Saturday, October 25, 2008

Getting Unstuck

According to the Yale Medical School web site, cognitive script is "the term used for the themes that flow habitually through our thoughts. These cognitive scripts can influence both our emotions and our behavior. They have been described as the tapes we play repeatedly in our heads—those things we tell ourselves over and over again, often without conscious awareness."

In my experience, substance-abusing teens generally have three basic cognitive scripts: act up, shut down, and use. With such limited options, these youth are stuck continuously rerunning these same maladaptive scripts, perpetuating already internalized beliefs that they are ineffective, incapable, and unable to make more adaptive choices.

Every time a youth uses the same maladaptive script, it becomes more likely that he will use it again. This is basic neuroscience. Hebb wrote, “[A]ny two cells that are repeatedly active at the same time will tend to become ‘associated,’ so that activity in one facilitates activity in the other" (qtd. in Siegel, p. 26). In other words, “Experience, gene expression, mental activity, behavior, and continued interactions with the environment are tightly linked in a transactional set of processes” (Siegel, p. 19).

These processes begin at birth. Repeated similar experiences lead the mind to make generalized representations that form the basis of mental models used to “interpret present experiences as well as anticipate future ones” (Siegel, p. 29-30), suggesting that an individual is most likely to respond to life events in standard, predictable and learned ways.

Cognitive scripts are learned. For an individual who experienced a positive childhood environment, her scripts will be adaptive and flexible. However, when a youth has only maladaptive scripts, eventually acting up, shutting down, and using can become so normalized that these scripts are no longer seen as problematic.

“Jennifer,” a former client, had a history of running away, shoplifting, and abusing marijuana. When I worked with her, she was on her third treatment episode. Jennifer lived in a group home with a drug testing policy and continued use would result in her losing her placement. Yet, she continued to use. Some drug counselors would say she was in denial or resistant to treatment. This seems overly simplistic to me. Jennifer couldn’t be successful because she had no mental model of success. All Jennifer knew was acting up, shutting down, and using. All Jennifer knew was being stuck.

If creating change in our clients is about helping them write new, more adaptive scripts, how do we make that happen? I’ve always believed the answer is not to provide endless didactic lectures. Rather, the answer is to present clients opportunities to try new behaviors. As they practice these new behaviors, new neural connections are being made and new cognitive scripts are being written. In other words, they are starting to get unstuck.

Beyond the Comfort Zone
In my experience, substance-abusing teens and other at-risk youth continue to engage in maladaptive behaviors until they break their cycle of stuckness. If this is true, then it seems to me that the goal of substance abuse treatment should be to help clients create new, more adaptive cognitive scripts. It seems to me that the first step in this process is encouraging participants to risk going outside their Comfort Zones.

There's a paradox among many of my clients. While they have done things I consider extremely high risk—like getting high on drugs acquired from a stranger who is inherently a criminal, exchanging sex for drugs, or stealing to support their habit—they almost universally present as risk-adverse. I'm frequently perplexed by how to confront this Risk Dichotomy, which my clients are usually unable to recognize. It seems those things have become so normalized to them that they are no longer perceived as risky.

For these clients, staying stuck seems safe. Acting up, shutting down, and using are solidly within their Comfort Zones, so don't seem like risky behavior. This cycle keeps the youth stuck—and every time this cycle repeats itself, it becomes more likely the youth will stay stuck. What fires together wires together. That's basic neuroscience. And, every time that happens it becomes more likely to happen again.

Getting unstuck requires the individual to step outside her Comfort Zone and experiment with new behaviors. This is much riskier—not to mention harder—than sticking with rigid, predictable responses. However, it is only through trying new behaviors that the individual will have the opportunity to develop more adaptive cognitive scripts.

Through participation in experiences that move them outside their Comfort Zones, experiential learning provides substance-abusing teens an opportunity to test their assumptions and reject those they discover to be faulty. It seems to me that this testing and rejecting is vital for movement through the Stages of Change, especially those stages most likely to be encountered in a treatment setting—pre-contemplation, contemplation, and preparation.

For a pre-contemplative client, testing and rejecting “increases the likelihood of serious consideration of change” (DiClemente, p. 27). For a client in the preparation stage, testing and rejecting fosters the likelihood of “a considered evaluation that leads to a decision to change” (DiClemente, p. 27). For a client in the preparation stage, testing and rejecting increases self-efficacy and can result in “an action plan that will be implemented in the near term” (DiClemente, p. 27).

You’re Freaking Me Out!
If opportunities to test and reject assumptions are necessary for movement through the Stages of Change, so, too, is some discomfort. According to Cozolino, “[M]oderate stress triggers the release of neurohormones that enhance cortical reorganization and new learning” (p. 24). In addition, Zull wrote, “Plasticity in the brain probably depends more on signals from the emotional centers than it does on new sensory input” (p. 223).

In other words, it is emotions—especially stress—that make our brains learn and change. Experiential learning is an excellent methodology for creating this change environment. In most experiential activities, there is a high level of perceived risk. In some cases, such as white water rafting or high ropes activities, this perceived risk is physical. In other cases, this perceived risk could be emotional or social.

Whether physical, emotional, or social, the perception of risk in experiential activities will likely result in a sense of disequilibrium. According to Luckner and Nadler, “Disequilibrium refers to an individual’s awareness that a mismatch exists between old ways of thinking and new information” (p. 19). "Vincent," a former client, provided an example of disequilibrium during a group activity.

I talk about appropriate risk-taking frequently during group sessions, and often use an activity called Pass the Mousetraps to illustrate this idea. As the title suggests, this activity involves passing around set mousetraps. Actually, this activity also includes tripping mousetraps with hands.

Although completely safe when certain parameters are followed, this activity appears to be fairly risky. In fact, while sitting in a room filled with teens tripping mousetraps, Vincent, a former client, blurted, “You’re freaking me out!” and quickly left the room. For Vincent, the perceived risk was simply too high, even after my extremely detailed safety directions prior to the activity.

Watching his group-mates trip mousetraps with their hands created too strong of a mismatch for Vincent. He believed this to be extremely dangerous behavior, yet nobody was being injured. Unable to revise his thinking quickly enough to reflect the reality of the situation, Vincent had no choice but to flee. Later, Vincent stated, “I left because I was sure someone was going to get hurt. And I couldn’t figure out why that wasn’t happening.” Vincent wasn't worried someone might get hurt; he was upset because what he expected to happen didn't.

With all my clients, disequilibrium appears when acting up, shutting down, and using become no longer effective. When faced with this scenario, a participant is confronted with one of two choices: assimilation or accommodation. According to Piaget’s developmental theory, when presented with new information an individual tries to assimilate it, or fit it into his existing understanding of the world. If this is impossible, the individual is forced to accommodate the new information by altering his schema, or mental models (Kassin, p. 343). When presented with an experience that requires accommodation, an individual is forced to alter his cognitive scripts.

Experiential learning is rich in these opportunities. Marie—the client discussed in my earlier posting Reflecting on Reflection—and her experience on the hike is a good example. Marie was confronted with two choices. She could give up by sitting on the side of the mountain and refusing to continue the hike, or she could resume the hike even though it was difficult and clearly outside her Comfort Zone. When Marie chose to continue the hike, she was required to accommodate this new option and alter her cognitive scripts.

I believe that these opportunities are one of the major values of experiential learning in treatment setting. Priest and Gass wrote, “By responding to seemingly insurmountable tasks [found in many experiential activities], participants often learn to overcome self-imposed perceptions of their capabilities to succeed” (p. 18). It seems to me that by definition, insurmountable tasks only exist outside one’s Comfort Zone. Perhaps, then, taking the risk of tackling an insurmountable task means a participant will automatically be more open to becoming unstuck.

For Marie, an insurmountable task was accomplished and the change was almost immediate. In Vincent’s case, he never tripped a mousetrap with his bare hand, but he did confront a powerful mismatch. What he expected didn’t happen and to accommodate that new experience, he needed to alter his cognitive scripts.

So, what does being slightly less afraid of a mousetrap has to do with sobriety? As a result of his experience that day, Vincent discovered that mousetraps aren’t inherently dangerous after all. This new learning required him to rearrange information in ways that formed new neural networks based on actively testing and rejecting an outdated belief. And, perhaps, with that was born a new perspective: There are possibilities other than those you’ve always believed to be true. Experiential learning helps participants become unstuck by helping them create new, more adaptive cognitive scripts and helping them discover those other possibilities.

Works Cited
Cozolino, L. (2002). Neuroscience of Psychotherapy, The. New York: W. W. Norton & Co.
DiClemente, C. (2003). Addiction and Change. New York: Guilford Press.
Kassin, S. (2004). Essentials of Psychology. Upper Saddle River, NJ: Prentice-Hall.
Luckner, J. & Nadler, R. (1992). Processing the Experience. Dubuque, IA: Kendall/Hunt Publishing.
Priest, S. & Gass, M. (2005). Effective Leadership in Adventure Programming. Champaign, IL: Human Kinetics.
Siegel, D. (1999). Developing Mind, The. New York: Guilford Press.
Yale Medical School. (n.d.). Glossary. Retrieved October 22, 2008, from
http://info.med.yale.edu/psych/3s/glossary_items/cog_script.html
Zull, J. (2002). Art of Changing the Brain, The. Sterling, VA: Stylus Publishing.

Saturday, October 18, 2008

Talking Despite Themselves

Zull wrote that reflection is an attempt to find unity in experiences (p. 154). He continued, “We get our data quickly, but it takes longer to see the unity it in" (p. 163). I believe that discovering this unity is especially important when using experiential activities in clinical settings. Without connecting the activity to the real world, transfer of learning will not occur. Processing a learning experience helps assure that this transfer happens.

Processing is “an activity that is structured to encourage individuals to plan, reflect, describe, analyze and communicate about experiences” (Luckner & Nadler p. 8). In experiential learning settings, a typical processing session involves participants answering facilitator-asked questions following some type of experience. Some participants are resistant to this approach, especially initially. In my experience, processing sessions that are simply facilitator-led question-and-answer sessions often lack depth. It seems to me this can be especially true when working with teens in treatment, where the youth are often reluctant to participate in the first place and may lack the skills necessary to be introspective.

Mandated to Change
Nearly all the youth I work with enter services in the pre-contemplation stage-of-change. They are there due to probation, other court involvements, school requirements, family pressures, or other external reasons. For them, treatment is viewed as the lesser of two evils, and minimal effort is all they initially will commit. The compelling nature of experiential activities works well with these youth for encouraging participation. However, attempting to lead these youth to process deeply can be painful at times!

There is a special challenge involved in working with these mandated youth, and the work can be filled with paradoxes. I consider their treatment voluntary, but not participating could result in a probation violation. I never force clients to participate in experiential activities, but not participating could be considered non-compliance. I try to minimize the coercive aspect of this throughout all dimensions of treatment, but mandated clients are always aware of it.

That said, although the mandated client is required to participate, that doesn’t mean she can’t choose to do so. Indeed, that is exactly what I always hope will occur with these clients, that their thinking will move from “I have to be here” to “I want to be here.” When this happens, I see it as a clear sign of movement through the stages-of-change.

Whether clients are mandated to treatment or not, one of the advantages of experiential activities is that the activities are inherently engaging. Priest and Gass refer to these as “activities that provide compelling tasks to accomplish” (p. 17). Even most reluctant clients want to participate in them, at least after an appropriate “I’m not doing that” protest. Perhaps they believe that the activities aren’t really treatment and therefore acceptable. That’s fine with me. I know there’s much more to juggling rubber chickens than meets the eye.

Reflection Skills
Reflection takes skill and developing this skill requires practice (Stanchfield, p. 134). In my experience, it is common for youth in treatment to lack the skills necessary to reflect. As a way to help my clients develop this skill, I’ve recently added a new element to my group sessions. At every session, we now start with a Question from the Box. I’ve created about 60 questions, which I have on strips of paper. At the start of each group session, a participant draws a slip out of the box and all the youth take turns answering the question.

Some of the questions are directly recovery oriented, such as “Describe the last time you felt like using.” Others are about self-disclosure, such as “Share something about yourself that nobody here knows.” Still others are simply for the sake of practicing reflection skills, such as “If you were a super hero, what would your super-power be?”

Recently, group members have spontaneously started asking each other follow up questions, which suggests to me that this processing practice is having a positive impact. In a simple, safe way, these Questions from the Box are providing my clients an opportunity to improve their skills at self-reflection. In some cases, though, it seems to me that a lack of reflective ability may suggest more than simply a skills deficit. It might indicate a history of trauma, abuse and/or neglect.

Many of the youth I work with have such histories. For these participants, introspection may be something they’ve spent years actively avoiding. Their use of alcohol and other drugs may be part of that effort to avoid introspection. Their other maladaptive behaviors may also be part of that pattern of avoidance. Yet, here I am as the facilitator, pushing them to do exactly what they have been trying to avoid. No wonder they seem reluctant.

It seems to me that providing opportunities to practice reflection is an important aspect of any treatment program. Once learned, the ability to think reflectively is a valuable skill these youth will take with them and be able to apply to life in general. Since so many of my clients have histories of trauma or neglect, facilitating for change means finding ways for my clients to feel safe while being reflective.

That Silly Amygdala
The amygdala is also where the fight-or-flight response is centered. The “fear center” of the brain, it is used primarily for analyzing experiences, assigning meaning to those experiences, and monitoring those experiences for danger (Zull, p. 59). When the amygdala senses danger, it communicates this to the body, so that the body can prepare to act (Zull, p. 60). Imagine a youth reluctant to attend group. Maybe he doesn’t think he has a problem and resent the mandate. Maybe she has a history of trauma. Maybe he doesn’t possess the skills to be introspective. It seems to me that these are exactly the type of situations that would be considered dangerous by the vigilant amygdala.

So what does this have to do with getting teens to talk? Well, according to Zull, there are times when the amygdala is less active, less vigilant. One of these times is when the cortical brain is busy with a cognitive task such as solving a puzzle (p. 60). Under those circumstances, the amygdala doesn’t have time to sense fear. It seems to me that presenting puzzles or other active processing approaches could be useful when working with reluctant-to-process teens. By keeping the cortical brain busy, they would be more likely to process.

Indeed, without knowing it, I’ve done this in the past. Occasionally I have Game Day in groups and one of my favorite games is Totika. Similar to Jenga, but with blocks of different colors, after successfully removing a block from the stack the player answers a color-coded question. About a year ago, we were playing Totika during a Game Day. While playing, “Carl”— street savvy, extremely guarded, and reluctant to engage in discussions, activities, or any self-disclosure—was asked to describe the worse day of his life. Without hesitation, he started talking about his mother’s death when he was four years old. Within moments, he was in tears as he continued telling his life story to the group.

For nearly a year now, I’ve been thinking about this incident, trying to figure out why Carl was suddenly willing to be introspective that day. Had he finally come to feel safe in the group environment? Was it simply that he was playing by the rules of the game? Had his need to talk about this overwhelmed his reluctance to engage? All of these are likely true to some extent, but it would seem that the task of carefully pulling a block out of the stack kept his cortical brain too busy to be fearful about sharing this experience.

Surely there are ways that I can more intentionally bring this knowledge about the amygdala into my groups in order help facilitate change.

Beyond Q & A
Totika is one example of ways to move beyond a traditional question-and-answer processing approach, to help assure a richer outcome for teens in treatment. “There are many innovative ways to engage a group in dialogue and reflection kinesthetically, emotionally, and socially that aren’t dependent on the facilitator’s leading a didactic question-and-answer session” (Stanchfield, p. 106).

One example is the use of consensus in processing. Stanchfield stated, “The value of practicing consensus in the context of developing group processing skills is that consensus is all about quality discussion and embracing and understanding the opinions of those with differing viewpoints” (p. 94). Stanchfield wrote about a processing activity that involved the providing the group a set of cards with metaphorical images on each, such as Chiji Cards (see www.chiji.com). The group’s goal is to choose one card by consensus that represented what they had achieved as a group.

I like this as a processing activity and have used it before. Not only does it function as an exercise in consensus, it turns processing into a decision making experience. Getting teens to process deeply can be challenging, so having participates engage in an activity like this can be an excellent choice. As Stanchfield wrote, “[P]articipants can become so involved in identifying with a card, and making an argument for their card, that they are unaware they are engaging in reflection” (p. 96).

As we have seen, if participants’ brains are engaged in such problem solving, they may truly be unaware they are processing. Even so, the reflection that occurs helps to assure transfer of learning. As a facilitator, becoming more intentional with processing approaches can also help assure the most value possible from participating in an experiential activity.

Works Cited
Luckner, J. & Nadler, R. (1992). Processing the Experience. Dubuque, IA: Kendall/Hunt Publishing.
Priest, S. & Gass, M. (2005). Effective Leadership in Adventure Programming. Champaign, IL: Human Kinetics.
Stanchfield, J. (2007). Tips and Tools: The Art of Experiential Group Facilitation. Oklahoma City, OK: Wood'N'Barnes Publishing.
Zull, J. (2002). Art of Changing the Brain, The. Sterling, VA: Stylus Publishing.

Sunday, October 12, 2008

Reflecting on Reflection

In the reflection stage of the learning cycle, participants process learning from an experiential activity in order to generalize it to other areas of their lives (Luckner & Nadler, p. 10). This processing provides an opportunity for participants to review their behavior during the experience and connect those reflections to the “real world.”

Processing most often occurs at the completion of an experience. However, it can occur at anytime. Indeed, if a facilitator stops an activity in progress because the participants are stuck and processes what is happening in the moment, an extremely powerful transfer of learning is possible.

When leading experiential activities or adventure programs in the past, I have always tended toward low levels of facilitation, preferring to allow participants the opportunity to get unstuck on their own. Only when this doesn't occur in a timely manner or when participants start to become escalated have I stopped the activity, with a problem solving prompt directed to the participants such as, “Who can name an obstacle for the group right now?”

Most often, this in-the-moment processing will be enough for the participants to get themselves unstuck, usually by trying something new and thereby stepping out of their collective comfort zone and making a change in hopes of decreasing the dissonance they are experiencing. However, I'm wondering if I should expect more from in-the-moment processing than the participants simply getting over an obstacle.

Luckner and Nadler wrote, “It is in the brief moment or moments prior to a unique action or breakthrough that the ingredients for change are found” (p. 28). When utilizing experiential learning to foster change, those moments prior to that breakthrough action should, perhaps, be the primary focus of the facilitator.

Luckner and Nadler refer to this as “edgework.” They wrote, “It is at the edge of the breakthrough where processing the experience is most important” (p. 29). I conceptualize this edge as the dividing line between a participant’s comfort zone and change zone. “When at this dividing line, “individuals either break through and take the leap or turn back to their safe territory” (Luckner & Nadler, p. 30). When at that dividing line, in-the-moment processing could be vital for assuring forward movement.

With this in mind, my low-level facilitation style might not always be the most effective strategy. Instead, a more active role focused on emphasizing those moments prior to that breakthrough action might be more beneficial to the participants.

Processing on the Edge
An example of this processing at the edge is “Marie,” a client from when I worked in the in-patient program at Ryther Child Center. As the experiential treatment facilitator, one of my roles at Ryther was to lead weekly hikes. When selecting a destination, I always tried to choose a hike that was clearly outside the participants’ collective comfort zones, but which I thought everyone could successfully complete. By moving outside their comfort zones, I hoped the participants would practice being unstuck. Not surprisingly, there was sometimes much resistance.

Marie always complained about and during the hikes. This day, though, she actually gave up, sitting down on the side of the mountain trail and refusing to continue. She wasn’t just stuck. She was immobilized. My best motivational speeches failed with her, and finally I asked, “Do you always quit when things get tough?”

Unimpressed, Marie responded, “Oh. You’re doing that metaphor thing, huh?”

I acknowledged that I was, indeed, doing that metaphor thing, then suggested she try something new and not give up this time. Eventually, she agreed to continue the hike. After attempting this new “don’t give up just because it’s hard” behavior, giving up was no longer the only option within her comfort zone.

For Marie, it was the processing on the edge that helped her become unstuck and move forward. Whenever it occurs, though, processing provides participants the opportunity to reflect, analyze, describe, and discuss an experience, while reinforcing perceptions of change and promoting transfer of learning (Luckner & Nadler, p. 8). Indeed, I would say it is the processing that turns an activity into a therapeutic experience.

As Marie’s sense of self-efficacy increased, her engagement in processing grew. Initially, she would say little during debriefing sessions, even when called on directly. Toward the end of her treatment, not only was she increasingly vocal during processing sessions, during hikes she actively encouraged her struggling peers.

Marie’s initial resistance to change was clearly evident. She was taken out of her comfort zone and repeatedly placed into new and unique situations that she considered risky. In her efforts to reduce the dissonance she felt, she was forced to reconsider her preconceived views. Because she was regularly placed into these new and unique situations, Marie’s resistance decreased dramatically.

Would this have occurred without processing? I believe so, but only to a limited degree. It was through opportunities to process her experiences that Marie generalized her learning to other areas of her life. It was through opportunities to process her experiences that Marie became unstuck.

Types of Transfer
The ideas about reflection presented in The Art of Changing the Brain and Processing the Experience made me think back to another idea about transfer of learning. Priest and Gass identified three types of transfer: specific transfer, non-specific transfer, and metaphoric transfer (p. 185).

Specific transfer is learning a particular skill or habit for use in a closely related situation. Non-specific transfer is learning general principles or behaviors and applying to different situations. Metaphoric transfer refers to discovering the parallels between two learning environments. At various times, Marie exhibited all three types of transfer, but most notable was her metaphoric transfer. This is clearly evident in her statement, “If I can complete this hike, I can stay clean.”

Zull wrote, “We need reflection to develop complexity. We may start with a direct and sometimes relatively simple concrete experience, but that experience grows richer as we allow our brain the freedom to search for those still unknown connections” (p. 164). In other words, reflection is about finding connections between the activity and the real world. For Marie, completing the hike may have had value in itself, but change occurred not when she stood at the mountain’s summit, but when she made connections between the hike, her recovery and life beyond.

Works Cited
Luckner, J. & Nadler, R. (1992). Processing the Experience. Dubuque, IA: Kendall/Hunt Publishing.
Zull, J. (2002). Art of Changing the Brain, The. Sterling, VA: Stylus Publishing.