Compelled

I feel compelled to respond on some level. And then I will let this go.

Okay… Here we go.

There are a couple of assumptions that are necessary up front. If we are going to have a reasonable conversation about this.

Assumptions

1. There is such a thing as – SCIENCE.
   
   Research methods apply to social issues. As a society we should be making our decisions and forming our policies based on research. NOT based on my personal (or your personal) experience, strength and hope.
   
2. Having a “problem” with drugs and/or alcohol is a – BAD THING.
   
   Regardless of what you call it (addiction, SUD, etc…) it is BAD for your health and bad for society.
   
3. Resolving a “problem” with drugs and/or alcohol is a – GOOD THING.
   
   Regardless of what you call it (recovery, remission, getting better etc…). It is good for your health and good for society for the problem to be resolved.

If you can’t agree with these 3 points. There is nothing anyone can say to you to facilitate a meaningful conversation.

You are dogmatically entrenched and an extremist. I wish you the best. I apologize if my opinions offend you.

The Research & Facts

Let me break down the data below. WARNING: This is research. Not opinion:

• 22.35 Million People Have Resolved a Substance Use Problem (over their lifetime). They HAD A PROBLEM. They NO LONGER HAVE A PROBLEM. That is a good thing.
  
• Only 10.28 million call it recovery.
  
• The other 12.07 million just got better. They don’t care if you think it’s recovery. They got better. And that is a good thing.
  
• Of the 22.35 million who got better:
  
• 12.04 million (53.9%) got help/assistance.
  
• 10.31 million (46.1%) DID IT ON THEIR OWN. They got better (that’s a good thing). And they did it on their own.
  
• Of the 12.04 million who got help:
  
• 5.4 million used 12-step meetings or some other type of mutual support group.
  
• 3.3 million got treatment and of those 283,800 used medication assisted pathway.
  
• 2.6 million were involved with recovery support services.
  
• 734,000 were involved with recovery centers.

Therefore, the typical/traditional pathway of meetings and/or treatment accounts for only 8.7 million (5.4 million meetings + 3.3 million treatment) of the 22.35 million who got better.

That’s 39% of the people. It’s an important part of the equation.

BUT THE “TRADITIONAL PATHWAYS” do not account for the majority of change.

61% DID IT SOME OTHER WAY

This should promote dialogue around alternative therapies and new ideas.

Furthermore, if you look a little deeper:

Of the 10.28 who say they are in recovery: **59.1 % report total abstinence. That means 40.9% or 4.2 million moderate.

Of the people who DID NOT say they were in recovery: **45.5% report total abstinence.

That means 55.5% or 6.7 million people moderate.

This leaves us with 10.9 million people who have resolved a problem with substance use via moderation.

That is 48.7%. Nearly half. Nearly half use moderation.

ALSO. THE RESEARCHERS FOUND NO DIFFERENCE IN HAPPINESS LEVELS OR SOCIAL FUNCTIONING AMONG THE GROUPS.

Moderation and total abstinence produced the same quality of life outcomes.

Here is the link to the full article: https://www.recoveryanswers.org/

Few Choices

Now at this point. You are left with only a few choices.

1. Research in general is not real. There is no such thing as science. Therefore, you disregard this information.
   
2. This particular research is not real. It was put together by Harvard Medical School and a bunch of idiots “up there”. You are much smarter and much more informed than any of those idiots from Harvard. Therefore, you disregard this information.
   
3. You “don’t give a shit about no research”. You know what worked for you and you know what worked for your group and therefore you don’t need no research. You and your 10 or 100 or 1000 acquaintances in recovery speak for all of humanity. All 7.5 Billion people. In which case, you disregard this information.
   
4. Or… perhaps there is legitimacy to this research. AND further discussion and exploration is needed.

Certainly, we should be trying to reach people via different avenues. Especially when, it is obvious that multiple pathways (including moderation) work.

Recovery Answers – National Recovery Study – Dr. John Kelly – Multiple Pathways to Recovery Conference

Access the original National Recovery Study research article:

Kelly, J. F., Bergman, B. G., Hoeppner, B., Vilsaint, C., & White, W. L. (In Press). Prevalence and pathways of recovery from drug and alcohol problems in the United States population: Implications for practice, research, and policy. Drug and Alcohol Dependence.

The post Compelled to Respond appeared first on The Recovery Cartel.

The Dopamine Diaries

“Dopamine” has been incorrectly promoted as the “pleasure chemical” in the brain.  I have said this and I have taught people (wrongly) that dopamine is associated with pleasure. 

First off, there are no chemicals in the brain. Better description would be something closer to “electrical pulses between cells” rather than “chemicals”. 

Second, dopamine does produce contentment.

The main function of dopamine is in “energizing us toward a goal”. 

It is more accurately described as the “reward” neurotransmitter. 

From an evolutionary point of view, dopamine made it possible for humans to seek out things like food, safe relationships, safe groups, and sex in a very dangerous, unpredictable and scarce environment.

It was not pleasure. It was reward. Dopamine made reward seeking possible.

In The Genes

The gene associated with dopamine is DRD4. The mutation, (allele), associated with a dysfunctional dopamine system is 7R.

Therefore, dopamine deficiency = DRD4-7R

Terminology:

• DRD4: DR (dopamine receptor) D4 (number 4).
• 7R: 7 – repeat allele  (“variation or version” ) of the DRD4 gene.
• 7R = Mutation.
• 7R is associated with poor dopamine accessibility (deficiency).

What Is It?

Dopamine is a key neurotransmitter.

It regulates cognition, attention, emotional processing, motor activation, short-term memory, behavioral inhibition and reward. (Wickens, 1990; Nieoullon, 2002; Dreber et al., 2009; Eisenberg et al., 2010b)

Dopamine is not the “pleasure” chemical.

It is involved in goal oriented activity and there is a pleasurable component / feel good component (energy, focus, excitability, confidence).

However, the idea of “pleasure” is a bit misleading.

DRD4-7R is a mutation present in 20.6% of the population.

The Wanderlust Gene

DRD4-7R has been called The Wanderlust Gene.

It’s called Wanderlust because this mutation is equated with adventure seeking, risk taking behavior and restlessness.

Dopamine has been getting more and more press over the past 5-10 years.

Here is a better description: Sensation Seeking.  I like that description. 

An insatiable pursuit of sensations.   

Dopamine & Addiction

Note: “The dopamine deficiency hypothesis” and the dopamine depletion explanation have been the cornerstones of the neurobiology of addiction for decades.

It is not typically talked about in a holistic manner. In that, the focus does not go beyond the addiction connection.

However, it has been the most common “scientific”/medical” explanation for addiction.

Yet, it is a controversial and frequently challenged explanation.

• There are multiple etiological explanations for addiction.
• There are sociological explanations.
• There are hardcore fundamentalist Christian explanations (sin).
• There are people who believe addiction is a social construct.
• And on and on…

A Tragic Comedy

Substance Use Disorder is contextual as well as an individualized experience. There is little certainty where matters of the brain are concerned. Addiction is a brain issue.

It is strange and dangerous when people present theories and explanations in a manner that implies certainty. There is no certainty to be found in terms of addiction treatment and recovery. It’s intuitive and recovery is an imprecise process. 

We understand only 5-10% of brain functioning.  We do not examine the brain when making a SUD diagnosis. 

Yet, we speak with 100% certainty on cause and cure. 

The arrogance and hubris of behavioral health = tragically comical. 

The Over-emphasis on The HIGHJACKED BRAIN

Absolutist application of the neurobiological brain disorder model has been problematic.

It is clear there is a “dopamine and addiction connection”.

However, this “connection” is over-used and over-blown.

It is inappropriately applied across the board in SUD settings. 

Dopamine Despair IS NOT UNIVERSAL

For example, nearly every person who walks into a rehab will be told their brain has been hijacked.

In reality, only a minority of the participants are dealing with classic dopamine depletion.  

The actual percentage of people with a true “brain-change” varies within any given population and treatment setting.

There are plenty of people who meet criteria for SUD severe; yet do not fall into a permanent state of dopamine despair. 

Going To Rehab?

People go to detox and rehab for a wide variety of reasons.

A few examples include: 

• To be physically safe during detox.
• To satisfy the requirements of a professional monitoring board.
• To satisfy the requirements of an angry spouse.
• To satisfy the requirements of a concerned employer
• And on and on…

It is reasonable to assume that a fair number of people who land in rehab – ARE NOT in the throws of full out dopamine distress.

Their brains have not been “forever” changed.

They have a medical condition that needs to be treated and stabilized. FULL STOP. Nothing more, nothing less. That is the purpose of acute care.

Beware The Broad Brush

This is why it is problematic to paint with such a far-reaching exceptionally broad brush.  

The reasons for a wide range of “dopamine depletion typology” include:

• Drug of “choice” (certain drugs dysregulate dopamine in more problematic ways—methamphetamine SPIKES for example). 
• Length of using career (the longer the using career the deeper the DRD4 problems)
• Genetic factors
• And a growing body of literature points to ethnic background, country of origin, etc..
• Along with cultural/societal factors (stress related to generational trauma/poverty). 

There are clearly people who have less baseline dopamine compared to the general population. 

“The Real Alcoholic” is how it has been described in some recovery circles.  

However, when we look beyond substance use disorders we see many other manifestations of the DRD4-7R phenomenon. 

“The Risk Taker” 
“The Workaholic”
“The Migrator” (ancient migration connection). 

People with Substance Use Disorder and people without substance use disorder have the DRD4-7R gene.

People who have never used alcohol or drugs and people who use the hell out of alcohol and drugs have the DRD4-7R gene.

This DRD4-7R Thing Goes WAY Beyond Addiction

20.6% of the population has DRD4-7R.

This conversation goes way beyond addiction.

And that is a good thing. We are human beings. Not DRD4-7R aliens.

We (people with SUD/people in recovery) are no different than our fellow man.

We are certainly no different than the 20% of Americans who make up the DRD4-7R group.

It’s not “addictive thinking”.  It’s DRD4-7R thinking.   

Stone Age Origins

Some History/Random Thoughts:

DRD4-7R appears on the “scene” for about 50,000 years ago.

They tell us there is a connection between migration and DRD4-R7. For instance, decreased dopamine action (presence of DRD4-7R allele) contributes to risk taking, recklessness, goal oriented behavior. All of which are necessary for migration.  

How do “they” know about the DRD4-7R allele and dopamine deficiency:

Psychology Today Is My JAM:

I found an article in Psychology Today that provides one of the better explanations:

Basically, “they” have employed new techniques and methodology to support this theory—focusing on gyrification. 

Quote from the PT article: 

“DRD4-7r is famous in neuroscience circles for being a problematic member of chromosome 11.

Palaniyappan et al. recently found that those with DRD4-7r and a diagnosis of ADHD had less prefrontal gyrification than those with a different DRD4 allele⁴.

Gyrification analysis is a relatively novel approach at assessing neural development by exploring the extent of cortical folding in contrast to volume analysis, which has been done traditionally using voxel morphometry.

Gyrification ceases and remains constant by around the second year after birth, but before this crucial milestone, gyrification can be disturbed by perinatal complications.

As gyrification is influenced by both environmental and genetic factors, the reduced folding in patients with ADHD and who have the DRD4-7r allele, seems to suggest that the 7r allele could be involved in this hypogyrification^”.  

Psychology Today – Jack Pemment, 2019

Here is link to the entire psychology today article:  https://www.psychologytoday.com/us/blog/blame-the-amygdala/201909/the-curious-personality-the-drd4-7r-allele

Side Note:  Who is the “they” mentioned above?  NEURO-SCIENTISTS of course. 

Dopamine Deficient Misfits

In reality, the DRD4-R7 allele is merely a marker for a neurobiological process and an accompanying set of behavioral norms.

Behavioral norms include restlessness, impulsivity, novelty seeking, risk taking and pleasure seeking.  

This DRD4-7R manifestation of the human condition is the result of many different factors.

These factors range from genetics to trauma to environment and culture.

There is no question that I have lived my entire life as one of the 20%.

I am surely one of the “Dopamine Deficient Misfits”.

My Case

In my case, I explain my dopamine “shortage” in the following manner:

The Rich Jones X Factor:

1. Genetics +
2. Early Trauma +
3. Early Use +
4. Toxic Environment/Messaging +
5. Larger Environment/Culture =
   A DEEP PROBLEMATIC DRD4-7R ISSUE

Larger Environment / Culture

What do I mean by “Larger Environment / Culture”. 

The 1980’s  were the twilight of the “suck it up” culture. Corporal punishment, for example, remained somewhat commonplace (beyond the pathology in any given home). 

It was a more domestically violent era. A more reckless era.

I grew up during the end times for free-range children. We played outside. We were left alone.

We found our way through the city. We drove motorcycles without helmets and seat-belts were an after-thought. 

Lot’s of opportunity for risk taking.

19 years in full sustained remission from opioid use disorder and alcohol use disorder.

I have no desire to use substances.  But I am still dopamine challenged. 

Why am I drawn to things that spikes dopamine?  I am drawn to all kind of things that spike dopamine. Big things and small things. 

Baseline Dopamine

When baseline dopamine accessibility is low (or lower than “normal”) the unconscious search to get a dopamine hit drives behaviors (increased impulsivity, risk taking, etc…)

Example: there is a clear connection between 7R allele (deficiency) and reckless spending.

Full article/link: https://www.frontiersin.org/articles/10.3389/fnbeh.2018.00034/full

Other random/weird behaviors (may or may not be a dopamine connection–not sure):

Why am I obsessively drawn to “motivational” videos.

Vikings soundtrack; Mulligan Brothers, and on and on…

If it’s “good” I will watch it over and over. In a very strange and obsessive manner.

Music : I will find a new song and listen to it over and over?

Sports. I had to play all day. Not only because I wanted to be a good athlete. I was obsessed. It went beyond the obvious athletic goals.

Side Note:  The problem of tolerance.  Drugs, alcohol, sex, screens, food all have very distinct limits. This has been written from the beginning. Hedonistic treadmill. Tolerance. Hedonistic Adaptation.

“The Real Alcoholic” 

Things we have heard, (very interesting things):

There is a bunch of information challenging the Alcohol Use Disorder and DRD4-7R connection (DRD4-7R variant) .

It’s just not completely clear how many people labeled “Alcohol Use Disorder” actually have progressed to the classic “alpha” alcoholic.

The classic “dopamine deficient” alcoholic—“The Real Alcoholic” 

Full article: https://onlinelibrary.wiley.com/doi/abs/10.1002/(SICI)1096-8628(19970919)74:5%3C483::AID-AJMG5%3E3.0.CO;2-P

Much More Work Needed

At the same time; there is a SUD/dopamine “connection” and more work needs to be done: 

Dopaminergic abnormalities are implicated in the pathogenesis of substance abuse.

Several genetic variants, especially DRD2 and DRD4, were previously reported in the literature as associated with substance abuse.

Carriers of the DRD4 7R allele showed greater susceptibility to alcohol dependence and opioid dependence.

Among carriers of the 7R allele, a higher rate of cigarette smoking was observed.

Ellis et al. described a connection between 7R and neuroticism and nicotine dependence, and Nederhof describes a connection to pathological gambling.

Full article: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3560519/

Kids With ADHD

Kids with ADHD: There seems to be more universal agreement about the ADHD/Dopamine deficiency connection. 

Article below:  “Conclusions: Children with ADHD possessing the DRD4 7R allele require higher doses of methylphenidate for symptom improvement and symptom normalization.

This pharmacogenetic study demonstrates that the 7-repeat allele of the DRD4 gene VNTR polymorphism correlates with treatment outcomes. 

Here is the Link: https://www.liebertpub.com/doi/abs/10.1089/cap.2004.14.564

More on KIDS with ADHD https://www.nature.com/articles/4001350.pdf?proof=true

Research–MORE RESEARCH

There is not enough research to speak with certainty on dopamine.

But there is enough information available to support more extensive study and we need to pay attention to dopamine.

Some other considerations:

The frequency of allele variants varies among ethnic groups, which makes the study of their associations more difficult.

The 7R allele has low prevalence in Asia (2%), but high prevalence in America (48%) [link].

The 7-repeat allele has been reported to encode a receptor with lower affinity for dopamine. 

In vitro studies indicate that the sensitivity of the 7R allele is half that of the 2R and 4R variants [link].

The 7R allele is associated with various psychiatric disorders including ADHD, dependences, pathological gambling, alcoholism, drug dependence and bulimia nervosa [link – link].

Autism & Schizophrenia

Several studies also described associations with autism and schizophrenia [link–link].

However, in these disorders other genes have received more attention (e. g. [link]).

DRD4 length polymorphism has been described in connection with specific behavioral phenotypes.

Including externalizing behavior problems [link], the personality trait of novelty seeking, impulsive personality traits, anger, short temper and thrill seeking and aggressive and delinquent behavior, as compared to other genotypes (e. g. [link]). COMMON THEME: IMPULSIVE; RISK TAKERS ETC…

Kang et al. [link] found that the short allele was associated with significantly lower anger in tendency to anger and higher forgiveness traits.

However, the functions of all the individual variants have not been confirmed [link] and the effects of the variants on transporter levels cannot be generalized to neuropsychiatric disorders.

Despite the large number of empirical studies in this field, a review article on the dopamine D4 receptor gene DRD4 and its association with psychiatric disorders is still lacking from the literature; hence, the present article reviews current scientific findings in this area. 

Link to complete article: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3560519/

Criticism

Common Criticism on the dopamine deficiency issue.

Heterogeneity problem: Kluger et al. , in a meta-analysis, stated that despite many authors having found the presence of longer alleles to be associated with higher novelty seeking scores, on average there is no association between DRD4 polymorphism and novelty seeking. The heterogeneity among the studies is very high.

Question extraversion and risk taking: De Luca et al., in a follow-up study, presented evidence indicating that there is a genetic influence of the DRD4 gene on human temperament at birth, at 1 month of age and at 3 years of age.

The study showed, only in part, previous results of a link between the DRD4 gene and human temperament.

None of the extraversion or exploratory behavior measures were related to the 7R form of DRD4.

ADHD & DRD4

ADHD is connected. But not surprisingly, still some questions and concerns:

VNTR polymorphism in the DRD4 gene associates with ADHD across numerous studies.

Association between ADHD and the 7-repeat allele has been widely documented.

The 7-repeat allele was found in 41% of ADHD patients, but in only 21% of the control group.

A meta-analysis of 21 studies revealed evidence of significant association; however, negative results were also published.

According to Faraone there is an association between ADHD and DRD4, but it is small.

Others Issues

Independent studies showed an association between the presence of allele 7 and personality traits associated with impulsivity.

Further studies are needed to confirm these findings and explore the role of specific gene-gene and gene-environment interactions and other co-occurring psychopathology among individuals with ADHD.

The spectrum (development disorders) may be impacted but little data exists.

Several studies found a positive association of the 7R allele of the DRD4 gene and autism, but the DRD4 exon 3 polymorphism is still unlikely to play a major role in the etiology of autism.

Good Stuff?

But there may be something good about DRD4-7R deficiencies.

Stress inoculation: According to various studies DRD4 variants can affect individual responses to stress or trauma, similar to several other gene variants.

Das et al. described the effect of the DRD4 gene and childhood environment interaction on resilience to stressors.

Armbruster et al found that carriers of the 7R allele together with the 5HTTLPR L allele exhibit lower cortisol stress responses.

Side Note: It appears I thrive in a crisis/acutely stressful situation.

Perhaps my DRD4-7R issues have an upside?  

Moderates, Influences & Arouses

The DRD4 genotype also moderates the association of experienced parental problems during childhood (e.g., parental depression, marital discord) with loss or trauma [61].

The 7R allele influences the development of personality in a way that provides protection against adverse outcomes [link].

Emotionally arousing situations/more sensitive if DRD4-7R :

Results showed increased brain activity in response to unpleasant images compared to neutral images in the right temporal lobe in participants with the DRD4-4R/7R genotype versus participants with the DRD4-4R/4R genotype.

The increase in right temporal lobe activity in individuals with DRD4-4R/7R suggests greater involvement in processing negative emotional stimuli.

Intriguingly, no differences were found between the two genotypes in the subjective ratings of the images.

The findings corroborate the response ready hypothesis, which suggests that individuals with the 7R allele are more responsive to negative emotional stimuli compared to individuals with the 4R allele of the DRD4 gene.

FULL ARTICLE: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4272659/

Evolution

Again, the evolutionary psychology is interesting.

All of the following traits/behavioral tendencies would serve a purpose in advancing the species. “SOMEONE NEEDS TO LEAVE THE CAVE”: 

The 7R allele is estimated to have emerged 40,000 to 50,000 years ago, which is the same time that major human migration occurred (Wang et al., 2004).

This genotype, including its homozygous and heterozygous variations, is found more frequently in populations who had to take great risks to travel long distances. Such as early immigrants to the Americas (Chen et al., 1999; Eisenberg et al., 2010a).

The association with risk taking was corroborated by research showing that individuals with the 7R allele of the DRD4 gene engage in more financial risk taking compared to those without this genotype (Dreber et al., 2009).

Humans with at least one 7R allele show increased levels of physical activity (Faraone et al., 2001; Kluger et al., 2002; Grady et al., 2003; Grady et al., 2005b; Li et al., 2006; Grady et al., 2013)

Also, they appear to be more reactive to environmental factors (Sheese at al., 2007; Belsky et al., 2009; Olsson et al., 2011; Grady et al., 2013).

The 7R allele is over-represented in the phenotype of Attention-Deficit/Hyperactivity Disorder (ADHD) (LaHoste et al., 1996; Faraone et al., 2001; Grady et al., 2003; Grady et al., 2005a; Li et al., 2006).

In addition, the 7R allele is associated with “limit pushing” behaviors including (among other things): disinhibition (Congdon et al., 2008).

Disinhibition will promote risk taking.

Contributes To Longevity

Intriguingly, a study by Grady et al. (2013) has shown that the 7R allele contributes to longevity by moderating the beneficial effects of an enriched environment in increasing lifespan.

The 7R allele of the DRD4 gene has been associated with the response ready hypothesis, which suggests that individuals with hyper-vigilance might be selected for by environments that are resource-depleted, time critical, or rapidly changing (Jensen et al., 1997; Wang et al., 2004).

It is speculated that the 7R allele and its association with the response ready hypothesis might have played a role in its positive selection and human migration (Chen et al., 1999; Ding et al., 2002; Wang et al., 2004; Grady et al., 2013).

More Psychology Today: 

Psychology Today:  DRD4-7r appears to have profound implications for the carrier, and seems to be involved in a number of fateful activities that could impact the carrier’s entire life.

A propensity for greater risk-taking, a heightened sensitivity to the environment, being at greater risk of attention and behavior issues, and demanding more parental attention in the formative years all set one up for an exhausting life – all because of one version of a receptor that isn’t as receptive to stimulation as the other versions.

In fact, the receptor, much like the carrier, does not seem to play well with others.

The 7r allele almost seems like a mischievous imp, inspiring and pushing the carrier into antisocial and asocial behaviors. 

Link: https://www.psychologytoday.com/us/blog/blame-the-amygdala/201909/the-curious-personality-the-drd4-7r-allele

Random Stuff

How do we get better? How do we get “normal”?

For clarification purposes: I DO NOT WANT TO GET BETTER.

Here is NORA VOLKOW on “Getting Better” and “Interventions” which address dopamine for addiction (food, drugs etc..)

Volkow: https://www.ncbi.nlm.nih.gov/pubmed/29142296

Test For Deficiency

How do I know if I have “dopamine deficiency”?

Example of a recommended test for Dopamine levels

• https://www.directlabs.com/bengreenfield/OrderTests/tabid/21021/language/en-US/Default.aspx

I will be making arrangements to take this test.

I will let you know how it goes. How much it costs etc…

Dopamine Mechanism

Great video on the actual mechanism of dopamine (it is not a pleasure neurotransmitter; rather an action/goal attaining neurotransmitter. 

It keeps us moving toward the “reward” (food, achievement, drugs, love/relationships etc…) 

• Robert Sapolsky:   https://youtu.be/axrywDP9Ii0  (dopamine basics-anticipation/delayed gratification)

Final Thoughts

At the end of the day, you need to speak with professionals, medical personnel, etc..

Find an integrative medicine doctor. 

Beware of people who talk with too much authority and act with too much certainty. 

These are uncharted waters.  Advocate for yourself.

I have come to my own conclusions. 

Now I need to develop my dopamine plan of attack. 

I will share this plan.  I am going to take a very holistic approach. 

Sign up for RECOVERY CARTEL (www.recoverycartel.com) to ensure you get the updates.

The post The Rich Jones Dopamine Diaries appeared first on The Recovery Cartel.

Mission Of The Brain Initiative

The mission of the BRAIN Initiative is to deepen understanding of the inner workings of the human mind and to improve how we treat, prevent, and cure disorders of the brain.

At this moment in time, it appears that human beings understand (at best) about 10% of brain function.

We simply do not understand how the brain works.

There is growing body of literature surrounding neurotransmitters, hormones, and neurobiology in general.

We Have No Clue!

However, when it comes to explaining behavior and human brain development the most common explanation is “it’s complex and it’s multifaceted”.

Which is code for “we have no freaking clue”.

If we understand only 10% of brain functioning, the most responsible thing we can do is simplify our approach.

When it comes to matters of the mind we should focus on first principles.

What do we know to be certain about any given presenting problem-mental health and/or substance use?

Unfortunately, not much. You may think you know. But you don’t, and your arrogance is dangerous.

Transmitters & Hormones

We do know, that most human beings respond in favorable ways to other supportive human beings.

We know that human contact and connection lights up all the “feel good” transmitters and hormones.

Evidenced based practices don’t address the brain.

They address symptom mitigation and other social constructs surrounding a hypothetical “brain-disease state”.

Psychiatry (therapy, counseling etc..) is a medial discipline that does not include “looking at the impacted organ” as standard practice.

Matters Of The Mind

When you mix in things like consciousness, morality, judgement, and sociological perspective we find ourselves wandering in an even darker forest.

Helping people with matters of the mind is more art than science.

We need to embrace this.

It’s likely that everyone can agree on the importance of connection, relationship and rapport.

In reality, therapeutic alliance may represent the true extent of evidenced based behavioral health.

More About The BRAIN Initiative

Learn more about the brain and the latest research advances from documents, images, and multimedia resources curated by Initiative participants and affiliates.

Please visit their website.

https://www.braininitiative.org/

The post The BRAIN Initiative appeared first on The Recovery Cartel.

As many of you know I am drawn to alternative approaches to counseling and drug and alcohol rehabilitation. A very popular approach for “young people” is wilderness therapy. I believe the expansion of this modality could benefit many people; regardless of their age.

I am recycling a research paper from grad school in effort to stimulate some reflection on the utility of “wilderness therapy”. This paper will focus on wilderness and adventure based experiential therapy.

On the surface this appears to be a very broad topic area.  There are many descriptions and definitions of this type of experience.  Russell (2001) uses challenge courses, adventure based therapy, wilderness experience programs, and wilderness therapy as examples of a process where activity and experience are utilized to affect positive change in individuals.

One could broaden this even further and include wilderness base camping under this umbrella.  It is necessary to acknowledge all these titles in order to provide a comprehensive exposition.  At the same time, it seems appropriate to narrow my focus on a unifying description or name of the approach I will be exploring.

To this end I will utilize “adventure therapy” (Berman & Davis-Berman, 2001) as the base that guides this exploration.  I will seek to establish a clear definition of adventure therapy.

It is important that this delineation takes into consideration “the considerable debate” (Itin, 2001) that exists related to adventure therapy.  This requires an examination of the historical foundations of wilderness programming so that a framework for the debate can be established.  I will include an investigation into the qualities of staff and programs which employ adventure therapy as a means of more fully illuminating adventure therapy.

An important aspect of this essay includes a thorough review of the theoretical underpinnings of adventure therapy.  In addition, I will explore counseling theories and approaches which are applicable to adventure therapy.  Finally, I will use this forum as an opportunity to explore my reactions and position where adventure therapy is concerned.  I intend to propose a framework appropriate to adventure therapy that did not appear in the literature (stages of change theory).

“The use of adventure experiences as a programming tool formally began in the 1940s” (Priest & Gass, 2005).  Furthermore, the importance of experience in the arena of learning and human growth can be traced to the philosophy of Plato and Aristotle who championed experience as the answer to the question, “How can we best learn or teach?” (Kraft & Sakoss, 1985).

Therefore, we can see that the concept of experience, mentoring and on the job learning has existed within human culture for centuries.  However, experiential programming as it is known today finds its roots in the 1930’s and 1940’s with the development and promotion of the “Hahnian approach” which ultimately resulted in the establishment of Outward Bound.

Kurt Hahn became interested in the “social diseases or declines that he believed were causing individuals within society to lose certain positive attributes” (Nicholas, 2008).  Nicholas (2008) enumerates these societal ills along the following lines: a decline in physical fitness due to modern methods of transportation, a decline in initiative or enterprise due to a social tendency towards being a spectator rather than a participator, a decline in the individual’s memory and imagination because of confusion and restlessness in modern life, a decline in skills and care because traditions of craftsmanship had diminished, a decline in self-discipline from an over-reliance on ubiquitous stimulants and tranquilizers, and a decline in human compassion because of the hurried lifestyle inherent to a modern lifestyle.

In response to this Hahn began Outward Bound as a program for youth, many of whom were destined for the armed services (Priest & Gass, 2005).  Hahn and his colleagues designed physically and mentally challenging courses that encouraged the youth involved to push themselves and work together toward identified goals.

Original Outward Bound courses included orienteering, search and rescue training, athletics, small-boat sailing, ocean and mountain expeditions, obstacle-course training and service to the local communities (Miner as cited in Priest & Gass, 2005).

Today’s Outward Bound programming has become even more varied and includes “long wilderness courses, urban education programs, short intense challenge training’s, or even custom courses designed to the needs of the client” (Nicholas, 2008).

Outward Bound does not equal adventure therapy, however, it has been widely accepted as the foundation of the movement that has lead to adventure therapy’s growth.  In addition, much of the philosophical foundation of Outward Bound can be generalized to adventure therapy and wilderness experience programs.

It is clear that Hahn felt that the in the moment experience associated with challenging outdoor activities could provide a way to overcome many of the ills of society.  Although he did not articulate this in a systematic clinical manner it is evident that his position is very similar to the foundations which exist today regarding the experiential framework of adventure therapy.

Over time Outward Bound expanded and other outdoor based programs took root.  These programs included the National Outdoor Leadership School (NOLS) established in 1965, Project Adventure established in 1971, and the Wilderness Education Association established in 1977 (Nicholas, 2008).

Nicholas (2008) reports that there were over 190 adventure based programs in the United States by the mid nineteen seventies.  These programs were established to provide various services including “therapy, recreation, and education” (Attariran as cited in Nicholas, 2008).  Despite the diversity of the mission there remained the underlying principle of outdoor, experiential based interventions as a means of initiating positive change.

Another noteworthy development in the wilderness programming realm was the development and formalization of wilderness base camping as a means of helping at risk youth.  Again, the challenge and intensity of the experience is the focal point of the process.  However, wilderness base camping involves the added dimension of daily residential life in a wilderness setting.

This provides incredible opportunity for activity intensive experiences, ranging from construction of living facilities to recreational activities and educational responsibilities.  This is accomplished through an intimate and intense group process: “The heart of wilderness camping is the structure of small groups process in the out-of-doors” (WRTCA).

Wilderness base camping provides a ready example of the processes deemed helpful in the area of outdoor programming.  In addition to the here and now experience, examples of these benefits include increase in self-worth, improved problem-solving, improved social judgment and interpersonal skills, and increased assertiveness and leadership skills which can be generalized to resisting negative peer influences.

Although wilderness experience programs cannot be distilled merely to Outward Bound and Wilderness Base Camping models alone, these paradigms provide a useful framework for understanding wilderness experience programs in general.

As previously mentioned, the experience is a fundamental and essential aspect of all wilderness experience programs.  It seems appropriate to discuss this aspect of the process in more depth.  The concept of experience is not unique to wilderness programming.

Many therapeutic and educational approaches promote the power of the experience.  In the case of education this is seen as a pragmatic and productive manner of working with students.  The idea of experiential education can be traced back to John Dewey who proposed that “subject matter should not be learned in isolation and that education should begin with student experience and should be contextual” (Breunig as cited in Nicholas, 2008).

Related to clinical underpinnings one need look no further than Fritz Perls and gestalt therapy to see the centrality of the experience in the therapeutic process.  Wagner-Moore (2004) describes the “processes underlying gestalt” as the “experience/contact cycle”.  The gestalt therapist provides a setting where the client is challenged to confront “unfinished business” with the intent of creating a here and now experience that is then processed by the therapist (Wagner-Moore, 2004).

The result is increased awareness and insight.  What is important for the gestalt therapist is processing what is happening right now rather than discussing what may have happened in the past.  This is very similar to the goal of the adventure therapist.  Different techniques (ie…physically and emotionally challenging outdoor programming) are utilized to create “client disequilibrium” (Fletcher & Hinkle, 2002).

This disequilibrium can be thought of as “a state of dissonance (which) is crucial for client change” (Fletcher & Hinkle, 2002).  A common term associated with this eventuality is “taking a client out of his or her comfort zone” (Fletcher & Hinkle, 2002).  Many times this situation provides an opportunity for the adventure therapist to use the here and now experience to encourage increased awareness, insight and possible change.

In addition to gestalt theory there are other clinical applications that should be discussed related to adventure therapy.  On its most basic level adventure therapy involves both individual and group sessions.  Individual sessions involved one-to-one interaction centering on the task at hand and the associated issues.  The adventure therapist needs to be able to develop trust to facilitate a productive therapeutic relationship much the way a traditional therapist does.

However, it should be noted that there are unique aspects associated with the therapeutic relationship.  For example, the amount of time and intensity of experience challenges the traditional view of professional boundaries (Fletcher & Hinkle, 2002).  “The primary individual counseling theories are cognitive, rational emotive, and reality” (Fletcher & Hinkle, 2002).

Fletcher and Hinkle (2002) explore the details of these theories as they play out in adventure therapy: cognitive theory use the adventure experience to highlight cognitive processes and the resultant feelings and behaviors which manifest themselves through interactions and self-talk; rational emotive theory takes center stage related to apparent danger associated with the experiential activity which can be used to challenge the client regarding existing perceptions of real versus perceived risk; reality therapy capitalizes on the natural and logical consequences which are ever-present in the adventure based activity.

At is core, however, adventure therapy relies on the experience in itself as the catalyst to raise awareness and insight and influence change. In most cases the modality of service delivery is group sessions.  The group is central to the experience.

The adventure therapist usually leads a group through the expedition or trek and typical group issues are magnified through the out-door setting.  Groups typically progress through clear stages which have been identified in a variety of ways.

One of the most useful has been developed by Tuckman and Jensen in 1977 (Priest & Gass, 2005).  Tuckman and Jansen used the following to describe group development:  forming is characterized by the discomforts, concerns, feelings, and doubts group members experience in a new group.

This is the initial stage of group formation; storming follows and occurs when members begin to question the group process and authority of the group.  There is growing comfort but overall the group remains unstable and potentially volatile; norming involves the establishment of appropriate and necessary standards for the group.

There is a greater sense of order and the members are generally comfortable with each other; performing arises when the group is focused on the task at hand.  Members concentrate on mutual support and the group is becoming very productive; adjourning involves closure and the end of the group.

Adjourning is also a period where the group can become restless as they struggle with appropriately closing relationships (Priest & Gass, 2005).  The experiential group provides extensive content and process opportunities for the effective facilitator.

At the same time the challenge inherent in the expeditionary aspect of adventure therapy requires a facilitator who can address and utilize the inevitable crisis states that may arise.  “Catching members in the act breaks the cycle of behavior, thoughts, and feelings by increasing awareness.  Awareness is the necessary precursor to change.  Awareness and insight are the goals attributed to group counseling experiences” (Corey as cited in Hill, 2007).

The wilderness experience and the associated stress and challenges provides innumerate situations that allow important issues to be highlighted: (1) here is what your behavior is, (2) here is how your behavior makes others feel, (3) here is how your behavior influences others’ perceptions of you, and (4) are you satisfied with the world you have created (Corey as cited in Hill, 2007).

The therapeutic factors that have been identified with group counseling include universality, altruism, group cohesiveness, and interpersonal and vicarious learning (Yalom, 1985).  It is clear how these elements can be translated to adventure therapy.

For example, during a trek everyone is equally involved in the expedition.  All share the same goal and responsibilities.  Everyone is truly in the experience together; it equals the playing field.  Another example, this one related to altruism, concerns the multitude of opportunities to assist other members.  One member may offer to share his or her water or assist in carrying a pack up a steep incline.

An effective adventure therapist will highlight all these occurrences as they arise.  Family counseling models have also been applied to adventure therapy (Fletcher & Hinkle, 2002).  Structural (Minuchin, 1974), strategic (Haley, 1987; Madenes, 1978), and systemic (Bowen, 1978) all have aspects that can be integrated into adventure therapy.

Structural theory drives assessment and restructuring the group’s transactional patterns, systems perspectives recognize that the individual’s actions influences the larger group or system, and strategic theory informs the use of intentional and planned activities to address presenting issues and concerns in the group process (Fletcher & Hinkle, 2002).

In addition to the clinical foundation an effective adventure therapist must have hard or “technical” skills (Priest & Gass, 2005).  This refers to the ability to manage the group in the wilderness and ensure the safety of all involved.  Priest and Gass (2005) conceptualize these technical skills on the generic and meta-skill level and clarify that the hard skills must be distilled down to the details related to each specific adventure activity.

For example, issues of risk management that apply to all adventure activities include weather interpretation, first aid, trip planning, physical fitness and mental awareness (Priest & Gass, 2005).   An adventure therapist must also have good leadership, problem-solving, decision making, ethical behavior, effective communication skills and experience based judgment (Priest & Gass, 2005).

These attributes apply across all the various experiential activities.  Examples of skills that apply to specific experiences include understanding and negotiating river crossings during back-packing outings, understanding movement techniques, chimneying, and counterforce belaying in top-rope climbing, and knowing snow climbing techniques for mountaineering (Priest & Gass, 2005).

What then constitutes a comprehensive and efficacious definition of adventure therapy?  This is a difficult question to answer as so much falls under the purview of adventure therapy.   The most effective manner of defining adventure involves a three level exploration.

On one level I will evaluate adventure therapy in comparison to other “wilderness experience programs” (Russell, 2001).  Secondly, I will explore adventure therapy as it relates to identified clients, approaches utilized, and intended outcomes (Itin, 2001).  Finally, I will address the characteristics of therapists and programs and associated issues such as degree held, certification and accreditation as a means of further differentiating adventure therapy from other outdoor experiences (Priest & Gass, 2005).

Adventure therapy can be understood when taken in context with other wilderness  experience programs (WEPs). These WEPs range from Outward Bound experiences to boot camps (Russell, 2001) and provide an opportunity to examine the differences across clearly defined domains.  Among these domains, Russell (2001) includes key components and wilderness dependency.  “Key components” refers to the elements that are required for a program to be considered adventure therapy.

“Wilderness dependency” is related to where the intervention must be delivered (Russell, 2001).  In the end there is a level of subjectivity associated with establishing a definition of adventure therapy.  At a certain point one must choose between the different positions in each domain.

Adventure therapy differs from other WEPs in many ways.  Key components of adventure therapy include the use of planned expeditions with the intention of challenging small groups as they move from place to place in a self-sufficient manner.  Examples of expeditions include back-packing, canoeing, rock climbing and caving (Crisp as cited in Russell, 2001).

Adventure therapy utilizes clinical assessment in the process of selecting candidates for involvement, treatment planning is part of the programming, and the provision of group facilitation is conducted by qualified professionals (Davis-Berman & Berman as cited in Russell, 2001).  Russell (2001) also cites the following unique aspects of adventure therapy.

Adventure therapy programs are licensed when appropriate and possible and the program is supervised by licensed practitioners.  The clients have contact with licensed therapists in group and/or individual sessions.  The adventure therapy program has staff which specialize in clinical areas (for example substance abuse counselors) and staff which are trained in managing the specific population they serve.  It is not necessary that all staff are trained and certified clinically but the program must be managed by such staff.  The appropriate degree and certification depends on the clientele being served.

The adventure therapy profession has not defined specific degrees required for service delivery.  The existing requirements for credentialing in the behavioral fields should be generalized to adventure therapy.  For example, if the adventure therapist is working with substance abuse clients in the state of Pennsylvania he or she should hold a degree and certification consistent with the regulations of the Pennsylvania Department of Health Bureau of Drug and Alcohol Program Licensure staffing requirements.

Wilderness dependency is an interesting question.  For purposes of my definition adventure therapy must take place in the outdoors.  The naturally occurring events involved with being in the wilderness provide the bedrock of adventure therapy.  Clientele appropriate for involvement in adventure therapy vary widely.

The most common group targeted for adventure therapy is “at risk youth” or adolescents with emotional and behavioral problems.  However, the Association for Experiential Education (1998) in the publication Exploring the Boundaries of Adventure Therapy: International Perspectives provides a more comprehensive account of clientele appropriate for involvement in adventure therapy.  These include “offenders and sexual perpetrators, mental health concerns, and families” (Association for Experiential Education, 1998).

Substance abusing clients and victims of abuse, trauma and disease have also been identified as appropriate for adventure therapy (Fletcher & Hinkle, 2002).

It is easy to see that defining adventure therapy is a difficult task.  However, I will boil it down to the following elements.  Adventure therapy must include a clinical component, at the very least at the level of supervision, preferably at the level of direct practitioner.

Adventure therapy must operate within an articulated framework and the experiences must intentionally target a desired goal and change.  This necessitates assessment and treatment planning.  Adventure therapy is appropriate for a variety of clients whom would typically be served in traditional settings.

Staff facilitating the experience should meet staffing requirements consistent with the realm in which the program operates.  Finding qualified adventure therapists is a challenge.  The ideal candidate has the education, training, and qualifications to provide clinical services and wilderness experience that ensures the safety of all involved.  This is an uncommon combination.  It represents an ideal and programs should work toward this ideal.

Choosing adventure therapy as a topic for my paper was not a difficult decision.  Due to my professional experiences I have come to embrace adventure therapy.

I am the director of an inpatient drug and alcohol rehabilitation center for court ordered youth.  I am responsible for the on campus delivery of services.  However, these clients also participate in expeditions while they are in the program.

This element of the program is supervised by another director who has a background as an adventure therapist.  He meets all of the expectations described above and is very accomplished in the area of adventure therapy.  My involvement in the process includes selection of candidates for the expeditions, clinical supervision of the wilderness addiction counselors, establishment and review of goals pre-trip, and review of progress/concerns post-trip.

I have participated in tripping (expeditions) on a very limited scale.  However, I am very supportive of the experiential part of the program.  I have seen the positive results of adventure therapy in many clients.  Examining the topic of adventure therapy in more detail has only reinforced my position.  Along with course content, writing this paper has opened my eyes to aspects of adventure therapy that I was unaware of.

For example, an understanding of the theoretical orientations and foundations of adventure therapy has been very helpful.  At best the uninformed believe that adventure activities are positive and beneficial to those involved; at worst they equate it with boot camps and view adventure therapy as a punitive way of dealing with problematic youth.  Rarely is adventure therapy viewed as a true clinical intervention.

Having the ability to cite the ways in which well established therapeutic theory applies to adventure therapy helps in clarifying these claims.  As I dug into the existing research and literature the same counseling theories came to the surface; cognitive approaches, behavioral/reinforcement, rational emotive, reality therapy, family systems, and gestalt theory.

These theories are widely accepted in the therapeutic world and bring legitimacy to the practice of adventure therapy.  Researching this topic provides me with the basics for articulating the clinical benefits of adventure therapy.

At this point I would like to discuss a theoretical orientation that did not appear in the literature.  However, it provides a structure that seems to fit well with adventure therapy.  Stages of change theory (SOC), as developed by Prochaska and DiClemente appeared in prominence in the early 1980’s (Connors, Donovan, DiClemente, 2004).

Although the details of SOC are beyond the scope of this paper I will describe the fundamentals.  SOC holds that, when it comes to changing a problem behavior, people go through identifiable stages.  Furthermore, there are interventions and approaches that are more or less appropriate dependent of the assessed stage of change.

By maximize the use of appropriate interventions the clinician can help move a person through these stages toward a lasting behavior change.  Connors, Donovan, and DiClemente (2005) identify these stages as pre-contemplation, contemplation, preparation, action and maintenance.  Within each of these stages there are change processes that are either behavioral in nature, experiential in nature, or contain both behavioral and experiential elements.  This is where the application of SOC is most appropriate.

Behavioral processes involve things that a client can do to develop and support change.  For example, a client can attend 12-step meetings to support long term recovery and this falls under the behavioral process of “helping relationships” (Connors et al., 2005).  Experiential processes describe events or experiences that precipitate and promote the change.  For example, a client may receive feedback from peers during a group that forces him to take a honest look at his past behavior leading to a revelation that increases desire to change.  This experience falls under the experiential process of “self re-evaluation” (Connors et al., 2005).

The behavioral processes are as follows (Prochaska as cited in Connors, et al, 2005): stimulus control, helping relationships, counter conditioning, reinforcement management, and self liberation.  Adventure therapy could be viewed through this lens.  For example, for a chemically dependent client participation in the activity or expedition could access the behavioral process of counter conditioning as the client experiences a substitute activity that does not involve the use of substances.

Reinforcement management is applicable when rewards are accented to support positive efforts toward change and these types of opportunities arise daily during expeditions.  Experiential processes are even more prevalent.  These include (Prochaska as cited in Connors et al, 2005) consciousness raising, dramatic relief, environmental re-evaluation, social liberation, and self re-evaluation.

During a typical trekking experience the client will be stressed and challenged.  The resultant state of “disequilibrium” (Fletcher & Hinkle, 2002) promotes dramatic relief which is defined as reacting emotionally and having a cathartic experience.  The intimacy of the group provides ample opportunities for social liberation which occurs when the client realizes that society may support a change in his or her behavior because the group supports the change.  One could take each individual processes of change describe by Prochaska (as cited in Connors et al, 2005) and make a case that highlights it applicability to adventure therapy.

On a personal note, I will be participating in my initial trek June 10, 2009 thru June 17, 2009.

This will be a float trip in the back country of Canada.  We will put in at Lake Ogaseanane and make our way to into the interior of the nature reserve.  The location is in western Quebec near Kippawa.

I am staying out for a week only and it is likely that the group will remain longer.  I am, after all, a beginner.

I am doing this with very seasoned staff and I am looking forwarding to gaining a greater appreciation for the intensity and dynamics of an expedition.  I have come to believe that it is necessary to have a certain hands on understanding of the process if I am to effectively evaluate who may be appropriate for trip.  This is a direct result of this course and researching this paper.

Although I will be unable to be a true adventure therapist, my hard skills are very poor, I can take advantage of opportunities to increase my knowledge base.  For me developing the technical skills is much more intimidating than developing and implementing the soft skills.  I have limited exposure to the technical aspects of being in the outdoors.

It is evident that picking an area of interest and comfort is appropriate for developing technical skills.  For example, I feel that I could make progress as it relates to back-packing.  I am in decent physical condition and it seems that the technical skills associated with hiking are less complex than the skills necessary for other disciplines such as top roping or mountaineering.  I am in no way interested in learning the skills necessary for caving.  That is left for braver individuals.  I am, however, certainly interested in expanding my abilities in the area of adventure therapy and my work place provides built in opportunities to go out and play.

References

Alvarez, A., Stauffer, G. (2001). Musings on adventure therapy. The Journal of Experiential Education, 24, 85-91.

Berman, D., Davis-Berman, J. (2001). Critical and emerging issues for therapeutic adventure. The Journal of Experiential Education, 24, 68-70.

Burg, J. (2001). Emerging issues in therapeutic adventure with families. The Journal of Experiential Education, 24, 118-122.

Connors, G., Donovan, D., DiClemente, C. (2004). Substance Abuse Treatment and the Stages of Change: Selecting and Planning Interventions. New York: Guilford Press.

Fletcher, T.B., Hinkle, J.S. (2002). Adventure based counseling: An innovation in counseling. Journal of Counseling and Development, 80, 277-285.

Hill, N. (2007). Wilderness therapy as a treatment modality for at-risk youth: A primer for mental health counselors. Journal of Mental Health Counseling, 29, 338-349.

Itin, C. (1998). Exploring the boundaries of adventure therapy, International perspectives: Proceedings of the 1^st international adventure therapy conference: Perth, Australia. Boulder, Colorado: Association for Experiential Education.

Kraft, R., Sakofs, M. (date unknown). The Theory of Experiential Education, 2^nd Edition. Boulder, Colorado: Association for Experiential Education.

Nicholas, S. (2008). Outdoor adventure education. Research Starters Education.  Great Neck Publishing.

Priest, S., Gass, M. (2005). Effective Leadership in Adventure Programming, 2^nd Edition. New Hampshire: Human Kinetics.

Russel, K. (2001). What is wilderness therapy?. The Journal of Experiential Education, 24, 70-79.

 Wagner-Moore, L. (2004). Gestalt therapy: Past, present, theory and research. Psychotherapy: Theory, Research, Practice, Training, 41, 180-189.

Wilderness Road Therapeutic Camping Association: The Wilderness Camping Program Description. Retrieved 6/4/09 from http://www.therapeuticcamping.org/WRTCA-program.html.

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