CASTLE Philosophy and the Application of The Imax Equation©

The philosophy of care at CASTLE blends traditional models of addiction treatment with our current understanding of the adolescent brain and its development. Underpinning both are components of Attachment Theory and the developmental construct of Theory of Mind and its extension. These are encompassed in a novel conceptual organizing principle called The Imax Equation© conceived and developed by Dr. Joseph Shrand, Medical Director at The CASTLE. The Imax rearranges the biopsychosocial model to reflect that substance abuse does not happen in a vacuum but in a complex interplay of the individual's home and social environments, his self-concept, and biological dispositions.

At CASTLE, the beginning of this philosophy is exemplified by the belief that every person is doing the best he/she can at this moment in time. No one chooses to do worse than his/her best. This is called an Imax: a current maximum potential. The Imax is in a dynamic equilibrium with four domains: the home environment, the social environment, the Ic or how I see myself, how I think others see me, how I see others, and how I want to be seen; and the integration of one's biology at this moment in time, i.e. am I hungry, tired, have diabetes, am high on heroin, am coming off heroin, in addition to one's genetic predisposition to addictions, diabetes, depression, etc. These domains interact fluidly with each other, all the time, to impact the Imax. As the Imax changes, it impacts the choices one makes in the domains.

Imax is operationalized throughout the program day. In the morning, patients start with their Imax goal sheet, exploring what they need to work on that day in the domains. For example, a patient may begin to explore the interconnection between conflicts at home and how these led to using drugs and school failure; how they began to see themselves as useless, angry, dismissed; and how they began to believe that others around them also saw them as useless or a 'druggie.' They integrate how drugs impact their brain and body, or perhaps they experience the throes of withdrawal and how this impacts their desire to use to avoid the cravings of their brains and body.

Imax is incorporated into the various daily groups, coming back to the external attachment issues that drive the first two domains (Home and Social), with the internal aspect of psychology and biology of the latter two domains, especially the Theory of Mind component of the Ic. Patients are taught the fundamental truth that human beings are very interested in what other people think and feel, but are especially interested in what are they thinking or feeling about 'me.' All of these domains link to a deeper awareness and understanding of how they led patients to their addictions. CASTLE is an acronym for 'Clean and Sober Teens Living Empowered.' It is this knowledge of why one uses drugs and alcohol that is the root of empowerment.

The adolescent brain is known to have differential myelination between the limbic system and the pre-frontal cortex (1, 2). This research finding drives much of CASTLE's programming. Recognizing that we cannot fight evolution, programming starts with teaching staff and patients about this fundamental biological concept and how it impacts addictions and choices made by adolescents in general.

Adolescents like to seek pleasure, take risks, and be social (3). All three are incorporated into the daily experience of the CASTLE program. Overall, staff tries to teach patients the connections between their world and their addictions and to help them find more productive and constructive ways of experiencing pleasure. In general, pleasure is about dopamine secretion,and CASTLE helps patients learn that dopamine can be secreted whether doing drugs or getting a good grade in school, or earning money for a job well done (4, 5). Using what we know about the brain, CASTLE hopes to empower patients to explore what gives them pleasure other than drugs and alcohol. There is growing evidence that traditional AA/NA approaches are not as effective for the teenager as are supportive, interactive, psychodynamic, and educational group approaches (6). At CASTLE, using the Imax Equation provides a novel approach to addictions, rather than trying to coerce patients into sobriety by scaring them straight.

The Imax© approach is well suited to crisis stabilization. Each domain contributes to the current Imax of the patient and family system: even though the patient and family may be in a crisis, it is still an Imax, still the best they can do at this moment in time. Using the Imax approach, each domain can be rapidly evaluated and a cogent and practical treatment plan implemented. The Imax approach sees the domains as having an augmenting synergy between them. As such, a small change in one domain can have an amplified impact throughout the system. CASTLE staff are well versed, trained, and practiced in this approach, making our facility an ideal location for crisis stabilization.

Imax has the advantage of utilizing the fundamental component of human dignity and respect to generate an open and focused crisis assessment. Appreciating the family-in-crisis in this way affords an opportunity for re-establishing attachments between teenagers and their guardians, analyzing the social environment and its contribution to the crisis, how the teens see themselves, how they think they are seen, and for an appreciation that all members of the system have their own Imax. In addition, but not least, the biological domain addresses any medical, substance induced, or co-morbid psychiatric presentation that may be contributing to the crisis. A Board- certified child and adolescent psychiatrist is part of the Crisis Stabilization Team and can rapidly assess medication efficacy and suggest changes, if any, to the current regimen.

From the Imax assessment springs a solution focused crisis intervention, clearly targeting the home and social environment, the way patients see themselves and how they believe they are seen, and the biological pull of genetic vulnerability, active substance abuse, and any underlying medical or neuro-developmental conditions. Active treatment involves the clinicians' appreciation of the patients' immediate response to crisis, and the creation of an effective diagnostic environment squarely based on treating the patient and family with dignity and respect. In this way, the threat of violence can be mitigated and a more rapid and appropriate treatment plan can be developed. For more information, please contact Dr. Shrand at 508-638- 6060.

1) Yurgelun-Todd D. Curr Opin Neurobiol. 2007 Apr. 17(2):251-7. Epub 2007 Mar 26. Emotional and cognitive changes during adolescence.

2) Schneider JF, Vergesslich K. Maturation of the limbic system revealed by MR FLAIR imaging. Pediatr Radiol. 2007 Apr.37(4):351-5. Epub 2007 Feb 27.

3) Eaton DK, Kann L, Kinchen S, Shanklin S, Ross J, Hawkins J, Harris WA, Lowry R, McManus T, Chyen D, Lim C, Brener ND, Wechsler H; Centers for Disease Control and Prevention (CDC). Youth risk behavior surveillance--United States, 2007. MMWR Surveill Summ. 2008 Jun 6;57(4):1-131.)

4) Phillips AG, Vacca G, Ahn S. A top-down perspective on dopamine, motivation and memory. Pharmacol Biochem Behav. 2008 Aug;90(2):236-49. Epub 2007 Nov 28.)

5) Adcock RA, Thangavel A, Whitfield-Gabrieli S, Knutson B, Gabrieli JD. Reward-motivated learning: mesolimbic activation precedes memory formation.Neuron. 2006 May 4; 50(3):507-17.)

6) Kelly JF, Myers MG, Rodolico J. What do adolescents exposed to Alcoholics Anonymous think about 12-step groups? Subst Abus. 2008; 29(2):53-62.