tremendously, not only between individuals, but also within the same individual at different stages of their illness (Magorrian, 2007). Schizophrenia seems to be more common in city areas and in some ethnic minority groups and premature mortality in people with schizophrenia is 2 to 3 times higher than that in the general population (Royal college of Psychiatrists 2008). The premature mortality might be due to poorer health care, physical health, unhealthy lifestyles and people with schizophrenia may be at greater risk of type 2 diabetes as a result of antipsychotic medications (Nash, 2005). Moreover, according to WHO (2008) schizophrenia is a treatable disorde r but many individuals remain untreated regardless of effective treatments. There has been an unresolved debate about how best to define patients engagement with medications and until the 1980s most work on patient engagement with medications regimes was described as compliance (Norman Ryrie, 2004). The term compliance is often used interchangeably with adherence or concordance (Snelgrove, 2005). According to Kikkert (2006) the term compliance has fallen out of favour in clinical practice because it carries an assumption that patients are the passive recipients of clinicians and implies unquestioning obedience with no opportunity for patients choice. To add to the complexity of this term, patients can be intentionally or unintentionally non-compliant such as a deliberate decision not to comply with treatment and patients may have misunderstood the guidance that they have been given or unable to open the medication container. Velligan et al (2006) claimed that in recent years there has been a shift from this paternalistic model of doctor-patient interactions with the consequent preference for the use of the term adherence. However, while adherence emphasises negotiation between clinician and patient, it still implies a degree of passivity and obedience (Snelgrove, 2005). Gray et al (2002b) assert that concordance may be a more acceptable term as it suggests a collaborative process of decision-making regarding medications regimes and acknowledges the importance of the two-way communication. The NHS Plan (2000) emphasises the importance of placing patients at the centre of services and the transformation of patients into consumers of the health service has changed the context of health care, as patients are expected to become more active and informed about their treatments (Jasper, 2006). Murray et al (2007) emphasise that shared decision-making between clinicians and patients has the potential to improve concordance with treatment plans. Furthermore, The Chief Nursing Officers review of mental health nursing (2006) recommends that building and maintaining positive interpersonal relationships with service users is essential to successful mental health nursing practice and person-centred values is helpful in building positive relationships. This indicates that by not agreeing to health professionals advice patients may be labelled as non-compliant. Nonetheless, compliance could also be problematic, for example if patients continue to take medication obediently, although it is causing adverse side effects. However, from the empirical knowledge the term compliance is still being used in clinical settings despite the paternalistic conception. Therefore, the term concordance is favoured here as it promotes the idea that medication treatment should be a collaborative process between clinicians and patients, which emphasises the patients rights. Ultimately, the term concordance corresponds with the current ethos of modern mental health care set out in the National Service Framework (1999), the NHS Plan (2000) and the Chief Nursing Officers review of mental health nursing (2006), which is concerned with working in partnership with patients and carers. However, according to the term concordance patients have the right to make t reatment decisions, for example, stopping medication even if health professionals do not agree with that decision. For decades researchers have worked to explain the causes of non-concordance with medication unfortunately there have been no valid way of measuring concordance (Velligan et al, 2006). Rates of concordance have been measured by using the subjective and objective methods. Subjective method includes patients` self report and direct interviews, although this method is less expensive, it tends to overestimate the degree of concordance, as patients may not admit non-concordance (Gray et al, 2002b). Snelgrove (2005) claims that objective method such as blood and urine analysis also pose problems as they do not account for individual metabolism and do not reflect inconsistencies in concordance over time. Moreover, from empirical knowledge blood test is effective in monitoring concordance with mood stabilisers such as lithium, but for schizophrenia it is the manifestation of symptoms can support the evidence of non-concordance. According to Gray et al (2002b) pill counts are more reliable, b ut it is impossible to tell whether patients have actually ingested the medication. Even expensive objective method such as electronic monitoring which records every occasion that a pill bottles is opened can also be problematic when patients choose not to swallow the medication that was removed or do not replace the caps and electronic prescribing is still fallible, just because medication is available does not mean that it is taken (Velligan et al, 2006). One of the major clinical problems in the treatment of people with schizophrenia is partial or complete non-concordance with medication and this limits the clinical effectiveness of the prescribed medications (Kikkert et al, 2006). Antipsychotics medication can only be effective if they are taken continuously over a sustained period of time (Norman Ryrie, 2004). Urquhart (2005) claims that partially concordant patients can be difficult to identify because they do not actively refuse to take their medication but the dosage deviations for different reasons and this may only be detected when psychotic symptoms re-emerge. Partial concordance creates significant problems for the treating physician as it creates difficulties in determining whether medications are working adequately, dosing is appropriate or concomitant medication is needed (Velligan et al, 2006). Therefore, this indicates that medication or dosage changes and the addition of concomitant medications are more likely to occu r among patients who are not fully concordant with prescribed medications. Non-concordance with prescribed medication is believed to be a significant factor to increasethe probability of relapse in patients with schizophrenia and relapse is one of the most costly aspects of schizophrenia (Almond et al, 2004). Knapp et al (2004) undertook a study of 658 patients receiving antipsychotics medication of whom 20% reported non-concordance with prescribed medication and concluded that non-concordance was one of the most significant factors in increasing service costs, predicting an excess annual cost per patient of  £2500 for inpatient services and an overall additional cost of  £5000 for total service use. In addition, Almond et al (2004) estimated that costs for relapse cases are four times higherthan those for non-relapse cases. Therefore, these two studies show that relapse in patients with schizophrenia as a result of non-concordance isa major factor in generating high hospitalisation rates and costs. This implies that patients who do not concord with the ir medication are likely to requiremore treatment and support from a range of services and given the high costs associated with relapse non-concordance is a key factor in the use ofin-patient and external services. Antipsychotic medication has proven efficacy in the treatment of schizophrenia and the prevention of relapse. In spite of vast evidence that antipsychotics can be effective in treating the symptoms of schizophrenia, almost 90% of patients will relapse within the first five years of treatment following an acute episode and in general the illness has a tendency to recur or become chronic (Velligan et al, 2006). According to White et al (2007) non-concordance with drug therapy is common in schizophrenia; approximately 50% of patients are non-concordant within one year and 75% within two years after being discharged from hospital. Such high rates of non-concordance with medication may initially seem alarming (Gray et al, 2002b). However, it is similar with other conditions such as asthma where maintenance treatment is required. A study of concordance with asthma medication conducted by Newell (2006) estimated that 70 % of asthma patients in the UK are non-concordant with medication and t he levels of non-concordance in long-term conditions, such as asthma are known to be high as many asthma sufferers will only take medicine when they feel they need it rather than as instructed by clinicians. Therefore, considering the Newell (2006) findings it can be argued that the rates of non-concordance with antipsychotics are not significantly different than those on non-psychiatric medications and the myth that non-concordance with medication is more common among mental disorders as compared to physical disorders needs to be dispelled. Several factors have been shown to increase the chance of relapse but probably the single most important cause of relapse is the discontinuation of effective antipsychotic medication regime. A large number of factors influence non-concordance with prescribed antipsychotic medications, however Gray et al (2002b) have identified the main factors as impaired judgement, negative beliefs about treatment, poor worker-user relationship and the side-effects of medication. Additionally, Kikkert et al (2006) conducted a study in four European countries exploring medication adherence in schizophrenia and identified insight, beliefs about treatment, side effects and treatment efficacy as factors that influence concordancewith medication in patients with schizophrenia. Urquhart (2005) suggests that the problem of non-concordance may be more prevalent among those with schizophrenia due to its nature, for example, lack of insight. Magorrian (2007) claimed that non-concordance with medication is often linked to the persons level of insight into his or her illness and lack of insight is a frequent concomitant of psychosis. In schizophrenia, insight has been defined as an awareness of illness and an ability to recognise symptoms as part of an illness (Gray et al, 2002b) According to Surguladze David (1999) between 50% and 80% of patients diagnosed with schizophrenia have been shown to be partially or totally lacking insight into the presence of their mental disorder and these individuals are often difficult to engage with treatments due to impaired insight. Recent conceptualisation has formulated insight as a continuum representing the combination of three factors; awareness of illness, need for treatment and attribution of symptoms. Lack of insight is continuously problematic but an emotional element can be associated with denial of symptoms or rejection of treatment at key points in the illness (Byrne, 2000). Mitchell Selmes (2007) claim that having a perception about the illness and the knowledge of medications are the key factors of concordance in mental health and patients who understand the purpose of the prescription are twice more likely to collect it than those who do not understand. A study by Cuesta et al (2000) reported that patients suffering from schizophreniashowed poorer insight than patients with affective disorders. Cuesta et al (2000) findings demonstrated that the severe disturbances of insight persisted over the time and the level of insight was not significantly improved in patients suffering from functional psychosis as between 29% to 49% of these patients continued to have fair to poor insight at the follow up assessment. This is consistent with the findings of Kikkert et al (2006), where poor insight was a strong predictor of non-concordance with medication. In contrast, Tait et al (2003) conducted a study to examine changes in insight and symptoms of psychosis on fifty participantswho met the ICD—10 diagnostic criteria for schizophrenia. The participants were interviewed and insight was measured duringacute psychosis using the Insight Scale with the score 0- 12 and all the participants were reinterviewed at 3 and6 months following the init ial interview. Tait et al (2003) findings indicated that duringthe acute episode, 48% of participants scored 9-12 on the InsightScale and the majority of participants (63%) werein the 9-12 range of scores. The study of Tait et al (2003) clearly indicated that level of insight was high among many participants. In considering the findings of both Cuesta et al (2000) and Tait et al (2003) it appears that some patients with psychosis are unaware of their illnesses and insight is a strong predictor of concordance with medications and a good indicator of prognosis. However, evidence for a relationship between insight and concordance with treatment is inconclusive as the discrepancies found between the two studies might be due to the methodological factors, such as selection of participants. In both studies all the participants had a diagnosis of schizophrenia and all of them gave informed consent to enter the study. According to Appelbaum (2006) several studies in America regarding the decisional-capacity of patients with schizophrenia to consent or participation to research have raise some concerns due to the cognitive impairments associated with schizophrenia and using the MacArthur Competence Assessment Tool for Clinical Research clearly indicated that patients with schizophrenia do lack und erstanding and reasoning of research ethics. McCann Clark (2005) emphasise that antipsychotic medications some of which have a sedating effect can also have an impact on the cognitive processes, such as illogical thinking and this can hinder the quality of responses. Moser et al (2005) argued that some studies have shown that a high percentage of individuals with schizophrenia have adequate decisional capacity to consent to research participation, however in a medication-free schizophrenia research, participants did not show a major decline in decisional capacity. In addition, Jeste et al (2006) claimed that there is a risk in assuming that decision-making capacity of individuals with schizophrenia is always impaired, when they are capable to make autonomous decisions and in considering their decision-making capacity as permanently impaired by virtue of their diagnosis. Consequently, in order to investigate factors associated with schizophrenia, it can be argued that only individuals with schizophrenia can provide the answers of their experiences and protecting vulnerable populations from research activity can also exclude them from its benefits. According to Gerrish Lacey (2006) there two key concepts that concern the quality of a research: validity and reliability. Roberts et al (2006) define reliability as how far a particular test will produce similar results in different circumstances, whereas validity is to ascertain the methods are actually measuring what is intended to measure. Both Cuesta et al (2000) and Tait et al (2003) had used structured interviews to gather the data and have chosen a quantitative approach. Structured interview provides the opportunities to change the words but not the meaning of the questions thus, Parahoo (2006) claimed that validity is enhanced because participants can be helped to understand the questions and interviewers can ask for clarifications and probe for further responses, if necessary and since all the questions are ideally asked in the same way, structured interview has a high degree of reliability. It seems that both Cuesta et al (2000) and Tait et al (2003) have adopted the appropriate approach to their research, as quantitative research is the conduct of investigations primarily using numerical methods. It infers that to examine correlations between insight and service engagement qualitative approach could not have produced the same data in this area of study. Moreover, in both studies purposive sampling were used as all the participants had a diagnosis of schizophrenia. According to Polit Beck (2006) all participants in a phenomenological study must have experienced the phenomenon under study and must be able to articulate what is like to have lived the experience. Johnson Orrell (1996 cited in Surguladze David, 1999 P 166) have argued that some patients may have their own explanations of their illnesses, such as religion or cultural beliefs which may not coincide with the Western medical model of mental disorders and this can be even more complicated if one tries directly to impose the models of insight on patients from non-Western cultures. Gamble Brennan (2006) claimed that different cultures in England perceive mental illness in different ways and this can have an impact on treatments as some cultures rather seek help from religious leaders than mental health services. Alternatively, religion or spiritual beliefs in the Western culture can have a positive impact on concordance with medication, as religious individuals with schizophrenia have a better social support compare to non-religious individuals with schizophrenia (Borras et al, 2007). Therefore, it can be put forward that awareness of illness is a crucial factor in the motivation to receive pharmacological treatment. Both cultures and religion can have a positive and negative influence on concordance with antipsychotics. Patients can have different levels of awareness into their illness and they may consciously or unconsciously avoid acknowledging that they are suffering from mental health problems because of their reluctance to bear the stigma of mentally ill (Surguladze David, 1999). Byrne (2000, p65) defined `stigma as a sign of disgrace or discredit, which sets a person apart from others and the stigma of mental illness although more often related to context than to a persons appearance, remains a powerful negative attribute in all-social relations`. Stigma of mental illness has become an indication for unpleasant experiences, such as bringing shame to the family or social exclusion. According to Phillips et al (2002), in some parts of china, schizophrenia is still considered as a punishmentfor an ancestors misbehaviour or for the familys currentmisconduct and the effect of stigmais greater if the patient had more prominent positive symptoms or highly educated. Moreover, a study by Lee et al (20 05) concluded that 60 % out of 320 patients with schizophrenia had experienced interpersonal stigma from p arents, siblings or close rel atives. This indicates that people with schizophrenia are more likely to experience stigma from family members than the general public. Having a diagnosis of schizophrenia does not only affect ones health but also carries all the prejudice, discrimination and social exclusion, for example many individuals are attacked on the streets, rejection in the society and denial of employments because they were known to have mental health problems (Gamble Brennan, 2006). According to Byrne (2000) in two identical UK public opinion surveys, 80% of participants claimed that most people are embarrassed by mentally ill people and about 30% agreeing `I am embarrassed by mentally ill persons`. There is also evidence that supports the concepts of stereotyping of mental illness. The power and influence of the media on mental illness has been a key issue of debate over many years as people with schizophrenia are frequently portrayed as violent and dangerous. In contrast, people with schizophrenia are more likely to be dangerous to themselves than to others, while the greater danger to the public is posed by people without mental health problems and people with mental health problems are six times more likely than the general public to be the victims of murder (Stickley Felton, 2006). Moreover, Gamble Brennan (2006) claimed that when the boxing champion Frank Bruno was admitted to hospital in 2003, one of the newspaper headlines was `Bonkers Bruno locked up`. This indicates that stigma has the grave potential to cause reluctance to seek treatments and this can be detrimental to the persons health. Therefore, as a mental health clinician, it will be vital to assist people wit h mental health problems to rebuild their lives and this requires moving beyond the traditional focus on symptoms and medication by exploring alternatives in reducing stigma of mental health that avert people from social inclusion. It has been predicted that families with high expressed emotion compared to low expressed emotion can contribute towards the relapse rate in symptoms of schizophrenia and this can also be a triggering factor for non-concordance with medication. High expressed emotion carers appear to perceive their caring situation as more stressful and this could be conceptualised as a catastrophic appraisal of the role of caring (Raune et al 2004). Kuipers et al (2006) identifies the components of expressed emotion as emotional over-involvement, hostility, critical comments, warmth and positive remarks. A study by Kuipers et al (2006) indicates that patients whose carers showed high expressed emotion had considerably higher levels of anxiety and lower self-esteem due to the components of expressed emotion. However, a significant amount of data from western cultures suggests that high expressed emotion subjects who were not on medication are three times likely to relapse than those who were on medic ation (Bhugra McKenzie, 2003). This clearly signifies that despite being concordant, high expressed emotion subjects are vulnerable to relapse. The interactions between patient and the carers are crucial, especially cross-culturally as in some cultures for example, in some parts of India, emotional over-involvement is the norm and if carers do not show emotional over-involvement, this can be seen as lack of care (Bhugra McKenzie, 2003). Hashemi Cochrane (1999) conducted a study in UK on expressed emotion and they observed that 80% of the British Pakistani, 45% of the White and 30% of the British Sikh families exhibited high levels of expressed emotion and emotional over-involvement was notably higher among the British Pakistani group. The findings concluded that White patients with high expressed emotion relatives were significantly more likely to relapse than those from low expressed emotion families, whereas for both Asian groups high expressed emotion did not predict relapse. The study of Hashemi Cochrane (1999) also indicated that that Pakistani families in the UK were more likely to be rated as high expressed emotion than White families, indicating that components such as emotional over-involvement may be cultural rather than pathogenic traits. Conversely, low expressed emotion families who are not over-anxious in their response to the patients illness may tend to perceive stigma in less threatening ways whereas, families with high expressed emotion, who respond to the patients illness in a highly anxious may experience stigma more intensely (Phillips et al 2002). Therefore, it appears that family members levels of expressed emotion could influence their perception and response to stigma of mental health and concordance with medication is essential for patients irrespective of the expressed emotion status in the family. Thus, family interventions need to improve in order to lower the levels of anxiety and to increase self-esteem among families with hig h expressed emotion. As a clinician it will be vital to acknowledge the cultural aspect of expressed emotion status in the family to facilitate concordance with medication. There is overwhelming evidence for patients with schizophrenia, who misuse illicit drugs and alcohol to have an increased rate of re-hospitalisation (Sokya, 2000). According to Barnes et al (2006) the higher relapse rate in people with established schizophrenia who usesubstances may be partially explained by non-concordant tothe medication regimen. Evidence suggests that the substance used most frequently by people with schizophrenia is cannabis (Gamble Brennan, 2006). Arseneault et al (2004) emphasise that rates of cannabis use in UK are higher among people with schizophrenia than among the general population and patients detained under the MHA (1983) have even higher rates of lifetime use of cannabis. Substance misuse in schizophrenia may be explained as a form of self-medication to alleviate the symptoms of schizophrenia, to improve the side effects of antipsychotics and to respond to social pressures (Sokya, 2000). There has been little evidence to support the self-medication hypothesis despite its popularity with users and in contrast, substance misuse can aggravate the symptoms of schizophrenia and can also trigger psychotic episode particularly in people with a pre-exis Factors Affecting Antipsychotic Medication Compliance Factors Affecting Antipsychotic Medication Compliance INTRODUCTION The aim of this dissertation is to explore the factors affecting concordance with prescribed antipsychotic medications. The rationale for selecting this topic is derived from personal working experience with mental health service users. Having worked as a nursing assistant for the past eight years on acute admissions wards and as a student nurse for the past three years it was observed that a large proportion of compulsory re-hospitalisation under the Mental Health Act 1983 occurs due to relapse of mental illness as a result of non- concordance with medications, particularly service users with a diagnosis of schizophrenia. This led to believe that concordance with antipsychotic medications plays a crucial role in managing psychosis as it positively contributes towards the effective management of the illness in the community. In support to this view, Gray et al (2002a) assert that prophylactic use of antipsychotic medication reduces the risk of relapse among individuals with schizophr enia and non-concordance with medication has the potential for frequent re-hospitalisations. This has been recognised as the revolving door syndrome. During most mental health placements it was noted that non-concordance with medication has become significant, as this has been identified as a risk factor within the risk assessment checklist. Furthermore, despite the well-documented therapeutic effect of antipsychotic medications, some patients are reluctant to accept treatments and some may even wish to cease taking medications altogether. Therefore, this empirical knowledge has reinforced the desire to examine the factors associated with non-concordance with antipsychotic medications. According to Brimblecombe et al (2005) medication is one of the major therapeutic tools available to help people with schizophrenia. There is also growing evidence that schizophrenia can be treated effectively with a range of psychological and social interventions together with antipsychotic medications. Norman Ryrie (2004) emphasised that antipsychotic medication has been the mainstay of treatment for schizophrenia since the 1950s when it was discovered that the dopamine antagonist haloperidol and chlorpromazine exerted antipsychotic effects. The National Institute for Clinical Excellence (NICE) (2002) recommends that atypical antipsychotic drugs such as amisulpride, aripiprazole , olanzapine, quetiapine or risperidone must be considered in the choice of first-line treatments for individuals with newly diagnosed schizophrenia or to promote recovery for those who have experienced unacceptable side-effects on conventional antipsychotics, as atypical antipsychotics appear to have less extrapyramidal symptoms (side effects) than the conventional antipsychotics such as haloperidol and chlorpromazine. The care and treatment of individuals with schizophrenia have advanced considerably over the past ten years, since the introduction of atypical antipsychotics and medication continues to be the first line treatment for schizophrenia (Walker MacAulay, 2005). However, Gray et al (2002b) claim that despite the effectiveness of these atypical antipsychotic drugs, non- concordance with prescribed antipsychotic medications is observed in around 50% of people with schizophrenia and is a major preventable cause of psychiatric morbidity. In addition, Mitchell Selmes (2007) claim that over the course of a year, about 75% of patients will discontinue prescribed antipsychotic medications, often coming to the decision themselves and without informing a health professional. According to Gray et al (2006) relapse rates is five times higher among individuals with schizophrenia, who are non-concordance with medication compared with concordance. Non-concordance during acute treatment of psychosis le ads to chronic symptomswhereas non-concordance after remission increases the risk ofrelapse and both may have serious consequences; re-hospitalisation (Hamer Haddad, 2007). Furthermore, the impacts of non-concordance with medication not only affect the individuals with schizophrenia, as each relapse causes a stepping down of cognitive functioning which is rarely retrieved but also their carers and the costs of treatments (Institute, 2007). To facilitate this project as a literature review, an analysis of secondary sources only will be use. Secondary sources were mainly obtained from nursing journals such as Nursing-Standard, Nursing-Times, Advances in Psychiatric Treatment, Mental health practice, Schizophrenia Bulletin and The British Journal of Psychiatry, containing the key words: schizophrenia, oral antipsychotic, medication management and non-concordance. An Internet search of Google was also done with the same keywords to access any relevant documents. To address the factors affecting concordance with prescribed antipsychotic medications, these will be divided into patient-related factors, medication-related factors and clinician-related factors. LITERATURE REVIEW According to White (2007) schizophrenia is a debilitating psychiatric disorder characterised by a range of positive and negative symptoms and these symptoms were first described in detail by the British neurologist Hughlings-Jackson in the late 1800s. There is no physical test for schizophrenia rather it is diagnosed by the presence of certain positive and negative symptoms over a period of time (Brennan, 2001). According to Issacs (2006) the neurotransmitter hypothesis suggests that the dopamine over activity in the mesolimbic dopamine pathway, which is between the midbrain, is thought to cause the positive symptoms of schizophrenia and dopamine under activity in the mesocortical dopamine pathway is thought to result in the negative symptoms of schizophrenia. Positive symptoms represent a distortion of normal experience, such as delusions, hallucinations and thought disorder, whereas negative symptoms represent a loss or dimming of normal function and social norm, such as avoidance of social interactions (Baker, 2003). There are different types of schizophrenia such as paranoid, disorganised, catatonic, undifferentiated and residual (Issacs, 2006). However, Gillam (2002) claimed that the exact causes of schizophrenia remain unclear but genetic, environmental and social factors are all thought to influence its development. The risk for a child to develop schizophrenia is 46%, if both parents have the disorder (Kirk et al, 2006). Women who have certain viral illnesses during their pregnancy may be at a greater risk of giving birth to children who later develop schizophrenia and the 1957 influenza A2 epidemics in England resulted in an increase in schizophrenia in the offspring of women who developed this flu during their pregnancy (Frankenburg, 2007). 1 in 100 UK populations will develop schizophrenia in their lifetime and the world prevalence is about 2-4 in 1000, as it affects men and women equally (Rethink, 2008). However, the onset in men is about five years earlier than women with the peak age of incidence is between 16 and 25 and the presentation of the illness varies tremendously, not only between individuals, but also within the same individual at different stages of their illness (Magorrian, 2007). Schizophrenia seems to be more common in city areas and in some ethnic minority groups and premature mortality in people with schizophrenia is 2 to 3 times higher than that in the general population (Royal college of Psychiatrists 2008). The premature mortality might be due to poorer health care, physical health, unhealthy lifestyles and people with schizophrenia may be at greater risk of type 2 diabetes as a result of antipsychotic medications (Nash, 2005). Moreover, according to WHO (2008) schizophrenia is a treatable disorde r but many individuals remain untreated regardless of effective treatments. There has been an unresolved debate about how best to define patients engagement with medications and until the 1980s most work on patient engagement with medications regimes was described as compliance (Norman Ryrie, 2004). The term compliance is often used interchangeably with adherence or concordance (Snelgrove, 2005). According to Kikkert (2006) the term compliance has fallen out of favour in clinical practice because it carries an assumption that patients are the passive recipients of clinicians and implies unquestioning obedience with no opportunity for patients choice. To add to the complexity of this term, patients can be intentionally or unintentionally non-compliant such as a deliberate decision not to comply with treatment and patients may have misunderstood the guidance that they have been given or unable to open the medication container. Velligan et al (2006) claimed that in recent years there has been a shift from this paternalistic model of doctor-patient interactions with the consequent preference for the use of the term adherence. However, while adherence emphasises negotiation between clinician and patient, it still implies a degree of passivity and obedience (Snelgrove, 2005). Gray et al (2002b) assert that concordance may be a more acceptable term as it suggests a collaborative process of decision-making regarding medications regimes and acknowledges the importance of the two-way communication. The NHS Plan (2000) emphasises the importance of placing patients at the centre of services and the transformation of patients into consumers of the health service has changed the context of health care, as patients are expected to become more active and informed about their treatments (Jasper, 2006). Murray et al (2007) emphasise that shared decision-making between clinicians and patients has the potential to improve concordance with treatment plans. Furthermore, The Chief Nursing Officers review of mental health nursing (2006) recommends that building and maintaining positive interpersonal relationships with service users is essential to successful mental health nursing practice and person-centred values is helpful in building positive relationships. This indicates that by not agreeing to health professionals advice patients may be labelled as non-compliant. Nonetheless, compliance could also be problematic, for example if patients continue to take medication obediently, although it is causing adverse side effects. However, from the empirical knowledge the term compliance is still being used in clinical settings despite the paternalistic conception. Therefore, the term concordance is favoured here as it promotes the idea that medication treatment should be a collaborative process between clinicians and patients, which emphasises the patients rights. Ultimately, the term concordance corresponds with the current ethos of modern mental health care set out in the National Service Framework (1999), the NHS Plan (2000) and the Chief Nursing Officers review of mental health nursing (2006), which is concerned with working in partnership with patients and carers. However, according to the term concordance patients have the right to make t reatment decisions, for example, stopping medication even if health professionals do not agree with that decision. For decades researchers have worked to explain the causes of non-concordance with medication unfortunately there have been no valid way of measuring concordance (Velligan et al, 2006). Rates of concordance have been measured by using the subjective and objective methods. Subjective method includes patients` self report and direct interviews, although this method is less expensive, it tends to overestimate the degree of concordance, as patients may not admit non-concordance (Gray et al, 2002b). Snelgrove (2005) claims that objective method such as blood and urine analysis also pose problems as they do not account for individual metabolism and do not reflect inconsistencies in concordance over time. Moreover, from empirical knowledge blood test is effective in monitoring concordance with mood stabilisers such as lithium, but for schizophrenia it is the manifestation of symptoms can support the evidence of non-concordance. According to Gray et al (2002b) pill counts are more reliable, b ut it is impossible to tell whether patients have actually ingested the medication. Even expensive objective method such as electronic monitoring which records every occasion that a pill bottles is opened can also be problematic when patients choose not to swallow the medication that was removed or do not replace the caps and electronic prescribing is still fallible, just because medication is available does not mean that it is taken (Velligan et al, 2006). One of the major clinical problems in the treatment of people with schizophrenia is partial or complete non-concordance with medication and this limits the clinical effectiveness of the prescribed medications (Kikkert et al, 2006). Antipsychotics medication can only be effective if they are taken continuously over a sustained period of time (Norman Ryrie, 2004). Urquhart (2005) claims that partially concordant patients can be difficult to identify because they do not actively refuse to take their medication but the dosage deviations for different reasons and this may only be detected when psychotic symptoms re-emerge. Partial concordance creates significant problems for the treating physician as it creates difficulties in determining whether medications are working adequately, dosing is appropriate or concomitant medication is needed (Velligan et al, 2006). Therefore, this indicates that medication or dosage changes and the addition of concomitant medications are more likely to occu r among patients who are not fully concordant with prescribed medications. Non-concordance with prescribed medication is believed to be a significant factor to increasethe probability of relapse in patients with schizophrenia and relapse is one of the most costly aspects of schizophrenia (Almond et al, 2004). Knapp et al (2004) undertook a study of 658 patients receiving antipsychotics medication of whom 20% reported non-concordance with prescribed medication and concluded that non-concordance was one of the most significant factors in increasing service costs, predicting an excess annual cost per patient of  £2500 for inpatient services and an overall additional cost of  £5000 for total service use. In addition, Almond et al (2004) estimated that costs for relapse cases are four times higherthan those for non-relapse cases. Therefore, these two studies show that relapse in patients with schizophrenia as a result of non-concordance isa major factor in generating high hospitalisation rates and costs. This implies that patients who do not concord with the ir medication are likely to requiremore treatment and support from a range of services and given the high costs associated with relapse non-concordance is a key factor in the use ofin-patient and external services. Antipsychotic medication has proven efficacy in the treatment of schizophrenia and the prevention of relapse. In spite of vast evidence that antipsychotics can be effective in treating the symptoms of schizophrenia, almost 90% of patients will relapse within the first five years of treatment following an acute episode and in general the illness has a tendency to recur or become chronic (Velligan et al, 2006). According to White et al (2007) non-concordance with drug therapy is common in schizophrenia; approximately 50% of patients are non-concordant within one year and 75% within two years after being discharged from hospital. Such high rates of non-concordance with medication may initially seem alarming (Gray et al, 2002b). However, it is similar with other conditions such as asthma where maintenance treatment is required. A study of concordance with asthma medication conducted by Newell (2006) estimated that 70 % of asthma patients in the UK are non-concordant with medication and t he levels of non-concordance in long-term conditions, such as asthma are known to be high as many asthma sufferers will only take medicine when they feel they need it rather than as instructed by clinicians. Therefore, considering the Newell (2006) findings it can be argued that the rates of non-concordance with antipsychotics are not significantly different than those on non-psychiatric medications and the myth that non-concordance with medication is more common among mental disorders as compared to physical disorders needs to be dispelled. Several factors have been shown to increase the chance of relapse but probably the single most important cause of relapse is the discontinuation of effective antipsychotic medication regime. A large number of factors influence non-concordance with prescribed antipsychotic medications, however Gray et al (2002b) have identified the main factors as impaired judgement, negative beliefs about treatment, poor worker-user relationship and the side-effects of medication. Additionally, Kikkert et al (2006) conducted a study in four European countries exploring medication adherence in schizophrenia and identified insight, beliefs about treatment, side effects and treatment efficacy as factors that influence concordancewith medication in patients with schizophrenia. Urquhart (2005) suggests that the problem of non-concordance may be more prevalent among those with schizophrenia due to its nature, for example, lack of insight. Magorrian (2007) claimed that non-concordance with medication is often linked to the persons level of insight into his or her illness and lack of insight is a frequent concomitant of psychosis. In schizophrenia, insight has been defined as an awareness of illness and an ability to recognise symptoms as part of an illness (Gray et al, 2002b) According to Surguladze David (1999) between 50% and 80% of patients diagnosed with schizophrenia have been shown to be partially or totally lacking insight into the presence of their mental disorder and these individuals are often difficult to engage with treatments due to impaired insight. Recent conceptualisation has formulated insight as a continuum representing the combination of three factors; awareness of illness, need for treatment and attribution of symptoms. Lack of insight is continuously problematic but an emotional element can be associated with denial of symptoms or rejection of treatment at key points in the illness (Byrne, 2000). Mitchell Selmes (2007) claim that having a perception about the illness and the knowledge of medications are the key factors of concordance in mental health and patients who understand the purpose of the prescription are twice more likely to collect it than those who do not understand. A study by Cuesta et al (2000) reported that patients suffering from schizophreniashowed poorer insight than patients with affective disorders. Cuesta et al (2000) findings demonstrated that the severe disturbances of insight persisted over the time and the level of insight was not significantly improved in patients suffering from functional psychosis as between 29% to 49% of these patients continued to have fair to poor insight at the follow up assessment. This is consistent with the findings of Kikkert et al (2006), where poor insight was a strong predictor of non-concordance with medication. In contrast, Tait et al (2003) conducted a study to examine changes in insight and symptoms of psychosis on fifty participantswho met the ICD—10 diagnostic criteria for schizophrenia. The participants were interviewed and insight was measured duringacute psychosis using the Insight Scale with the score 0- 12 and all the participants were reinterviewed at 3 and6 months following the init ial interview. Tait et al (2003) findings indicated that duringthe acute episode, 48% of participants scored 9-12 on the InsightScale and the majority of participants (63%) werein the 9-12 range of scores. The study of Tait et al (2003) clearly indicated that level of insight was high among many participants. In considering the findings of both Cuesta et al (2000) and Tait et al (2003) it appears that some patients with psychosis are unaware of their illnesses and insight is a strong predictor of concordance with medications and a good indicator of prognosis. However, evidence for a relationship between insight and concordance with treatment is inconclusive as the discrepancies found between the two studies might be due to the methodological factors, such as selection of participants. In both studies all the participants had a diagnosis of schizophrenia and all of them gave informed consent to enter the study. According to Appelbaum (2006) several studies in America regarding the decisional-capacity of patients with schizophrenia to consent or participation to research have raise some concerns due to the cognitive impairments associated with schizophrenia and using the MacArthur Competence Assessment Tool for Clinical Research clearly indicated that patients with schizophrenia do lack und erstanding and reasoning of research ethics. McCann Clark (2005) emphasise that antipsychotic medications some of which have a sedating effect can also have an impact on the cognitive processes, such as illogical thinking and this can hinder the quality of responses. Moser et al (2005) argued that some studies have shown that a high percentage of individuals with schizophrenia have adequate decisional capacity to consent to research participation, however in a medication-free schizophrenia research, participants did not show a major decline in decisional capacity. In addition, Jeste et al (2006) claimed that there is a risk in assuming that decision-making capacity of individuals with schizophrenia is always impaired, when they are capable to make autonomous decisions and in considering their decision-making capacity as permanently impaired by virtue of their diagnosis. Consequently, in order to investigate factors associated with schizophrenia, it can be argued that only individuals with schizophrenia can provide the answers of their experiences and protecting vulnerable populations from research activity can also exclude them from its benefits. According to Gerrish Lacey (2006) there two key concepts that concern the quality of a research: validity and reliability. Roberts et al (2006) define reliability as how far a particular test will produce similar results in different circumstances, whereas validity is to ascertain the methods are actually measuring what is intended to measure. Both Cuesta et al (2000) and Tait et al (2003) had used structured interviews to gather the data and have chosen a quantitative approach. Structured interview provides the opportunities to change the words but not the meaning of the questions thus, Parahoo (2006) claimed that validity is enhanced because participants can be helped to understand the questions and interviewers can ask for clarifications and probe for further responses, if necessary and since all the questions are ideally asked in the same way, structured interview has a high degree of reliability. It seems that both Cuesta et al (2000) and Tait et al (2003) have adopted the appropriate approach to their research, as quantitative research is the conduct of investigations primarily using numerical methods. It infers that to examine correlations between insight and service engagement qualitative approach could not have produced the same data in this area of study. Moreover, in both studies purposive sampling were used as all the participants had a diagnosis of schizophrenia. According to Polit Beck (2006) all participants in a phenomenological study must have experienced the phenomenon under study and must be able to articulate what is like to have lived the experience. Johnson Orrell (1996 cited in Surguladze David, 1999 P 166) have argued that some patients may have their own explanations of their illnesses, such as religion or cultural beliefs which may not coincide with the Western medical model of mental disorders and this can be even more complicated if one tries directly to impose the models of insight on patients from non-Western cultures. Gamble Brennan (2006) claimed that different cultures in England perceive mental illness in different ways and this can have an impact on treatments as some cultures rather seek help from religious leaders than mental health services. Alternatively, religion or spiritual beliefs in the Western culture can have a positive impact on concordance with medication, as religious individuals with schizophrenia have a better social support compare to non-religious individuals with schizophrenia (Borras et al, 2007). Therefore, it can be put forward that awareness of illness is a crucial factor in the motivation to receive pharmacological treatment. Both cultures and religion can have a positive and negative influence on concordance with antipsychotics. Patients can have different levels of awareness into their illness and they may consciously or unconsciously avoid acknowledging that they are suffering from mental health problems because of their reluctance to bear the stigma of mentally ill (Surguladze David, 1999). Byrne (2000, p65) defined `stigma as a sign of disgrace or discredit, which sets a person apart from others and the stigma of mental illness although more often related to context than to a persons appearance, remains a powerful negative attribute in all-social relations`. Stigma of mental illness has become an indication for unpleasant experiences, such as bringing shame to the family or social exclusion. According to Phillips et al (2002), in some parts of china, schizophrenia is still considered as a punishmentfor an ancestors misbehaviour or for the familys currentmisconduct and the effect of stigmais greater if the patient had more prominent positive symptoms or highly educated. Moreover, a study by Lee et al (20 05) concluded that 60 % out of 320 patients with schizophrenia had experienced interpersonal stigma from p arents, siblings or close rel atives. This indicates that people with schizophrenia are more likely to experience stigma from family members than the general public. Having a diagnosis of schizophrenia does not only affect ones health but also carries all the prejudice, discrimination and social exclusion, for example many individuals are attacked on the streets, rejection in the society and denial of employments because they were known to have mental health problems (Gamble Brennan, 2006). According to Byrne (2000) in two identical UK public opinion surveys, 80% of participants claimed that most people are embarrassed by mentally ill people and about 30% agreeing `I am embarrassed by mentally ill persons`. There is also evidence that supports the concepts of stereotyping of mental illness. The power and influence of the media on mental illness has been a key issue of debate over many years as people with schizophrenia are frequently portrayed as violent and dangerous. In contrast, people with schizophrenia are more likely to be dangerous to themselves than to others, while the greater danger to the public is posed by people without mental health problems and people with mental health problems are six times more likely than the general public to be the victims of murder (Stickley Felton, 2006). Moreover, Gamble Brennan (2006) claimed that when the boxing champion Frank Bruno was admitted to hospital in 2003, one of the newspaper headlines was `Bonkers Bruno locked up`. This indicates that stigma has the grave potential to cause reluctance to seek treatments and this can be detrimental to the persons health. Therefore, as a mental health clinician, it will be vital to assist people wit h mental health problems to rebuild their lives and this requires moving beyond the traditional focus on symptoms and medication by exploring alternatives in reducing stigma of mental health that avert people from social inclusion. It has been predicted that families with high expressed emotion compared to low expressed emotion can contribute towards the relapse rate in symptoms of schizophrenia and this can also be a triggering factor for non-concordance with medication. High expressed emotion carers appear to perceive their caring situation as more stressful and this could be conceptualised as a catastrophic appraisal of the role of caring (Raune et al 2004). Kuipers et al (2006) identifies the components of expressed emotion as emotional over-involvement, hostility, critical comments, warmth and positive remarks. A study by Kuipers et al (2006) indicates that patients whose carers showed high expressed emotion had considerably higher levels of anxiety and lower self-esteem due to the components of expressed emotion. However, a significant amount of data from western cultures suggests that high expressed emotion subjects who were not on medication are three times likely to relapse than those who were on medic ation (Bhugra McKenzie, 2003). This clearly signifies that despite being concordant, high expressed emotion subjects are vulnerable to relapse. The interactions between patient and the carers are crucial, especially cross-culturally as in some cultures for example, in some parts of India, emotional over-involvement is the norm and if carers do not show emotional over-involvement, this can be seen as lack of care (Bhugra McKenzie, 2003). Hashemi Cochrane (1999) conducted a study in UK on expressed emotion and they observed that 80% of the British Pakistani, 45% of the White and 30% of the British Sikh families exhibited high levels of expressed emotion and emotional over-involvement was notably higher among the British Pakistani group. The findings concluded that White patients with high expressed emotion relatives were significantly more likely to relapse than those from low expressed emotion families, whereas for both Asian groups high expressed emotion did not predict relapse. The study of Hashemi Cochrane (1999) also indicated that that Pakistani families in the UK were more likely to be rated as high expressed emotion than White families, indicating that components such as emotional over-involvement may be cultural rather than pathogenic traits. Conversely, low expressed emotion families who are not over-anxious in their response to the patients illness may tend to perceive stigma in less threatening ways whereas, families with high expressed emotion, who respond to the patients illness in a highly anxious may experience stigma more intensely (Phillips et al 2002). Therefore, it appears that family members levels of expressed emotion could influence their perception and response to stigma of mental health and concordance with medication is essential for patients irrespective of the expressed emotion status in the family. Thus, family interventions need to improve in order to lower the levels of anxiety and to increase self-esteem among families with hig h expressed emotion. As a clinician it will be vital to acknowledge the cultural aspect of expressed emotion status in the family to facilitate concordance with medication. There is overwhelming evidence for patients with schizophrenia, who misuse illicit drugs and alcohol to have an increased rate of re-hospitalisation (Sokya, 2000). According to Barnes et al (2006) the higher relapse rate in people with established schizophrenia who usesubstances may be partially explained by non-concordant tothe medication regimen. Evidence suggests that the substance used most frequently by people with schizophrenia is cannabis (Gamble Brennan, 2006). Arseneault et al (2004) emphasise that rates of cannabis use in UK are higher among people with schizophrenia than among the general population and patients detained under the MHA (1983) have even higher rates of lifetime use of cannabis. Substance misuse in schizophrenia may be explained as a form of self-medication to alleviate the symptoms of schizophrenia, to improve the side effects of antipsychotics and to respond to social pressures (Sokya, 2000). There has been little evidence to support the self-medication hypothesis despite its popularity with users and in contrast, substance misuse can aggravate the symptoms of schizophrenia and can also trigger psychotic episode particularly in people with a pre-exis