Cognitive Rehabilitation

Introduction

Abstracts

Theory

Practice

Cognitive rehabilitation does not assume that individuals start with any motivation to change. Creating conscious choice is the heart of motivating antisocial offenders to change. The program challenges children to make a conscious choice and to accept full responsibility for that choice. Giving choice and acknowledging that they have the potency to make such choices is empowering. It changes the dimensions of the situation, acknowledging potency rather than attempting to control. The understanding of what to change, how to change, and the motivation to change will lead to the ultimate goal of the program: reduction of antisocial behavior. This goal will not be achieved in everyone who completes the program. Cognitive change is self-change.

A man is literally what he thinks, his character being the complete sum of all his thoughts. James Allen [ 1864 -1912]

Cognition is defined as the action or faculty of knowing. Habilitate means to qualify. Thus cognitive rehabilitation could be defined as requalifying knowledge, coming to know differently or relearning. The process of cognitive rehabilitation can happen developmentally or with professional guidance. In the professional arena cognitive restructuring is usually used when working in corrections and cognitive therapy when working in the mental health arena. Both are based on the same principles and use essentially the same process and techniques. At the environmental level an environment or culture which challenges one to rethink their beliefs would be a rehabilitative or change environment. One can manipulate the environment to address beliefs just as behaviorist manipulate the environment to change behaviors. In fact cognitive rehabilitation grows out of behaviorism and uses much of the language and application.

Cognitive factors play an important and well-documented role in antisocial behaviors and conduct disorders, just as they do with anxiety and depression. Common themes of thinking, automatic thoughts, and cognitive errors can be identified through direct experience and inference. Within the context of these cognitive factors, the behaviors of the individual, usually make sense.

If we treat people as they are, we make them worse. If we treat people as they ought to be, we help them become what they are capable of becoming.
Johann Wolfgang von Goethe
[1749 - 1832]

There is little difference between the actions of a person who is in danger of physical assault and one who believes s/he is in danger of physical assault, but it is untrue. A sudden action by the presumed assaulter may be met with fight or flight. If the assaulter really had no such intentions, the actions might seem quite bizarre or hostile. Unfortunately, behavior - either verbal or physical - is interactive and there is often a response. If I have no intention of harming you, but you suddenly attack me, I may defend myself, thus justifying your belief that I intended harm.

Learning would be exceedingly laborious, not to mention hazardous, if people had to rely solely on the effects of their own action to inform them what to do. Fortunately, most human behavior is learned observationally through modeling: from observing others one forms an idea of how new behaviors are performed, and on later occasions this coded information serves as a guide for action" A Bandura [1997]

The nature, onset, prevalence and prognosis of disruptive disorder syndromes appear to be remarkably stable. Whereas internalizing disorders may respond to treatment or ameliorate spontaneously over time, some aspects of conduct disorder may persist in a relatively constant form and be resistent to treatment. There are several possible reasons for this, but the most likely is the interactive nature of cognitive development. The literature suggests that such disruptive disorders run in families. This is not unlikely since aggressive behavior often receives an aggressive response. A child growing up in a family that has an aggressive parent is likely to develop a belief system that aggressive behavior is the "right" way to act, since aggression may be a response learned through modeling of physically punitive behavior of adults. Physical aversive, in the form of corporal punishment have failed to produce sustained suppression of inappropriate behaviors [Rose, 1981], increase the likelihood that the child will behave aggressive in other settings [Maurer, 1974], and make no contribution to the development of new, appropriate behaviors [Goldstein, Apter, & Harootunian, 1984].

Even if the family holds no aggressive adult, they may be unprepared to appropriately handle the early aggressiveness of the child and respond with attempts to control the behavior in ways that set in motions increased aggression. These movements towards more aggressions are impacted by other things. As the child gets to school, they may be met with a series of increasingly severe punishments. By the time they reach the secondary level, they have been lectured to, yelled at, sent out of the classroom, kept after school, referred to the office, suspended in school, suspended from school, expelled -- and they simply no longer care. Punishment is temporary and transitory. Once the punishment is over, the student has 'served his time' and is 'free and clear' from further responsibility. Punishment also stirs feelings of fear, flight or fight. [Marshall, 1998] Once having survived the fear and possible pain of punishment, the person knows they can handle it, and the psychological impact is reduced. Aggressive people build a cognitive structure in which they are 'super' strong, able to accept punishment and hand it out.

Support for disruptive behavior also is influenced by the peer group, which is probably the most pervading and important of all the affectional systems in terms of long-range personal-social adjustment [Harlow, 1974]. Physical free play, which is the easiest for the child, and most disturbing for parents and teachers, is rough and tumble, often appearing hostile to outsiders. When such play goes beyond the bounds, and someone gets hurt, empathetic responses are required. Children who believe that 'might makes right', and that it is important to be strong, able to take it and hand it out, are unlikely candidates for empathy. On the other hand, an adult may be present and punish the aggressive child for 'going beyond the bounds' of fun, reinforcing 'victim' thoughts - "I was just having fun and "Johnny" wasn't tough, so I get punished." With victim-stance thinking, there is no room for remorse. Righteous anger produces feelings and images of power.

Finally, either the peers or the individual child reject the group. Removing the primary opportunity for the discovery and utilization of social and cultural patterns. The child may become a "loner", responding aggressively to attempts to befriend, or find a group which supports his 'might makes right' attitudes resulting in deviant social and cultural patterns being learned and reinforced.

While internalizing children also get reinforced with behaviors that enable them to continue to view themselves as victims of an unfair society and often reject peers and 'frighten' away potential curative relationships. A concerned adult or friend who has both a solid emotional intelligence and a willingness to dispute negative explanatory styles can at least approach and attempt. As the externalizing student approaches adulthood, it is increasingly unlikely that they will be able to form relationships with such positive influence.

Finally, the traditional approaches to people with thoughts and behaviors that cause them problems in living tend also to increase the problems. Delinquency is often punished rather than rehabilitated, and mental health 'controls' through chemical or physical restraints. Both procedures are easily interpreted as unhelpful, if not downright hostile.

The future is not a result of choices among alternative paths offered by the present, but a place that is created - created first in mind and will, created next in activity. The future is not some place we are going to, but one we are creating. The paths to it are not found but made, and the activity of making them changes both the maker and the destination.

John Schaar

Despite the poor prognosis and stability given by the mental health professionals, all is not lost. For our cognitive structures and even the unconscious contexts, are open to conscious consideration and decision making.

Cognitive change is based on the simple fact that how people think has a controlling effect on how they act. Common themes of antisocial thinking include the belief and mind-set that they are being victimized. Many offenders are accustomed to feeling unfairly treated and have learned a defiant, hostile attitude as part of their basic orientation toward life and other people. From the cognitive perspective, both their perception of being victimized and their hostile responses to it are learned cognitive behaviors. These are learned ways of thinking that are reinforced by experiences of success and self gratification. For instance, the sense of victim outrage is itself a feeling of strength and righteousness, much preferable (in their mind) to feelings of weakness and vulnerability. [Bush & Bilodeau, 1993]

Most disruptive children have an emotional stake in remaining as they are. They know how to feel okay by relying on their old attitudes and ways of thinking. They don't know how to feel okay using new attitudes and new ways of thinking. Alternative thinking patterns must be emotionally, as well as, cognitively available.

The understanding of what to change, how to change, and the motivation to change will lead to the ultimate goal of the program: reduction of antisocial behavior. This goal will not be achieved in everyone who completes the program. Cognitive change is self-change. The techniques of cognitive self direction taught in this program can be applied by an individual only to his or her own thinking. For this reason, the service is goal driven, rather than need driven. It is important that we help the person reach his/her goals. What is happening is that their thoughts, emotions and behaviors are placing barriers to their own goal seeking.

If we are seen as helping them to reach their own goals, resistance and compliance are no longer current. Motivation is self induced. However, we must recognize that we are talking about a lifetime of habitual thinking. Such thoughts will not disappear over night. In fact, in crisis, most people will return to long held habits. But if the choice to change is real, the process will help to inoculate the individual against future stress and each experience will become a learning experience which can be evaluated in light of the new evaluative capacities.

The responsibility for growth and development lies fundamentally with each individual; the responsibility for providing the opportunity for growth and fulfillment lies with society.