Volume 302, March 6, 2021

CASN NeuroNotes®
ISSN 2758-1772

The Journal of the Center for

Applied Social Neuroscience (CASN )
Focusing on cognitive development and rehabilitation and the
promotion and maintenance of personal well-being through the
principles of Applied Social Neuroscience (ASN)

CNE and Person-Centered Care vs. the Distorted Medical Model (Revised)

® 2018 by the Center for Applied Social Neuroscience (CASN ), 638-2 Keyakidai, Eiheiji-cho, Yoshida-gun, Fukui 910-1223 Japan
CASN NeuroNotes (ISSN 2758-1772)
Volume 302
March 6, 2021

CNE and Person-Centered Care vs. the Distorted Medical Model (Revised)
SPENCER M. ROBINSON
Executive Director and Chief of Research and Development
Center for Applied Social Neuroscience (CASN )

Abstract

A great culture change movement and a rigorously researched, whole new paradigm in
understanding cognitive and behavioral disorder (i.e., so-called “mental disorder”) together
offer a potent, dramatic new approach to addressing elder care and both the prevention of
and recovery from cognitive decline, dementia and other neurobehavioral sequelae that
particularly affect elders, especially so those residing in a long-term care facility. The
culture-change movement embraces the concept of person-centered care (PCC), while the
innovative cognitive and behavioral intervention model, referred to as Cognitive
Neuroeducation (CNE), fuses a neuroscience-informed base with a human-values
orientation, both PCC and CNE rejecting the distorted medical model.

This paper outlines the affinity of the philosophy and objectives of the PCC and CNE
paradigms, elucidates the misdirection of the medical model, and suggests that CNE and
PCC, in a fully integrated approach, can give a whole new lease on life for the elder,
redefining elderhood as a meaningful, rich, and rewarding stage of life, even in physical
decline and when living in a long-term care facility.

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The Culture Change Movement and the Distorted Medical Model

There is a startling culture change movement that is gaining ever more traction within the
community of caregivers for elders in long-term care facilities. This movement and the
initiatives it inspires are referred to by a variety of similar terms, such as: person-centered
care, patient-centered care, person-and family-centered care, resident-centered care,
client-centered care, person-directed care, etc., which we will herein simply refer to
generically as “person-centered care,” and, though each of the different initiatives propose
their own specific guidelines, they all embrace a philosophy that focuses on the humanity of
care, recognizing that every individual is a unique personality, every long-term care resident
an individual with a unique set of needs, and that life in a residential care facility need not,
and most definitely must not deny the resident the fundamental right to maintain her/his
individuality with dignity and respect. In this philosophy, the long-term care facility, rather
than a place that simply provides for the rudimentary physical needs of a dead-end
existence, becomes the hub of a nourishing environment that facilitates the engagement of
life, providing challenge and growth to the fullest of each individual’s capacity that
continues to develop and expand, revealing new strengths and activities that excite the
individual’s interests and promote: a) a sense of accomplishment, b) bonding with others; c)
joy of the moment; and d) a keen anticipation of the discoveries, camaraderie and
achievements tomorrow may bring.

We refer to this culture change movement as startling because it repudiates the dominating
medical model constructed on a distorted concept of pathology and the overuse of
pharmaceuticals for every behavioral difficulty and physical discomfort that accrue in
residents in the traditional nursing home or long-term care environment, “remediating”
every condition through drugs that numb tactile sensation and cognitive and emotional
reaction, stifling awareness and personality into a zombielike state for easy management.
The medical model treats as pathological the physical and psychological manifestations of
the distress of the dead-end environment, with its miasma of futility and its depressing,
restrictive institutional structure lacking adequate social and physical outlets so necessary to
physical and psychological/cognitive well-being, ignoring the individuality of the elder
possessing social and psychological needs like everyone else, choosing instead to drug the
elder rather than address unmet needs and the stagnant environment that induces distress
and triggers the onset and progression of both physical and cognitive degeneration.

The culture change movement is startling when considering the strength of the person-
centered care advocates’ commitment and courage and most enlightened perspectives to
resolutely resist the dominance of the commercial juggernaut of Big Med and Big Pharma
and the pervasive dogma of the medical model, especially in the medical model’s approach
to pathologizing situations and circumstances whereby negative situations or pressures,
particularly in situations perceived by an individual to be inescapable and of interminable
duration, or of sudden, dramatic trauma inducing counteractions designed to obfuscate or
distort reality as a built-in psychological defense mechanism protecting one’s core psyche
from the full realization of one’s loss or the desperate position in which one has been
entrapped, the resulting behavior labeled by the medical model as inappropriate, disruptive,
uncooperative, unresponsive or even hostile or threatening, whereas, however, the
problem is the situation, not the behavior, which, initially, is only a reaction to a situation,

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that, if allowed to persist, in the long-term often results in serious cognitive disorder. It is
the negative situation that must first be resolved, then inappropriate behavior can be
modulated by naturally reestablishing cognitive integrity in eliciting and constantly
reinforcing more positive, self-affirmative and productive behavioral outcomes.

To come to this realization in the face of Big Med bullying, and to dare to challenge the
purported scientific authority of Big Med in rejecting the medical model, even when such
progressive person-centered care advocates as the various national and regional
Alzheimer’s societies as well as many long-term care facilities that have fully implemented
the person-centered care approach absolutely depend on medical advice and support,
mostly from “experts” wholly indoctrinated in the medical model, is dramatic testimony to
the amazing strength of conviction that the proponents of the person-centered care
approach have in the integrity and efficacy of that approach drawn from a heartfelt
humanitarian concern and a deep well of experience working directly with elders and
providing care to individuals in all stages of dementia in long-term care facilities.

It is the experienced healthcare workers at the front line daily interacting directly with
elders in long-term care and the responsive behaviors associated with dementia in addition
to the more extreme behaviors falling under the umbrella of the equivocal diagnostic
category of BPSD (behavioral and psychological symptoms of dementia) and those very
residents in long-term care and individuals living with dementia themselves that are the real
experts in the field. However, in spite of the valor of the advocates of the person-centered
care approach and the inherent veracity of that approach, there remains a critical problem,
which is, the tension in repudiating the medical model while simultaneously depending on
the medical profession trained in the medical model. Not only does this tension create great
conflicts between the person-centered care workers and the physicians, psychiatrists,
psychologists, social workers and nurses treating the residents in the long-term care facility,
but also drives a troublesome wedge between the person-centered care approach and the
authority of the medical field that seeks to regulate all practices related to disease
intervention and mental healthcare.

While the dramatic results in improvement in cognitive functioning, behavioral stability and
sense of well-being of residents in long-term care facilities that have fully implemented a
person-centered approach have convinced a number of medical professionals of the power
and efficacy of the approach, the dogma of the medical model remains entrenched within
the vast majority of the medical community simply unaware of the problem, indifferent for
either lack of concern or for self-serving interests, or fearful of challenging the distorted
concept of the pathology of behavior. In spite of the resistance of the medical community
per se, many forward-thinking individuals within the medical community recognize that the
drug-oriented, pathology obsessed approach to cognitive and behavioral disorganization is
exceedingly narrow and theoretically vacuous – the fundamental nosology inconsistent and
even contradictory, and, in clinical practice, often causing more harm than good. This
nosology is transcribed in the Diagnostic and Statistical Manual of Mental Disorders (DSM)
of the American Psychiatric Association, considered the “bible” of the field [the European-
based counterpart, the International Classification of Diseases (ICD), presents a similar
nosology].

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Up to the fourth edition of the DSM (DSM-IV) the nosology totally ignored the most obvious
fact that behavioral problems are very often basically problems in adjustment to
environmental conditions and are frequently embedded within the context of a conjunction
of tensions between social pressures, cultural constructions, self-concept and core values.
DSM-IV gave some lip-service to the sociocultural dimensions of behavioral problems by
introducing the Outline for Cultural Formulation, a sophomoric, vacuous view of the effect
of social situations and cultural perspectives on behavior. The current fifth edition (DSM-5)
claims to update and extend the Outline for Cultural Formulation, primarily through a
ludicrous 16-item questionnaire [the Cultural Formulation Interview (CFI)] that attempts to
define: a) an individual’s cultural domain and the impact of that domain on the presenting
clinical problem; and b) the individual’s perception of the problem (as well as that of those
identified as significant members of the individual’s social network through the Informant
Version of CFI) as a means to clarify diagnosis and “improve therapeutic efficacy.”

In the DSM-5, just 10 out of more than 950 pages address the social and cultural impact on
human behavioral outcomes and just 16 items on the CFI (17 on the Informant Version)
propose to construct a revealing composite of the unique nature of an individual and define
the presenting problem and its treatment from the individual’s perspective. This approach
most disturbingly reveals the utter lack of understanding of: a) the fundamental concepts of
human behavior and the neurophysiology and cognitive processes of the antecedents of
human behavior; b) the whole person as a unique individual; and c) the myriad intricate
interactions of finely nuanced cultural and social dimensions by which every individual is
self-defined and continuously and subtly but meaningfully redefined by the experiences of
life unfolding day-by-day.

Like its earlier editions, the DSM-5 is based on categorizing some arbitrarily assembled
behavioral characteristics (so-called “symptoms”) as pathologies, i.e., organic disorders or
diseases, distinguishable solely by a specific aggregate of symptoms – defining behavioral
disorganization as fundamentally a biological process, and though giving some lip-service to
social and cultural agents contributory to behavioral disorganization, the DSM-5 basically
ignores environmental factors (inclusive of factors relating to lifestyle) as major causes of
cognitive and behavioral dysfunction as well as organic pathology. Of course many instances
of cognitive and behavioral dysfunction are sequelae of physical injury or organic pathology,
but which was the initial cause, environmental factors resulting in organic pathology
inducing cognitive and behavioral dysfunction, or environmental factors resulting in
cognitive and behavioral dysfunction inducing organic pathology? In both cases the root of
the problem is environmental, and these sociocultural factors must be addressed as the
front line of intervention.

Paraphrasing Liah Greenfeld (2013), the DSM-5, in spite of its changes, simply carries on the
fundamental problem of all the preceding DSM editions, that, predicated on the medical
model of behavioral pathology, fail to provide a fundamental understanding of the human
mental processes, i.e.; the human mind, and fail to answer the critical questions: 1) what is a
dysfunctional human mind as opposed to a functional one, i.e.; what are the criteria for

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determining whether a certain manner of cognitive reaction or character of behavior is
dysfunctional or not, and most importantly, 2) what are the bases for such criteria and what
are the causes of cognitive and behavioral dysfunction and the attendant principles by
which such dysfunction may be remediated.

Because of its nearly exclusive biological focus and fundamental distortion of equating mind
with brain, the medical model minimizes (in clinical practice, often repudiating) the role of
the sociocultural environment in the adaptation and ongoing modification of human
behavior in response to the interpretation of experience, basically ignoring the very
components that motivate and drive human behavior and the essential sociocultural
avenues by which cognitive and behavioral dysfunction may be remediated. Thus, the
medical model and the DSM in all its editions neither reflect the reality of human experience
nor provide any helpful understanding of cognitive or behavioral disorganization or realistic
avenues of remediation thereof.

The essential problems with the DSM-5 and the entire medical model of mental health
include: 1) the total lack of theoretical grounding; 2) the enormous overlap of so-called
“symptoms” from one diagnostic category of so-called “mental disorder” to another; 3) the
lack of definitive etiological bases distinguishing different alleged disorders; 4) the blind
dismissal of the critical importance of the role of sociocultural factors as a source of
cognitive disruption and psychological distress in the onset of cognitive and behavioral
dysfunction as well as organic disorder; and 5) the growing number of alleged disorders in
each subsequent edition of the DSM resulting in the medicalization (i.e., pathologization) of
typical socialized defensive responses to different situations as shared cultural traits of a
particular socioculturally defined population while ignoring the negative, destructive
behavior inculcated by the “sick society.” Within all this is the constant jockeying of self-
serving interests for political power among the various factions competing for authority and
influence in both professional and academic circles and a larger share of the vast
commercial enterprise of Big Med and Big Pharma— the motivation is clear, as it cannot be
denied that the medical/healthcare industry is the world’s largest commercial sector, “Big
Business” with a capital “B.”

CNE and Person-Centered Care

Cognitive Neuroeducation (CNE), an activities-based, social-integration-oriented modality

for the prevention of and recovery from cognitive and behavioral disorder, signifies a major
breakthrough in understanding and addressing the causes of cognitive and behavioral
disorganization. In identifying the basic principles of brain-mind-behavior interaction, the
CNE framework applies these principles to broadly stimulate and exercise the brain to build
brain and cognitive reserves as a neuroprotective shield and renew or expand cognitive
acuity in reclaiming or discovering one’s selfhood and one’s social instincts in engagement
with others and one’s environment.

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The CNE curriculum, unique among all behavioral modalities and cognitive rehabilitation
programs, centers on an enriched environment of highly eclectic learning and bonding
activities in a cohesive group dynamic that combines high cognitive functionality with
emotionally compelling social engagement that emphasizes group interaction and
teamwork; individual responsibility; perspective taking; social context appraisal; empathetic,
attentive listening; constructive feedback; individual initiative, facilitation of the voice of the
individual, and the confirmation of self.

The major features that distinguish CNE from all other cognitive and behavioral intervention
modalities are as follows:

1) Originating from a platform with a proven track record

CNE is derived from the highly vetted, highly successful cognitive rehabilitation modality
Cognitive Enhancement Therapy (CET), which is backed by more than 15 years of clinical
trial studies as well as a history of program outcomes from different mental health facilities
running CET clinics, and formal recognition by the APA (American Psychological Association)
and SAMHSA (The United States of America Substance Abuse and Mental Health Services
Administration) [Robinson 2018, pp. 2-3]. A listing of CET background research reports and
clinical trial results may be found in Robinson and CASN 2018.

2) Theoretically grounded from basic principles validated by an extensive body of studies

CNE is neuroscience-informed, built on well-established principles in a rigorous theoretical
framework defining the antecedents of human behavior and the mechanisms in
environmental-neurophysiological interactions that lead to cognitive and behavioral
disorder and the prevention thereof and recovery therefrom. These principles are validated
in an extensive body of studies, a representative example of which is presented in Robinson
and CASN 2018.

3) Inherently person-centered, human-values oriented

While research-based and neuroscience-informed, CNE, like the person-centered culture-
change movement in elder and dementia care, repudiates the distorted medical model,
replacing a negative, pathologically oriented medical model with one that fosters human
values with emphasis on the individual and an environment that provides enriching
activities and promotes self-identity, social integration, the joys of companionship, the
positive engagement of life and self-fulfillment.

4) Provides the vital mental health component missing from person-centered care
With its human-values emphasis, CNE can effectively address the missing component of
person-centered care. This vital missing component is a dedicated framework and
curriculum for the prevention of and recovery from dementia and other age-related
neurobehavioral sequelae within a seamless person-centered intervention-care
environment.

Cognitive decline and behavioral disorientation severely impact an individual’s well-being. In

addition, the stress placed on personal support workers (PSWs), other interprofessional
staff as well the residents in a long-term care home (LTC) by the disruptions and difficulties
caused by responsive behaviors or more serious so-called behavioral and psychological

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symptoms of dementia (BPSD), can be wearing and produce a tense atmosphere disturbing
the ambiance and harmony within the facility. Preventing cognitive decline and maintaining
cognitive and behavioral stability while stimulating the cognitive growth of the residents
fosters their self-fulfillment and more understanding and cooperation between residents
and staff leading to more involvement of the residents in their own care, reducing the
burden of care in more compatible, smoother-running care and living conditions.

CNE, with its rigorously researched base and legacy derived from a foundation with a proven
track record, offers a real, viable efficacy in nonintrusive, nonpharmacological intervention
in cognitive and behavioral disorder. CNE is founded on a major breakthrough in mental
health. In distinction from conventional atheoretical, generally baseless psychotherapies
with a history of dubious outcomes, CNE effectively rebuilds cognitive acuity and behavioral
balance even in the presence of organic damage (where tissue damage has not exceeded a
threshold of neuroplasticity), while both supporting and enhancing the person-centered
environment of care in a seamless person-centered intervention-care model with the
principles and philosophy of the person-centered care movement built into CNE and fully
implemented within its framework from its inception.

5) Ready framework for intergenerational programming and building strong community

connection
CNE, restoring and expanding cognition and balancing behavior through a cohesive group
dynamic, can provide intergenerational programming and community mental health
services through its highly flexible curriculum and group structure, expanding the social
network of the program participants as well as the services provided by the retirement or
long-term care home.

“It has been demonstrated that well-designed contact between people from the broader
community and nursing-home residents contributes to the psychological well-being and
physical health of the residents (Chamberlain, Fetterman and Maher 1994; Lambert,
Dellmann-Jenkins and Fruit 1990; Newman, Lyons and Onawola 1985; Ward, Kamp and
Newman 1996). There are also potential educational and attitudinal benefits for those who
visit, particularly young people. As early as 1975, the U.S. government sponsored programs
that involved transporting senior citizens to schools in order that they might participate in
classroom activities. Research has attempted to describe guidelines for successful
intergenerational programs. These guidelines include intimate rather than casual contact
(Amir 1969); predictable, scheduled visits (Schulz 1976): mutually rewarding, cooperative
activities [emphasis added] rather than ‘performances’ by the children (Seefeldt 1987);
integration into the school curriculum (McCollum and Shreeve 1994); and careful
preparation of all participants (Griff, Lambert, Dellmann-Jenkins and Fruit 1996)” [Hamilton
and Brown et al. 1999, p. 235].

In their 1999 paper, Hamilton and Brown et al. describe how planned, coordinated and
regularly scheduled and more enduring intergenerational contact resulted in both increased
health and a new “zest for life” for the LTC residents. While this 1999 paper and the studies
it references focus on contact between young children and elders, the benefits of
intergenerational interaction for elders in long-term care has been well known for years and

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more recently great attention has been directed at sustained contact between young adults
and elders, for example, in such experiments as intergenerational living where the LTC
doubles as a student dormitory (Jansen 2015).

While the experiments reported by Jansen have been highly successful to-date, there still
remains the lack of an integrated person-centered orientation dedicated to directly
addressing cognitive and behavioral disorder in a stable, on-going, structured program of
prevention and remediation.

CNE fluidly solves this problem as well as perfectly matching the general guidelines for
successful, efficacious intergenerational programming as suggested in the Hamilton and
Brown et al. 1999 paper. The CNE curriculum, centered on an enriched environment and
engaged through a cohesive group dynamic, combines the constancy of a well-formulated
structural base with an enormous flexibility in curriculum content and procedural
arrangement designed for tailoring to specific circumstances. The basic CNE structure
consists of placing CNE program participants in stable groups of 6-8 individuals who interact
interdependently in a group dynamic in a prescribed schedule of specific activities and
learning situations.

It is in this group dynamic that participants learn to value each other’s input as well as their
own – where success in learning and accomplishing tasks, and engagement and enjoyment
of the moment are products of group and individual effort, leading to growth of the
individual and the group, to self-confirmation, bonding with others, identification with the
group and sense of belonging. It is these interactions in the group dynamic in an on-going
CNE program that, paraphrasing the guidelines stated in Hamilton and Brown et al. 1999,
provide “intimate rather than casual contact,” “predictable, scheduled interaction,”
“mutually rewarding, cooperative activities,” “integration within an ongoing curriculum”
and “careful preparation of all participants,” the latter as an inherent component of the CNE
group structure and its dependence on the cooperation, constructive feedback and planning
that constitutes teamwork.

Taking full advantage of the flexibility built onto the CNE framework, CNE group activities
can be tailored to include individuals from the surrounding community (hereinafter referred
to as “nonresidents”) as stable group members. Nonresident members may include those
seeking recovery from cognitive or behavioral disorder, those seeking to build stronger brain
and cognitive reserves for the prevention of dementia or other cognitive and behavioral
disorder, or volunteers who simply wish to participate in the activities designed to help
elders in long-term care to rebuild their cognitive faculties, expand their social networks and
enjoy life.

Nonresident participants may include a wide range of ages, with the group dynamic and
activities tailored to specific situations, such as an orientation whereby the elders in a group
that includes a child or children act as mentors for specific activities within the group or the
elders assuming roles as surrogate grandparents in a dynamic that emphasizes bonding, or a
group dynamic that switches mentor roles between young adults and elders. Group
composition can be periodically varied in different activities to give both residents and non-
residents a rich range of experience in wider opportunities for social networking and

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interpersonal interactions. LTC vacancies and respite beds can be put to use in providing full
accommodation for fixed periods for nonresidents requiring a more complete absorption
within the enriched environment in recovering from cognitive and behavioral disorder, or an
LTC may find that is to its advantage to expand in dedicating more resources for non-
resident fixed-period accommodation as a major community center for mental health in
CNE programs that bring youth, community and LTC residents together in closer and more
enduring interaction.

Together, in a seamlessly integrated enriched environment, the person-centered care

approach and CNE can end the tyranny of the distorted medical model that pathologizes
behavior and stigmatizes individuals, and instead promote new life, dignity, selfhood,
meaning and self-fulfillment to those residing in a long-term care home, in turn giving a new
vibrancy to the LTC as well as a new important role as an intergenerational community
center and major community resource for the provision of mental health services.

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