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What can science tell us about Noah's Ark and the Flood? Anything? A recent National Geographic Channel program aimed to find out:
A wicked world. An angry god. A righteous man named Noah who built an Ark, and survived a flood. But did it happen the way the Bible describes it? While some scientists are looking for answers, others search for confirmation on the biblical account. Will they find it? Or, was the story of Noah simply a story? Of God … and man … and a promise?
The story of a man, and a boat, and a flood first appears in the Middle East—the same part of the world that gave birth to Judaism, Christianity, and Islam. It's told in both the Bible and the Qur'an. The account of a catastrophic event that happened very early in human history, not too long after the creation. Many of us learned the story when we were kids, even if we didn't go to Sunday School. But how seriously should we take the story of Noah and his Ark? Did it happen the way the Bible tells us it did?
With that intriguing introductory narration, the program embarks on a review of major theories for what caused the Flood, whether the Flood was global or local (or entirely mythical), whether there is geological evidence for the Flood, whether Noah's Ark could have been built to survive the Flood, and so on. Interviewees range from Tom Vail, a creationist who heads up AiG Grand Canyon raft trips, to Alan Gishlick, a geologist for the staunchly anti-creationist National Center for Science Education.
The program makes its first mistake early on when the narrator explains that both the Bible and Qur'an contain "the account of a catastrophic even that happened very early in human history—not too long after the creation." Actually, according to the chronology the Bible presents, the Flood happened over 1,500 years after the creation.
The viewer is then shown a scene less common now than it one day was: a Sunday School classroom full of children learning about Noah and the Ark. After the narrator comments that most of us learned the story as children, he asks, "But how seriously should we take the story of Noah and his Ark? Did it happen the way the Bible tells us it did?
Opposing perspectives come from Bob Cornuke, author of Ark Fever, who believes in the biblical account of the Flood, and George Washington University archaeologist Eric Cline, who doubts that there was a worldwide flood and comments that he "[doesn't] see any evidence in the geology or anything else for a worldwide catastrophe. Next, Rev. Dr. Francis Wade of Washington DC's St. Alban's Episcopal Church explains his compromised view:
I believe the story about the Flood. Now, if you ask me, do I believe that there was a 450-foot-long Ark with all the animals of the earth crammed inside of it … specifically, probably no.
"But Can the Bible Be Taken Literally?"
It is under this narratorial inquiry that the program begins its investigation of the biblical account of Noah. The first question delved into is the ages of people involved in the account.
Pre-Flood Ages
"Noah, for instance, was about 500 years old when he got the warning [of the Flood], and that poses a problem for many modern readers." The program turns to archaeologist David Merling of Andrews University, who explains that the ages of Noah and other men in Genesis pose an "unusual problem because that's not what we see today."
"But it's not an insoluble problem," the narrator cautions. Merling suggests that humans may have originally been intended to live longer lives, but that environmental changes may have disrupted the length of human lives.
But the program then turns back to Reverend Wade, who metaphorizes the numbers in Genesis: "When the Bible talks about years, age, it's talking about respect … it's a culture in which age was respected. So when you assign more years to a person, you're talking about the great respect with which they are held."
Notice the word Reverend Wade uses—assign—to describe the age records in Genesis. According to his view, the numbers in Genesis have no relation to actual data, but are merely ascriptions of respect. But such a hermeneutic creates many problems if it is extended across the Bible; it leads one to doubt many important miracles. If the Bible effectively lies about data presented straightforwardly and without literary decoration, how could we possibly take literally the more extravagant miracles of the Bible? For example, the Bible tells of Elijah ascending to heaven in a chariot of fire. But there is little doubt Reverend Wade considers this a mere figurative description to indicate the respect Elijah carried. And, of course, when one carries this hermeneutic to its consistent logical conclusion, one must ask if Jesus truly rose from the grave, or if this passage was figurative and shows only the great awe and respect early Christians had for Jesus.
Tom Vail, president of Canyon Ministries, compiler of Grand Canyon: A Different View, and leader of Answers in Genesis Grand Canyon raft trips, enters the fray next. "God's Word can be taken literally ... and in the beginning, 'God created in six days' means He created it in six literal, 24-hour days."
Dating the Flood
The program's narrator then follows a tangential path, leaving the issue of Noah briefly and instead recounting the chronology work of Archbishop James Ussher (you can read more about Ussher's work in The World: Born in 4004 BC?), who dated the year of the Flood to 2348 BC. An actor portrays Ussher working on his calculations, but the program soon segues to a three-dimensional rendering of what the Ark may have looked like. The program then reviews the dimensions of the Ark.
One admirable step the program takes is to accurately portray the Ark's general appearance. Most people inaccurately think of the Ark as a small vessel (due to the influence of so-called "bathtub arks"), but in fact, the Ark was a massive ship, easily able to house the required animals and supplies and remain seaworthy. The program portrays an Ark with appropriate dimensions, claiming that "if the Bible's dimensions are correct, it would have been the largest wooden vessel in the history of the world—the original man-made wonder."
Finding the Ark
Next, viewers are whisked away to scenes of Ark-hunting teams exploring the mountains of Ararat. The program takes a tour of the history of Ark-hunting, replaying black-and-white footage of the Russian Revolution while recounting a possible Arkology expedition dispatched by Russian Czar Nicholas II. This history lesson also reviews the advent of the use of aerial and satellite photography in the search for the Ark, then takes its cameras to an interesting site: the Noah's Ark National Park Visitors Center, near one of the alleged Ark remains. Haji Hassan Bey of the Noah's Ark National Park Museum, who describes himself (through a translator) as "the historian of Noah's Ark," is adamant that the the Ark is at his site. Dr. Farouk El-Baz, a Boston University geologist, recounts the efforts of James Irwin, Ark-hunting astronaut and author of Destination: Moon. The program next turns to Professor Porcher Taylor of the University of Richmond, who discusses the use of satellite imagery in Ark-hunting—from the Ararat anomaly onward.
The Ark-hunting field is understandably exciting, but has resulted in numerous "false" discoveries. The problem comes when people base their belief about the Flood (and its representation of the coming judgment) on archaeological discoveries instead of the Word of God.
Ark Construction—Feasible?
After reviewing the history of Ark-hunting, the program backs up, asking, "But are the Ark-hunters combing the mountains for a boat that might not even exist? Could Noah have really built a boat that big? Some modern shipbuilding experts have their doubts … ."
"Noah's project is pretty unbelievable, as far as the size of 450 feet dimensions and 75 feet wide. Being a boatbuilder, that would be a glacial task," laughs Peter Johnson, a Boothbay Harbor (Maine, USA) shipwright. The narrator jumps in, explaining that a twelve-man crew at Boothbay Harbor takes about a year to build a 60-foot-long wooden boat. Marine architect David Stimson suggests that Noah "wouldn't have been steam-bending wood," and instead would have used edge-cutting tools to shape pieces for the Ark's hall. The narrator is quick to point out that Noah's tools would have most likely been made of stone. But the Bible implies the opposite. In Genesis 4:22, Tubal-Cain, son of Lamech, is said to have "forged all kinds of tools out of bronze and iron"; because Tubal-Cain lived before the Flood, Noah would have probably used metal tools.
The narrator continues:
It's clear that Noah would have faced a number of challenges. The mysterious gopher wood Noah used would have had to have been super-strong, though some fundamentalists believe Noah could have solved the problem by building a vessel that was shaped more like a barge than a boat. But the question is, could such a gigantic vessel have survived a mighty storm and a flood?
Shipwright Peter Johnson jumps back in while images of storms and raging water roll across the screen. "In big seas a big boat gets working and twisting and it can break in half. Noah's boat could have withstood a moderate storm. I wouldn't say it would survive a catastrophic storm—boats can't even survive those now." Yet standing opposed to Johnson's view are nine scientists from the Korea Research Institute of Ships and Engineering. Read their conclusions in Safety Investigation of Noah's Ark in a Seaway.
"What Were Those Waters?"
The program then turns to looking for evidence of a global flood: "Whether the Ark of Noah existed or not, some people think there are clues that point to a global flood," leads the narrator. Dr. Bruce Masse, an archaeologist with the Los Alamos National Laboratory, states, "Every culture worldwide has a Flood myth. It's probably the only truly universal myth that we have."
The program then refers to the Epic of Gilgamesh, and Dr. Cline lists some of the similarities between the Gilgamesh Epic and the Genesis Flood account. Cline concludes that "there are enough similarities between the story in the Bible of Noah's Ark and the story in the Epic of Gilgamesh that, without a doubt, they are related." We certainly agree; the similarities between the many Flood accounts clearly indicate a universal origin. The question is, which is the true account of the Flood, and what explains the fact that cultures on different continents all have such alarmingly similar Flood stories? Also, read about the similarities between the Flood accounts in the Gilgamesh Epic and Genesis—and which came first—in Introduction.
Where did the waters come from? The program tackles this question next. First, it reviews the idea that the "fountains of the deep" were geysers releasing trapped subterranean water. "It's not a theory mainstream geologists take seriously," the narrator cautions, and turns it over to Dr. Alan Gishlick, a geologist with the National Center for Science Education. "You don't have to really propose what might happen if water came up from below because we just know there's no water down there," explains Gishlick, who obviously ignores the possibility that subterranean water released during the Flood might have settled in ocean basins rather than returning underground. "If all the geysers erupt globally, you wouldn't really put that much water up into the planet to do anything, but it might be kinda cool standing around in Yellowstone waiting for geysers to go off," continues Gishlick. Again, Gishlick assumes that conditions now reflect pre-Flood conditions, and presupposes that the relative lack of subterranean water now means there never could have been more underground water. This method of presupposing that the present is the key to the past is the basis of uniformitarianism.
The next theory the program deals with is canopy theory, first proposed by Henry Morris and John Whitcomb. Canopy theory postulates that a large amount of water vapor existed in the pre-Flood atmosphere, extending far above the surface of the earth. (Answers in Genesis recommends against the use of canopy theory, as it is an extrascriptural concept that has never been fully perfected—though a partial canopy may have been present before the Flood.) Dr. Gishlick argues against canopy theory in the program, accurately explaining that "it really wouldn't be a pleasant place to live, because it would be like sitting at the bottom of the deepest trench on [sic] the ocean." The narrator brings viewers' attention to Venus, whose vapor canopy generates crushing pressure at the planet's surface.
The program then turns back to Dr. Masee, who has a different idea about the origin of the Floodwaters: a cometary collision. "Many different [Native American] cultures that relate to the Flood, usually it's in association with water serpents, feathered-headdress serpents," explains Masee. "When you look at comets, you see the tails—what looks like a headdress, or a horn. Based on the mythology, it's very clear to me that we are looking at a comet hitting the ocean somewhere as the basis for the Great Flood." (Masee is not the only scientist to propose such an idea.)
The program's narrator enthusiastically explains that the scenario is "not that far-fetched," and calls upon Dr. El-Baz, who claims the model "is actually the most plausible of all theories [of Floodwater origins]." (The program also sneaks in a reference to a meteorite impact "probably" killing off the dinosaurs 65 million years ago.) For an in-depth look at the origin of the Floodwaters, see Was There Really a Noah's Ark & Flood?
Is There Any Geological Evidence of the Flood?
"A flood that covered the whole earth: that's what the Bible tells us in the story of Noah. But most geologists can't find any evidence to support such a theory," voices the narrator, while video of Dr. Gishlick poring over Grand Canyon rocks is shown. Dr. Gishlick claims "we really don't know if there's been any point in the earth's history where the planet was completely covered by water."
Yet the narrator quickly overturns geologist Gishlick's claims. "Conventional geology does assert that the earth was almost entirely covered by water about 500 million years ago, when the climate was much warmer than it is now. That's when many of the marine fossils we find on mountaintops today were deposited. At least, that's what most geologists believe. But not those who regard the Bible as the supreme authority."
The program then turns again to Tom Vail, airing video of his rafting trips and recording some of Vail's experience at the canyon. "To Vail," the narrator begins, "the Grand Canyon is a laboratory that proves the earth was created in the last few thousand years, and then blanketed by a worldwide flood. And the evidence is in the rocks." Vail is shown near a bent section of Tapeats Sandstone, explaining how the intact-but-folded layers are a sign that the sandstone was wet and malleable when originally deposited—evidence for a catastrophic flood, not for slow deposition over millions of years.
Dr. Alan Gishlick counterargues that the large U-shaped bends in the canyon argue against its rapid formation. But canyons with similar twists and bends are known to have formed rapidly. For instance, the canyon drainage basin of the Toutle River, which is up to 140 ft (43 m) deep in places, was cut in a single day (March 19, 1982) by a flash mudflow.
Mr. Vail then points out that the distribution of fossils in the Grand Canyon is not uniform, and that marine fossils (considered extremely old by evolutionists) are found throughout the layers. Dr. Gishlick responds that if a catastrophe caused the fossil layers, one would expect absolutely no organization in the layers—that is, uniformly distributed fossils. But the model that best explains both the organization that we find and the frequent disorganization (finding fossils in the "wrong" stratum, finding polystrate fossils, etc.) is the ecological view of the geologic column.
But Dr. Cline jumps back into the program, ridiculing the creationist view by claiming that the Bible is "not a history book … it's not a geology textbook." Of course, regardless of whether one agrees with it, the Bible is very much a history book in many regards (though not all parts of the Bible are historical narratives, of course). Furthermore, although the Bible is certainly not a geology textbook, this does not mean the Bible has no connection to geology; instead, it means that, although the Bible may not detail exactly how a worldwide Flood caused the geology we see today, it still clearly states that a worldwide Flood occurred—a Flood which, science tells us, would have catastrophic geological implications.
Finally, Rev. Dr. Wade appears once again to similarly discredit the Bible: "The Bible is like a person, and if you torture it long enough, you can get it to say almost anything you'd like it to say. But it's not a science book." One wonders how a reverend such as Dr. Wade builds a theology if he believes the Bible can say anything—and, thus, really says nothing.
The program returns to Bob Cornuke and his search for the Ark, who calls the Ark an "unprovable hypothesis," since "Noah didn't leave his fingerprints." Indeed, it would be difficult to "prove" the story of the Flood from an archaeological perspective without finding the Ark—hence the problem of basing one's ideas about the Bible on what science can uncover. However, Cornuke has made some interesting finds, including partially unfossilized clams on top of the mountains of Ararat. Dr. El-Baz claims there's nothing peculiar about "finding a little shell on top of a mountain," but offers no explanation for how the clams actually got there.
"But There's one Final Theory to Explore—and it Might Be the Most Reasonable of All"?
In the program's final segment, we meet geologist Drs. Bill Ryan and Walter Pitman of the Columbia Earth Institute, who are busy proposing another theory as to the origin of the Flood accounts: a sudden overflow of the Black Sea. While mapping the Black Sea, the two discovered underwater beaches—a sign that the sea level had risen catastrophically in the past. Core samples from the floor of the Black Sea indicate that "marine mollusks all seem to have appeared at all depths in the Black Sea at the same time—7,600 years ago, so something big had happened there," explains Dr. Ryan. The narrator explains the theory further: global warming ended an ice age, melting polar and glacial ice and flooding the Mediterranean Sea (and other bodies of water), which overflowed into the Black Sea via the Dardanelles and the Bosporus in about "thirty to ninety days."
Dr. Fred Hiebert, a National Geographic Archaeology Fellow, suggests that the land around the pre-catastrophe Black Sea would have been occupied, and that the "almost incomprehensible" catastrophic flooding of the Black Sea would have given rise, over thousands of years, to the Flood account. Dr. El-Baz returns to credit this theory for the "legend of the floods." The narrator explains that "such a catastrophic event would seem like it was encompassing the whole world," a chronologically snobby comment that implies our ancestors were not intelligent enough to realize that as long as there was land to walk on, the world was not covered by a flood. The program then credits migrations for the expanse of the story, and its evolution into the Gilgamesh Epic and, eventually, the Genesis account.
But What About …
As the program draws to a close, the viewer is clearly presented with a general idea of what he "should" believe about a worldwide Flood—about what is a "reasonable" meeting of the Bible's account and mainstream science. Essentially, the program watered down the main elements of what Genesis teaches about the Flood. "Maybe there was a Flood," they say, "but it probably wasn't global. Maybe there was an Ark, but it couldn't have been as big as the Bible says it was. Maybe there was a 'hero' character, but he certainly wasn't spoken to by God, and the Flood certainly wasn't caused by man's wickedness. Noah may have lived for a long time, but not hundreds of years—that's just a sign of respect." And, of course, "The Genesis account isn't the real story of the Flood, but just one of many accounts descended from a proto-Gilgameshian Epic."
Though these ideas are presented as rock-solid, they clearly fail to answer several important questions. For example, nearly all Flood accounts have a "hero" figure, representative of Noah, who is "tipped off" by God as to the coming catastrophe. Yet if the story that inspired the Flood accounts was "merely" a natural disaster of less-than-apocalyptic proportions, how would any human know in advance to prepare some way of avoiding the disaster? Another question unanswered by secularists is why a flood would have caused such universal "legends," even though many other natural disasters (volcanoes, hurricanes, earthquakes, etc.) would have also afflicted man significantly. Also, one must ask how a single Flood account (albeit with variations) could have spread to nearly every people group around the world without a population "bottleneck" such as the one caused by the [real] Flood.
Proving the Bible?
Searching for the remains of the Ark, examining the many cultural accounts of a worldwide flood, and trying to understand the science behind the Flood is all well and good. The problem comes when individuals base their view of Scripture on science, only trusting the Bible if the current science "validates" it. But man's ideas are fallible and in constant flux; what happens when the prevailing scientific view changes? Furthermore, placing science "ahead" of Scripture inevitably results in eisegetical reading of the text.
Yet Jesus and Peter, in the New Testament, referred to the Flood as historical fact even without using (or knowing, in Peter's case) any modern-day scientific theories to explain the physical dynamics of the Flood (see Matthew 24:37–39 and 2 Peter 3:3–7).
When one starts from Scripture and builds science on Scripture, the two are in their proper places, and each fill meaningful roles. This view makes sense of not only the Genesis account of the Flood, but also the geological and anthropological evidence of a worldwide Flood. When one abandons the foundation of Scripture, one is adrift in the sea of man's constantly overturned ideas and left still searching for the truth.


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If you follow me on Instagram,
We started on the bridge overlooking the Danube River. Fun fact I learned is that Vienna legalized street art so there are certain walls that have beautiful graffiti art because of it. One of those walls is along the Danube river.
Vienna has a rich history in the arts, as the home of Mozart and Freud, and a storied past from the Holocaust to their longest-reigning emperor Franz Joseph. Below is the Schönbrunn (meaning "beautiful spring") Palace, where he lived. Behind the palace is beautiful garden and a spectacular view if you make the hike up the hill.
And if you're looking for a cheap but delicious bite to eat after sightseeing, check out Schachtelwirt.
Vienna also has a lot of beautiful architecture. I was staying in a hotel around the corner from the Belvedere Museum, which today houses the the world's largest Klimt collection but was before the home of Prince Eugene of Savoy(1663-1736).
Vienna is a beautiful city to visit, I only wish I had longer to explore it. I'd highly recommend it as a great central European city to see and doable on a long weekend escape. It has a lot of green spaces within the city and is rated as one of the best places to live in the world. The people are very friendly and food was delicious (although I had my fill of schnitzel by the end).


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Sam Dynamou | 15/08/2018
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Ben is the most successful men's rugby sevens coach in the world, the only coach winning Continental, World and Olympic […]
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No biographical data survive.
Primary Sources of Information
The only known work of this author, the Glossarium latino-arabicum, offers no meaningful factual information on his life. But as van Koningsveld has thoroughly shown, its contents and composition indicate that he was a learned Mozarab who designed this lexicon to assist other Mozarabs, whose language had for long been Arabic, in acquiring a knowledge of Latin.


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In the aftermath of the Calgary Flames' disappointing playoff exit, some good news. Flames captain Mark Giordano has been announced as one of the three finalists for the James Norris Memorial Trophy.
Your 2019 Norris Trophy Finalists: Burns (SJ); Giordano (CAL); Hedman (TB)
— Elliotte Friedman (@FriedgeHNIC) April 21, 2019
Giordano, 35, flat-out had the best season of his career, one of the best over-35 seasons in league history and one of the best seasons for a defenseman in Flames franchise history. He had 17 goals and 74 points in 78 games, and was one of the top all-around defensemen in the NHL.
Being a finalist means that Giordano finished top three in the Professional Hockey Writers Association's balloting for the award. He's been "in the mix" for the Norris since he turned 30 and inherited the Flames captaincy from Jarome Iginla in 2013-14:
- 2013-14 (30): 14 goals, 47 points, +12, 10th in voting
- 2014-15 (31): 11 goals, 48 points, +13, 6th in voting (missed last quarter of season with injury)
- 2015-16 (32): 21 goals, 56 points, -5, 13th in voting
- 2016-17 (33): 12 goals, 39 points, +22, 8th in voting
- 2017-18 (34): 13 goals, 38 points, even, 16th in voting
No Flames player has ever won the Norris Trophy. Al MacInnis finished second in balloting in 1989-90 and 1990-91, as did Dion Phaneuf in 2007-08.


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Mild autumn conditions heighten BYDV threat - Duncan Connabeer - Anglia Farmer
Posted on
- Early infection can lead to bigger losses
- Management means careful monitoring
- Last chance for neonicotinoid dressing
Mild weather and early emergence of winter cereals may mean aphid populations establish quickly this autumn – posing a threat of barley yellow dwarf virus (BYDV) infection.
BYDV is the most widely distributed viral disease of all cereals. It generally affects barley and oats to a greater extent than wheat, with early infections holding the potential for significant yield losses.
The yield impact is generally greatest when plants are infected while small, explains Hutchinsons technical support manager Duncan Conabeer. Winter cereals are generally considered as susceptible up to growth stage 30, he adds.
Damage can be accentuated by the speed at which the virus is transmitted between insect and crop. Aphids can become infected within 24 hours of feeding and re-infect healthy plants in less than a day, says Mr Conabeer.
This autumn is the last opportunity for UK growers to use neonicotinoid seed dressings containing the active clothianidin (Deter/Redigo Deter). The final date of issue is 19 December 2018 after which growers will only have pyrethroids to fall back on until new insecticides arrive.
The years 2012 and 2016 were relatively high pressure and notably difficult season for BYDV control says Mr Conabeer. But 50% of the wheat crop still had a neonicotinoid seed dressing.
"Looking ahead, we are moving into an even more challenging situation as many growers and agronomists will not have experience of managing BYDV without dressed seed, especially in high risk scenarios."
Without clothianidin, BYDV management will require careful monitoring, cultural and chemical control methods. It is important to get control correct from the start because crops will be at risk if there is suddenly a significant flight of aphids.
"There is no second chance with BYDV," says Mr Conabeer. Growers should identify potential risk periods to control populations of vector aphids and reduce virus inoculum, but it is unlikely that growers will be able to maintain BYDV levels as low as in the past.
"Whilst the latest monitoring by AHDB and Rothamsted suggests aphid activity remains low, with the current mild autumn conditions the threat is high as aphid flights will continue much later than usual – the risk only goes away once aphids stop flying – its not controlled by diary date."
Grain aphids, bird cherry oat aphids and rose grain aphids can all transmit BYDV so there's a need to control all of these particularly in mild autumn conditions where aphids keep flying.
Issues have been observed from low levels flying into crops late then multiplying in mild autumns and winters leading to significant secondary infection.
Mr Conabeer recommends that crops sown in high risk areas including East Anglia – should use Deter or Redigo Deter for early drilled crops.
"This will provide about 6-8 weeks protection when the crop is at its most vulnerable during emergence and establishment. The added benefit of dressed seed is that it is a useful management tool where subsequent treatments may be delayed by the weather."
Hutchinsons agronomist Conor Campbell says growers should consider using an aphicide spray where seed has not been protected. The message is not to delay treatment when warnings are issued, he says.
"Whilst trials suggest the optimum timing for single sprays is between mid-October and early November, depending on emergence dates, any crops that were through the ground in late September or early October may benefit from an earlier spray.
"Pyrethroids do still have significant impact on aphid control. We only have resistance recorded in the grain aphid, so it is important to use cultural methods to reduce the risk of BYDV initially."
A focus on improving crop rooting and vigour through nutrition and disease control can boost growth quickly past the most susceptible stage since aphid's area attracted to yellow crops and this is also true of crops affected by herbicides.


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I know what you are thinking.. snails? You live in Tuscany and you want to eat shelled creatures that slime their way across sidewalks after a rain shower? Well, if shrimp do the same on the ocean floor and yet we bread them, cover them in coconut and toss them in the deep frier – why not try this too!
Luckily for me, I had my first opportunity to try this very French dish recently at a really cute new French restaurant located on one of my favorite streets in town, Via dei Macci [ Sant'Ambrogio area]. I heard about the place from my friend Kristina, the yelp firenze community manager who told me that I had to go! There really aren't any French restaurants in Florence, at least that I know about except for Le Fondue on the other side of the river. When I heard about this place and peeked into its cute interior when strolling in the center one afternoon, this bacame a must try for moi!
The cool thing about this place is that far from being t00 fancy for the common folk, they offer a pretty wide menu and a nice selection of lunch baguettes, some of which include duck and foie gras.
We opted for dinner and decided that why not go big or go home – let's try those Escargot alla bourguignonne! I wasn't that squeamish because well, I pretty much will eat anything at least once. Living in Italy has opened my mind to all sorts of food that I never would have touched before, including Tuscan classics lampredotto and tripe.
Our snails are pictures above and were dressed in a herb and butter sauce. We were given the surgery-like tools to open them which was way harder than I thought it would be. The actual snails though were delicious, I would try them again though it takes a little too much work than I am prepared to give on a weekend. Afterwards, we opted for fondue because who doesn't love to dip bread in really yummy cheese.
What to drink? A dry Riesling white wine went perfect with the cheese and even after stuffing ourselves we still left room for dessert which sadly I did not take a picture of [how is this possible?!]. We got a tarte tatin [famous French apple tart that is literally to die for] and Crepes suzette – [a crêpe with beurre Suzette, a sauce of caramelized sugar and butter, tangerine or orange juice, zest, and Grand Marnier.
I am still dreaming about those desserts.
Note: The restaurant itself has only been only for a few months and I truly hope it remains in Florence for many years to come. I look forward to trying everything else on the menu, especially Chef Frederic's suggestions. Another awesome aspect is that they have a really pretty outside courtyard that is an oasis from the chaos of Sant'Ambrogio.
*Some suggestions for the owners: Perhaps include more types of bread for the fondue, not just one type. Also it would be nice to know what kind of cheese is in the fondue :-), we had a little trouble working the flame. A little explanation can go a long way for these sort of 'cook it yourself' meals.
For a bottle of white wine, one portion of snails, fondue for two and two desserts, the bill came out to about 70 euros. Not super cheap but well worth it!
*They also have Tuscan dishes on the menu if you are not a fan of French food
La Brasserie, Via dei Macci 77r, 50122 Firenze. TEL: 055 2478326. FB page.
Bon Appétit


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|Article outlines current recommendations for treating malaria in the u.s.
|Written by NetDoc.com Medical News Feed
Kevin S. Griffith, M.D., M.P.H., of the Centers for Disease Control and Prevention, Atlanta, and colleagues conducted a review of medical literature from 1966 to 2006 to provide clinicians with recommendations for diagnosing and treating malaria in the U.S. With an increasing number of U.S. residents traveling to regions in the world with high levels of malaria, there continues to be a need for treatment of this disease in the United States, with there being an annual average of 1,200 cases reported, almost all imported, resulting in up to 13 deaths per year.
Discuss this article on the forums. (0 posts)
The researchers write: "Important measures to reduce morbidity and mortality from malaria in the United States include the following: obtaining a travel history, considering malaria in the differential diagnosis of fever based on the travel history, and prompt and accurate diagnosis and treatment. Chloroquine remains the treatment of choice for Plasmodium falciparum acquired in areas without chloroquine-resistant strains. In areas with chloroquine resistance, a combination of atovaquone and proguanil or quinine plus tetracycline or doxycycline or clindamycin are the best treatment options."
The authors add that chloroquine remains the treatment of choice for all other malaria species, with the exception of P vivax acquired in Indonesia or Papua New Guinea, in which case atovaquone-proguanil is best, with mefloquine or quinine plus tetracycline or doxycycline as alternatives. "Quinidine is currently the recommended treatment for severe malaria in the United States because the artemisinins are not yet available."
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
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BRASA 2020: Brazilian Studies Association Congress, Day 2 of 3
Fri, March 27, 2020 | University of Texas at Austin, various locations
LLILAS Benson is proud to host BRASA 2020, XV Congress of the Brazilian Studies Association, on March 26–28, 2020. View the Call for proposals at https://www.brasa.org.
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THE BACKSTORY: Matt's mom is his mom and he'll always loves her, but she definitely says incredibly bigoted things so casually. There's some stuff that your conservative, homophobic, racist, and religious mother really doesn't want to know the answer to… Well really, I think she does imagine she knows the answer and wants her disapproving thoughts on the matter heard. This kind of negativity about love and relationships is so profoundly narrow-minded that it's haunting because it permeates our culture and bombards us even when we don't want any part of it… And I am sure many people think non monogamy is not quite right on a more subtle level they are not as vocal about which can wear a person down too, I don't think people realize how obvious they are about their prejudices sometimes, even when they're not actively voicing them (you know, microaggressions). I know I fend off a lot of devaluing or ignorant remarks regularly, some are blatant and some are more subtle and insidious. The funny thing being that, to some of us, this kind of loving comes naturally and it's something we've struggled to just protect within ourselves, to love without quantifications or ownerships. For me, it's natural to fall in love with someone who is wonderful, regardless of who else I love, who else they love, their gender, their race.. It's about how I feel when they walk in the room, or the burning desire I have to share my life with them, or our shared intentions in life, or wanting to hear their next story… Love is about how I feel for someone because of who they are, not to possess them or to attempt to fulfill some role for each other that society would assign us in relationships.
Words That Hurt.
This entry was posted in Comic and tagged art, bigotry, comics, homophobia, ignorance, love, non monogamy, polyamory, relationships, sex, shaming, three-way, unnatural. Bookmark the permalink. Follow any comments here with the RSS feed for this post. Post a comment or leave a trackback: Trackback URL.


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When it's super-hot outside, the first thing you want to do is turn on the AC to cool off! Imagine on the hottest day of summer – you try to turn the AC on and nothing happens. Now you're left wondering what happened and why it's not running on the day you need it the most! This could have all … Read More
Choosing New Lighting for your Kitchen
Kitchen Lighting 101 Your kitchen is probably one of the most used rooms of your home given it's where you cook all of your family's delicious meals. But being in the kitchen means more than just preparing food and is an extension of your overall style, which is why many homeowners take pride in their kitchens. It's also a space … Read More
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Maintain Clean Air this Summer!
Spring has arrived! The winter forced most Pittsburghers to spend longs hours indoor due to the chilling conditions. Even if you are an avid outdoorsman, you must have been compelled to spend most your time indoors. By staying indoors, you might think that you must have been breathing a very high quality of air and assume that the dawn of … Read More
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Building on the success of its storefront and fulfillment services, Amazon now allows businesses to "rent" computing power, data storage and bandwidth on its vast network platform. This book demonstrates how developers working with small- to mid-sized companies can take advantage of Amazon Web Services (AWS) such as the Simple Storage Service (S3), Elastic Compute Cloud (EC2), Simple Queue Service (SQS), Flexible Payments Service (FPS), and SimpleDB to build web-scale business applications.
With AWS, Amazon offers a new paradigm for IT infrastructure: use what you need, as you need it, and pay as you go. Programming Amazon Web Services explains how you can access Amazon's open APIs to store and run applications, rather than spend precious time and resources building your own. With this book, you'll learn all the technical details you need to:
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How to Draw Ferb Easy
Okay folks, I noticed that Ferb was in the top 50 so I thought that making a lesson on "how to draw Ferb easy", step by step would be something that folks would appreciate and enjoy. This lesson was fun making because I haven't heard much on the animated television series Phineas and Ferb but I know it still airs, or at least I think it does. Anyhow, something as simple as this creation is going to make drawing Ferb easy fun and exciting. There isn't going to be any speed bumps in the road because I made sure to recreate Ferb in an extremely simple manner. Well, that's it folks have fun and enjoy yourselves. ....
Step 1
Start off the first step by making two small shapes for the eyes, then draw the hunker of a huge nose.
Step 2
The next thing you need to do is draw the lid lines on each eye, then draw the eyeballs.
Step 3
Next, draw Ferb's forehead and back part of the head and neck, as well as the mouth and front part of the neck. You will then draw the shirt collar and then move to step four.
Step 4
All you have to do now is draw out Ferb's messy hairstyle, then you're all done. Erase the mistakes you made along the way.
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Here is Ferb when you are all done. Now you can color him in then join him with the rest of the gang.
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Home | About Us | Trainers Director
Organizing a Training | Contact Us | Resources | Events
Website developed by Cal Donnellycolt • email@example.com • 2004
About Us
Over 50 activists throughout New England who have experience facilitating nonviolence training sessions are part of the Nonviolence Trainers Network. The purpose of the Network is to make nonviolence training widely available and to provide trainers with a variety of resources. The Network, through the support of the New England War Resisters League, provides opportunities for nonviolence trainers to share skills and resources, and learn new methods of training. Trainings for those wishing to become nonviolence trainers are also organized.
Activists chain themselves to the gates of a teargas plant in Saltsburg, PA to protest shipments of C.S. gas to Israel to use against Palestinians. April 1988. Photo by Barry Lavery.
Workshops We Can Offer
Does your group want to organize a demonstration but is not sure how to maintain a nonviolent presence? Do you struggle through meetings because members lack facilitation skills? Would you like an opportunity to become more aware of racism, sexism and homophobia and learn nonviolent responses to oppression? Nonviolence trainers in New England are able to offer the following workshops:
Conflict resolution
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Solidarity with people in struggle


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11 Pleasant Drive
Available for monthly rentals Oct-May and for weekly vacation rentals year-round.
Great location just steps from South Cove Activity Center and South Cove beaches. Open and bright living room, kitchen and dining area with 3 sliders to the deck! Well-equipped kitchen with breakfast bar and comfortable furnishings in the living area. Three spacious bedrooms with additional sleeping area in loft and two full baths. Upper level master bedroom features a lovely brick fireplace and sliders to a private deck.
Eastman is a four-season community with exceptional amenities in a beautiful natural setting. Enjoy lake activities, a championship golf course, tennis courts, 30+K of groomed cross-country ski and snowshoe trails and more in Eastman! Easy access to I-89 and the Upper Valley and Dartmouth-Lake Sunapee Region, and conveniently located just 2 hours from Boston.
Check Availability for 11 Pleasant Drive, Grantham, NH
Bedroom Configuration:
Main Level - Bedroom with 1 Full Bed
Upper Level - Bedroom with 2 Twin Beds
Upper Level - Master Bedroom with Queen Bed
Upper Level - Loft Area with 1 Twin Trundle Bed
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Seasonal Weekly Price: $1,500
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M&R License #: 052133
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Interior Features
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Exterior Features
- 2 Parking Spaces
- Deck


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Here's what Shane's new 'Conspiracy Series' is about
21 January 2019, 12:08
We cannot wait for this
Shane Dawson has teased a new video series and fans are beyond excited.
'Conspiracy Series' is a two-part series which will cover... something. It's not actually clear just yet, but fans are already starting to piece together some clues. Take a look at the trailer and then we'll dive into what the series is probably about.
The show even has its own bespoke opening titles
New year. New intro. 👁🔺 pic.twitter.com/ewYl10hTmJ— Shane Dawson (@shanedawson) January 20, 2019
What is the series about?
The tagline of the series is 'Don't Believe Everything You See'. When you combine this with certain bits of footage from the trailer and from the credits for some of the footage in the description ("Fake App Donald Trump Video", "Fake App Selena Gomez Actress"), a clear pattern starts to appear.
It seems certain that the series will in some way focus on using technology to obscure your identity - an issue that is commonly referred to as 'deep faking'.
'Deeps fakes' are digital recreations of people's faces that can sometimes be almost entirely indistinguishable from real videos, making crimes like identity theft and fraud easier than ever before - and even more dangerous.
However, there are all kinds of other intriguing elements in the trailer - including a focus on McDonalds. So perhaps we will be seeing more than one conspiracy covered in the two-parter, or even some kind of much larger, illuminati style conspiracy.
Naturally, fans and fellow creators are shook
um wow! cannot wait!— Mark (@MarkFerris199O) January 18, 2019
WTF you look like a model in this thumbnail. I'm way into it.— Husky 🐺 (@Husky) January 18, 2019
MY BRAIN AND SOUL AND HEART AND BODY CANNOT HANDLE THIS. PLEASE DON'T DO THIS TO US SHANE. PLEASE RETHINK THIS.— NICHOLAS MEGALIS (@nicholasmegalis) January 18, 2019
January 18, 2019
We'll just have to wait and see what the series is all about, when it drops on the 30th of January. We can't wait!
In other Shane news, a comedian recently posted a video where he does a perfect impression of him, and it's actually so accurate it's hilarious.


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Yesterday the trailer for the third season of the web series Carmilla was released and we can't wait for things to kick off!
Yesterday the trailer for the third season of the web series Carmilla was released and we can't wait for things to kick off!
This is a strange, strange novel. Don't get us wrong, we very much enjoyed reading it. It's great, but that doesn't make it any less strange. The clash between the realistic and the otherworldly enhances the mystery the book presents and it is very good at keeping you guessing right up until the end.
We're doing things a little differently this week. As we said last time, we're having a lot of trouble finding novels to write about in May. Part of this is the fact that most novels came out in the first 2 weeks and almost nothing came out later. The other reason is that what little did come out later in May either made us gag or put us to sleep just from reading the summaries.
We figured we were better off not writing about those. So we decided to look at some of the novels that had already been released this month, but we haven't read yet. In fact, for two of these we couldn't even determine a release date beyond 'sometime in May.'
At any rate, we found three that are well worth talking about once again and we hope you'll enjoy reading. Next week we'll be looking at June, so let's hope next month will give us less trouble.
April is over and May has just begun, so it's time for us to look at some of the new novels coming out this month! We've done our research and picked out a few that jumped out at us. We hope you'll find them to be interesting too!
Well, there's plenty of novels we haven't talked about yet, but we only do one of these a week and April is drawing to a close. Next week we intend to look ahead a bit and focus on what's coming out in May. Hopefully we'll find plenty of interesting novels to talk about then.
For now, let's talk about the three we picked out this time, shall we?
Er zijn nog zat boeken waar we het nog niet over gehad hebben, dus we gingen weer ons op zoek naar een paar interressante opties. Dit is waarschijnlijk de laatste keer dat we naar de boeken in April kijken. Volgende week kijken we vast vooruit naar Mei. Hopelijk zien we dan ook weer een hoop leuke boeken.
Laten we nu eerst maar eens kijken naar de drie die we deze keer gevonden hebben.
Sometimes you just don't want to travel and explore different lands. Sometimes you don't want to be the daring hero, charging at a dragon with sword held high.Sometimes you crave that little bit of insecurity. That little bit of mystery. Well, we've got some here for you. While not all technically mystery novels, these authors do understand that sometimes things are supposed to be a bit mysterious.
We can expect around 23 new fantasy novels in April and that's great, but you're probably not planning to read all of them. To help you find some interesting ones, we decided to talk about a few upcoming releases that stood out to us. All summaries were provided by the publishers.


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We offer a variety of leagues for all ages and skill levels. From beginners to experienced athletes there's something for everyone! All games are played on our indoor, non-boarded fields.
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The Military Support Committee was established to sustain and enhance the adoptive relationship between the City of Laguna Niguel, the USS Stockdale, the First Battalion, Fourth Marine Regiment and the 1st Assault Helicopter Battalion, 140th Aviation Regiment.The Committee meets on the 2nd Monday of each month at 12 p.m. (except in January and February when it meets on the 4th Monday) in the Council Chambers. Agendas are available from the calendar links below.The Committee consists of 20 members including two City Council Members who serve as Co-Chairs. The Committee also established several Ad-Hoc Committees, including Ex-Officio Members, to help carry out the duties and responsibilities of the Committee.
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Comorbidity and case formulation
- About comorbidity and case formulation
- Using case formulation to understand complex veteran presentations
- Elements of case formulation
- Taking a collaborative approach to case formulation: helping shape client goals
- Case Studies - Example of case formulation with veterans with complex needs
- Principles of treatment sequencing
- Further Information
About comorbidity and case formulation
Veterans commonly present with comorbid disorders and complex needs that require careful treatment planning. For example, up to 90 per cent of veterans with posttraumatic stress disorder (PTSD) will meet criteria for another mental health problem. More complex presentations also require ongoing negotiation with presenting veterans around treatment goals to ensure that underlying problems likely to hinder recovery are addressed. This chapter provides general guidance on case formulation and treatment sequencing for complex clients. While there is some evidence about treatment sequencing, many of the principles presented here are based on clinical opinion, rather than empirical evidence, and need to be applied judiciously by practitioners using their own independent judgment.
Using case formulation to understand complex veteran presentations
Case formulation assists in focussing on presenting problems that are likely to have the most impact on veterans' recovery and helps set priorities for treatment. There are a number of reasons for systematically and collaboratively developing a case formulation for veterans with complex needs. First and foremost, if a veteran presents with two or more diagnoses, using a diagnostic approach to guide treatment does not help sequence treatment.
In addition, it may be difficult for veterans with long standing comorbid conditions to understand how their mental health problems are maintained and to identify counselling goals that will have a meaningful impact on their recovery. For example, it is not unusual for veterans with chronic PTSD, alcohol dependence and depression to present to counselling with a goal to manage relationship problems. In this instance, avoidance symptoms associated with PTSD, low energy associated with depression, and reluctance to address alcohol problems may mean that the veteran has little awareness or motivation to address underlying problems contributing to relationship difficulties.
Finally, because complex problems often lead to ongoing crises and elevated risks, therapists sometimes focus on crises that emerge during the course of counselling and can be distracted from addressing underlying problems that maintain the client's presentation.
There are a number of definitions and approaches to case formulation. A commonly accepted definition of case formulation is, "a hypothesis that relates all of the presenting complaints to one another, explains why these difficulties have developed and provides predictions about the patient's condition" (Wolpe &Turkat, 1985). In other words, case formulation brings together all the information gathered during assessment to develop a working hypothesis that explains how a veteran's presenting problems have developed and are being maintained (Persons, 2005). It also includes a description of factors that influence and help predict recovery, including protective factors such as social connections and the veteran's strengths.
In conclusion, case formulation goes beyond summarising information gathered during assessment and provides an explanatory story that is used to focus treatment. The case formulation is used to develop a treatment plan that tackles factors that maintain presenting problems and takes into account factors that may hinder or promote change for the veteran. Because case formulation is a working hypothesis, it involves an ongoing review process throughout counselling where the formulation is tested on a regular basis and adjusted if necessary.
Elements of case formulation
A widely used case formulation model is presented below. This model can be easily adapted to fit in with most treatment approaches or orientations, taking into account factors that lead to and perpetuate presenting issues as well as the client's vulnerabilities and strengths. A case formulation includes the following elements (see Appendix K for a suggested one page template):
- presenting problems
- factors that cause the individual to be vulnerable to the development of these problems (vulnerabilities)
- factors that trigger the onset of the presenting problems (triggers)
- factors that might be barriers or supports for change (positive and negative prognostic indicators).
The case formulation culminates in the following element:
- a hypothesis about the relationship between presenting problems and what maintains them (maintaining factors).
In order to be a useful tool, a case formulation needs to move beyond describing or listing the above factors. It should describe the relationships between these factors and provide a coherent story about the way the veteran is presenting in counselling. There is a free online DVA course on Case Formulation and Treatment Planning available here.
Taking a collaborative approach to case formulation: helping shape client goals
A good case formulation includes and informs a client's expectations about treatment and can help collaboratively develop goals for therapy. Although the evidence about the impact of a collaborative approach to case formulation on the treatment alliance is inconclusive at present (Rainforth & Laurenson, 2013; Kuyken, Fothergill, Musa, & Chadwick, 2005), it is considered good practice to involve the client in the process as it helps shape their goals for therapy. As discussed earlier, this may be particularly important for clients presenting with complex issues as it may help them understand the importance of addressing underlying problems in order to recover.
A collaborative approach to case formulation also allows the clinician and veteran to discuss factors that maintain current problems, discuss progress and revise treatment goals throughout treatment.
What makes a good case formulation?
For a case formulation to be useful, it needs to quickly and easily lead both therapist and veteran to what needs to be prioritised in a treatment plan. A case formulation is principally a tool to ensure that treatment is targeted to what is most likely going to lead to change for the veteran. It also needs to have the right balance of information and be brief so it can guide the planning and review of treatment effectively. Too much information can lead to a lack of clarity. In addition, it is important that the hypotheses about what leads to, and maintains, presenting problems are informed as much as possible by current evidence.
Lastly, a case formulation is most effective if it explains relationships between presenting problems, vulnerabilities, protective and maintaining factors and triggers. There is evidence that many clinicians use case formulation to summarise assessment information rather than to integrate it into a coherent story that leads to a hypothesis about what maintains clients' presenting problems (Kuyken, Fothergill, Musa, & Chadwick, 2005). Examples of brief case formulations that explain rather than just describe a client's presenting problems are provided below.
Case Studies - Example of case formulation with veterans with complex needs
A DVD with three case studies is included at the back of this book. An example of a case formulation for all three cases is outlined below.
Ron: 62 year old Vietnam veteran
Ron has PTSD and a long established pattern of dependent drinking, consuming between 10-20 standard drinks per day. He also uses high amounts of codeine to manage the chronic pain he experiences in relation to a hip injury sustained in combat. He has very high levels of social anxiety, has experienced panic attacks and spends much of his time at home. Ron and his wife have little interaction but no intention to separate and he has difficulty getting along with his adult children. He has mentioned that he has difficulty remembering things that he feels he should remember. He now gets easily frustrated when trying to complete tasks in his workshop and around the home.
Case formulation in brief - Hypothesis about how main presenting problems are maintained
There are a number of working hypotheses about Ron's presenting problems. Most importantly, avoidance seems to be the way Ron tends to deal with his problems and this avoidance seems to be perpetuating Ron's re-experiencing of traumatic events, social anxiety, substance use and social withdrawal. As part of this avoidant pattern, long standing alcohol dependence seems to be a significant contributor to psychological distress and disengagement from others. It may also have led to cognitive decline, which in turn may impact on levels of distress and capacity to change. Chronic pain may also be contributing to Ron's distress, PTSD symptoms, avoidance and substance use. Finally, it could be that the lack of treatment goals and the long-term failure to address and treat Ron's PTSD could be leading to low motivation, increased avoidance and substance use.
Predisposing factors - vulnerabilities
In Vietnam, Ron's involvement in both platoon and civilian deaths led to the development of PTSD.
Precipitating factors - triggers to presenting problems
Ron has experienced PTSD symptoms for a number of years and it is likely that his alcohol dependence and social anxiety stem from a desire to reduce some of these symptoms. His need to avoid distress – whether caused by reminders of traumatic events, pain, or social anxiety – triggers drinking, potential codeine misuse and social withdrawal. Pain may also indirectly trigger substance use as it may act as a reminder of Ron's time in Vietnam, a time he wishes not to think about. Given the amount of alcohol and codeine consumed by Ron, cravings and/or withdrawal symptoms may also be present and lead to increased substance use. Ron's excessive drinking may have led to his recent difficulty remembering things and his increased frustration and irritability. Pain and anxiety might also be contributing factors to his memory problems.
Prognostic indicators - barriers or supports for change
A number of factors would indicate that Ron can engage in changing his behaviour and outlook. He has reduced his alcohol consumption and has some insight into the negative effects of alcohol on his life. However, Ron's motivation to change is limited and he has consistently avoided talking about his trauma. In addition, he appears to have poor expectations of the outcomes of treatment. While the fact that Ron is in a relationship may assist with his recovery, it is evident that this relationship is distant.
Perpetuating factors - what maintains the presenting problems
Ron's PTSD and social anxiety are perpetuated by the prolonged and pervasive avoidance of emotional distress. He avoids distress by using alcohol, withdrawing from social situations and potentially, by misusing codeine. He has also avoided having surgery on his hip although it causes him increasing pain.
Tim: 28 year old, veteran from Afghanistan
Tim has been diagnosed with PTSD. He binge drinks and uses cannabis on a daily basis. He also occasionally takes methamphetamine whilst at parties. Tim has intermittent bouts of extremely low mood associated with suicidal ideation. Angry outbursts are common; on several occasions he has hit his girlfriend, he has punched walls and he has been involved in a few fights outside nightclubs when intoxicated.
Case formulation in brief - Hypothesis about how main presenting problems are maintained
Two main issues seem to be contributing to Tim's current presentation: his need to avoid thoughts and feelings related to traumatic events in Afghanistan and difficulties with regulating emotions. Tim's inability to manage emotions and need to shut out memories of traumatic events lead to substance abuse and impulsive destructive behaviours which in turn lead to feelings of self-hate and hopelessness. These feelings contribute to depression and suicidal ideation which in turn increase the likelihood of substance abuse. Tim's inability to self-regulate and his need to be in control also contribute to domestic violence.
Predisposing factors - vulnerabilities
A number of factors caused Tim to be vulnerable to the development of PTSD, substance abuse, depression and anger. He has witnessed multiple deaths whilst serving in Afghanistan and witnessed the traumatic and violent death of a friend whilst deployed. In addition, Tim has described being "belted" by his father when he was a child.
Precipitating factors - Triggers to presenting problems
Tim states that he wakes in the morning with low mood, stating that he "hates himself". He drinks alcohol and uses cannabis to assist with his mood but states that this makes him feel bad about himself and worsens his mood in the longer term. Tim also feels overwhelmingly angry, helpless and scared when he is reminded of events in Afghanistan and tries to shut these emotions out by using cannabis or alcohol. Tim's suicidal ideation and risk taking (such as fights) seem to be triggered by feelings of self-hatred and a sense of hopelessness that follow a bout of drinking. Tim's verbal abuse and physical violence towards his partner seems to be the result of a need to be in control and is triggered by events such as her being out of contact.
Prognostic indicators - barriers or supports for change
Tim was given an ultimatum by his partner, Kim, to attend therapy to ensure the longevity of their relationship. While Tim seems to be willingly engaging in the process, he faces a number of barriers to change, most importantly his high levels of alcohol and substance abuse. In addition, Tim presents with low motivation to change, is unsure about what he can get out of therapy and is fearful of talking about his experiences in Afghanistan.
Perpetuating factors - what maintains the presenting problems
Tim's PTSD is perpetuated by the pervasive avoidance of any reminders of the event. Tim's attempts to avoid and shut out any thoughts of Afghanistan lead to increased intrusive PTSD symptoms such as nightmares, as well as alcohol and cannabis abuse. Increased alcohol and substance use contributes to Tim's depressive symptoms. Given Tim's exposure to childhood abuse and his impulsive behaviour, it is likely that his aggression, risk taking and substance use are maintained by an inability to regulate his emotions. This, together with a need to be in control of his partner, would perpetuate his verbal and physical abuse.
Lisa, 32 years, ex-peacekeeper in East Timor
Lisa served in East Timor when she was 23 years old. She has presented for help in relation to poor sleep patterns. When she lies awake at night she ruminates on her experiences in East Timor and sometimes has nightmares. She is misusing sleeping tablets prescribed by her GP. She is experiencing low mood, a loss of interest in activities and has poor energy levels. She also may be at risk of self-harm, stating that "sometimes it is all too much". She is being "performance managed" by her supervisor because of difficulties in concentrating at work, and frequent absenteeism.
Case formulation in brief - Hypothesis about how main presenting problems are maintained
Lisa's rumination about events that she witnessed in East Timor, coupled with her overuse of sleep medication both appear to be contributing to Lisa's poor sleep patterns, anxiety and low mood. These in turn have contributed to Lisa withdrawing from social relationships and activities that she used to enjoy. The lack of pleasurable activities and social withdrawal act to maintain her low mood and substance use problems. Lisa's low mood and fatigue are likely to be impeding her ability to work effectively. Given Lisa's high standards, her difficulties at work are likely to cause her anxiety which has led to her increased absenteeism and, in turn, contribute to Lisa's low mood.
Predisposing factors - vulnerabilities
Lisa sets very high standards for herself. She believes that she should be in control and that it is her responsibility to perform well. These beliefs may have made Lisa vulnerable to self-recrimination and depression when faced with a situation in East Timor where she was not in control and unable to deliver help as she would have liked.
Precipitating factors - triggers to presenting problems
Lisa's misuse of sleeping tablets is triggered by her anxiety and low mood. Given that Lisa is building a tolerance to sleep medications, it is possible that worry about not being able to contain her anxiety or cravings are contributing to her anxiety and increased medication use. Negative ruminations about East Timor have led to sleepless nights and low mood. Her reduced role at work and difficulties managing tasks exacerbate self-recrimination and criticism which contribute to her low mood and anxiety. These in turn have led to social isolation and could increase her risk of suicidal ideation and self-harm.
Prognostic indicators - barriers or supports for change
A number of factors may help Lisa in her recovery. Although she is currently socially isolated, Lisa used to have a close relationship with her mother and her sister, relationships which are still important to her. Lisa did not want to attend therapy but had enough insight and motivation to attend, and whilst in session, spoke willingly of her experiences. Lisa appears to have insight into the detrimental effects of her misuse of sleeping tablets and social isolation. However, Lisa's precarious position at her work is of concern. Should she lose her job, Lisa may be at risk of increased depression, substance use and self-harm.
Perpetuating factors - what maintains the presenting problems
Lisa's poor sleep patterns and low mood are perpetuated by rumination, her misuse of medication and her withdrawal from social situations. Lisa's premorbid functioning was characterised by an active and social lifestyle and her current lack of activity is likely to be impacting on her mood and outlook. Lisa's current difficulties at work also contribute to ongoing problems with mood and substance use.
Principles of treatment sequencing
In addition to developing a case formulation, there are a number of general principles about treatment sequencing that can help inform treatment planning. Consistent with the general principles of good mental health care, practitioners should focus on treating the disorder presenting most severely. Severity refers to the disorder that is most disabling and most likely to lead to risk of harm to the person or others. Practitioners should also focus on problems that are likely to impact on the veteran's ability to engage in treatment. For example, problems that impair alertness, motivation, attention and emotional stability must be resolved before treatments that are dependent on these characteristics can begin. Suggestions for treatment sequencing for commonly co-existing mental health problems in veterans are outlined below.
Depression and high-risk alcohol use
When depression and high-risk alcohol use conditions are severe, treat the alcohol problems first, maintaining active monitoring of the risk of self-harm or suicide. This is because depression may have an organic basis associated with alcohol dependence, including delirium, impaired liver function or systemic illness. Treatment for depression without a reduction in alcohol use, will only have limited effectiveness. Depression may lift once the veteran is successfully treated for high-risk alcohol use. If both conditions are mild to moderate in severity, treatment can progress simultaneously.
Posttraumatic stress disorder and high-risk alcohol use
Treatment for PTSD and high-risk alcohol use can commence simultaneously, excluding the trauma-focussed component. The trauma-focussed component should not commence until the veteran has demonstrated a capacity to manage distress without resorting to alcohol. Once the veteran has reached this stage, practitioners can begin the trauma-focussed component of PTSD treatment.
Posttraumatic stress disorder, depression and high-risk alcohol use
Where conditions are severe, treat the alcohol use first, with active monitoring of the risk of self-harm or suicide. Initial phases of PTSD treatment, excluding trauma-focussed treatment, can commence simultaneously with the treatment of alcohol-use problems. Where all conditions are mild to moderate, simultaneous treatment can commence, excluding the trauma-focussed component of PTSD, until the veteran is able to tolerate two to three days per week without using alcohol.
Posttraumatic stress disorder, depression and panic disorder and/or generalised anxiety disorder
Where PTSD, depression and panic disorder and/or generalised anxiety disorder (GAD) are severe, treat the depression first. This is because depression has been demonstrated to impair the effective treatment of anxiety disorders. If the conditions are mild to moderate, treat the PTSD first. This is because improvements in PTSD are likely to result in reductions in demoralisation and depression.
Moderate to severe depression and panic disorder and/or generalised anxiety disorder
Where moderate to severe depression and panic disorder and/or GAD are present, focus on treating the depression first, ensuring you include breathing control to reduce panic. This is because depression is potentially life threatening, but also because there is evidence that poor morale and impaired attention will impair learning of arousal management, attention to exposure cues and compliance with self-care treatment.
Further Information
Complex Cases Assessment and Treatment: Provides further information, clinical tools and resources to assist health practioners in the assessment and treatment of comorbidity and case formulation in the veteran population.