The Application of Traditional Martial Arts Practice and Theory to the Treatment of Violent Adolescents
Twemlow, Stuart W., Sacco, Frank C., Adolescence
Single-parent households with fatherless children, gangs, and out-of-control inner-city students present psychotherapists with unique challenges. Violence and neglect have reached epidemic proportions, and children often grow up with egregious emotional scars that eventually lead to hardened, angry, intractable adolescents. Too often, they come to regard prison as a rite of passage.
Limited access to mental health coverage, capitation, and subcapitation have all but eliminated long-term, one-to-one care for most psychiatric disorders. This has forced greater numbers of adolescents who would benefit from outpatient treatment into the juvenile justice and psychiatric hospital systems. Psychotherapy is therefore challenged to design interventions that are intensive enough to reach delinquent, aggressive adolescents while still being affordable. Martial arts, integrated into a coherent treatment program, show promise in this regard. This paper reviews the literature on the use of martial arts in the treatment of violence, and explores the elements of such a program. First, the basic components of any program for violent adolescents are described.
COMPONENTS OF AN EFFECTIVE TREATMENT PROGRAM FOR VIOLENT ADOLESCENTS
There are considerable difficulties in motivating violent youth to participate in such an abstract activity as verbal therapy. This is not to say that psychotherapy is useless, only that, on an outpatient basis, it often does not provide the level of care necessary to change violent behavior and offer society a measure of safety.
Other approaches to treating violent adolescents call for a higher level of government spending. They range from community interventions to long-term treatment and high-security detention. Violent adolescents are often expelled from school and placed in special programs; then attempts are made to reintegrate them into normal educational settings. If they again break the law, they are removed from family and placed in highly structured settings that sharply limit unsupervised access to the community. This "rescue orientation" has been popular in state and federal programs in recent years (Pelton, 1989). However, these approaches either are insufficient to ensure public safety or place the violent adolescent into an artificial milieu.
There is little evidence that the changes youngsters make while in residential programs are maintained after they leave these highly specialized environments. Studies indicate that the effectiveness of residential care is linked to the intensity of aftercare intervention (Small, Kennedy, & Bender, 1991; Wells, 1991). Thus, it appears that successful treatment of violent adolescents begins and ends in the community. In short, an effective treatment program would (1) ensure public safety by eliminating violence, bullying, or other criminal activity; (2) help maintain improved behavior in the normal or special educational setting within the community; (3) keep the adolescent at home, with the family acting as social control agent; and (4) increase the adolescent's participation in positive social/recreational activities.
In order to design such programs, it is critical to understand why so many adolescents are powerfully attracted to criminal street gangs. These gangs appear to be the only consistent means by which some adolescents can feel safe and successful. The experiences of a 16-year-old male high school student is illustrative. He was participating in a collaborative peer mentorship program at a local elementary school as part of his rehabilitation for poor school grades and disruptive classroom behavior. His performance with the elementary school children was exemplary, although he did not significantly change his own classroom behavior. He was sensitive, helpful, and dedicated. On one occasion, after spending time in jail for a gang-related activity, he was very embarrassed that the children knew of this incarceration. He wrote the following essay, "Life as a Gangbanger," describing his gang involvement.
It all started about two years ago in the summer of 1994. It was a hot day in about mid-June. The only thing on our minds was our initiation later on that night. It was me, C.C., Dirt, Monster, and Mone. These were the names given to us by the bigger homies. Then night came around and it was time for us to join the set. So after getting drunk at our first ESC [East Side Click] get-together, the big homies, Keno, C Side, and Houston, called attention to us. All of a sudden we was catching blows left and right; the only thing to do was fight back, but eventually I was knocked to the ground and beaten. After a few minutes it stopped; then we was given some love and started to celebrate again. Next was to show if we was down for the hood. So we loaded up into three cars and was headed for Slur Hood (Slur is a disrespectful term for Surenios 13, who is the ESC's mortal enemies). When we got there, we spotted three of them standing outside a Kwik Shop. Our job was to beat down the enemy until they could no longer move. Only then could we return to the cars. So we did, and got respect from the older homies for what we did. This was the whole initiation night. This was the first work I did for the set; it wasn't the last. With my two years being with the set, I did enough dirt and earned enough respect to surpass the first three ranks and now I'm a Baby Gangsta [B.G.], only two ranks away from being an O.G. With earning the B.G. rank, I'm allowed to do things I couldn't do before; for instance, I can ball the big homies' cars, teach and tell the younger homies what to do and not to do, and sell drugs. But to break it down, there is nothing wrong with representing East Side Click, one of the many Crip sets. You get paid, known, and respect - the three things gangbangers want. But behind all of the glamour, like me, you get shot at, you shoot at. I've been jumped four times and put in the hospital for stitches once. Had my house shot at, been locked up, have partners locked up, and worst of all I lost two homies - D-Monster and Houston both killed in Houston, Texas, for what we believe in. For some, this is all we got so we're gonna represent to the fullest no matter the pain or cost: only to live up to every gangbanger's dream of having riches, respect, and to live in a world where everyone looks up to you and have worries of watching your back 24-7. But until then I'm gonna keep Cripping and stick to my motto, "can't stop, won't stop; East Side Click ride, till my casket drops."
As this 16-year-old's essay reveals, gangs satisfy several needs:
1. Affiliation with a group. A street gang allows adolescents to feel that they are participating in something important. Just as middleclass adolescents can sport a team jacket, inner-city youth need to feel that they are part of a team, a group, or a family. Instead of school colors, they sport gang colors.
2. Power. Gangs offer power, which leads to social status, access to money and members of the opposite sex, and a sense of security. Power is gained by participating in criminal activities, such as selling drugs (e.g., crack cocaine).
3. Physical security. Many adolescents grow up without a father or any sense of security at home. Criminal street gangs fill this void, or as one adolescent said, "somebody always at my back." This feeling of being protected is often illusory, but difficult to argue with when adolescents see how violent their neighborhoods are.
4. Activities. Alienated, bored youth may participate in violent activities to pass time. They are often school dropouts, unemployed and unemployable, and spend their time watching television, using drugs, or seducing young women. A gang offers these adolescents the opportunity to be with similar-minded peers. They may meet to plan and engage in criminal activities, parties, or fights.
5. Role models. Many adolescents are woefully lacking in positive adult role models. Gang leaders, who appear successful, drive nice cars, have fancy jewelry, and associate with beautiful women, become role models for younger gang members.
6. Sparring. Mock fighting, jostling, and other physically aggressive play are common among gang members. These mock fights sometimes get out of control and erupt into serious violence. Nevertheless, a considerable amount of time is spent roughhousing, exchanging gibes, and engaging in other types of sparring, both verbal and physical.
Properly applied, martial arts can provide an alternative method of fulfilling these needs.
Using the MMPI, Trulson (1986) studied the impact of a Korean martial art (tae kwon do) on delinquent adolescents and found that those who trained in the "old style," stressing not only physical but also the psychological, meditative, and philosophical aspects, demonstrated lessened aggression, lowered anxiety, and increased self-esteem. In addition, scores on the Jackson Personality Inventory revealed a significant increase in social adroitness and value orthodoxy. It is important to note that youths trained in the more "modern style," which emphasizes fighting and competition, showed little change. Apparently it was the combination of mental and physical discipline that resulted in reduced aggression.
Nosanchuk (1981) studied 42 youths and found that karate training did not increase aggressiveness. However, it was hypothesized that the more violent youths would tend to drop out of training, thus confounding the results. A follow-up study (Nosanchuk & Mac Neil, 1989) supported the traditional training hypothesis rather than negative selection as an explanation of reduced aggression. The researchers suggested that there are three key elements when working with violent adolescents. First is the role of the sensei (teacher) as an "exemplar of restraint," a parent figure, and someone with faith in the student. Second is the teaching of the do (the ethics and philosophy of martial arts) along with the physical training. Third is the use of the kata (noncombative physical forms), which stress technique rather than conflict.
The psychotherapeutic aspects of martial arts were outlined by Weiser, Kutz, Kutz, and Weiser (1995), and included a focus on enhancing self-esteem through the use of physical activity, group experiences, relaxation training, concentration, assertiveness training, and rewarding honesty in communication. Layton, Higaonna, and Arneil (1993) also found that the practice of kata in two different styles of karate (goju-ryu and koyokushinkai) lowered aggression. Kurian, Verdi, Caterino, and Kulhavy (1994) found that the longer a karate student practiced and moved up in belt rank, the higher the levels of self-reliance and optimism. In their study, higher belt rank in tae kwon do was associated with more positive attitudes toward life. In an earlier study using Cattell's 16 Personality Factor Questionnaire, Kurian, Caterino, and Kulhavy (1993) found that the longer a student studied tae kwon do, the lower the score on anxiety and the higher the score on independence.
Windle and Samko (1992) drew parallels between aikido and Ericksonian hypnosis. Aikido's psychophysiological state of "centering" - a readiness for the incoming attack, a Zen-like openness to movement - was compared to a hypnotic trance. Saposnik (1986) highlighted the use of aikido principles in the mediation of conflict. The three stages of aikido defense (perception, evaluation, and decision/reaction) were found to be useful in verbal conflict resolution.
Fuller (1988) found that applying the principles of aikido led to a general improvement in psychological health, especially in terms of assertiveness and stress management. Rothpearl (1980), reviewing four studies, concluded that, despite problems assigning causality, involvement in a martial art helps students cope with stress in a less violent manner. Pyecha (1970) found that students who took judo, as compared with those engaging in other physical education activities, were significantly more warmhearted and easygoing. Back and Kim (1979) have theorized that the benefits of martial arts stem from building strong moral character and the promotion of nonviolent attitudes and behavior.
Guthrie (1995) found that martial arts instruction for traumatized women (survivors of rape, incest, and other forms of violence) helped them to heal. Feminist ideology was combined with martial arts training to improve the women's self-image and decrease their self-perception as victims.
MARTIAL ARTS PROGRAM PHILOSOPHY
The findings regarding the beneficial aspects of participation in martial arts are not definitive. There are many confounding variables, as well as limited samples and inadequate research designs. Nevertheless, martial arts show promise for helping a particularly problematic group--violent adolescents. The literature suggests that the key therapeutic elements are the teacher as role model, the use of physical exercise, the philosophy of ethical behavior and restraint, and group participation.
Research and our teaching experience suggest that the successful application of martial arts to the treatment of violent adolescents involves a strong philosophical component. Rehabilitation is pursued through training as a "gentle warrior." In the tradition of Gandhi and Martin Luther King, Jr., violence is resisted. Thus, the philosophy of a martial arts program must be to encourage violent adolescents to work toward the following goals: (1) a commitment to a respectful attitude, kindness, and self-protection through nonviolence; (2) a commitment to leadership and nonjudgmental role modeling, virtuous behavior, and altruistic service to others; (3) a commitment to try hard, stay healthy, learn to overcome fear and possessiveness, develop confidence, and exercise restraint in the face of provocation.
Program philosophy is drawn from several traditions. Being fully focused in the present (Zen) is highly valued in all aspects of the training. Bushido, the Japanese code of conduct, is used to exemplify virtues esteemed by ancient samurai. The chivalrous acts of the English Knights of the Round Table also serve as examples.
Rankings within the martial arts offer students concrete status and recognition. Unlike many dysfunctional homes, the training program provides consistent, positive reinforcement for altruistic and focused behavior. Out-of-control behavior is quickly discouraged and, more importantly, acceptable behaviors are clearly presented and easy to follow. Belt testing, patches, and special rewards, combined with an encouraging milieu, provide an antidote to negative family, community, and school experiences.
Parables and ethical principles are constantly woven into the physical training. Stories from such texts as William Bennett's Moral Compass (1995) and Book of Virtues (1993) can be included as homework. Yuzan's The Code of the Samurai (1988) can be used to emphasize the importance of bravery, respect, responsibility, and loyalty.
Two other elements of a program incorporating martial arts into the treatment of violent adolescents are critical for success: an organizing framework and a sense of history. First, the teaching/learning process in a traditional martial arts program provides students with a method of organizing and understanding the world in which they live. The stages of learning are traditionally described as follows.
Gyo. This initial stage provides a basic identification with the teacher and the art, and familiarization with the body as a mode of self-expression.
Shugyo. This phase involves immersion in the technique, which may become almost an obsession. Youths will often irritate other family members with their enthusiasm - they may talk about nothing but martial arts and practice their strikes and kicks everywhere, to the embarrassment of those they are with (for example, while waiting in restaurants). This phase is usually viewed ambivalently by family members; it is irritating, yet moves the adolescent from disruptive to disciplined behavior.
Jutsu. Skill mastery is accompanied by a more graceful calmness. The concepts behind the technique are fully grasped.
Do. A centered state of mind emerges at the advanced level of practice. Each martial arts technique reminds the practitioner of life and its complexities. The system becomes a way of conceptualizing reality based on a conflict model, in which the enemy is seen to lie within; the task is to embody humility, compassion, and self-awareness.
Second, traditional martial arts often trace their origins back many hundreds of years. Thus, the adolescent can experience a sense of cross-generational, historical connectedness. For violent adolescents, this typically causes a shift from a narrow, narcissistic perspective to one that is broader and more compassionate, which comes, in part, from a feeling of being solidly linked with a long and revered tradition.
GENERAL PRINCIPLES OF A CLINICAL MARTIAL ARTS PROGRAM
If martial arts alone were the answer, there would have already been a great reduction in the amount of violence because of the proliferation of martial arts schools in the United States since the 1960s. Other treatment components are therefore necessary. The following is a broad overview of the elements of a successful martial arts treatment program.
1. For a martial arts intervention to be maximally effective, there needs to be a leader who is clinically trained in mental health to provide psychological oversight. Although the bulk of the "treatment" (i.e., daily instruction, follow-up, outreach) is accomplished by individuals who are highly trained in martial arts (black belts), clinical oversight is essential. This entails ongoing involvement with the instructors (i.e., consultation, supervision) and intervention with the adolescents (i.e., evaluation, counseling, medication). The involvement of the clinician may be as little as one or two hours per month, in contrast to the much greater clinical oversight required in more traditional interventions. Nevertheless, the clinician's role is crucial for keeping treatment on track.
2. The martial arts school or intervention site needs to be accessible, so adolescents can participate on a daily basis. The location needs to offer complementary training opportunities, running the gamut from martial arts and self-defense training to meditation techniques, painting, yoga, dance, and music.
3. The curriculum must address nonviolence. Participants need to be constantly motivated to broaden their participation in healthy activities as alternatives to the self-destructive use of drugs and alcohol, exploitative sexual activity, and gang involvement. Leadership training, with the goal of becoming a peaceful role model, is stressed.
4. The program should have strong links to the adolescent's family, school, and court or social work agency, where applicable. The martial arts instructors need to become intimately involved in the adolescent's life; they cannot simply teach technique. Students need to be comfortable with their instructors, and be willing to confide in them. In short, instructors are not just gym teachers, but outreach workers as well.
5. Martial arts instructors need to be specially trained to fulfill their role as therapist/instructor/probation officer. They must be firm with their students, yet accepting of periodic lapses and failures. Instructors also need to be sensitive to transference/countertransference issues that arise with students. There is a strong tendency for students initially to idealize their instructors, and then just as quickly to devalue them; the challenge is not to react negatively to these fluctuations. In addition, instructors must model behavior that serves to reduce violent adolescents' mistrust and help them overcome aggressive tendencies (Twemlow, 1996).
Adolescents in such programs often have a variety of learning deficiencies. Psychotherapy, which requires verbal skills, may cause frustration and eventually rage. Martial arts, on the other hand, involve kinesthetic skills, which enable adolescents to express themselves through body motion. Instructors can then foster students' verbal skills by making them assistant instructors, which compels them to translate physical skills into words. This, in turn, stimulates concentration and reflection rather than impulsive, violent behavior.
SPECIFIC MIND-SETS IN MARTIAL ARTS
Within Zen and other Eastern philosophies, the concept of mind-set offers a method of extending martial arts skills to other aspects of life. The first mind-set is known as selfless concentration (mushin). In this mental state, students learn how to control their emotions. The practice involves loss of self-awareness while engaging in physical activity (e.g., martial arts). The mind is taught to fade into the awareness of movement, which becomes effortless and "thoughtless." This practice encourages the development of empathy, listening skills, and self-reflection.
The opposite mind-set is one-pointed concentration (samadhi). Students are taught to focus on one object, a skill that is noticeably absent in adolescents with attention deficit hyperactivity disorder. One-pointed concentration is helpful for adolescents who live in a disruptive, dysfunctional environment. It enables them to complete homework and other assignments by shutting out distractions.
A third mind-set is known as automatic thinking (hishiryo). The mind does not actively process every activity, instead responding in pretrained ways. Routine tasks, such as driving, illustrate this mindset. Martial arts training facilitates the acquisition of complex skills, with this mind-set allowing the efficient and effective expression of learned behaviors. Scanning (fushiryo), which involves an overall awareness of the immediate environment, is a related attentional skill. This "soft focus" is learned in sparring (practice fighting). Scanning is useful in the detection of danger, as well as opportunities, and it promotes general mental alertness. It helps students handle bullying, since it allows broader awareness of the varied facets of bullying and ways to avoid it, as opposed to a narrow, fearful, anxiety-laden focus.
Most martial arts schools, especially the more modern, sport-oriented, competition-based programs, fail to blend in a philosophical curriculum. Traditionally, the fiercest samurai also trained in brush painting, flower arrangement, haiku writing, and solving conundrums that foster a positive ethic. Examples include: "To fall seven times, to rise eight times; life starts from now." This emphasizes the value of tenacity, endurance, and patience. "No fight, no resistance, no injury." Here the idea of giving way is offered as a method of conflict resolution. "If you know your techniques, you will win sometimes and lose sometimes; if you know your enemy, you will win most of the time; if you know yourself, you will have no enemies." This points to the value of self-awareness and the need to work on internal problems rather than blaming others.
Thus, cognitive-behavioral exercises should accompany physical training. Attainment of rank and privilege within the school can be made contingent on mastering the philosophy. Sumi-e brush painting and haiku are excellent ways to foster the softer side of hardened, violent youth, especially when they observe very tough instructors immersed in these apparently "sissy" arts.
THREE PROGRAM APPLICATIONS
Adults are often skeptical about the use of martial arts as a therapeutic tool. The fear is that teaching "fighting" will increase violence. Also, it may be difficult for them to envision a sports instructor in the role of therapist. However, martial arts can be organized to provide desirable social outcomes, such as decreased conflict at home, increased academic achievement, and reductions in violent behavior.
Obviously, simply signing up for karate classes is not sufficient. The therapeutic use of martial arts begins with a properly trained teacher. The therapeutic effect stems from students committing to a complete mental and physical training program.
One application is in specialized martial arts schools (an example is the School of Martial and Meditative Arts, operated by the first author; further information is available on request). Open enrollment results in a heterogeneous group of students. This application includes supervision by a trained therapist, but the bulk of student interaction is with black-belt instructors who constantly model the principles of the school. This approach is a cost-effective alternative to traditional therapy for violent children and adolescents.
Another application of the program involves special classes organized in public schools. Groups can be set up for all ages. For example, a martial arts program has been implemented, using a rigorous research design, at an elementary school in Topeka, Kansas. Results indicate that this "gentle warrior" class is having a dramatic impact (a 50% drop in school suspensions, a 32% drop in visits to the principal, and a 20-point increase in standardized academic achievement test scores have been noted in the first 18 months of the project).
In this model, a martial arts teacher conducts a one-hour class, one or two times per week, for selected students displaying either bullying or victimization. These classes take place during school hours. The main focus is to develop respect and self-control. Physical training begins very slowly, with breathing exercises, visualizations, and stretching. Eventually, the students learn simple breakaways, falling, and other personal safety techniques. They also role-play bully, victim, and bystander scenarios. Such a program depends on a dialectical view of the bully-victim-bystander interaction (Twemlow, Sacco, & Williams, 1996).
A host of add-on activities can be developed, such as honor groups, in which selected students are trained to be junior monitors in school hallways or the playground. Adult volunteers can create the vital link to the community (Twemlow & Sacco, 1996; Sacco & Twemlow, 1997).
The martial arts program can also be introduced into residential treatment settings for use with violent adolescents. The training becomes part of the medical/psychological intervention. Thus, the instructor must not only be a martial arts expert, but also a licensed mental health provider.
In residential treatment, the focus of the martial arts program is on self-control and conflict avoidance. The groups tend to be revolving, with new participants being cycled in according to the facility's intake and discharge policies.
Whatever the format of the intervention, a key element is the philosophy of the teacher. Curative aspects of the intervention arise from feeling connected to a respected instructor. This attachment creates a positive affiliation and a growing sense of goodness and control. The "bad" ethics of the street or pathological family are slowly replaced by the "good" ethics of the teacher.
A Residential Program
Angel, 16, was placed involuntarily in a residential treatment program. His record indicated that he had been orphaned at age 12 and raised by gangs. He was an explosive adolescent with an extensive criminal record, including assaults with deadly weapons. After four months, he was about to be moved into a high-security facility because of constant violent outbursts with teachers.
During the martial arts program, the instructor modeled the technique of looking past, or through, an opponent and focusing on internal states. The exercise involved a competition in which program privilege points were the reward. The task was to develop a nonresponsive stare in the face of intense provocation involving verbal abuse. Angel could not maintain self-control for even 10 seconds. He would burst out laughing or get angry and stomp away. Eventually, he developed a nonreactive expression that allowed him to win the contest; no one could say anything to rattle him. Angel was able to apply this technique whenever necessary, and he never exploded violently again, thus avoiding five months' lock-up time.
A Specialized School (Dojo)
Paul, 14, had been suspended from school on many occasions, was diagnosed with ADHD, and was being treated with Ritalin. He was briefly hospitalized after threatening to kill himself and his mother. He had a history of self-mutilation and other self-destructive behavior, including banging his head against concrete, burning himself, and slicing his arms with a knife. He also had a history of marijuana use, fighting, and vandalism. Despite these problems, psychological testing showed he had normal intelligence, and that he was a sensitive, introspective, perceptive young man.
Paul was interviewed for admission to a school of martial and meditative arts. He was provocative with his mother and tried to shock the interviewer with his "unusualness." He remained in treatment, but joined the school as a student, not a patient.
Paul energetically committed himself to both the physical and mental training, with the goal of receiving a black belt. He reported that he was able to function better at school by using the meditative techniques. His grades improved and he required no further hospitalization or even regular therapy, just minimal psychiatric consultation.
A Special Public School Class
Ricci, 10, was attending an elementary school in a bad neighborhood of a large city. His family was involved in criminal activity, and he had witnessed a murder, as well as men's violence toward women.
He was constantly disruptive in the classroom, and tried to bully peers and terrorize girls. Nevertheless, I.Q. testing indicated he was highly intelligent, but his inability to concentrate made learning impossible.
Ricci was enrolled in the gentle warrior class and quickly developed an idealizing transference with the instructor. He became the instructor's helper, and after mastering the physical skills was quickly promoted to assistant instructor. Thus, his need to dominate and bully peers was sublimated into constructive leadership skills. At the same time, his capacity for compassion improved; for example, he was observed helping to tie the shoelaces of a kindergartner who was crying because he could not do it himself. His classroom behavior also improved and psychomotor agitation decreased. Eventually, he requested counseling, which also proved helpful. The therapist later indicated that he considered the gentle warrior training to be the turning point in the development of Ricci's self-esteem and capacity for self-control.
Martial arts - in a therapeutic setting with properly trained and supervised instructors - can be an extraordinarily helpful, ego-building form of psychotherapy. The training strongly supports synthetic ego functions, particularly control of aggressive impulses. It may be especially helpful in assisting verbally limited students in mastering leadership skills.
Carefully supervised therapeutic interventions using martial arts as the change agent can enhance mind-body coordination, which is quite helpful to students with attention deficit disorders. Martial arts taught in a traditional way also offer an organizing framework for understanding the world and a sense of historical connectedness, helping violent adolescents overcome their dysfunctional circumstances.
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Stuart W. Twemlow, M.D., Private Practice, Psychiatry and Psychoanalysis, Topeka, Kansas; Topeka Institute of Psychoanalysis, The Menninger Clinic, Topeka, Kansas; Clinical Professor of Psychiatry, University of Kansas School of Medicine, Wichita, Kansas; and advanced black belt and master teacher, kenpo karate and kobudo.
Frank C. Sacco, Ph.D., President, Community Services Institute, Springfield, Massachusetts; Adjunct Faculty Member, American International College, Springfield, Massachusetts; and black belt instructor, han pul system of martial arts.
The authors are grateful to Ed Levy, M.D., for his contributions to this paper; the students and instructors of the School of Martial and Meditative Arts, Topeka, Kansas; Master Robert Morini of Chung's School of Martial Arts, Springfield, Massachusetts; and the high school student who allowed the use of his personal essay.…
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Publication information: Article title: The Application of Traditional Martial Arts Practice and Theory to the Treatment of Violent Adolescents. Contributors: Twemlow, Stuart W. - Author, Sacco, Frank C. - Author. Journal title: Adolescence. Volume: 33. Issue: 131 Publication date: Fall 1998. Page number: 505. © 1999 Libra Publishers, Inc. COPYRIGHT 1998 Gale Group.
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