Doctorweblog. About Health & Medicine

Achievers are different to the E-types in that their desire for the approval of others is not as pronounced. They are more confident and self-centred. They seek to achieve partly for the status and kudos and certainly for the material rewards they desire and believe they deserve. They are very ambitious. In time, achievement for achievement’s sake becomes a prime motivator. They thrive on challenge and in extreme cases believe their life has no meaning without it.

Achievers are always on the go. So busy are they, in fact, that they hardly have time to draw breath, an expression many of them use when describing a typical day in their lives. Such shallow breathing practices help to explain why so many of them are burnt out. They work hard and long hours. Being positive and highly motivated, many of them are into taking care of themselves, as they perceive ‘taking care’ to be. Many of them play some sort of sport, work out with weights, do aerobics, or jog or swim regularly.

The more extreme achievers get into heavy competition sport or take part in triathlons. Many of them stay away from junk food preferring whole meal breads, sprouts, lentils, and other high-fibre natural foods.

The big problem is they never get time to rest. The irony is that high-fibre, natural foods are harder to digest than refined, fast foods and if they don’t take time out to sit quietly they never absorb the nutrients from their food which, being high fibre, passes rapidly through and out of them. Insidious malnutrition is a big problem for achievers who are perplexed at feeling so tired when they are working so hard at keeping fit and eating properly.

Extreme achievers take themselves, life and everything they do very seriously, often too seriously. They view life as a struggle for existence and remain stressed until they change this attitude. Some achievers pursue their chosen path in lieu of a relationship or because their present relationships are unfulfilling.

Achievers have to recognise that time out for quiet, restful moments in their day, plus eight hours’ sleep, is imperative if they are to have it all. Reduction in work and exercise loads are also needed. Retaining the high goals they have set themselves is fine. Extending the time frames needed to achieve these goals is the answer. Apply the principle of the hare and the tortoise rigorously.

Achievers always argue that their exercise regimen is a release from stress and up to a point this is true. It is at least a diversion from work and it does at least get some oxygen into the blood and the blood moving. Unfortunately, high impact exercises also fill the muscles with lactic acid, which lowers the body’s calcium reserves predisposing it to nervousness, headaches and irritability. The tension achievers incur through the course of a busy day has already put high levels of lactic acid in their muscles. To achieve true tension release from their busy schedule, achievers will benefit from taking up yoga, Tai Chi or yogic walking. The only good reason to go to a gym is for a sauna, swirl pool and massage.

Achievers burn out because they want results too quickly. If they can get the balance between work and rest right, they lead a fulfilling life and end up achieving more than they ever dreamed possible. High achieving is fine—over-achieving makes us ill.

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The holistic therapist is the therapist who can treat competently a whole range of problems encountered in the individual, dyad, or family. He or she views the patient as a whole person in a series of relationships and will address the individual and/or the relationships as appropriate. The means by which problems in these areas are addressed—the modalities, schools, techniques- may be less important than the attitude of the therapist to the wholeness of the patient. Still, certain skills are essential. Again, because sex is so fundamental to the functioning of both the individual and the dyad, because its ripple effects extend to and often include the family, and because sexual functioning is both a reflection and a determinant of other aspects of individual and dyadic functioning, the holistic therapist must be a sex therapist as well as an individual, dyadic, and family therapist.

Theoretically, a psychotherapist can start out in any single area of application and expand in any direction. In practice, it is unusual at this time for a person to begin his or her career as a sex therapist and proceed to individual/dyadic/ family therapy; the reverse is much more likely. It is crucial that such a person, no matter what his or her background may be, undertake training at a recognized sex therapy institute.

Sex therapy is simultaneously a theory, a body of behavioral techniques, and an encounter with patients. The theory is easy to grasp. The exercises and their applications are not difficult to learn. The encounter with patients can be devastating unless adequate preparation has been made.

The reason for this is in the difference between sex on a symbolic level in the mind, and sex in the body as organs with sensations. Most psychotherapists of all persuasions have had some sort of training therapy or analysis in which their own sexual history, fears, and fantasies were considered in terms of ideas, symbols, and emotions. Issues of Oedipal conflicts, homosexual impulses, fetishes, fixations, orality, anality – all have been explored. On the ideational and emotional level, most qualified psychotherapists can function very well. This training also is very useful in working with the resistances to sex therapy.

But none of it has the slightest use in, for example, telling a woman how to masturbate her husband being treated for premature ejaculation. One does not speak of impulses, drives, desires; one speaks of organs and parts of organs in the patients’ own language, which may range from the formal to the obscene. And one describes, in great detail, exactly what the patient and the partner are to do with those organs. For the inexperienced therapist, this kind of confrontation may be virtually impossible.

A psychiatric resident was undergoing sex therapy training in a sex therapy clinic. His first actual session as a trainee dealt with an anorgasmic woman. In the course of the session, the woman was helped to overcome her inhibitions against pleasuring herself, and was given detailed instructions on how to stimulate her genitalia, in brief, how to masturbate. Later, in going over the session, the trainee remarked that he was fine up until the point at which the step-by-step physiological instructions began, but from then -on he couldn’t remember a thing!

Another psychiatric resident, after a few sessions of sex therapy training, left the program with the comment that it had been the most valuable training he had ever had, but that he knew now that he could never be a sex therapist.

The exposure to sex therapy training on the organ/sensation level reawakens many of the anxieties associated with sex that were thought to have been resolved or understood but have not been eliminated completely. The typical reaction of the inexperienced sex therapist is to deny (as in the example given) or to avoid. Beginning trainees typically are eager to treat intrapsychic or interpersonal difficulties (which may be very minor), even when these are not resistances to the sex therapy and should be bypassed, postponing their confrontation with the physicality of sex for as long as possible. Working through the trainee’s anxieties takes varying amounts of time, but the individual, dyadic, or family therapist who wishes competence in sex therapy should allow for a training period of approximately two years.

Sex is one of the dominant factors in the functioning of whole people with, presumably, greater awareness of the barriers to experiencing one’s wholeness. Like everyone else, therapists are not immune to problems in the sexual sphere; like everyone else, their individual and interpersonal lives benefit greatly when sexual difficulties are alleviated. So does their impact as therapists. For the patient, holistic therapy is most effective when it is performed by therapists secure and enthusiastic in their own holistic functioning.

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Just as it is impossible to draw a sharp chronological line between the young and the experienced, it is impossible to draw a sharp chronological line between the experienced couple and the older couple. It is true that the sexual functioning of the elderly (especially the elderly man) differs from that of the non-elderly in certain age-related physiological changes (time required for erection, length of refractory period, and so on) (Masters and Johnson). Sex therapy for the elderly must take these changes into account.

But in their extrasexual functioning elderly couples exhibit all the variations in type, intimacy, and style as do younger couples. Once age-related changes are recognized, sex therapy for the elderly is the same as sex therapy for the younger, with perhaps a stronger attitude on the part of the therapist that “forbidden” normal practices are in fact not merely permissible but even desirable.

The elderly are popularly supposed to be resistant to change, but I have not encountered this phenomenon in my own practice. I have concluded that this resistance of the elderly is not so much inherent as evoked. It is a reaction to two complementary sets of changes experienced by the elderly: those they perceive in their own physical functioning and those they perceive in the way they are treated by others.

The perception of internal change, especially the perception of weakening powers, can provoke anxiety. However, this anxiety can be managed satisfactorily by most of the elderly when they understand that weakening powers do not mean reduced gratification. But when this anxiety is coupled with the attitude of most other people that the elderly person is less competent and less useful than other people are, the elderly feel diminished indeed. This external attitude is harder to fight against because it seems to be confirmed by their own aging bodies. Undermined by the loss of their sense of themselves as accomplished, whole people, they regain a sense of mastery by assuming a rigid posture, by insisting on no-change. When the elderly then are directed to change, this insistence can be defended successfully and a sense of strength is gained.

But only let the therapist encourage the elderly with the same attitude of optimism with which he or she encounters younger patients, and the results are striking. When the external world confirms not the diminution but the sustenance of the elderly, the elderly most often will respond with a mental and emotional (and often physical) vigor that can serve as a lesson to the younger.

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Typically, the couple will not go to any therapist until the situation has become very painful. Up to that point, contending with change has seemed too much of a threat. Once in sex therapy the experienced married couple exhibits the same sabotaging behavior and fears of desertion as the young married couple does. Further, the experienced marrieds are much more likely than the young marrieds to have had extramarital affairs. In a sense, they covertly have left the relationship already.

Sometimes one has an affair in order to obtain the sexual (and other) satisfactions missing in the marriage, but often the purpose is to retaliate for the injuries, real or imagined, or to alert the partner that the marriage has reached the breaking point.

In two ways, the extramarital affair can at least temporarily assist the marriage. When it is done in order to obtain otherwise unavailable gratification, it can help that partner to be more generally content and better able to tolerate the other stresses in the family. Clearly, when the unfaithful partner deliberately allows the other to learn of the affair (one man phoned his lover from his home, knowing that his wife usually listened to his conversations on an extension phone), it is a signal that the relationship has become too dysfunctional to be tolerated, and a stimulus for change. Often it is the last stimulus for change before a permanent separation.

Although the early problems of the dysfunctional, experienced married couple may not have been sexual in nature, sooner or later (usually sooner) they reach the sexual sphere. A sexual dysfunction appears or becomes aggravated, or the sex life of the couple begins to suffer in one way or another. From that point on, as with the young married dyad, the experienced married couple usually identifies the sexual problem as the core problem. Although in an etiological sense this may not be true, the therapist may take advantage of this belief by starting sex therapy as early as possible (if hostility between the couple has not progressed too far). With the experienced married couples, the most dramatic extrasexual effects of sex therapy are encountered. Like most couples, they have begun their relationship by being in love and over a period of time have seen all or most of their positive feelings for each other change to or become over-laden with tension, hostility, distrust, resentment, and defensiveness, until they seem to themselves to be trapped in a situation at once intolerable and unchangeable. As sex therapy proceeds and as the initial and intermediate results bring both partners not only new sexual satisfaction but also new ways of relating, the incrustation of negative feelings and habits begins to drop off, and the couple experiences again the initial feelings of love, trust, and excitement. Whether or not other problems remain, and usually they do, this recaptured early ardor is almost always enough to propel them through those problems with eagerness and hope.

Of all the types of dyads or couples who come into sex therapy, the quickest and smoothest progress is often made by the experienced unmarried dyad or newly remarried. Usually but not always, these two people have been married before, care about each other, and are committed to a long-term relationship, usually remarriage. Resolved not to repeat the mistakes of the past, they also have learned how to help their partner avoid falling into old, painful patterns.

One middle-aged couple had just been married to each other, the second marriage for both. The presenting symptom was secondary impotence in the man. During their courtship he occasionally had experienced secondary impotence, but after their marriage it seemed to have become permanent. The man suggested to the woman that she see other men for sexual satisfaction, a clear regression to an earlier mode of coping with anxiety. The woman flatly refused and insisted that they go into sex therapy together. Within four sessions, with the wife’s full cooperation every step of the way, the secondary impotence was cleared up.

Although the rapidity of this cure was unusual, the general outlines of the case are not. The experienced unmarried couple, or the experienced newly married, are very promising candidates for sex therapy.

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The young married dyad with relational difficulties may or may not visit a marital therapist first, but if a sexual difficulty accompanies the relational problem, that sexual difficulty almost always will become the focus of the complaint. The dysfunctional young married dyad with a sexual dysfunction tends to attribute all their problems to the sexual sphere and assumes that once that is alleviated, their basic problems are solved. Clearly, this is far from being always true, although it should be pointed out again that even when other difficulties precede the sexual difficulty, resolution of the sexual problem usually will help greatly in resolving the more general problems.

When sex therapy begins, both partners tend to be equally enthusiastic. As the therapy proceeds and as the results become apparent, covert sabotaging often begins on the part of the non-dysfunctional partner.

A couple in their late twenties, married for two years, had not consummated their marriage. The husband would become flaccid upon attempting entrance to the vagina and had never been able to penetrate. After the first six months, he was even unable to obtain the firm erections he had had up until the attempted entrance.

In the first phase of therapy, with intercourse prohibited, the husband was able to sustain long, firm erections. When intercourse was permitted, at the couple’s discretion, the couple reported a very strange phenomenon. Even though the wife (not a virgin) was well lubricated, even using the least-threatening (for the male) female superior position, and even with good erections, the husband had not been able to penetrate.

Questioning revealed that the wife was actually dodging the husband’s penis; by her movements she was preventing him from entering the vagina. Further discussion helped the wife realize that she was fearful that once her husband became fully potent and functional, he would be unfaithful and then desert her.

This session was enough to dissolve the unconscious sabotaging problem, and four more sessions concluded the sex therapy. Therapy for other problems, however, continued.

As noted earlier, sabotaging usually results from low self-esteem, although more complicated intrapsychic factors may be present. Ironically, as mentioned earlier, it is rare for the cured partner to leave the other partner, either formally or by seeking extramarital sex, or for example, by the newly orgastic woman turning into a nymphomaniac. In almost every case the whole relationship is bolstered by improved sexual functioning; the typical reaction of both partners is to wish that they had had sex therapy when the problem first arose.

It probably has been noted that I did not define “young” in young dyads. The reason is that there is no real line of demarcation between the young and what I have called the experienced. But it is reasonable, I believe, to consider as young those who are in their twenties, who have been married (or have had a strong commitment) to each other for up to five years, and who do not have children past the age of two. When children come, the couple’s perception of itself alters radically, but it takes some time for the transformation to be complete. When the baby first is born, the couple remains a young couple with a baby; only after about two or three years does the couple consider themselves a family. At that point they are or may be an experienced couple.

How the experienced married dyad views themselves as individuals and as a couple is reflected in their approach to therapy. Most often, when problems, including sexual problems, arise, the couple’s initial visit will be to a marital or family therapist. Even if the patients believe explicitly or tacitly that the sexual difficulty is and has been at the root of their global problem, they still will tend to start out with marital or family therapy.

By the time they do seek therapy, the global problem usually has become severe. Problems neglected before the children came have grown worse. The children, even those without problems, have added new stresses to the relationship, and those with problems have exacerbated the tension and hostility.

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Lawnmowers are heavy, yet have to be heaved backwards, humped over lawn edges and in and out of sheds. Pushed mowers are the lightest and comparatively easy to manoeuvre. When using a push mower, wear boots or shoes with good grip and use your body weight to help the movements. Avoid jerky manoeuvres

Of the powered mowers, the lightest are those with electric motors which run off the mains, followed by those with petrol engines. Cylinder mowers are on the whole heavier than rotary mowers, but, being more compact, are easier to manoeuvreand are usually self-propelled. The additional cost is often justified! Rotary mowers are handy for rough grass but there the effort of manoeuvring is far greater, particularly if the mower has small wheels.

Many people empty the grass box into a wheelbarrow but unless you have an ergonomically satisfactory barrow or cart, it may be easier to empty the grass box on to a sheet with handles at the corners which is easy to pull across the lawn to the compost tip.

With mowing, as with all gardening and other heavy work, the rule is not to do too much at a time. Plan all the work so that you can divide it into many short sessions, rather than a few long ones, and allow plenty of time to do the work. If working alongside somebody else, do not feel that you have to keep up; work at your own pace. If your back starts hurting, do not struggle on to finish because the weather is right or you are going away tomorrow – stop.

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Patients may be referred to occupational therapy (often referred to as OT) after recovering from surgery as part of rehabilitation, or after being inactive because of a prolonged spell of pain (where there was no surgery).

Patients are referred to occupational therapy in the same way as they are referred to physiotherapy. The two types of treatment are likely to overlap; the physiotherapist may start treating the patient when the patient is in bed, while occupational therapy does not start until the patient is up and out of bed.

Occupational therapists have completed a four year full time course. Occupational therapy is usually requested by the doctor, but the actual treatment is left to the discretion of the therapist. It may take the form of any activity, work or recreation which will most effectively help the patient to achieve full recovery and return to work; or which will minimise the effects of permanent disability and help the patient to live with such a disability.

Occupational therapy services are available in the public health system, especially in public hospitals, rehabilitation centres, psychiatric centres, centres for the intellectually disables, geriatric nursing homes and community services. OT is covered by Medicare and most major health funds. There is also a growing number of occupational therapists working in private practises. Depending on the type of service being offered and the size of the practice fees range from $95 to $112 per hour.

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Over the centuries, victims of back pain have submitted to a vast variety of treatments. The bizarre nature of some of these testifies to the sufferers’ desperation: they were willing to try anything – even, it is said, having a tame bear tread on their back. In spite of great advances in medical science generally, these unorthodox treatments – except, perhaps, the bear – are still in with a chance.

Back pain therapy presents special problems. It is often difficult to diagnose accurately the cause of an attack of back pain. Damage to the structures of the back does not, as a rule, show on the surface, many do not show up on X-ray and even in-depth specialist investigations may not reveal anything obviously amiss.

Moreover, very often back pain is out of proportion to the problem causing it; although the pain is severe and disabling, the structural damage may be minor, and one accepted view is that it will heal, given time, provided movement is restricted to the pain free range. Another school of thought considers this to be short-sighted and holds that correct treatment by a qualified therapist will expedite recovery and may help to reduce scar tissue, the presence of which can produce long-term problems.

If any treatment is given, it is sure to get the credit for the recovery. But the next time it is tried on someone, it may not work, either because it is valueless, or because the problem is not the same.

The information gleaned from each case may be of only limited use in the next one, and the treatment of back pain has had to be largely empirical. The fact that diagnoses are often less than accurate makes the choice of therapy problematic and specific therapies which exist for one condition are sometimes applied erroneously to another. There is no scientific body of knowledge which allows a doctor or any other practitioner to state with certainty that a particular treatment will cure the trouble.

The rationale of advising rest, and particularly bed rest, is based on the clinical observation that lying down may relieve pain. This applies to a diagnosis of disc prolapse: intra discal pressure is lowest in the lying position. However, disc prolapse constitutes only a small percentage of all lower back pain and treatment for disc prolapse cannot necessarily be extrapolated to all lower back pain. However, rest is the first line of treatment for acute attacks of back pain.

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The kinds of back trouble that have been described so far derive from some dysfunction of the spine or from a congenital deformity, or from a violent injury, or from gradual deterioration with use and age.

There are other kinds of back trouble. Some of them affect the spine mainly or solely; others affect various parts of the body, the spine being just one of them. A third category includes disease which produces back pain without necessarily involving the spine.

Ankylosing spondylitis-This is a chronic inflammatory condition or arthritis, predominantly affecting spinal joints. It tends to run in families (but not always so that every member is afflicted). It affects men more than women, and symptoms often start young, in the teens. It is a systemic disease; the person feels ill when the disease is active, and other parts of the body (for example the eyes) may be affected.

In ankylosing spondylitis, the same process of laying down calcium deposits which creates osteophytes may continue to the point of fusing together some vertebrae, so that the spine in that region becomes completely stiff.

It starts usually in the lining of the sacroiliac joints and spreads gradually upwards to the other joints of the spine; it sometimes also spreads downwards into the hip joints and, more rarely, other leg joints. Over a period of time the inflammation may cause the ligaments of the joints to calcify, so that the joints become ankylosed (rigid) producing, in the worst cases, a spine locked permanently in a bowed posture. The ligaments joining the ribs to the spine may also harden, flattening the rib cage and making breathing difficult. This is one of the early symptoms. Others are pain and stiffness in the hip joints, which feel worst in the morning, because they are made worse by lying still and are relieved by movement. Pain-killers and anti-inflammatory drugs as prescribed by the doctor will help considerably. Controlled exercise is invaluable: it should be taught by a physiotherapist. Done regularly, it may help to keep the joints flexible and avoid severe deformity. Many patients take up squash, tennis, swimming and other sports and prefer this to the repetitive use of formal exercises over many years.

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Muscles are the fleshy part of the body and consist of long, thin fibres, bound together in bundles by connective tissue, and supplied with blood and nerves. What is remarkable about these fibres is that they can become shorter in response to a stimulus. The shortening is caused by protein filaments inside the cells which pull against each other; on relaxation, the muscles are pulled back into their original position, by gravity or by the action of other muscles. Sometimes the cells are unable to relax their hold – this involuntary contraction of a muscle is called a spasm and may be caused by pain.

There are, roughly speaking, two types of muscle: the involuntary and the voluntary. The heart and the hollow organs (digestive system, uterus, blood vessels, etc.) are of the first sort. They work without conscious control while life lasts – you do not need to instruct your heart to beat. The voluntary muscles are mostly under conscious control, so that it is for you to decide to move your limbs, for example; but you do not, of course, have to plan the movements of each muscle. When you decide to bend your knees, for instance, reflex actions determine the different movements of the several different muscles which this entails, and you neither know, nor need to know which ones they are.

The voluntary muscles also respond to various stimuli through reflex actions – when you touch a hot stove, messages racing along the nerves will jerk away your hand faster than thought.

Because they can be controlled, the voluntary muscles can be trained to work more efficiently. With suitable training, the nervous system learns how to recruit muscle fibres more rapidly and more precisely, and the muscles themselves become stronger and bigger and more capable of clearing away the waste products of their activity, so that they can continue working for longer. If they are not exercised, they waste away quickly.

The action of a muscle is to develop tension between two points on the skeleton, so as to draw them together or prevent their being pulled apart or control the rate at which they are being pulled apart. Without muscular control, the spine is much less stable – as in an unconscious person.

The muscles which control the spine are those of the back and neck and the abdominal muscles.

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