Crown vs Dhanani Essay Example | Topics and Well Written Essays - 1000 words

Crown vs Dhanani - Essay Example Courtroom Number and Name of the Judge: The courtroom number was 308 and the presiding judge was R. Low. Level of Court: The trial took place on what is a provincial court level. Facts: The defendant, Mr Ayaz Dhanani, was convicted of fraud as well as breach of his prior conditional sentencing. What transpired was that Mr Ayaz Dhanani sought to have his house refurbished and subsequently sought out a furniture company to accomplish this task. The issue was further complicated when the cheque that Mr Ayaz Dhanani wrote to the furntire company bounced due to insufficient funds available in his account. For writing a bad cheque, Mr Ayaz Dhanani was arraigned and served a brief period of time in jail. After which, he was released on a conditional sentence. During the period of his conditional sentence, Mr Ayaz Dhanani was found by authorities at the Shangri-La hotel. When apprehended, Mr Ayaz Dhanani was consuming large quantities of expensive liquors and had a very large sum of cash on his person as well as in the hotel’s vault. He was subsequently taken into custody and pleaded guilty to all charges. Procedural History: Mr Ayaz Dhanani (the defendant) was subsequently convicted of fraud and sentenced to serve jail time. Once he was released from detention, his conditional sentence placed restrictions on his mobility and certain freedoms. Due to the fact that he flagrantly violated these conditions, he violated his conditional release and was subsequently taken back into police custody. Issues: Did Mr Ayaz Dhanani violate his conditional sentencing? Decision: Mr Ayaz Dhanani was found guilty of all charges and sentenced to one day in prison. In addition to this jail time, the court also ordered Mr. Ayaz Dhanani to perform an unspecified amount of community service. Reasons: Judge R. Low’s decision was subsequently based on the following two reasons. 1) Mr Dhanani did not seem to appreciate the importance and gravity of the conditional sentence which he was given and was â€Å"living large† in the face of it. 2) Mr Dhanani did not seem to grasp the seriousness of his crime as it related to what he had done to his parents. The argument that the crown prosecutor pursued with relation to this case hinged upon the fact that Mr Ayaz Dhanani was found to be drinking alcohol that was in excess of $60 dollars per glass. At the same time, he was staying in what could only be deemed a luxury hotel. In addition to violating the terms of his conditional release, Mr Dhanani was in personal possession of a very large sum of sequentially numbered US bills ($12,000.00). Thus this provided even further evidence of a breach of his conditional sentencing. Likewise, the argument that the prosecution eloquently made was that due to the fact that Mr Ayaz Dhanani’s parents had already been forced to sell their house in order to pay for the debts incurred by their son, the money that was found in the hotel vault of the Shangri-la should h ave immediately found its way back into the hands of his parents. The fact that this did not occur coupled with the fact that Mr Ayaz Dhanani was apprehended while â€Å"living large† was yet another proof that the good faith conditional release was not respected by him. The judge further stated that due to the lack of lessons learned coupled with his â€Å"unwillingness to be mature†, the court was left no choice but to put him into custody. The defence was left to argue, rather weakly one might add, that the result of the lavish accommodations and drinks that Mr Dhanani was enjoying were the result of his female friend who was paying for these. Furthermore, the defense argued that the money that was found in the safe was not a pertinent legal concern. Ratio: Specific: A conditional senten

Equal Rights Essay Example | Topics and Well Written Essays - 750 words

Equal Rights - Essay Example Was there really no means for him not to emulate Eve given the fact that he loved her? But we are no longer living on biblical times. The apple had been swallowed and the Garden of Eden is but a distant memory of our apparent disobedience from the commands of God in his paradise. An amendment pertaining to equal rights amendment, specifically, on gender equality has been long overdue. The drafted 1972 Equal Rights Amendment, with all its content and significance duly brought to notice the need for this statute. The clamor not only by various organizations that advocate its ratification can be viewed as nothing less than the legislative’s duty to bring about justice especially in this ever-changing society. It is by virtue of evolution that such changes are inherent to us as a nation. The righteousness of our democracy yields the empowerment of the people not only to be theoretical but must be realized in such a manner that it is in constant concurrence with the applicability of the manner of the times we live in. No longer are we, regardless of gender, mere audience to our own existence. The intent for which this amendment is based on gives supremacy to the need for substantial change that must be implemented. This conflict in the Constitution, the supreme law of the land, must be addressed with expediency. Over a century preceding the adoption of the Equal Protection Clause, it has yet to be given its ‘teeth’ so to speak in the decisions of the Supreme Court. In a 1983 law from the state of Illinois which prohibits women from practicing law, the court ruled that it was in accordance with the Constitution as such that no law was violated in its implementation. Furthermore, it had become more apparent that the courts cite in its opinion the prevalence of the belief that man should be the protector of women and that a woman’s primary duty not only in the eyes of the family but of the law, is to be a good wife and mother as such is the law of the

Canon Case Study Essay Example | Topics and Well Written Essays - 2000 words

Canon Case Study - Essay Example siness the company is to pursue, with the nature of the activities it intends to be and the nature of the economic and non-economic contribution it intends to make to its shareholders and stakeholders†. In effect, it corporate strategy maps out a sense of direction for a company’s activities. Corporate strategy in effect maps out the businesses in which an organisation intends to compete in (Andrews, 1997, Lynch 2006). To formulate its corporate strategy, many researchers have call on organization to assess their strengths and weaknesses, as well as its environmental threats and opportunities, so as to give the organization an edge in chosen among alternative courses of action. (Hofer and Schendel, 1984) cited in Schneider, (1998). Thus, it is recommended that an organization performs a SWOT (strengths, weaknesses, opportunities and threats) analysis prior to formulating corporate strategy. Today’s numerous challenges have pushed companies not to compete as individual companies but to try and corporate with other businesses in their activities (Wu & Chien 2007:2). Canon an electronic company began in Japan with a typical and traditional Japanese business form having customer’s satisfaction and profit as its center of attention while specializing in the production of business machines, cameras, optical and other electronics. The company was founded by the first Chief executive officer Gerard in Japan and the father who later recruited a team of outstanding professionals to support its activities. In less than three decades of operation, the company assumed leadership role in the electronic market (Lynch 2006). Thanks to its innovative focus ideas, huge investment on research and development, good employee’s retention, and differential focus strategies, Canon innovative ideas and the company’s cost focus and differentiation strategy earned it that position. Canon case has been analyzed using some analytical models. From figure one above, Porter

Equal Rights Essay Example | Topics and Well Written Essays - 750 words

Equal Rights - Essay Example Was there really no means for him not to emulate Eve given the fact that he loved her? But we are no longer living on biblical times. The apple had been swallowed and the Garden of Eden is but a distant memory of our apparent disobedience from the commands of God in his paradise. An amendment pertaining to equal rights amendment, specifically, on gender equality has been long overdue. The drafted 1972 Equal Rights Amendment, with all its content and significance duly brought to notice the need for this statute. The clamor not only by various organizations that advocate its ratification can be viewed as nothing less than the legislative’s duty to bring about justice especially in this ever-changing society. It is by virtue of evolution that such changes are inherent to us as a nation. The righteousness of our democracy yields the empowerment of the people not only to be theoretical but must be realized in such a manner that it is in constant concurrence with the applicability of the manner of the times we live in. No longer are we, regardless of gender, mere audience to our own existence. The intent for which this amendment is based on gives supremacy to the need for substantial change that must be implemented. This conflict in the Constitution, the supreme law of the land, must be addressed with expediency. Over a century preceding the adoption of the Equal Protection Clause, it has yet to be given its ‘teeth’ so to speak in the decisions of the Supreme Court. In a 1983 law from the state of Illinois which prohibits women from practicing law, the court ruled that it was in accordance with the Constitution as such that no law was violated in its implementation. Furthermore, it had become more apparent that the courts cite in its opinion the prevalence of the belief that man should be the protector of women and that a woman’s primary duty not only in the eyes of the family but of the law, is to be a good wife and mother as such is the law of the

Assignment Example | Topics and Well Written Essays - 250 words - 370

Assignment Example My confidence is 4. My experience with LMA has indicated that it can deliver higher oxygen saturation during emergency. A documented failure of the colorimetric carbon dioxide exists. The detector failed to indicate the color change in morbidity obese female patient with a history of schizophrenia, bronchiectasis, and remote burns (Levitan, Vanderbeek, and Kuhfahl 636). Despite the right placement in the trachea, the detector failed considerably to display color change. In my clinical site, uses the End-tidal carbon dioxide detector to maintain the safety of the patients. The method is used in the anesthesia department at my clinical site. The detector measures the carbon dioxide in the expired air to identify the changes in the elimination of the gas from the lungs. The digital numeric and waveform display confirms the concentration of the carbon dioxide. I would attach pulse oximeter and record oxygen saturation, resting heart rate, color, and respiratory rate. The second step would involve removing humidivent and performing tracheal, the attaching manometer. Placing the Passy-Muir Speaking Valve to monitor oxygen saturation, heart rate, color, state and respiratory rate together with measuring passive exhalations would follow. The third step would entail removing the manometer and replace humidivent. Lastly, I would determine the pass/fail in order to take appropriate action I would use the voice tracheostomy tube to enable the patient speak during the ventilation. The complications that may occur include bleeding, pneumothorax, pneumomediastinum, damage of esophagus, and injury of nerve

Assignment Essay Essay Example for Free

Assignment Essay Essay Sustainable tourism is being able to the deliver positive environmental, social, and economical results with thought to the needs of the visitors, host community and surroundings. Sustainability as defined in the Brundtland commission report it states as â€Å"meeting the needs of the present without compromising the needs of the future generations to meet their needs†. For example, the small business are starting to practices sustainability principles by changing to renewable energy sources, reducing use of paper and recycling more. As a result, the concept of sustainability addresses the aspects of â€Å"triple bottom line† meaning the balance of societies, economy and the environment are described by (Bonevac, 2010). According to the World Tourism Organization, â€Å"sustainable tourism means meeting the needs of the present tourist and host regions while protecting and enhancing the opportunity for the future†. Instead of just being a product, sustainable tourism is a philosophy that underpins all tourism actions (Owens, Is there a Meaningful Definition of Sustainability? , 2003). To all tourism development and management, it is a fundamental concept instead of being an add-on factor. The foremost aim of sustainable tourism is to maintain the economic and social return of tourism development while reducing or justifying the unattractive impacts on the natural, historic, cultural or social environment (Governemnt, 2009). The stated objectives attained by matching the needs of tourists with those of the destination. Sustainable tourism is an industry, which challenges to make a little impact on the environment and the local culture, though helping to produce income, employment and the preservation of local ecology. Hence, responsible tourism is both cost-effectively and culturally responsive, meaning have minimum impact on the environment and culture of the host community (Group, 2007). Scotland Tourism Organization has defined sustainable tourism as â€Å"tourism committed to generating a low impact on the surrounding environment and community by acting responsibly while generating income and employment for the local economy and aiding social cohesion† (Organisation v. s. , 2013). Scotland Sustainable tourism aspires to guarantee that economic development in terms of encouraging experience for each one involved local community, Tourism Companies and visitors. In practice, sustainable tourism means greener transport, given that transport is innermost to tourism; however it also put pressure on our natural resources and contributes to our worldwide environment impacts. Procedures like cheering visitors to utilize communal transport, and advance in cleaner forms of transport will assist in this area (Organisation v. . , 2013). Regular and environmental strains a more even stretch of visitors lessens pressures on the natural and built environment and on communities, and capitalizes on the financial payback. Scotland Tourism Organization modifies its advertising drive to persuade a stretch of visitors throughout the year and around state (Organisation v. s. , 2013). For example, â€Å"surprise yourself†. There is necessary to work with the public, private and independent sectors to determine the environmental and social impacts of tourism. These guarantees that tourism expansion carries a encouraging experience for home people, tourism companies and the tourist themselves (Organisation v. s. , 2013). Green accommodation is one in that all room offers lessens their misuse, energy and water use. The green Tourism Business Scheme persuades businesses to trim down their environmental impacts. The scheme is one of the largest of its land in Europe with over 800 Scottish members (Organisation v. s. , 2013). However, any tourism industry can take advantage from flattering more sustainable through safeguarding the very features on which tourism depends; taking a sustainable move to tourism expansion is the only way to guarantee long-term tourism expansion in the South Pacific (Organisation v. s. , 2013). The success of tourism in any country depends on taking care of the environmental or social impacts of tourism development. The visitors benefit from sustainable move to tourism throughout from enhanced relates with local communities, a tall value tourism experiences and a natural and fabricated environment. Thus, by fetching a sustainable tourism destination will provide the South Pacific Tourism Businesses a cutthroat frame by producing community assistance for tourism; attaining value savings and designing innovative marketing prospect. As the tourism industry develop in as many regions and countries, it generates noteworthy impact on the consumption pattern, natural resources, pollution and social systems (Organisation v. s. , 2013). For the industry to survive as a whole it is vital to understand and interpret the need sustainable and responsible planning and management. To begin with, education and collaborative partnership are approaches that can assist destinations attain more sustainable tourism. The whole idea of sustainability based on the association through environmental, ecologically and socially responsible tourism. Partnerships with local communities through rural community gathering before and during development are needed in order to let alone the frequent divergence between conservation initiatives and traditional resources users (Billington, Carter, Kayamba, 2008). The departments from the government can collaborate with the resource owners to develops and negotiate over the investment on proposal (English National Park Authorities Association, 2009). For example, the Chumbe Island Coral Park is a good example of collaborate partnership, which was developed to sustain the natural beauty and attractions of the island (English National Park Authorities Association, 2009). Chumbe Island is located in the Indian Ocean channel of the coast of the semi autonomous region of Zanzibar (English National Park Authorities Association, 2009). The person responsible for the project on the natural park at Chumbe Island was (David, 2011). During her work life, (David, 2011) experience the need for the conservation and sustaining of the natural flora and fauna. (David, 2011) developed an innovative approach to protect marine conservation combined with tourism development through the sustainable and multilevel partnership approach to promote successful marine park management, awareness of marine conservation and sustainable tourism management. David, 2011) Develop a small marine park that would help consume a unspoiled coral reef, offer environmental education for both the locals and the foreign visitors and generate management fund through authentic ecotourism. Thus, the need for the park at Chumbe Island arose due to improper aid and the government in the country noted conservation programs. Hence, the collaborative partnership arose to sustain the nature conservation of Tanzania for the future (English National Park Authori ties Association, 2009). Secondly, the partnership approach deals with the local communities because they are the essential people who are the resource owners (Governemnt, 2009). Engaging the local community in the environmental education on sustainability through workshops and seminars will increase their concerns for the global issues such as climate change (Clark, 2013). In addition, collaboration with NGO has to hold workshops with the angler’s, to engage them in sustainable fishing practices and conservation of the resources (David, 2011). Thus, the young and the old generation in the area is to be informed about sustainable fishing practices, laws and regulation regarding fishing practices and marine conservation area and the benefits of marine protected areas (Ki-Hoon Ball, 2003). All this environmental awareness, education and training initiative with the community are to provide skill development on sustainable tourism (Group, 2007). The scale of growth of the tourism industry In the South Pacific is rapidly and that the environmental and social, economic impacts of it cannot be overlooked (Azam Sarker, 2011). This has caused the Pacific Region to find ways in which the industries could be made more sustainable. The industry is more sustainable through minimizing resource use and waste production (Othman, 2004). For the sustainability of tourism, water is the major issue for concern. For example, a tourist in a hotels uses on standard one third of more water per day than a local inhabitant uses and put severe restriction on local supply (Othman, 2004). Activities such as golf course, artificial snow ski’ resorts are in demand of water. For small and medium sized business, sustainability thought of an expensive and difficult idea (Billington, Carter, Kayamba, 2008). Most of the dominating tourism industries in the South Pacific have not actively engaged in government activities that encourages that adoption of sustainability practices (David, 2011). There are a number of barriers identified by the researchers that hinds implementing sustainability practices in South Pacific tourism businesses including the financial crisis for implementation, the labor insecurity of being certified, lack of government and industry support the technical nature of information forums. Hence are a number of actions businesses could undertake to improve environmental performance (Azam Sarker, 2011). Activities’ relating to efficient resources use and waste management includes minimizing energy consumption, for example using open ventilation instead of air-conditioning and heaters encouraging the use of renewable sources and improved technology also Getting involved in accreditation programs (Owens, Is there a Meaningful Definition of Sustainability? 2003). There is a need to promote and facilitate the reduction, reuse and recycling of materials and water quality including the efficient treatment of sewerage, avoiding discharge into marine and rivers (Organisation, 2005). For example, in Australia the Australian formula 1 ING grand Prix Corporation, which works with environmental packaging and waste recycling partner to minimize the impact of the race on the environment? Billington, Carter, Kayamba, 2008) Thus, by minimizing waste use, energy use and waste production, businesses can reduce their impact on the environment and achieve cost savings (Ki-Hoon Ball, 2003). Furthermore, the conserving and giving value to natural and cultural heritage is of critical importance’s, in order to enhance the quality of life of local communities through tourism, and connect the people in is scheduling and management (Organisation, 2005). The growing awareness’s and generating direct and indirect support for conservation is the key role played by the tourism industry (Group, 2007). The generation of economic propensity for the tourism industry is to provide with quality natural and cultural heritage (Azam Sarker, 2011). This would ensure the long-term competitiveness, viability and the prosperity of tourism enterprises and destinations and the quality of life of local communities and to the visitor experience by providing a safe, satisfying and fulfilling experience to the visitors available to all without discrimination by gender, race, religion, disability or in other ways (Organisation, 2005). Areas that are of importance to tourism natural and cultural includes the natural landscapes quality and variety, man-made cultural landscapes, heritage and historic sites, the flora and fauna diversity, local uniqueness such as art, crafts, cuisine, language events and festivals (Organisation, 2005). Thus, to address these issues listed above relevant action like being more prepared to use the tourism argument as to fund the prevention of nature and culture and to prevent damaging change (Clark, 2013). Also strengthening the relationship between protected area and local tourism interest, within the context of a sustainable tourism strategy and action plan would lead the South Pacific to be more sustainable (Organisation v. s. , 2013). Sustainable development is holistic in nature; therefore, it requires management of policies and coordination of action between sectors (Othman, 2004). To control the impact of tourism initiated by environmental or developmental strategies and policies legislation and regulations are necessary (Governemnt, 2009). Appropriate strategies or sets of policies for specific aspects of tourism were developed. For example, in Bulgaria the separate strategy for ecotourism, which reflects the sustainability principles? (Bonevac, 2010) This initiative can also be taken by the local Ministry of Environment of Tourism to integrate the strategy in terms of regulations (David, 2011). In coordinating and ensuring success of this specific sub-sector, such regulations and legislations can be very helpful. This can be very helpful in demonstrating processes and formulating policies that could be modified more widely in tourism (Ki-Hoon Ball, 2003). Strategy and policies must be developed and implemented at both local and national level in order to achieve effective result. Most countries in the South Pacific are in the process of decentralizing their political and administrative structures so local decision-making is the vital aspect toward sustainability development (English National Park Authorities Association, 2009). An integrated approach to the development and management of tourism is within local destinations, is recognized as the most successful direction to sustainable tourism (Governemnt, 2009). Thus, it is vital for the national and local strategies to be corresponding but these two variable in tourism strategies vary in terms of national tourism strategies relates to the national tourism vision of the overall position and direction (Organisation v. s. , 2013). While local tourism strategies relates to the holistic of the local destinations in areas such as local objectives and priorities, local resource opportunity and constraints and many more (David, 2011). Hence, the identifying of policies and instruments to create the enabling environment for sustainable tourism is more of national strategy while the determining of what happens on ground is more of local strategies (Governemnt, 2009). Both the national and local tourism strategies are required for sustainable tourism to embrace the principles of sustainable development and both strategies are reliable and commonly reinforcing (Othman, 2004). Finally, the command control instrument allows government to exert strict control over certain aspects of development and operation, backed by legislation (Organisation, 2005). Legislation, regulation and licensing are the interdependent tools that can be used to strengthen sustainability by setting out requirements that are compulsory and enforceable and which lead to sanctions and penalties if they not met (Billington, Carter, Kayamba, 2008). The process of checking and signaling compliance with regulations or otherwise identified obligatory standards; assigning permission to operate is called licensing (Organisation, 2005). To control aspects of business development and operations and to influence people’s behavior government are in a position to apply laws, regulations and penalties. These legislation and regulations must be applied when the governments believes that it is necessary to do so (Governemnt, 2009). Thus, for regulations to be successful, it has to be relevant, clear, practicable in terms of compliance and capable of being enforced. In order the tourism industry to be more sustainable the laws and legislations should enable and support the sustainability of tourism and give authority to act (Billington, Carter, Kayamba, 2008). It should also seek to raise sustainability performance above such standards through other means, which would also stimulate personal commitment towards continual improvement. For example, in the government of Fiji builds up a (EIA) environmental Impact Assessment regulation, which stated that for any company or hotel with an EIA reports in Fiji, has to provide the Fiji Government with an EIA report of the development to progress (Turnbull, 2003). There are a number of areas in which laws and regulations can be implemented to attain more sustainable tourism industry and that includes operation, management and development which are controlled by this legislation to protect the environment, communities, culture and heritage, visitor experience and the business as a whole (Turnbull, 2003). The purpose of government intervention in the sector as law provides a vehicle for underpinning sustainability. These legislations can also provide the basis for enabling the control and licensing of activities specific to the tourism sector and for the undertaking to certain action to support tourism development (Organisation v. s. , 2013). To conclude, sustainable tourism is all about forecasting of long-term, working together examining on results and adaptive to change and the most effective thing is communication to put across the message of sustainable tourism. It is the duty of the private, public and independent sector to acquire leadership role in tackle the challenge of this sector. The degree at which the tourism industry is increasing in the South Pacific forecasts that the environmental and social impacts of tourism cannot be disregarded. Traditionally, a number of sustainable tourism activities has been carried out and is supported by the national Tourism Organization of the South Pacific countries. However, there are a number of challenges that still stay alive and need attention in order to be more sustainable tourism industry, like climate change. In order to tackle these challenges and grip future sustainable opportunities in a harmonized manner, research and development done in these South Pacific countries to handle these issues through sustainable tourism strategy plan. The tourism strategies plans would assist the tourism industry to change unenthusiastic community discernment of the industry and achieve economic benefits through sustainable practices. It believed that it would egg on business to hold sustainable tourism practices in order to meet consumers demand and to improve business performance. Sustainable tourism should be broadcasted and celebrated amongst tourists, host communities and the participants in the industry move the industry toward sustainability. Nevertheless, the commitment to change and improve must be authentic and supported on well-established procedures and actions that is to be achieved.

Cognitive And Dialectical Behaviour Therapy Borderline Personality Disorder Nursing Essay

Cognitive And Dialectical Behaviour Therapy Borderline Personality Disorder Nursing Essay AIM: To give a brief history of Borderline Personality Disorder and research the effectiveness of Cognitive Behavioural Therapy and Dialectical Behaviour Therapy. Method: A review of the literature and review of controlled trials and uncontrolled trials. Conclusion: In the management of Borderline Personality Disorder, there are many problems to consider, out of these problems self-harm and suicidal tendencies are considered the most important to treat. Chapter 1 Introduction 1.0 Despite the many treatment options for people with Borderline Personality Disorder (BPD), many professionals in mental health services continue to believe that personality disorders are untreatable. This essay provides evidence the effectiveness of Cognitive Behaviour Therapy (CBT) and Dialectical Behaviour Therapy (DBT) with Borderline Personality Disorder. Background To understand BPD, I will attempt to give a historical overview of BPD. Philippe Pinel in the 1800s, first described people who engage in deviant behaviour, but with no signs of thought disorder such as hallucinations or delusions as mania without delirium or in French manie sans delire (Friedel, 2004). Although the meaning of the term has changed through many writings on the subject over time, the writing of Cleckley and his use of the label psychopath in The Mask of Sanity brought the term into accepted usage (Meloy, 1998). The Mask of Sanity is a book written by Hervey Cleckley first published in 1941; he gave the most significant clinical description of psychopathy in the 20th century. An expanded edition of the book was published in 1982, when the name was changed from psychopathy to Personality Disorder. In 1972, newer editions of the book reflected a closer alliance with Kernbergss (1984) borderline level of personality organization, in particular defining the structural criteria of the psychopaths identity integration, defensive operations and re ality testing. The diagnosis borderline was introduced in the 1930s to label patients with problems that seemed to fall somewhere in between neurosis and psychosis (Stern, 1938). Adolph Stern a psychoanalyst described the symptoms, which are now considered to be the criteria of BPD. He suggested the possible causes and what he thought the most successful psychotherapy treatments were. He renamed the disorder, by referring to patients with symptoms as the borderline group (Friedel, 2004). In 1940, the psychoanalyst Robert Knight introduced his explanation theory of borderline disorder. Ego or sense of self psychology deals with mental function, which allows us to effectively combine our thoughts and to develop helpful responses to our life around us. He stated that people with BPD have impairments in a lot of of these functions, and he referred to them as borderline states (Friedel 2004). The next important input was made by the psychoanalyst Otto Kernberg (1967); he introduced the term borderline personality organisation. He proposed that mental disorders were determined by three distinctive personality organisations: psychotic, neurotic and borderline personality. Kernberg has been a strong promoter of modified psychoanalytic therapy for patients with borderline disorder (Friedel 2004). The first research on BPD was published by Roy Grinker in 1968, which he called Borderline Syndrome (Friedel 2004). The next major article was published in 1975 by Gunderson and Singer. They defined the major characteristics of BPD. Gunderson then went on to publish a research instrument to enable an accurate diagnosis. Internationally researchers were then able to verify the validity and integrity of BPD (Friedel, 2004). This followed with BPD becoming a genuine psychiatric diagnosis and appeared in the DSM-111 in 1980. Personality disorder categories are not firmly grounded in theory, nor are they empirically based (Livesley, 1998). Some critics say that personality disorder categories are so flawed that the best option is to abolish them and start afresh, but most pragmatists recognise that so much has been invested in them that they are very likely here to stay (Blackburn 2000a; Livesley, 1998). The Nice Guidelines for Personality Disorder (2009) state that borderline personality disorder is associated with significant impairment, especially in relation to the capacity to sustain stable relationships as a result of personal and emotional instability (NICE 2009). The severity of the symptoms, are related to the severity of the individuals personal/social situations. Stone (1993) argues that some people with BPD can still function at high levels in their lives and careers. Paris (1994) stated that about one-third of patients with BPD reported severe abuse involving an incestuous perpetrator; about one-third reported milder forms of abuse; and about one-third do not report abuse. Personality disorders are common conditions; studies indicate prevalence of 10-13% of the adult population in the community and are more common among younger age groups (24-44 yrs) and equally distributed between males and females. However, the sex ratio for specific types of personality disorder is variable e.g. antisocial personality disorder is more common among males, and borderline personality disorder more common amongst females (DOH 2003). Cognitive Behaviour Therapy (CBT) can be seen as an umbrella term for many different therapies that share some common elements. The earliest form of Cognitive Behavior Therapy was developed by Albert Ellis in the early 1950s. Aaron T.Beck independently developed another CBT approach, called Cognitive Therapy, in the 1960s. Cognitive Therapy rapidly became a favorite intervention to study in psychotherapy research in academic settings. In initial studies, it was often contrasted with behavioral treatments to see which was most effective. However, in recent years, cognitive and behavioral techniques have often been combined into cognitive behavioral treatment. This is arguably the primary type of psychological treatment being studied in research today. One specific form of cognitive-behavioural therapy is dialectical behaviour therapy (DBT), a broad-based, cognitive-behavioural programme developed specifically to reduce self-harm in women with borderline personality disorders (Linehan, 1993a; Linehan 1993b). Recent research has shown that dialectical behaviour therapy (DBT) is one of the first therapies that have demonstrated to be effective for treating borderline personality disorder as well as being effective in treating people who display varied symptoms and behaviours associated with mood disorders, including self-harm. DBT combines standard cognitive-behavioural techniques for emotion regulation and reality-testing with concepts of mindful-awareness, distress tolerance, and acceptance. 1.2 Rationale As a mental health nurse coming from a forensic background, I have experience of working with clients with personality disorder. I feel that by getting more of an understanding of CBT interventions, it will make a huge difference to my future practice in the future. McKenna et al (1999) state that it is unacceptable for health care not to be based on sound evidence of its effectiveness, and back up their practice with research-based evidence (NMC, 2008) to ensure effective clinical practice. Often nurses find it frustrating working with disorders of personality. These clients can be manipulative, socially inappropriate and difficult, for these reasons, such clients need all the patience and skills nurses have to offer. But despite this service in the NHS, services have been varied and inconsistent (DoH, 2003). Besides functional impairment and emotional distress, borderline personality disorder is also associated with significant financial costs to the healthcare system, social servi ces and the wider society (NICE 2009). 1.3 Aims and objectives The aims and objectives of this project are to review the evidence on the efficacy of Cognitive Behavioural Therapy and Dialectical Behaviour Therapy with people who have Borderline Personality. 1.4 Methodology and parameters This literature review was conducted using the following resources Electronic databases: Cochrane library, CINHAL, Medline, Psychinfo, Psychology and Behavioural Sciences and Academic Search Premier Key journals were hand searched: British Journal of Psychiatry, Journal of Personality Disorders, Mental Health Practice, Journal of Personality and Mental Health University and Trust libraries Google Google scholar The following types of literature were sought and reviewed where available Randomised control trials Systematic and structured review Quantitative and Qualitative research studies Position statements/guidelines from professional bodies Government policies (NICE (2009), NSF (1999) Text Books Inclusion and exclusion criteria Eligibility for this review was determined by the following criteria: à ¢-  Participants: adults with BPD (diagnosed according to DSM-III/DSM-III-R, DSM-IV, DSM-IV-TR or ICD-10 criteria for BPD), with or without co-morbidity. à ¢-  Intervention: psychological therapies, including CBT, DBT à ¢-  Comparators: CBT/DBT or treatment as usual à ¢-  Outcomes: self-harm, suicide, interpersonal and social functioning à ¢-  Study type: published papers were assessed according to the accepted hierarchy of evidence, whereby systematic reviews of RCTs are taken to be the most authoritative forms of evidence, with uncontrolled observational studies the least authoritative. à ¢-  Exclusion criteria: papers on personality disorder without separate BPD subgroup analyses. The studies were obtained through a number of sources, as above. Searches were performed by entering the key words Borderline Personality Disorder, Cognitive behaviour therapy into several databases, which yielded many secondary references of current best evidence. Search filters developed consisted of a combination of subject headings. The topic-specific filters were combined with appropriate research design filters developed for systematic reviews, RCTs and other appropriate research designs. These articles were selected after careful reading of the title and abstract to identify the most useful. I then limited my search to full articles which made my search a lot easier. The definitive text that will be used to aid my search will be NICE Clinical Guidelines for Personality disorder 78. This guideline makes recommendations for the treatment and management of borderline personality disorder in adults and young people (under the age of 18) who meet criteria for the diagnosis in prim ary, secondary and tertiary care (NICE, 2009). BPD is present in 1% of the population, and is most frequent in early adulthood. Women present to services more often than men. BPD is not often formally diagnosed before the age of 18, but the features of the disorder can be identified earlier. Its path is changeable but many people do recover (NICE 2009). This search will comprise both British and international articles. When choosing which articles were going to be relevant, I found it impossible to ignore the amount of articles I had on DBT and as DBT was evolved from CBT and made specifically for BPD, I decided to bring it into my research project. The articles are mixed quantitative and qualitative research. The qualitative means of gathering subjective data is centred on an individuals experience, beliefs, empowerment and quality of care and does not solely concentrate on clinical outcomes for the individual. One could argue that this is the most appropriate aspect of research for mental health nurses as mental illness is individual for each person involved in the process and although BPD is not a mental illness. The National Service Framework for adult mental health sets out our responsibilities to offer evidence based, effective services for all those with severe mental illness, including people with personality disorder who experience significant distress or difficulty (NIMH 2003). While these can be misconceived as an easy option form of research, qualitative research offers rich, reflective and exhaustive data that is invaluable and has a profound contribution to make to take to practice. The qualitative evidence was lim ited with regards to the treatments reviewed, with an emphasis on DBT. Quantitative research is a formal, objective, and rigorous statistical process for generating information about the world (Burns Grove 1999), whereby the researcher would gather a range of numerical data in order to answer the research question, or prove, disprove a hypothesis (Parahoo 2006). Philosophies or schools of thought in research are called paradigms (Parahoo 2006). One such paradigm is positivism. Parahoo (2006) asserts that positivism relies on observations by the human senses to create fact (empiricism), and believe in the unity of science, and the notion of cause and effect (determinism). The positivist researcher will endeavour to test a hypothesis or theory using the deductive process of a course of experiments. This paradigm utilises a quantitative approach in its research methods. For the positivists, quantitative research is believed to provide hard evidence and objective fact that can provide knowledge on which to base best practice (Parahoo 2006). Efficacy studies focus on the usefulness of a specific helping methodology for a particular kind of problem. Comparisons are made between the methodology in question and some other methodology between clients with some disorder who do receive the treatment and those who do not or between two different methodologies for treating the same disorder. These studies are carried out under controlled conditions. Many of the studies are well designed and demonstrate efficacy. In a healthcare context, efficacy indicates the capacity for beneficial change (or therapeutic effect) of a given intervention. Chapter 2 The Literature Review Having undertaken a critical review of the literature, I have come to explore a number of issues which I feel necessary to consider, key themes emerging from this literature review are the impact of CBT DBT on suicidal behaviours, the impact of CBT DBT on self-harming behaviours, and the impact of CBT DBT on engagement. This chapter sets out to explore these themes in more detail. On the whole the most suitable research design to answer this is the Randomised Controlled Trials (RCT); hence the evidence base reviewed include accessible RCTs undertaken in those with a diagnosis of BPD (NICE, 2009). The causes of BPD are complicated and remain uncertain. Contributing factors may include an inherited vulnerability, a particular temperament, early life experiences and, in subtle neurological or hormonal disturbances (NICE 2009). NICE (2009) state that the history of specific psychological interventions designed to help people with borderline personality disorder is intertwined with changing conceptions of the nature of the disorder itself. Swartz (1990) wrote that BPD is more common among drug and alcohol users. And within these dependents there will be more women diagnosed than men. Zanarini (1998) also adds that the disorder is more common in those with eating disorders, and also among people with self-harming behaviours (Linehan et al., 1991) 2.1 Defining Cognitive Behaviour Therapy and Dialectical Behaviour Therapy NICE (2009) define CBT as a structured psychological treatment that focuses on helping a person make connections between their thoughts, feelings and behaviour. Originally CBT was used as a treatment for depression which has now been modified to treat BPD. CBT focuses on altering the thoughts, emotions, and behaviours of patients by teaching them skills to challenge and modify beliefs, to engage in experimental reality testing, and to develop better coping strategies. The goals of these interventions are to reduce the delusional beliefs, and consequently their severity, and to encourage effective coping and decreasing distress. This essay will attempt to assess the contribution of CBT and the disorder by discussing reviews on effectiveness. CBT for BPD was developed with the idea that people with BPD have learned distorted beliefs and thoughts overtime. Distressing emotional responses and behaviours develop as a result. Beck Freeman (1990) outlined such beliefs, relating to dependen cy, distrust, and rigid perceptions. The distorted thoughts are modified by monitoring,  analysis and questioning.   Davidson (2000), adds that particular attention should be paid to the problems that can disrupt therapy, and so disrupt the therapeutic relationship (NICE, 2009), such as non-engagement, loss of structure, losing focus and lack of compliance. CBT for BPD attempts to create change by improving the attitude of the patient toward treatment, the enhancement of specific skills, and the reduction of hopelessness (Friedel, 2004). The therapist and patient will construct a list of problem areas. A set of tasks will be developed that will generate and reinforce new attitudes and behaviours, which will replace the old attitudes and behaviors that have caused problems in the past. Within the past 15 years, another, newer psychosocial treatment termed Dialectical Behaviour Therapy (DBT) was developed. DBT joins standard cognitive behavioural techniques with acceptance based strategies, as well as strategies designed to keep the therapy balanced between change and acceptance (dialectical strategies). Marsha M. Linehan, a psychologist from the University of Washington in Seattle, developed DBT specifically for people with BPD, especially those who engage in self-destructive and self-injurious behaviours. DBT is based on the belief that the symptoms of BPD result from organic impairments in the brain that control emotional responses. The early behavioural effects of this impairment are exaggerated, as the person with this biological risk factor interacts with people who do not validate their emotional pain and dont help them learn effective coping skills. DBT has gained significant support in the treatment of BPD because of the results it has achieved in several r esearch studies. It has been shown that DBT can be taught to and used by many, but not all, mental health professionals. For the time being this seriously restricts the use of this helpful treatment approach. DBT seeks to validate feelings and problems, but it balances this acceptance by gently pushing to make productive changes. DBT also deals with other opposing or dialectical tensions or conflicts that arise, such as the patients perceived need for a high level of dependence on the therapists, and the fear and guilt aroused by such extreme dependency. DBT combines both cognitive and behavioural techniques and designed specifically to treat BPD. It is a combination of individual psychotherapy and psychosocial skills training that has been shown via controlled clinical trial to be effective in treating individuals with BPD (Linehan, 1993b). One of the most limiting factors of treating and delivering therapies is that there is not enough staff in the NHS trained to a high standard ( NICE 2009). Cunningham (2004) interviewed fourteen women with BPD to discover why and how DBT is effective. The women were provided with tools to help them deal with their problems and so enabled them to to see the disorder as a controllable part of themselves rather than something that controlled them (NICE, 2009). Cunningham (2004) found that although their problems did not disappear, they became more manageable. It also seemed to have encouraging results on their relationship interactions, and, in addition DBT instilled hope and an ability to try to live independently (NICE, 2009) 2.2 Suicidal acts NICE (2009) define suicidal acts as, deliberate; life threatening; resulted in medical attention; medical assessment consistent with suicide attempt. The main problem staff face in managing BPD is suicidal behaviour (Paris Zweig-Frank, 2001). There is also an association between BPD and depression (Skodol et al., 1999; Zanarini et al, 1998), and Solof (2000) adds that the combination of the two disorders increases the number of suicide attempts. People with BPD possibly will take part in a number of negative and reckless behaviours including self-harm, eating disorders and substance misuse. Self-harming in BPD has different meanings to each individual, including relief from feelings and distress, such anger, or to reconnect with feelings after episodes of emptiness (NICE, 2009). Because of the high occurrence of self-harm, the risk of suicide is higher (Cheng et al, 1997), with 60-70% of patients with BPD making suicide attempts at some point in their lives (Oldham, 2006), however, unsuccessful attempts are far more common and the actual rate of completed suicides is estimated at between 8-10%. A specific therapy for BPD, DBT tak es a behavioural approach to self-harm and suicidal acts that include skills training in emotional regulation and validation of client experience (NICE, 2009). Cognitive-behavioural therapy along the lines of Beck, Freeman, Associates (1990) has been investigated in at least two uncontrolled trials. Brown, Newman, Charlesworth, and Chrits-Cristoph (2003) found significant decreases on suicide ideation, hopelessness, depression, number of BPD symptoms, and dysfunctional beliefs after 1 year of cognitive-behavioural therapy for suicidal or self-mutilating patients with BPD. Results were maintained at a 6 months follow-up. Effect sizes were moderate (0.22-0.55). Dropout rate was 9.4%. Arntz (1999a) found positive effects of long-lasting cognitive-behavioural therapy in a mixed sample of personality disorders, including 6 patients with BPD. Two patients with BPD dropped out prematurely, but the other four attained good results. Linehan et al (1991) conducted a randomised controlled trial using 44 chronically parasuicidal women with BPD to assess the effectiveness of DBT. Among the two groups, there was very little difference between measures of depression, hopelessness and suicidal ideation. Overall the group which received DBT had an average of 8.46 inpatient days compared to the controlled group which had 38.86 days. A naturalistic follow up review was conducted on 39 on the women one year later, to determine the effects of DBT. The women that had completed the DBT course had fewer parasuicidal episodes, but after 18-24 months there were no significant differences between the two groups, although psychiatric inpatient days were still lower for the DBT group. Rathus et al. (2002) went on to conduct a study with a group of 111 suicidal teenagers. 29 were assigned to DBT, while the other 82 had treatment as usual (TAU). It is worth mentioning that the DBT group had far more severe symptoms pre-treatment. The study therefore was not randomised. During the 12 week treatment, the DBT group had fewer inpatient hospitalisations, although the number of suicide attempts made during the treatment did not differ between the groups, but, the attendance and completion was higher in the DBT group. A smaller case study was conducted by Hengeveld et al (1996); he reported of 9 female patients who were given a 10 week course of CBT, they had all attempted suicide at least twice. Of the 9 women, four of those were diagnosed with BPD. Following up the women 10 months later, by phone or examining medical records, all four BPD patients had reports of further suicide attempts (NICE, 2009). Linehan et al. (2006) conducted a one-year randomized controlled trial with one year of post-treatment follow up. The objective was to evaluate the hypothesis that unique aspects of DBT are more efficacious compared to treatment offered by non-behavioural psychotherapy experts. The study included 101 female participants with recent suicidal and self-injurious behaviours that met DSM-IV criteria. The subjects who received DBT were half as likely to make a suicide attempt. 2.3 Self-harm NICE guidelines (2009) use the definition that self-harm is self-poisoning or self-injury, irrespective of the apparent purpose of the act. Self-harm BPD is connected with a range of diverse meanings for the individual, including release from distress and feelings, such as emptiness and anger, and to reconnect with feelings after an episode of dissociation (NICE, 2009). There have been positive attitudes from patients about DBT, as it has helped improve their ability to control their emotions, improves their relationships and significantly reduces the occurrence of self-harm (NICE, 2009). In a large sample, Tyrer et al (2003) found that CBT was equivalent to TAU for the treatment of recurrent self-harm and noted that this method was less effective for patients with BPD. In an uncontrolled study by Brown (2004), patients with BPD with self-harming tendencies received CBT over 12 months; they then stayed in contact with them by phone over the next 6 months. Therapists were on call to emergency phone calls throughout. A randomised controlled study by Verheul et al (2003) was carried out to compare DBT with TAU for patients with BPD, 58 women received treatment for a year were randomised to DBT or TAU. The results: the 12 month attrition rate (37%) for DBT was substantially lower, compared to TAU (77%); DBT treatment also resulted in a large reduction of self-harming behaviours than TAU. A follow up review of this study was carried out by Van den Bosch et al (2005), to ascertain whether the previous results were continued over the following 6 months. It was discovered that the benefits of DBT after the treatment were sustained, and levels of self-harm were lower. It must be said, however, that the definitions of self-harm were all slightly different in each of the RCTs, this can make it very difficult to compare results (NICE, 2009). Another case study series by Alper (2001), presents data on 15 women in a forensic setting, with a diagnosis of BPD. Nurses in the hospital carried out the DBT, and over 4 weeks there was a significant reduction in the occurrence of self-harm. Alper (2001) also carried out qualitative interviews with the nurses to describe how they felt about the treatment, they were all very positive. Bateman Tryer (2004) state that the extensive implementation of DBT is a acknowledgment of its founder, Marsha Linehan, with its mixture of acceptance and change, skills training, manualisation, and an opinion that is willing to embrace this comprehensive approach (NICE, 2009). The evidence strength though, is not justified, however (Tyrer, 2002b), and answers about the long-term success of this therapy as a treatment for BPD are premature. In view of the fact that the original trial, which was handicapped by many methodological limitations, there has only been one study that supports the findings clearly, which was that of Verheul et al (2003) (NICE, 2009). 2.4 Non-engagement For effective treatment, commitment to therapy is required, and research shows that fewer people drop out of DBT than other therapies (Verheul et al 2003) Haigh (2003) interviewed service users and according to them the services could be improved if staff recognised and accepted that BPD can be treated; they felt a more positive experience at their preliminary referral would aid further engagement with services; therapeutic relationship endings were dealt with effectively; and when signs of improvement are observed, services should not be removed immediately, as this tends to raise anxiety and discourage future progression (NICE, 2009). Hodgetts et al (2007) studied five people with BPD. The participants were told that DBT was the only treatment for BPD. This raised expectations and anxieties in the service users. Some preferred the structure of DBT, but others would have preferred a more flexible treatment that is adjusted to each individuals needs. Service users each felt differently about individual therapy and group therapy. One participant dropped out of therapy as she found the challenges too much to deal with. The same lady reported that she was turned away from the crisis team as she was already involved in the DBT group; this was another reason for her departure. All of the participants in this study found that the therapeutic relationship is essential, also they appreciated the importance of collaborative working and sharing their experiences (NICE, 2009). Other studies have reported quite high drop out rates from CBT, for example up to 37% (Verheul et al, 2003). It is probable that some patients did not engage because they did not find the therapy useful, but ratings from patients who had at least five sessions of CBT suggest that both the patients and therapists view the experience of therapy to have been a positive one. Even so, some patients simply did not attend. Chapter 3 Discussion and Conclusion This research project has tried to look at research evidence on the efficacy CBT and DBT in the management of Borderline Personality Disorder. This work has been done using the NICE Guideline (2009) as the definitive text. This is because this guideline is main reference document in clinical practice. Borderline Personality Disorder is one of the most challenging entities for todays therapist; in fact, this category originated as a repository for patients who fail to improve with ordinary treatment methods and whose particular pathology is most likely to provoke a negative emotional reaction in the therapist. Comfort and effectiveness in the treatment of BPD implies mastery both of ones own emotions and of therapeutic techniques in general. It is not realistic to expect success in every case, and successful treatments are usually long and stormy. Because the BPD diagnosis have common characteristics with schizophrenia, psychoses, anxiety and depression, Gunderson (2001) believes it to be a wastebasket diagnosis, which lacks diagnostic accuracy and strength, and so would only be useful to service users that did not fall into other diagnostic types. It is thought that BPD has responded badly to the treatments, and a lot of health professionals also unfortunately, believe this to be true (Friedel 2004). It seems that overall the non-RCT outcomes suggest that individual therapies are more suitable to people with BPD. Positive outcomes were shown generally, these need to be compared to the RCTs before definite conclusions can be made (NICE, 2009). It seems that the evidence base is fairly poor for therapies of BPD, the studies are minimal, the number of patients are low and the outcomes too numerous, with very little commonalities between studies (NICE, 2009) Giesen-Bloo et al (2006) are critical of DBT, stating that it fails to reduce core symptoms related to deeper personality change. The most difficult problem is that DBT is resource-intensive and expensive. Where it is available, there are usually long waiting lists. However, DBT is the treatment of choice for individuals experiencing severe impulse and self-harming behaviours. 3.1 Strengths and limitations of the review Having never done a substantial piece of work before, I did not realise the amount of work required to achieve it. I was aware of how to narrow down a search, which was needed due to vast amount of information available, but the confusion came as I particularly wanted to look at standard CBT for BPD, which very little research has been done. There was far more research for DBT, and so I decided I would explore this t