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Treatment of Mental Illness and Antisocial Behavior - the Evolution of a Disaster and a New Paradigm for a Way Out by Edwin L. Young, PhD II. http:// UNDER CONSTRUCTION 4-3 revision moving B. Objectification of Man http:// UNDER CONSTRUCTION 4-3 revision moving B. The Evolution of Mental Health Treatment and the Objectification of Man A Historical, Systems-Structures-Processes Approach Objectification of Man PAGE 32 CAN THERE BE A PARADIGM SHIFT IN PSYCHOTHERAPY 1 Designing Programs that are Reoriented away from a medical 'Illness and Cure Model' and from a justice 'Crime and Punishment Model' and toward a 'Maturity and Structural Change Model'. Thesis: the thesis of the proposal is that all of the various traditional forms of treatment of psychological problems have had goals that have fallen far short of the mark and that the Natural Systems approach can overcome these deficiencies. The thesis has six parts. First, typically these unmet goals include treatment meant to result in enduring improvement with respect to the following problems for which people enter treatment, or are referred to treatment: 1. Destructiveness to self and other 2. Illegal or Behaviors harmful to society 3. Psychosis 4. Disorders that are supposedly caused by brain chemistry imbalance 5. Emotional distress 6. Psychologically related health problems 7. Behavioral and communication ineffectiveness 8. Relationship dysfunctions 9. Immaturity 10. Deficiencies in ego mastery or coping skills Second, there are alternatives to these traditional approaches to these problems that are based on a revised perspective on humans, society, and the relations between humans and their social environment. Third, as a result of this revised perspective, a wide range of both old and new concepts and techniques can be integrated in new configurations of modes of delivering treatment that are especially designed to address goals for all of the problems listed above. Fourth, this proposal presents a new method of analysis of the full range of causal factors of these problems from this holistic perspective. dredyoung Page 1 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc Fifth, use of this method of analysis can yield a wide range of new systems and devices to be used in designing these news modes of treatment. Sixth, quantitative performance indicators will demonstrate the increased and enduring effectiveness of this new approach. This new approach is called the Natural Systems approach. ________________________________________ I. What Good Is Psychotherapy? A. My Personal Experience as a Client and as a Therapist in Private Practice Being seventy-four years old and a retired psychotherapist, if I were suddenly transformed into a fifty-year old me, would I want to practice psychotherapy again? Yes! I liked it. I enjoyed doing it and I enjoyed my clients. I liked listening. I found my clients fascinating, all of them. Obnoxious or charming, brilliant or stupid, richly articulate or practically mute, powerful or nobodies, accommodating or intransigent, deceptive, manipulative, transparent, rude, babbling crazies, planet X psychotics, whatever, each in their own way were intriguing. Clients with all kinds of problems from amnesiacs to steely cold serial killers; from sycophantic homosexuals to brutal white Aryan nation militants; from prostitutes to sex addicted priests; from multiple personalities to compulsive personalities; from anxiety and panic disorders to bullies; from sarcastic feminists to hard core misogynists, whatever, they were all fascinating and each an intriguing and compelling puzzle. For me it was a matter of "What"s not to like?" because it was virtually a first rate "personality" museum, the kind you could stay mesmerized in all day. Moreover, my heart went out to all, truly all, of them. So, why do I knock it? Many of you have heard the put-downs of psychotherapy – head shrinking - more than you cared to, I am sure! So now let me say what "I" feel is good about it. First, I, myself, was a client for many years and loved going to my therapy sessions, gut wrenching though many of them were. I started "shrinking" at age nineteen when I was a sophomore at UT and went off and on for probably a cumulative of nearly twenty years from start to when it ended at around age fifty-one. I always felt like it was helping even though I maintained the same self-defeating patterns and miserable symptoms up until around age forty-five. I usually felt good after a session. I gained incredible insights and had heart-wrenching catharses during almost all sessions. I felt I learned a tremendous amount about "me"; about why I was the way I was; and about what made me "tick". All of this wonderful stuff happened and nevertheless I maintained the same self-defeating patterns and most of the miserable symptoms. Much too late I learned that there is placebo affect in psychotherapy as well as with medications. In the old days, we called it the "Mask of Sanity" and both clients and therapists were equally likely to be taken in by it. I did not realize it until much later but there was a "disconnect", a gap larger than from here to the moon, between the wonderful stuff in therapy and perpetual negative stuff in daily dredyoung Page 2 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc life. It was not until many years later that I saw the reality and the therapy session juxtaposed for a reality check, for a realistic comparison. However, again, I would, if I were back in my younger days, do it again because it was kind of like my anchor during those tormented years. After years of working with my own clients, I eventually concluded that the comfort and the small benefits supplied by the sessions did not offset the lack of change in behavior or symptoms. Consequently, early on, I began to try things, to branch out and experiment sometimes with modest additions and sometimes with innovations that some might consider bizarre. I studied, in situ, the living process going on in my clients and between my clients and me. I also used questionnaires to track, quantitatively, the effects of therapy for sometimes up to five years after termination of therapy. Sometimes conventional therapy paid off with respect to some of their problems and sometimes the unconventional techniques paid off as well. Since I did not sample therapists at large, I cannot generalize on the basis on my practice alone. B. Some Positive Outcomes Did Come from Individual Psychotherapy Here are some of what I think were positive outcomes. On issues like major life choices such as choosing or changing an occupation or engaging in an education program, therapy seemed to make the process more objective, lend confidence to their decisions, and even add a little more belief in their decision-making ability. However, I am not sure that those benefits carried over to future, similar choices. Immediate difficulties with people like intimate partners or work supervisors seemed to be helped by using problem- solving techniques. When they gained insight into them, some of these insights seemed to make clients more comfortable with themselves, at least with respect to scary or annoying misgivings they had about themselves. If the therapy was of long duration, the quality of the therapeutic relationship seemed to make clients gradually more self-accepting and to increase their self-esteem or sense of self worth. Some clients with anxiety reactions and panic attacks seemed, or at least reported, to get some relief from these symptoms. One unusual outcome that seemed to be enduring was with respect to psychosomatic or somatic-psychic symptoms. For instance, a woman with repeated surgeries for endometriosis was deemed by her doctor as not in need of a forthcoming surgery and dredyoung Page 3 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc pronounced her symptom free. This result was still in effect many years after therapy. A man with high blood pressure for which he was taking medication was relieved of that symptom and his doctor took him off the medication. In part, the technique that accounted for these changes involved the use of hypnosis. In addition, hypnosis, in combination with insight-talking therapy, seemed to help clients with early sexual and/or physical abuse to recover the related memories and be relieved of problems with the sex act with their current partners. Some phobias also were overcome using similar techniques. Many more symptom types were relieved as well. C. A Program in a Closed Institution Suggests Ways to Overcome the Weaknesses of Psychotherapy I have often noted the positive aspects and outcomes cited above yet I have cited the problems with psychotherapy as well. If psychotherapy, whether with conventional or unconventional techniques, seemed to be effective, then why do I keep harping on the shortcomings of psychotherapy? Because, once having seen alternatives that were more effective, I began to pursue them and, naturally, parallel to that endeavor, seriously to question traditional psychotherapy. The aspects questioned or reasons for questioning are twofold. Let me dispense with the first of the reasons quickly at the outset. Most of the above-cited reduction in symptoms using psychotherapy also disappeared when using, in a closed institution, a Natural System"s structured program called "Stars and Stripes". The institution referred to was a juvenile correctional facility for boys who had committed serious felonies and who had been repeat offenders. They had an average age of fifteen and a range from thirteen up to seventeen. Before "Stars and Stripes", the facility was much like a strictly controlled, medium security, adult prison. Under the prison-like system, these youths were constantly aggressively acting out and escaping. Over seventy percent of the population was on psychotropic medications prescribed by the institution"s psychiatrist. Once the "Stars and Stripes" program was fully implemented, almost all of the youths were taken off psychotropic medications. Prior to this program, a few of the youths, possibly ten percent, were provided with individual counseling. After implementing the new program, a few continued to receive traditional, dredyoung Page 4 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc one hour per week, counseling in order to appear to comply with professionally recommended county policy. After implementation of "Stars and Stripes", the institution changed from a cauldron of constant violence, escapes, property destruction, and a wide variety of neurotic symptoms to being more like a well-disciplined, model school, with healthy, respectful youths. The residents became more mature and their school achievement soared. Instead of being alienated, the youths positively identified with the institution. The benefits of this Natural Systems program accrued to almost all of the residents (inmates). Furthermore, the benefits endured in post release, when they were free in their home community. These benefits occurred in spite of the fact that less that ten percent had received individual counseling. Prior to this program, individual counseling had made no observable changes in behaviors. For me, this was reason enough to question traditional psychotherapy. These questions, however, relentlessly persisted in nagging me. Why was individual psychotherapy less effective than the Natural Systems" program, which was successfully applied simultaneously to an entire population without the use of psychotropic medications and with ninety percent receiving no counseling? What was missing in individual therapy? Seeing the comparative ineffectiveness, what was its significance? What was this trying to tell me? On the other hand, an even more profound question was what were the causes of such massive effectiveness? In almost all cases of mentally ill patients, behavior disorders, and convicted criminals, a stock answer with respect to their cause was that these problems were due to a biological, or genetic, predisposition to a chemical imbalance in the brain. To the contrary, however, if, when all but five percent of the entire population of the institution"s youth were taken off psychotropic medications, the youth began behaving normally, then one had to question psychiatry"s assumptions about imbalance in brain chemistry or neurotransmitters being "the cause" of their varied types of abnormal and antisocial behavior. Of course, it is doubtful that psychotropic medications were the cause of the troublesome behaviors, since these behaviors were present long before being administered the medications. Assumptions that pre-program negative behavior was "associated with" or caused by brain chemistry imbalance, namely neurotransmitters, seem false. Obviously, symptoms were only modestly ameliorated when on the medications since the institution dredyoung Page 5 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc had been churning with pathological and violent behavior. Neither should the positive changes exhibited with the new program be attributed to the withdrawal of the medication. After all, they had been given the psychotropic medication to calm them and reduce their unmanageable behavior and that had not worked. The simplest and most reasonable hypothesis should be that it was the change in the structure of the institution, namely the way the "Stars and Stripes" program was designed, which was the cause of the change to positive behavior. By inference, it might seem to be a reasonable hypothesis that the program could have corrected the youths" brain chemistry imbalance, or neurotransmitters. It could have been something about the structure of the program and the behaviors and feelings it elicited that was simultaneously bringing their neurotransmitters back into balance. On the other hand, it is just as reasonable to assume that brain chemistry is either irrelevant or a mere transitory phenomenon related to arrest and incarceration. It is possible that brain chemistry can change or adapt to factors in the structure of their world be it in their natural home environment or the way the institution is structured. It has always seemed strange to me that when discussing the cause of delinquency or criminal behavior the structures of the social environment are rarely considered and quickly dismissed. In the popular Leonard Bernstein musical, "Westside Story" film (1961), the social structure causation theory is even ridiculed. In the middle of the twentieth century Robert Merton, a renowned American Sociologist, made a good case for some prominent aspects of the structure of society being the cause but his theory never gained much of a following. Social Theory and Social Structure (1949; rev. ed. 1968) One of his theories that gained influence was that of what he referred to as "Anomie". He saw anomie as a major cause of social deviance but he also emphasized the threat of punishment as the only viable way to control rebellion and crime and delinquency. He was primarily a social theorist. Consequently, in spite of several other popular structural ideas such as the influence of role models, he never provided an effective method for analyzing structure or altering structure. Structure easily bowed to the ideas of causation with more popular appeal, such as genetic predisposition and Merton"s idea of breakdown of the family in a society with increasing "normlessness". The "Stars and Stripes" phenomenon, however, revives the concept of structure, especially levels of social structure, as the dredyoung Page 6 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc primary causal factor in both delinquency and the reform of delinquents. The first question regarding the cause of the transformation of the youth in the correctional institution was answered, quite inescapably, with the observation that the structural design of the "Stars and Stripes program" had to be the cause of dramatic, positive changes in the entire population of the institution. Obviously, psychotropic medications were not the cause. More important to the thesis of this manuscript, however, is the observation that traditional psychotherapy does not get such astounding results while the institution"s program did. How many therapists and how many hours of therapy would it take to get results of this magnitude, if ever? Would results be as enduring for when using either approach? Finally, what is the reason that psychotherapy "does not" result in such a dramatic difference? This is a vitally important question. Pursuing these questions, I found the following additional likely answers. Aside from the enormous gain when using a Natural System"s program in a closed, structured institution, a comparison yields a second and by far more significant reason for psychotherapy"s failure. Through my analysis, I came to believe that when traditional therapeutic modalities are compared to the Natural Systems approach in this structured environment, the traditional therapeutic modalities exhibited a wide range of drawbacks. For instance, with psychotherapy, behavioral patterns rarely changed but, when they did, it was usually only after many sessions over a long period. Negative behavioral patterns typically resurface later on. Furthermore, while clients often reported feeling better after each session and, particularly, after the extended period of therapy had ended, the actual maturity of behavior patterns had not increased and the breadth and level of sophistication of ego-mastery skills seldom grew or had only slightly improved. Why was this? I suspected that another reason for this lack of behavior change when using psychotherapy was because, outside of the therapy hour, everyday life continues to exert its influence for the remaining six days and twenty-three hours. After that one therapy hour, the constant pull of influences from their home and work environments to get a person to exhibit their previous standard, ineffective, self- defeating behavioral patterns is relentless. The force of their natural environment exerts a powerful pull to get the patients" behavior to return to its status quo Families persist in keeping a "designated" dredyoung Page 7 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc problem person in their problem role within the family role system. The expectations and pressures to maintain the status quo behavior that exist in work relations, peer relations, relations with significant others, and so on, persist. Try as hard as the client may, these mostly unwitting external pressures in the non-institutional, open social environment tend to mercilessly and tyrannically maintain the client"s same old ineffectual, problem behavior patterns. Not only is their environment unwittingly maintaining these negative behaviors, but also the "maintainers" exert their negative influence in spite of the fact that they are simultaneously vocally disapproving of those same behaviors and urging them to "get well", "shape up", and "take your meds!". Who could charge these ostensible well-wishers with being to blame for the failure of the patient"s therapy? The "Stars and Stripes" program was able to avoid all of these weaknesses examined above. The challenge now is to find the courage to consider that psychotherapy is in need of a Paradigm Shift. The Duplex Pyramids Model of Natural Systems External Structures and Systems Intentionality Processes Internal Structures and Processes http://dredyoung.com http://TheNaturalSystemsInstitute.org dredyoung Page 8 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc III. Natural Systems, and its Duplex Pyramid model and Intentionality Model, suggests an alternative form of psychotherapy A. Describing the Duplex Pyramid model"s top and bottom pyramids, time, and the integrating Intentionality model: Natural Systems is an approach that includes the Duplex Pyramid model. It also includes the Intentionality model that makes it possible for the human being to interact with the external world and integrate the internal and external structures represented by the Duplex Pyramid. The Duplex Pyramid is one pyramid stacked on top of another one. TABLE I. BELOW IS A GRAPHIC REPRESENTATION OF THE DUPLEX PYRAMID MODEL WITH THE TEMPORAL DIMENSION AND INTENTIONALITY INCLUDED dredyoung Page 9 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc NATURAL SYSTEMS" SCHEMA PERSPECTIVES USING THE DUPLEX PYRAMIDS Encompassing Environments Institution or Organization Settings within Institution INTENTIONAL PROCESSES Situations Formal Roles Dyadic PAST FUTURE Interaction Informal Roles And Relationships Physical/Verbal Behavior Cognition Emotion/Feelings Perception Life History Genetics Brain Chemistry 1. Introducing and Defining the Top and Bottom Pyramids The top pyramid, as you can see, is inverted. Each pyramid is divided into sections called levels. The top pyramid represents the external world. Its levels are arranged in terms of their scope. The topmost level of the top pyramid represents the largest scope but that can be defined according to your purpose. In this case, the topmost level represents the encompassing environment, which in this case is the social environment. The next level represents an institution or organization but could also represent a community or whatever meets your purpose. The next lower level represents settings in an institution such an educational or training class. The next level represents situations that occur in that particular setting. The next, or lowest, level represents the formal roles in the setting such as teacher and student. The bottom pyramid represents a person"s internal world. It has levels arranged according to structures inside the person. The dredyoung Page 10 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc bottom most level represents what is deepest and most inaccessible in person such as their life history and its secrets, for example. Moving up, the next level represents perception. The next up represents emotions and feelings. Next, there is cognition. The next level near the top represents physical and verbal behavior. Finally, there is a level called informal roles and relationships. In the very center is what I refer to as the fulcrum of the pyramids, dyadic interaction. will introduce you to understanding how to use the Duplex Pyramids and will illustrate how to change and adapt your mental processes to take in the scope of both Pyramids, examine each level of each Pyramid, and then bring the whole, both Pyramids, into a unified perspective. When one is working on any concept related to humans and human society, this Duplex Pyramid approach can help gain a more comprehensive and more detailed perspective. For the reader to keep all of the levels of both pyramids in mind is a daunting task. It is even more difficult when one is trying to apply it later. Accomplishing this takes a very long time with much practice. Adding the temporal dimension makes the model more realistic and dynamic but even more complicated and intimidating. Add to that another critical component to be presented later on, "The Intentionality Model", and mastering this system becomes formidable. "The Intentionality Model" reveals the dynamism of humanity"s real life way of interacting with their world. The world with which people are interacting and the manner of interacting with it is mostly mental and not immediately perceived. This world consists of levels of the aforementioned internal and external structures. Putting all of these factors together in one holistic system increases that complication even further. Yet, this is the true nature of human existence. This Natural Systems is a way of presenting the world that is not fragmented, contrary to what is customary. Most people prefer to be presented with models and systems that are simpler and less multidimensional. Fragments of the world are easier to learn and comprehend. The problem with that is that humans and human societies are by nature highly complex, highly multidimensional and in flux with all of these factors continuously accelerating in our modern, techno, global world. Our world is holistic and we try to integrate its complex and forever fluctuating collision with our senses. Our modern, fragmented systems just make this task virtually impossible. dredyoung Page 11 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc I am hoping, however, to provide, with these integrated models, something like a roadmap or a set of integrated roadmaps to facilitate the mental process of understanding the whole individual/society welter, while at the same time facilitating the development of a new form of therapeutic practice that integrates and addresses that whole in a synergistic, effective way. This project is dedicated to that end. 2. Introducing and defining and explaining the levels of structure of the bottom pyramid As noted, I have given Natural Systems a logo called the Duplex Pyramid model. It consists of two pyramids with one on top of the other. The top is an inverted pyramid representing the external structures and systems while the bottom pyramid represents the internal structures and processes. Both the top and bottom pyramids are arranged with levels ascending and descending in width from the center out. The center designates dyadic interaction, which is observable to an outsider but also has a parallel aspect that is available only to the awareness of the individual, like the two sides of a coin. This is also meant to indicate that all social interaction has as its primary focus, solely, the interaction between two people. In other words, if you are in a group, when you engage in interaction, you only focus on one person at a time. If you are addressing a group, you may focus on one person, the entire group, or neither. You may address a group and yet be solely focused on what you are saying and not on a person or persons. When you focus on one person in a group, the rest are peripheral. The interaction is with the one. The others may be an audience, but still peripheral to the dyadic interaction. Most modalities of psychotherapy are explicitly designed as dyadic interaction, therapist and client. This also is true of couples, family, as well as group therapy. The focus is one person at a time. The levels of external structures and systems shape the personalities of people. External structures have varying degrees of direct influence on the internal structures and processes, or the personality of the person. For the purposes of this paper I have categorized the top pyramid"s external structures, starting with the topmost, as the encompassing environment; institutions, organizations, or community; settings within the institution, dredyoung Page 12 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc organization, or community; situations within settings; and formal roles. Dyadic interaction is the fulcrum between the upper and lower pyramids. The lower pyramid includes the internal structures and processes to be discussed in the next section. The Duplex Pyramid Model also has a temporal dimension. The temporal dimension is represented in the graph below by the bi-directional arrow in the center, between the two pyramids. This takes into consideration the degrees of distance that both the past and future have from the present. Later on, after thoroughly addressing the lower pyramid, I will be able to show what the levels of structure of the upper pyramid are influencing in the lower pyramid. In the lower pyramid, at the levels below the central dyadic interaction, there are internal structures that are arranged in order the degree to which they are immediately observable, the ease with which they are can be observed or studied, and their directness of connection to the external world. These internal levels of structures, with the exception of physical and verbal behavior, are only observable indirectly through psychological experiments or self- report. The further down these levels one goes, the less easily observable (or rather the less easily detectable) they are through these indirect means. For convenience, I have elected to give a brief label to each level of the bottom pyramid in the following descending order. The first level is informal roles and relationships. The second level is physical and verbal behavior, which, while observable, are difficult to study since words and acts have no significance without reference to indirect studies of their complex networks of meaning. The third level is cognition or thinking and imagining. The fourth level is emotion and feelings. The fifth level is perception. Finally, the sixth level is the person"s life history. As you can see, each level seems to have some conceptual overlap with the others. They are, nevertheless, differentiated or demarcated from each other in order to illustrate how different modalities have developed to focus on their special level. On the other hand, if one starts at the lowest level of the bottom pyramid and works up to the fulcrum dyadic interaction, it is possible to view the ascending levels from a different perspective. From this perspective, we move from the factors that have both the most pervasive influence over dyadic interaction and yet are the least specifically determinative of, or have the least direct effect, on immediate dyadic interaction. dredyoung Page 13 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc For instance, life history and genetics are the least determinative and have the least direct effect on dyadic interaction. Next, since the relations between what one actually perceives, and the way one actually perceives, the acts of the dyad"s other and how one comes to act toward that other are often quite out of kilter with one another. Of course, the other cannot directly perceive these inconsistencies. On the other hand, emotions and feelings can be suppressed and their meaning can be disguised. Nevertheless, emotions are usually visibly observable while their import remains difficult to infer. Interestingly enough, it is even possible for a person to disguise from themselves what their true perceptions are and what their true feelings or first feelings are. Cognition, or what one is thinking, has a somewhat more direct effect on one"s actual verbal and/or physical behavior. Nevertheless, humans are notorious for the pretending, scheming, manipulating, and craftiness of their behavior. People seldom want the other to know exactly what their thoughts are. Of course, this is both a reflection of the disconnection between thought and act but also their direct connection. Cognition is immediately affected by and effects dyadic interaction. It is a two-way street. Thinking about what to say and how to act becomes increasingly swift as one grows from childhood into adulthood. Even children are somewhat swift but less adept at disguising their true thoughts from adults. Yet, somehow, perhaps through extensive repetition over the years, human minds develop somewhat stereotyped patterns or habits of thought and consequently of behavior that often make their interaction oddly ineffective or maladaptive with respect to the other"s behavior in the interaction. It often said that a person acted without thinking. In fact, it is more likely that the two are bound together as a reflex. In isolation from a dyad, people often rehearse for the upcoming interaction. Some may even repeat deprecatory or conceited self-talk referring to themselves and deprecatory or flattering self-talk directed to the other. For some these rehearsals are repeated somewhat like a mantra. They may have the same mantra-like repetitions in reference to the other. They may rehearse positive and negative talk strategies for the upcoming interaction as well. They usually develop, during their rehearsal, several versions of this solitary talk. Their repertoire of references to self and other expands as they move into adulthood. While they carry on this mental dialogue between themselves and the other, when they are actually face to face with the other, nothing from dredyoung Page 14 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc their rehearsal is likely to be used. Nevertheless, many would feel lost and vulnerable without it. Cognition, therefore, is more determinative and has a more direct effect on physical and verbal behavior and the eventual dyadic interaction than do the lower level structures of the bottom pyramid. At the next higher level, Physical and verbal behaviors are in an immediate reciprocal relation with informal roles and relationships. Physical and verbal behaviors certainly do not completely determine the enactment of an informal role when engaged in dyadic interaction. All of the successive lower levels make their own contribution. Nevertheless, the behaviors enacted through an informal role are the direct cues to and from the participants in the dyad for each successive act or word. Acts and words require interpretation and can be misinterpreted, yet they are the essence of the immediate interaction. The behavior or communication of each can quickly change directions simply on a subtle inflection of the voice or nuance of meaning. I assume that nothing gets through to the lower level structures except through some form of personal dyadic interaction. As an aside, it is notorious that the impersonal reading of self-help books is ineffectual in achieving their stated purpose. As we descend the levels of the bottom pyramid, the influence over successively lower levels diminishes. However, referring back to the temporal dimension of the Duplex Model, if a consistent structure of the external world permits a perpetual, long-term, and well-designed influence on all dyadic interactions, eventually the influence begins to shape, by successive levels, the whole person. Old patterns of each level are supplanted and new patterns become incorporated. If this goes on long enough, even the highly indirect but pervasive influence of the lowest level, life history, is permanently, significantly altered. The levels all become highly resistant to alteration. The final principle here is that the uppermost levels change the most and the most rapidly. The lowest levels change the least and the most slowly. Therapy aimed at dyadic interaction can make rapid but ephemeral changes. Therapy aimed at the lowest level takes by far the longest time. Yet, if a person lived in a social vacuum, therapy aimed at this level might eventually result in persistent changes in dyadic interaction. Unfortunately, it, namely psychoanalysis, does not take place in a vacuum with respect to the social environment. The perpetual bombardment of one"s relatively and typically dredyoung Page 15 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc unchanging social environment tends to undo the work of such depth-oriented therapies and this reinstates ante therapy status quo behavior. On the other hand, the more surface-oriented therapies are not able to have lasting effects on the lowest, more indirect, yet more pervasively, more enduring lower levels. I envision that the Natural Systems modality will be able to overcome this dilemma. It is interesting to me that each modality did primarily develop in order to address a specific level of the bottom pyramid. As such, they each brought significant insights that were level-specific to the general field of psychotherapy. As each modality gained prominence, their insufficiency eventually would become apparent and another modality arose to remedy the insufficiency by focusing on another specific and usually higher level in the pyramid. In and of themselves all of the modalities only address and represent one major aspect or internal, structural level of human beings. Taken all together, however, they seem to me to form this pyramid of mutually influencing internal structures. Therefore, all of the levels taken as a whole seem to be a reasonable representation of all of the structures that constitute the human being. The Natural Systems modality is meant to address all of these levels using an integrated approach. 3. Features of psychotherapeutic modalities are selectively related to the separate levels of the bottom Pyramid These aforementioned levels of the lower Pyramid can also be seen as arranged in a descending order that relates to typologies of modalities of psychotherapy that tend to focus primarily on that level. The upper most level relates to roles and relationships and the corresponding type of therapy involves role analysis, role-playing, psychodrama, and role structuring with dyadic interaction, transactional analysis, and cognitively restructuring roles and relationships. The focus is not on formal roles such as you would find in corporations, agencies, or organizations. These roles are a part of job descriptions that are very narrowly prescribed. This is why one rarely sees non-conformist, deviant, or symptom-behaviors of mental illness when a person is performing a formal role on the job. In this context, however, I am referring to informal roles that occur in open society. Roles of husband and wife; parent and child; dredyoung Page 16 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc roles in peer groups; roles in social clubs; informal gatherings after work are all examples of informal roles that have no or very loose prescriptions for behavior. The psychotherapeutic modalities mentioned at the beginning of this section are all designed to treat informal role related psychological problems. For example, these therapies could involve analyzing and altering the way clients communicate or talk to one another. In its simplest form, transactional analysis will point out how two people can each assume various combinations of one of three primary roles: parent, adult, and child. Therapists sometimes instruct clients to speak to one another as though they inhabit a different role vis-à-vis the "other", for example, husbands and wives may be asked to switch roles. A husband could be taking the role of parent and the wife taking the role of child and so on for their several permutations. Once clients understand the point of view of the other"s role, it is possible to begin attempting to alter the client"s own style of relating and communicating. Therapists suggest ways for clients to alter their communication patterns with each other. To follow the instructions, each client must rely on their own inner resources to try to enact what the therapist is suggesting. They also have to imagine and enact what they feel to be their significant other"s, peer"s, parent or child"s, for example, styles of relating. Communication therapy such as that used by Virginia Satir fits into this category as it is also concerned with the way people in relationships communicate with one another. The clients do the inner work of imagining and preparing to assume the role and then move into the interplay of dyadic interaction. The therapist gives feedback or analysis of defects in the communication pattern and they cycle through until they have a mutually satisfactory style interpersonal communication. The concepts of family of origin techniques, family systems, and family styles are often used in the therapy in these contexts, especially when working with the extended family. Descending to the next level, this structure involves both physical and verbal behavior, yet here they are dealt with independently of roles and relationships. Therapies such as these may use positive reinforcement as is found in behavior modification to train a client to act or speak in a certain way. The therapist may provide the source material and may use coaching or modeling to illustrate the suggested ways of behaving and speaking. Desensitization is a technique that is typically for the individual client dredyoung Page 17 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc and may be used to reduce anxious, fearful, and avoidance behavior. Behavior is the focus and variations in stimuli and types of reinforcement are used to alter behavior. The justification for using these techniques is that these emotions are painful to the client and they inhibit and thwart effective behavioral responses. Traumas and traumatic life conditions are typically the initiators of these painful emotions. War, natural disasters, and accidents account for many panic, fear, and anxiety reactions. Extremely embarrassing incidents are also a common cause. The most widely used modality, Psychiatry, also deals with physical or overt behavior. Its assumption is that a chemical imbalance in the brain is the primary cause of psychoses and personality and behavior disorders. We could call Psychiatry a brain-chemistry manipulation modality as its principal and almost exclusive treatment is the use of psychotropic medications. At the next lower level, there are the more sophisticated, cognitively oriented therapies that are used with the individual client. A sample of these is reality therapy, rational emotive therapy, cognitive restructuring, problem solving, values clarification, journalizing, and guidance and life-decision counseling. Life conditions can prevent normal development and growth in maturity and discourage or prevent the acquisition of ego mastery skills. If a person grows up with life conditions that are disadvantaged, harsh or dangerous, involve racial prejudice, or when tragedies like the death of a parent or divorce have occurred, the person"s personality can become malformed. These cognitively oriented therapies have been designed to deal with such personality disorders or immaturity. They may focus on how to intellectually can gain insight and alter various aspects of such problems. Therapists help them become more aware of and alter problems such as the following: their self-concept and identity problems; their self-defeating patterns; their negative self- talk; and deal with relationship problems and make more well- informed life choices. At the next level near the bottom of the pyramid, we have Gestalt therapy that is also for the individual client. It is especially designed to work with the way perception has been distorted by lessons from parents and the culture. Gestalt therapists suggest that, as the child begins to develop, its primitive, direct perceptions are transformed into socially sanctioned but unrealistic interpretations. Gestalt therapists focus on how such distorted perceptions determine the dredyoung Page 18 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc way the client interacts with the world. They work with clients to help them get back to objective perception that is uncontaminated by these imposed interpretations. They especially attempt to help them get in touch with their true, unadulterated perceptions, sensations, and feelings toward the world versus their false interpretations. The Gestalt theory of phenomenology attempts to present and to put into obvious contrast with objective reality, its subjective perception, or interpretation, of reality. This new realism attempts to help the client get at objective reality and thus cast out the demons of subjective interpretations that are full of illusions, delusions, and nightmarish views of the world. The intent of this therapy is to bring the client to this point of perceiving realistically and authentically, free of neurotic conflicts. While Gestalt therapy does focus on how the social environment influenced the development of the distorted perceptions, it is still primarily focused on the person and "how", or the processes by which, the person is engages in the act of perception, rather than on the "what" of the perception, namely the external environment. It must be noted that this "how" of perceiving is considered in isolation from all of the other processes of intentionality, which are essential to Natural Systems. At the final and lowest level of the bottom pyramid, we have psychoanalytically oriented psychodynamic psychotherapy that focuses on the individual client and deals largely with clients" life histories. The expanse of the psychoanalytic model is deeper and broader than most of the other modalities. The mental arena of psychoanalysis includes time, mainly past time, with the focus being on the individual"s life history. The focus of this model is principally inside the person and on the dynamics of the person. Freud, the founder of psychoanalysis, began his career as a medical doctor. In medicine, doctors made a diagnosis and prescribed a prescription with detailed instructions that another doctor or, even in some cases, a nurse could follow. This is somewhat like an algorithm. Medicine had "disease" taxonomy. Each label in their diagnostic taxonomy has its preferred treatment. Each illness in the taxonomy also includes an etiology, which was an explanation or description of the cause and the course or stages the disease will follow. This is the essence of the medical model. After discovering conversion reactions in which psychological rather than physical causes were attributed to certain illnesses, Freud"s version of medicine turned toward a wholly new direction. dredyoung Page 19 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc This led to the new discipline of "psycho" "analysis". This new discipline evolved into a focus on client"s non-medical complaints and a search for causes inside the person, in their psyche. Etiology became factors in the person"s life history, particularly their early childhood development and their relations with family members. Freud focused inside the person and toward the person"s past. The dynamics of the patient"s illness were also to be found in primitive desires in the person. These had their origin in the physical nature of the person, that is to say, their biological drives. From this point on, a new taxonomy developed. This became a taxonomy of psychological, or mental, illnesses. Etiology in this new discipline was a combination of life history plus family dynamics plus biological drives. Initially biological drive that was the most important was the sex drive. Working from this combination, Freud formed a tripartite division of the personality consisting of the id, ego, and superego, which were in conflict with one another. He also constructed a structure of the mind that consisted of the conscious, pre-conscious, and unconscious. Freud created an additional kind of taxonomy, called defense mechanisms, to describe how people dealt with conflicts between the parts of his tripartite model of the mind. In the relatively calm social environment of pre-war Austria, there was no need to focus outside the person and their social environment. Right before World War II, when the country became turbulent due to the threat of Nazism, he came to America where the social environment was calm and stable. He died the next year, 1938. By this time, his system of psychoanalysis was virtually complete. For a considerable period thereafter, Freud"s psychoanalysis was a virtually unchallenged, highly popular, and highly revered new treatment discipline. Of course, classical psychoanalysis was quickly recognized as something only the rich could afford. In its classical form, a patient would see their analyst for an hour five times a week at a charge higher than other modalities. In addition, in classical analysis, the technique consisted of the analyst listening, with little of no input, to the patient for the entire hour. He had his patients recline on a couch and encouraged them to speak freely about themselves. As an aside, reclining on a couch is much like being in bed for a night"s sleep. In this situation, with no influence from the pressures of daily life, thoughts, fears, fantasies kept at bay during the day begin to surface. Again, this was another stroke of Freud"s genius. It dredyoung Page 20 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc seems odd that he followers abandoned this technique so quickly after the master died. In spite of the hallowed status the Freudian system, there was one challenger. This came from a close associate whom he had mentored and in whom he had seen much promise, named Jung. Jung had tried to refocus therapy toward the influences of the external world. He was particularly interested in bringing concepts related to culture into psychoanalysis. Another challenger was Adler who tried to shift the focus toward the future and away from being primarily on the past and on the achievement motive rather than the sex drive. He presented humans as goal-oriented. However, no challenges within the discipline of psychoanalysis were persuasive enough to cause a swerve away from the course that the huge momentum of Freud"s psychoanalysis had gained. A more affordable and practical version of psychoanalysis sprang up in the form of psychodynamic psychotherapy. Initially, this related modality used Freud"s theory of personality but the technique was more interactive and was limited to one hour per week, which made it more affordable. These varieties of psychotherapeutic modalities suffer from the same intractable problems of all individually oriented therapies mentioned above. As was mentioned above, Psychiatry is associated with and belongs with the second level on the pyramid. This is due to its focus on overt behavior and employing a brain-chemistry manipulation modality that alters neurotransmitters. Psychiatry eventually assumed the legacy of the Freudian tradition. It vastly expanded the taxonomy of psychological illnesses found in the regularly updated DSM, manual of diagnostic criteria. The majority of categories in this taxonomy are diagnosed by collecting direct or chronological observations of overt behavior, reliable self-report, or reports coming from family or institutional staff. Psychiatry found the search for Freud"s kind of etiology too illusive and explanations of illnesses derived from Freud"s theory of drives and conflicts within the tripartite self to be inefficient. Psychiatry"s taxonomy became codified descriptions of behavioral patterns. Their diagnosis came to be based on objectively observed behavior rather than illusive concepts of the inner world. Their etiologies relied less on life history. Even life histories were reduced and codified to aid in gauging the severity of the illness. Their explanations switched from Freud"s conflicts between id, ego, and dredyoung Page 21 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc superego to the more scientifically demonstrable disturbances in brain chemistry and endocrine glands and their hormone secretions. As behavioral descriptions that fit within taxonomic labels were studied in relation to physiological patterns, medical research was finding correlations between these labels and types of disturbances in the persons" physiology, particularly brain chemistry. Corresponding in time and collaborating with psychiatry, psychopharmacology was beginning to find chemicals, tranquilizers, which could quickly ameliorate the condition or disturbance in brain chemistry and the accompanying symptomatic behaviors as well. Psychiatry and psychopharmacology were able to demonstrate quick and easy cures simply by giving the patient a pill. Their focus primarily became restricted to the person"s observable behavioral patterns with corresponding imbalances in brain chemistry. Psychiatry became the hero of the modern world. Symptoms that developed because of pathological influences in the external structures of the changing modern world could quickly be diminished so that people could adapt to them. People could be made to adapt to the rapidly evolving disorder and stresses of modern culture. They were, therefore, were less of a problem to their employers. One additional intractable problem that is attached to psychiatry and that is only remotely related to those mentioned above was the fact that giving a person a diagnostic label that entailed a select aggregate of behavioral patterns, or traits, subsumed under it did not guarantee that they would be constant and immutable. A person could change from situation to situation and time to time. A simple example is that a person who killed someone would typically be given a diagnostic label like antisocial personality. If a person went to war and killed someone on behalf of their government, were they an antisocial personality? In this situation, they were usually referred to as decorated heroes. Many veterans, on the contrary, experienced this as an overwhelming cognitive dissonance accompanied by persistent guilt, depression, and alienation. The government had to proclaim the murderous deeds of warfare as morally legitimate but to many veterans, the deed was the same regardless of the situation. For many veterans, the attempt by authorities thusly to assuage their guilt only seemed like hypocrisy and added to their despair and alienation. Psychopharmacology merely turned most of them into harmless zombies for life, as, underneath their prescribed psychotropic medication, their condition typically remained dredyoung Page 22 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc intransigent. However, of course, they could not be labeled antisocial personality nor described as suffering from moral angst and indignation. That would be politically incorrect. This zombie-like condition, however, remained true regardless of how they were treated. Another example of a labeled mental illness being situation- specific would be that of a person who is chronically anxious. They are given a diagnosis of chronic anxiety reaction. It is as though the person "is" the label or what the label describes, now and forever more. Yet, a wife living with a chronically threatening husband should be chronically anxious while with him but could very likely eventually stop being anxious after she leaves him and enters a safe, secure, supportive circumstance or set of relationships. Once again, this suggests that the structure of the environment accounts for the lion"s share as the cause of so-called mental illnesses. Meanwhile, psychopharmacological pills began to be doled out ever so freely by the psychiatric profession and yet they were not proving to be effective in resolving the moral dilemmas, effects of pathological social structures, or social and economic injustices that are rife in our nation"s pell-mell rush into social chaos. In fact, the marketing practices of the mind pill industry are now so pervasive, powerful, and mesmerizing that they dupe even highly intelligent consumers. These unfortunate and unwitting people suffer from painful emotions and socially unwelcome symptoms. These pills numb their senses and dumb down their faculties sufficiently to meet the daily demands of work and family. Yet these vulnerable, easy human targets are paying the price of psychologically never working through the underlying causes of their misery. One cannot deal with painful emotions and their roots if emotions are drugged into oblivion. They are cheated out of the chance of developing ego mastery skills for coping with the past unfinished-business and psychological traumas, as well as life"s future challenges. We all are paying dearly for having a blind eye turned toward these malignant external structures of our national and medical culture. The final contrast, therefore, is with this medical model mode of treatment used by the vast majority of psychiatrists. Today that treatment consists almost entirely of the following the following steps. The psychiatrist conducts an initial brief, structured, thorough and professionally recommended interview. From the results of this dredyoung Page 23 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc interview, the psychiatrist notes the range of symptoms presented by the patient. He compares those with the symptoms related to symptoms listed under diagnostic categories in their DSM manual. He assigns the patient one or more diagnostic labels. Based on his diagnosis, he selects from the medications that are supposed to treat that particular form of mental illness. He prescribes one or more of the medications that are recommended as the approved treatment. He then has the patient follow up every few weeks or months to check their progress in improvement or reduction of symptoms, and to see if changes in their medication need to be made. Psychiatrists infer from information gathered from the patient and possibly other reliable sources what their illness most likely is. They view the patient as "having that illness", that is to say, the illness is located "in" the individual. Also, in a sense, this could be interpreted as implying that the "label" that indexes the patient"s collection of symptoms is "the cause" of their illnesses or that the label indicates that the illness is an "entity" located in the person and a cause of the overt behavior. Even if they do not intend to do this, the patient and the public at large tend to treat the label as though it were an entity and the cause. Of course, this is circular logic. If argued in a court of law that the a person committed an illegal act because they had, or were, the type of mental illness implied by the label, the judge would not allow that to be considered in the jury"s deliberations on the basis of the claim"s circular logic. The search for an explanatory cause of the symptoms, nevertheless, stops. If asked in a more probing manner what the cause is, they might suggest something like a chemical imbalance. No one knows exactly what is "meant" by chemical imbalance. If the diagnosis and prescription entail chemical imbalance, there is often reference to a specific (or some) neurotransmitter. This would lead one to assume that the offending neurotransmitter or the configuration of neurotransmitters is a permanent condition. In fact, researchers studying neurotransmitters have isolated over one hundred of them. In addition, their research clearly demonstrates that neurotransmitters are in continuous flux. The configuration of neurotransmitters is constantly changing and the major cause of the flux is the person"s response to their environment. This tendency to tag one or two neurotransmitters as the cause seems more like a shorthand way of covering a multitude of generally, informally dredyoung Page 24 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc accepted but unverified assumptions. The role of the environment, being unobserved and inaccessible to the psychiatrist, is not given its due in this treatment process. Environmental causes, diagrammed in the top pyramid of the "Duplex Pyramid Model" are not considered in either the diagnosis or treatment. This disconnection tends to perpetuate both the illness and the myth of chemical imbalance as "the" causal factor. At this point, the all-important question of effectiveness of this type of treatment arises. What happens when a person is given a psychiatric diagnostic label and treated with psychotropic medications? Let us dispose of a most conspicuous criticism. In a majority of cases, once a person has been given a label, they are assumed to "be" that diagnosis and therefore to have that illness for the rest of their lives. Therefore, they must remain on a psychotropic medication for life. The implications for the person"s life in the present, on the other hand, are more subtle and illusive. The devastating affects of being given a mental illness label must be addressed. What is in a name? For friends and relatives, this person suddenly "becomes" the stigmatizing psychiatric label. Psychiatric labels are generally frightening to people. They no longer know what to expect but sense that they should expect something embarrassing or even dangerous. If experiences from past associations with the labeled person did not include behavior they should have been wary of, now that past is discounted or revised with the worst of intimations. Friends and relatives now treat that person in a guarded manner. The slightest sign of some unexpected or peculiar behavior is met with the well-known shuttering inhale of breath that a rash breach of decorum brings. After a certain number of "aghast" reactions, the patient"s identity becomes colored as though they were a pariah and they tend to be avoided and excluded. What are the implications for the patient (person) to having a psychiatric label that eventually transforms their identity and causes these shunning reactions? Some may become inhibited around others. Some may feel despair over being forever treated with caution and even avoided. Some may become resentful and blame others for their so-called or assumed condition. Some may flaunt their label as though it makes them special in some way. For others the concept of self-fulfilling prophecy may come into play. Some may simply give up and say to themselves that if they have the name dredyoung Page 25 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc (label) they might as well have the game. Some could feel relieved that they no longer have to probe or be probed with myriads of homespun theories of causation. It may also be easier simply to conform to the perverse and defeatist expectations of relatives and friends and put on exhibitions of insanity and perplexing behavior for them. The main and most crippling result is that having their problem solved by proxy due to the "label being the cause", and therefore any genuine quest to explore themselves or to look for ways to become healed is aborted. Self-understanding, self-development, personal growth, attempts to restructure their lives, and just plain hope are foreclosed. Furthermore, attempts by friends and relatives to help them overcome their problem and find alternatives that might lead them out of the psychological prison psychiatry has put them in cease with a bitter but final sense of resignation. Who will listen to them as a mere fellow human being rather than a "stigmatized label"? Therefore, in what ways do psychiatric treatments shape or influence personality and behavior? The conclusion must be that psychiatric treatment, at best, smothers any further self-knowledge and stunts psychological growth. It makes the person forever dependent upon the psychiatrist and the psychotropic medication prescribed. It does not matter if improvement means only a reduction in symptoms. When their condition seems to worsen, do they question the treatment or the psychiatrist? No, because the psychiatrist is supposed to be the ultimate authority and it would be foolish to question such an awesome expert. Their hope that someone might listen to them as they would any other human is dashed. Their belief in their own ego, their longing to fulfill their dreams, their willingness to take the risk of adventuring, their independent existence as a human being is dead. These very results of psychiatry are haled as a miracle of modern medicine by the shallow media. Coming to the rescue of this psychological doom is an amazing finding that emerged when an innovative program was introduced into a juvenile delinquent correctional institution. As I noted at the beginning, juvenile delinquents who had been given psychotropic medications for chemical imbalance in the brain showed minimal change in behavior. When the structure of the institutional environment became more positive and supportive and positive, responsible behavior was approved and rewarded, these youths dredyoung Page 26 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc exhibited no abnormal symptoms indicative of disturbed brain chemistry. They no longer needed psychotropic medication. Obviously, a person"s personality is not as static as a diagnostic label would suggest. Furthermore, a search for causal explanations that focuses solely on the person"s behavioral patterns, on their past, or on their inner dynamics is far too narrow. The structure of one"s social environment provides a far better explanation and prediction of the status of one"s mental health than a psychiatrist"s diagnosis of the individual. In summation, this section on the features of psychotherapeutic modalities that are selectively related to the separate levels of the lower Pyramid revealed many deficiencies. I conclude that each of these modalities fall short of their goals. This is because they each focus too narrowly on one level of the person"s inner structures. They exclude the relevance of the other levels of structure within the person as well as the external levels of structure that also have major impacts on the person"s personality and treatment outcome. Understanding a person requires a multidimensional mental arena. Finding a successful treatment requires a multidimensional focus. It is hard simultaneously to focus on the inner person and their external world, on their own past and future, and on the past and future of their culture. It is even more difficult simultaneously to try to correctly guess or determine the mutual influences of factors in the structures of the external world and the processes of the internal world. If you are trained to focus one way, it is hard to adopt a different type of focus. If you are trained to focus in a unidirectional way and at one or only a few dimensions, it is hard to adopt a multi- directional, multi-dimensional focus. The era of the one-dimensional, unidirectional modalities, plus the medical model and its offshoots, has proven to be unequal to the challenge of dealing with the problems of individuals in this exceedingly complex, exceedingly fluid, and disturbed modern external world. While all of these therapies cited above offer something of value to clients, each modality in and of itself retains intractable problems. However, each of these more individually oriented therapies do contain some insights and techniques that are of unquestionable value. There are, nevertheless, four serious, intractable problems with them all. First, as was discussed above, psychotherapy is conducted in the cloistered one-hour session, while the majority of influence on the client is in the rest of the seven, twenty-four hour, dredyoung Page 27 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc days. Second, the inner intentional processes are addressed only accidentally, if at all. Third, practice of new, more mature behaviors or ego mastery skills does not become a significant part of these therapies. Fourth, and finally, while these therapies address specific precipitating situations or incidents, they do not address the powerful, indirect influences from the levels of external structures. External structures are the primary cause of immediate behavior. Internal structures, or rather intentional processes, are the secondary cause of immediate behavior. Autochthonous intentional processes are the tertiary cause of immediate behavior. Autochthonous, in this case, means that the cause of an act was mainly something originating in the person with minimal stimuli and instigators from the immediate environment, for example something creative, novel, or original. This is least reliable of all to be attributed to the person as the cause of their behavior. Nevertheless, however, behavior is most likely and easily to be linked to a person"s intentions. Typically, common sense and folk psychology is most likely to attribute the cause of action to be autochthonous due to a belief in free will. Hence we have the tendency to neglect External structures as significant causal factors worthy of consideration in explaining behavior or when making a diagnosis or prescribing a treatment. 4. There is a temporal dimension to the Duplex Pyramid Model and it can be used to describe intractable problems with psychotherapy that are related to altering longitudinal behavioral schemes There are categories of behavior that could be called longitudinal patterns. They are similar to a series of related behavioral skits that might recur throughout a movie drama. In a movie, such longitudinal patterns that might unfold over months or years in real life are compressed into two hours, making it much easier to grasp the concept. In real life, some such patterns could be related to a person"s long-term objective or even life"s goal. The acts or skits required to realize the objective are sequentially strung out in segments or phases over time. This is often seen when a character in a movie is a clever manipulator, enacting each different, brief skit as part of a longer devious scheme. Each skit at each stage could be enacted with a different person, but they are essentially either a dredyoung Page 28 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc variation of the same skit or different skits designed to reach the same end. On the other hand, each variation of the same skit could be repeatedly enacted with only one or a few people, for example one or a few family members. The skit may be slated to appear only when the time is ripe for that version of the skit or scene. Imagine, for example, a teenage trying to manipulate both parents. For one instance of their scheme, they have a skit that is designed to play one parent off against the other in hopes of getting their way. For a second instance, they could alternate their skit between parents. Yet, the goal of the scheme could be roughly the same in each instance. Very sharp parents may be able to figure out that they are both being played. Cognitively, detecting such patterns is a task that is next to unattainable in the one hour a week sessions of psychotherapy. Yet, it is easy to see that absent an addressing of this tricky pattern in the therapy hour, little progress will be made with respect to relations with parents or with respect to detecting and altering manipulation schemes. As noted, these longitudinal patterns are even more difficult to detect in real life. To deal with this sort of thing in traditional psychotherapy is nearly impossible. The obvious reason for this is that the client tends to focus on each skit or bit of behavior separately, without reference to its role in the longer sequence. From another point of view, it is extremely unlikely that the client will see the whole pattern with its inclusion of both parties in the dyadic interaction. How often do you have a client describe interpersonal interaction from the viewpoint of the other party? The therapist might point this out, but does the client listen or buy it? Therefore, with respect to this category of behavior, it is next to impossible for the client, much less the therapist, to call up, during any one session, each longitudinal instance that unfolds scene by scene, stage-by- stage, perspective versus perspective, over a much longer period, as for example, months or even more. Is it not of a far more serious consequence that such patterns are very unlikely to be amenable not just to detection but to change when played out in the natural environment over long periods? It is necessary to find a way to review each instance as a part of an entire longitudinal behavioral pattern. It is necessary for the client to grasp the unconscious function, goal, and covert significance of this scheme. The therapeutic purpose of doing that would be to compare repetitive or devolving instances across the longitudinal dredyoung Page 29 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc path, grasp how they dovetail toward a dénouement or climax, imagine alternative criteria for fulfillment, imagine alternative patterns and their mutual effects in dyads, and practice, implement, and maintain these more positive alternatives. This is what solid progress would mean. On the other hand, these longitudinal patterns are more readily detected and dealt with in the closed institution. Paradoxically, it is unnecessary and even counterproductive to do so if the institution has a program like "Stars and Stripes". The reason for this is that the Natural Systems program in the closed institution is designed to facilitate acquisition of positive ego mastery skills and foster personal growth and maturity. As this takes place, the need for such longitudinal schemes is supplanted by the more mature coping and ego mastery skills. If one enters into and gets a realistic perspective on the longitudinal concept, whether it be an isolated scenario within or an entire longitudinal pattern, it is easy to see that this is beyond the capacity of clients in hour-a-week sessions. It is impossible for them to focus on each and all of the relevant problematical instances of such patterns as they occur in the midst of the fast flow of life in open society. Nevertheless, doing this is crucial to long-term success in therapy. To assist in solving this problem, a chronology of experiences, insights, feedback from other participants, and practice can be recorded throughout the course of the Group. In the open, natural, social environment, participants in a Natural Systems Group can use various techniques to record their progress over the life of the group. These techniques create a chronological record of a participant"s events, actions, insights, exercises, practice, and progress that unfold in concert both within the Group and in their daily life over the course of treatment and even afterwards if they so wish. 5. The Intentionality Model: Introducing that part of the Natural Systems approach that integrates the top and bottom pyramids and the temporal or longitudinal perspective A few early psychoanalysts had discussed the "will". However, intentionality, as a set of sequential processes each of which could be addressed with specific techniques, has never been addressed. The separate, descending, levels of the bottom pyramid were shown to be dredyoung Page 30 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc related to corresponding psychotherapeutic modalities. The Intentionality Model and its processes will be elaborated later in this document. For now, I will simply point out the powerful role of the Intentionality Model in the Natural Systems" therapeutic approach. Each of the separate processes of intentionality can be treated using collection of tailored therapeutic techniques. Another important feature of the intentionality processes is that their methods of treatment can come largely from aspects of the top pyramid. This feature will also be discussed in detail later in this document. Looked at from inside the Intentionality Model out, its processes serve to store and integrate the inner and outer observations our world. Looked at from the outside in, the intentionality processes can be seen to be influenced by aspects of the levels of the external world. Those aspects of the external world can be redesigned to have a therapeutic effect on the intentionality processes. The most powerful characteristic of the therapeutic approach that Natural Systems uses with intentionality processes is that it does not have to be oriented to treat illnesses, disorders, or psychological illnesses. Rather, this approach is oriented to designing structures that elicit growth in traits we associate with increased levels of maturity. In other words, this is a positive psychology. B. The Evolution of Mental Health Treatment and the Objectification of Man III. The Evolution of Mental Health Treatment and the Objectification of Man A Historical, Systems-Structures-Processes Approach List of Contents 1. THE EVOLUTION OF THE TREATMENT OF MENTAL ILLNESS FROM THE DAWN OF HISTORY 33 2. THE ANCIENT TRENDS MEET A DEAD END 34 3. A DOOR TO A PROMISING NEW APPROACH TO TREATMENT CLOSES 35 4. FROM MEDIEVAL TIMES TO EARLY AMERICA, THE MENTALLY ILL TENDED TO BE DEMONIZED 35 5. THE MODERN PARADOX: BAD PERSON OR BAD STRUCTURE? 36 6. STAR CROSSED HISTORICAL AND AHISTORICAL APPROACHES 36 7. WESTERN OBJECTIFICATION OF PATIENTS IN THE TREATMENT OF EMOTIONAL DISTURBANCE 37 8. PSYCHIATRY CREATES A HANDBOOK WITH A TAXONOMY OF MENTAL ILLNESSES 37 dredyoung Page 31 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc 9. THE RISE OF PSYCHIATRY AND THE RISE AND FALL OF PSYCHOTHERAPY 39 10. PSYCHIATRY"S ROAD FROM ASCENDANCE TO PREEMINENCE 39 11. CARL ROGERS BUCKS THE OBJECTIFICATION TREND 41 12. HUMANE ROGERS OPPOSES OBJECTIFICATION BUT STAYS IN THE CULT OF THE INDIVIDUAL 42 13. WHAT IS REQUIRED TO OVERCOME THE CULT OF THE INDIVIDUAL 43 14. THE PERSON BECOMES THE LABEL :: THE LABEL BECOMES THE PERSON 44 15. THE CULT OF THE INDIVIDUAL IS REINFORCED WITH DIAGNOSTIC LABELING 44 16. MENTAL HEALTH SUFFERS A HOSTILE TAKEOVER BY THE CORPORATE MENTALITY 44 17. PHARMACY, INSURANCE, AND NOW JUSTICE SYSTEM REINFORCE PSYCHIATRY"S PREEMINENCE 45 18. PSYCHOTHERAPISTS PLAY-FOLLOW-THE-LEADER WITH PSYCHIATRISTS 48 19. PSYCHIATRY GETS PHYSICAL AND PSYCHOTHERAPISTS TRY TO TAG ALONG 48 20. EVOLUTION OF MENTAL CARE DURING THE SECOND HALF OF THE TWENTIETH CENTURY 49 21. ERAS OF MENTAL HEALTH CULTURE FROM THE PERSPECTIVE INSURANCE REIMBURSEMENTS 52 22. QUESTIONING THE 'PERSON AS OBJECT' IN AMERICA"S NEW MENTAL HEALTH CARE SYSTEM 58 23. STIGMATIZING BECOMES FASHIONABLE IN TV ADS AND SWEEPS ACROSS AMERICA 59 24. NAME CALLING REINFORCES PRESSURE FOR CONFORMITY VERSUS TOLERANCE 61 25. THE MODERN ZEITGEIST OF "SIGNS" 62 26. WHAT IS CHEMICAL IMBALANCE IN THE BRAIN ANYWAY? 62 27. MODERN LIFE STYLES CREATE A GENERATION ADDICTED TO PILL POPPING 63 28. FROM PILL POPPING TO PILL HOPPING 63 29. PSYCHIATRY"S MODERN PATERNALISTIC POSTURE 63 30. ON THERAPY AND BEING A PATIENT UNDER THE NEW LORDS OF THE MIND 64 31. THE PUBLIC HAS UNWITTINGLY ABDICATED ITS AUTONOMY 65 32. HOW THE MEDIA KEEPS THE MEDICAL-INDUSTRIAL-COMPLEX WHEELS WELL GREASED 66 33. A CULTURAL ANTHROPOLOGIST ASKS, "WHO IS REALLY SICK HERE??" 66 34. HOW CAN THE CONCEPT OF STRUCTURE PLAY A ROLE IN MENTAL HEALTH? 68 35. THE DIALECTICAL TENSION BETWEEN SOCIAL STRUCTURES AND INDIVIDUAL FREEDOM 69 36. A NEW PROPOSED GOAL WOULD BE FACILITATING MATURATION VERSUS CURE SYMPTOMS 69 37. PRESCRIBING ALTERNATIVE METHODS TO RECOVERY FROM OUR CULTURAL SICKNESS 69 dredyoung Page 32 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc 38. WAYS OF RELATING IN TYPES OF ROLES AND RELATIONSHIPS IN THE NEW MENTAL HEALTH SYSTEM 69 39. TO REVERSE THE OBJECTIFICATION OF MAN: RESPECT THEIR TOTAL INNER PERSON, LIFE HISTORY, LIFE CIRCUMSTANCES, AND INTENTIONS 69 40. ALL OF THIS BEING SAID, WHAT DO WE DO NOW? 69 1. The Evolution of the Treatment of Mental Illness from the Dawn of History Over many millennia, modern humans, with the help of languages, gradually developed civilizations. Sometime after people in Western Civilization began to write, a few began to record histories. Eventually they began to philosophize and record their philosophies. Among other things, they philosophized about the origin and nature of their external world. After the introduction of numbers, perhaps over five millennia ago, they eventually began to quantify. Quantification assisted with trade and commerce, building, and defense, and eventually with government for tax and census purposes. The use of words eventually led to trying to name persons" positions in a tribe or community and to trying to describe one another and, finally much later, there were even attempts to develop taxonomies of types of people. The pairing of quantification with construction, commerce, and all of the other externally observable aspects of the world was extremely successful. Their observations of the physical world led to, or improved, suppositions about cause and effect relations. Physical causes began to replace supernatural causes, at least among the intellectual elite. Since the supernatural had been assumed to cause effects in the physical world, it was natural to assume that it caused bizarre, disapproved, behaviors. Religious rituals had been used to try to exorcize the evil spirits, which they presumed to be the cause of those bizarre, disapproved, behaviors. It was natural for intellectuals to begin searching for physical causes of and cures for what they felt were bizarre behaviors, whether demons were involved or not. Trepanning, primitive surgery on the brain, in use for millennia, had begun to be used as a physical cure for bizarre behaviors caused by demonic spirits. It was supposed that trepanning might release the demons from the brain. Within some groups of people during these ancient days, their religious leaders had even recommended beating the person to drive out the evil spirits. Early on, the Greeks began to reject the notion that demonic spirits caused mental illness. They developed rudimentary taxonomies of mental illnesses and prescribed the application of external treatments such as dieting, rest, exercise, and the like. In a quantum intellectual leap, but without totally rejecting earlier notions, Plato, circa fourth century B.C., put forth the idea that childhood experiences shaped adult behaviors and this hinted at a new form of causation, psychosocial causation. 2. The Ancient Trends Meet a Dead End Note the sequential trend of this long drawn out historical evolution with respect to the cause and treatment of bizarre and disapproved behavior. The earliest attempts both to understand and to treat bizarre people initially focused on: a) supernatural causes and treatments b) supernatural causes with physical dredyoung Page 33 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc c) objects having supernatural powers as treatments d) a combination supernatural causes and physical treatments e) a more sophisticated physical treatment that involved the use of trepanning to either fix the brain or release evil spirits f) much later, the next development was the creation of rudimentary taxonomies bizarre and incomprehensible people and the use of more benign physical treatments that did not involve the supernatural g) Finally, Plato sought understanding or explanation of bizarre and disapproved behavior in a causal relation between childhood experiences and adult behavior. The latter somehow did not spark a movement to develop a new discipline designed to explore what kinds of early childhood experiences produced bizarre adult behavior. The Greeks of his day, unfortunately, were not inspired to explore how negative early conditions could be replaced with positive ones. 3. A Door To A Promising New Approach To Treatment Closes The focus during Plato"s period of history was on the person. Plato"s novel explanation was a tiny "crack in the door" could have led to explanations of bizarre behavior oriented toward aspects of external structures of the social world. Taking this perspective might have provided clues as to what the primary causal influences might be. Certainly the dramatist"s plays during these centuries were alive with powerful illustrations of how early childhood experiences influenced adult behavior. This tendency could have opened the "crack in the door". It did not. 4. From Medieval Times to Early America, the Mentally Ill tended to be Demonized In Medieval times, the mentally ill were regarded as possessed by the devil or evil spirits. Their nonconformist acts could often be regarded as sin. The treatment was to pray for them and preach at them at first. If that did not work, they might be subjected to exorcism or even burned at the stake. In the early days of America, the mentally ill, or sinners, might be regarded as possessed by evil spirits or the devil. They could be regarded a witches and put on trial and even hanged. Exorcism might be tried or they might be shunned, ostracized, cast out of town. Later, particularly before the Civil War, bizarre behavior at religious revivals was often regarded as being possessed by the Holy Spirit. At other times, they could be treated by the ritual of "laying on of hands". In the latter part of the 19th century, hospitals for the insane were built, especially in cases where families needed to be relieved the burden of caring for them. There was an attempt to treat them humanely, provide moral instruction, and teach them a trade. These Asylums took care to treat them with respect and to avoid restraints or physically abusive treatment. Innovative forms of medical treatment were tried to no avail. Eventually these Asylums became overcrowded and degenerated into mere custodial care. Then, at the end of the 19th and beginning of the 20th centuries, medical doctors were evolving into psychiatrists. Europeans began to make close careful observations and developed rudimentary classification systems. They also dredyoung Page 34 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc began studying autopsies of the brain to try to determine if brain abnormalities or lesions might be the cause of mental illness. Again, these efforts met with little success. Mesmer and his star pupil Freud began the first truly psychological approaches to treating the mentally ill. Freud"s incredibly astute observations of his patients" discourse during hourly sessions, five days a week led to his theory of psychoanalysis extensively described in his many books. These books had great appeal to the medical community and even non-medical intellectuals. His works eventually led to the initial rise to prominence of psychiatry. Different schools of psychiatry evolved. The difficulty of practicing psychoanalysis in mental hospitals led to their being replaced with more physical, less labor intensive methods like using drugs, electroconvulsive therapy, insulin-induced comas, and surgery such as lobotomies. Drugs only gained popularity after World War II. From then up to the 1950s the drugs of choice were sedatives. By 1952, psychiatry had a fairly elaborate manual for the classification of mental illnesses. On the heels of the rise of psychiatry, social work entered the picture in order to assist psychiatrists in the documentation of case histories but, most importantly, for the management of patients. 5. The Modern Paradox: Bad Person or Bad Structure? To this day, the paradox remains that while mental health professionals explore life or social histories to understand the patients they classify (classify now equals an elaborate taxonomy of mental illnesses or diseases), they, nevertheless, treat "patients" as though the locus of the illness is in the person"s personality. Life histories are perused and then set aside. Usually a life history includes a description of the patient"s parents and extended family; their ethnicity; whether there were divorces; remarriages; serious physical or mental illnesses, deaths; substance abuse; incarcerations; degree of poverty; and whether the family had been on welfare. Also included were descriptions of the general life conditions or environment, for example the types of neighborhoods, in which the patient grew up. It may also include the schools the patient"s had been enrolled in and problems with school, agencies that had been involved with the patient, and their work history. Oddly, for the psychiatrist"s diagnosis and prescribed treatment, the person is virtually ahistorical, as though existing in a psychosocial vacuum. The patient is treated as though problem lies not in the past but in the way the person, the patient, is at present. The present pattern of behavior is the problem and nothing else need be considered. The cause of the problem is the person, that is to it say resides inside the person. Bizarre acts are considered generated by something within or intrinsic to the person and influences of external structural factors are subtracted out. With this way of framing the question of cause, the alternative explanations intrinsic to the person are narrowed to a defect in the brain, with a genetic version of the "bad seed", or some intrinsic proclivity to act in their particular bizarre, disturbing manner. In other words, they either have an "illness" or there is something wrong in their personality. Vestiges of the medieval days and Puritan America have merely evolved into the person with behavior that is discomforting to others, essentially, having a "bad" personality, or being diseased. Bad structure and bad history simply do not enter into the equation. dredyoung Page 35 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc 6. Star Crossed Historical and Ahistorical Approaches Contemporary mental health professionals, particularly psychiatrists, typically treat patients as though the mental illness is due to an imbalance in brain chemistry. An imbalance in brain chemistry is cited as the physical, inner cause of the pathological behavior. Yet, paradoxically, they use life histories as a kind of backup source of validation of their judgment, perhaps as a form of professional insurance, if you will. Initially, their modus operandi, therefore, is simultaneously historical and ahistorical. The historical part, however, somehow surreptitiously slips behind a shroud, never to be invoked again. The historical aspect certainly will be unlikely to be invoked as explanatory when called to testify as an expert witness in a court of law. Consequently, that early Platonic tiny "crack in the door" that could have opened the way to exploration of current external structures and early life conditions or experiences as the primary causes of mental illness or behavioral aberrations has remained just that, a once tiny "crack in the door" that has remained tightly closed. Those contemporary iconoclastic protagonists who would open the door to exploring life histories, social influences, and current external structures as plausible explanations and guides to effective treatments continue to bang their heads to no avail against that ancient "door". 7. Western Objectification of Patients in the Treatment of Emotional Disturbance The tendency to regard mental illnesses as having physical causes entails looking at humans who exhibit unusual and disturbing behavior as objects. Early Western Civilization, that so successfully looked "objectively" at their physical world, also looked in the same way at their fellow humans, yet, I sadly suspect, misunderstanding them. They looked at physical objects, things, and saw ways to invent and transform matter and nature into irrigation ditches, crops, swords and projectiles, wheels, maps, coins, arches and towers, and the like. It is impossible to empathize with persons when taking this "objective" perspective. When focusing on the physical aspects, such as behavioral patterns, samples of blood, or PET scans, in order to explain and attempt to heal emotional disturbance, understanding how the person feels and sees their world is irrelevant. The psychiatrists" mentally deranged fellow humans intransigently resist this impersonal approach to helping them. Nevertheless, because of the logic of social roles, those in the role of healer are automatically considered experts and authorities into whose hands the patients must yield their trust. Patients have always had to submit to being treated as objects when involved in this stratified role structure. Humans have a strange capacity simultaneously to inwardly resist and outwardly submit to an authority"s dominance with respect to diagnosis and treatment. 8. Psychiatry Creates a Handbook with a Taxonomy of Mental Illnesses Following in those early traditions, psychiatry"s contemporary taxonomy of mental illnesses helps lend credibility and expert status to this "objectification" aspect of their dredyoung Page 36 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc endeavor. Around the beginning of the twentieth century, psychiatrists had begun to create a rudimentary taxonomy with about twelve diagnostic labels. They appeared to allow the psychiatrist to look, seemingly objectively, for patterns of behavior that fit the criteria for some diagnostic label in the taxonomy that they think might apply in this case. Add to this the fact that pharmaceutical medications have been developed specifically for particular labels in the diagnostic handbook. That is to say, in psychiatric parlance, if you have such and such label of mental illness, you need such and such medication as the treatment. Psychiatry, insurance companies, and the pharmaceutical industry have to have a uniform standard of determining whether treatment is appropriate and justified for the type of illness and whether the fees for reimbursement justifiable and reasonable. To accomplish this uniformity the psychiatrists are required to assign the patient a label taken from the taxonomy of mental illnesses in the American Psychiatric Association"s "Diagnostic and Statistical Manual of Mental Disorders" (First Edition 1952). This diagnostic manual has grown from 60 types of mental illness in 1952 to 374 diagnostic codes by the year 2000. As the maladies multiplied, so did the psychiatrists" patient loads. The patient is given a particular label because he or she seems to fit some of the patterns listed as the criteria under a diagnostic category. The patterns subsumed under the label, which are the criteria for ascribing the label, are now assumed to be the actual characteristics and patterns of the individual. Now the patient "becomes" that label and that assessment is solidified when the appropriate kind of treatment is chosen and the matching psychotropic medication is prescribed. Since these uniform standards unanimously are agreed upon by the giant three industries, an air of unquestionable authority and legitimacy has formed. So how did this classification system come about? As mentioned above, this was a gradual process with the psychoanalysts being the progenitors. However, to create the taxonomy for their diagnostic manual, psychiatrists formed a group of esteemed colleagues from the American Psychiatric Association. These leaders came together and laid out their collective knowledge of mental illnesses. They first agreed on a uniform terminology. Next, they honed from their observations of patients those whom they felt had similar patterns that could fit the various diagnostic labels. Next, they further refined the characteristics of each type of mental illness into what they felt would turn out to be universally acceptable to their fellow psychiatrists and called these characteristics, or patterns, the criteria for assigning each diagnosis. Over time, they organized the types into major categories and subcategories and these names rapidly began to be used until almost all of their fellow psychiatrists were familiar with them. Finally, major categories and subcategories were given a numbering system to be used as codes, similar to physical illnesses. The codes came to be submitted to the insurance companies for reimbursement. The diagnosis, code submission, and reimbursement process became standard and routine and paved the way for psychiatrists eventually to branch out into private practice. A major problem with this taxonomy was that it was not quantified or validated. Since each psychiatrist made their observations of a small sample of their patient"s behavioral patterns, how could they be sure that this sample was representative of the full range patient"s behavior and not just an aberration? Actually, in most cases the psychiatrist relied upon the patient"s self-report in the interview. Occasionally their diagnosis was based on anecdotes provided by family members. There was no way to dredyoung Page 37 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc validate these informal reports. In addition, in spite of the attempt at precision in developing criteria for assigning labels, one could never be sure as to whether what they were observing and concluded matched what the framers intended. To correct this problem of ambiguity, many studies using "validated" psychological measurement instruments were designed to test the degree of correspondence between the psychiatrists" diagnosis and scores on the measurement instrument. Unfortunately, these studies were seldom well designed and rarely resulted in a statistically significant outcome. In spite of and because of the persisting ambiguity problem, clinical psychologists became occasional handmaidens to psychiatrists by backing up their diagnoses with these objective measurements of validated clinical personality assessment instruments. This was a very loose procedure but soon the two groups began to develop a common language and consensus so that they usually approximately made a match. In an attempt to gain credibility, there were also a few experiments designed to hypothesize how a person with a specific diagnosis would behave in an experimental condition. The experimenters must guess what conditions or situations might evoke their symptomatic behavior. If their hypothesized behavioral reaction occurred in this condition, they would conclude, erroneously, I feel, that their diagnosis was validated. These, too, seldom provided support for the taxonomy and the psychiatrist"s methods of making their diagnoses. A fatal flaw with such experiments is that the experimental condition is probably not even close to the kinds of situations that evoke the patient"s characteristic symptomatic behavior. In the end, psychiatrists had to settle for trusting their individual judgment and hope others, particularly insurance companies, did as well. It revealing statistic late in the twentieth century was the way the frequencies of diagnoses clustered demographically. The number of diagnostic labels assigned in one region in relation to the population of that region differed widely when looked at across regions. This suggested that assigned diagnoses were more a function of consensus among the psychiatrists within a region than accurate parings between diagnostic criteria and the actual characteristics of their patients. Also revealing is the way, in the latter part of the twentieth century, frequencies of diagnoses varied precisely with changes in the diagnoses for which Managed Care organizations were granting reimbursement. 9. The Rise of Psychiatry and the Rise and Fall of Psychotherapy Psychiatry had succeeded in becoming dominant among the mental health professionals, helped greatly by the American Psychiatric Association"s DSM-III-R Manual for diagnostic classification and the widespread use of psychotropic medications. Due to the higher cost of seeing a psychiatrist, insurance began to favor non-medical therapists such as social workers, clinical psychologists, and psychological counselors. The founding fathers of mental health treatment, the psychoanalysts, and their progeny, the psychotherapists, began to recede from prominence and popularity in the public mind. Psychiatry, seeing this shift to non-medical therapists as a threat, seized the opportunity that psychotropic drugs, coupled with their Manual"s diagnostic codes, offered. Being the only one that could prescribe medications, psychotherapists had to become subordinate to psychiatry and receded from prominence. Psychiatry"s rising success had been like an earthquake of history, which transformed the entire dredyoung Page 38 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc mental health landscape. Therapy was leaving behind the tradition of sitting with patients or clients for an hour or more a week sometimes for years while patiently listening to them. Psychotherapists had had their heyday of empathically listening to their clients talk out their personal and interpersonal conflicts, resolve their self doubts, gain insight into their defenses, confront their inner demons, ventilate suppressed feelings, experience catharsis, and abreact old traumas. Because of these dramatic changes, psychotherapists made efforts to ally themselves with this breed of healers that was dominating the landscape. Psychotherapists too shifted to using rapid diagnosis. Next, they attempted to gain the legal privilege of committing patients to psychiatric hospitals and prescribing medications. Their efforts were in vain. They began a tragic journey into near obsolescence. Their numbers as private practitioners gradually declined. Their decimation, however, was to come later. 10. Psychiatry"s Road from Ascendance to Preeminence It is important to examine the foundations of this new and dominant mental health professional. In the beginning, psychiatrists, with intuition as their main tool, primarily worked in state mental hospitals, which in effect were giant warehouses for society"s outcasts. Psychiatrists were aided by the fact that their ancestors, the psychoanalysts had written a plethora of books on patients with unique abnormal symptoms and patients whose personalities and symptoms were common. Paranoia, anxiety, phobias, social withdrawal, compulsions, impulsivity, depression, mania, psychosomatic illnesses, conversion reactions, physical disorders caused by psychological factors, various types of psychoses, suicidal tendencies, identity confusion, amnesias, and a variety of other personality disorders had been exhaustively written about. There were major differences as to the etiology and dynamics of these types but there was consensus about the existence of the types. Psychiatrists were now widely employed in state mental hospitals, adult prisons, and juvenile institutions. By the 1950"s, they had developed rudimentary techniques such as structured interviews for quickly identifying or diagnosing the familiar types of patients. They were successful in using clinical psychologists" personality tests and social workers" life histories to back up their diagnoses. They had become "an establishment". Parallel to the evolution of psychiatry, the pharmaceutical companies had had early success with a few tranquilizers. These tranquilizers reduced symptoms, particularly in psychotics. Selecting the appropriate tranquilizers for the different types of psychotic patients was difficult and was more an art than a science. Initially this was not too difficult since diagnoses had not yet multiplied and there were as yet only a few tranquilizers. One of the most often prescribed of the patients" medications was called Thorazine and this usually resulted in a calmness that made patients much easier to manage. A major problem was that the medications often caused severe and sometimes painful or immobilizing side effects. Yet there was exhilaration from their success and psychiatry and the psychotropic drug industry developed an immediate affinity. In those early days, this great excitement in both groups gave them confidence to branch out. This motivated the psychiatrists to build private psychiatric hospitals. These new hospitals were used mainly by the rich who had family members with bizarre dredyoung Page 39 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc and embarrassing behaviors. Insurance companies began to write policies for care of the mentally ill in these private psychiatric hospitals. It was a profitable relationship. Since a rudimentary diagnostic manual was in use, it could be codified and the code submitted to the insurance agency just as physicians did when filing for reimbursement for treatment of physical diseases. This made the practice of psychiatry as legitimate and professional as the rest of the medical professions. As the numbers of psychiatrists graduating from psychiatry departments of medical schools rapidly increased, positions with state mental hospitals were no longer an option and therefore most newly graduated psychiatrists went into private practice. The public was accustomed to the hour a week talk therapy in vogue for psychoanalysts and psychiatrists. Therefore, in the late 1950s and through the 1960"s, this new breed of psychiatrists offered one from among the many the popular psychotherapeutic modalities to their patients. However, having been schooled in how to assess presenting symptoms and quickly diagnose, they supplemented their therapy with prescriptions for psychotropic medications. For the most part, their patients came from wealthy families. When the lower upper class and upper middle class caught on to what their wealthier acquaintances were doing, many of them sought treatment as a mark of social status. Along with this trend came a sharing of their experiences in therapy with one another and it was natural to share the medication their psychiatrist "had them on". At this juncture, psychotherapy and counseling were common in universities and community mental health clinics. Psychotherapy had found a way to share, to some extent, the aura cast by psychiatry. Psychotherapists, also, began to move into private practice and eventually reimbursement by insurance companies was routine for them as well. Holding themselves out as being nearly on a par with psychiatrists, they asked for comparable reimbursement. To receive reimbursement, they too had to include psychiatric diagnostic codes in their forms for reimbursement. Clients of psychotherapists usually knew what diagnostic label they had been given. They shared their labels as well as the names of their prescribing psychiatrist and their medications as though these gave them some exotic form of status. Psychiatric diagnosis and prescription was a rapidly growing social movement. The language of diagnostic labels and psychotropic medications became a common language in the culture. By the 1970"s the majority of Americans were familiar with a wide range of labels and medications. The inherent fuzziness of the process of diagnosis, the process of assigning labels with their subsumed criteria and matching these with appropriate medications ceased to be a concern. The mindset of psychiatry was now ingrained in our culture and accepted as "reality". If one"s psychiatrist said it, it was bound to be true. However, new problems with insurance companies" policies, costs to corporate America, and cost of prescriptions, federal health programs, and percentage of the Gross National Product spent on healthcare all combined to challenge and undermine psychiatry"s preeminence. In addition, an awareness of widespread off-the-cuff labeling just to make sure they were reimbursed and the way labels varied arbitrarily and chimerically across doctors, regions, years, and with whatever were in vogue and reimbursable at the moment became glaringly in evidence. Noticing these trends throughout America"s institutions meant that harsh changes were just over the horizon. dredyoung Page 40 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc 11. Carl Rogers Bucks the Objectification Trend Bucking the objectification trend was the psychotherapist Carl Rogers who came to fame in the late fifties. Rogers took no life histories; did not use psychological assessments; did not rely on medications; made no prescriptions of any kind for treatment; refused to use the label "patient" and used the word "client" instead; did not diagnose and give clients a diagnostic label; did not regard clients as having an "illness"; did not assume an expert posture in relation to his clients; and instead of any form of structured psychotherapeutic modality he used what he called a non-directive, empathetic approach to his clients. His was the only type of therapy that posed a real alternative in this rapidly expanding movement to professionalize the treatment "mental illnesses. Beginning in the fifties and reaching its peak of popularity in the sixties, it was doomed to fade as the numbers of certified psychiatrists burgeoned. With the success of certified psychiatrists, psychotherapists pushed for their own certification. Rogers sternly warned that this would spell the end for quality psychotherapy and respect for and humane treatment of clients. In other words, he was sounding the alarm against what he saw as the inevitable "objectification" of man. His colleagues in the psychotherapy field did not (or would not) see the danger of objectification implicit in his warning. Rogers had had also encouraged all those who wanted to be psychotherapists to undergo psychotherapy as clients themselves. He could foresee how certification would cause psychotherapy programs in graduate schools to create required courses that bright persons with unhealthy personalities, unsuited for the role of therapist, could easily pass. Such programs would not have to require candidates to undergo therapy. This would lead to candidates passing all required courses and being certified without working through their own personal problems. This had occurred in psychiatry when it created the requirements and exams to become Board Certified Psychiatrist. Any medical doctor who had fulfilled all of the requirements but had not passed the Board could still be and hold himself out to be a psychiatrist. Unfortunately, neither Board certified nor non-Board certified psychiatrists had to undergo therapy. Later this would repeat itself for Clinical Social Workers and Licensed Professional Counselors, as well as Clinical Psychologists. In addition, without this experiential aspect, they could graduate without having a feeling for what it is like to be a client. Certification without undergoing psychotherapy, he felt, would lead to a dominant, stratified, impersonal role relationship vis-à-vis the client. Because of his certified expertise, the professional could claim to have superior knowledge of the client"s problems. These professionals would be likely to feel free to exert control over their clients" lives. For Rogers, no one should have a license to direct another"s life and usurp their will or self-determination. For Rogers, no one could know better what the client was feeling than clients themselves. The certified therapist could feel they had the credentials that authorized them to analyze, assess, and examine the client just as one does a bug in a laboratory. Treating clients as objects could lead to all sorts of legitimized abuse of clients. Rogers sensed, or rather foresaw, that this would lead to sinister consequences for clients. Furthermore, he sensed sinister consequences for all humans if, and wherever, the objectification-subordination trend became dominant. dredyoung Page 41 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc History is full of cases that would support his fears. Empathy makes regarding the person as an object impossible. 12. Humane Rogers Opposes Objectification but Stays In the Cult of the Individual Rogers focused on the client"s feelings. In addition to the catena of things in the paragraph above that he resisted was attention to external structures and systems as causal factors in emotional disturbance. Naturally, that omission also entailed that one not use the redesign of structures to overcome emotional and behavioral disordered and to promote positive personal growth. However, he did address and write on the topic of management of organizations to promote empathy, mutual regard, and personal growth. This document was virtually ignored even by devoted Rogerians. While this document was concerned with organizational climate and a new philosophy of administration, it mainly focused on the individual person. Before the total triumph of objectivistic psychiatry, several renowned psychoanalysts, for example Harry Stack Sullivan, had begun to emphasize the "structure" of the therapist-patient relationship. This movement was also short-lived. Subsequently, there was period during which those who engaged in research of psychotherapy modalities and the psychotherapist- client relationship. They found that the quality of the relationship was the greatest determinant of success with clients. They enumerated certain critical qualities exhibited by successful therapists. This endeavor, seemingly having exhausted its run of valuable and undisputed findings, subsided into books on the history of psychology. The corner of psychiatrists" objectivism and quick and easy pharmaceutical cures had been rounded and won the day. Sadly, Rogers did not see that empathy could and should include both an attempt to understand how a person perceived and reacted to the conditions and structures of the life in which they were imbedded. Conceptualizing how social structures could be redesigned and conditions could be created to foster positive, mature growth was far beyond Rogers" field of vision. 13. What is Required to Overcome the Cult of the Individual Both empathy for the individual and understanding of the structures in which their life is imbedded are necessary to overcome the cult of the individual. Why is this so difficult? Here is the problem with which we are faced. First, clients are limited to what they have experienced just like everyone else. Second, Rogers" non-directive, feeling oriented therapy, therefore, entailed the critical limitation of not addressing external structures encompassing individuals. Clients may lack awareness of what behaviors are causing them problems; lack knowledge of behavioral possibilities; lack knowledge of the consequences of types of interpersonal interactions or scenarios; and lack knowledge of the way different factors in structures shape behavioral and emotional reactions or feelings. If this is the case, then solely empathically focusing on the client"s feelings limits their possibilities for acquiring new understandings of their world, new ego mastery skills to deal with their external structures, higher levels of maturity related to the many domains of their life, and increased personal growth for a full life in their world. From a different perspective, just as the theory of psychoanalysis was difficult to master, it seemed that Rogers" unique approach of empathic listening was difficult to dredyoung Page 42 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc master. Psychiatrists" prescribing psychotropic medications circumvented these difficulties. If Rogers" clients did not improve, the fault must lie with the therapist or his technique. If the psychiatrists" patients" symptoms did not subside, the fault lay in the medication and that could easily be changed. In the case of both types of therapy, the focus was on removing or reducing the problems "inside" their patients or clients. Their focus, therefore, was on the individual exclusive of the structures of their world that might be producing their problems. Supposedly, community psychiatry was designed to deal with such external structures. However, with the medical-prescriptive mentality of psychiatrists, and all other mental health professionals for that matter, these structures did not have to be addressed. None of the extant types of therapy found it necessary to assist their patients in understanding those structures and their impact or in finding ways to cope successfully with them. The cult of the individual was the status quo and remains so today. This was true of all modalities that came before and is true of all that came after them. The cult of the individual has yet to be overcome. i 14. The Person Becomes the Label :: the Label Becomes the Person These labels have even come to be regarded as not just a correct assessment of patterns or symptoms. Now a label is regarded as the "cause" of the pattern of behavior. The experts refer to the person (patient) by their label. For example, the patient is diagnosed as a Sociopath or Paranoid Personality, for example, and then he is discussed and referred to in terms such as "the Sociopath" or "Paranoid Personality". The person or patient"s actual patterns are now virtually discarded since it is much easier to deal with the label as shorthand for its subsumed defined patterns. It is much easier to adopt this shorthand convention of referring to patients using their label rather than their name and their unique patterns. When this convention is in use, the possibility that there is not, or very likely may not be, an isomorphic relation between the patient"s actual, daily behaviors and the label or criteria of the label is overlooked. Furthermore, there is a hidden assumption that all persons with that label are the same. Consequently, the individual"s patterns and even the defining patterns under the label are as good as discarded or eliminated from the conversation and only the label is dealt with. A person "has become" a label. In the next stage, the person not only "is" the label but now the label is treated as the "cause" of whatever referring behavior is under scrutiny. Precipitating conditions, circumstances, and structures are completely excluded from awareness. The collected life histories are stuck in the patients" file and forgotten as possible causal factors. Life histories and external factors are treated as superfluous and exempt from consideration. The cult of the person has triumphed! 15. The Cult of the Individual Is Reinforced With Diagnostic Labeling Under the reign of this objectification zeitgeist, the structures and systems that I regard as the ultimate causal factors in what are generally regarded as emotional, mental, and behavior disorders are never brought into consideration. Of course, this structuralist perspective would have been irrelevant in psychiatric cases, especially once a diagnosis has been made. Now, is some strange contortion of reason, the patient (person) "is" the label and, furthermore, the label "is" the cause. For example, if a dredyoung Page 43 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc person committed the act, once having been given the diagnostic label, the label is used as the explanation for the behavior. If he has that label, he has to have the patterns of behavior, has to be the kind of person who would commit that kind of act. Initially, he only has to have been reported to act that way in at least one instance to get that label. It does not matter that an instance does not constitute an observed, recurring pattern. If he has that label, he has to be the kind of person that would commit that act. No other causal explanation of the behavior need be sought, is required, nor is welcome. A quaint form of circular logic; is it not! For example, the defense attorney will argue that the accused committed the crime due to being a" ------ " (substitute here a label from the psychiatric taxonomy). In such cases, the defense attorney often will argue that, having his particular diagnosis, "he did it because he was off of his medication". 16. Mental Health Suffers a Hostile Takeover by the Corporate Mentality Ironically, we have an incipience of a cultural illness here. With the increasingly vast numbers of professional people involved in some direct way to a mental health industry that is increasingly generating new categories of mental illness and increasing percentages of the population to fill their categories, psychiatry itself is now subject to the ascription or diagnosis as a malignant cultural illness. Three interdependent industries are perpetuating the myth of mental illness and multiplying the numbers of patients who fill their coffers. These perpetrators responsible for this contagious cultural disease are the mental health professionals, the pharmaceutical companies that supply medicines that supposedly cure almost all entries in the psychiatric diagnostic handbook, and, in the background, the insurance companies that reimburse them. Together their triumvirate represents such a huge percentage of the US Gross National Product that Federal that legislators dare not ignore it. For the same reason they dare not deny the suggestions from their lobbyists for legislation that benefits them. While members of this medical-industrial triumvirate jockey with each other for their share, or more, of the financial pie, they keep a well-maintained and well-coordinated front for their mutual success and benefit. Beneath them are the disconnected, unsuspecting flock of patients who annually pay huge sums that are distributed among the big three. Patients have no lobby, other than frail, ineffectual ones like the AARP for the elderly, to vie against the overwhelming influence of the big three and their newest member that is Managed Care. The people do have a voice, albeit a small one, when the Democratic Party, the party supposedly of the people, is in power. When this happens, the big three, or four, bring out their full arsenal to prevent losing their advantage. In 1993, at the beginning of the Clinton administration, Hilary Clinton waged war with them, or rather their pawns in the legislature, to change all of that with universal health care and parity for mental illness. She fought a valiant battle but lost. Vice President Gore"s wife Tipper, and Congressman Wellstone continued to lobby the American people for mental health insurance coverage and parity through the media, but to no avail. 17. Pharmacy, Insurance, and Now Justice System Reinforce Psychiatry"s Preeminence dredyoung Page 44 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc In the case of both the diagnosis and the treatment, the person has become an "it". You need not try to understand the possible role of external structures, or even internal psychological processes. All that matters is that the psychiatrist gleans from self-reports, arrest records, or family anecdotes some patterns of behavior that match the criteria for one or more of the diagnostic labels. The label for this "object" is nailed! Now all you have to do is to determine where to commit him, what chemicals to inject in him, and to which program to assign him. If the "prospective" patient refuses to be committed voluntarily to a psychiatric hospital, the recourse for the family and/or the psychiatrist is to turn to a Justice of the Peace and get him to declare the person a danger to himself or others and/or declare the person non compos mentis. It is all an objective manipulation of an object. Strangely, the paradox mentioned above remains intransigent. The paradox remains because while mental health professionals explore life social histories to understand the patients they classify they nevertheless treat "patients" as though the locus of the illness is in the person"s personality. They act as though the illness is not in the history or structure of a person"s like. Rather, the illness is inside the person, minus influences of external structural factors and history. Currently, if the person is mentally ill: a) There is something physically wrong b) The physical cause surely has to be in the brain c) The problem or cause in the brain is an imbalance in brain chemistry d) An imbalance in brain chemistry requires a psychotropic medication e) Being prescribed a psychotropic medication is sufficient evidence to insurance companies that person has a mental illness and requires outpatient psychiatric treatment and/or hospitalization; f) Treatment by psychiatrists and their auxiliary therapists requires reimbursement by the insurance companies g) Psychotropic medication prescribed for treatment is to be paid for by the insurance companies. The result is a scaffolding of agreement concerning the nature of mental illness upon which a mammoth structure of collaboration between pharmaceutical, insurance, medical, and mental health industries is built. This scaffolding contains, yet conceals, the age-old paradox of the mixture of the historical and ahistorical. This fallacy must not be challenged and exposed or the scaffolding and edifice will collapse. Joining the pharmaceutical, insurance, medical, and mental health industries, justice system enters the picture and helps to validate the mental health-industrial complex by disallowing a defendant"s past as an explanation or excuse for their crime.ii The justice system further abets the mental health-industrial complex by disallowing the use of a psychiatric diagnosis as an explanation or excuse for a crime. The only exceptions are: a) If the defendant is a case of extreme mental retardation b) If the defendant clearly does not know the difference between right and wrong c) If the defendant is so obviously psychotic, that they cannot act in their defense and they cannot be held accountable for their actionsiii dredyoung Page 45 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc An unintended consequence of all of this is that when authorities, families, or enough people regard someone"s behavior as too bizarre, non-conformist, or disturbing, they are stigmatized as either criminal or crazy. It might be that they are not mentally ill. It might be that the structure of their world is a more than sufficient explanation for their bizarre behavior and offense. It might be that their life history, holistically considered, is a legitimate excuse. However, if the person is excluded from the normal conversational give and take, this evidence will not be considered. In this case, they are treated as though they are deaf, like a piece of furniture, an "object", an "it". Their exclusion from the conversation also prevents the history side of the history versus a-history paradox from seeping in. If defendants are either too vocal and articulate in their opposition to the judgments of the court or insufficiently vocal and articulate, a pronouncement of non- compos mentis can be made and this discredits their opinion. One or the other is almost always the case, consequently defendants are discouraged from acting in their own defense, and their attorney speaks for them. Since one of the criteria for participating in a trial is that, the defendant understands the meaning and significance of what is said in the proceedings. A ruing against non-compos mentis means that, in a legal sense, the defendant does understand. This is prima facie rather absurd since almost no one, other than the lawyers, understands what is being said or what is transpiring. As this is the usual case, it is inevitable that the defendant be treated as an object or "it", whether or not non-compos mentis. The result of these legal conventions is that people appearing before the court on charges of committing a crime are extremely rarely found not guilty by reason of insanity (NGRI) or guilty but mentally ill (GBMI). The GBMI cases are typically placed in hospitals for the criminally insane for unusually long stays. Sociopathy does not qualify for the insanity defense. People found guilty of crimes, therefore, rarely are placed in psychiatric facilities. Psychiatrists are relieved of the obligation to treat criminals in private practice or psychiatric hospitals. They treat criminals only when they are employed by a prison and the prison pays for their services. Very few are employed by prisons and their function is mainly to prevent liability and as window dressing for the prison"s "humane" image. If insurance companies had to reimburse for the psychiatric treatment criminals, they would go broke over night. If it were easier to try cases based on an insanity plea, the courts would be so clogged that either they would have to cease functioning or their budgets would have to be dramatically increased. On the other hand, in the contemporary world, the majority of prison inmates do receive psychotropic medications. Of course, the pharmaceutical companies benefit from this while insurance is spared outlays for this enormous expense. Who picks up the tab for all of this? It is paid for by federal, state, county, and municipal governments. In other words, the taxpayers pay for the prison and jail expenses. Psychiatry is spared the unpleasant burden of treating those with obnoxious diagnoses that lead to prison like sociopathy, anti-social personalities, substance abuses, and those prone to aggression. The insurance companies are spared a huge expense, and the pharmaceuticals get a bonanza. Ironically, receiving psychotropic medications should qualify for a diagnosis of mental illness and yet these inmates got to prison because they could not claim mental illness as a defense. Conveniently failing to dredyoung Page 46 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc notice such inconsistencies, these symbiotic parties trudge along with an arrangement that works to the benefit of them all excepting the people. Even though less that one percent plea insanity, these insanity laws have become an airtight mechanism to keep this arrangement between these symbioses intact. Moreover, let us not forget how Nixon"s crime agenda added to burgeoning prisons and thus vastly increasing these expenses to taxpayers. There may not be a conspiracy here. It seems as though their various positions evolved as a natural consequence of each of them acting in the best interests of their own industry. What are excluded from the dialogue are people for whom they exist, namely the patients. Ironically, what is in the best interest of each industry involved is extremely detrimental to the patients they proclaim they are helping. Psychiatry may be the direct link to the patient, but they are all enormously benefited from the "symbioses" within and between their systems. Several things that are of benefit to the parties in these symbioses and to the detriment of both the patient/criminal and the public have been examined here. 18. Psychotherapists Play-Follow-the-Leader with Psychiatrists I have neglected, so far, a prior and eventually parallel development in the broadening, modern, mental health movement. Psychotherapy, beginning with psychoanalysis, began in the early part of the twentieth century. Over about seventy- five years, it unfolded as consecutive differentiations of modalities that were not related to physical medicine and the diagnostic taxonomy of psychiatry that originated in1951. Usually psychiatrists met their clients in their offices for a once-a-week, hour-long talking session. Likewise, most of these evolving modalities of psychotherapy structured their manner of treatment to meet clients in the therapist"s office for a one- hour per week individual interview. Each modality had its unique philosophy of how to conduct these interviews. They tended not follow the psychiatric pattern of focusing on brain chemistry or prescribing psychotropic medications. They had their own style of dialogue with clients. They each focused on mainly on one particular aspect of their clients" personalities. Eventually, they evolved to include small groups of clients in group therapy and then broadened to include clients and their families in family therapy. A few therapists even expanded the length of sessions to several hours and some even designed weekend retreats when treating groups, couples, and families. Nevertheless, eventually psychotherapists increasingly modeled themselves after and allied with psychiatrists who, in the second half of the century, had triumphed in the arena of public opinion. 19. Psychiatry Gets Biological and Psychotherapists Try to Tag Along What set psychiatry apart from their progenitor, psychotherapy or psychoanalysis, was their focus on the physical nature of the client. Psychiatry assumed that clients" mental, emotional, and behavioral problems were symptoms of an underlying sickness. This sickness came to be seen as being a result of an imbalance in brain chemistry. Being allied with the medical community, it was natural for dredyoung Page 47 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc psychiatry to adopt their style of diagnosing and prescribing. Therefore, they developed a taxonomy of mental illnesses, to phrase it more appropriately, sicknesses. Psychiatry outstripped psychotherapy as the dominant mode of treating people with bizarre, disturbing behavior. The public soon attributed an aura of ultimate, expert authority to them. Psychotherapists reacted to the dominance of psychiatry by trying to become mini-psychiatrists. Consequently, psychotherapy adapted to the situation and adopted the psychiatrists" taxonomy, hoping to share in their aura of authority. Finally, psychotherapists began to develop sub-modalities or variations of treatment tailored to diagnostic categories. Mental illnesses such as anorexia, depression, panic, phobias, withdrawal, addictions, and many others began to have designer treatments. Many psychotherapists formed alliances or even partnerships with psychiatrists as the expert, controller, and authenticator of the treatment. The psychiatrist had control of prescribing and dispensing the crucial element of therapy, which was the psychotropic medication. Psychotherapists had to go along with this development in order to insure reimbursement from insurance companies. Consequently, a splinter group of psychotherapists began a movement to establish a lobby to gain the legal right to prescribe medications, to commit patients involuntarily to psychiatric hospitals and along with it to gain the status of having equal authority with psychiatrists in the mental health world. Their efforts failed. Psychiatrist"s sole control over prescribing medications was the coup de grace. Psychotherapy capitulated and accepted being their fate of being dependent upon and subservient to psychiatry. Thus began the long history of contorted interactions between psychotherapy, psychiatry, and insurance companies. 20. Evolution of Mental Care During the Second Half of the Twentieth Century In 1951, I had my first real experience with a mental hospital as I was walking past one in Austin, Texas, where I was attending the University of Texas as a freshman. Three years prior, when in high school, I saw the movie "Snake Pit" (1948) with all of its scariness and eeriness causing me to fear insane people and Insane Asylums. I recall that in my first year at the university I often walked on the sidewalk along a high wire fence that kept patients from running away from the Austin State Mental Hospital. One day as I was walking past the mental hospital, a man was leaning against the fence and watching the cars go by. I stopped to say hello and he made an interesting comment. He said, in a pleasant but ironic tone, that if people like him were in the majority, he would be on the outside and people like me would be in this hospital and behind the fence. I never forgot what he said. The next year I took a job as an attendant in the hospital and got to know the patients. From then on, I was hooked on working with mental patients, the mentally retarded, prison inmates, incarcerated juvenile delinquents, and the disadvantaged. In the History of the mental health movement, initially the states funded large state mental hospitals. People who did not fit in, whose behavior was a nuisance or burden were simply dropped off at the state mental hospital. In the first part of the twentieth century, these patients were subjected to some gruesome treatment, even horrifying treatments. Many of these state hospitals had populations of over three thousand and were gruesome warehouses. They were very costly to states. Gradually they began to institute care that was more humane. dredyoung Page 48 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc In the fifties, they recruited elderly doctors who were regarded as psychiatrists. Many of the staff believed insanity was genetically caused. A movie called "The Bad Seed" (1956) seemed to validate this hopeless belief. By the sixties, these hospitals were staffed with young psychiatrists who were trained in the new mode of diagnosis and who used the new (1952) American Psychiatric Association"s Manual. While most of them had a psychoanalytic background, there was little chance of practicing that in these human corrals. They each had hundreds of patients. These patients were a mystery even to the professional staff. The psychiatrists were trained in the use of the new tranquilizers. They used electric shock therapy and insulin therapy and prescribed a variety of tranquilizers. These hospitals also hired a few clinical psychologists to administered paper and pencil psychological tests and projective tests to a small percentage of entering patients with seemingly good prognoses, and assigned them a diagnosis. The wards in the hospitals were run by head nurses. Psychiatrist spent only a few hours a week on the wards. Most of the patients just hung out in halls and sitting rooms all day. Over time, the state introduced rudimentary occupational, educational, and art programs. Eventually, they established internships for graduate students and psychiatric residents. They were to provide more personal contact with as many patients as they as possible. This was also limited due the fact that there were such large populations. These primitive hospitals remained warehouses throughout the fifties but in the sixties, they had begun to be more humane and to incorporate the more modern, advanced treatment techniques. Maintaining these hospitals was a large financial burden on the states. When private psychiatric hospitals slowly emerged in the late fifties and early sixties, they were meant primarily to serve the rich. They took away a very small portion of the financial burden state mental hospitals had put on the state"s budget. The 1957 movie "The Three Faces of Eve" glamorized psychiatric treatment. People bought into idea of the awesome power of psychiatrists presented in this movie. Their almost magical ability to cure Eve"s multiple personality, a serious but dramatic psychosis, was very appealing to the naïve and gullible generation of the fifties and sixties. These factors both symbolized the growing trend toward seeing a psychiatrist and promoted private psychiatric practice and hospitals. This trend generalized into a humanizing movement and support for and hopes for the success of the emerging social programs and early tranquilizers. A romantic movie about two teenagers in a private psychiatric hospital ("David and Lisa", 1962) further added to this glamorization and belief in psychiatry and private psychiatric hospitals. During the Johnson era (1963-1969) of the Great Society more and more of the down and out and outcast members of society were brought under this umbrella. Johnson ordered the creation of commissions to study how to reform these human services and make them more successful and humane. All over the nation, huge numbers of people were hired to carry out these reforms. The costs for these reformed human services programs and institutions grew very large. With the initial success of the mental health-industrial complex, the justice system picked up the treatment drift and began implementing rehabilitation programs in adult prisons and, to some extent, juvenile delinquent facilities. Psychiatry"s origins in psychoanalytic movement had proven to be increasingly awkward. Psychoanalysis was absolutely useless in these dredyoung Page 49 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc times of huge caseloads. The initial successes of B.F. Skinner"s Behaviorism and of behavior modification and token economies, gave them a legitimate way to transition out of the psychoanalytic model. Now since they had had their APA Diagnostic Manual since 1952, they were prepared to justify making diagnoses based on "behavioral" observations. They could also easily install makeshift reward systems with a pretext that it was shaping behavior. In fact, they had found a way to make management of large populations of patients much easier. This behavior shaping movement also influenced educational programs, occupational training, and, the big-ticket item, psychological rehabilitation or treatment in the form of reward systems supplemented with medication. By the early 80s, behavior therapy had proved either too labor intensive or simply too narrow and modest in its behavioral results. Psychological rehabilitation also entailed the excessive cost of hiring many psychiatrists, psychologists, social workers, educators, and other technicians. Psychiatrists, of course, eventually met this cost problem by importing the new fad of prescribing psychotropic medications. These had at first had been aimed primarily at making patients and inmates more manageable. Eventually, however, hope began arising that these new medications would cure or at least dramatically ameliorate their symptoms. This caused many mental health professionals and even politicians of this era to feel that these new humane treatment trends were imperative. However, the expense burgeoned with the increase of these programs in mental hospitals and prisons. This, coupled with the expense of many other social programs leftover from the Johnson era such as the model cities" poverty programs, made cost a major concern once again. Now we had a situation in which to provide humane treatment to these vast numbers of welfare recipients, other wards of the state and of state institutions and programs, state budgets and federal matching funds were escalating out of site. By the late seventies, these costs had also combined with the cost of the Viet Nam war and became such a burden that something had to give. Aside from these considerations, from the late 50s up to the early 80s, hospital populations steadily and dramatically declined due to cost. During the Nixon (1969-1974) era, crime was dramatically increasing, prisons were filling up, prison rehabilitation expenses were escalating and state, and federal budgets were continuing to skyrocket. Nixon had inherited a war and a big federal budget. The federal budget was strained to the bursting. Nixon saw that one of the ways to avoid a fiscal crisis was to cut the Johnson era programs and cut their exorbitant costs along with them. Nixon secretly commissioned a nationwide study of institutional and community rehabilitation programs (Martinson"s National Evaluation of Rehabilitation Programs, 1970). The results of this massive study were that no rehabilitation programs were successful. Consequently, these programs were considered a huge waste of money and they began to be shut down by, 1973, all over the nation. The new miracle psychotropic medications helped make this transition easier. At the same time, movies such as "Asylum" (a ghoulish film that takes place in a ghoulish psychiatric hospital) in 1972 and "One Flew over the Cuckoo's Nest" (a movie that turns a psychiatric hospital into the personification of sadism) in 1975 were beginning to sour the public on the once romantic psychiatric treatment and institutions. There began to be a return to deinstitutionalization and officials settled for mere management of patients. This aided the new commitment to cost reduction. "Clockwork Orange", 1971, added another angle to the shift toward "managing" mental dredyoung Page 50 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc patients and prison inmates, and away from the new treatment fads. With treatments such as the grossly inhumane use of behavior modification, particularly aversive treatment, treatment and treatment institutions lost their allure. Behavior modification was out but using behavioral observations to make diagnoses remained. In fact, psychotropic drugs did modify, or rather mollify, behavior much more quickly and easily. Why? If the drugs turned patients into tranquil, manageable zombies, their behavior was changed. Treatment with drugs, therefore, was deemed successful. The growing disillusionment over poor results from the labor-intensive behavior modification meant there was a safe rationale for ending that practice and moving exclusively to medications. "Clockwork Orange" had given the impression that the psychiatrists and hospital and prison staff administering these institutions were evolving into Machiavellian-like characters. They had to get this albatross off their necks. At the same time, all of this bad press aided the Nixon agenda to end rehabilitation. Certainly, the pharmaceutical industry was pleased with this sea change. These and many other factors of his day made it possible for Nixon to easily switch to an appealing political stance with a constructive ambiance of getting tough on crime, such as convicting people for less serious crimes and extending the lengths of their sentences. The rationale or justification was that this would result in an eventual drop in the crime rate and along with that a reduction in the cost of community social programs. In fact, many people who had been committed to mental hospitals were now sentenced to the much less expensive prisons and jails. The anticipated result of crime reduction, however, did occur a few years later, only to rise again several years after that. Over time, however, it became obvious to Nixon that something had to be done because costs of these Johnsonian humane services were still too high. During the late sixties, a small movement to place recovering mental hospital patients in Community Mental Health Centers had begun. Many felt that the new success of psychotropic medications now made this feasible. However, with the coming of the Nixon stringency era, this movement was transformed into a way dramatically to decrease the expense of mental hospitals whose populations were still much too large. Commissioners of state human services agencies began a massive, orchestrated phasing out of state mental hospitals and phasing in of community treatment facilities. What this trend eventually led to, however, was actually dumping mental hospital patients on the street. Huge numbers of them became what we now call "the homeless". Veteran"s mental hospitals followed suit and many of these mentally ill or drug addicted veterans also became what we now call the homeless. Eventually, this mass of homeless people sleeping in the doorways of major businesses and churches was considered blight to city councils to and county commissions. Their only recourse seemed to be putting these forgotten, sick people in jails, especially during harsh weather. This could never work and finally there was a revolving door of the mentally ill, veterans, and ex-convicts homeless in and out of the county jails. However, many of the homeless committed petty crimes to survive or maintain their drug habit and these were convicted and sent to prison, thus overcrowding prisons even more.iv 21. Eras of Mental Health Culture from the Perspective Insurance Reimbursements dredyoung Page 51 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc At the beginning of these massive transitions, in the pre-Nixon era, 1965, the nation had Medicare. Eventually Medicare began covering mental health treatment for many who were not impoverished and homeless but were too poor to afford expensive private psychiatric treatment. This was Stage 1 in the history of Medicare and insurance coverage of treatment of the mentally ill. This was a new kind of movement toward humane mental health care. This became a minor bonanza for psychiatrists, psychologists, and social workers. At the same time, insurance companies had developed policies, aided by corporations, which included mental health riders on their health insurance policies. In the beginning, insurance companies" policies allowed unlimited therapy sessions and were not concerned when psychotherapists and clinical social workers were seeing patients without psychiatric oversight and without psychotropic medication. However, many of these professionals were prone to see patients for exceedingly long periods, some even for years. The ranks of these professionals naturally swelled, becoming a problem for insurance companies. The led to Stage 2 and was a huge reversal in policy. In the mid-eighties, the insurance companies made a complete turn about, began restraining the duration of sessions, and instead wrote policies for treatment in psychiatric hospitals. Insurance companies were not concerned at the time since there were legal and medical limits on who qualified for commitment to psychiatric hospitals. With this change in insurance policies, treatment professionals like schools of fish, began to refer patients to psychiatric hospitals. Interestingly, Carter a deeply committed humanitarian was in office from 1977-1981. Early in Carter"s administration the movie, "I Never Promised You a Rose Garden" (1977) came out, signaling a re- emergence of humane mental health care. This movie portrayed psychiatric hospitals as places where painfully disturbed people could go and find a nurturing environment, be genuinely helped, and eventually return home and live happily ever after. Since only psychiatrists could commit patients to a psychiatric hospital, psychologists and clinical social workers allied themselves with psychiatrists. Under the auspices and supervision of psychiatrists, psychologists and social workers could see in-patients. Psychiatric hospital administrators encouraged psychiatrists commit their patients, diagnose, and prescribe psychotropic medications. Hospitals also hired psychologists, and social workers to have sessions with them in the hospital. In addition, some psychologists administered psychological tests and social workers worked up social histories to backup the psychiatric functions. Fees for inpatient sessions were lower than for outpatient, but administrators encouraged them to have many patients and therapy sessions. Now all of these mental health professionals began to make a good deal of money working with patients in these new psychiatric hospitals. Hospitals took a high percentage of what insurance paid for the sessions. Initially, therefore, hospitals also found this to be a bonanza. In addition, many policies were written to allow extended stays in psychiatric hospitals, some even allowed for as long as a year. The hospital administrators started a push actually to recruit patients. They found ways to concoct diagnoses that they knew insurance companies would accept. To increase reimbursements and bilk insurance companies, they created a wide range of diversified inpatient treatment programs. Hospitals and professionals both now had a gravy train. These abuses of Medicare and insurance largesse led to Stage 3 in the evolving history. While these dredyoung Page 52 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc abuses were raging out of control, a series of movies depicting disillusionment with psychiatry, psychotherapy, and psychiatric hospitals. First, there was "Endless Love" with a love obsessed youth being sent to a hospital and returning just as dangerous as he was before. Then there was "Frances" (1982) that depicted how a mother drove her daughter crazy, had her committed to a psychiatric hospital where she was eventually lobotomized. She spent the rest of her life as a complacent human vegetable. There followed "Lovesick" (1983); and "Nobody"s Child" (1986), all showing the dark side of therapy and psychiatric hospitals. This trend reversed temporarily with "Another Woman" showing the benefits of outpatient psychotherapy and "Clean and Sober" that showed how outpatient drug treatment could succeed, both in (1988). In 1990, the movie "Awakenings" first showed the dramatic success of psychiatric medication but ended with a gravely disappointing failure. These movies of the 80s up to 1990 were paralleling the intense conflict unfolding with mental health systems. It should not have come as a surprise to hospitals and mental health professionals that serious negative consequences were in the offing for them. Nevertheless, they were caught off guard and much to dismay of hospital administrators, this abuse soon met with extreme reprisals. Around 1992, hospitals were investigated for fraud, the federal government spread their search across the nation, and the outcome was that many hospitals were shut down and their multi-billion dollar parent companies were fined billions of dollars. Some hospital administrators were even sentenced to prison. Overnight, a few psychiatrists actually relocated to foreign countries that had no mutual extradition treaties. Ironically, also in 1992 a movie called "Whispers in the Dark" was playing. It was an extremely sinister, intricate, murder mystery depicting psychoanalysts in deadly romantic involvements with clients and each other. The movie industry was reflecting disillusionment with psychiatry just as psychiatric hospitals were beginning to be shut down. "Mr. Jones" (1993), on the other hand, was showing the sincerity and expertise of psychiatrists and the desperate need that patients like Jones, a manic-depressive, had for their services. It was like a last ditch cultural plea hoping to hold off the end of the grand and lucrative hospital era. However, backing up a bit to before the fall of the hospitals, therapists had caught on to the hospital"s brilliant scheme of taking advantage of insurance companies during the 1980s. They quickly transformed traditional modalities into of diagnosis- specific treatment techniques. These evolved into glamorous treatment packages. They began tailoring these packages for outpatient therapy. Insurance companies would see these packages as far less expensive than inpatient treatment and bought into the scheme. To succeed with this they had to sell their outpatient clients and insurance companies on this new wave of therapy. They convinced outpatient clients by reifying diagnostic labels and finding ways to make as many as possible fit within the package"s label. They designed ways for regimenting and freezing the treatment procedures. This way they could apply the same formula to all with the paired diagnosis. They then had to impose diagnoses uniformly, as if they were templates, to any patient with characteristics that could be squeezed into the diagnosis. Each individual client"s unique characteristics had to be pruned or dismissed as unimportant to go unnoticed by the insurance companies. These packages were presented as being so good that they would work for even for outliers who might question the appropriateness of including them under the label. An example of this kind of in-patient dredyoung Page 53 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc package was shown in the movie "The End of Innocence" (1990) in which a patient with an addiction to prescription drugs and with horrific family conflicts was cured by abreacting her rage. It was as though this movie was crying out against the oncoming dismantling of the prize achievements of this era in mental health treatment: "hold on" these new programs are worth keeping. A package with a diagnosis specific treatment had to have an elaborate set of technique procedures that would all appear to be necessary to cure anyone with that diagnosis. However, when a diagnosis was tied to a treatment specialty, the treatment procedures had to be implemented almost as though they were algorithms to avoid having to waste time reinventing with each staging. It also had to have an air of legitimacy and sophisticated expertise. Therapists quickly learned to be expert at marketing and advertising the packages. These novel and elaborate packages seemed to inspire awe in potential clients and the new wave became such a rage that soon clients with minimally disturbing symptoms wanted to "get in the game" as though it were a new fashion statement. Being less costly, insurance companies got on the bandwagon as well. As Stage 3 was abruptly unfolding, Stage 4 was slowly emerging. The 1981- 1992 Reagan-Bush administrations were oriented toward conservative, cultural conformity and rugged individualism. Department heads, taking their cue from the administrations orientation, reacted to the way psychiatric hospitals and treatment professionals were taking advantage of their benefactors and nudged along the Justice Department and Health and Human Services to stem the runaway expenditures in this area. Stage 4 came in the wake of this reaction against the abuses of the mental health system provided a solution. It involved a novel way of cost cutting called Managed Care. After gradually was being formed during the Reagan-Bush administrations, Managed Care organizations were inaugurated around 1990, about a year before the federal crackdown began. Managed care is a generic term for various health care payment systems that attempt to contain costs by controlling who and what qualified for service and the type and level of services provided. Health maintenance organization (HMO) is a term that is often used synonymously with managed care, but HMOs are actually a particular type of managed care organization. Managed Care companies had been well prepared in advance, infiltrating mental health communities like insurgents canvassing for hits. They methodically and resolutely made their push to create a pervasive bureaucracy and campaign strategy with aim the toward cost cutting. Managed Care was to be a gatekeeper between the insurance companies and hospitals and professionals. As they began, Managed Care representatives invaded hospitals and set strict requirements on who could be admitted, how long they could stay, and what kinds of treatment they could receive. They set restrictions on which patients of private practitioners would qualify for reimbursement. Cleverly, they started selecting some professionals to act like a clearinghouse for which patients would qualify and decided which therapist would see the patient. In every case, patients had to be seeing a psychiatrist for diagnosis and prescribing psychotropic medication. Therapists soon found that their reimbursement was reduced by fifty to twenty-five percent. The number of sessions was typically restricted to six per patient. Under these conditions, many psychotherapists simply left their private practice of psychotherapy. Those remaining in the Managed Care programs were offered training classes in short term dredyoung Page 54 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc treatment methods. Other professionals turned to only seeing patients who pay out of their own pockets. This, of course, meant that their practice would be limited to well-off clients. The highlights of this Stage 4 thrust involved a radically new therapeutic approach dominated by Managed Care in which the therapist and patient were to set goals for their therapy and submit these for approval to the insurance companies. Of course, this flew in this face of ninety years of massive experience and study of the therapeutic process. Those ninety years had unanimously concluded that clients or patients came to therapy with a presenting complaint but the real reason for coming to therapy did not surface until many weeks or months of sessions. Typically, when the client finally realized what they had really come for it was a complete surprise to them. Therapists were also required to document thoroughly what transpired in each session. This too was a farce, as therapists never know what their clients are really working on any more than clients do. The therapeutic process is riddled with defenses and unconscious agendas. Setting circumscribed, definitive goals and recording therapists" impressions or even verbatim notes is like advertising, the show is to impress and persuade and not to disclose the facts or realistic advantages or necessity. The paperwork required for reimbursement was so excessive that for every hour with a patient, thirty minutes to an hour had to be spent filling out insurance forms. The therapists were required to focus on visible changes in behavior and determine if these were consistent with the treatment goals. In other words, psychotherapy had actually become a coercive process. The psychiatrists had been accustomed to seeing inpatients for about fifteen minutes just to confirm their need for continued treatment and renew or alter prescriptions. The work of the psychiatrist had become, once again, a means of both social control and cost reduction. This continued with their outpatients after the clamp down on hospitalizations. Managed Care found therapists and psychiatrists who would agree to these terms. Some psychiatrists were expert at herding large numbers of patients each day. Eventually, Managed Care realized that it was very cost efficient to have a few psychiatrists who would see an exorbitant number of outpatients solely for checking on how their patients" medications were working. To prevent seeming like they were merely a cost cutting scam Managed Care companies quickly developed a battle plan to have credible professionals available all over the nation touting the superiority and efficacy of short-term therapy techniques and were able to tie they to each profession"s annual requirements to maintain their accreditation. It was a masterful and highly successful battle plan. Insurance companies and many corporations were very pleased with this new development. For the mass of people with mental illness, this became a psychological form of the Great Depression. Another grand era in psychotherapy subsided into books on the history of psychology. Ironically, that grand era of genuine psychotherapy that focused solely of what was good for the client and let the client decide when to terminate their therapy was now only a faint memory. It was now a forgotten legacy even though it is still glamorized or spoofed in movies and TV shows as though it still exists. There is another unfortunate set of ironies to this story. The professionals have had to capitulate to Managed Care. Reimbursements to providers were reduced by twenty-five to fifty percent. At the same time, the annual national cost for health care dredyoung Page 55 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc has risen by at least twenty-five percent. Not surprisingly, with the takeover of the health industry by Managed Care, the quality of care given to those with mental illnesses and to patients with physical illnesses as well has been degraded by at least twenty-five percent. Some corporations, especially those who were self-insured, opted out of the Medicare-insurance scheme of Managed Care. They saw a way to avoid these topsy-turvy financial outcomes of Managed Care and instead invented Employee Assistance Programs (EAPs). Some of these new EAPs avoided siphoning off money meant for psychological services that were then directed into the contorted, pseudo- medical, mangled Managed Care organizations that were headed by profit driven health care bureaucrats who had no legitimate background to be controlling medical decisions. Instead, EAPs made it possible for psychotherapists and clinical social workers to treat without being under the supervision of psychiatrists. This also had the advantage of obviating the necessity for medically prescribed psychotropic drugs. Other EAPs eventually returned to the Managed Care model and became gatekeepers for cost cutting. Why has therapy been degraded? Managed Care officials (bureaucrats), who had trainers, supervisors, and administrators of psychotherapists under their jurisdiction, now had to steer them toward short-term therapy techniques. Instead of helping psychotherapists work through issues in their own personalities that might get in the way of helping clients to deal with those same kinds of issues, they had to focus on quick fix gimmicks. Instead of helping them overcome factors in them that were impeding their clients" ability to grapple with their deeper, often suppressed or repressed conflicts, they had to teach them how to keep clients on track toward resolving pseudo goals agreed to before the therapy even began. Keeping in mind that presenting complaints are seldom the real problems, keeping them on track actually sabotages the chance to reach the real problems. Instead of teaching psychotherapists more advanced techniques that might improve their effectiveness so as to create conditions promoting client transparency and growth toward authenticity, they had to guide them toward structuring the process to keep clients oriented toward the initial agreed upon set of goals. Instead of helping psychotherapists gain deeper insight into client dynamics, they had to teach them how to shore up clients" defenses. Supervisors and administrators had to forego helping psychotherapists understand how to wait for the appropriate moment to help clients gain flexible skills to cope with and react to their critical life situations and conditions spontaneously and intuitively, with trust in themselves, rather trying to obsessively plan rigid advance strategies. Instead, they had to teach them how to train clients to adopt simple, canned, behaviors that were oriented to their specified treatment goals. They had to forego helping facilitate psychotherapist"s mastery skills for managing the clients" therapy to optimize their potential. By the early nineties, physicians, psychiatrists, psychotherapists, and patients all had lost control over their mental and physical health. The people and legislators of the early 21st century decry this development, but no one dares look back into the root cause, which is the callousness and greed of the medical-industrial complex. The power of lobbyists for the medical-industrial complex is rich and strong that legislators are forced to back off form considering how to provide mentally disturbed persons with dredyoung Page 56 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc humane treatment The subjugation of mental health care to commercialism was complete. It had virtually destroyed genuine mental health care.v Ironically, at first, the era saw this decline and disintegration and attacked mental health care. For a the next decade, a rash of movies came out depicting mental health professionals, programs, hospitals, and even medication as not only as failure but also as superfluous and somewhat ridiculous. A good relationship with a healthy friend is all you need to be set free from your inner hell. The rest is a hoax, bad joke, recipe for disaster, torture chamber, or a further descent into your private hell. For example, "Another Woman" (1988); "The Young Poisoner"s Handbook" (1995); "A Couch in New York" (1996); "As Good as it Gets" (1997); "Analyze This" (1999) and "Analyze That" (2002); "Girl Interrupted" (1999); "28 Days" (2000); "Requiem for a Dream" (2000); "Flowers for Algernon" (1968; 2000); "Prozac Nation" (2001); "Pollock" 2001; "Sylvia" 2003; "Intimate Strangers" (2004); "The Aviator" (2005); "Tom and Viv" (2005); and "The Treatment" (2006) all slammed mental health professionals and care in one way or another. Eventually, however, Managed care became the kicking post and a new rash of TV and radio shows like "Infinite Mind" and movies came out that virtually vivisected insurance companies and Managed Care for the way they usurped the authority of the medical professionals and withheld authorization for necessary treatment. These attacks, while dramatic, have been ineffectual. Commercialism has continued to reign during the second Bush"s administration (2000-present). Objectification of the individual is fait accompli and now it has been joined by the objectification of the American people as a whole!vi 22. Questioning the 'Person as Object' in America"s New Mental Health Care System Objectification of persons means persons are related to as though they were objects. An object is looked at on its surface. An object is looked at in isolation from its surrounding structures. An object is looked at a-historically. I have been making the case that mental health care, while still taking case histories, treats the person as though in isolation from their history, as though in a time vacuum. I have been making the case that mental health care diagnoses and treats the persons "supposed" behavioral patterns. I have been making the case that mental health care treats the person as a biological entity, as an "it" whose disordered behavioral patterns are the result of a biological defect or imbalance. I have been making the case that a person"s diagnosis and treatment is conducted as though "it" acts independent of its surrounding structures. An object can be regarded in terms of its physical context such as an object in water, exposed to air pollutants, temperature, and the like. In other words, the immediate physical context can be taken into consideration. However, with regard to persons, if, and when, surrounding structures are taken into consideration, they are restricted to interactions in close personal relationships such as parent-child, spouses, extended families, and peers or authorities with whom they have significant, influential, and continuing relationships. The impact of general cultural factors, sociological factors, social institutions that shape lives such as education, religious and social affiliations, recreational resources, the legal system, medicine, the economic systems, media, the dredyoung Page 57 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc Zeitgeist of a decade or two, in summary the life topography of the person, are disregarded or discounted. In addition, if, and when, regarding a person, their multiplicity of inner psychological structures and intentional processes are disregarded or discounted, they have been transformed into a physical object. When workers are regarded as commodities or patients are regarded as consumers, they can be manipulated like objects without regard to their status as a person, for example, as one would regard a loved one, whether spouse, child, or close friend, for example. The military, for example, is expert in regarding military persons as objects. In a similar way, let us say a car salesperson has a goal of selling a customer a car. He or she has to learn to disregard the inner feeling and economic circumstance of the customer. He or she must try to sell a car, regardless of the impact on the customer"s life, and keep his or her focus on meeting their quota for car sales for the month. The person is now an object to be manipulated and treated without regard to their welfare or regard for what is in their best interest. Our culture is suffused with language that objectifies persons. For example, politicians have constituents and they use Madison Avenue, mathematically sophisticated, techniques of marketing and advertising to get their constituent"s votes. A person who steals or assaults is a criminal and therefore becomes somewhat like a different species from the rest of us. The medical-industrial complex has come to regard persons, that is to say patients, and prospective patients, in just this way, as an object or collection of objects. This is so tragically true with respect to mental health care. In opposition to this trend, the Natural Systems" Duplex Pyramids Model takes into consideration the whole person, the totality of their inner world, the totality of their social environment, and with respect to their history and the history of their culture. Natural Systems is a de-objectification of the person. 23. Stigmatizing Becomes Fashionable In TV Ads and Sweeps Across America New varieties of Puritanism and new "Scarlet Letters" are evolving all the time. After the success of psychiatry a tsunami of new ways to judge people appeared. Labeling had always been a part of the American cultural landscape. The varieties of new ways to stigmatize new began to increase. Now there were not only religious and moralistic ways to judge people, but new clinical deviations could be used to stigmatize. Stigmatizing people by their political leanings or affiliations had been in vogue for a long time, taking a surge during the Joe McCarthy Era (1945-1960) by labeling persons a communist, red, pinko, or leftist, and so on to defame them. McCarthyism had the effect of making those involved in social reform and progressivism, such as social workers and others in the helping professions and Hollywood back off and restrain or curtail their efforts. This was a period of the rise of the importance of television in American life. The McCarthy era is an excellent illustration of the power of stigmatizing, especially when movements like McCarthyism are able to saturate the airways. Television made it possible for populace to learn new language conventions for character assassination, defaming, discounting, denigrating, ostracizing, encouraging prejudice, putting down rivals, ridiculing, getting revenge, and so on. With the growing familiarity with psychiatric diagnostic labels and the art of diagnosing, people began to dredyoung Page 58 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc say, "That is a sign of. . . ", followed by a diagnostic label. An amazing range of "signs" indicating that something was wrong with you began to "catch on". Such fads have always seeped in and out of language currency, but before television, this usually took considerable time. However, modern media made it possible for the entire country to stay hip with the psychiatric jargon. Prior to the contemporary scene, if people thought you had sinned, that made you an evil person. The reaction when a person was called evil was for them to be shunned, purged or cast out of a group, or excommunicated from a religious organization. For some people, if you exhibited one moral peccadillo, that could be taken as a "sign" that you are through and through an immoral or a bad person and must be censured. If you said things that were considered self-righteous, or you judged others behaviors based on your own morals, some would say you were a "holier than thou", a fanatic, or zealot. In some periods of US history, if a family put a US flag in their yard they might be regarded by some as a right-winger, ultra-conservative, chauvinist or jingoist. If you were known to have favored legislative reform, you might be called an activist. In the 1960s, if you uttered statements about what a woman"s role should be, this would very likely be considered an insult by women. A negative insinuation against a womanly characteristic could result you being regarded as a sexist. From the sixties on, if you uttered a racially tinged word or epithet, you would be labeled a racist or a bigot. If one openly shows some form of indiscrete behavior or improper manners, it may be taken to be a sign that you are lower class and polite "society" should shun you. Even in the present, if you broadcast a disagreement with the political majority then you may become anathema to them. Deviate too far to the left and perhaps you may be labeled a liberal, socialist, communist or communist sympathizer, or too far to the right and be labeled a fascist, or Nazi, say some things and you are unpatriotic and other things and you are a right-winger. Labeling and casting aspersions has become a favorite game for some people. Impugning a person by pointing out that an utterance or mannerism is a sign of something worse, something wicked that is hidden from view, is a vicious, insidious game. With the popularity of psychiatric labels, there came a sub-rosa movement that has progressed from diagnosing observable patterns to taking certain behaviors as a "sign" of some underlying, unobservable, awful disorder. For example, if a person exhibits a certain kind of hand gesture, they may be labeled gay, queer, or homosexual. As each new stigma becomes au courant, those who exhibit its signs are fair game for psychological bullies. Among teens, physical bullying is often condoned by the authorities if the victim has been labeled, even if the label is based on a "sign" and is completely inappropriate. This cultural trend of stigmatizing was a harbinger for the current perverse misuse of psychiatric diagnosis. Ironically, this trend has been unwittingly seized upon by other professions, as well as psychiatrists, as an opportunity to broaden the coverage of behaviors that could fall under a label in the psychiatric taxonomy. To an ever greater extent, modestly odd behaviors, or "signs", are now being diagnosed as psychiatric illnesses. Most of these merely irritating or odd behaviors were easily tolerated in earlier times. This is a windfall for psychiatrists as the more behaviors that can be included under diagnostic categories, the more patients, the more drugs dispensed, the more money for the psychiatrists and pharmaceutical companies. When dredyoung Page 59 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc administrators in the educational, welfare, mental health, and justice "industries" find out what behaviors many parents and family members do not like, they tend to give them psychiatric labels. Find out what behaviors teachers do not like in their students and give these behaviors psychiatric labels. Find out what behaviors staff in organizations do not like and give them psychiatric labels. Once you are given a label you have (must have) the game. That is to say, if some authority gives you a psychiatric label, then it is assumed that you have the corresponding illness. If you have that illness, you must be treated by a psychiatrist and prescribed psychotropic medications. This is a self- fulfilling prophecy has begun to operate extremely effectively. Once a person is labeled, a cycle through stages begins. First, if you have the "name" then you must have the game. If you have the game, then you are the stigmatized. Once stigmatized, it is assumed you are, or more less permanently have, the associated illness. If you are stigmatized you must be set apart in some way, put in a special program, treated in a special way that implies some kind of inner inferiority. If you have that special kind of ostracism, " the program", then, of course, you must be medicated. If when you receive the special treatment, including the medication, you do not exhibit the "signs" , this is taken to mean that the treatment worked, but unfortunately, also, it means that you "indelibly, unalterably, have" the illness and must stay in the program to prevent a resurgence of the symptoms, "signs". This is a powerful, self-perpetuating, vicious cycle. This is an unconscious pattern. It has become a part of the fabric of our national language, our of perceiving people, our way handling the targeted people, a part of our belief system, and now a second nature, knee jerk reaction. No alternative makes sense, and those who suggest alternatives and considered not just to be flat out wrong but virtually idiots. This vicious cycle is, itself, the true illness – an illness of our culture. 24. Name Calling Reinforces Pressure For Conformity Versus Tolerance Those whom one perceives as eccentric and unintelligible are not necessarily insane. From extreme conformity out of fear of being labeled as communist, or one of its wide range of synonyms, in the fifties, the pendulum swung far to the left. Paradoxically, in the sixties extreme liberalism was also accompanied by name-calling. The NOW movement and the feminists, the anti-racism, the fad of dressing down, sexual liberation and encouragement of experimental life styles all attacked stereotyping. Gender, race, and class were attacked as barriers that closed avenues to educational and occupational opportunities. Yet, at the same time, the movements of this era were facilitated by labeling and name-calling those who showed signs of preserving traditional roles and identities. Whether it was McCarthyism or liberalism, both used labeling and name-calling to pressure others to conform. Name-calling and labeling was effective in reinforcing pressure people toward conformity or tolerance. The same tool could be used to reinforce rigid social standards or to encourage freedom of expression the right to be different. This was nothing new. Even in isolated, rural towns, this was a means of choice for exerting social pressure. Interestingly, this era of tolerance extended to the mentally ill. This meant that the movers and shakers were encouraging the population to revamp its perception of the mentally ill. One renowned psychiatrist wrote a highly popular book entitled "The Myth of Mental Illness". dredyoung Page 60 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc Sixties" people were encouraged to be more accepting and tolerant of those exhibiting what had formerly regarded as psychotic. This new attitude toward psychological deviance helped pave the way for the community mental health movement. There was a parallel movement to redefine criminals as having a social disease and to establish halfway houses to facilitate their reintegration in to society. While psychiatry was now able to have a thriving private practice outside of state mental institutions and private psychiatric hospitals had begun to thrive, the treatment of the criminal element took another and problematic course. Psychiatry"s diagnostic handbook typically labeled those with criminal records as sociopathic, psychopathic, anti-social, aggressive, and unsocialized. These types were generally considered incorrigible and therefore bad risks from a cost-benefits point of view. In addition, when persons with a criminal record received these diagnoses, they were generally considered too dangerous to be seen in private practice or to be committed to private psychiatric hospitals. Managed Care and insurance companies complied with this drift and discouraged their inclusion as mental patients. Drug addicts were covered since theirs was considered an illness but they proved even more unmanageable and resistant to treatment than criminals did. Programs sprang up everywhere to deal with drug addicts but had little success. Prisons created faux treatment programs for drug addicts so as not to appear absurdly inhumane. Psychiatrists and other mental health professionals did see a few criminals and the addicted when they were placed on probation and the terms of their probation required entering therapy. Therapists tended not to welcome them as patients. Drug addicted probationers wound up being sent to prison and entering a prison revolving door. The Nixon era"s crackdown on crime soon included drug addicts and prisons, which were now rapidly becoming overcrowded with criminals, began to be filled to overflowing with drug addicts. Nixon"s cost reduction agenda of "being tough on crime" had backfired. Nevertheless, psychiatry was spared the drain on their practice of having to deal with criminals and drug addicts unless they were in prison or psychiatric hospitals. Likewise, insurance companies were spared a cost-ineffective obligation. The sixties era of tolerance had wound down to a rather harsh ending for the deviants, wretched, and unwanted of society. A new era of name- calling, labeling, rejection, exclusion, neglect, insensitivity, intolerance, and cruelty had ascended to cultural dominance. ADHD, ADD, (escalated 700% in last 30 years) and related syndromes are excellent examples of dealing with unwanted demands from fellow human beings, in this case mostly children and youth, by using name-calling (In professional parlance it is called diagnosing.), medicating, and in too many cases segregating them in special classes. Just briefly, let us look at this so-called problem of inattentiveness and hyper- activity from the point of view of evolutionary psychology. Parent teacher social skills. Wilting ego mastery skills. Validating results. Devotion to the diagnosis and Ritalin. Spreading of a new cultural beliefs system and common language. Conspiracy of pharma, FDA, research, and psychiatry and unwitting collaboration of schools and PTA, local physicians, administrators, etc. Schools and ADHD. It only seems right to help the labeled by medicating. It seems to work so well. To consider going back and ceasing to give medication to solve the problem seems idiotic to caregivers who once had to deal with the troublemakers. Damage to kids. Boon to pharma and psychi. Eventual lawsuits. vii dredyoung Page 61 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc 25. The Modern Zeitgeist Of "Signs" Got it now - got it for life. One swallow does not a sign does not make signified patterns Starting to look at oneself for signs of some deeper malady seeing signs of others or reading about them and imagining that one might have the malady because on sees something similar in oneself having seen it one begins to act that way or simulate having that disorder. Humans are high suggestible. What the sociology of "signs" has evolved into. From a sign of a mental disease to a sign of a chemical imbalance. 26. What Is Chemical Imbalance in the Brain Anyway? When a prescribed medication fails?? If psychotherapy had not bought into the hoax of diagnosis and its complement of prescribing meds, they might have used their brilliance to find an alternative approach to treatment. Rogers had resisted all of these trends that led to the supremacy of psychiatry. CHEMICAL IMBALANCE AND PILLS 27. Modern Life Styles Create a Generation Addicted To Pill Popping By waging an advertising war Decades ago, with the aid of a ceaseless bombardment of ads about disorders and meds in the television media, the big three slowly achieved a total and invincible cultural coup. The people were taken in and no one noticed how they and the culture gradually had been transformed. Their invincibility can also be attributed to tradition of the country doctor and the implicit faith people had long ago developed with their doctors. Finally, the culture that evolved in the second half of the twentieth century was mobile, fast-paced, and stressful. While the bond and trust with one"s family doctor faded, this belief in his authority endured and even was transferred to pharmaceutical ads. Dual career families became the norm. People lacked the calm leisure to work things out with one another and be understanding of and tolerant with one another"s problems. The era of frozen dinners and fast food restaurants had arrived. Appliances now had push buttons and remotes could even be set to go off at appointed times. America had become the quick and easy culture. When offered a pill to stop every little pain and uncomfortable emotion, they took it. 28. From Pill Popping to Pill Hopping Since they had not loss the childlike faith in the well-meaning authority of their doctor, they believed that if some authority said it would work, they wanted it and took it. Even if did not really work, the belief caused powerful, albeit ephemeral, placebo effects. If the benefits did not last, or if there were negative side effects, one simply got a new prescription to quickly deal with the problem. They had no time to take note and dredyoung Page 62 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc raise efficacy questions. They just simply and quickly succumbed to the next fad. No one wanted to hear that real, effective, enduring results had to come from psychological therapy that took a lot of time, emotional discomfort, and effort. What is more, who wanted to deal with the possibility of being stigmatized as mentally ill or of being too weak to cope with their problems independently? 29. Psychiatry"s Modern Paternalistic Posture The people"s trust in the country doctor"s expertise and their belief that their doctor had a genuine, special interest in their welfare is a legacy that has transferred to modern "commercialized" doctors and the wholly interrelated health care industrial complex. In this earlier paternalism, there was a sense that the family doctor was actually, to a degree, a part of each family under their care, somewhat like the country pastor. These professions were nurturing, personal, non-authoritarian, and non- legalistic, always respecting the autonomy of their patients or congregation members. Since they were in small communities, everyone had a history with one another that provided a basis for this trust. There were no pressures from interdependent corporate groups like insurance and pharmaceutical companies. As these commercial, profit driven, corporate conglomerates emerged and the medical professions split into specialties, the close personal bonds that patients had with one, well-known country doctor shaded into a sterile, technical, officious, impersonal, business-medical-person style that processed patients through assembly lines where billing forms and documentation of treatments were more important than the person being treated. The control of the patients" health destiny had shifted to corporate policies. Now, the doctor mechanically examines, diagnoses, prescribes, and dictates notes as patients who had been waiting sometimes for hours are formally routed, room to room, in and out in a few minutes. Patients do as the doctor says without question. After all, the doctor"s choices are restricted to treatments and medications dictated by insurance companies" bureaucratic gatekeepers who are ordered to keep costs at a minimum. Who can question when the doctor"s choices are dictated by distant, invariant algorithms. This is medical care by proxy. The medical profession has had to abdicate autonomy in exercising their expertise to distant bureaucrats and accounting- dominated, impersonal algorithms. Furthermore, what is relevant for this topic is that the industry-wide transformation into impersonal commercialism has even extended to psychiatry where the non-linear person"s personality and personal needs should be preeminent. Furthermore, the impersonal, authoritarian paternalism, in the same manner, infected non-medical psychotherapists since reimbursement for their services required both a psychiatric diagnosis, which in turn required some kind of supervision by or affiliation with a psychiatrist, and approval by insurance companies" bureaucratic gatekeepers and corporate, mercenary, mechanistic policies. The old paternalistic posture of psychiatrists remains, in a sense. Yet, in a sinister way, their paternalism is now possessed by mercenary, mechanistic, corporate accounting mentality. This accounting mentality has taken control but asserts itself in a deceptively caring manner that is nevertheless authoritative and admitting no leeway for dredyoung Page 63 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc interjections of the patients worries or wishes. This has become a most insidious form of the new psychiatric paternalistic control over the patient. 30. On Therapy and Being a Patient Under the New Lords of the Mind Within the therapeutic relationship during the "hour" of therapy, the client (patient) was still defined as sick and dependent and the therapist was still defined as the expert healer. This vertical structure of the therapy relationship unwittingly had the effect of maintaining the client"s identity as a "sick" person. The expert, if a psychotherapist, was to heal the sick person"s symptoms in collaboration with his dominant medical counterpart, the psychiatrist. It was now assumed that when the symptoms were ameliorated and the client"s behavior was no longer seriously bizarre, disturbing, or disordered, "the therapist" could conclude the therapy. However, in fact, when the managed care bureaucrat dictated that the allocated number of sessions was up, the therapy was over. With most modalities and in most cases, reduction of symptoms was the goal. The "nominal goal" was supposedly arrived at through consensus between therapist and patient. In fact, the therapist was forced to orchestrate, scrumptiously, the consensus over the goal. Once the nominal goal achieved, the "patient" was considered to be in remission. This, due to the new structure of the relationship, had to be determined by the therapist. Thus, the vertical status remained. On the one hand, here was an expert who knew all about the client and who must be deferred to regardless of the patient"s feelings and whether symptoms returned or new ones developed and then, on the other hand, there was the patient, the person designated as in remission, modified, ameliorated, or the recovered "sick" person. In other words, the patient was like a second-class citizen, not to be trusted with his own life, and never considered as an equal or self-determinant vis-à-vis the expert in the decision-making process. This is akin to the treatment of slaves; ethnic groups regarded as inferior; children; or even sub-humans. The patient is now a "thing" that has to be managed and that could be disposed of at the discretion of the master expert class or race. Woe be under to unfortunate soul that fell into this category of mentally "ill" patient. Like criminals who, when convicted, lose their citizen"s rights, a person being diagnosed as mentally ill has their autonomy forfeited, virtually, their human rights are written off. This expert decision transforms the person and thereafter has an almost mysterious sticking power, like an embossed identity, a contagious disease, or a supernatural stigma, which, when somehow someone is exposed to it, it could not be rubbed or cast off. Like the effect of being in the presence of a leper, the formerly "normal" human, an equal among humans, might be vulnerable to having the stigma rub off, or transferred onto them and shunned for life. The tragedy is that all of this psychological interplay takes place on a subliminal level and therefore is immune from ever being consciously addressed. 31. The Public Has Unwittingly Abdicated Its Autonomy dredyoung Page 64 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc A completely new class of humans has evolved, sociologically, which is somehow psychologically an underling and has to be managed and repaired as one would one"s car. A whole, contemporary, population of humans has somehow descended into a subordinate, dependent, inferior status vis-à-vis the mental health professionals and their corporate masters. This population is no longer completely in charge of its own destiny. Gradually and surreptitiously, the populace has been redefined. Now, since their problems are not in their intrinsic personality, it is in their genes, or their brain chemistry. All unwanted causal bases for mental illness have been excluded, all bases are covered, and the people are none the wiser. The lay population seldom looks to life history, life conditions, or external structures for causal explanations of their misfortunate psychological conditions. If, along with those factors, their individual personalities are excluded then the people would turn to the new mysterious, secret domain over which no one but the psychiatrists have access. Within this secret domain they could be unchallenged if they claimed that the fault of mere, ordinary humans" predicaments lay not in their disordered selves, or lack of capacity for self-determination or self-direction, but rather in their "brain chemistry" over which they have no control. According to our new world of expert authorities, media oracles, and institutional overlords, imbalanced brain chemistry is the exclusive domain of the lords of personhood and sanity, namely the psychiatrists. Faced with this formidable assemblage of seers, what ordinary human would presume to rely on their own meager judgment. They seem to assume that it is better to decommission this ego mastery skill and defer to new lords of the mind. Of course, this is also true of so many other domains of modern life that is it easy to concede this one as well. "Listen, accept, obey, and do not question or search out answers on one"s own" seems to be the motto of modern man. 32. How The Media Keeps The Medical-Industrial-Complex Wheels Well Greased 33. A Cultural Anthropologist Asks, "Who Is Really Sick Here??" A comprehensive structure and systems: Pharma, corps, legislat, managed care, prof, justice, factory mass production model, persons =numbers, force of media, insurance, belief in bureaucracy, belief in cost/benefits analysis, structuralism- management by objectives-participatory management Limitations of philosophy of man, one size fits all, faulty psychology, myopic psychotherapy, using career insecurity to blackmail, exploitation of lack of organization of MH consumers and professionals. Academic assimilation of business culture. See history of management philosophy does efficiency entail effectiveness? Does the personal touch matter? For money, effectiveness or for well-being and life quality of persons. Modern management in the complex of Insurance-Managed Care-Professional providers-and client/consumer. dredyoung Page 65 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc During the bonanza days of psychiatric hospitals, they became very big business. Giant corporations sprang up and built new psychiatric hospitals wherever they could, as fast as they could. They set management systems built on a marketing model. This was highly successful in bringing in new patients and many patients meant billing insurance company"s increasingly large sums. This had been made possible because of the rewriting of the mental health clauses that were changed to permit costly long stays in psychiatric hospitals rather than pay the swelling ranks of mental health professionals. Unlimited visits to private practitioners had taken the burden off the states for their state mental hospitals, which had been overflowing. Insurance companies had not had to worry about how to manage the costs of treating physical illnesses. The latter had remained steady with only a gradual increase over the years. However, this mental health cost bubble caused them to rethink their management philosophy. Their solution was to create a mid-level organization to exert cost controls over the mental health sector. Physical medicine costs were beginning to escalate, however, so they applied the managed care approach to it also. Insurance companies abandoned their loose management of providers and switched to a cost accounting management model. By injecting managed care between the insurance companies and the providers, they restructured not only the reimbursement policies and procedures but also restructured the doctor-patient relationship. Managed care employees were usually not medical or mental health professionals. They were more like bureaucrats. In their role of bureaucrat, they were responsible for keeping costs at a minimum. To do this, as was mentioned above in section 21, they became gatekeepers. They were responsible for reviewing requests to treat patients and weed out prospective patients whom they thought did not meet their criteria. They were to keep the number of sessions to a minimum. They required providers to submit huge numbers of forms and reports. They made providers develop, with the patient, goals for the therapy, to record progress toward the goals, and to record the degree of success when the allotted number of sessions had been met. The bureaucrats also kept records of their evaluation of provider"s performance. Providers with "good" performance records were rewarded with more referrals and vice versa. Under this cost accounting management system, the locus of control shifted away from both the provider and the client. Previously, providers were like consumers of a retail product. Insurance companies had to "sell" their goods to the consumer and, as any good salesperson; they had to court and persuade the consumer. Clients were consumers of a service, the provider"s service. The providers had to hone their therapeutic skills for their clients. In a sense, therapists were like small business owners in which they were their own boss and their own evaluator of their performance. Their criteria for the evaluation were whether the client felt they had resolved their issue and were ready to terminate. Their most important skill was empathy. The client determined the course of therapy. Consequently, the locus of control lay with both the therapist and the client, but primarily with the client. From the onset of managed care on, the therapist/client, relationship underwent a radical restructuring. The changes were insidious. Most therapists felt but did not understand what was happening to them. They were stuck in between the needs and self-determination of their clients and the requirements put upon them by managed care. In effect, therapists had to become manipulators par excellence in this dual role. dredyoung Page 66 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc There was another irksome and costly annoyance. Managed care bureaucrats exercised an unacknowledged prerogative of refusing to reimburse, often without prior notification. However, worse than this, they scaled down the amount of the reimbursements. Many providers went from $150.00 an hour to $25.00 an hour. This, plus the other repugnant impositions, drove many therapists out of business. Of course, this did not displease managed care. In fact, these bureaucrats were typically advised by their superiors, and ultimately of course, the insurance companies they were serving, that those who had the best cost control records would be rewarded with a bonus. War seems to require a nameless, faceless enemy. form (structure) follows function in the biological world (Ernest Cassirer) until culture arrives and then function (human behavior and personality) follows form (structure as in the institutions, roles, etc. of culture) this is important for understanding the relation between managed care, providers, and clients The new language of mental health and the cultural zeitgeist as a part of the structures and systems of modern MH 1971. Cultures as systems: Toward a critique of historical reason, Bucknell Review, XXII:151-161. Ludwig von Bertalanffy (1901--1972) his General Systems Theory 34. How Can the Concept of Structure Play a Role In Mental Health? Teaching participants to identify and use the eight systems of structures of their organizations. Questioning and suggesting to orgs they and their children belong to. To understand family structures and fragmented-blended families and extended families and Neighborhoods. Questioning public high school organization, school boards, and violence programs. The psychology I present there is very different from conventional psychology. When I first began to see things differently, back in the middle 1960s, I realized that I had to make a paradigm shift from psychology I had been taught. I eventually came to see it as like a Copernican revolution in which the earth was no longer the center of the universe. Copernicus saw the Sun as the center. Of course, now we know that the sun is only the center of our Galaxy. Likewise, I began to reverse my perception and see that a person-centric psychology was a disastrous mistake. I replaced that model with a structure-centric psychology because it became obvious to me that when external or social structures are changed, the person changes. Upon reflecting on my own practice and that of others over the years, I saw that attempts to change the person, especially if they were "mentally ill" or criminal offenders, and the like, had only short-term effects if they had any. Sometimes, the results of therapy with individual clients, whether in or out of an institution, were even negative. This was particularly true of inmates in prisons or juvenile correctional institutions. On the other hand, when I made constructive changes in the structures and programs of mental or correctional institutions, the results were dramatic and enduring in a very positive way. Treating people outside of these types of institutions did not work so well with the structure-centric model. I reasoned that I was applying the traditional model of the therapist treating an individual (or group as in group therapy or family therapy) and dredyoung Page 67 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc therefore this approach could not address the negative factors in the structure of their home and home community environment. In 1968, I had directed a community development project with the focus on a group of about sixteen habitually impoverished individuals. However, I was able to enlist the involvement of many agencies and institutions in the project and I, therefore, made sweeping changes in the structure of their social environment. Once again, enduring and dramatically positive effects were achieved. I now believe that, if a change agent understands people in terms of a structure-centric model and if that person is given the freedom to be able to design structures and programs to elicit positive, mature behaviors, then they will achieve enduring, dramatically positive, changes in the individual persons involved in the program. If you have the time to study my web sites and all of its sub webs, you will see this philosophy spelled out in great detail. The "Stars and Stripes" site is the best example of the successful application of this approach to an institution. I am currently working on a way to apply this model to people with a wide range of issues and problems outside of institutional environments. 35. The Dialectical Tension Between Social Structures and Individual Freedom Hegel and Marx spoke of the dialectic of history. Hesse"s Beneath the Wheel and Kafka"s The Penal Colony illustrate the dominance of external structures. Management philosophy (Peter) of the 60s put emphasis on the individual. This was followed by tough-minded management of the 80s and 90s. Mental health had its swings during these decades: 1900-1930; 1930-40; 1940-50; 1950-60, etc. Managed care arose in the early 90s. In a sense, the Duplex Pyramids Model represents a Dialectical tension be could be trained to use, in a more elaborate sense of course, the figure-ground reversal technique. By bringing into play the Duplex Pyramid Model, with its detailed methods of analysis of the levels of both pyramids and their interaction, or mutual influences, such groups could systematically and methodically work through to designs that do, in fact, include both the top and bottom pyramids in a mutually facilitating manner. 36. A New Proposed Goal Would Be Facilitating Maturation Versus Cure Symptoms Designing Programs that are Reoriented away from a medical 'Illness and Cure Model' and from a justice 'Crime and Punishment Model' and toward a 'Maturity and Structural Change Model' 37. Prescribing Alternative Methods to Recover from Our Cultural Sickness 38. Ways of Relating in Types of Roles and Relationships in the New Mental Health System 39. To Reverse the Objectification of Man: Respect their Total Inner Person, Life History, Life Circumstances, and Intentions This means no discounting and no imposing. dredyoung Page 68 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc 40. All of this being said, what do we do now? . C. Critiquing current individual treatment modalities and institutional programs 1. Traditional psychotherapeutic modalities do have aspects that relate positively to their counterpart levels in the bottom pyramid of the Duplex Pyramid Model a. Dyadic Role-relationship therapies Transactional analysis has its paradigm of how people relate to each other. One person can assume one of three root positions or roles: Parent, Adult, or Child. The other person can also assume any one of the three. As for instance, if a person takes the role of Parent, the other can assume a Parent, Adult, or child role. With each combination, the dynamics of the relationship will change considerably. Each of the three root roles can have different styles. For instance, one could have a punitive parent style and the other a rebellious child style. This combination would likely be stuck in endless conflict. If the punitive parent switches to acting like a rebellious child, the rebellious child will sometimes switch to acting like the punitive parent. The ideal is for two people to both assume the adult role. Their relationship will likely be one of equality, fairness, reciprocity, rationality, mutual respect, support, and facilitation of each other"s goals. Of course, if a grown up is a parent with a child, assuming the adult role with the child would have inherent unrealistic expectations. However, when the adult takes into consideration that the child will be operating at a child"s level of emotional, moral, social, and mental development and adapts their communication with the child in a manner appropriate for the child"s level of development, the child will gradually grow more rational, fair, responsible, and respectful with the adult. This development will, as mentioned occur gradually. If the parent"s expectations do not get ahead of where the child is, the child will not only mature but also have an accompanying self-esteem, confidence, and pride in their expressions of increasingly more mature and adult-like responsibility. dredyoung Page 69 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc When the staff in an institution learns to assume the adult role illustrated above, their client population will also begin to relate and an increasingly more mature way, just as did the child example cited above. The client population will tend to bond more easily with the staff and to take them as role models to emulate. Likewise, in the Natural Systems groups in the "Open Society", there could be opportunities to adopt this adult-adult model. Members, of course, will be interacting and discussing their personal concerns, ideas from lessons, plans, and progress related to projects, and the like. As they do so, one of their functions will be facilitate each other"s growth in acquiring ego mastery skills and maturity. An important example of these skills will be relating to each other on an adult-adult basis. b. Role-playing variations and especially Psychodrama: Psychodrama, usually a group technique, and role-playing therapies are designed to help clients understand their roles and the roles of others in their network of close relationships by dramatizing and switching roles and simulating role interactions. Through these mini-scenarios, clients can also learn new and more effective ways to interact with others. Role-playing is also used in sessions with just the individual client and the therapist enacting roles somewhat as is done in psychodrama. The problem with this technique is the same as with all modalities used with the individual client. That problem, as was noted in the beginning, concerns the one-hour a week. Through out the rest of the week, the insights gained in the sessions fade and the pressures coming from so many other interactions during the week cause a regression to their status quo ante. Most of these role relations are informal and constantly requiring adaptations to all of the various persons with whom they interact in all of the various settings and situations. However, the main handicap is the fact that there is neither the time nor opportunity to learn a wide range of role behaviors or to incorporate their changed role and role behaviors into their identity vis-à-vis their full range of relationships nor to integrate these changes into their self-concept. Nevertheless, the concept roles and role behaviors is a vital part of the Natural Systems institutional program. In the case of Stars and Stripes, the youth are given formal roles to enact and they have to learn to adapt their behavior to these roles. As they move up in rank, dredyoung Page 70 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc their roles not only change but also demand more responsibility, skill, and maturity. Since they hold each of their roles for several weeks, their peers and staff begin to identify their roles for each rank. This role enactment becomes, therefore, a part of their identity and eventually it is incorporated into their self-concept. Since the ranks of the program are graduated in a manner similar to the developmental stages from childhood through late adolescence, their identity is also assumed to be becoming increasingly mature. As they move through the ranks and levels of maturity, they are developing ego mastery skills in the areas of person maturity, interpersonal maturity, social maturity or maturity in identifying with the institution and serving to maintain and enhance the quality of community life. Assuming formal roles in the context of the institution"s program is a powerful way for the youth to incorporate maturity and ego mastery skills that they are proud of and that will help with the test of time. Regression to status quo ante behavior becomes much less likely with this approach. Natural Systems groups in the "Open Society" can also benefit from this technique. Members can be assigned formal roles for conducting various tasks or presentations. They can be provided constructive feedback from fellow members to assist them in improving their leadership skills while the members providing the feedback can do the same with each other. As they enact their formal roles as leader and audience, they acquire these new skills and styles that then become incorporated into their behavioral repertoire and their identity and self-concepts as well. The informal roles they attempt to assume and the group attempts to assign to them can also be detected, shared, and discussed to give each insights into their unconscious tendencies in informal role assumption and their preferred informal roles. This feedback and these insights can then be viewed as choices to be evaluated from among alternative informal roles. Engaging in this activity is highly personal. It will require acquisition of sensitivity and non-judgmental communication styles. The employment of formal roles and evaluation of skills and styles in both formal and informal roles should be a powerful part of the Natural Systems groups. c. Communication therapies and Virginia Satir and family systems: dredyoung Page 71 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc Natural Systems groups can benefit from the great contribution made by family systems therapists and communication therapists. Previous modalities had focused on having people talk out their conflicts or act them out in groups. Psychodrama with groups was eventually adapted to Psychodrama with families. What family systems and communication modalities did was to shift the focus on "the way" people or families talked and "the way" families developed a system of roles and relationships which was revealed in "the way people or families talked differently to each other depending on their role in the system". This turned the previous focus upside down. Instead of inferring roles by listening to the way members talked to each other and then dealing with the pathology in the role system, the focus became dealing with the communication pathology. This does not involve an inference or a construct. This is what is immediately apparent. Clients could hear a therapist or another client say, for example, "You are not listening to me. You are talking down to me. You are side stepping the issue. You are not revealing yourself. You are not giving that person an equal chance to talk." This is immediate. The therapist could take the spoken words, or the manner of shutting a person out, or the angry and hostile manner of speaking, and such, and focus on them. Then the therapist could turn it around to, without pejorative diagnosis, labeling, or being judgmental, directly retrain the communication pattern. Clients could see for themselves that, when they talked differently, they got different results. When they listened differently, they got different results. These results changed the quality of the relationship and this became rewarding and satisfying to the clients. Changing the communication pattern did not involve invading their private personality that tends to make clients uneasy and defensive and lends toward defining their identity in a negative way. Yet, when the communication pattern changed in a therapeutic way, the clients began to be more transparent and empathetic. They did not defensively have to maintain their public personality. Therefore, they had less reason to be defensive and guarded against being accused of such things as deceptiveness, of being manipulative, or self- righteous, and the like. The labyrinthine paths taken by former modalities to get at the underlying cause was short-circuited. The immediate small successes could be self-reinforcing. dredyoung Page 72 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc In a somewhat similar manner, Natural Systems groups can engage in mutual assessments of one another"s transparency and empathy, assist one another in finding more effective communication skills, and mutually support and verbally reward with other for practicing these skills. They can do this as a part of tasks that likewise circumvent those labyrinthine paths and pejorative labeling of former modalities as well. They can do this in a positive and objective way that merely says, "Lets try this alternative and see if it helps." A neutral member can take the assessed information and their immediate observations and actually coach, for example, pairs that are trying to improve their communication skills. Their success instantly can be given recognition and encouragement to persist, just as a coach does. Only one that includes learning to communicate and change role relations within the "family system". d. Psychiatry and psychopharmacology: In collaboration, these two have provided significant insights into normal and abnormal brain chemistry. It is helpful to know, or suspect, that a certain type of treatment, whether psychological therapy or psychotropic medication, has restored the brain to a balanced chemistry, or healthy pattern of neurotransmitter interaction. On the other hand, if after taking psychotropic medications, a patient reports inner comfort, exhibits self-enhancing behavior, and appropriate social skills, it adds little to state that there may no longer be a brain chemistry imbalance. Alternative explanations are just as justifiable in the absence of empirical evidence or demonstrated cause and effect relations. If after withdrawal of psychotropic medications a person is symptom free, the same argument applies. Consider, for example, that if first there were unhealthy symptoms, then a patient entered an institution and psychotropic medications were administrated and the symptoms were not reduced, and then a treatment program was introduced and at the same time the medications were withdrawn and then the symptoms disappeared, would the best explanation be that the program was the causal agent? Could we assume that initially negative external environmental conditions induced an imbalance in brain chemistry and then subsequently positive environmental conditions influenced a balance dredyoung Page 73 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc in brain chemistry? How could faulty brain chemistry be the best explanation as the cause of the symptoms or their reduction? Nevertheless, it would be interesting if an unbiased research organization could test brain chemistry before and after a program like "Stars and Stripes" or a Natural Systems group in the Open Society. Nevertheless, finding correlations between neurotransmitters and symptoms can be helpful. If studies can show that configurations of neurotransmitters seem to fit with changes in the structure of the external environment and/or a person"s life conditions, this can be helpful. Likewise, a determination of configurations of neurotransmitters that seems to correspond with a person"s symptoms could be helpful. If such results demonstrate or suggest that brain chemistry or neurotransmitters are sensitive to and closely related to shifts in the person"s external world, this suggests that there is more than a mind-body connection but also there is a mind-body-external world connection. In other words, a holistic philosophy of mind-environment could lead to an entirely new direction in treatment, namely one that begins to emphasize the importance of external structures in mental health. e. Behavior modification: Behavior modification is based on learning theory and particularly on reinforcement theory. It uses positive reinforcement or rewards and negative reinforcement or the withholding of rewards. It uses punishment. Reward and punishment can come in an immense variety from words; to physical sensations; food; tokens; ceremonies; or whatever the inventiveness of the therapist can devise. Reinforcement can be scheduled to come at fixed or varied times and to come consistently or intermittently. There are two principal problems or concerns with behavior modification. 1) That a very small response set is treated in isolation from the rest of the person and their social environment. 2) That it is administered either impersonally and mechanically or without taking into account the nature of the relationship between the client and therapist and without regard for whether or what kind of a bond exists between them. In other words, it is mechanical, impersonal, without regard for the whole person, and the reinforcement is administered in a non-bonded relationship. dredyoung Page 74 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc Nevertheless, the idea of reinforcement can be used in a positive and effective way. First, the mechanical aspect must be discarded. Then reinforcement through personal recognition within a bonded relationship will be appreciated and the behavior is not likely to be faked. When it is truly deserved and not used to manipulate it can be very meaningful to the client. With this approach, the reinforced pattern or achievement will tend to be incorporated on an enduring basis. It is especially meaningful and effective if it is meant as an acknowledgement of positive, community related achievement from both the therapist or a staff member and the person"s peers. With this kind of approach, the reinforcement aspect of behavior modification can be adapted to Natural Systems groups. In this regard, the reinforcement aspect of behavior modification can make a significant contribution to the Natural Systems approach in the Open Society as well as in juvenile correctional institutions. In behavior modification, verbal behavior is a subset of behavior that is to be modified and is not a means through which a client may gain insight. Insight is disregarded. The isolated unit of verbal or physical behavior is the focus of the treatment without regards to anything else. It is virtually the opposite of a holistic approach. In some juvenile correctional institutions token economies (a form of behavior modification adapted for institutions) have been used. In each case it has not worked. The residents not only do not change in a positive way, but they become more expert in their negative behaviors. They learn to bully, cheat, manipulate, lie, and feign improvement. Since it is an impersonal form of treatment, the residents come to understand that it is being used to control them and that those administering the program do not care for them as persons. The response to being not cared for as a person is that they do not care for the others or themselves. Without care, the ostensive objectives of the program are not incorporated. Even if they do manage to conform and modify their behavior, the change is for appearances sake and is short-lived. Contrariwise, in the "Stars and Stripes" program, teaching and training those in a rank below to rise to your rank instills the content being taught in the teacher, but it also instills the helping or teaching behavior. Those being trained to attain the next higher rank are rewarded when the goal is achieved. Parallel with that, the behaviors engaged in to reach that rank do not merely involved learning content. It is mainly behavior, repeated actions, that was rewarded. dredyoung Page 75 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc When the learned behavior is enacted intentionally, consistently, and repeatedly, it is far more likely to become incorporated. The person has to choose and set a long-term goal to reach the rank and follow through with the appropriate behavior. Attaining the rank under these conditions reinforces both setting long-term goals and the persistence necessary in working to reach that goal. The attained rank is a reward but it also entails greater responsibility and more advanced pro-social roles. Contrary to behavior modification, a reward in "Stars and Stripes" is redefined. Reward now signifies gaining a desire to being identified as more mature, responsible, and entrusted with a more responsible pro-social role. Rewards in this context are for not just used as positive incentives and influences on those of lower ranks. They mean that the more advanced rank entails responsibility for maintaining a positive community. The reward entails a positive membership in a group of one"s peers. Furthermore, it entails identification with the institution as a whole. The reward is more than a higher rank. It imbues the youth with a new identity that entails respect and implies the capability and trustworthiness of the youth. Even though being quite different from the traditional behavior modification modality, it can still be considered a form of behavior modification because it relies on reinforcement theory. It is, on the other hand, far different from traditional behavior modification because it is implicitly reinforcing in the youth a broader perspective on the world. Understanding it on an experiential rather tha a conceptual level, it nevertheless includes the full range of levels of the top pyramid"s external structures. It is simultaneously reinforcing alteration of all of the internal structures. That is to say, it reinforces aspects of dyadic interaction; developing healthy relationships; roles and the ability to change and adapt to different kinds of roles; physical and verbal behavior patterns; ways of communicating; ways of thinking and learning to think before one acts; identifying emotions and feelings and expressing feelings effectively; perceiving reality or what a person is really like versus projection; and understanding and re-construing one"s life history. All of this means that this form of reinforcement includes attaining a higher level of the ego mastery skills. Finally, when successful by attaining the highest rank, it means that the youth has reached a higher level of maturity and therefore regression is far less likely. The reward is multifaceted and comes dredyoung Page 76 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc from their peers, the staff, and the community as a whole. The reward for attaining each rank is presented in a ceremony before the whole community that, thereby, is acknowledging the youth"s advance in responsibility and status and at the same time, the community is demonstrating appreciation for the youth"s rise to greater responsibility in and for the community. In other words, this form of behavior modification is no longer a part of the cult of individualism. The whole reformulation of it makes it an integral part of the whole, the community, and virtually a part of the larger social structure. However, in this system, at each higher level of rank, there is an increase in the youth"s competence at each of the levels of the internal structures and processes. These are all evolving in the youth as they move up through the stages of maturity. In this way, becoming more mature means that all of the components of the self and the youth"s schemata of the institution and social world are simultaneously involved and integrated by the maturation of the essential integrating processes of intentionality. Behavior modification is taken from a focus on extremely isolated units of behavior to the whole human being in its whole environment. It is transformed into a holistic approach. The concept of reinforcement is a vital component of the Natural Systems approach to treatment. f. Cognitively oriented therapies such as cognitive restructuring, problem solving, and reality therapy: Cognitive restructuring is one of the newer modalities. In cognitive restructuring, there is an attempt to identify the client"s self- defeating thoughts, negative self-talk and irrational beliefs. The tendency to set unrealistic or unachievable goals is an example of thinking that involves a vicious cycle. Many people hold irrational worldviews or schemata of the world that produces depression or anxiety. Most people are not aware of the fact that this kind of thinking is stress producing. The therapist tries to help the client learn to recognize and change these unhealthy thoughts and attitudes so that they can reduce stress and the physical symptoms related to it. Unhealthy thinking tends to produce negative emotions, such as anxiety, fear, sadness, frustration, anger, or guilt. These negative emotions can in turn result in physical problems, such as headaches or fatigue, or behavior problems, such as irritability with friends or addictions. You first learn to identify your own cycle of thoughts, dredyoung Page 77 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc emotions, physical symptoms, and behavior. Then you learn to change your thinking, irrational beliefs, faulty world schemata, tendencies to misperceive others as threats and changing these patterns into more realistic and positive ones can reduce stress, improve your relationships, and benefit your health. Cognitive restructuring can be combined with other techniques, such as relaxation response therapy, healthy diet and exercise, breathing exercises, meditation, visual imagery, and yoga. In other words, this modality espouses a holistic philosophy. Since youth in a correctional institution are typically hostile to attempts to use counseling with them or get them to recognize their faulty thinking, cognitive restructuring as an individual therapy modality is virtually useless. However, it is clear that the negative structure of their thoughts and beliefs is a major contributor to their behavior and emotional disorders, particularly their delinquent behavior. Instead using employing a therapy modality, the institution"s program is designed to bring about an identification with and bond with the staff, the institution, their peers, and ultimately bring about a redefinition of the world, society, and representatives of society"s agency such a police. This indirect approach results in a pervasive change in their thinking and beliefs that is simultaneously associated with their behavior and feelings. Reality therapy and goal orientation only therapy involving goal setting but therapist is dominant and interactive in the goal setting and enforcing rule of "no excuses" Reality therapy also involves Identity concept in that goals set also involve a change in identity and/or self concept My assumption is that there is a value inherent in cognitive restructuring but that this can be accomplished more effectively through indirect means. This same approach can be adapted to the Natural Systems groups. By designing the group so that group members engage in cooperative tasks for the sake of the rest of the group, they will come to bond and identify with each other. For example, a few of them at a time could prepare and present a lesson. If they chose to do one on the nature of an agency or corporation that is taking a beating in the press one of their goals could how structure rather than administrators or staff was the problem. Alternatively, dredyoung Page 78 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc they could present something on the causes of stress, delinquency, poverty, or homelessness, or the like. In this case, they could be charged with trying to show how the structural factors are influencing these social and personal problems rather than some defect or ill will inherent in the person. All in one project, they bond with each other, come to understand each other better, identify with the group, take ownership of the purpose and conduct of the group, and begin to alter their beliefs about the world their ways of thinking, and their worldview. While the modality, cognitive restructuring, has the same intractable problems mentioned at the outset, it is still possible to see the potential value of some of its underlying philosophy that can contribute to Natural Systems groups. g. Rogers Client-Centered, psychodynamic, and feeling oriented therapies: From Rogerian non-directive, psychodynamic, and analytical therapies, Natural Systems takes training staff group leaders and support team surrogate parents to be accepting, non-judgmental, and empathetic so that the youth come to feel free to express their true emotions, learn to verbalize them so that they are transformed into more refined expressions of feelings - - while being related to with non-judgmental empathy from staff and staff surrogate parents in support teams the youth model and learn to be empathic and non- judgmental iin allmostt allll ttherapiies tthere iis an obviious or n a mos a herap es here s an obv ous or iimplliiciitt sttrattiiffiied rellattiionshiip,, and one up tto one down rellattiionshiip mp c s ra ed re a onsh p and one up o one down re a onsh p bettween ttherapiistt and clliientt off sttaffff and resiidentt be ween herap s and c en o s a and res den ttherapiies are a herap es are a doiing tto or ffor ratther tthan a muttuall,, pariitty,, equalliitty,, same llevell do ng o or or ra her han a mu ua par y equa y same eve rellattiionshiip even iiff clliientt iis encouraged tto diirectt ttheiir own ttherapy iin re a onsh p even c en s encouraged o d rec he r own herapy n ttheiir own way and ttiime -- tthatt iis as iin Rogeriian non--diirecttiive – whiich he r own way and me ha s as n Roger an non d rec ve – wh ch encourages ttheiir openiing up ttheiir priivatte person -- PARADOX encourages he r open ng up he r pr va e person PARADOX Rogeriian ffeelliing oriientted and owniing ffeelliings and psychodynamiic Roger an ee ng or en ed and own ng ee ngs and psychodynam c gaiiniing iinsiightt iintto repressed and suppressed priivatte person and ga n ng ns gh n o repressed and suppressed pr va e person and iintto whatt lliies beneatth deffenses and publliic personalliitty PARADOX off n o wha es benea h de enses and pub c persona y PARADOX o ttransparency,, autthenttiiciitty,, empatthy versus ransparency au hen c y empa hy versus off confformiing tto o con orm ng o rolle prescriipttiions assumiing a publliic persona assumiing tthe iidenttiitty ro e prescr p ons assum ng a pub c persona assum ng he den y enttaiilled iin tthe fformall rolle iin order tto llearn and tto iincorporatte ego en a ed n he orma ro e n order o earn and o ncorpora e ego masttery skiilllls ffor tthe devellopmentt off tthe ttraiitts off iincreased llevells off mas ery sk s or he deve opmen o he ra s o ncreased eve s o dredyoung Page 79 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc matturiitty enacttiing and practtiiciing tthe behaviiors off tthe rolle ""jjob ma ur y enac ng and prac c ng he behav ors o he ro e ob descriipttiion"" versus autthenttiic behaviior and sponttaneiitty autthenttiic sellff descr p on versus au hen c behav or and spon ane y au hen c se percepttiion and ttransparentt sellff revellattiion versus adopttiing tthe goalls percep on and ransparen se reve a on versus adop ng he goa s off tthe fformall rolle and confformiing tto tthe ttraiitts off tthe rolle assumiing o he orma ro e and con orm ng o he ra s o he ro e assum ng tthe sttrattiiffiied – one up – one down – rellattiionshiip off hiigher ranked he s ra ed – one up – one down – re a onsh p o h gher ranked youtth ttraiiniing,, tteachiing,, and hellpiing tthe llower ranked youtth and you h ra n ng each ng and he p ng he ower ranked you h and siimullttaneouslly llearniing tto rellatte as equalls and llearniing tto cooperatte s mu aneous y earn ng o re a e as equa s and earn ng o coopera e as equalls --peer tto peer – adulltt tto adulltt as iin ttransacttiionall anallysiis as equa s peer o peer – adu o adu as n ransac ona ana ys s avoiidiing tthe rolle off reward--er and reiinfforce--er off tthe otther""s avo d ng he ro e o reward er and re n orce er o he o her s behaviior as iin Rogeriian non--diirecttiive ttherapy versus assumiing as iin behav or as n Roger an non d rec ve herapy versus assum ng as n tthe adopttiion off tthe reiinfforcementt rolle rellattiionshiip off tthe fformall rolle he adop on o he re n orcemen ro e re a onsh p o he orma ro e systtem Natural Systems groups sys em h. Gestalt therapy: From Gestalt therapy, Natural Systems in the institution achieves its emphasis on learning to differentiate between their mistaken perception and interpretation of the world and objective reality through the corrective feedback provided by both staff and peers. Eventually they learn self-correction and to be brutally honest both with respect to their misperceptions of themselves, their misperceptions of the "others", of the institution, and the world. Natural Systems groups. i. Psychoanalysis: When psychoanalysis laid out the theory of the role of parents in the development of the child"s personality, it generated much controversy. This, in turn, generated much research in psychology, sociology, and child development. Such extensive questioning and research contributed to developments in psychotherapy. Of particular importance were the efforts that led to family systems theory and therapy. Margaret Mead"s cross-cultural studies opened the way to explorations of alternatives to Freud"s ideas about the nature of the family. Family systems theory explored role-systems in the family. It proponents demonstrated how members of a family, especially children, were unconsciously assigned roles. The experts in family systems gained insights into how parents" motives in assigning roles were sometimes pathological. dredyoung Page 80 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc Consequently, the child who assumed these assigned roles developed pathological behavior and interaction patterns with parents and even with peers and other adult authorities. Using the combination of Freudian family concepts and concepts from family systems, Natural Systems saw that building a way to have two positive parent surrogates placed in roles in which they could maintain a close, positive, supportive relationship with a youth. In this role they could encourage the youth to use their own judgment, set their own goals, self-evaluate consequences, and learn to be self-corrective so that they could progress through developmental stages in their growth toward increased maturity. "Stars and Stripes" also emphasized ways to alter the youth"s interaction with their family of origin, or biological family. The youth"s were taught how to use negotiation and mediation skills within their family. They taught to understand how their families" unconsciously assigned them negation roles and how to resist this. Further, they were instructed to expect a two-week honeymoon period upon return home. After returning home, pressure to return to ante- incarceration status quo behavior and to their assigned role in the family system will start to build. Knowledge of this pattern serves as a kind of inoculation against caving in to this post honeymoon pressure. Building on Freud"s concept of transference as a natural phenomena that occurs in a close, bonded relationship with a caring and accepting adult and his concept of the superego as an introjections of a child"s parents, Natural Systems uses a similar concept of the Implicit Other. Even with severely antisocial and emotionally disturbed youths and adults, if the required type and quality of bond forms with the staff or therapist, original negative parents can be supplanted. If this relationship persists over a sufficient length of time, the adult authority as parent surrogate can become incorporated, supplanting the original parents as Implicit Others. Over time, this close relationship can result in the adult becoming a role model whom the client or youth attempts to emulate. The client or youth will seek their approval by trying to become as much like them as possible. If this pattern of interaction is successful, the supplanting Implicit Others will stand the test of time and function somewhat like a subliminal voice guiding choices and behavior and serving as a perpetual unconscious positive reinforcer. The introjections of staff surrogate parents as their new implicit dredyoung Page 81 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc parents also serves as a powerful inoculation against the negative family systems" pressure. These Implicit Others also assist in the formation of a new Secondary Implicit Other, or implicit peer reference group, guiding selection of new friends and assumption of new informal roles with possible subsequent new peer groups. This is one place where the concept of longitudinal patterns mentioned at the beginning comes into play. These concepts, originally based on the Freudian model, hopefully, can also prove useful in the Natural Systems groups in the "Open Society". j. In summation: In contrast to the criticisms offered above, each of these modalities has their own contribution to make to the new Natural Systems group therapy. For example, the concept of transference in psychoanalysis means that the child introjected their parents and when in therapy they initially project their introjected parent images onto the therapist. The therapist is non-judgmental and accepting as the client expresses their conflicts and confesses their guilt. Eventually the client perceives the difference between their parents and the therapist. The client replaces their introjected parents by introjecting the therapist and takes the therapist"s attitude toward himself. Thereby, they are learning to live with self-acceptance. In The Natural Systems" "Stars and Stripes" program the staff, while not doing psychotherapy, took a similar non-judgmental and accepting attitude toward the youths. The youths eventually introjected the staff as implicit parents and unconsciously took this non-judgmental and accepting attitude toward their selves. DDDDDDDDD Psychoanalysis looks to the vague, hidden human drives while Natural Systems looks to publicly detectable external structures in the culture that shape and create drives. Psychoanalysis and most modalities are essentially amoral and unconcerned with levels of maturity. Their aim is to eliminate or reduce painful emotions and alter malfunctioning patterns in internal structures and processes such as, for example, perception, communication, behavioral habits, or faulty strategies for relating to others. Ego mastery skills become involved in traditional therapies when underdeveloped and ineffective ones must be replaced. Ego mastery skills are also addressed in Natural Systems since they are required increase maturity and to dredyoung Page 82 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc make a mature person"s character more successful. The approach is far different. Traditional modalities focus on or work exclusively with the individual client through their preferred level of internal structure. Natural Systems can work with large numbers of persons and focuses on designing structures that can elicit more skillful and mature behavior. A Natural Systems program can be designed to work with any or all of the internal structures as well as any or all of the inner intentional processes. When considering the problems with and contributions from the major individual or group treatment modalities, Existential therapy purposely was left out. Existential therapy was not considered in those discussions of modalities because it is the only one that addresses meaning, significance rather than one of the internal structures. Also, in contrast to the others, Existential therapy addresses the person"s ethical nature in relation to their mental health and maturity issues. In a sense, Existential therapy has more in common with a critical aspect of Natural Systems. They both relate to the man/world Gestalt and they both assist the client in coming to grips with the human condition and learning ways to creatively cope with it. Existential therapy looks at this in terms of humans" needs to have meaning in their lives and to live a life that has significance. Natural Systems approaches this concern differently, however, in that while the focus is on how to cope with and alter their external world, it is assumed that when the person acquires the ego mastery skill and maturity to do this, they will have a sense of community and collaboration with others in an attempt to reshape their world so that it becomes a mutually supportive, mutually facilitating community. It is assumed that this will give each person a sense of purpose, significance, and meaning. When they sense their world is at cross- purposes with this, their sense of purpose, significance, and meaning will come from a commitment to correct this and reshape their world. They will not be focused on the defects and symptoms of their fellow humans, but rather on the structures that are their cause. Someone could assert that "the reason" why "Stars and Stripes" works is because the youths are given a sense of control or actually a sizable degree of control. There is no doubt that control, which is fostered by the program"s design, is a causal factor. However, that conclusion would overlook two of the most significant causal factors. First, the program"s design has to include many structural factors, all of which are integrated by the principle that all of those structural dredyoung Page 83 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc factors are carefully designed to evoke growth in all of the youth"s internal structures and each and all of their processes of intentionality. Second, and this where the underlying philosophy of Existential therapy comes into play, is an aspect of the program that transcends the mere sense of control by evoking a sense of purpose, meaning, and a sense of positive identification with a large whole, namely the quality of life of the community within the institution. The concept of control or self-determination is a neutral concept that does not include the person gaining meaning, significance within the whole, and a higher purpose, a purpose beyond mere self-interest or self-enhancement. When the arrives, through difficult growth and self-correction, as well as constructive feedback from others, at the level of that sense of personal meaning, significance within the whole, and the higher purpose of responsibility and commitment to the quality of community life, they have transcended mere ego mastery skills. Ego mastery skills are crucial, but they are more like tools or means to ends. The level of maturity that entails those attributes of meaning, significance, and purpose signifies transcendence, which is, I understand as the goal of Existential therapy. In the case of "Stars and Stripes", this is achieved without therapy, which also often is the way it is reached in the "Open Society". Ordinarily, however, the clients of Existential therapists are people of high intelligence, a high level of skills, and are generally quite successful in life, yet have a haunting sense of despair and the meaninglessness of life. Yet, when a person reaches this level of maturity and transcendence while in Existential therapy, then, what we call pathological symptomology simply disappears from awareness. This is why Existential therapists claim that a person"s illness somehow disappears after they have the moment of epiphany of seeing a meaning, significance, and purpose for their lives. Interestingly, goal orientation and execution is centered in the left front orbital cortex and is associated with a sense of well being and even improved physical health. This is what Existential therapy is all about, that is assisting clients in gaining a sense of purpose and becoming goal oriented. Happily, those far less advantaged can also be given the opportunity to experience that same sort of epiphany and transcendence to a higher, more fulfilling level of existence when exposed to a Natural Systems treatment program, whether in an institution or in the "Open Society". dredyoung Page 84 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc PARADOX cited above (20 and 27) also involves inclusion of all levels of structures of both Duplex Pyramids. see the reference to "S & S" program description in the "Essential Features of Stars and Stripes". 2. Natural Systems and Psychiatric Categories and Treatment Approaches Contrasted Reinterpreting Psychiatric diagnostic categories and treatments so as to reflect the man/world Gestalt and supplant the cult of the individual. Natural Systems and Psychiatric Categories Below is a list of problems, personality types, or behavioral patterns for which society uses psychiatry, governmental human services, or agencies to ameliorate, control, or contain. These problems are typically easily observable. They may, or may not, be seen as problems to the individuals having them. Contributing causal factors for them can usually be found in the levels of structures and systems. However, society, its institutions, and helping or controlling professions tend to see the locus of the problem in the individual and tend to exclude consideration of external factors as the cause. There is a special set of problem behaviors that are harmful to others but are treated differently. Society tends to take a laissez faire approach toward this special set. The difference between the special set and the non-special set appears to be that the special set are committed by persons of high socio-economic status, heads of corporations, or high level governmental officials. The non-special set tends to be committed by or characteristic of the poor and powerless. In the Natural Systems approach, all of these problems are regarded as being caused by factors in the levels of external structures and systems that do, in fact, evidence themselves as problems within the person"s internal structures and processes. The problems within the person that involved processes are primarily the processes of intentionality When these problems are treated in an institution with a program like "Stars and Stripes", there is no diagnosis or psychological assessment. The individuals are not given any psychiatric or other types of labels of mental illness or disorder. dredyoung Page 85 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc There is no prescription of treatment for any of the institutionalized individuals. No psychotropic medications are prescribed or administered. There is not even any use of any psychotherapeutic modalities. The structure of the institution, the structure of the "Stars and Stripes" program, is the treatment. It is uniformly applied to all. Since the "symptoms", or the behavioral or emotional problems gradually disappear and the person behaves normally, or appropriately, one must assume that the cause and treatment is structural. Since these institutional residents gradually increase their ego mastery and social skills and grow in maturity, it is assumed that the way the structure is designed elicits this growth in the individuals. It is the growth in each of the hidden, inner, intentional processes which constitutes the evidential growth in ego and social mastery skills and maturity. There was coercion, manipulation, or bribery, and there was no psychological intervention or treatment directed, specifically or overtly, at any of the inner, intentional process. In spite of that, the observable problems such as rage, impulsivity, ADHD, depression, and all of the rest in the right column disappeared. The question of great concern here is can such changes, or improvements, be achieved in the non-institutional, "Open Society"? It is impossible to restructure the "Open Society" so as to be similar to that of the institution. Given this assumption, or rather fact, could there be a way to structure a program in the "Open Society" that could have something approaching the kind of positive impact achieved inside the institution? The labels in green below are emotional problems but have negative consequences for either others, the individual, or both. They are typically diagnosed and treated by psychiatry as the individual"s problem without reference to structural causes. The locus of the problem is in the person. The prescribed treatment primarily will be the administration of psychotropic medications. The problems listed below in red and some of those in green are frequently seen in juvenile correctional institutions. They are found in adult prisons and in psychiatric hospitals as well. These are also problems are frequently found in the general population of the "Open Society". The labels in red are primarily behavioral problems that have negative consequences primarily for others. They too are typically dredyoung Page 86 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc diagnosed and treated by psychiatry as the individual"s problem without reference to structural causes. Their locus is also seen to be in the person. The prescribed treatment for these will also be the administration of psychotropic medications. Individuals having some of these problems will assert that their cause comes from the actions of other people, situations, or life conditions. Some of these problems, especially the painful emotions, will sometimes be attributed to themselves. a. Destructiveness to self and other: Rage Antisocial Behavior Dangerous Aggression Suicidal behavior Destructiveness is typical in prisons and to a lesser extent in psychiatric hospitals. Actually, many psychiatric labels have the potential for destructiveness. In the past, anger and rage were not even listed in the DSM Index, and neither was aggression. Aggressive behavior is mentioned in reference to Conduct Disorders. Antisocial was touched upon very slightly and mainly in reference to criminal behavior. Suicide or suicidal behavior is more frequent in psychiatric hospitals than anywhere else. Suicide was not mentioned in the early DSM. Why would being a danger to others of self not be considered a mental, emotional, or behavioral disorder? Interestingly, to be involuntarily committed to a psychiatric hospital, someone had to certify that the patient was a danger to themselves or others. So, why was there no entry under any label in the DSM for destructiveness to self or other? Dangerous people seemed to be avoided like the plague by psychiatry. Could this inconsistency be due to the desire to avoid liability, because psychotropic medications either had little effect on these two significant problems or occasionally seemed to precipitate them? Destructiveness to others and criminal behavior was left to the Departments of Correction. Oddly, the psychology and psychiatry departments in adult and juvenile corrections have gone to great lengths to provide psychological testing and psychiatric diagnosis to inmates. Even stranger, neither correctional institutions nor psychiatric hospitals have been equipped to treat or deal with the dangerous people other than by extreme sedation, solitary confinement, or by putting them in manacles. Treatment and rehabilitation programs in adult and juvenile correctional institutions have long been known to be titular. dredyoung Page 87 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc The use of psychotropic medications in these institutions did not make the inmates or inmate population as a whole any less dangerous, either to others or themselves. Genuine attempts to treat always failed because you cannot enforce therapy and therapy at the hands of extremely oppressive staff is like an oxymoron. Contrariwise, my own programs in both adult and juvenile correctional institutions was more successful than any type of treatment modality or program precisely because it restructured the organization and transformed the staff from being oppressive to being supportive. In other words, the transformation of the environment was effective with dangerous people even in the absence of therapy or psychotropic medications. There is such a thing as Social Psychiatry, yet strangely it is seldom heard from and when it is heard from through the media the impression is of a meek, insignificant, impotent voice. The social problems it is called upon to address have to do with extreme examples of violent acts of youth, typically in gangs or small groups attacking other youth and occasionally attacking the homeless; parental physical abuse of children; occasional instances of extreme discipline measures by teachers; and police brutality; abuse of the elderly, particularly in homes (private and public) for the aged; In the case of parental abuse or extreme neglect, the state provides Child Protective Services and treatment is a very low priority. Orphaned and abused children are typically housed in group homes or foster homes which are notorious for their poor and inhumane care of these children. Why is the influence of Social Psychiatry so conspicuously absence in this huge arena of misfortune and inhumane treatment? Why is Social Psychiatry"s influence so pitiful with respect to the severe and chronic problems of physical and emotional violence in the public schools? Why is there their influence missing in regard to breeding ground of bullies, sociopathic behavior, sanctioned violence within high school athletics? My suspicion is that School Boards and community leaders, particularly wealthy and influential businesspersons encourage Social Psychiatry to stay out of it. There are societal problems that virtually facilitate or even create violence, inhumane treatment, neglect, exploitation. Leaders in the world of commerce perpetrate these social atrocities. Such problems are in evidence in governmental policies formulated through the collaboration of leaders in business and industry and politicians. Examples are below subsistence wages and substandard benefits dredyoung Page 88 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc and other forms of legitimate care of full time employees and part time and unprotected workers. If a powerful parent abuses, neglects, or exploits their children, if a fully capable adult commits economic crimes like fraud, scams, not honoring economic obligations, passing bad checks, the various social systems like the justice systems are called upon to see that justice is done and punishment exacted. When these categories of abuse, neglect, or exploitation are perpetrated on a large scale upon the poor and powerless by corporations, causing a domino effect of additional individual and social problems, who stands ready to convict and punish them, and what is Social Psychiatry"s role in this arena? The media plays to the public"s lust for reports over which they can moan, "Ain"t it awful!" Broadcasting these human catastrophes is a virtual cash cow for the media corporations. Nevertheless, when they hear about America corporations exploiting children as laborers in their factories in horrible conditions, the only consequence is temporary bad publicity, which spin-doctors quickly dissipate. Is this not antisocial, sociopathic, and criminal behavior on a grand scale? Small-scale crime and you do the "time", large-scale crime and you buy off the "time" while your stock climbs! Is not apparent, after all, that human services are there to serve the wishes and economic interests of the elite? Is not apparent that the justice system is in bed with the rich and powerful? Is not apparent that the very idea of "social justice" suffers extreme disfavor in our society? They used to say "you cannot fight City Hall". Now you can say "you cannot fight the global corporations" and now they own City Hall as well. Are not media commentators who expose our society"s tendency to blame the victim ridiculed and lefties, socialists, even communists? If neither politicians, agency heads, the media, business leaders, nor religious leaders are willing to, have the strength of character to, provide oversight to those perpetrating such ubiquitous causes of mental illness, crime, and poverty in our society and call the economically and politically powerful to accounting for their version of white collar, legislatively sanctioned inhumane treatment of their less fortunate fellow human beings, who will provide this oversight and extract retribution commensurate with their misdeeds? Where are the experts who can clearly explain to the public the nature of our "social pathology" and its consequences "for everyone" and for our future? It seems that Social Psychiatry has definitely abdicated this role and dredyoung Page 89 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc instead assumed the role of caretaker of the victimized by this social disease when it is profitable to do so. b. Sexual Aggression: Sexual Offenses as Illegal or Behaviors harmful to society. As mentioned above, behaviors designated as criminal offenses are treated as criminal cases to be handled through criminal courts and penal institutions. They receive scant treatment in the DSM and are almost exclusively consigned to incarceration. Sexual aggression, such as child molestation, rape, prostitution, and the like are likewise handled through the justice system. Adults having sex with minors is probably one of the most under reported offenses. Its incidence is, as reported, highly biased toward males. In fact, if it were possible to gain reliable statistics, the incidence of sex with minors is probably more frequent among adult females but the nature of our culture makes reporting in these cases unlikely. The only difference in treatment of "sex offenders" is that they often are compelled to participate in treatment programs in penal institutions. It should be no surprise that these programs are notorious for their failure rates but, nonetheless, continue to be provided and funded by the state. Sex addicts, on the other hand, are treated in the private sector by both psychiatrists, using psychotropic medications, and psychologists, using modalities of choice. Who should define what sexual addiction is? It should be no surprise that failure rates in these settings are also notoriously high. After all, who are sex addicts harming? Where does this appellation come from? I suspect that its source is spouses whose husbands or wives are chronically unfaithful. Some have a compulsion for engaging in sex acts in public even though, or perhaps because, it is a crime. Offenders, when caught, which is probably very rare, are typically told to put on the brakes and move on. If arrested, they are usually given probation with the stipulation that they enter therapy. This criminalizing reaction from authorities is odd seeing that risky, public sex is so glamorized in the media. I suspect that if the "culprits" can find a way to be more circumspect, they will continue to pursue the risky, intensely erotic, mildly illegal, public sex. Many women and men find sex in public places to be the ultimate form of eroticism. Furthermore, what is their incentive to reduce their frequency or manner of engaging in this kind of sex? Why all the fuss dredyoung Page 90 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc about it anyway? In the past such peccadilloes were always successfully handled by a verbal reproach and order to cool it and move on. This peculiar modern phenomenon is signaling that a very important transformation is taking place in our society. Could it be that the way sex offenses are handled represents our contemporary obsession with and tendency toward litigiousness? The legal profession now seizes upon so many conflicts that were once handled by the parties themselves along with the help of friends, the clergy, or others in their community. Could it be that lawyers have a great deal to gain by inflaming these issues? Could it be that along with our mobility and other alienating aspects of contemporary industrialized culture, others, even neighbors, are looked upon with suspicion and we can no longer make a personal connection with fellow human beings. We have lost the ability, the ego mastery skills, to deal with ordinary, everyday interpersonal interaction. Our knee jerk reaction is, "Sue the bastard. Or, just call the police and let them handle it." The legal profession is happy to oblige and profit from our loss of interpersonal skills. Could it be, also, that politicians have found this cultural condition and these petty kinds of issues easy to exploit during their campaigns, just as "getting tough on crime" has been for over a century? Could it be that taking a rational approach to this issue, just as is the case with narcotics, is a sure way to lose an election? What I am doing here in making a very brief analysis of the roles of structures and systems, of which historical developments are a part. I am putting the spotlight on this one issue of sexual offenses (to use the example from above), in order to expose how the professions and agencies are getting increasingly involved in our lives. They are dealing with these issues in ever more futile, costly, and counterproductive ways. Yet, at the same time that they are making these problems worse, they are also making the population weaker. Do we make the effort, do we dare, to ask the question "What it is about the structure of our culture that is creating and shaping these problems?" Do we question whether the cost of our ineffectual approaches may be far greater and far worse than the behaviors themselves, anyway? This illustrates the fact that these questions are difficult to ask and examine because, while most crimes are odious, sex offenses are taboo and clever men know that they tread this ground only at risk of grave peril to themselves. We have, consequently, reached a new and most unfortunate status quo. dredyoung Page 91 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc The most important question, however, is, given the point we have reached in this negative spiral of our culture, what can the Natural Systems approach do to make the best of a bad situation and design a program that can deal effectively with this problem? c. Psychosis: Psychosis in the most general sense is a disconnection between what is going on outside the head and what is going on in the head. People who are diagnosed as psychotic are seldom dangerous or harmful to others. For the most part they a nuisance to others, disrupting business or requiring that extra effort be exerted to manage them. Their behavior in inexplicable and therefore frustrating and communicating with them or getting them to cooperate is usually impossible. Regardless of what the cause is, this disconnection with the world outside of themselves is the most essential feature of psychosis. There are many kinds of psychosis. Nevertheless, one does not need to know the kind in order to recognize it when you see it. Similarly, the bizarre behaviors and verbal expressions still lead back to the essential disconnection, at least from the point of view of the rest of society and the helping professionals. "Normal people" who interact with psychotics find that some say things that are incomprehensible and some do things that are incomprehensible, irrational, outlandish, and even scary. "Normal people" find them useless and frustrating to deal with. In a sense, they seem unpredictable but that may due to infrequent encounters with them. For those who have frequent interaction with them, they begin to be very predictable even while remaining incomprehensible. From among all of the bizarre behaviors and expressions, some are seem related and typically are grouped together and placed under one of the Psychotic psychiatric DSM diagnostic classifications. Psychotherapists who try to treat them or merely to interact with them are soon ready to relinquish them to psychiatrists who prescribe medications based on the diagnosis and pattern of symptoms. I am oversimplifying here because the essential point has nothing to do with the etiology or symptomatology. Let me enter a caveat at this point. There most probably is a small percentage of cases of psychosis that are biologically based. Autopsies on deceased psychotics have demonstrated that did in fact have malformed brain architecture. These account for a small percentage of the total diagnosed as psychotic. Recently a research dredyoung Page 92 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc study using the autopsies of psychotics has shown abnormal neurotransmitter behavior in regions of the brain. This study had a very small sample. However, the real problem is the question of which came first, the chicken or the egg? Given the small percentage of biologically based psychoses, that leaves open the question of how to explain and treat the remaining large percentage. In order to deal with the inquiries from nonprofessionals, or laymen, concerning explanations for the psychotic disorder, psychiatrists use the shorthand statement, "It is due to an imbalance in brain chemistry". The use of this brief diagnostic explanation makes it easy to transition to informing concerned parties, or laymen, such as parents, relatives, or committing judicial authorities that the prescribed treatment will consist mainly of psychotropic medications designed to correct this imbalance and reduce symptoms. Quite often the concerned parties are informed that the patient will most likely have to take the medication for the rest of their lives. Nevertheless, since such medications either do not work or work in undesirable ways such as negative side effects, the prescribed medication is frequently changed and sometimes new medications are added to counteract negative reactions. Often the patients report that the medication is so disagreeable that they want to stop taking it. They and concerned parties are warned that the consequences of getting off the medications could be disastrous. Sometimes psychotherapy is recommended as an adjunct to the medication. The research literature is full of conclusions that the best formula for treatment of psychosis is a combination of psychotherapy and medication. The recommended psychotherapy du jour seems to be the cognitive-behavioral modality since most other modalities researched has shown poor results. The results of this combination are cited as being salutary in spite of the fact that the studies typically have short follow up periods and are usually severely flawed and even what is called favorable is often below fifty-percent with a very generous description of what is favorable. A question that is not asked but that seems crucial to me is whether some preceding factors caused the imbalance in brain chemistry. Was the imbalance in brain chemistry there all along and just waiting until some internal schedule set it off? If that were the case, then there should be extensive research to find this internal alarm clock. There is not. For over sixty years the psychiatric profession and the pharmaceutical companies have been doing dredyoung Page 93 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc extensive research both to determine the exact nature of the imbalance in brain chemistry, such as which neurotransmitters were either in excess or deficient and/or which regions of the brain or over or underactive. The pharmaceutical companies have searched for psychotropic medications that will block or enhance the behavior of these neurotransmitters or brain regions. During these years of search for chemical causes and chemical cures there have been an enormous number of Eureka experiences. Repeatedly, these "so-called" efficacious treatments have been discredited and replaced by newer ones "discovered" and then marketed by the pharmaceutical industries. On each of these occasions, the psychiatrists begin to use the psychotropic medications du jour. Similarly, the psychotherapeutic profession has cycled through one modality, or combination of modality and medication, in tandem with their symbiotically superior relatives, the psychiatrists. Through all of this, repeatedly coming to my mind decade after decade is the aforementioned question, "that is not asked", but, nevertheless, seems crucial, is whether some preceding non-physiological factors caused the imbalance in brain chemistry. Of course, what I am thinking of regarding the preceding causative factors relates to factors in levels of structures and systems that could be precipitating the psychosis. Why has this question not been asked? Why have the same old approaches been used in spite of their pitiful rates of success? The answer lies partly because there is no well-known and esteemed group of experts available to do the questioning. The most plausible explanation concerns "vested interests". Psychiatrists and the medical profession in general (all M. D."s can legally prescribe psychotropic medications) in collaboration with the pharmaceutical industry represent two of the largest, wealthiest, and politically most powerful groups in the country. They have a huge interest in perpetuating the status quo. They have captured the trust of the entire population. They have convinced them all, even to the point of virtually mesmerizing them, of their ultimate authority as mental health experts. Their word is like the law or god. They have the funds and lobbyists to influence US legislators. They seldom have more than minuscule, ineffectual, competition from detractors. With the wealth of these powerhouses, they are able to saturate television with highly appealing ads that successfully bate the populace to find reasons to see their doctor and ask for the latest dredyoung Page 94 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc cure for even the most trifling worries about themselves. These companies are like the hawkers of old peddling fake panaceas yet with their acts carried to unbelievable heights of bedazzling showmanship. They are convincingly presented as our lifesavers. Who would dare take a chance on questioning such awesomely educated and revered authorities in whose hands their lives are dependent? Sometimes I suspect they even have mesmerized themselves so that they are no longer capable of questioning their compromised research methods and counterfeit "scientific belief system". They are no longer capable of considering alternatives. Now we shall turn to the central issue to be considered with reference to psychosis. From the Natural Systems point of view, if psychiatrists or psychologists take a blanket approach to all patients exhibiting behavior and expressions that are typically classified as psychotic, they are making the mistake of devotion to an obsolete treatment paradigm. While some few exhibiting such symptoms may have a genetically caused defect in brain architecture or brain chemistry, the assumption that all have this sort of defect is a grave error and injustice. There is high probability that many of such people have the potential to behave in a manner sufficiently normal so that they can join naturally into any activity with their fellow humans and interact appropriately and well without the aid of medication. The problem preventing mental health professionals from exploring this possibility has been due to the dominance of the "medical model paradigm". The psychiatric profession has tried no other alternative or paradigm. Natural Systems does provide such an alternative. In fact in my experience, going back to the latter sixties, very many of those exhibiting psychotic behaviors or symptoms have resumed behavior closely approximating what we call normal when in a Natural Systems" type of program in an institution for several months without psychotropic medications. I am referring here not to the "Stars and Stripes" program mentioned near the beginning, but to other instances where the patients were male and female adults. When the program in these institutions changed so that they embodied the concepts and principles of Natural Systems, these adults resumed normal and pro-social behaviors rather quickly. These results occurred while they were not on medications and were not in psychotherapy. Reiterating, the philosophy and approach of Natural Systems assumes that the root or locus of the problem is not dredyoung Page 95 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc inside the individual but rather lies in the manner in which their institutional or social environment is structured. Outside of the institution, in the "Open Society", Naturally Systems faces its greatest challenge. The problem here is that, if there are structural factors that are precipitating or causing psychosis, how does one go about detecting them. If it took finding the point of origin for a person becoming psychotic, it would be a hopeless task, neither the psychotic individual nor their parents or others overseeing them would be able to answer that accurately. Furthermore, if you tried to find out what the parents might have done to bring this on, you would only find them pleading ignorance, and insisting that they did all the right things. They would be adamant that they did nothing to bring about these bizarre symptoms. Fortunately, it is not necessary to determine a point of origin or the causative forces. Ironically, this ahistorical approach is similar to the psychiatric approach. Psychiatry may look into the etiology but it is mainly concerned with gaining an accurate depiction of the pattern of symptoms. However, a rough index of the point of origin, whether it began in childhood or adulthood is important to diagnosis. Determining whether there was in recent precipitating event such as something to cause posttraumatic stress reaction is also important. For Natural Systems, detecting causal or precipitating factors is irrelevant. Classifying the pattern of symptoms is irrelevant. As was mentioned in the beginning of this section, a person who is disconnected from the outside world is hard to miss. For Natural Systems, the concern is how to relate to disconnected people whose behavior and verbal expressions are too bizarre for comprehension. How to relate to psychotics, therefore, is the central issue for Natural Systems. I have to go on my own past experience to address this issue. In the late fifties, I had the good fortune to be working in State Mental Hospital while studying psychology. I was working with psychotics in the position of Attendant. I was given great liberty by the professional staff and was able to spend most of my time caring for and talking with patients. I had already had minimal training in counseling but the nature of my duties made counseling impossible. Very often I was confronted with patients who were hallucinating; were delusional; uncommunicative or uncooperative; babbling incoherently; engaging in repetitive; ritualistic like behavior; catatonic behavior; lassitude; explosive episodes; extremely manipulative behavior; childlike behavior; extremes of emotionality like crying, dredyoung Page 96 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc laughing, or giddiness; fabricated stories; highly unrealistic promises or predictions, and so on. I was very curious and listened to them and interacted with them in personal way. I eventually found myself entering into the world as they saw it. I even did this if a patient was hallucinating. I would talk with them as though what they were experiencing was real to me also. A funny thing happened when I did this. Eventually they would break out of their hallucination and begin to talk directly to me about it. We would engage in a serious conversation about it. From that time on, I found that they would talk with me and they were not talking about a hallucination but about their everyday concerns or even about their past. It was as though they had developed a normal friendship. One man was hallucinating about being attacked when he was walking with me on an errand. At one point, he was even threatening me but I continued to talk with him about the imagined threat as though it were real. I entered into the drama with him. He came out of it and began talking with me about a terrifying event that happened to him in his native country. He seemed very relieved after that. He eventually became friendly with me. Overtime, the hallucinations diminished and then disappeared. In another case, a psychotic who had been standing rigidly in the same spot for years, not saying a word, with a somewhat (to me anyway) saturnine smile. I walked past him several times every day and each and every time I would smile, say hi, and say his name. After a few months of this, I was suddenly surprised to hear him say hi back. After this happened for a few days, I stopped and talked briefly with him and he conversed with me. Eventually he stopped standing rigidly all day in the same spot and mingled about the ward the same as everyone else. I had numerous experiences like this. I finally arrived at the conclusion that the way these patients were treated was the immediate cause of their psychotic behavior. The explanation could be found in the structure of the relationships between staff and patients. The symptoms were unique to each patient and most probably had something to do with earlier life experiences. However, the fact that I treated them differently, in a friendly way as though they were persons like me and equal in human dignity to me, resulted in their dropping their symptomatic behavior. After that period in my life, I worked in other psychiatric facilities and adult and juvenile penal institutions and always found that treating them as though they dredyoung Page 97 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc were persons like me and equal in human dignity to me almost always resulted in their assuming normal, friendly relations with me. After consistently seeing this style of doctor-patient relation, I wondered, "Could it be that the psychiatric profession acts so superior, so clinical, so cold and distant, that it actually freezes the patient within their defensive symptoms? Could it be that the psychiatrists are so much like insensitive veterinarians treating a "supposedly" feeling-less, disposable, subhuman animal, that their patients must disconnect and exhibit bizarre behavior as a defense to keep from interacting with these Nazi-like professionals?" As the years rolled on, and my official position rose to being director of treatment or other similar positions, I expanded this principal of humane treatment and attributing the cause to external structures rather than something inherent and unalterable in the individual, I began to include more and more of the natural features that I found so helpful. I thought I had discovered a principle that these psychotics were disconnected because others were disconnected from them. It took a while to re-establish a connection with them but it did not take overly long and was certainly worth the time and patience. After a long career in this field, I codified all of the features of this approach into what I now call Natural Systems, the essence of which was to treat each person as though they were persons like me, equal in human dignity to me, and deserving of equal respect. While the simple act of treating them like any other human being is not sufficient to develop their ego mastery skills and develop a level of maturity sufficient for successfully handling life"s challenges and forming fulfilling, intimate interpersonal relations, it is definitely essential and a very good place to start. Healthy role system. Goal orientation. d. Substance Abuse: Substance abuse is by far the most difficult human problem to treat. Psychotics account for a small percentage of the population while addicts and substance abusers in general constitute a very large percentage of the population. Psychotics are difficult but for the most part, they are easy to keep track of and control, regardless of the lack of efficacy of the treatment they receive. Drug addicts, on the other hand, run away, steal, lie, cheat, renege on appointments, have a revolving door in jails and rehabilitation centers, pretend, dredyoung Page 98 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc manipulate, and constantly offer sincere intentions for recovery which they abandon in due time. A therapist can watch them bite the hand that feeds them and slowly degenerate in health until even the most caring relatives have to cast them out. On the other hand, treatment professionals and officials have made matters worse. They set up new centers and treatment programs or support traditional ones but for the most part they rely on knowledge laid out long before them or on new research that is a mere extension of the same. There have been variations and innovations but these do not venture far outside the ruts of tradition. The innovators, of course, do not see it that way. They offer new, high hopes. They display statistics verifying their success rates. Yet, out of sight and absent from print are the dirty truths of their dismal failures, such as their soft criteria for success, their biased methods for collecting outcome data, and their carefully selected client populations, decade after decade. Judges have no viable choices and therefore sentence addicts to prisons that have nominal drug treatment programs. In reality, such programs are not only a complete farce; they are like secret little markets at the crossroads of the massive drug dealer industry. While in prison, addicts seldom go without drugs for more than a few days. Visitors and even officers and staff are often guilty of being suppliers on the sly. The judges have to defend themselves by saying that they rely on whatever trusted psychiatric professionals and prison officials say about these programs. Without evidence or information to the contrary and without alternatives, they will keep sending drug offenders to these sham programs and keep despairing over seeing them repeatedly back in their courts. The courts, therefore, become swamped with these cases. Therefore, from among the genuine candidates for prison that come before judges, a large percentage must be placed on probation. Probation for an addict is the kiss of death as for as any hope of abstinence or recovery is concerned. Another farce is making one of the terms of probation attendance at support groups for addicts such as AA or NA. These are ideal places where to meet fellow addicts, commiserate, and seduce each other to get high after the meeting, exchange drug shoptalk and experiences, and trade information about suppliers or dealers and their going rates for drugs. The tragedy is that while rehabilitation and treatment centers are holding out hope if addicts will just muster enough "will power", dredyoung Page 99 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc medical research is contradicting this false hope. Medical research has convincingly demonstrated over and over again that once a person is addicted, a human body that goes a short time without their drug "fix" begins a physiological chain reaction that completely overwhelms and decommissions rational thought and the best of good intentions or will power. Fortunately, as far back as the late fifties the medical professional proclaimed, not entirely opportunistically but also kindly and realistically, alcoholism to be and illness. Lately they have made the same pronouncement with respect to narcotics. Much to my dismay, by illness they meant medical-physiological illness having nothing to do with absence of will power. They did not see these addictions as a societal illness or as having external, structural causes. Over the years, their attempt to extend this perspective to drug addiction has met with even less success as far as altering the way addicts are perceived and treated. As an illness, it is clear why therapeutic programs or interventions are impotent. None of the medications has been found to work when the craving inside the brain takes over. It is similar in intensity to having gone without water or food for a very long time. They get desperate and will do almost anything to get their drug or alcohol and in order to get relief from the miserably painful feelings of craving. The brain chemistry of addiction overrides all forms of treatment. Addiction is accompanied by a psychological component that is almost as powerful as is the physiological, namely a perpetual feeling of desperation. Being alone or feeling lonely and feeling empty, lost, vulnerable, abandoned, unreal, and disconnected from any human help, addicts descend into a terrifying, highly primitive, nightmarish sense of desperation. Combined with the agonizingly gnawing of the craving coming from their brain chemistry, panic sets in and they begin a frenzied quest for their narcotic without regard for consequences. Once again, as with psychosis and many other ailments, the pharmaceutical industry finds a way to profit from this human tragedy. The human tragedy for the addict and their family and friends and the enormous cost to society is a powerful motivator to keep trying to find a pharmaceutical cure. Over the last sixty or more years I have heard of one medication after another that is supposed to work wonders in curing addicts. One after another, these discoveries are eventually tossed in the refuse can of chemical history. dredyoung Page 100 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc Psychiatrists and physicians faithfully take the bait offered by the pharmaceutical companies and faithfully prescribe the amazing new medical discovery only to find their hopes dashed once again. What alternative do they have? A recent research discovery may shed light on why the medical approach has such daunting odds against it. This new finding has determined that psychological stimuli can trigger the same chemical chain reaction that going without the drug for a period does. Let us more deeply examine why treatments fail. In the case of substance abuse in its many forms, in contrast to most purely psychological disorders, looking into its etiology may be helpful. Etiology of each individual case, however, is not what is important. Instead, we need to examine etiology in the abstract. We have already briefly reviewed the treatment and control programs such as the pharmaceutical, psychiatric, and judicial and penal factors. Now, we need to turn our attention to differentiating etiological factors that are obvious and have received nearly all of the attention such as the genetic; physiological; psychological; education; social and familial; gender related; ethnic; occupational; socio-economic; demographic; legal or laws related to substance use; history and tradition; and societal factors from certain other structural factors that have been left out of the search for causes and treatments. Ubiquitous structural factors such as media, marketing, sales, politics, predominant forms of recreation, language conventions, widely held belief systems about addiction in the culture, and even the role of religion have an unaddressed influence on inducing and maintaining the various addictions. These factors can be seen as structured in levels each having a shaping influence on the level below them but also as forming components of systems that work together to perpetuate alcohol, illegal narcotic, and medically prescribed narcotic addictions. It is not that Research in genetics has come up with several interesting findings. It has been found that certain persons are born with a gene that allows them to drink more with less intoxicating effects than others, metabolize alcohol better, and be free from hangovers. This would of course make such persons vulnerable to becoming alcoholics. Oriental people tend to be highly allergic to alcohol while Native Indians are highly susceptible to alcoholism. Cultural aspects of ethnic groups probably part a big part with respect to the individual"s propensities. Once they begin to drink at parties or with dredyoung Page 101 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc friends and find that they have few side effects, drinking should be more to continue. When partying has this effect, consumption should even increase. Not having knowledge of the negative effects that alcohol can have on their health, there is little else to prevent them from drinking for the rest of their lives. Unfortunately, medical science has shown that alcohol does damage to the brain, liver, and the kidneys, and due to its tendency to reduce eating healthy food, vitamin depletion occurs and they become vulnerable to disease and aging. Many of these harmful effects are irreversible. It is also well know now that as health degenerates, a person must drink even more in order to get drunk. This is a particularly nasty vicious cycle. When a person drinks, the immediate physiological effects on the brain are behavioral. Becoming drunk decommissions the higher intellectual functions and removes inhibitions so that a person can say and do things that would otherwise be suppressed as socially unacceptable and even offensive. They may be acting in a way that they think is funny while others see it as silly and boorish. They can become melancholy, vulgar, hostile, grandiose, sexually aggressive, intrusive and even intruding on complete strangers or strangely enough do so with police, or become withdrawn, and all taken to such extremes that they make others very uncomfortable and repulsed. Often they will vomit in front of everyone and even on people. They can also begin to lose their equilibrium and timing so that they stumble and fall, fall on others, break things, blurred vision along with loss of control of their body can cause them to drive dangerously, lose their way home, or fall asleep is strange places. Many who get this intoxicated will a poor or no memory of all of the things they did. Because of all of this, they may wind up retaining as friends only those who have the same drinking habits as they. The drug addict tends to run a course similar to that of the alcoholic but the pattern will vary somewhat depending on the class of narcotic they use. Addicts and alcoholics usually eventually learn to be deceptive with disapproving friends, spouses, family, employers, therapists, some members of their support group, and with other close associates. These are people who are typically, uncomfortable, tense, anxious, or miserable. Nevertheless, they want approval and acceptance. What they find, however, is just the reverse. While people may be superficially friendly, there is a lack of genuine closeness and the spontaneity, authenticity, and transparency common to close friends. This increases the feeling of dredyoung Page 102 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc loneliness in substance abusers. It also produces suppressed resentment that may show itself through sarcasm or may not come out until they are high or drunk. Certain types of speed can rot teeth, damage the heart, kill brain cells, and when taken long enough will result in dangerous paranoia. Speed users often find that they cannot concentrate or are dull without their drug but when they are on it, they are unbearably hyperactive and though attentive tend to talk too much, to make miscues, or make rash and impulsive decisions. Yet they feel they cannot perform without the drug. Psychological Education about drugs and alcohol is typically inappropriate to the learner. The lessons may be attended to but they do not have any effect as far as changing behavior is concerned. Social peer pressure to do it, developmentally vulnerable teens, and family rejection or enabling or longsuffering and then ousting; roles in families and implicit parents have a contributing role. Gender related –men may have different precipitating factors. Ethnic aside from genetic predisposition, ethnic groups combined with other factors may increase the probability of substance abuse Occupational status, security, and the kind of occupation for example traveling salesmen, corporate representatives, public relations, professional sports and entertainers, Socio-Economic Demographic Legal or laws related to substance use History and tradition Societal Learning the role of learning theory. The pull of the structure of a person"s life topology. Counterintuitive things to avoid; addicts as friends. Involvement of family. Ignoring identifiable places and times of vulnerability. Lack of opportunity for habituation to alternatives. What is needed: Long term inst. And well struc long enough to overcome separation pain. New implicit others. Each process of intentionality. New secondary peers and roles. Natural Systems prog. No return to home and friends and job. Establishing a completely new life dredyoung Page 103 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc topology. e. Disorders of mood that are "supposedly" caused by brain chemistry imbalance: Aside from psychosis, there are a number of other disorders that are viewed by many professionals as apparently unrelated to what is going on outside the person, that is to say they are unrelated to environmental or life conditions and situations or any of the levels of external structures and systems. These mood conditions do not seem to be directed toward anyone or blamed on anyone. They are nevertheless disliked by or frustrating to others. Of course, these conditions are unpleasant to persons having them. These people often do, however, express disaffection with life conditions, others, or the requirements or demands of others. They do not know the "why". They cannot point to anything specific outside of themselves as "the" cause. Therefore, it must be them, something wrong with them. A few of these are examined below. ADHD, Attention Deficit Hyperactivity Disorder, has become famous, or rather notorious, in last forty years. Irritability, tension, restlessness, Depression Mood Swings Despair (sense of meaninglessness) Boredom Numbness or automaton like behavior f. Emotional distress: Phobias – fears accompanying a sense of suspicious of dangerous intentions of others Chronic Anxiety Panic Other than the mood swings from depression to elation, there are some intense emotions that are examined below that are less prominent but equally disturbing to the people having them. To them, the locus or cause of the emotion is typically inside of them and others heartily agree. Moreover, the way they show themselves in observable behavior is usually disturbing to others, especially those who try to help. Still, both others and they themselves tend to treat the problem as though it is independent of or unrelated to relations dredyoung Page 104 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc with the outside world. This is true even though they may point to some present, or possibly becoming present, external stimulus as the cause for these unpleasant feelings. Outsiders would say they are reacting to something unreal or extremely improbable and try to convince the sufferer of the irrationality of their feeling. The professional sees the symptom and the sufferer feels the unpleasant feelings, yet neither sees nor understands the powerful causal forces in structures and systems. Likewise, neither sees the powerful forces of some internal structure or intentional process. Especially, neither sees how whatever is in the external structures and systems are integrally related to whatever internal structure or processes may be involved as the combination erupts into what they can see and sense. They both choose the option of dealing with the immediate. The sufferer just wants to be rid of awful feelings and the professional just wants to change something in the person, something in their personality or in their brain chemistry. The ultimate unseen cause is left unaddressed. A sufferer may try to talk it out and be encouraged to search for causes in past experiences. They can usually identify some such experience but this serves to mislead both professional and client. This is point where the entire field of psychologically and medically oriented mental health professionals gets stuck and never takes the leap to explore the non-immediate but truly causal unseen structural factors in integral dynamic combination with unseen internal structures and processes. The old saying, "You can"t get there from here." certainly applies to this situation. For instance, with respect inner processes, neither the client nor professional will ever identify the role of negative implicit others, as a part of intentional processes, that are immediately determining the symptoms and enduringly perpetuating their negative influence regardless of devoted efforts within the current treatment paradigm. They cannot get there from here (the current paradigm). Unfortunately, the contemporary culture or zeitgeist and treatment paradigm are of a piece, woven together in the same tapestry. For example the prominence in our culture of a belief in competition, status, the struggle for upward mobility, and the acquisition the approved material indicators, from cars, to perfume, to seats in bleachers, to grades, to invitations and so on, all fit neatly together with social comparison and feelings of success, acceptance, and status or rejection, failure, neglect, and exclusion. Built into our belief system so that we do not see their pathological effects, their cause of painful dredyoung Page 105 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc symptoms or sociopathic discrimination and exploitation, they are like the air we breathe, a reality we do not question as possible candidates as monstrous, ubiquitous causal agents. We say "ain"t it awful" when a politician becomes corrupt but we do not understand that they live within a vicious adversarial systems where the need to win overrides all other values. The means, however sinister, "have to" be justified by the end, everybody does it or else they lose. You have to have the in "jeans". You "have to" get the latest face lift. You "have to" be whistled at and at the same time pretend you are annoyed. You have to dive off the diving board even if you are terrified, or be ridiculed. But the terror comes from having to be a reckless risk taker without proper preparation. You see, these themes run through our entire culture and are the ultimate causal agents, wrenching our guts and driving us nuts, while we attempt in vain to deal with the immediate symptom or problem. It is the art of depicting their corruption as heroic and virtuous that must be mastered. You either master this art or you lose, you are "out". One outcome is that Americans put mountainous pressure on their children to succeed at any cost and look like choirboys at the same time. These mostly caring parents do not understand what they are doing and especially do not understand why. Great profits can be made from those who can be made to play this game. This is a part of the system that is also a powerful inducement to perpetuate the system. Ironically, both adults and their children are victims of the system. Nevertheless, the unquestioned system gets away with blaming the victim. g. Psychologically related health problems: Psychogenic health problems such as sleep disorders, ulcers, headaches = physical health problems whose etiology cannot be traced to viruses, bacteria, cancer, material trauma or poison, aging, or genetic defect. h. Behavior or communication that is unacceptable, inappropriate, or ineffective: Unsocialized behavior dredyoung Page 106 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc Impulsivity i. Relationship dysfunctions: Shyness Manipulative behavior Oppositional Defiant These problems cannot be attributed to a serious psychiatric diagnosis or physical illness. Problems that relate to deficient or erroneous life lessons, lack of knowledge of how successfully to engage in relationships, imitating poor models, having been poorly life coached or educated to manners or social obligations. These patterns stand out as especially underdeveloped and inappropriate social or interpersonal skills. 3. Tables 1 and 2 below compare traditional individual therapy modalities as treatments for emotional and behavioral disorders There are certain kinds of emotional and behavioral disorders that occur with greater frequency in the general population. These disorders are listed in Tables 1 and 2 below. The discussion about the contribution of major level-specific modalities to Natural Systems did not go into their efficacy with these specific disorders. Seven emotional disorders and nine behavioral disorders are covered. Both behavioral and emotional disorders are a function of the levels of external structures. Any or all of the levels of internal structures can be involved to some degree in any of these disorders. I have described the problems with all of these modalities. However, I did not specify whether there were types of disorders with which they might be effective. It seems in order now to examine this question and make comparisons of their relative effectiveness with these two sets of disorders. TABLE 1 Which of the individual treatment modalities in the left column below will eliminate or ameliorate the EMOTIONAL DISORDERS in the top row? Insert a 1 in the row across from a modality if it is very likely to be successful; 2 for modest of brief success; 3 very unlikely to be successful. Enter 1 for likely Success; 2 for Minimal; and 3 for unlikely Success; 4 for likely Worsening. dredyoung Page 107 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc Disorders Posttrauma Depression tic stress Shyness Phobias Chronic Anxiety Swings Mood Rage Modality: Family 3 2 2 3 2 2 3 systems Psychotropic 3 2 4 2 4 2 4 medications Behavior 2 3 3 3 2 4 4 modification Cognitive 3 2 3 3 2 3 3 restructuring Reality 4 4 4 4 2 3 4 therapy Guidance 4 4 4 4 4 4 4 counseling Client- 2 2 2 3 2 3 3 Centered Gestalt 3 2 3 3 2 3 2 therapy Psycho- 3 2 3 3 3 3 4 analysis TABLE 2 Which of the individual treatment modalities in the left column below will eliminate or ameliorate the BEHAVIOR DISORDERS in the top row? Insert a 1 in the row across from a modality if it is very likely to be successful; 2 for modest of brief success; 3 very unlikely to be successful. Enter 1 for likely Success; 2 for Minimal; and 3 for unlikely Success; 4 for likely Worsening dredyoung Page 108 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc Modality: Manipulativ Unsocialize Aggression Narcissism Achieveme Opposition aggressive Impulsiven immaturity Anti-social Centricity al Defiant Sexual Under ADHD Ego ess nt d e Family systems Psychotropic medications Behavior modification Cognitive restructuring Reality therapy Guidance counseling Client- Centered Gestalt therapy Psycho- analysis a. Life Topology considerations for clients in individual treatment b. Special Focus Support Groups for clients during and after individual treatment 4. Tables 3 and 4 below compare models of institutional correction and treatment programs for emotional and behavioral disorders TABLE 3. For the Institutional Programs in the left column, which will be effective with these EMOTIONAL DISORDERS? Insert a 1 in the ROW dredyoung Page 109 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc across from a program if it is very likely to be successful; 2 for modest or brief success; 3 very unlikely to be successful. Enter 1 for likely Success; 2 for Minimal; and 3 for unlikely Success; 4 for likely Worsening Institutional Depression Correctional- traumatic treatment Shyness Phobias Chronic Anxiety Swings programs: stress Mood Post- Rage 1. Traditional - Punitive 2. Boot Camp 3. Token Economy 4. Point System 5. Positive Peer Group 6. Wilderness 7. Treatment Community 8. Stars and Stripes TABLE 4. For the institutional programs in the left column below, indicate which will eliminate or ameliorate the BEHAVIOR DISORDERS in the top row? Enter 1 for likely Success; 2 for Minimal; and 3 for unlikely Success; 4 for likely Worsening BEHAVIOR DISORDERS dredyoung Page 110 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc Institutional Impulsiveness Ego Centricity Achievement Unsocialized Oppositional Manipulative Correctional- Aggressive Narcissism aggression Immaturity Anti-social treatment programs: Defiant Sexual Under ADHD Traditional- Punitive Boot Camp Token Economy Point System Positive Peer Group Wilderness Treatment Community Stars and Stripes a. Topology considerations for clients post institutionalization b. Special Focus Layman Support Groups Alcohol Anonymous Narcotics Suicide Sex Addiction IV. Examining the top pyramid"s levels of external structures and systems The top, inverted, pyramid is concerned with how external structures shape personality. Each of the levels of the bottom pyramid can be influenced, to varying degrees, by levels of the top pyramid, selectively and either dredyoung Page 111 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc negatively or therapeutically. Ascending by level of structure from the bottom of the top pyramid up, the influence on personality, of each successive level is decreasingly observable. Beginning with the topmost level, we have what I call encompassing environments. You may choose your perspective, depending on what you wish to analyze. For instance, you may want to analyze how the American culture as a whole shapes the character and personality of American individuals, relationships, or families. You could begin with the nation as a whole and then designate your next lower level structure to be a community or organization. You could analyze how being a member of an ethnic group influences personality tendencies, how these influenced tendencies vary with the group, or which aspects of the personality are influences in what ways. For example, how identity is generally influenced or how does skin color result in mistakenly attributing ethnic stereotypes. On the other hand, you may want to analyze how a corporation, social organization, institution, community, and so on, influences personality. What aspects of these encompassing structures influence certain tendencies of its members? You may start with an arrangement of one set of categories occupying the successive levels and later change categories to get a different perspective. This is merely an analytical device to assist in gaining the most productive perspective. Off and on, I have been interested in how the media affects life styles, interests, values, etc., or how socio-economic status influences language, or how technology has influenced gender behavior and relations. I have also tried to track how the influence of these global structures has changed through periods of history. The value of using this model is that, once you choose a category for a level, you can then select each the categories for each successive level of structure and then analyze their mutual influences. One of my main concerns has been how the structures of correctional and mental institutions influence the personalities, behavior, and especially the intentional processes, of their wards. I have been observing, studying, and experimenting with the structural side of this Duplex Model equation in institutions for almost fifty years. After all these years, my question is this. What are the differential effects of approaching institutions from the perspective of external structures in relation to intentional processes versus external structures in relation to internal structures? One perspective involves grasping the nature of the institution and the way it is organized and how that affects the client population. I began to examine the structures and systems in the institution. I noticed that changing structures changed the way staff acted but also changed the way the client population behaved. How did these changes in structure shape the behavior of employees and the client population? The structure of the institution is mediated through the staff. However, positive results came from such unexpected aspects of the structure as simply rearranging where the offices of staff were located. Residents had anxieties over uncertainty about visitations, release dates, being granted privileges, whether they could see the nurse, and the like. With continuous access to their caseworkers, these anxieties disappeared, pestering the caseworkers for information ended, and the build up mutual hostility ended. Engaging all staff in dredyoung Page 112 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc participatory management with the top management had similar effects with respect to uncertainty, anxiety, paranoia, and mutual hostility. Each level of structure within the institution have many such aspects than can be redesigned to have positive rather than negative effects on the dyadic interaction between staff and staff, staff and residents, and between residents. When these structural aspects changed and dyadic interaction changed, then communication and behavioral acting out problems receded. The way they reasoned about their situations, planned for and anticipated their future, and explained or resolved conflicts became more rational. There was far less projection of evil intentions and blaming. Their feelings mellowed and became more positive. Staff and management perceived each other more positively as was true for residents and staff perceptions of each other and residents" perceptions of each other. If the reader will recall some passages at the beginning of this text, psychiatrists stopped giving residents psychotropic medications because they assumed their brain chemistry had become balanced. So, you see, each level of structure of the bottom pyramid was affected when factors in the levels of structure in the top pyramid were redesigned. Another vital perspective involves how to redesign the structure of the institution so that it has positive effects on the intentional processes of the staff and residents. This topic will be addressed in sections C., D., and E below. A. Descending Levels of External Structures and Systems in Institutions 1. GLOBAL, ENCOMPASSING STRUCTURES Understand Influences of, gain different perspectives on, master, and their temporal aspects Police and the loss of community living skills Law and justice Rapid turnover neighborhoods and depersonalized relations and litigiousness Technology and home items Mass education with unit progress and competition, winners and losers, and identity and self-concept Institutions for the casualties of modernity Corporations and special interest social organizations as the new community; non-personal internet communities Housing developments, urban segregation, and blaming the victim Corporations, capitalism, corporate law, Media and marketing; marketing and money purveyors versus home economy dredyoung Page 113 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc Media and the behavior of governing bodies – co-opting the spotlight; disaster addiction; sound bytes and unaccountability The church versus the media: Who is the authority now? Sports, competition, violence, and communication of values Im-personalization of warfare Heroes, models, celebrities, and media idols Computers and impersonal-personal communication Chemical products and home items, kitchens, hygiene and cosmetics and fashion, chemistry and sex Music and movies News and conversation topics Geographical mobility, demography is destiny Transportation mobility Food franchises and diet Weltanschauungen in relation to Zeitgeist 2. INSTITUTIONS, AND THEIR STRUCTURE AND SYSTEMS 3. SETTINGS IN THE ORGANIZATION OR INSTITUTION, INFORMAL GROUPS IN THE INSTITUTION 4. SITUATIONS IN SETTING IN THE ORGANIZATION, INSTITUTION, FAMILY, AND PEER GROUPS Problems developing new situation-specific behavioral templates and practicing 5. Formal ROLES IN SETTINGS Problems learning to alter roles and identities and the inner restrictions they impose SECTION X B. Descending Levels of External Structures and Systems in the Open Society Life Topology: Where Did You Go Today? dredyoung Page 114 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc Minds are accustomed to reverting to their current, accumulated repertoire as their life typology seldom encounters situations so novel that they cannot be assimilated to their reliable, left brain oriented, stock of schemata and schemes. Temporary, minor adjustments, if they have to be made, are categorized as exceptions not likely to be encountered again. They are shelved as not essential for retention and the principle of disuse means that they soon will be forgotten. Life typologies are shaped and trimmed for the familiar, reliable, efficient, minimally demanding, and routine and as such rarely require the invocation of the novelty handling, new learning oriented right brain. The mind prefers the familiar world and second nature responses of a stagnant life typology. Disruptive, demanding, and uncertain new-learning types of situations and tasks are inherently aversive and ulikely to be voluntarily sought out, Old haunts, well-trodden trails, and well-established boundaries do not require being "mentally seen". Familiar yet unexplored locations of your community cease being "mentally seen"; they rely on an automaton mentality. Intentional mentality is decommissioned. Routes and Roles about Town FORMAL CIVIC AND SOCIAL ORGANIZATIONS AND INFORMAL GROUPS IN THE OPEN SOCIETY Systems, Settings, and Situations in Schools Communities and their organization Neighborhoods and their parameters: Open; Personal; Organized; Rewarding; and Productive Police and Courts State and County human and health services Business, corporations, and business organizations Labor organizations Social organizations Churches Sports and recreational organizations Public Entertainment Home Entertainment Communications: public and private Public Schools in the Open Society School Extracurricular activities Homes, Family and Extended Family dredyoung Page 115 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc 1. Illustrations, using the concepts of Settings and Situations, of the psychology of the effects of External Structures on Internal Structures and Processes in the Open Society There is, of course, an exchange involved in dyadic interaction, our fulcrum concept. However, each party to a dyad is a recipient of input from the external levels of structures. Everyone in a population is theoretically a potential party to a dyad. At the lower levels of external structures, their differential impact on each member of a dyad potentially can be observed. Typically, the members ("A" and "B") of a dyad are focused on each other but in their subconscious minds, the nature of the potential influences of their different external structures is taken into account by each. Let us take an example of a dyad engaged in a debate in a church with some church members present. Let us say that A is a member of the church and B is a member of a very different kind of church or religion. What transpires in the debate will be influenced by their different external structures. If they were in another, neutral, location, the content and style of debate of both A and B the might be very different. Consider another example of the influence of structure over dyadic interaction. A husband (Bill) and wife (Sue) go to be with their respective extended families during a holiday. They arrive at Sue"s family first. After settling in and seated all together in the living room, family members ask Sue and Bill how things have been going for them. Naturally, Sue speaks of first and recites a list, diplomatically but with insinuations that could be better if Bill would have done so and so and if he had not done such and such. Bill makes a few grumbles and sheepishly tries to take for himself but that does not go so well. While meekly trying to defend himself, Sue"s younger brother, a swaggering, mans-man and ex athlete enters and listens for a moment and then aggressively starts to run interference for Bill. Sue politely suggests that they must move on, as they are due to be at the home of Bill"s family. They and the whole family settle in and are seated in the living room and family members ask Bill and Sue how things have been going for them. Naturally, Bill speaks up and seizes the opportunity to get back at Sue for her performance at her family"s home. Bill proceeds to ask the women seemingly innocuous questions about how they would do a number of things that the women usually handle. Sensing the opportunity to both show off and put Sue down, they give copious advice that is quite different what dredyoung Page 116 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc they know about the way Sue has been doing things. Sue cowers under the onslaught and glares at Bill out of the corner of her eyes. During the subtle savagery, Bill"s older sister, a confirmed feminist, comes and catching the drift of the conversation launches a tirade against Bill for his male chauvinism. Sue gloats. When Bill suggests that it is time to go, Sue perks up and states that she is enjoying Bill"s family and feels would be rude to leave so soon. What we can learn from this vignette seems obvious. Conversational style shifts dramatically as the composition of the group shifts back and forth in being weighted in favor of Sue and Bill. Entry of allies causes sudden changes in conversational style. Extended families and their homes are Settings with Formal Roles of traditional positions in the family such as parent, grandparent, sibling, and so on. These Settings and Formal Roles make it possible for informal family roles to be shaped and family systems to arise. When in an informal role, the person knows what others expect of them and what they can, in this case, get away with. New additions such as a husband or wife are typically at the mercy of a family when their informal role in the family system initially being carved out. This power of these alliances and the vulnerability of the newcomer can lead to either spouse exploiting it to get revenge or increase leverage and bargaining power in their relationship. It only takes minimal interpersonal skills for people to grasp the nature of situations that eventuate and quickly invoke their ploys. I use the word "structure" rather religion in the first example to emphasize the abstractness of the Natural Systems approach. One can substitute many things under the abstract concept of structure. The influencing factor could be religion, politics, race, rank, neighborhood, academic subject or class, winner or loser in a contest, and so on. Typically, people in a dyad are in a "place". The place could be in a supermarket, church, stadium, factory, street, and so on. The abstract word I use for place is "Setting". A Setting is where the dyad interaction is transpiring. Of course, the setting could be in two different places as for example when using a cell phone or video conferencing. Settings have constituent parts or aspects. For example, a classroom setting could be on the lawn of a campus or in a room in a building with a chalkboard, desks, chairs, windows, teacher(s), student(s), video or audio equipment, computers, and so on. The constituents of a Setting are also a part of the external structure and will have an influence over the dyadic interaction. The dredyoung Page 117 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc purpose for being in the Setting is a constituent. Many things are possible constituents. Within a stable Setting and constituents, one would expect Situations would arise that will shift the topic and nature of the dyadic interaction. Situations are highly transitory and variable. Situation, therefore, is another abstract structural concept under which there can be an almost infinite number of types of situations. However, a relatively stable Setting will usually be host to only a few types of situations. Most of the other possible situations in the universe of possibilities would never arise in a given, stable Setting. If the street were the Setting under consideration, the range of possibilities can expand vastly. Depending on the type of neighborhood, for instance, the range of situations could expand or contract. For most of us, this is just common sense. Consider two types of dyads, a therapist and client and a romantic pair, and a solitary person, a monad, who is at home, in bed, and about to go to sleep. What do these have in common? These are all contexts in which people will confide their secret longings or fears. Their private person will surface. If the therapist is very empathetic and nonjudgmental, most clients eventually will confide things that they have kept hidden from everyone. As for the romantic pair, on some enchanted evening, they see each other across a crowded room, as the song goes, and have an immediate attraction. They make contact. They try to impress each other and find common interests to share. They begin to meet for dates. They touch and feel an excitement and electricity. Eventually they may wind up in bed and having sex. They tell each other how wonderful the sex was and how comfortable they feel with each other. Both are maximally accepting of everything said and done by each other. What do they have in common with the therapist-client dyad? They begin to reveal their secret longings and fears; they may even recount details of their sexual histories, and the things they say to each other, as with a therapist, they would never say to anyone else. Now consider the monad about to go to sleep. At this point, as they are sinking into a sleepy reverie and the hubbub of the world is passing away, this same private self with its secret longings and fears begins to surface and drift dreamlike and sometimes fitfully through their head just before falling to sleep. Here we have three different Settings between which we normally would see no connection. Using this method of abstract dredyoung Page 118 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc analysis, we can ferret out the common factor, which is the fading away of the pressures of their world along with a waning of fear of being judged. In the two cases of dyads, even though another person is present, it is as though nothing exists but the two of them, the world has been shut out. Similarly, in the case of the monad, this special kind of Setting permits the same kind of neutral, world dissolving, situation in which private, authentic issues and concerns can resurface from their subconscious. If the monad were an incarcerated person after lights out, and a warm and empathetic staff comes and quietly sits by their side on their bunk bed to comfort them, oftentimes these same kinds of issues concealed in their private self will begin to surface just as with the client, lovers, or safe at home in one"s own bed. It is possible to create these conditions and this kind of situation in other types of Settings. This is one of the hallmarks of effective therapy, regardless of modality. Remarkably, these conditions were created in the juvenile institution cited above. The question remains as to whether these conditions can be created with a Natural Systems therapy group in the "Open Society" and without resorting to one of the traditional treatment modalities or combining some of them in a contrived eclectic approach. This is one of the essential challenges for the new Natural Systems group approach. This issue will be addressed in full when the description of the Natural Systems group approach begins below. It is important to note that, while the quality of acceptance is a major key to success in any type of traditional modality, it alone is not sufficient to meet the goals stated in the Thesis at the beginning of this document. Group therapy and psycho-educational groups do not create these special therapeutic conditions. These conditions are most likely to be created when using modalities that address emotions and feelings, perception, and life history, in other words the lower levels of the bottom pyramid. Psychiatry is an exception here because it addresses brain chemistry. Few psychiatrists address emotions and feelings, perception, and life history. Psychodrama, while addressing depth factors, revolves around the therapist providing scripts and metaphorical behaviors to induce clients to act out the deeper aspect of family relationships and past traumas. This method, however, does not create the conditions that allow clients to have that sense that the world has faded, it is only the two of them, therapist and dredyoung Page 119 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc client, with the therapist offering empathy and a non-judgmental attitude along with the uninterrupted personal space and undistracted time within which the secret, private self can resurface. Ironically, the therapeutic approach that resulted in the greatest increases in maturity and ego mastery skills and the most enduring change was the Natural Systems institutional program. Yet it did not create these special therapeutic conditions. It did provide conditions that were close to being non-judgmental. It definitely did not involve a therapist being in control of the interaction in order to intervene, induce abreaction or resurfacing of past traumas, and overcome clients" defenses against revealing their private, secret selves, as is the case with some Group therapies and Psychodrama. On the other hand, it did attempt to provide and accepting atmosphere and empathic relationships with at least two staff as non-judgmental parent surrogates and all staff being non-invasive coaches especially with respect to interpersonal relations and maturity. This approach is uniquely suited to work with adolescents since they are typically resistant to counseling, direct guidance, and exploration of their life history and past psychological traumas. Adolescents, in contrast to adults, are urgently focused on dealing with immediate interpersonal conflicts and are future oriented in the sense of learning how to become adults. They are readily open to non-judgmental coaching and copying or emulating mature, respect models. All of their internal levels of structure and intentional processes are constantly in a flux of experimentation in order to find ways to survive in interpersonal situations, avoid ridicule, and demonstrate the superior coping or ego mastery skills of adults, which they tend to refer to as being "cool". It is this nature of adolescence makes the Natural Systems institutional program so successful. Once again, it is sophistication in understanding the role of structure, as in the Duplex Pyramid model along with its processes of intentionality and their integrating role, which provides the most effective tools for designing a successful therapeutic model, especially in the case of adolescents. Moreover, once again, the major challenge for Natural Systems group therapy is how to adapt these concepts and tools to the task of therapeutic work with adults. 2. An example of a high level organization that has the broad authority to alter the way the entire field of mental health treatment dredyoung Page 120 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc transforms the work of all mental health professionals with their clients, regardless of their chosen treatment modality. Managed Care is an example of the highest level of encompassing structure within the realm of a specific type of occupation and institution. V. How the Intentional Model is related to and integrates both pyramids of the Duplex Pyramid model and its temporal dimension Finally, while clients in or out of an institution can be trained for behavior change through behavior modification, role-playing, psychodrama, and the like, the problems described above still remain. However, and more to the point, the situations or stimuli that clients face in the rapidly and forever changing everyday open society are so vast and variegated that no psychotherapy client could maintain a battery of ready-to-use, situation-specific, behavioral templates, or repertoire, to select from. Expecting clients, in the flux of daily life, to review and choose which would be the better or more effective behavioral strategies is unrealistic. Even more daunting is the challenge of reviewing and selecting the more mature inner, intentional, processes to invoke prior to enacting the related behavioral patterns. That expectation borders on absurdity. It takes reserving time and calmness in order to step back and choose and revise inner processes and then to act on this choice with the most wise and appropriate behavioral strategy. The demands of the day do not permit the luxury to go through entire arrays of complex processes and then apply them appropriately, Johnny-on-the- spot. Overwhelmed, as most people surely must be, if they were to try to do this, they are bound to surrender and simply react instinctually, unconsciously, and with minimal variations from their ingrained inner processes and behavioral habits. A. The following are simplified and followed by complete descriptions of the intentional processes: Perceiving the world (immediate experience) Learning what is perceived which includes the quality of accompanying sensations Incorporating or dis-incorporating the sensation dredyoung Page 121 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc Seeing where, when, and how to act in relation to the immediate experience Forming expectations of what should happen because of the action Acting, guiding, and correcting the action Storing the outcome, as an expansion of knowledge of the world since we tend to expect a repetition of similar situations These are all separate, sequential, intentional processes. They are incrementally shaped and continuously transformed. They each become more complex with additional experience and as one ages. They are all relevant to the vast storehouse of psychological concepts we eventually apply to our self and to others. They underlie all psychological problems and all psychological attributes. Solely dealing with psychological attributes and stated psychological problems means that we are only dealing with the surface. The underlying intentional processes remain essentially unchanged and continue to determine behavior and quality of life. Changes are temporary because behavior tends to be brought back into the status quo of the behavioral repertoire. This regression is because the underlying intentional processes have not been addressed. The first intractable problem was dealing with longitudinal behavioral patterns. The second intractable problem with traditional psychotherapy, therefore, concerns dealing with these inner, intentional processes. Can you imagine one of your clients just sitting there while you try to lead them through an examination of all of the hidden processes that go through their head when they confront a salient situation? Can you image them enduring being coached to change any or all of these inner processes? I think not. Clients come to get things off their chest and resolve problems as they surface, willy-nilly, in that hour. They expect to go away feeling better and they expect to go away prepared for a new life free of such problems. Those expectations are in marked contrast to the hypothetical, labored therapeutic process I just described. dredyoung Page 122 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc Often the problems or feelings they unloaded in the session may seem to them to have been resolved. Nevertheless, we find that same problem focus or issue may resurface periodically. Clients are often driven by a need to unload the troubling thoughts and feelings of the day, or sometimes those from the night before, or even their dreams. They want someone to listen patiently, warmly, empathetically, and especially non-judgmentally as they tell their story. Sometimes the troublesome issue unfolds in bits or aspects. These may be examined in one session and then other snippets may surface be examined in later sessions until finally a precipitating causal event is recalled, disclosed, and ventilated, often with intense emotion. This latter stage is sometimes called catharsis. When they have arrived at a resolving and satisfying insight or understanding of the event or issue, they move on. There may even be additional discussion of how to cope with such situations in the future. Therapists sometimes contribute their thoughts on coping strategies. Nevertheless, it is rare that the coping skills related to how to deal with the initiating event or subsequent similar situations are practiced in the session. It is even rarer for the client to practice enacting such coping skills outside of therapy. When the situation subsequently arises outside of the session, the same old behavioral patterns are the ones most likely to be played out. Notice that when these emotional self-disclosures take place in the interview, those rapidly cycling intentional processes referred to above are not addressed. Now, here is the crux of the matter. This is what I consider one of the most serious flaws in traditional psychotherapy. The necessary coping skills require and entail a restructuring of each of those intentional processes, the final stage of which is behavior, or, as it is referred to in the model, Adventuring. Each of the sequential intentional processes plays an integral part in the complete act that culminates in observable behavior. Not only are these elements or processes not addressed but the crucial stage of practicing new behavioral patterns is generally not a part of the therapy session. They are not included as a simulation in the session. There is no rehearsal to prepare for a real life setting in the home environment. At home, one tends to focus on the activity or situation at hand and the recommendations from therapy just do not come to mind. Even inside of a closed institution with a Natural Systems program, it is very difficult to engage in "practicing" coping skills in vitro for the troublesome situations. However, the features of dredyoung Page 123 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc this program are designed to elicit the optimal inner processes repeatedly with recognition when successful. The structure of the program makes it is possible to deal with the inner intentional processes underlying behavioral acts or longitudinal patterns without directly focusing on them. These intentional processes are going on implicitly and continuously. They are exquisitely sensitive to the social environment. With a correctly designed program, each intentional process is being shaped to enhance maturity and increase ego mastery skills for twenty-four hours of each of the seven days a week. 1. Below, there is the complete graphic model of intentionality This model was designed to reveal the steps or stages through which each of the intentional processes cycle. They are cycling very rapidly and continuously through the mind. As a person goes through developmental stages over the years, these processes change from being very simple to being extremely elaborate. They constantly interact with the external world. The personality also becomes more complex. Each level of the internal structures becomes more complex. These intentional processes are exquisitely sensitive to the external world but they are also exquisitely sensitive to their internal world. Part of their external world consists of other persons like themselves. Each person becomes aware of the others as having a personality and of their interacting with the world with similar components of the self. Each person has an implicit psychology of what others are like. They infer that others are to varying degrees reacting to and interacting with the world in ways similar to their own. Each person subconsciously senses that others are also similarly, exquisitely sensitive to their world yet each in their own unique way. Each person learns to talk about the machinations and dynamics of people"s inner worlds. Most significantly, each person is integrating their reactions to levels of their external world with the structures on their internal world. To give a simple example, most people are aware of their being a government. They infer that the government has some degree of awareness of what citizens or their constituents" lives are like. They suppose that government officials perceive the conditions in their state, think about these conditions and what to do about them, have feelings about what they see and preferences, values, or tastes related to their state, its people, their activities, and their life conditions. Based on this information, they envision plans to deal with conditions in their state, they act on some plans, evaluate consequences, and revise plans, and so forth. In other words, people are integrating their external world and internal world through the processes of intentionality. This graph below illustrated how these intentional processes operate to integrate the external and internal worlds. dredyoung Page 124 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc a. INTENTIONALITY MODEL The Duplex Pyramids" External and Internal Structures are implicitly represented in memory as a part of the Intentionality Model. External Structures Internal Structures b. Flow Chart of Intentional Processes that Integrate the Duplex Pyramids dredyoung Page 125 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc 2. Defining and explaining the intentional processes and the way they cycle through the mind. Addressing how each of the processes of the Intentionality model works to overcome these problems, facilitates maturation, and increases ego mastery skills INTENTIONALITY MODEL dredyoung Page 126 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc LABELS PROCESS DEFINITIONS COMPONENTS ADDRESSED BY PROGRAM Levels of External These exist prior to the person but when the External Environmental persons enter any Setting they must quickly Structur Contexts accommodate to it. Different contexts and es in the Settings within them settings affect people differently. Their world and the Setting"s internal structures and processes are constraints affected or challenged. Learning how to Situations faced and adapt or cope is life"s great challenge. anticipated within Adapting or coping can mean employing or the Setting. Each learning the skill to change one or more instance of levels of external structure or change one encounter with or some internal structures of and in their these contexts will self. People make these adaptations using eventually be their intentional processes. Typically, some incorporated by of their intentional processes have not persons as optimally developed to master the representations. adaptation or coping task of every context That is to say they and setting, including all of the levels of will store them in external structures they meet. The memory as a intentional processes cycle quickly, dynamic, unified continuously revising until a sufficient level Gestalt of the of mastery has been reached. From the schemata of the perspective outside the person, those who external context and can must learn how to restructure the the schemes salient aspects of the most relevant levels appropriate to it. of the external structures. The restructuring person has the formidable task of initially understanding which aspects of the external structures must and will optimally address which internal structures. Second, they must understand how to optimally evoke and develop or reshape which ones of the other person"s intentional processes. Based on this understanding, the restructuring person, or reformer, must plan, design, and then implement the restructuring plan. An dredyoung Page 127 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc optimal design will facilitate not just the other"s adaptation but the growth of the ego mastery skills and maturity. Percepti People always One important ego mastery skill is learning on, perceive a Context to differentiate between what one expected Receptio and begin to receive to see or projected onto the setting and n, this perception in what is the present reality. Gestalt therapy and their unique way sees this as one of its major functions. Retrieval and then retrieve However, one does not have to use the their relevant stored Gestalt modality to facilitate a person"s Gestalt of memories acquisition of this ego mastery skill. The of prior schemata principal involved in this facilitation may and schemes that merely be similar to that used in Gestalt occurred in that therapy. context and setting. Internal People construct an Represe Internal n-tation Representation of of the the Context and External retrieve their world by Schemata Schemat concerning how this a context operates and which aspects of settings and social "Sets" are expected and which appropriate schemes of other people are expected to be enacted. Typically, what actually occurs is to varying degrees different from what was anticipated. dredyoung Page 128 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc Person"s typically Accommodation first try to assimilate Assimilation or the actual context to their Schemata and if not successful, they accommodate by altering their Schemata When person"s have related Behavioral settled on the Schemata for the Schemata and Setting, they invoke memories of memory patterns of Storage of Schemes the relevant behavioral Schemes they may enact as Situations arise Levels of As the activities and Assess- functions of the ment of Setting unfold, the person"s begin to perceive assess how this d instantiated Setting external is consistent with its world larger and the encompassing expected external behavior environmental context; they assess how or whether this Setting is consistent with what they would expect for its type; they assess the various aspects of the Setting such as its time of occurrence, those dredyoung Page 129 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc holding leadership roles and the appropriateness of their behavior. Concomitant with these assessments of the external factors, they also assess their sensations such as temperature, lighting, sounds, comfort of accommodations, how proximate and invasive or permissive are the others in the setting, the agenda or scheduled activities, the presence and nature of supervision or evaluation, the degree of freedom of access and departure, the presence or nature of consequences, the characteristics of those present and their estimate of how others feel about them and they feel about others, and finally they assess what all this implies about their personality, identity, dredyoung Page 130 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc their comfort with assigned or possibly chosen roles and how these factors make them feel about themselves. Individua As they are rapidly -tion in going through all of accord these complex- with multi-level hedonic assessments, they sense- are registering the tions degree of and pleasantness feeling versus reaction unpleasantness s they experience with each The Because of these Psychoanalytic defense mechanisms Hedonic combined should be contrasted with Incorporation tone assessments and States. Incorporation states as different associat their hedonic from psychoanalytic defense ed with quality, they nearly mechanisms. Incorporation is dealing external instantaneously with the outside conflicts and defense stimuli route aspects of the mechanisms is dealing with inner or Setting and the forbidden drives and conflicting objects situations that tendencies. directs eventuate into the states that classify objects them as alien to to be them integral to stored in them. In many the cases the assign various them to a tentative states of state in which they Incorpor reserve judgment a-tion for after more and familiarity. In many dredyoung Page 131 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc Disincor cases, they assign p-oration them to a class that requires pretending likely or disliking or to pretending they are integral to their self or alien. The states to which aspects are assigned may be allowed to be obvious to others or their behavior may be designed to disguise their true relation to these aspects or true involvement with them. These assignments will become an essential part of how they intend to act in the immediate and for the duration of their presence in the Setting. Envision Having made the -ing what assignments action to indicated above and take grasped the nature begins. of the Setting, Envision persons will begin -ing to envision their tends to immediate actions include but also couch the these intended Environ- actions so as to be mental consistent with their dredyoung Page 132 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc Condi- life outside of or tions beyond this Setting. within They quickly which envision whether actions how they act now will take will fit in with what place others in the next and the Setting of further time into the future will con- expect of them or straints what the or consequences will possibili- be for them at some ties for future date with the some significant actions. other or others. Action They quickly strategie estimate how they s are might successfully consi- rationalize any dered. inconsistent Envision behavior. They -ing also must work out a takes sketchy, tentative perspec- strategy of how they tives on will justify having the adopted seemingly impact inconsistent roles or tentative identities. All the strategie while, they have s will their omnipresent have on implicit parents or Levels of surrogate parents External lurking in their Structur preconscious or es. subconscious mind Tentative and judging their intention actions so that they s to act also have to try to dredyoung Page 133 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc are avoid a sense of subcon- violation of sciously expectations or monitore betrayal to them of d by the kind of person one"s these implicit Implicit parents want them others. to be. Summing up, Envision instant by instant -ing these processes are must rapidly cycling involve a through their minds Time and they are Perspec- typically making tive split or instantaneous decisions about how they will act now and they their goals for varying distances into the future will be. Criteria for Fulfillme nt Foresha- Another important dowing aspect of this envisioning process is an interstice- process of imagining what the experience will be like once the act is completed or achieved. People often imagine based on dredyoung Page 134 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc their current or past state of relation to the envisioned act or goal. If they have foreshowed a paradise of fulfillment and reality does not turn out that way, there can be a profound experience of "let- down". Depending on the nature of the foreshadowing and its basis in reality, the end experience can be an extreme sense of fulfillment or extreme disillusionment and despair. Deciding Goal Setting Adventur Instantly on the -ing heels of these Timing amazingly complex Tempora mental l Experi-machinations, they ence have to act. Of course, on some occasions their Emotion ambivalence will al By- result in inhibition Products of any act or freezing. However, as they begin to act and as they are in the midst of action, dredyoung Page 135 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc discords between the above factors may cause they body to become tense or to act awkwardly or hesitantly, this make cause their timing to be off. Those who have no such discord will act with smooth integration of their acts with the flow of acts of the others in the Setting. Their degree of accord and involvement versus discord and hesitancy or inhibition will affect their temporal experience. Time may seem to drag in one case and in another they will be oblivious to time. With the prospect of negative consequences when they are ambivalent and hesitant and not performing well, as the deadline or end approaches time may seem to be fleeting to fast but when in accord and performing well, dredyoung Page 136 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc their obliviousness to time may also make it seem life like it is flying but on retrospect, the experience of being "in the zone" may make it seem like their enactment was an eternity. In these different modes of enactment, the accompanying emotions can be either extremely painful and negative or exhilarating and ecstatic. In the one case there is a desire to forever avoid a repeat of that situation and in the other there is a desire to do it over and over again. Body Body experience and its relation to Experi- sexuality. The body has sexual sensations ence. and feelings. External stimulation typically Example evokes arousal of sexual sensations and s: feelings. These are powerfully pleasant. It sexuality is the manner and circumstances that ; initially shapes sexual behavior patterns. in The social structure initially guides it >< action; ><><><><><By the time a person is acting ineffectiv on sexual urges and/or arousing stimuli, e action; they had previous had some form of sexual failure; sensation or stimulation of varying degrees success of pleasure or pain that occurred in a situation and setting in the context of dredyoung Page 137 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc persons, significant or otherwise, with varying degrees of positive or negative beliefs that have been communicated and who were prone toward approval or disapproval with concomitant consequences. All of these conditions, taken together, results in assigning the sexual experience and acts to one of the inner states of incorporation. Therefore, each person"s proclivity to engage in the range of possible presented sexual opportunities will be unique. They will conform to the cultural practices of which they have knowledge or they will secretly evade detection and give outlet to their unique proclivities. The degree of strictness or restraint, or their opposite, of present, impinging structure will determine their likelihood of engaging in forbidden or taboo practices. The implication of this complicated state of affairs is that each individual"s sexual desires will be expressed in a manner that will have such a wide range that their sexual motivation cannot be assigned to any unified theory of sexual motivation. Some forms of sexual expression will seem normal to some people, bizarre to some, repugnant and perverted to some, pathological to some, and even criminal to some. There is no concept of a normal or natural form of sexual expression that applies universally. In conclusion, there can be no universal theory of sexual motivation and there be no universal form or forms of sexual expression. These aspects of the sexuality are relative to cultures, subcultures, communities, institutions, settings, and situatiolns. Each configuration of these dredyoung Page 138 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc levels of external structures is not only unique but also exist as the mere accidental and arbitrary evolution and history of every culture"s manner of sexual expression. Disenga g-ing, Mirroring , Re- Envision -ing, Altering Criteria for Fulfillme nt Revising Strategy, Re- engagin g Complet- ing success- fully or Failing Exiting the Intention al Cycle Storing aspects of the Cycle"s Experi- ence with dredyoung Page 139 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc Schemat a and Schemes Repeatin g the cycle Achievin g Mastery and Storing Transce Mastery and Transcendence means more than moving to nd-ing progressive a higher level of skill mastery. It entails a levels of transcendence with more mature perspective, vision, ethical mastery respect of each of man/world responsibility. Maturity involves by the ego mastery an expansion of the arena of the mind. It creating skills involved in means a higher level of development in a more levels of maturity character. It means an increase in depth effective mean endurance of and breadth of one"s character. It means intention progress in the face moving beyond acceptance and empathy to al cycle of the challenges to care. It means moving beyond entailing be met in the Open transparency to authenticity, and from increase Society. authenticity to oneness with humanity and d earth. maturity of all of the intention al processe s and Storing 3. Restructuring the intentional processes of a client population requires restructuring the levels of external structures so that they target levels of internal structures while providing for a continual longitudinal influence that elicit optimal maturity of each of the dredyoung Page 140 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc intentional processes. Examples. Since I am claiming that restructuring intentional processes is crucial for therapy to be successful in an enduring and comprehensive way, we must get a deeper understanding of them. Let us back up and consider how these inner intentional processes begin as the person"s life begins. They develop slowly and they develop in a way that is adapted to their life situation. As these processes begin to evolve, they are incorporated without awareness and usually with little or no competition from alternative versions of them. Therefore, such things as one"s view of their world, their home, their caretakers, what they eat, how they are fed, and so on become ingrained perceptions as their sole reality, almost like stereotypes, and in fact, one could call them prejudices even those this term is reserved for a special meaning. Life as it is lived in different environments seems strange and is not incorporated, rather is incorporated as "not my world". As a child grows and explores its world, their view of it becomes more complex but always limited to what is available. Knowledge of the world, what people expect, and how to behave becomes ingrained but these are also accompanied with experiences that involve feelings, some negative and some positive. The child, or person, soon becomes aware of their emotions, feelings, and sensations of pleasure and pain. As this happens, they are instructed by their caretakers and peers about how they are to relate to these experiences. Without knowing it, they are being taught not just how to relate to feelings and sensations but whether to relate to them at all. Informally, the people in their world are also teaching them what to believe about what is good or bad, what one can or must do, and what one cannot or must not do. This is a crucial stage of life. Things that initially are pleasant may be described as unpleasant and to be avoided. Things that initially are unpleasant or painful may be described as necessary and pleasant. The taste of a food may initially be repugnant but described as great, as something "everybody likes" and "everybody does". The world of real sensations and feelings are being transformed with no, or at least fleeting, awareness. Later in life, the person will insist that they really like something that is unpleasant and really do not like something that is pleasant. This is dredyoung Page 141 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc an acculturation that everyone goes through and everyone forgets. These distortions of initial experience, being unconscious, are not brought up in the therapy session. They do not present themselves as a problem to the person. These distortions have become reality, unquestionable reality. I have been describing how a few of the inner intentional processes are acquired and how they have become a non-conscious part of the person"s life. These very processes typically, without awareness, have become aspects of the structure of the person"s world that could be having extremely destructive effects on their well- being. Clients are not going to bring these up in an interview. There are healthy alternatives to them but the person is either not aware of them or discounts them out of hand. The concept of free will and choice is often discussed in our culture but usually ends without clarification and then dismissed as irrelevant. However, what I am offering here is a different slant on the free will concept. A person is not free to choose an alternative if they do not know it exists or if, for some other reason, it remains unavailable to them. Traditional psychotherapy was not designed to deal with this condition. The Natural Systems Group, on the other hand, is designed to make these alternatives available so that they become a part of the possible alternatives from which one can choose. For a familiar example, parents may unwittingly be training their children to distort their experience. Eventually the children learn to do the distorting to their own selves, totally without awareness of what they are doing. They are, of course, totally unaware that there might be alternatives from which to choose. Usually parents do this to their children naively and with the very best of intentions. Consequently, parents do not raise such issues in therapy. They do not come up in therapy because parents do not perceive them. Parents certainly do not perceive this as a part of their child rearing problems. If this issue does happen to be brought up by parents and the therapist perceives that it falls in this category and chooses to describe alternative approaches to the parent, the parent will not accommodate their concepts to the new information about unwittingly training the child to distort their experience. Rather, they will somehow assimilate it to what they already do or already know and to their current practices. It may seem, to the therapist, as if they have understood and accepted what was offered. Unfortunately, the therapist only discovers later on that this was not the case since the dredyoung Page 142 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc problem tends to be brought up repeatedly. The parents will use stock phrases like "we tried your suggestion but our child resists" or that "our child is just too stubborn" or some such explanation that may seem perfectly plausible to them. They expectantly look to you for some new miraculous suggestion. In the Natural Systems Group, on the other hand, the participants can express these same concerns and puzzlements but here there are two advantages. One, they have the concepts before them to readily refer to in presentation form. Two, they can stimulate one another to look at things differently, to re-examine the interaction with their children, and to make a fresh attempt to experiment with new things. In this context, when parents finally do show positive results, fellow participants can give each other recognition and positively reinforce each other for their progress. Dealing with the underlying intentional processes is precisely one of the major purposes of Natural Systems Groups. B. How the role of Intentionality integrates the levels of both the upper and lower pyramids figures in developing a Natural Systems group therapy within the Open Society It should be noted here that I have taken what I feel to be the most productive concepts from these other modalities and put them to use in the Natural Systems approach. Before progressing to a description of the upper pyramid"s structures and systems, I must make it clear that the intentionality model is in a sense separate from the Duplex Pyramid model. The intentional processes of the Intentionality Model are not a part of these modalities nor their features. I have also reiterated that they are not a part of the levels of structures and processes in the lower pyramid. From my point of view, the upper and lower pyramids mutually influence each other yet the process by which they do so is the heretofore un-researched inner, intentional processes. The intentional processes reveal how these structures and processes operate, or rather, what the details are of the workings that the mind goes through to accomplish these mutual influences. As was mentioned toward the beginning, if behavioral patterns are changed because of therapy but the intentional processes that must be gone through to make those dredyoung Page 143 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc behavioral pattern changes are not changed, then the therapeutic changes will not persist. Behavior can change because some person, like a professional induced, recommended, or demanded they change. For the change to endure, the person"s own intentional processes must have voluntarily become involved. When these processes are voluntarily invoked, ego mastery skills are being acquired. The person not only takes and feels ownership but these processes and skills become second nature, which is to say they become an unconscious, automatically produced pattern appropriate to the invoking situation. The levels of the lower, internal pyramid are involved in the change, brought into play as and when needed by the intentional processes. Any one of the intentional processes can invoke or use any of the structures of the levels of the lower pyramid. Traditional psychology has researched each level thoroughly but not the underlying intentional processes that brought about the outcomes of its research hypothesis and design. Intentional processes have been the proverbial "black box". Modalities, similarly, have focused on one or another level of the lower pyramid but left the exploration of the "black box" out of the equation or made assumptions about its contribution. This policy of holding implied, unverified assumptions about the "why", the "black box", behind the process and outcome of their modality is what has created the chasm between clinical psychology and psychotherapy and experimental psychology. The one, experimental, has called the other soft, speculative, armchair, unscientific, unproven, and subject to the bias of the therapists. The other, clinical, has called experimental inhuman, cold, impractical, inapplicable, too objective, and out of touch with the real world living of life. The intentional processes are like a fulcrum. They are like the secret machinations behind the magician"s magic. There is no magic without these secret machinations. They are also the force that makes the mutual influences between the two pyramids possible and melds their new configuration. The intentional processes are exquisitely sensitive to their world. Nevertheless, they can be, and have been, scientifically researched. This research has demonstrated that it is highly relevant to both experimental and clinical psychology. Research on the intentional processes has brought these two worlds together. It has also brought the Duplex Pyramids together in a unified world. The word world in this instance means both the dredyoung Page 144 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc external structures and systems and the internal structures and processes. The clients need not know in any conceptual or cognitive manner to what they are being exquisitely sensitive. They need not "know" what a feeling is to be sensitive to it, nor what a perception is to be using it, and certainly not what intentional processes are for them to be organizing and administering their interaction with the world. People need not "know" or have a present awareness of the people in a room or where the doors are located, but if there is some subtle change in what is transpiring in the room that might involve people or doors, they are instantly sensitive to and responsive to them. Their intentional processes make this responsiveness possible. That being said, for most people, the powerful and ubiquitous forces shaping the structures and processes of the lower pyramid are the external structures and systems. It is these to which the intentional processes are so sensitive. External structures are continuously affecting and influencing the internal structures and the intentional processes use and organize them for instantaneous and usually appropriate responses. The intentional processes are continuously integrating these influences, that is to say, the influencing external structures and the influenced internal structures. This entire interaction is the amazingly complex, unifying entity we call "mind". Clients must ultimately come to recognize and understand, in a primitive, immediate, and elementary way, both the external and internal factors and forces. They must ultimately gain conscious control over these forces. Each acquisition of successful new patterns of processes is an increase in ego mastery skills on the way toward a higher level of maturity. I say they must do this because it is that recognition and that accomplishment that increasingly will lead to them to true personal freedom. With each increment of accomplishment, the individual"s freedom to choose the kind of life they will live is expanded. Prior to this radical transformation, all humans are mere puppets of cultural and biological determinism. The more they are aware of these factors and forces, the more possible true freedom becomes, degree by degree. 1. Intentionality, the Duplex Pyramids, and overcoming the formerly intractable problems of the temporal or longitudinal dredyoung Page 145 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc dimension 2. Intractable problems with identifying and altering inner, mental, intentional processes and the way they are related to the client"s external world Invisibly underlying behavioral acts occurring in everyday life situations, there are an exceedingly large number of inner, mental, intentional processes cycling through millisecond by millisecond. No human can be aware of all of these intentional processes as they occur. Being aware of even one would be difficult and probably is very rare. Being aware of your many, or any, inner processes at the very same time that you are producing the intended behavioral or speech acts is not possible. With intense concentration and persistence, a psychologically aware person can backtrack and detect subtle processes or aspects of the mental processes that led to an utterance or act. The act is supposed to realize the intent of the intentional processes. The intent is analogous to the goal and, in some sense, you must be aware of that. Yet, the processes that culminate in the intent are non-conscious. The motivation behind the intent could be either conscious or subconscious. Imagining what you intend is conscious, but how you do the imagining is not. Analogously, when we act, we are not aware of the bodily functions and physiology that make possible and produce the act. Our focus is on, and our awareness is of, the external world with which we interact. We do not know how we perceive the external world. We do not know the nature of our worldview, yet it is exerting a powerful influence over our choices. Similarly, you cannot, at least not without great awkwardness, speak and listen to your voice at the same time or act and focus your attention on how the act is produced at the same time. In fact, you do not know how speech or behavior is produced. However clients can and typically or often do focus on what they do or do not want to say "before" speaking. We can recall past events and we can feel feelings or emotions that are in some sense related to the initial event, but we do not know how we do this. People are seldom aware of how some past events affect their choices and function to direct, impel, or inhibit their acts and lives. Nevertheless, clients tend to spend a great deal of time talking about recent events that have troubled them or more distant dredyoung Page 146 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc memories that are related or may been their cause. Occasionally, clients may become occupied with recovering a memory of an event from their distant past, yet with little or no understanding of how it relates to their life today. Some therapists refer to this influence from the past as "Unfinished Business". Not unexpectedly, very few people are motivated to explore their covert or non-conscious intentional processes, nor would they know how if they did want to. The science of psychology proclaimed, long ago, that experiments designed to get at inner processes, particularly by using introspection, are too subjective and unreliable and must be dispensed with in favor of more objective scientific methods. Yet, if, as I said at the beginning, these hidden intentional processes are the engine propelling all behavior all of the time, it behooves us to question the history of psychology and take a second look at them, at their importance in perpetuating negative behavior and symptoms, and to look for possible ways to address them in therapy. Contrary to this tradition of ignoring inner processes, I have spent the last forty years trying to track and describe these intentional processes. It is now possible to design experiments to infer the unobservable from the observable in psychology just like in physics, astrophysics, and psycholinguistics, to name a few. In the late 80s, I conducted a broad scale experiment that conformed to the canons of scientific experiments and that was designed to demonstrate what these processes are and how they behave. Using a different but complementary tactic, I took an applied research approach in the early 90s. The program was "Stars and Stripes". This project demonstrated rather astounding success. The quantitative part was institutional performance indicators. Since the late 60s, I designed programs with features that were supposed to influence, or correct, inner processes of delinquents in correctional institutions, patients committed to psychiatric hospitals, adult prison inmates, and my clients in private practice. Through the years, the most success I have had has been with institutionalized populations. Unfortunately, the least success has been with my clients in individual psychotherapy. In the first paragraphs of this manuscript, I noted the institutional successes but also expressed my serious doubts and questions regarding the efficacy and practicality of individual psychotherapy. These doubts include using Natural Systems concepts in my individual psychotherapy practice. dredyoung Page 147 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc As I intend to address what I feel could be a viable alternative, I will first describe what I feel to be some of the "problems in identifying and altering inner, mental, intentional processes and how these are related to the client"s external world" when using traditional individual psychotherapeutic modalities, but also traditional group therapy modalities. 3. Natural Systems integrates intentionality, the Duplex Pyramids, and the temporal dimension and opens the way to innovation in treatment in the Open Society 4. Finding a replacement for traditional psychotherapies that can deal successfully with all of their intractable problems VI. Prospects for a More Efficacious Alternative to Traditional Psychotherapy A. An example of success in a closed institution using the natural systems" topics described above In a Natural Systems-type, well designed, structured program or institution, clients can be coached to check themselves and alter their behavior to react more maturely to presented situations. Programs are designed to evoke these situations as "generic situations" that make it much more likely to foster transference to relatively similar types of situations in "the free". This in itself is helpful. However, a situation-response paradigm is similar to the stimulus-response paradigm alluded to earlier and which was pointed out to be too "rapidly and forever changing everyday world" and therefore making the discrimination of situation types and matching response selection too complex and chancy. What is needed for transfer of learning to "the free" is something more identified with the people themselves, something that provides more continuity within the flux of reality in "the free". The concept of "role", so popular in sociology, seems to be the ideal vehicle for this purpose. Roles can, or rather must, have role-specific behaviors. Wherever and whenever the role is called for, the battery of associated behaviors, a much smaller universe than the dredyoung Page 148 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc random flux of possible but unpredictable situations becomes readily available for the client to draw from. If they learn the role well, the transfer of role-specific behaviors has a much greater probability of transfer to new environments in "the free". However, there are several problems with the role learning technique. Institutionally fashioned roles are shaped by institutional staff in and for institutional settings. In "the free", as was alluded to earlier, roles are assigned by multiple groups of people such as families, peers, work relations, intimate relations, relations I social and recreational organizations, etc. There are formal and informal role structures in such groups. These roles also have role specific behaviors. People occupying roles within the formal and informal role structures within such groups interface role to role with expectations that the role they interface with moment by moment will respond in the expected way. If these expectations are not met, there can pressures brought to bear to restore conformity and quite harsh psychologically negative consequences for lack of compliance. Institutionally shaped roles, however wholesome and positive they are, will bend to such pressures in "free". How can the client be inoculated against caving in to such pressures from the many groups that have their own needs for conformity to role prescriptions? First, if role shaping in the institution is integrated with a complex of factors one of which is as an overarching role structure that includes a hierarchy of roles through which the client must progress and includes the criteria for progression as well. The criteria are increasingly mature behavior. Therefore, there is a strong incentive to become more mature. At the same time, he lives with a small number of youths, all of whom are trying to become more mature. The program structure requires them to help each other attain this goal. They bond with each other and become a mutually supportive, mutually facilitative, positive peer group. His peers also have to learn to be realistic and objective and to assess each other"s readiness to ascend to higher ranks accurately. The youths become aware of each other"s progress in attaining the characteristics of more mature behavior. They assess not just whether more mature behavior is exhibited, but also whether it is being genuinely incorporated. Each of them is becoming aware of the fact that the control over their attainment of the more mature behavior primarily rests with themselves but is also interdependent with the rest of the group. They come to know that all of these factors dredyoung Page 149 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc are involved and required to reach the next level in the progression within the hierarchical role structure. That aspect of "more control" means that he can be the one to choose which behaviors to exhibit. More importantly, he becomes aware of the fact that he can control the kind of consequences that go along with his choices and behavior. He can now discriminate situational demands and decide whether to succumb to the negative pressure from the people in the situation. He knows that he may have to deal with the negative consequences, should they arise. He knows his peers are not going to let him off the hook for bad choices. Not only can he discriminate between situations, but also he can anticipate group-specific role expectations. He can now decide to reshape the group"s expectations of him. He can let them have to be the ones dealing with his change and his departure from yielding to their negative conformity pressures. In other words, he is selectively invoking inner processes at different stages of group interaction that will affect consequences and his progress. At one stage, he is assessing the nature of the group he is entering or about to enter and recalling the types of situations that occur with that group and the role structure of that group. After having entered and experienced the pressures and consequences and then exiting, he can then decide what his future posture will be. He can decide whether he will avoid the group altogether or will openly reveal what his differences with the group are and how his preferences have changed. If he decides to remain in the group, he can let them know that it will be on his terms. Anticipating the conflicts that will very likely arise, he can arm himself with strategies to deal positively with the probable conflicts. He can recall the feelings and emotions that such transactions provoke in him as well as members of the group. He can recall the strategies he can invoke to deal with these volatile emotions and hostile behavior as well. He has had practice with this back with his peer group in the institution. His interpersonal skills are becoming more sophisticated. One of the problems in "the free" that can be met with a complementary advantage in the institution is that of identity. Assigned roles in the family or peer group and the other types of groups can eventually be codified in a name or names that encapsulate the range of role-specific behaviors. Such names are called "identity". Identity is owned, so to speak, not by the person themselves, but by the social group bestowing the identity names. dredyoung Page 150 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc When the person departs from role expectations, group members can say he is not being himself, meaning he is not being true to the bestowed identity. Inconsistency can arise when identities change from group to group. Typically, however, identities are not simple, monolithic, and perseverating across groups. In fact, often identities and their related role behaviors quickly change as the person moves across organizations, settings within organizations, or even situations within settings. For the majority of people, these inconsistencies are normal and inevitable. The problem is that occasionally when someone sees a member from their group in "the other group" and detects inconsistent behavior, that is when the "not being yourself" accusation can be made. This often carries the even worse implication that the person is being "a hypocrite". This possibility creates pressure to resolve such identity inconsistencies and conflicts. The offender may try to either smooth out the differences by promising to modify their behavior or to become an expert at either providing rationalizations or rational explanations, or may try "spinning" a story to avoid being called a hypocrite. One common problem of this type arises in the occupational setting when a person is promoted to be supervisor over his former co-workers. The role behaviors have to change as the office changes and as the identity changes. The new supervisor becomes the target of all sorts of accusations such as being a hypocrite, disloyal, lording over, betraying, feigning superiority, etc. His task is to provide a rational explanation that his former colleagues can accept and help them deal with the prescribed behaviors of his new role as supervisor. Roles, therefore, can be used to facilitate acquisition of new, different, more skillful, and more mature behaviors. A hierarchical role structure for residents in an institution that includes more mature behaviors that must be attained in order to be elevated to higher ranks plus recommendations for promotions by peers can help ease the way for a redefinition of his identity. However, if his bid for promotion is turned down, he can be helped to learn to deal maturely with rejection and failure as temporary setbacks. If the increase in rank includes a new name, then it also entails as well as solidifies the change in identity. If the new role involves assisting his former peers to acquire the behaviors necessary for them to move up as well, this also eases acceptance of the change in identity. As he moves up through the ranks in this fashion, he learns, from the repeated experience of making such role dredyoung Page 151 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc transitions, how to deal with inter-group identity changes, but he also learns how to constructively cope with maintaining his new identity when he re-enters old groups that still "hold" onto his old identity. If the awareness of the significance of identity and its association with related mature behavior is incorporated firm enough, then when encountering negative peer pressure and family influences, he can assert his new identity and shape the expectations of others with respect to his new more mature role behaviors. Then they can choose whether to accept his new self-assigned identity and role behaviors or move out the group or away from him. As the client who is undergoing such transformations learns to accept flexibility and positively changing identities along with the related mature role specific behaviors, the invisible, inner processes of intentionality are also growing. Together, we can call these new developments the acquisition of ego mastery skills. The Ego mastery skills to be acquired should include but are not limited to: Inner personal skills in self-reliance Independence of judgment Realistic and positive goal setting Strategies for persisting in the pursuit of those goals Mutual support Social skills that particularly involve coping with interpersonal conflicts in the family and with peer groups Management of feelings and emotions; As well as many other inner processes in combination with the more observable mature behavior. As the person lives with the beneficial consequences of this new life style, it becomes self- reinforcing and therefore will tend to persist and resist regression. However, notice that all of these benefits result from the structure of the institution, from the way the Natural Systems program is designed. B. Learning from the closed institutional program and adapting the Natural Systems Model to treatment in "The Open Society" Adapting the natural systems model to treatment in "the open society" means taking some of the principles of what worked in the dredyoung Page 152 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc closed institutional environment and some of the principles that worked in psychotherapy and finding a way to make them work in an integrated manner in the minimally or unstructured society at large. Let us consider Natural Systems as having a scaffold-like model from which to derive and design tailored types of therapies and programs suitable for the non-institutional, natural environment. If a merging of these principles from psychotherapy and the institutional program were adapted to the "Open Society", this could mean a new genre of treatment could be created. If this were done so that together they could approximate the advantages and positive results seen in programs that were designed using Natural Systems for the structured environments of closed institutions and the results that come from psychotherapy, this would revolutionize treatment in the minimally structured, non-institutional, natural environment of the "Open Society". A project like this would first require staging arenas or settings where large numbers of people routinely gather like schools, churches, corporations, public libraries, community activity centers, recreational centers, social organizations, and neighborhood centers. Next, it would have to be possible to disseminate information to members, employees, or participants at these locations. Programs would have to be designed for specific target groups such a married couples, parents of teenagers, teenagers, people in positions or professions that work with such groups, and the like. If large corporations were targeted, programs could be designed for parents of teenagers or employees with personal problems, for example. Another example might be an institution like a YMCA or community activity center where teenagers regularly gather. In such settings, programs could be targeted to either teenagers or teenagers and their parents. A program in a church could be targeted to married couples. As you can, there are numerous possibilities. Using the Natural Systems model, for example, one type of program could use a format like a classroom, a seminar, or a discussion group. With this format, a program could have features such as slide presentations of problems and potential solutions targeted to the nature of the particular group. The information in the slides should be such that participants can see its relation to their own lives. Feelings would likely be evoked causing the participants to want to share their related experiences. Since prospective solutions would be included in the presentations, the discussion dredyoung Page 153 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc could also be directed to them as well. Group members would probably weigh and exchange opinions about the likelihood that each of the solutions would work. Rather than try to arrive at a conclusion, assignments could be given to the members. The assignments could involve selecting one of the proposed solutions or ways to handle the problem. They would be challenged to experiment with using a strategy, making a note of their results, and bringing the information to share at the next meeting. Members would become involved in sharing information about their unique experiences, problems encountered, and offering each other suggestion about alternative ways of dealing with the problem. Any group could be given additional structure by having them make decisions about what issues would be addressed and in what order they would be presented. They could decide on how the result from their experiments should be presented. They could form a role system in which persons would be assigned roles to orchestrate features such as these. Roles could be rotated. The processes involved in each of these features could also become topics for a presentation or discussion, or both. In other words, the process of assigning roles, transitioning in and out of roles, group interaction during decision making about topics and about experiments and how results of experiments are shared could all, themselves, become topics. Each of these group activities can evoke strong feeling and can rekindle memories of related life history episodes and past family relationship problems. Instead of provoking endless cathartic expression, the evoked issues and feelings can be shaped into an educational illustration addressed by a related topical presentation with complementary experiments or exercises. Each time the group shares opinions, especially positive opinions, shares alternative approaches, and shares results of experiments, the group leader can provide recognition and reinforcement for their sharing and encourage the members to do the same with each other. This builds bonds between members and teaches them how to be mutually facilitative and supportive. dredyoung Page 154 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc C. Contrasting Results Expected from Traditional Group Treatment Modalities versus the Natural Systems Groups in the "Open Society" To understand more deeply why Natural Systems groups can be more effective than other modalities, contrasting it with traditional group therapy and psycho-educational groups should be helpful. Let us consider group therapy first. In group therapy, clients with somewhat similar characteristics meet with a therapist. Clients each bring their unique life histories with them to the group. They bring all of the traumatic experiences; twisted and damaging relationships; life circumstances that distort their expectations and perspectives; prior roles in their family and peer groups through which they learned self- defeating behaviors; ascribed identities that harness their potentials. Along with those negative life experiences they also bring all of their suppressed resentments, rage, jealousies, rivalries, hidden taboo desires, and morbid and anxious feelings that went with those experiences. The confessions and accusations of the group members mutually provoke each other"s ambivalent yearnings and fears of confiding. Alternatively, they compete for attention to unload or reproach those too timid to open up. The therapist may use the group interaction as means of attempting to give individuals awareness of or insight into difficulties in their styles of relating. Participants may also be encouraged to give each other feedback on aspects of their styles of relating. None of the participants will find the undivided attention of the therapist that they would get in a one on one therapy session. If the therapist imposes rules to maintain order in the chaotic group communication, this merely tends to suppress spontaneous disclosure of their delicate, fragile, private selves. There is little opportunity to learn and master new social skills and virtually no opportunity to learn more mature ego mastery skills. Finally, and in addition, participants in group therapy have all of the disadvantages of individual psychotherapy, as was mentioned above. In psycho-educational groups, there is another class of disadvantages. Typically, the participants in these groups are given instruction in mental health, lectures on techniques of handling dredyoung Page 155 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc difficult life situations such a parent child relations, and group behavioral exercises or role-playing. Occasionally the participants are administered mental health, relationship, addiction, personality, or mood questionnaires. Such tests are used, ostensibly, to tell the participants what type of person they are; what their traits are; what their values are; what their personality problems are; what their interests are; what their aptitudes are; and even what their psychiatric diagnosis is. Sometimes the leader presents the results to the group and then uses their reactions to generate therapeutic discussion and group process. An erroneous assumption implicit in these questionnaires is that the score or scores derived are accurate and descriptors of the testee"s permanent personalities. In fact, what the scores indicate are traits that have very vague meanings. It is almost akin to reading tealeaves. The way a person answers the questions may be quite different from what was intended by the item. They may also, unconsciously or consciously, be trying to answer to create a certain type of impression. In real life, the person probably rarely exhibits that trait only in special circumstances, situations, or with only a few people. People are always changing and rarely exhibit any traits consistently and in their pure form. People also can change over their lifespan and may do so often. Whether an observer ascribes a trait to a subject may depend more on their own bias. Who knows what the source of a testee"s answer to a question might be. Is it from self-observation? Common sense and everyday observations tell most of us that humans are notoriously bad self-observers and prone to all sorts of bias in making self-attributions. Take any one trait and then consider that the reference group for their comparisons could range all over the universe. If their reference group is their peer group or small hometown, how representative is that of what the test maker had in mind? In other words, objective tests are not so objective! When discussing the results of their tests in the group, many kinds of obfuscating and misconstruing for many undisclosed reasons may predominate. This word hash of defensive and offensive attributions could hardly be described as therapeutic. The approaches used in most of these groups are didactic, assessment, experiential, guided-imagery, or some combination of these. They usually do include a certain amount of question and answer give and take within a leader moderated group discussion. Within this framework, the superficial "public self or persona" is dredyoung Page 156 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc seldom challenged. If so, the reaction is likely to be defensiveness and/or hurt feelings. This makes therapeutic, open, productive participation very difficult for the victim but also has a dampening effect on the other participants. Notice, however, that in psycho- educational groups, self-expression and confession is minimized. Participation-stress that comes from revealing secrets of their private self is minimal and therefore participant comfort levels are much greater. Contrasted such methods as group therapy, where there can be an abundance of therapist feedback or group mutual feedback on styles of interacting in the group, comfort levels can be reduced with the consequent that private self-revelations can become minimized. If transparency and revealing secret private selves is one of the goals, none of these methods is very effective. However, one of the key points regarding disadvantages of these kinds of group methods is that they primarily tend to be intellectual and primarily to focus on generic versions of problems rather than uniquely individual problems. In addition, the content of these sessions is related only indirectly or tangentially to everyday life outside of the sessions. Furthermore, as with group therapy, most group techniques offer little opportunity to learn and master new social skills other than those specific to the group-process of each group. Moreover, there is virtually no opportunity to learn more varied and more mature ego mastery skills as they relate to each individual"s home life and practice them in life outside of the sessions. Unless some aspect of the therapy takes place in the actual home life, work, or everyday life situations, transfer of training is highly unlikely. Otherwise, the knowledge and insights gained in session will quickly fade when the session is over and the participants return home. Since they are usually learning a great deal of "academic knowledge" about mental and behavioral health, they may come away with the feeling that the benefits will be carrying over into their everyday life. On the contrary, in some cases, in fact, a spouse or parent, for example, may remember just enough to bring up information from a session when they want to make accusations. With respect to group therapies, there all of the same disadvantages associated with individual psychotherapy mentioned in Sections I. 3 and 4. The main advantages of the psycho-educational group are that it is easier for the therapist or leader to manage and does not threaten participants" comfort levels. This is not much of a recommendation, dredyoung Page 157 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc in light of all of the disadvantages. 1. Understanding "Degrees of Structure" and why these are expected to produce different results in institutions versus the "Open Society" TABLE 1. Needs Revision THE DYNAMICS OF STRUCTURAL INFLUENCES Effects of changing degrees of rigidity of the external structure on how the internal structure"s lower levels influence dyadic interaction Top Pyramid"s Influence The more loose the NATURAL SYSTEMS " SCHEMA PERSPECTIVES USING THE DUPLEX PYRAMIDS descending levels of Op Encompassing Environments ce the upper pyramid"s en en an flu structure, the more d Institution or Organization in influence the lower lo e os Settings within Institution or levels of the bottom e m Le ls pyramid and the more ve Situations ve INTENTIONAL PROCESSES ls le Le influence the distant ss id Formal Roles R ig past have over present behavior. Dyadic PAST FUTURE Interaction In flue ds nc D ya Informal Roles e And Relationships fro on m e Physical/Verbal Behavior The more rigid the nc Dy l ue Cognition ad descending levels of g inf sD ec the upper pyramid"s sin Emotion/Feelings re crea Perception as structure, the less es De Life History Genetics Brain Chemistry influence the lower levels of the bottom pyramid and the less influence the distant past have over present behavior. 2. Assumptions of differential causal influences resulting from degrees of structure in institutions versus the "Open Society" TABLE 2. DEGREES OF STRUCTURE IN INSTITUTIONS dredyoung Page 158 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc HIGHLY STRUCTURED; STRICT RESTRICTIONS MODERATE LE STRUCTURE AD WITH S TO POSITIVE : AVENUES LE AD S TO LACK OF : LE STRUCTURE; AD HIGHLY S TO PERMISSIVE : REPRESSED UNINHIBITED BEHAVIOR: BEHAVIOR: PRIVATE PERSON PRIVATE CHANNELED, IS TENSE AND PERSON PRODUCTIVE ENGAGES IN BEHAVIOR FANTASY LIFE, IS DOMINANT REBELS, PUBLIC PERSON IS DOMINANT TABLE 3. Structure in the "Open Society" dredyoung Page 159 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc The "Open Society" is, in general, free of imposed structure. Within it, there are private institutions, businesses, social organizations that vary in structure. LACK OF STRUCTURE; HIGHLY PERMISSIVE LE AD S TO : UNINHIBITED BEHAVIOR: PRIVATE PERSON IS DOMINANT 4. Degrees of structure in institutions versus the "Open Society" and their relation to the chemical imbalance theory of mental illness Neurotransmitters and their changing configurations as aspects of the external structures change dredyoung Page 160 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc 5.The configuration and dynamics of Natural Systems groups and their differential contributions to mental health, ego mastery skills, and maturity 6. So, does Natural Systems offer as a superior alternative to traditional modalities when adapted to the Open Society? VII. Designing Natural Systems Ego Mastery Skills Groups A. Goals for the Natural Systems Groups Natural Systems designs structures that will overcome the shortcomings of traditional individual and group psychotherapy. In psychotherapy, they just unfold. If they are unaware of some negative behavior or if they too fearful or defensive to bring up a problem or if it is too deeply suppressed, it will never be addressed. Once addressed, no new coping behaviors are learned or practiced. Expressing the feeling is somehow supposed to work major and transform the client"s behavior, way of relating, or way of being in the world. NS has lessons and formats that are designed to: 1. Reduce the need to maintain the Public Persona. 2. Elicit suppressed emotional memories and issues as all learn sensitivity to and respect for delicate self revelations and confessions 3. Assure comfort with openness and bonding with each other. 4. Assist overcoming defenses against transparency and revealing their private self. 5. Assist the group in learning to identify negative behavior patterns of which the participants are not aware and to do so diplomatically. 6. Initiate advanced experiments in practicing ego mastery skills related to personal maturity 7. Help the group to learn and practice sensitivity to and respect for each other"s personal boundaries 8. Initiate self-evaluation, self-correction, and participation in the group"s respectful mutual feedback and correction. dredyoung Page 161 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc 9. Initiate advanced experiments in practicing ego mastery skills related to interpersonal maturity 10. Initiate practice in altering roles and identities, practice assuming different positive roles, practice switching gender roles, and practice new relationship skills from the point of view of the different, assumed role. 11. Initiate advanced informal experiments in practicing ego mastery skills related to maturity in intimate relationships 12. Replace their negative primary implicit others and secondary peer-related implicit others by supplanting them with the group leaders and the group as positive primary and secondary implicit others. 13. Expand participants" cognitive awareness of factors or structures in their home, work, and everyday life environments that negatively influence their behavior and learn to effectively counter and cope with them. 14. Expand their awareness of the influence of factors and structures (levels of structures, settings, situations, etc.) in the global culture that shape their values and behaviors and learn to decide whether to constructively inoculate against them, accommodate to them, or, when appropriate, facilitate changing them. 15. Initiate advanced experiments in practicing ego mastery skills related to intellectual maturity 16. Encourage practice in exploring unfamiliar settings and territories and experiment with altering and expanding their life topology 17. Assist them in learning how to learn new ego mastery skills appropriate to paths in their new life topology or adapt their current ego mastery skills to their changed life style 18. Assist them in understanding their choices with respect to whether to conform to their life conditions or to shape a new life style and adapt more flexible, relativistic, and situationally appropriate approaches to variant sets of values 19. Assist them in learning how to be a force for changing the socially and psychologically significant structures of their world. 20. Encourage them to experiment with practicing ego mastery skills related to societal maturity dredyoung Page 162 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc 21. Assist them in making gradual progression toward attaining and consistently acting based on an integration of higher levels of personal, interpersonal, intimate, intellectual, and societal, maturity. When a person comes to understand the way "Degrees of Structure" influence behavior, they will tend not to attribute the cause of negative behavior to inveterate personality or genetic traits. When a person comes to understand how a minimum degree of structure in the Open Society will cause a person"s life history, personality traits, and to a small extent their genetics to predominate as the cause of a person"s negative behavior, they can also begin to understand how important it is to restructure that person"s life topology. They can also begin to understand how important it is for the person with negative behavior to be educated with respect to the influence of both minimum structure and which factors in the Open Society do influence them and how those factors influence them. Understanding these structural factors leads the way to helping people inoculate themselves against and gain control over structural influences. The structure of Natural Systems groups makes it possible to acquire new and more advanced ego mastery skills that can be generalized to a wide variety of real life settings and situations. When a person truly incorporates new behavioral patterns and more advanced ego mastery skills, their painful, self-defeating, neurotic symptoms tend to disappear. This phenomenon would seem to make traditional therapy unnecessary. B. Introducing the Key Components, Procedures, and Techniques of the Natural Systems Groups The goals of the group are to increase individuals" ego mastery skills and maturity in many areas of their lives. Each group will be begun with an explanation of how Natural Systems groups work. A format will be developed. Each group will be involved to some extent in the design of the format for their group. This is part of the treatment approach of Natural Systems groups. Lessons using slide presentations will begin. Exercises to practice skills and gain insight will be used during group sessions. dredyoung Page 163 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc 1. Homework related to skills learned in each lesson will be assigned. This homework will require practicing these skills in the home and work situations. Participants will discuss the experiences they had practicing skills. Homework will also include viewing movies related to the theme of the week"s lesson. Insights gained from viewing the movie will be shared with the group. 2. A notebook will be kept that will include copies of lessons, their responses to homework practice and their experiences with ongoing participation in the group. Participants will be administered brief questionnaires about their progress at the beginning of each session and these will be included in the notebook. 3. Finally, participants will keep a journal describing their experiences, skills they have mastered, and growth related to participating in the group. Their journal entries will be added to the notebook. When the group is terminated, participants will have a record of everything they learned. They could use this to turn to for help in the future. The hypothesis is that the nature of the Natural Systems treatment will increase the participants" ego mastery skills and maturity. At the same time, and as a by-product, the nature of this approach is such that it will also relieve participants of symptoms that might possibly have been treated, but with less success, using traditional psychotherapeutic modalities or psychotropic medications. A parallel hypothesis is that, as there is a gradual increase in ego mastery skills and maturity, the participants" neurotransmitters will also gradually change toward balance and health. The goals of Natural Systems groups are designed to elicit, over time, increases in ego mastery skills and maturity. Each of the goals is should positively affect the relations between the participants and the external structures of their home and work environments and complementary aspects of selected internal, or intentional, processes, brain chemistry, and physical health. The outcome should be a successful, happy life style and positive relationships, with optimal mental, emotional, and physical health and a dramatic reduction in unwanted, unhealthy behaviors and symptoms as well. 1. The first component: The nature of the Natural Systems Group approach dredyoung Page 164 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc a. Communicating the essential features of The Natural Systems group b. Explaining to the group how the differences between degrees of structure in the open society can effect their behavior; i. minimum structure being the norm for open societies; ii. medium structure being the goal for a Natural Systems group; iii. maximum structure being typical of incarceration, public schools, and many kinds of businesses and occupations; iv. explaining the necessity for medium structure if a Natural Systems approach is to be successful c. Communicating the rationale for the format of the group, procedures of the sessions, and the way the lessons are to be used d. Presenting the Table of Contents of all available lessons 2. The second component: Developing an agenda a. Developing and setting a tentative agenda for the group and selecting appropriate lessons b. Establishing a progression of group offices or roles that have graduated criteria such as levels of maturity of mastery skills c. Designing roles so that they evoke the behaviors suggested in lessons d. Periodically engaging the group in the design of plans and setting goals that require envisioning e. Implementing group procedures and techniques that are designed to develop identification with the group and bonds between members of the group f. Initiating a group decision making process so that members learn how to achieve consensus with respect to decisions about plans and goals 3. The third component: Introduction to Lesson Presentations a. Presenting the first lesson b. Showing the group how the message of the lesson relates to life experiences dredyoung Page 165 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc c. Instructing the group about lesson exercises d. Explaining to the group how, when each member shares their experiences with applying the lesson, it benefits both themselves and the whole group e. At the beginning of sessions, taking a brief inventory or questionnaire about progress the member has made; changes they have made in some aspects of their life such as perceptions of others, feelings about others, general mode, ways of relating, expressing feelings, sharing intimate affection, listening, negotiating, managing home life, dealing with children, as others as applicable. 4. The fourth component: Homework done between sessions a. Implementing plans to perform informal experiments by practicing lesson related skills at home, work, and organizations with which one is affiliated b. Sharing and evaluating with the group the outcomes of practiced roles and skills c. Going to an internet discussion site to share feelings, thoughts, experiences, and suggestions related to the group such as topics, procedures, group interaction, etc. d. Downloading last week"s lesson to refresh their memory and for future reference e. Keeping a private journal of experiences in the group, life changes and problems, feelings, desires, etc., using the Natural Systems Journalizing technique f. Viewing movies and picking out scenarios related to the lesson"s message and relating to personal life situations g. Analyzing the role of structure in shaping lives of people in the movies viewing h. Discussing and practicing taking perspectives of different levels of structure portrayed in the movie I .Keeping a notebook with: i. Records of one's chronology of progress ii. Inventories and questionnaires answered iii. Journal writings dredyoung Page 166 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc iv. Movies and their plots and one's insights gained from seeing and discussing the movie v. Chronology of online discussions C. Types People Targeted for Types of Natural Systems Groups Working With Neuroses – Different Tracks for Different Folks – making different types of groups available for special populations -- neurotic symptoms obviated by ego mastery skills. Lessons are designed to evoke deep conflicts and suppressed and repressed memories. These are presented in such a manner as to imply that individuals dealing with such problems are not unique but hold them in common with many others. They are not rotten or untouchable lepers but rather share this plight in common with all of humankind. Other members of the group can reveal their variation of the disturbance can mutually facilitate each other"s exploration of the problem and be empathetic and mutually supportive. They can put the problem in perspective by each recounting the origin and history of the problem. They can also, collectively and cooperatively, explore possible effective alternative ways, if they could revisit their childhood trauma but as an adults, of coping with the incident, both with respect to the past and as repetitions of similar situations occur in the present. These new coping strategies then become homework exercises. At the next session . . . Furthermore, the theme of the lesson can be examined and discussed by the members to increase their understanding of the many structural forces and inner dynamic factors are in play in such themes and the situations in which they are reified. Develop perspectives on influences shaping their lives during and after seeing pertinent movies. D. Conducting a Natural Systems Group Male and female leaders as implicit parents dredyoung Page 167 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc VIII. Lesson Topics and Web Sites for Each Lesson Series It is possible to select from the available topics and sections listed below those that are most relevant to the needs of each particular group. Individual members can select from the remaining lessons any that may find helpful. Agendas and lesson schedules can be changed through group discussion. Members are advised, however, to adhere to the group"s schedule. The format for each type of group will be similar yet adjustments will be made so that it is relevant to the nature of each particular type of group. Groups designed to focus on couples and their relationships will have lessons tailored to their needs. Groups for parents, with or without adolescents present, designed to focus on raising adolescents will have lessons tailored to their needs. Groups designed to focus on adolescents will have lessons designed for their needs. Groups designed to focus on personal psychological growth of individual adults will have lessons tailored to their needs. A. Table of Topics for Group Types 1. Ego Mastery Skills Training for Individuals and Couples Topic 1 contains seventeen Sections with a total of over seven-hundred slides. 2. Training for Parents, Parents and Adolescents, or Adolescents Topic 2 contains twelve Sections with each Section containing from five to fifteen Lessons and each Lesson containing from five to twenty slides. There are about one-hundred-forty Lessons and over one-thousand-four- hundred slides. 3. Increasing Achievement and Decreasing Violence in Public High Schools Topic 3 contains six Sections with a total of about one- hundred and ten slides. 4. Issues Related to Psychologically Influential Structures in Our Culture Topic 4 contains thirty Sections with a total of about one- hundred-fifty pages. dredyoung Page 168 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc B.Secondary Sources and their Hyperlinks underlined below 1. Introduction to Natural Systems Institute Theoretical Roots 2. Natural Systems Analysis of Issues 3. Neighborhood Organization 4. Training for Organization Development 5. Addiction Workshops 6. Outlines for Workshops on Adolescence Parenting Relationships Organization and Creativity 7. Training Lessons for Parents, Youth Leaders, Natural Systems Group Leaders 8. The Essential Features of the Stars and Stripes Program C. Examples of Topic Choices in the Natural Systems Lesson Pool [See: http://www.dredyoung.com ) Leaders of Natural Systems groups can use a preset agenda, they can design their own or they design agenda with the collaboration of the participants. The list below is meant to suggest topics for possible inclusion. There are lessons (see Table of Topics above) constructed for the most part with MS PowerPoint although some are in the MS Word format. Open the web site above, select a sub web, and open any lesson to see an example and see what they include and test how they operate. 1. FAMILY INFLUENCES a. Assessing family styles b. Assessing family history c. Assessing immediate family and extended family structures d. Assessing individual roles in family systems dredyoung Page 169 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc e. Describing and understanding behavioral patterns and one"s roles in family systems and the effects of family structure, members" personalities, and on one"s own personality f. Role playing practice of lesson"s message experimenting with playing different roles g. Practicing altering the influencing patterns of structures, systems, and roles in the family and altering the influenced patterns of family structures, systems, and roles 2. MAINTAINING A HEALTHY BODY AND STRESS-FREE, CREATIVE LIFE 3. ROLES AT WORK, ORGANIZATIONS, AND INFORMAL GROUPS 4. UNDERSTANDING AND IMPROVING CLOSE RELATIONSHIPS a. Assessing listening and communication skills b. Practicing transparency and empathy and reducing the difference between c. public and private personality d. Altering inter-gender relationship styles e. Dynamics of attraction and romance f. Components of compatible relationships g. Exploring the effects of secret sexual criteria for fulfillment on intimacy h. Assessing reciprocity and negotiation skills in interpersonal and intimate relations i. Tracking stages in intimate relationships from first encounter to post separation j. The role of levels of intimacy maturity in relationships 5. THE INNER PERSON a. Detecting the difference between genuinely incorporated pleasures and pseudo-incorporated preferences and likewise for values and taste b. Detecting the difference between genuinely disincorporated pains, disincorporated pains, and pseudo-incorporated pains; genuinely disincorporated pleasures and pseudo-disincorporated pleasures c. Learning to detect the difference between genuinely incorporated and genuinely disincorporated beliefs versus pseudo- incorporated and pseudo-disincorporated beliefs dredyoung Page 170 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc d. Learning to express feelings and opinions with transparency generally and in mixed gender groups 6. THE INNER PERSON AND INTENTIONAL PROCESSES 7. THE STRUCTURE OF THE PERSON"S WORLD 8. CHARTING AND CHANGING ONE"S LIFE TOPOLOGY a. Journalizing about one"s criteria for fulfillment, experiments with practicing pursuing alternate criteria, and changes in perspectives, life topology, behavioral patterns, quality of relationships, and accomplishments b. Tracing the origins of criteria for fulfillment back to family influences, community and culture influences, the media, social comparison with peers, the structure of institutions such as schools and churches and sports c. Restructuring your life topology and life style 9. PERSONAL GOALS a. Learning how to foresee and anticipate environmental conditions and consequences of actions b. Learning to foresee, plan, and schedule in terms of changes or anticipated changes in circumstances, life-conditions, and levels of structure c. Learning to see influences and consequences in terms of levels of structure d. Practicing foreseeing, anticipating, and revising 10. INTEGRATING GOALS AND BEHAVIOR WITH TIME AND CONDITIONS a. Learning to assess the past and future in terms of different ranges of time spans, to gauge and coordinate with time factors, and to implement actions that are consciously integrated with skillfully estimated time b. Learning to envision, decide, set goals, and act in relation to levels of structures and environmental conditions c. Learning to develop and inner feedback systems to evaluate progress and revise strategies and behavior dredyoung Page 171 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc d. Learning to be realistic about foreshadowing, accept discrepancies between reality and what was foreshadowed, and adapt accordingly 11. ADOLESCENT DEVELOPMENTAL STAGES OF MATURITY and ADULT MATURITY IN FIVE DOMAINS OF LIFE IX. Measuring Results for Natural Systems Maturity Training Groups A.What Are the Criteria for Success Using Natural Systems in the "Open Society"? Let us begin by assuming and examining a premise that there are degrees of structure by which the way humans have organized their social groups, social settings, or social activities. Let us arbitrarily use three degrees of structure: maximum, medium, and minimum. The labels for these three arbitrary degrees can be changed depending upon what is being analyzed and how the analysis is conducted. Sticking with minimum, medium, and maximum for now, we can define, heuristically or tentatively, the degrees in terms of unrestricted free choice and free movement versus a limited number of free choices within a limited range of options provided by a programmed social organization versus little or no choices within a controlled and regimented social organization. Adapting the labels somewhat to the domains being analyzed, we can use as examples public schools with maximum structure being elementary school, medium structure being high school, and minimum structure being college. Another example is adult prisons that are categorized as minimum, medium, and maximum security (structure). Leadership style has been classified as laissez faire, democratic, and authoritarian. Even world religions could be categorized in terms of specified degrees of structure, for example in terms of their ideal or textbook descriptions and/or versus their actual observed variations. Families could also be loosely categorized in terms of degrees of structure. Perhaps psychotherapy modalities dredyoung Page 172 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc could be categorized as having minimum, medium, and maximum degrees of structure. For example, the degree could probably be categorized as maximum for Behavior Modification, medium for Reality Therapy, and as minimum Rogerian Therapy or Psychoanalysis. If one selects a system of categorizing for studying some form of social organization, then the meanings of the labels and terms and the method used in categorizing must be clearly defined, as should be the aspects measured and the techniques for measuring and analyzing the data. If the intent is to compare features while the client population is in each designated group the definitions, methods, etc. must be comparable across groups. The same would be true if one were comparing outcomes after clients had exited the groups. Open society in a democracy would be an example of minimum structure. Totalitarian, autocratic governments would be likely to be categorized as having maximum structure, but not necessarily so. Monarchies can have minimum structure for its citizens. The denominations of religions and the churches within denominations will likely vary considerably in terms of degree of structure. The same would be for types of corporations and businesses. It is hard to imagine any form of human social organization that would not exhibit variations that could be categorized in terms of degrees of structure. The point is to choose and clearly define your terms or labels for your categories or degrees of structure, related methods of analysis, and techniques of measurement. In Section II. 1., features of a closed juvenile correctional institution were sketched and criteria for success for the program and the clients were described. The measures for the program centered on reduction in such things as violence and escapes and number of grade levels achieved. These measures were compared across several institutions, each with a different type of program. The measures for the clients were also quantified. However, in contrast to the program measures, the clients" progress in levels of maturity that was central. Of course, many variations in the measurement approaches have been used. In the juvenile correctional institution cited here, initially aggressive, hostile, anti-social, uncooperative youths were dredyoung Page 173 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc tracked using objective measures. As they progressed through their ranks, they eventually were supposed to attain a level of maturity that involved being a positive, responsible citizen of their community as well as being personally and interpersonally mature. Maturity was determined by records and ratings of observed, increased maturity of behavior before they could be awarded each successively higher rank. Ratings were made by their peers and by all of the staff with whom the clients were involved. Follow up reports of their post- release behavior in their home community demonstrated that levels of maturity attained in the institution were maintained in their home communities. The critical point to notice here is that there was no attempt to determine or measure any internal personality changes. How does this differ from criteria and measures used with traditional psychotherapeutic modalities? It is important to note that, traditionally, with respect to psychotherapy, the focus has been on performance indicators or outcome results that measured personality change, specific symptom reduction, or client satisfaction. A wide variety of projective and objective personality instruments as well as self-report inventories or questionnaires have been used. Psychotherapeutic modalities have rarely used measures of retention of benefits at long intervals such as one to five or, even more rarely, ten years. Measurement instruments typically have been administered during the course of therapy or immediately upon termination. Behavior modification programs measured reduction in observable negative behaviors or symptoms while institutionalized or during the ongoing outpatient treatment. This is in stark contrast with The Natural Systems institutional program or my own private psychotherapy practice. It seems to me that without measurements taken a long time after treatment ends, outcome measures are essentially useless. B.Measuring and evaluating Natural Systems outcomes in relation goals. X. Proposed Planning and Implementation Strategies Possible locations for groups: dredyoung Page 174 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc Corporations Social organizations Churches Advantages for Businesses to consider: Employee Mental Health Insurance Costs Reduction Physical Health Outlays Reduced and Productivity Up Human Relations and Employee-Staff Relations Proposed alternatives for remuneration Marketing to organizations and to individuals Strategies for securing cooperative agreements with prospective organizations External Structures and Systems Intentionality Processes Internal Structures and Processes i http://www.forumonpublicpolicy.com/archive06/lazaroff.pdf The Role of the Diagnostic and Statistical Manual of Mental Disorders in the Maintenance of the Subjugation of Women: Implications for the Training of Future Mental Health Professionals Ann M. Lazaroff Associate Professor, Center for Programs in Psychology, Antioch University Abstract Since the publication of the first edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1952), the diagnostic classification of mental health issues has been rooted in an individualistic view of mental disorders. Although many of the changes in subsequent editions have resulted in clearer diagnostic classification, this individualistic approach fails to take into account the context within which many of the symptoms of mental disorders emerge. While the codes of ethics of the mental health professions require a consideration of clients" socioeconomic and cultural experiences when diagnosing mental disorders, the research that contributed to the classification system often failed to take these experiences into account. This paper provides a look at the impact of social and political pressures on the diagnostic decisions made by mental health professionals, while also exploring the ways in which psychiatry"s classification system has contributed to maintaining the dredyoung Page 175 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc oppression of women. The historical minimization of the effects of violence against women and the insidious trauma of sexism will be explored. Finally, the importance of teaching a contextual understanding of the DSM, as well as the impact of socially embedded cultural values and biases in regards to gender will be explored. ii Requirements for the court to consider the competency and insanity pleas: Detailed background information of the defendant. Past psychiatric history Medical history Substance abuse history. Description of the offense in question by the defendant and by the collateral sources. Review of collateral information reconstructing the mental state of the defendant at the time of the offense, and the time proximate to the offense. These usually include police reports, witness accounts, notes and discharge summaries from recent hospitalizations, accounts of communications of the defendant with others, etc. Diagnostic Impression. (The absence of mental disorder usually precludes further evaluation). Detailed account as to how the given diagnosis was reached. Description of the correlation between the defendants behavior at the time of the offense with the symptoms of his/her mental illness. (In the case of multiple legal charges, each offense would be addressed separately) The defendant must, in order to be subjected to any criminal proceedings, possess a satisfactory level of mental capacity to understand and comprehend the proceedings.(8) Once the trial court is convinced that the defendant satisfies this requisite level of competency, the defendant may be put to trial. This guarantee of fundamental fairness during criminal proceedings additionally incorporates those procedural safeguards enumerated in the Bill of Rights that are "essential to a fair trial."(9) Included in these safeguards are the Fifth Amendment prohibition against compulsory self-incrimination and the Sixth Amendment right to the assistance of counsel.( Virtually no state allows sociopathy to be grounds for an NGRI defense, and voluntary intoxication cannot by itself end culpability. Only a few states still contain the volitional question. Several state decisions have noted that criminal intent is an absolutely necessary part of any crime. In recent years, some states have redefined their laws to focus more tightly on the mens rea, or guilty mind. Under those laws, a dredyoung Page 176 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc person must, as a result of a mental illness, lack the ability to willingly or knowingly commit an act. This looks at criminal intent, rather than psychiatric diagnoses, therefore claiming an end to criminals getting off free. Public perceptions are that the insanity defense occurs far more commonly than records indicate. In fact, the insanity defense is used in less than 1% of criminal proceedings and is successful in approximately one- quarter of those cases. Furthermore, defendants who are found insane spend as much, or more, time in state custody than their criminally convicted counterparts. The media may foster the notion that criminals get away with feigning mental defect, only to be released and recidivate. However, the insanity plea is actually based on a long-standing legal tradition and is rarely successfully completed. In fact, approximately 70% of insanity acquittals result from agreements between opposing attorneys, in which the prosecution agrees that society would be better served by placing the defendant in treatment, rather than in prison. iii The "McNaughton rule" was a standard to be applied by the jury, after hearing medical testimony from prosecution and defense experts. The rule created a presumption of sanity, unless the defense proved "at the time of committing the act, the accused was laboring under such a defect of reason, from disease of the mind, as not to know the nature and quality of the act he was doing or, if he did know it, that he did not know what he was doing was wrong." The Durham rule states, "That an accused is not criminally responsible if his unlawful act was the product of mental disease or mental defect." In 1972, the American Law Institute, a panel of legal experts, developed a new rule for insanity as part of the Model Penal Code. This rule says that a defendant is not responsible for criminal conduct where (s)he, as a result of mental disease or defect, did not possess "substantial capacity either to appreciate the criminality of his conduct or to conform his conduct to the requirements of the law." In 1984, Congress passed, and President Ronald Reagan signed, the Comprehensive Crime Control Act. The federal insanity defense now requires the defendant to prove, by "clear and convincing evidence," that "at the time of the commission of the acts constituting the offense, the defendant, as a result of a severe mental disease or defect, was unable to appreciate the nature and quality or the wrongfulness of his acts" (18 U.S.C. § 17). This is generally viewed as a return to the "knowing right from wrong" standard dredyoung Page 177 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc iv In any given year, approximately 3.5 million Americans experience homelessness, 39 percent of whom are children. On any given day there are an average of 750,000 homeless. Research by the University of Alabama last year based on intensive interviews with 161 randomly sampled homeless people and review of the community's Point in Time Count found a 29.1% chronically homeless population, of which 76% were male, 73% were over age 40, and 20% were veterans. 54% of those identified in the Point in Time count self reported a substance abuse addiction, 33% a mental health illness, and 18% reported a physical disability. behavior ... reciprocal relation between physical illness and becoming or being homeless. US in denial as poverty rises | Special reports | The Observer http://www.observer.co.uk/worldview/story/0,11581,825150,00.html Statistics released last month by the government census bureau show that for the ... rate for children in the US is worse than in 19 'rich' ... Report on Homelessness http://www.bethesda-mission.org/report.htm ... statistical information on homeless person's mental ... except by exhibiting blatantly bizarre or disruptive behavior ... reciprocal relation between physical illness and becoming or being homeless. National Coalition for Homeless Veterans - Background & Statistics http://www.nchv.org/background.cfm#facts ... communities, 45% suffer from mental illness, and half have substance abuse problems. ... physical health care, substance abuse aftercare and mental health ... Homelessness in the United States - Wikipedia, the free encyclopedia http://en.wikipedia.org/wiki/Homelessness_in_the_United_States Homeless individuals report mental illness as being the number three reason for ... homeless statistics show the number of homeless has remained high. ... Criminal Justice / Mental Health Consensus Project http://consensusproject.org/the_report/toc/appendix/glossary dredyoung Page 178 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc ... where patients stay for a period of time to receive treatment. ... person who is homeless or transport to a hospital for a person who has a mental illness. ... Mental Health and Treatment of Inmates and Probationers http://www.ojp.usdoj.gov/bjs/pub/pdf/mhtip.pdf State prisoners. U.S. Department of Justice. Office of Justice Programs. Bureau of Justice Statistics. Special Report. Mental Health and Treatment ... Study finds 744,000 homeless in US http://www.kxnet.com/getArticle.asp?s=rss&ArticleId=84514 AP-NDHomeless,0150 Study finds 744,000 homeless in U-S WASHINGTON (AP) A study out today estimates nearly three-quarters of a (m) million people were homeless in the U-S in 2005. It's the first national estimate of homelessness in Study: 744,000 homeless in U.S. in 2005 http://news.yahoo.com/s/ap/20070110/ap_on_go_ot/homeless_2 There were 744,000 homeless people in the United States in 2005, according to the first national estimate in a decade. Service Delivery and Community: Social Capital, Service Systems Integration, and Outcomes Among Homeless Persons with Severe Mental Illness.(Statistical Data Included) http://www.highbeam.com/doc/1G1:78059751/Service+Delivery+and+Com munity~C~+Social+Capital,+Service+Systems+Integration,+and+Outcome s+Among+Homeless+Persons+with+Severe+Mental+Illness~R~(Statistical +Data+Included).html?refid=intlxt_watson ... outcomes among homeless people with serious mental illness. Study Setting ... conducted of homeless people with serious mental illness at 18 sites ... system for persons who are homeless in each community ... employment, physical health, or ... outcomes for ... Report on Homelessness http://www.bethesda-mission.org/report.htm ... statistical information on homeless person's mental ... except by exhibiting blatantly bizarre or disruptive http://www.nchv.org/background.cfm#facts Study finds 744,000 homeless in US http://www.kxnet.com/getArticle.asp?s=rss&ArticleId=84514 AP-NDHomeless,0150 Study finds 744,000 homeless in U-S WASHINGTON (AP) A study out today estimates nearly three-quarters of a (m) million people were homeless in the U-S in 2005. It's the first national estimate of homelessness in dredyoung Page 179 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc National Coalition for Homeless Veterans - Background & Statistics http://www.nchv.org/background.cfm#facts ... communities, 45% suffer from mental illness, and half have substance abuse problems. ... physical health care, substance abuse aftercare and mental health ... Report on Homelessness http://www.bethesda-mission.org/report.htm ... statistical information on homeless person's mental ... except by exhibiting blatantly bizarre or disruptive behavior ... reciprocal relation between physical illness and becoming or being homeless. Service Delivery and Community: Social Capital, Service Systems Integration, and Outcomes Among Homeless Persons with Severe Mental Illness.(Statistical Data Included) http://www.highbeam.com/doc/1G1:78059751/Service+Delivery+and+Com munity~C~+Social+Capital,+Service+Systems+Integration,+and+Outcome s+Among+Homeless+Persons+with+Severe+Mental+Illness~R~(Statistical +Data+Included).html?refid=intlxt_watson ... outcomes among homeless people with serious mental illness. Study Setting ... conducted of homeless people with serious mental illness at 18 sites ... system for persons who are homeless in each community ... employment, physical health, or ... outcomes for ... Study: 744,000 homeless in U.S. in 2005 http://news.yahoo.com/s/ap/20070110/ap_on_go_ot/homeless_2 There were 744,000 homeless people in the United States in 2005, according to the first national estimate in a decade. Study finds 744,000 homeless in US http://www.kxnet.com/getArticle.asp?s=rss&ArticleId=84514 AP-NDHomeless,0150 Study finds 744,000 homeless in U-S WASHINGTON (AP) A study out today estimates nearly three-quarters of a (m) million people were homeless in the U-S in 2005. It's the first national estimate of homelessness in Mental Health and Treatment of Inmates and Probationers http://www.ojp.usdoj.gov/bjs/pub/pdf/mhtip.pdf dredyoung Page 180 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc State prisoners. U.S. Department of Justice. Office of Justice Programs. Bureau of Justice Statistics. Special Report. Mental Health and Treatment ... Criminal Justice / Mental Health Consensus Project http://consensusproject.org/the_report/toc/appendix/glossary ... where patients stay for a period of time to receive treatment. ... person who is homeless or transport to a hospital for a person who has a mental illness. ... Homelessness in the United States - Wikipedia, the free encyclopedia http://en.wikipedia.org/wiki/Homelessness_in_the_United_States Homeless individuals report mental illness as being the number three reason for ... homeless statistics show the number of homeless has remained high. ... National Coalition for Homeless Veterans - Background & Statistics http://www.nchv.org/background.cfm#facts ... communities, 45% suffer from mental illness, and half have substance abuse problems. ... physical health care, substance abuse aftercare and mental health ... Report on Homelessness http://www.bethesda-mission.org/report.htm ... statistical information on homeless person's mental ... except by exhibiting blatantly bizarre or disruptive behavior ... reciprocal relation between physical illness and becoming or being homeless. US in denial as poverty rises | Special reports | The Observer http://www.observer.co.uk/worldview/story/0,11581,825150,00.html Statistics released last month by the government census bureau show that for the ... rate for children in the US is worse than in 19 'rich' ... v Recent articles have raised questions about the assumptions concerning the effectiveness of Managed Care. Critics of the system argue that managed care is reducing the introduction of new technology, interfering with the physician-patient relationship, worsening outcomes, restricting clinical research, reducing funding for physician training and adversely effecting community based hospitals. Others raise concern about dredyoung Page 181 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc monopolistic trade practices, ruthless business techniques and the subversion of medical ethics. Has the essence and tradition of humane services provision been sacrificed through management systems that embody corporate principles, systems, language, and values. Is humane managed care an oxymoron? As consumers, payers, and providers of mental health services increasingly become focused on outcomes-oriented data, states will need to reorganize epidemiologic, financing, and service delivery data and link databases in order to monitor mental health care and assess outcomes associated with that care. vi Managed Mental Care arising from attempts to manage (reduce) costs http://www.cga.ct.gov/2005/pridata/Studies/Mental_Health_Parity_Briefing. htm http://www.fmhi.usf.edu/parity/parityreport/managedcare.html http://www.naswpress.org/publications/books/health/humane_mngd_care/2 944preface.html vii http://psychrights.org/Research/Digest/ADHD/ADHDAsFraud.htm The American Psychiatric Association"s Diagnostic and Statistical Manual has grown from 112 mental disorders in its initial, 1952 edition, to 163 in the 1968, DSM-II, to 224 in the 1980, DSM-III; 253 in the 1987, DSM-III-R, and, 374 in the 1994, DSM-IV. http://www.shirleys-wellness-cafe.com/ritalin.htm ____________________________________________________________ 'Duplex Pyramids' above is the logo of the Natural Systems Institute. The top inverted pyramid represents layers of external structures and systems and the bottom pyramid represents layers of internal structures and systems. The extension of the pyramid to the left represents degrees of distance into the past, while extension to the right represents degrees of projection into the future. The underlying theoretical assumption is that effective, enduring change in humans and human social systems dredyoung Page 182 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc comes only when these multidimensional relationships of the external, internal, past and future perspectives are all addressed as change efforts are attempted. THE NATURAL SYSTEMS INSTITUTE Introduction to the Theory Underlying the Natural Systems Institute 1. Stars and Stripes: A Correctional Program for a Juvenile Institution for Felons 2. Parenting Skill Training 3. Solutions to School Violence 4. Psychological Self Help 5. Neighborhood Organizing 6. Addiction Online Workshops 7. Organization Restructuring 8. A New Paradigm for Psychological Treatment Based on Natural Systems 9. Stages of Growth in Maturity and Suggestions for How to Facilitate that Growth 10. A Description of Natural Systems' Structural Theory of Personality 11. Postings of Essays Addressing Major Problematic Issues in Our Culture 12. Outlines for Workshops on Adolescence, Parenting, Relationships, Organization Restructuring, and Creativity 13. Creativity and Managing the Conscious Mind 14. A Plan for Restructuring the Harris County Juvenile Probation Department Young Family Home Page For questions or comments, mailto:email@example.com dredyoung Page 183 11/10/2011 C:\Docstoc\Working\pdf\c7d1a5ce-8e49-4e9a-9df2-c4ad8bfb9f11.doc
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