In a psychological experiment…, Bruner and Postman asked experimental subjects to identify on short and controlled exposure, a series of playing cards. Many of the cards were normal, but some were made anomalous, e.g., a red six of spades and a black four of hearts. Each experimental run was constituted by the display of a single card to a single subject in a series of gradually increased exposures. After each exposure the subject was asked what he had seen, and the run was terminated by two successive correct identifications .
Even on the shortest exposure many subjects identified most of the cards, and after a small increase all the subjects identified them all. For the normal cards these identifications were usually correct, but the anomalous cards were almost always identified, without apparent hesitation or puzzlement, as normal. The black four of hearts might, for example, be identified as the four of either spades or hearts. without any awareness of trouble, it was immediately fitted to one of the conceptual categories prepared by prior experience. One would not even like to say that the subjects had seen something different from what they identified. With a further increase of exposure to the anomalous cards, subjects did begin to hesitate and to display awareness of anomaly. Exposed, for example, to the red six of spades, some would say: that’s the six of spades, but there’s something wrong with it – the black has a red border. Further increase of exposure resulted in still more hesitation and confusion until finally, and sometimes quite suddenly, most subjects would produce the correct identification without hesitation. Moreover, after doing this with two or three anomalous cards, they would have little further difficulty with the others. A few subjects, however, were never able to make the requisite adjustment of their categories. Even at forty times the average exposure required to recognize normal cards for what they were, more than 10 per cent of the anomalous cards were not correctly identified. And the subjects who then failed often experienced acute personal distress. One of them exclaimed: “I can’t make the suit out, whatever it is. It didn’t look like a card that time. I don’t know what color it is now or whether it is a spade or heart. I am not even sure now what a spade looks like. My God!” In the next section we shall occasionally see scientist behaving this way too.
As reported by Thomas Kuhn – The History of Scientific Revolution
INTRODUCTION
One can hardly help noticing the anomalies in the ‘mental health’ system. Ever since Thomas Szasz wrote the definitive book on the Myth of Mental Illness, doctors, pharmaceutical companies and other fellow travelers have been scrambling to hold a paradigm in crisis together. Yet the anomalies continue and the ‘expert’ medical model leaders are not even sure what a ‘spade’ looks like.
“The most dangerous of all lies is the lie everyone believes to be a model truth. It is the fruitful mother of all other popular errors and delusions. It is a hydra-headed tree of unreason with a thousand roots. The lie that even intelligent persons accept as fact – the lie that has been inculcated in a little child at its mother’s knee is more dangerous to contend against than a creeping pestilence!” Arthur Desmond
“Over the past twenty years, numerous reports have chronicled the lack of appropriate services to meet the needs of children and adolescents with serious emotional disturbances. These previous studies report that children in need of mental health care often do not receive it or receive care that is inappropriate or inadequate.”[Koyanagi & Gaines, All Systems Failure – 1993]
- The Joint Commission on the Mental Health of Children [1969],
- The President’s Commission on Mental Health [1978],
- The Office of Technology Assessment [1986],
- The Institute of Medicine [1989], and
- The House Select Committee on Children, Youth and Families [1990]
“all concur that there are too few resources and that too many of the services that do exist are uncoordinated, inefficient and ultimately ineffective.” [Koyanagi & Gaines, 1993]
We could add to this list, of course, but will only note the President’s Freedom Commission Report of 2003.
This report provides a blueprint for transforming the delivery of mental health services based on changes in values, skills, attitudes, the incorporation of demonstrably effective treatments, and a shifting of services from traditional inpatient and residential treatment to home and community based services and supports.
In order to achieve this transformation, the Commission recognizes the urgent need to address workforce training issues.
Achieving the Promise, Transforming Mental Health Care in America – 2003
Let us look at the CODE WORDS that are used to avoid calling a spade a spade.
- changes in values, skills and attitudes – nominally these words mean the beliefs that people hold – if changes must occur, they are from what to what? Could it be that the Commission is suggesting that the belief in the metaphor of mental illness is no longer valid?
- incorporation of demonstrably effective treatments – clearly the implication is that the system has no demonstrably effective treatments – medication and incarceration are not only ineffective, they are costly. While legitimate medicine has a protocol for effective treatment, psychiatry does not. It simply provides a pejorative label, toxic medication and incarceration – and then bemoans the fact that ‘patients’ are resistant and fail to comply. Continued failures are thus placed on the clients, not on the system.
- shifting of services – not just away from incarceration, but to something that provides substantive outcome.
It is all there. It is not about enough money, access, fragmentation, and the like; it is about the failure of a paradigm and the inability to ‘see’ the solution. This is true despite the fact that the replacement paradigm has already been identified. The problem is that the ‘experts’ control the system – and they cannot even perceive what is happening. However, it is time to change the model. We can no longer experiment with the lives of people with severe and persistent problems in living, we must seek solutions, if for no other reason than the distorted thoughts of those we serve become the parental teachers of distorted thoughts to their children. A cycle which has already grown to exponential proportions.
“The fact that an opinion has been widely held is no evidence that it is not utterly absurd; indeed, in view of the silliness of the majority of mankind, a widespread belief is more often likely to be foolish than sensible.”
Bertrand Russell
THE NEW PARADIGM
Social Learning Theory
The present Social Learning Theory perspective is that learning is a result of acquiring or failing to acquire those behavior patterns which society expects. The theory focuses on what and how people learn from one another – significantly, what messages [information] is sent through verbal and nonverbal behavior and how this information is interpreted by the learner. Social cognitive theory’s perspective is on how both environment [external] and cognitive [internal] factors interact to influence human learning and behavior.
The impact of this on the present system is that personal problems in living are caused by what and how the child has learned. Learning creates a body of knowledge [a theory of meaning] and resulting emotional content that is used to perceive, understand and control the world. People who have severe problems in living in the world have a distorted ‘inner logic’ that can be changed if they choose to change it. Such change is always self-change, but it is often helpful to have a psychological mirror to help overcome sustaining bias.
Social Competence Model
Social competence can best be conceptualized as consisting of several interacting components that operate on one another to produce a kind of self-perpetuating cycle, elements of which may be operating at a very automatic stereotyped level. Social competence is a construct that summarizes this entire chain of events.
The components of the model include:
Component 1.
Overt behaviors – refer to directly observable behaviors, or what the individual does both verbally and nonverbally in an interpersonal context.
Indicators
a) Frequency and quality of social interactions. Specifically, the amount of time spent alone, observing peers, and interacting with peers and adults and the interactions are also coded as involving cooperative, affectionate, noncompliant, derogatory, or attacking behavior. Behavioral ratings are significantly related to Sociometric ratings.
(1) their spatial proximity to other children;
(2) the amount of physical contact with others;
(3) the frequency of aggressive episodes; and
(4) the children’s location in relation to the rest of the group.
b) Nonverbal behaviors (such as facial expressions, gestures, gaze, spatial behavior, nonverbal aspects of speech, bodily contact and appearance), as well as verbal acts (e.g., instructions, questions, comments, informal chatting, performance utterances, social routines, and the expression of emotional states, attitudes, and latent messages).
Component 2.
Covert behaviors (cognitive processes) – refer to the thoughts and images (self-statements, expectancies, appraisals, etc.) that precede, accompany, and follow overt behaviors, as well as the thinking skills and styles of information processing that the individual employs in social situations.
Indicators
a) Internal dialogue that accompanies behavior and reflects the individual’s thoughts and feelings about the situation and/or him or herself
• negative self-referent ideation – anxious, self deprecating thoughts particularly about performance tasks.
• taking an examination
• responding to social challenges
• tolerating pain
• performing in athletic competition
• failure to adopt a problem solving set.
• explanatory constructs
b) Expectancies with which the individual approaches the situation and his or her appraisal of situational or personal outcomes, as well as the amount and nature of the social information that the individual possesses about the situation. Expectancies represent the individual’s personal prediction (whether from previous experience or the affective meaning that the situation holds for him or her) about what will happen in a given social situation
Social outcomes represent the wide range of events to which an individual may have some cognitive or behavioral reaction. These may include tangible results (e.g., another person’s verbal or nonverbal response), as well as internal events (such as physiological reactions, mood states, etc.). It is not the social outcome per se that is important, but the individual’s appraisal of this outcome.
The model suggests that expectancies and appraisals of social outcomes interact in complex ways with one another and with social behavior.
c) The individual’s ability to create and maintain positive and supportive social environments. Social competence must include not only the individual’s cognitive or behavioral response to a social situation, but his or her active engendering of a changing social environment.
d) Social cognition – the intuitive or logical representation of others, that is, how the individual characterizes others and makes inferences about their covert inner psychological experience
e) Social problem solving thinking
(1) sensitivity to interpersonal problem situations;
(2) generation of alternative solutions to a problem situation;
(3) means-ends thinking (the ability to plan, step-by-step, toward attainment of an intra- or interpersonal goal);
(4) the tendency to weigh consequences in terms of their probable effectiveness and social acceptability; and
(5) the ability to perceive cause-and-effect relations in interpersonal events.
f) Role-taking skills – the ability to take the perspective of another person
(1) person perception (the characterization of what an individual is like),
(2) empathy (the ability to perceive and feel another’s affective state), and
(3) referential communication, (the ability to effectively communicate with another person).
g) Information processing styles – Chunking of information – the way information is chunked has important effects on the individual’s proficiency in the performance of an act.
(1) level of organization and the use of inferences in their descriptions of others.
(2) It is not the ability to chunk per se that is important for effective behavior, but the fit between the task and the information- processing strategy employed.
h) Automaticity – the degree to which a behavior will be enacted ‘mindlessly’ or without intentional cognitive activity.
(1) conscious, controlled process that produces slow but accurate performance,
(2) automatic process that allows the rapid execution of highly stereotyped response sequences without the necessity of conscious control
(3) individual’s ability, not only to recognize the information-processing demands of the situation, but also to adjust appropriately between automatic and controlled modes of operating.
Component 3.
Meaning system (cognitive structures) – refers in the present theory of meaning which leads to an inner logic that provides motivation and direction for both thought and behavior
(1) self schema includes thoughts about self in specific and general
domains – the process of inner dialogue is constantly comparing
self to others and trying to place attribution on the difference.
(2) other schema is intertwined with self schema and includes
projections about what others think of self – the comparisons
may enhance or diminish others in comparison to self or vice
versus.
(3) future prospects in general and specific social settings – the nature and number of an individual’s concerns about social situations should be predictive of the magnitude of anxiety in social situations, and thus the potential for distortion of social information and/or interference with. socially competent behavior.
The nature of an individual’s concerns should also be predictive of the generality of social anxiety across situations (parties, informal small gatherings, interviews, dates, casual conversations, etc.) and the particular situations in which it might occur.
Component 4
Affective system
(1) The accurate appraisal and expression of emotion in self and
others
(a) identify and label emotions: must be able to understand feelings and use words to describe them.
(b) must be able to identify and identify explanatory style
(c) must be able to express emotions effectively [the meaning of communication is the response it evokes]
(2) The adaptive regulation of emotions in self and others
(a) emotional control: must be able to mediate impulsive responses to strong emotions
(3) The utilization of emotions to plan, create and motivate action.
(a) must be able to place an affirmative value on self; either because of demonstrated competence and other response, realistic acceptance of self as becoming, or acceptance of the self as you are
(b) must be able to use emotional content to motivate to reach personal goals
Cognitive Behavior Management
This is a catchall term which brings together the:
Fundamental Assumption of Behavior:
People are the sum total of their thoughts and cannot behave differently than they think.
Theory of Change:
People will only change when they think differently.
Process of Change:
Thought –→ Emotions -→ Behavior
Essentially, it is necessary to help the client change the meaning of disturbing event in such a manner as to help him or her ‘feel’ differently about the experience, which will in its turn influence the way in which s/he behaves. The easiest method is to change the thought and Cognitive Process Correction is a five-step [awareness, attendance, analysis, alternatives, and adaptation] method to do this. Some thoughts, however, are intuitions, notions, hunches, gut feelings – we call these quirks – which are ineffable and must be approached through imagery or unanswerable questions in order to help the client bring them into some form of consciousness.
While there are some indications that change can occur through a change in the memory coding of emotional content, this has yet to be evidence based – partially because of the unwillingness of ‘experts’ to develop and evaluate useful tests. When imagery and unanswerable questions are used to get at quirks and metaphors, this is a deeper process and for this the term Cognitive Restructuring is reserved.
There are also many rituals processes [Life Space Crisis Intervention, Psychological First Aid, Good Choice/Bad Choice etc] which are helpful in structuring the role of both the teacher and learner for change.
PREVENTION
Greenberg, etal have provided a report that identifies critical issues and themes in prevention research with school-age children and families through review and summary of the current state of knowledge on the effectiveness of preventive interventions intended to reduce the risk or effects of psychological disorders in school-age children. This section is a liberal adaptation of the initial section of that report.
Prevention has moved into the forefront and become a priority for many federal agencies in terms of policy, practice, and research. This shift began with a report by the National Advisory Mental Health Council (1990) and is reflected in the combined work of the National Institute of Mental Health (NIMH, 1993) and the Institute of Medicine (IOM, 1994). More recently, the National Advisory Mental Health Council Workgroup on Mental Disorders Prevention Research (NIMH, 1998) outlined a number of priorities and recommendations for research initiatives in prevention science.
Public health models have long based their interventions on reducing the risk factors for disease or disorder as well as promoting processes that buffer or protect against risk. This is another of those anomalies, since one cannot prevent a disease that one cannot identify nor indicate how it is contracted.
Risk factors and their operation During the past decades, a number of risk factors have been identified that place children at increased risk for psychological problems. Empirically derived, generic risk factors have been grouped into the following seven [07] individual and environmental domains:
1. Constitutional handicaps: perinatal complications, neurochemical imbalance, organic handicaps, and sensory disabilities;
2. Skill development delays: low intelligence, social incompetence, attentional deficits, reading disabilities, and poor work skills and habits;
3. Emotional difficulties: apathy or emotional blunting, emotional immaturity, low self-esteem, and emotional disregulation;
4. Family circumstances: low social class, mental illness in the family, large family size, child abuse, stressful life events, family disorganization, communication deviance, family conflict, and poor bonding to parents;
5. Interpersonal problems: peer rejection, alienation, and isolation;
6. School problems: scholastic demoralization and school failure;
7. Ecological risks: neighborhood disorganization, extreme poverty, racial injustice, and unemployment.
The complexity of developmental pathways is clear from research relating risk factors to disorders. There appears to be a non-linear relationship between risk factors and outcomes. Although one or two risk factors may show little prediction to poor outcomes, there are rapidly increasing rates of disorders with additional risk factors. However, not all children who experience such contexts develop adjustment problems, and no one factor alone accounts for children’s adjustment problems. Just why this is true is not accounted for in the report, but can be found in the pattern formation and decision making of the individual which is built over time from random data collection [i.e., not all stimuli are received equally by the individual in proximity nor are they necessarily interpreted the same. Thus, as the child creates a theory of meaning about the world and his/her place in it, the patterns formed and the judgements made about those patterns differ and create either a balanced and rational or a distorted and irrational ‘inner logic’ which determine what the individual will even consider stressful, let alone how they will act in stressful situations.
Given the above findings, it is apparent that many developmental risk factors are not disorder-specific, but may relate instead to a variety of maladaptive thoughts that are supported or disputed by the ecosystem surrounding the child. Recent findings in behavioral epidemiology indicate that psychological problems, social problems, and health-risk behaviors often co-occur as an organized pattern of adolescent risk behaviors. Thus, because risk factors may predict multiple outcomes and there is great overlap among problem behaviors, prevention efforts that focus on risk reduction of interacting risk factors may have direct effects on diverse outcomes.
Protective factors and their operation
Protective factors are variables that reduce the likelihood of maladaptive outcomes under conditions of risk. Although less is known about protective factors and their operation, at least three [03] broad domains of protective factors have been identified.
• The first domain includes characteristics of the individual such as cognitive skills, social-cognitive skills, temperamental characteristics, and social skills.
• The quality of the child’s interactions with the environment comprise the second domain. These interactions include secure attachments to parents and attachments to peers or other adults who engage in positive health behaviors and have prosocial values.
• A third protective domain involves aspects of the mesosystem and exosystem, such as school-home relations, quality schools, and regulatory activities. Similar to risk factors, some protective factors may be more malleable and thus, more effective targets for prevention.
By specifying links between protective factors, positive outcomes, and reduced problem behaviors, prevention researchers may more successfully identify relevant targets for intervention. However, the development of rational and balanced thoughts concerning what is happening around you substantially buffers the potential for dysfunction as well as disrupting the mediational chain by which risk leads to disorder. By enhancing the balanced and rational thinking of the child managers, one reduces the negative messages and nonconscious reinforcements that may contribute to the disorder itself. In fact, to attain any of the protective factors, it is required that the child develop at least a modicum of balanced and rational thought about self and others.
The specification of intervention goals is an important component of preventive-intervention research and practice. This requires both an understanding of risk and protective factors that contribute to outcomes, and also the identification of competencies that are presumed mediators or goals of the intervention. Although these goals may include the prevention of difficulties (e.g., absence of psychological distortion, abstention from substance use), they also involve the promotion of sound developmental outcomes. Further, the prevention of deleterious outcomes involves the enhancement of competency mediators (e.g., effective social problem-solving as a mediator of reductions in delinquency).
Definition of Levels
The three [03] defined forms of preventive intervention are:
• Universal interventions target the general public or a whole population group that has not been identified on the basis of individual risk. Exemplars include prenatal care, childhood immunization, and school-based competence enhancement programs. Because universal programs are positive, proactive, and provided independent of risk status, their potential for stigmatizing participants is minimized and they may be more readily accepted and adopted.
The universal prevention aspects are directed at creating a prosocial environment in home and school which will send consistent balanced and rational messages to students in elementary schools about self and others. This will require the training of adult child managers in the ability to listen effectively for distorted thinking and to provide on a regular and consistent basis prosocial messages.
• Selective interventions target individuals or a subgroups (based on biological or social risk factors) whose risk of developing psychological disorders is significantly higher than average. Examples of selective intervention programs include: home visitation and infant day care for low-birth weight children, preschool programs for all children from poor neighborhoods, and support groups for children who have suffered losses/traumas.
When students with exceptionalities or other identified risk factors are grouped, selective cognitive behavior management interventions can be used within schools for the purpose of helping these children address difference and create more balanced and rational interpretations of themselves and others.
• Indicated interventions target individuals who are identified as having signs or symptoms or biological markers related to inner logic distortions, but who do not yet meet eligibility criteria. Providing social learning family interventions [social skills &/or parent-child interaction training] for children who have early behavioral problems are examples of indicated interventions.
School is a natural and valued setting where all children convene. It is also a professional context, which makes it an ideal forum for all three levels of intervention. A fourth level – remedial intervention – may require greater clinical skill, but still can be provided within a school context.
STAGES OF CHANGE: The Temporal Dimension
This is a key organizing construct of the suggested model, in part, because it represents a temporal dimension. Change implies phenomena occurring over time. However, this has largely been ignored by alternative theories of change. Behavior change is often construed as an event instead of as a process involving progress through a series of stages. Were it not for the stigma that the profession has given to problems in living and the addictiveness of certain behaviors, most people would readily accept help when they begin to feel the painful consequences of their thought, emotion and behavior. It is important in the helping process to understand where the client is in the process of change and to respond effectively to those thoughts.
Pre-contemplation is the stage in which people are not intending to take action in the foreseeable future. People may be in this stage because they are uninformed or under-informed about the consequences of their behavior or because their distortion of self/other schema interferes. Typically other people are disturbed by the individual’s behavior and may be vocal in their concern, pressuring the individual to take action. This, in itself, can set up normal resistance. In this stage, people with strong behavior problems are almost deaf to the voiced distress of others. It would be easy to call this ‘denial’, but much more accurate would be to describe Pre-contemplation as a state when a person is ‘uninformed’ in the sense that no personally convincing reason for change has been perceived as of yet. On the other hand they may have already tried get help a number of times and become demoralized about their ability to change given the failure of our systems and therefore, believe that they are unable to change.
Either group will tend to avoid talking or thinking about their high risk behaviors. Professionals, often characterize people in this stage as resistant, unmotivated or not appropriate for intervention programs. The fact is traditional programs are often not designed for such individuals and are not matched to their needs. People in this stage are often either gaining some benefit from their behavior and therefore resistant or are learned helpless. The appropriate role of the counselor with this population is brief and with the limited focus on reduction of harm, helping the individual examine any ‘downside’ consequences of their behavior and to explore ways of diminishing that ‘downside’. The Motivational Interview is the option of choice for intervention, since it empowers the client to focus on contemplation, but makes no demands for action. In this stage a person may recognize his/her distress, but continue to feel the benefits of his/her behavior.
Contemplation is the stage in which a person is intending to seek help in the next six months. They are more aware of the pros of changing but are also acutely aware of the cons. What frequently jars people into the next stage, that of contemplating the possibility of change, is convincing, personal and timely information about the consequences of their behavior – not coercion or even advice. People not yet contemplating change are not particularly open to advice, much less confrontation. However, learning more about what is problematic for the individual specifically, being afforded data which is very relevant and convincing, very often forces the person to at least consider the option of modifying his/her behavior, even in the face of a belief that the difficulties are caused by other people.
It is important to understand that what makes the difference is not generic information, but rather information specifically catered to the individual. The most powerful information is that which is intimately tied to your own behavior, runs contrary to established expectancies and has intimate ramifications for some or many aspects of your life. The secondary benefits of many problems in living, even severe and persistent problems may be hard to give up. Peers may be especially helpful in identifying such moments and simply by reiterating a personal statement made by a friend, may support the desire for change.
One of the reasons for accepting a person in a helping relationships even though s/he acknowledges no desire for help with the specified behavior, is that professionals are then afforded the opportunity to provide casual information which serves to increase the desirability of change. It is very important not to miss out on the opportunity to use this information to shift gears. It is very easy to miss out on a brief window of opportunity, a moment in which the client is saying to him/herself, “I’ve had it! No more of this! I’m doing something about this right now!” People are very vulnerable to old influences at this time, both external pressures and convincing data from within. It is imperative to tip the scale of ambivalence in order to move from contemplation to determination and action. Teachers, guidance counselors and parents must be focused on the motivations of the child and not their own desires to persuade if they are to be able to opportunistically use these motivational moments.
The balance between the costs and benefits of change can produce profound ambivalence that can keep people stuck in this stage for long periods of time. Professionals often characterize this phenomenon as chronic contemplation or behavioral procrastination. These people are also not ready for traditional action oriented programs. They, may, however, be able to tolerate brief motivational enhancement counseling or solutions focused counseling regimen of from four to twelve sessions.
Preparation is the stage in which people are intending to take action in the immediate future, usually measured as the next month. Many people have fleeting moments of determination that swiftly vanish when all of the horrors involved come back into awareness. Determination will lead directly into action if the individual has thoroughly considered all aspects of the problem realistically, if s/he has begun to modify expectancies and has established a goal that is conducive to individual needs and values, and particularly, if s/he has established a trusting relationship with a helping adult. Such people have typically taken some significant action in the past year. These individuals have a plan of action, such as joining a social education class, consulting a counselor, talking to their physician, buying a self-help book or relying on a self-change approach. This is where a counselor can be extremely helpful in identifying new strategies to achieve the change that the person already is seeking, and if those strategies can be tied to the individual’s personal goals and are provided in a manner that respects the autonomy of the individual to make choices, the chances for success are substantially increased.
Action is the stage in which people have made specific overt modifications in their life-styles within the past six months. Since action is observable, behavior change often has been equated with action. But in the Social Competence Model, Action is only one of five stages. Not all modifications of behavior count as action in this model. People must attain a criterion that scientists and professionals agree is sufficient to reduce risks and provides substantive improvement in their quality of life. The Action stage is also the stage where vigilance against relapse is critical. To some extend relapse is to be expected. Change is difficult and a ‘two steps forward, one step back’ process is not unusual. If such relapses impact the professional with a lack of confidence, this can be extremely detrimental to the continued progress of the client – since the interpersonal expectancy effects produced by the professional will signal negative expectations.
Maintenance is another stage in which people are working to prevent relapse but they do not apply change processes as frequently as do people in action. They may have learned the skill of ‘mindfulness’, but they are no longer filling out a Thought Journal. They are less tempted to relapse and increasingly more confident that they can continue their change. The learned skills of cognitive behavior management strategies continue to be useful and a fifteen minute ‘check’ of the ‘inner logic’ and mindfulness once a month fading into once a quarter then once a year, allows for a booster to morale and additional resources, if necessary.
Two different concepts are employed in the temporal dimension of change. Before the target behavior change occurs, the temporal dimension is conceptualized in terms of behavioral intention. After the behavior change has occurred, the temporal dimension is conceptualized in terms of duration of behavior.
Regression occurs when individuals revert to an earlier stage of change. Relapse is one form of regression, involving regression from Action or Maintenance to an earlier stage. However, people can regress from any stage to an earlier stage. The bad news is that relapse tends to be the rule when action is taken for most behavior problems. The vast majority of people regress to Contemplating or Preparation. Helping the client to understand the biological, psychological and social factors [e.g., immediate gratification, habituation, creative construction of reality, state learned bias, the attraction to that which is prohibited, and reactance] that pertain can be helpful to them in negotiating potential regressive behavior. The individual should always have three aspects taken from the helping process to avoid future regression, even in stressful situations: 1) specific skills that can be used in times of potential regress, 2) a mindfulness which allows them to identify points in which to use the skills, and 3) a rehearsal [future pacing] of plans to identify stressful situations and use skills. Finally, the person should always have a specific contact person that they can call on in the future for support.
These five steps are articulated here for the person who has had chronic issues with problems in living, and while the stages are clearly identifiable in all cases, they are considerably collapsed by factors such as youth, early identification of potential problems, consistent monitoring by family and school, etc.
SYSTEM CONCEPT CHANGES
Any replacement paradigm requires change in a plethora of interrelated concepts and this transformation is no different. While each of these conceptual changes is important, this is not an inclusive list.
• Needs to Goals: for too long we have allowed ‘experts’ to decide what the client needs. Goals are personal need statements. People with severe and persistent problems in living often have problems with goals, articulating only avoidance and not achievement. Therefore the creation of a vision statement that covers goal expectations in all life domains becomes a ‘therapeutic’ process that reorients the person to achievement.
• Deficit to competence: professional must assume that the person, no matter how distorted in their thinking, is capable of making appropriate decisions about their own lives. This is diametrically opposed to a pathology position. The professional expectation is that the counselor will be able to help the individual client articulate their own personal goals and create plans to reach those goals.
• All human services are experimental: professionals are not experts in what they do, although they do have expertise. Human behavior is such that each individual is unique even though common qualities exist. Because of this and the emphasis on client choice [always contrasted with client goals], the experimental qualities of the intervention, with this person at this time by these professionals, requires client protections [See the Belmont Report].
• Community Interaction: People do not learn how to perform in valued setting by being removed from them. Children, in particular, belong in their own school, in their own neighborhood, with their own friends. While certain economies of scale do pertain, these cannot be the only consideration for placement.
• Thought -> emotion -> behavior: the fundamental assumption is that it is the way the person thinks that is the driving force behind what s/he feels and how s/he acts.
• Victim to hero [personal responsibility]: the placement of rational hope and optimism in the process of self change is the key to helping the person take personal responsibility for the change. No longer can we say a child ‘can’t’ sit still – simply that s/he doesn’t sit still. Now we have a responsibility to teach the child ‘sitting’.
• Discipline is a noun, not a verb: we do not discipline a child, we teach a child discipline. We don’t ‘make’ the child sit still, we teach the child how to sit still. Incidentally, if you don’t believe that the child can sit still – recuse yourself from any direct helping for your self-fulfilling prophecies will do more harm than good.
• Change is a process – know where the client is in the process: parents usually learn rather quickly that, except for the very young child and in specific circumstances, you can’t make anyone do anything. Those who don’t learn this lesson are often founded for abuse. You can, however, influence how the person makes his/her choices. Knowing where the person is in the choice process can be very useful in helping you frame their next decision.
• The consequence of inappropriate behavior must be renewed instruction: If a child makes a mistake on a math problem, we must find a way to re-teach the math. If a child makes a social mistake, we must re-teach the appropriate behaviors.
• That which gets rewarded gets done: Human beings are extraordinary in ability to reinforce behavior and absolute dunces in knowing what they are reinforcing. Teachers, clinicians and parents often reinforce the very behaviors [overt and covert] that they would prefer not to have occur. Understanding this, a concerted effort to a) teach the fundamentals of reinforcement and b) become mindful of our own thoughts, emotions and actions may help to support more appropriate growth and behavior.
• Language and Vocabulary: we must create a whole new language and vocabulary for use in dealing with children and families with problems in living. Medical model language is inappropriate and eroding. It takes away personal responsibility and suggests helplessness, hopelessness and worthlessness. Even reasonable terms such as ‘therapeutic’ have gained a connotation that is potentially harmful.
• Outcome orientation: partially because we have no evidence of outcome, we do not expect any – except meeting the ‘dead man test’. Because we now know that the client’s expectations [goals] in all domains of life are substantive issues to be addressed, we must begin to collect outcome [not just custodial output] data formatively, summatively and cumulatively.
• Learning organization – we must use the feedback from outcome to create continuous quality improvement. No longer can we just ‘increase the cocktail’, now we must produce evidence that what we are doing has a substantive effect on the lives of the people we serve. We might not know how to do that effectively for everyone now, but we can learn.
SUMMARY
We started with a citation from The History of Scientific Revolution by Thomas Kuhn. The citation focused on the difficult of perceiving the change in paradigm, particularly for those embedded firmly in the old paradigm. In science, paradigm crisis and paradigm change leave some scientists appearing to history to be ‘stupid’, for we see them from the new perspective. The helping paradigm has been contested throughout history and in crisis for over fifty years. Unfortunately, supporters of the defect model have entrenched themselves in the regulatory and economic fabric of the system. Change may not ever occur in the mental health or substance abuse systems. It may need to change through psychological counseling and related services in the schools. But the paradox of present efforts cannot be more apparent. The efforts by the federal government in education and in mental health/substance abuse are pointed towards integration and enhanced referral. Yet, if we accept the transformational needs as correct, this would be the worst of all worlds, for it would bring the inadequacies of the defect model directly into the schools. More access is more detriment to children and their families. Educational personal have struggled with the ‘common knowledge’ of ‘mental illness’ and their own more pragmatic behavior approaches. They might more easily insert covert behavior into their paradigm and be able to implement the shift more easily. The purging of psychiatrist from the mental health system will be an enormous task, particularly since most psychiatrists would become unemployed and unemployable without the public mental health system and they would have the powerful resources of the pharmaceutical companies to fight their campaign for the status quo.
This paper is also not suggesting more responsibilities for educations beyond what is already applicable to IDEA. The parameters of psychological counseling and related services including the requirement for “parent counseling and training” [See 34 C.F.R. Sec.300.24(b)(7)] allows for the complete access to provide what is needed. Establishment of the school as the place for ‘social education’, with emphasis on prevention in the only natural [valued] professional environment through the use of a social learning model makes eminent sense.