JOURNAL ISSUE 11

2004/2005

 

 

Inter-University Centre Dubrovnik

2005 Symposium

“Reaching the Inner World”

Running head: A Synthesis of psychotherapy and neuroscience

The Integration of Treatments That Work: Principles, Practices, and Applications.


Martin Masar, MSW, LCSW
YouthConnect International
La Junta, Colorado


All rights reserved.  Republication or redistribution of content is expressly prohibited without the prior written consent of YCI. © 2005 YCI

 

Abstract

This paper was presented at an international symposium of Psychology and Social Work academics, therapists, educators, researchers, and youth advocates in Dubrovnik, Croatia in June of 2005.  The presentation demonstrated the efficacy of an advanced system of treatments currently available to adolescent males (ages12-21) with social-emotional disabilities and severe mental illness in a psychiatric residential treatment facility in the USA. This article illustrates how a psychiatric treatment facility utilizes a conceptual framework based on current advances in psychotherapy and neuroscience.  The program design includes psychotherapy, enriched environments, and neuroscience. The epistemological assertion made in this presentation is that these interventions produce essential neurological changes in the brain responsible for transformation in overall psychological health and functioning.

 

The Integration of Treatments that Work:  A Clinical Narrative

Some youth who have come my way in the past twenty years are just too hard to forget.  Joseph was sixteen years old when he was admitted to YouthConnect.  Reading his history I discovered that Joseph had been in forty placements before coming to YouthConnect.  He was a stout young man, who learned to survive by using his strength and aggression to his advantage.  Soon after he was admitted to our program, in a show of power and defiance, Joseph forcibly removed an entire toilet from the bathroom floor.  Over the next several months Joseph became increasingly aggressive with staff and peers.   

 

Whenever he felt circumstances were not going his way, or the way he wanted them to go, he would aggress against staff with increasing physical violence.

 

Joseph lived in a world of anger, defiance, and hatred.  During his early childhood he was repeatedly beaten for his behavior and then locked in a dark closet for hours.  His earliest memories are of stark isolation, terror, and fear.  In Joseph’s mind the world was a terrible place and he had come to expect the worst.  Imprinted in his mind became a solution: use aggression and strength to control others, thereby controlling the fear he had of the world.

 

In our treatment sessions Joseph continuously demonstrated his physical power through the use of strong words and threats.  He would say things like, “Don’t even go there, if you know what’s good for you” and “I’ll do whatever it takes to get out of here. I could easily beat you and then they will take me out of here.”  In addition, Joseph had an almost evil stare and when he would give you that look, you knew he meant business. 

 

One night as I worked late, the residential staff called my office asking if I would speak with Joseph.  He was very angry and threatening to hurt anyone who got in his way.  I had Joseph brought to the office.  Trying to problem-solve through his difficulties that night was a fruitless task.  For each solution I suggested, Joseph would counter with a number of different excuses.  During our talk I noticed his anger diminishing and after numerous attempts to assist him with his current problems, I asked him bluntly, “Tell me what makes you so angry.”  Joseph stood up in what seemed like an angry explosion, turned around and grabbing his shirt, lifted it above his head.  There on his back were the scars of many beatings.  Embedded forever were the deep scars of his childhood, of his rage, and of his hatred (Masar, 1999, CBRYC Confidential Case Material).

 

There is a saying, “To know who you are and where you are going, you must first know where you have been.”  Joseph’s story reminds us that as we look towards the future, we must also know where we have been.

 

The following is a summary of “The Integration of Treatments that Work”, a report compiled over twenty years by YouthConnect International (YCI). The report summarizing this research and experience found that the three most effective areas of adolescent and family mental health treatment are:  Psychotherapy, Enriched Environment, and Neuroscience.  Each will be addressed in this report. 

 

About YouthConnect International

YouthConnect International, the umbrella organization for CBR YouthConnect (CBRYC), was Incorporated 46 years ago as Colorado Boys Ranch (CBR) Foundation. It remains an operating Foundation, providing leadership and resources for CBR YouthConnect, a psychiatric residential treatment and educational institution for adolescent males with severe emotional and behavioral problems.

 

YouthConnect founders envisioned the growth of an organization that would not only support residents at the Colorado, USA-based campus, but also expand its reach to youth and families throughout the nation and world. That dream is now being realized. YouthConnect, through its highly trained professionals, is exporting its expertise in the field of psychiatric treatment and specialized education to troubled youth throughout the world. This is embodied in the multi-cultural environment that exists at CBR YouthConnect.  Our residents come from more than seventy communities throughout the United States to receive the care and treatment that YouthConnect provides (CBRYC White Paper, 2005).                           

 

Who We Treat

Youth admitted to YouthConnect have severe behavioral, psychological, educational, and psychiatric problems, which prevent them from appropriate functioning in their homes, schools, and communities.  Many, though not all, of the youth admitted to our facility have legal histories. We treat youth between the ages of ten and twenty-one, with an average length of stay of fifteen months.  Eighty-five percent of the youth discharged from this facility continue to function well two years and eight months after discharge. 

 

Youth admitted to our facility are presented with a variety of mental health diagnoses.  As of December 2004, the Axis I Primary Diagnosis, according to the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) of youth admitted to our program included the following:

  • Aspergers Syndrome - 2% (percentage of all youth in 2004 with this diagnosis)

  • Intermittent Explosive disorder - 1%

  • Attention Deficit Hyperactive Disorder - 11%

  • Anxiety Disorder - 1%

  • Bipolar I Disorder - 2%

  • Bipolar Disorder - 11%

  • Organic Brain Syndrome - 1%

  • Depressive Disorder - 27%

  • Cyclothymic Disorder - 2%

  • Dysthymic Disorder - 5%

  • Major Depressive Disorder - 7%

  • Schizophrenia - 2%

  • Schizoaffective Disorder - 1%

  • Bipolar II Disorder - 1%

  • Psychotic Disorder - 5%

  • Impulse Control Disorder - 1%

  • Posttraumatic Stress Disorder - 9%

  • Mood Disorder - 10%

The Intelligence Quotients (IQ) range from 55  to 130.  The percentage of unplanned discharge from YouthConnect is 3%.  Our voluntary family participation in treatment is 97% and the rate of youth returning to live with their families at discharge is 93%—the remaining will be placed in alternative settings such as group homes, independent living, or other functional and less restrictive environments.

 

Core Values Influence Psychotherapy, Neuroscience, and Enriched Environments

To fully appreciate The Integration of Treatments that Work requires a brief look at core values.  Values are assumptions, convictions, or beliefs about the manner in which people should behave and the principles that govern behavior.  Values serve as a baseline for actions and decision-making and as guidelines for intentions and interests.  A strong value system turns beliefs into standards (Patterson, 1959).

 

Psychotherapists, as the practitioners of psychotherapy, need to appreciate the significance of their own values and the organization’s values.  This understanding enables the therapist to employ a more objective view of the client’s world and reality.  Values affect the way we view other persons and groups, thus influencing interpersonal relationships. Values affect the way we perceive situations and solve problems. Values affect the way we determine what is and is not ethical behavior. Values affect the way we treat and care for others. 

 

At YouthConnect we have made a determination of our values from the human and organizational perspective (CBRYC White Paper, 2005).

 

Human Value:

Children, youth, and families are inherently good.  It is our pleasure and privilege to treat youth and families.  Our youth and families deserve the best in mental health treatment and education.  It is our job to never fail.  It is our job to never blame the client.

 

Organizational Values:

  • Respect and dignity for people: emphasizing human potential in a safe, ethical environment; based on research, individual opportunity and choice; that no two people are alike; and that each person has unique skills and attributes which make them special.

  • Commitment to relationships: fostering a culture that promotes close and vital relationships; developing all treatments first through a therapeutic relationship.

  • Manage by fact: decisions based on clear and accurate information.  All treatment decisions are based on best practice.

  • Continuous improvement: a commitment to ongoing quality, innovation, and problem solving; improving what we currently provide and searching out new and better ways of being more effective.

  • Financial stewardship: acquiring and using assets wisely while balancing needs, regulations, and donor intent.

  • Growth oriented: extending our help and expertise to as many youth and families as possible. (CBRYC White Paper, 2005).

By establishing these basic core values we are building upon a foundation for psychotherapeutic treatment that is driven by the mental health needs of the children, youth, and families.  The above are not mutually exclusive or all inclusive, but rather represent a basis by which YouthConnect makes decisions and incorporates the essential elements of psychotherapy, enriched environments, and neuroscience.  In essence we are establishing that this organization is committed to the integration of treatments that work and is committed by value to impart these critical elements across the scope of the organization’s services.                               

 

Three Core Elements: Theory

To discuss the three core elements within The Integration of Treatments that Work, we must first briefly discuss theory.

 

A theory is an attempt to organize and integrate knowledge and to answer the question “Why?”. A theory organizes, interprets, and states in the form of laws and principles the facts and knowledge in an area or a field (Patterson, 1980).

 

In theory, as in life, there are no absolutes.  The human condition has literally hundreds of thousands of variables that affect our behavior.  No single explanation or theory can address every element of every human interaction and behavior.  Each of us has had unique individual experiences that shape our opinions, perspectives, values, and beliefs.  The very way in which we view the world is unique and different to each person.  It is important to keep this in mind when reading this material or trying to decide which theoretical and practical intervention you might choose with a client.  Many times the answers are not so clear, or the theory does not answer all aspects of the human condition, rather we need to employ theoretical principles that can with minimal effort be used to address most circumstances across the vast domain of the human condition.

 

At YouthConnect we have developed a philosophy or conceptual framework that guides our choice of theory and interventions.  That philosophy states that all treatment is to begin where the youth and family are at emotionally, maturationally, cognitively, educationally, and culturally; and that all treatments are to be individualized to meet the unique mental health needs of each person. 

 

Therefore, from a best practice perspective, the choice of theory and interventions are dependent on the interpretation by the treating professional in consideration of the uniqueness of each person.  At this point we now have the convergence of values and theory; values affecting the interpretation by the practitioner and theory affecting the course of treatment for the youth and family.

 

Three Core Elements

This next section discusses the three core elements of enriched environment, neuroscience and psychotherapy.  These three elements integrated with values and theory have been found to create optimal conditions and interventions for the effective mental health treatment of youth and families (Zimmerman, 2003).

 

Enriched Environment

The brain is constantly changing to reflect features of its environment.  In neuroscience terms, the brain’s activity changes to reflect the environment that shapes it.  An enriched environment is defined by a positive level of stimulation, education, and complexity, all of which enhance learning and growth.  Enriched environments include challenging educational and experiential opportunities that encourage us to acquire new skills and expand our knowledge.  Higher levels of education, practicing skills, and continued engagement in mental activities correlate with more brain activity and neural network growth.  Increased brain activity leading to new neural networks is the optimal brain state for learning.  In the opposite, impoverished environments, absent of stimulation, education, and cognitive complexity do not promote brain activities, i.e., growth and new learning.  An enriched environment is not to be confused with an economically privileged environment.  Having a lot of money does not necessarily mean the individual is living in an enriched environment.  I am certain we can all think of situations where the youth and/or family did not provide the essential elements of stimulation, education, and complexity to encourage healthy brain development.  Stimulation (motivation, participation), education (to acquire new information), and complexity (mild to moderate stress or emotional excitation) provide an optimal environment for new learning and growth (Cozolino, 2002; Dawson, 1994).

 

The psychotherapy environment or office can be thought of as an enriched environment that promotes the development of cognitive, emotional, and behavioral abilities.   The treatment process can impart a level of stimulation, education, and complexity, which also enhances brain activity and new learning.  The essential elements within an enriched environment are safety, belonging, acceptance (respect), consistency, and nurturance.

 

For those of us working in the residential field, where children actually live in assigned homes, cottages, halls, or units, the area of enriched environments becomes very important.  An unhealthy environment can have a significant deleterious effect on the therapeutic process.  While an enriched environment can support and promote the effectiveness of psychotherapy, an impoverished (or negative) environment can actually undermine the therapist’s and client’s effectiveness. 

 

As psychotherapists it is very important to remember the Adaptive Response—or behavior change in response to one’s environment.  In neuroscience terms, the brain changes to reflect features of its environment.  This is the adaptive response.  This concept in neuroscience means that psychotherapeutic involvement of the youth and child’s family, parents, and the guardians of the treatment process are extremely important.  Psychotherapeutically we need to work with the influential aspects of our youth’s lives, as they can have both a positive or negative influence on the individual, despite our best psychotherapeutic treatment. The environment may also include the residential unit, cottage, group home, foster home, and the educational setting or school. 

 

By providing an enriched environment for our youth and children, we are beginning the first of three integrated elements that we have found to promote effective conditions for successful mental health treatment.  We now move to the second element— neuroscience. 

 

Neuroscience

Neuroscience is the study of the nervous system, or more simply the brain.  Neuroscience advances the understanding of human thought, emotions, and behavior.  Neuroscientists study how the brain grows, learns, and changes.  Science provides us with many views on how the brain functions, including comprehensive but separate perspectives on the human experience.  For example, neuroscience can inform us about how the brain functions in relationship to mental processes such as memory and perceptions.  The area of developmental psychology offers us a view of how children’s minds grow within families across time.  Psychiatry gives us a clinical view of how individuals may suffer from emotional and behavioral disturbances that profoundly alter the course of their lives.  Psychology offers explanations for the causes of mental illness across a variety of different perspectives. Often these disciplines function in isolation from one another.  However, when we examined the convergence or integration of these individual fields an incredible unification of these findings is discovered (Cozolino, 2002; Siegel, 1999; Dawson & Fischer, 1994).

 

Connections Between Neuroscience and Psychotherapy—Implications

Why?  Why worry about the connections between neuroscience and psychotherapy?  The field of psychotherapy is at a very exciting time in our history as we now have the ability to integrate the clinical field of mental health with the field of neuroscience.  If we were to state the processes of change in psychotherapy, ultimately we would have to identify changes, depending on the individual theoretical perspective, in the individual’s thinking and behavior.  These changes ultimately reflect changes in the brain of the individual, and thus we have the powerful union between neuroscience and psychotherapy.  (Pliszka, 2003; Russell, 1979).

 

In the 19th century, psychotherapy and neuroscience were similar fields of study.  Differences in perspectives lead psychotherapists to break away from the scientific structures of neurology.  Psychotherapists took a subjective view of the human experience, while neurologists took an objective or empirical view.  As we begin the 21st century, neuroscience is providing psychotherapists with theoretical models and research data that allow us to begin to understand what is happening in the brain during the change processes of psychotherapy.  This powerful reunion of psychotherapy and neuroscience can serve to advance patient care by helping psychotherapists with a greater understanding of how treatment works, attains its results, and imparts change successfully within the brain.  “From the perspective of neuroscience, all psychotherapists are in the brain rebuilding business” (Cozolino, 2002).

 

This paper presentation is not lengthy enough to explore and discuss the neuroanatomical structures and functioning of the brain.  However, for the sake of learning, I will introduce some basic elements of neuroscience and follow up with some general parameters for the practice of psychotherapy.  This listing is not meant to be all inclusive and depending on the individual neuroscientist additional elements may be emphasized.  From our perspective, I have tried with great simplicity to narrow the focus of each principle into a “user friendly” format.

 

Basic Principles of Neuroscience

  • The brain from embryo to adulthood is constantly changing.  It is suggested that brain growth, not to be confused with change, continues through the first two to three decades of life.

  • At birth the brain has already acquired 30% of learning.  This includes such elements as the mother’s voice, smell, and suckling response.  Babies are born equipped with the information for survival.

  • The lower regions of the brain, emanating from the brain stem, are fully developed at birth and are responsible for physiological homeostasis, motor movement, and alertness.

  • The mid-regions of the brain, containing the limbic system, are involved with learning, memory, and emotion.  This region of the brain is ready at birth for learning, memory, and emotion (Beitman & Nair, 2004; Severe, 2000; Swenson, 1980).

  • The cortex, although active, is not yet fully developed at birth.  The cortex serves as a sort of information processing center, including perceptions, self-awareness, thinking, and reasoning.

  • Much of our most important emotional and interpersonal learning and memory during the first years of life occurs outside our ability for conscious thought, reasoning, and thinking.

  • During the process of brain development, neurological connections are made, forming neural networks.  These networks are the basis of learning and memory.  They tell the mind how to respond in given situations or to certain emotions.  The more a neural network is used the more it is encoded into memory (Schore, 1994).

  • Neural growth and development are also functions of biological, environmental, and genetic influences.  These influences have a participatory effect in how the brain learns, remembers, and grows.

  • Neural networks will find the quickest route to return the brain to a state of homeostasis.  This does not necessarily mean the most reasonable or appropriate action, rather, it means the most customary and usual means of returning the system to homeostasis (Walsh, 1982).

  • The manners in which an individual begins to think, behave, and feel are determined by the neural networks.

  • Neural networks are adapting and changing constantly throughout life.  Some are strengthened, some are altered, some are completely changed, and others are lost or never used.

  • Neural networks are formed through chemical messengers called neurotransmitters.  Different neural networks utilize different neurotransmitters dependent on the chemical effects of the neurotransmitter.  Neurotransmitters such as dopamine, norepinephrine, and serotonin are relevant to psychotherapy because of their role in regulating cognition and emotion (Adams, 1997).

  • Individuals with mental illness have neural networks that for a variety of reasons create dysfunction within the person.

  • Changing neural networks is a process of creating nurturance and mild stress or emotional arousal.  Mild stress produces a biochemical substance in the brain that promotes learning, while high stress triggers a different set of biochemical substances that actually inhibit new learning.  In times of high stress we need to act without thinking (Walsh, 2004; Corrigall, 2003)

  • Empathic attunement with the therapist provides an optimal environment for emotional receptivity of the brain, thus allowing the opportunity for new learning.  The individual is less defensive and guarded. Although various schools of theory tend to accentuate their differences, the therapeutic relationships may be the most curative agent in promoting sustained mental health.  Therapeutic attunement is equal to warmth, unconditional positive regard, acceptance, and empathy.  In neuroscience terms, we are increasing the individual’s receptivity by attuning to the emotional centers of the brain; an increase in receptivity equals diminished defensiveness and an increase in subconscious and unconscious cognitions.  A decrease in defensiveness equals greater insight and awareness and an increased susceptibility to the therapists interpretations/techniques.  With greater insight, awareness, and susceptibility to the therapist we are impacting deep emotional regions of the brain and beginning the process of lasting change (Norcross, 2002).

  • Cortical awareness or thinking and reasoning also require integration with emotion, sensation, and behavior.  This is an effort to combine the lower, mid-sections, and upper regions of the brain in synchronicity.

  • The process of synchronic brain function is essential in the development of new neural networks.  Just because you think you should not do something does not mean you won’t do that particular behavior.  Have you ever done something you knew you should not do, but you did it anyway, because it felt good?

  • Repetition, repetition, repetition is essential to strengthen new neural networks.  The neural networks that are most used (customary and usual) will be the ones that the brain calls upon for future choices and behavior.

  • When a new neural network is being formed, the old neural networks may create tension, in that the brain system is having difficulty returning to homeostasis.  The new neural network may not feel as good, at least in the beginning, as the old one.  Therefore, we can expect a period of increased agitation prior to the integration and use of the new neural network (Behaviorism Tutorial, 2005; Adams, 1997;. Andreason, 1985; Miller, 1972).

We have now discussed the integration of values, and theory; values affecting the interpretation by the practitioner and theory affecting the course of treatment for the youth and family; and the influences of an enriched environment and the elements of the brain which effect psychotherapy.

In this last section we will explore the concept of psychotherapy and its integration across the domains of neuroscience, enriched environment, values and theory.

 

Psychotherapy

Psychotherapy is a means of creating, adapting, modifying, changing, or restoring neural networks.  Research demonstrates that successful psychotherapy correlates with active changes in the brain.  As we have discussed, effective psychotherapy is aimed at changing the way a person thinks, behaves, feels, etc., and that these changes take place in the brain.  Therefore, we can see the connection between what we do as psychotherapists and what changes are taking place in the brain.  Neuroscience provides the psychotherapist with information about the brain, therefore strengthening our efforts towards successful treatment of the individual (Cozolino, 2002: Howard, 200; Dawson & Fisher, 1994; Patterson, 1980).

 

One of the most unique elements in the relationship between psychotherapy and neuroscience is that of the basic principles of neuroscience, as noted earlier, across various theoretical perspectives and models.  Neuroscience does not necessarily subscribe to one theoretical perspective, but rather provides the psychotherapist with additional information which can be incorporated with various theoretical models.  The possible exception is the use of a pure behavioral model, one that does not incorporate the areas of sensation, thinking, and awareness.  

 

The psychotherapy models currently used at YouthConnect include:

  • Cognitive Therapy (Beck, 1995).

  • Cognitive – Behavioral Therapy (Young, 1994; Linehan, 1993).

  • Psychodynamic Therapy (Patterson, 1980).

  • Psychoanalytic (Cozolino, 2003).

  • Rational Emotive Behavioral Therapy (Patterson, 1980).

  • Client – Centered Therapy  (Clarkin, 1996).

  • Interpersonal Therapy (Clarkin, 1996).

  • Schema Focus Therapy (Dattilio, 2005).

  • Gestalt Therapy (Patterson, 1980).

  • Family Systems Therapy (Sexton 2000; Bross, 1987).

  • Strategic Family Therapy (Bowen, 1978).

  • Structural Family Therapy (Minuchin & Fishmnan, 1981).

Listing of the current psychotherapy models at YouthConnect is done to illustrate that a variety of different theoretical orientations can be employed by the psychotherapist, incorporating the concepts of neuroscience.  There is no particular order or preference given in the above listing.  As we learned earlier, the theoretical choice of the psychotherapist should meet the needs of the individual, not the needs of the therapist.

 

Application of Neuroscientific Principles to Psychotherapy

In this next section, I will briefly discuss ways in which the psychotherapist can incorporate neuroscience into their daily practice.

  • Establish a safe and trusting relationship through Emotional Attunement or Therapeutic Attunement.  Provide an environment (office or other setting) in which the essential elements within an enriched environment are present, i.e., stimulation, education, and complexity; along with a sense of safety, belonging, acceptance (respect), consistency, and nurturance.

  • Provide, facilitate, or discuss learning new information and experiences across the areas of emotions, cognitions, sensations, and behavior.

  • Provide, facilitate, or discuss learning about dysfunctional and ineffective emotions, cognitions, sensations, and behaviors.

  • Facilitate mild to moderate levels of stress or emotional arousal.  This might be accomplished through mild confrontation or through positive emotional excitement by the individual.

  • Combining new learning with emotional and behavioral experiences.  Create repetitive positive experiences, designed to promote new neural networks.

  • Discuss the influences of cognitions, sensations, emotions, and behavior both within the old learned behaviors and the new learning.

  • And finally, develop a method of processing new experiences, so as to continue ongoing growth.

We have now discussed the integration of values, theory, enriched environments, neuroscience, and psychotherapy.  We have discussed The Integration of Treatments that Work.  We have seen that the integration of these elements can enhance the practice of psychotherapy and ultimately can improve the kinds and types of mental health treatment services we offer.  In the end, the greatest beneficiary of all our efforts is the individual receiving or seeking psychotherapy.

Closing Story

In this closing story, I am attempting to discuss the elements of neuroscience as they applied to this individual case.  Please be advised, while based on an authentic treatment case, I did not attempt to discuss every element of my treatment with this delightful young man.  Rather, I pulled from the case record those aspects I felt demonstrated the use of neuroscience and psychotherapy. 

 

“Tell me what makes you so angry? I asked Joseph.”  After he showed me the deep scars, I sat quietly in my chair, trying not to show my disgust for those who inflicted this torture upon that young child so many years ago.  When Joseph had returned to his seat I told him his scars made me sad.  I told him no child ever deserved to be beaten, and if I could turn back time, I would have protected him from ever being hurt.  Here, I was verbalizing Joseph’s feelings; bringing to awareness a long standing belief, while assuring him he was cared for, not judged, but appreciated and safe. 

 

As our treatment continued, I noted that Joseph had firmly entrenched beliefs, i.e., neural networks.  While his behavior never satisfied his emotional needs, it served him well in feeling safe from harm.  I remember one particular incident when Joseph became angry over some event.  He picked up a large living room chair and just when he was going to throw it at the staff; he turned and threw it at the wall, shattering it in many pieces. 

 

Learning of this event, I quickly found Joseph.  I briefly reviewed the incident and asked Joseph what he felt would be an appropriate consequence for his behavior.  Joseph immediately told me he should be locked in his room.  I smiled at Joseph, which made him give me a confused look.  I told him I was proud of him for not hurting the staff and that for the first time since he arrived at YouthConnect, he had released his anger away from people.  I told Joseph the best consequence for that day was to come have a soda with me.  Joseph was in shock.  He stood there in amazement.  Here, we see the beginning of new neural connections.  Something was changing in Joseph and it was extremely important to praise (strengthen) this change, and to bring this change to his awareness.  Secondly, my smile and the soda were emotional gestures.  I was accessing the deep emotional centers of the brain and reinforcing the new experience.

 

As therapy progressed with Joseph, we often discussed the emotions he could not express, especially those of his early childhood.  I worked on his dysfunctional beliefs by inserting new perspectives or choice points in his thinking.  I would then role play through situations using various facial expressions to show emotion, each time trying to find a better solution—one that made him feel emotionally secure and physically safe.  Here, I was helping Joseph by tapping into his early traumatic memories and subsequent dysfunctional beliefs.  By inserting a new perspective combined with his awareness and emotions, I was creating new neural networks related to his dysfunctional beliefs.  In a shaping manner we were gradually altering old neural networks. Next, I was helping him learn healthy emotional expression and emotionally effective problem solving through my physiological actions and emotional expressions.  Through role play and other methods, I was transferring this information/experience across the domains of cognition, sensation, and behavior. 

 

I also initiated a special behavior plan with Joseph, one where he could earn rewards for good behavior.  However, each time he acted out in a negative manner, Joseph would have to either write or answer a series of questions.  These questions repeated themselves in various ways.  Here, I was using repetition to reinforce the ineffectiveness of his homeostatic behavior, while repetitiously reinforcing new and better ways of handling his needs, i.e., new neural networks.  The behavior plan also supported my office work through the enriched environment.  I would ask him to think about the event, what he was feeling at the time, what he was actually trying to accomplish, if his behavior made him feel emotionally safe, and then describe better ways of handling the conflict or problem.  His resolutions to the conflicts needed to address the needs of his emotions and the environment.  Now all the staff and Joseph were working in the same direction for the same end result.  Here, I am bringing to awareness old neural networks and having Joseph describe new neural networks.  Repetition is the key to retention.  By including the environment, the residential & educational staff, I am addressing the adaptive response, which means to change behavior in response to one’s environment.  From the neuroscience perspective the social environment has a profound effect on changing behaviors.  The special treatment plan develops a unified methodology by which all persons within his environment respond in similar ways to his behavior.  At this point positive reinforcement becomes a product of the environment, thereby strengthening the developing new neural networks.  As new experiences occurred we would visit about them, each time trying to incorporate them into his array of neural networks.   

 

After almost 18 months Joseph successfully completed his treatment at YouthConnect.  He returned to live with an Uncle.

 

Three years after leaving YouthConnect, I continued to think about Joseph and often wondered what became of him—some youth who have come my way in the past twenty years are just too wonderful to forget.  Returning to my office after the Christmas holiday this past year, I received a brief hand written card.  It was from Joseph and his uncle.  It read: 

“Hey Martin this is Joseph, I’m doing good—haven’t gotten into any trouble—my Uncle says I’m doing really good.”  “Hi Martin” writes the Uncle.  Joseph continued, “I’m graduating from mechanics school, I’m doing good, I’m doing real good.  I’m glad you’re still there.  Thanks, Joseph”

 

 

 

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