IMMEDMCY AND PRIMACY OF CONTACT

IMMEDMCY AND PRIMACY OF CONTACT

One of the difficulties encountered in engaging addicts' families in a

program described by Ziegler-DriscolV" was that family treatment could not begin until the IP had completed a therapeutic community (inpatient) program. This had the double disadvantage of starting -treatment- when the client was supposed to be "cured,- and also of reinforcing the idea that the problem was the patient's, not the family's. Another hindrance, noted with nonaddicts' families by Sager and associates,126 and others, was the frequency with which clients were passed from one agency or treater to another. This reduced the chances for family engagement. We ran into these problems also, albeit to a lesser degree. Of central importance is the immediacy with which both the IP and family are engaged.

Principle 5: The closer the family therapist's first contact with the index patient is to the time of intake. the greater are the chances for recruiting the family. We discovered early that this was a critical variable. If the family therapist cannot see the client on the day of intake, he should set an appointment for no later than 2 or 3 days afterward. At the very' least he should be able to manage a brief telephone conversation with the client prior to the actual meeting. We were sensitive enough to this issue to eventually equip therapists with beepers. In this way we increased the chances of contacting them immediately and having them talk to the IP over the phone, should they have been unable to come to the drug-treatment clinic that day. This procedure added to the urgency of the situation and was a sign to the client that the therapist was sensitive to his need for help.

Principle 6: The earlier the family therapist enters the chain of -treaters" encountered by the client, the better are chances for family recruitment. As noted in Chapter 3, we observed that a kind of -imprinting- process occurs during the intake period, whereby the client attaches strongly to the first person (or persons) offering him help; this person appears to have much more leverage with him than do those who deal with him later. Consequently, if the therapist does not want his influence diluted, he should try to be among the first in the line of treaters with whom the client will come in contact.

Principle 7: The sooner the family is contacted, the more likely they are to be engaged. This conclusion is obvious from the above discussion, and has also been emphasized by Davis.37 In addition, it speaks to the possibility that the family may be in crisis (see below, and also Chapter 4) and more amenable to help at the time of intake than later on; the therapist has greater leverage because defenses are most vulnerable and the family is more in a posture of requiring help. This is the best time to expect everyone to come in.

PRINCIPLES AND TECHNIQUES

PRINCIPLES AND TECHNIQUES

While engaging families in treatment is a major problem in the addic-tion field, there is almost no literature on how to do this in prac-tice. Aside from an occasional pointer in a few articles,'4, 2". ".."6, [8° the therapist trying to recruit addicts' families—or even difficult nondrug- families—is essentially without published guidelines. This chapter will attempt, at least partially, to fill that void and provide therapists with material aimed at optimizing the recruitment effort.

The material in this section is subdivided into various content areas. Within each of these, one or more principles are set forth, followed by explanation and discussion. The reader may note an air of finality in these principles. This is not altogether unintentional. While every rule has exceptions, these tenets have been arrived at through the pain of multiple failures, so we feel we can state them with a certain degree of confidence.

MONITORING OF PROGRESS AND PROCEDURES

MONITORING OF PROGRESS AND PROCEDURES

There were at least two areas in which the AFP had interesting effects on the DDTC. The first of these concerned the monitoring of urine reports. Progress and changes in drug taking were a key part of family therapy. Clear contingencies were established for -dirty- urines given by family (and movie) therapy cases—especially in the two -paid-conditions. The treatment was sharply focused on this behavior. Thus it was essential that the urinalysis results processed at DDTC be obtained and recorded accurately and efficiently. In the early stages of the program, however, it was discovered that the DDTC was going through a -slippage phase'' regarding strict adherence to urine test results: records were sometimes -lost,- patients were able to get away with denying that dirty urines were their own, and (previously firm) established rules preventing clients with dirty urines from obtaining certain privileges, or even remaining in the program, were not being strictly followed. The AFP attention to, and insistance on, (1) clarity and efficiency of urinalysis results, and (2) adherance to program strictures based on urine results highlighted areas where slack had set in. As a result, the DDTC tightened up its urine-monitoring procedure and the total urine-reporting system was improved.*

Paralleling the above, a number of areas were uncovered by the AFP in which patients were finding it easy to manipulate the DDTC system. These included ways of getting around program rules, tricks for obtaining permission from staff for higher methadone dosages, methods for triangulating staff members and instigating or exacer-bating conflicts between them, and so forth. Some of these are described in Chapter 16. As they came to light with AFP cases, or within AFP team meetings, they were responded to and corrected by DDTC staff, thus allowing improvement in the overall drug-treatment

program.

THE RESEARCH ETHIC

It is important to mention some significant aspects of the DDTC that

contributed immeasurably to the success of this work. Because the

DDTC (1) was established partly as a research center, (2) was

*This sequence of clinical research impacting positively on clinical procedures had happened before the AFP and has recurred since. It presents an interesting example of the interplay between treatment and research.

somewhat less vulnerable to severe viscissitudes of funding (compared to many other agencies), and (3) incorporated many treatment modali-ties within its walls, it was (and is) a very result-oriented institution. The treatment philosophy was not rigid, and there was a sincere interest in alternatives to methadone (in contrast to the total commit-ment to various forms of pharmacological substitution—mentioned in Chapters 1 and 6—that sometimes occurs in drug-abuse programs). This pragmatism fostered a kind of "live and let live- attitude toward new kinds of treatment, resulting in an atmosphere in which competi-tiveness between different modalities could be minimized. It is con-ceivable that a program such as the AFP, had it been established within a different context, might have encountered much greater difficulty and that resistance could even have increased as it began to demon-strate effectiveness. This did not occur in the present case.

CONCLUSION

Given the inherent problems that occur when two separate institu-tions collaborate, we feel that the relationship and cooperation that developed around this work was closer to optimal than one can normally expect. Our task was certainly facilitated by common ex-periences shared (prior to the study) by several of the principal figures, and also by the shared institutional affiliations and research interests. On the other hand, some of the problems we faced would not occur in situations where all programmatic components exist within the same administrative, physical, and institutional structure. No doubt there are areas in which the PCGC and DDTC philosophies may never reach assimilation. Nonetheless the marriage seems to have "worked,- and divorce has never been necessary.

JOHN M. VAN DEUSEN/M. DUNCAN STANTON/

PATIENT CHARACTERISTICS: FAMILY THERAPY GROUPS

The essential thrust of this book is to deal with clinical events and techniques for those cases actually involved in family therapy. While Chapter 5 discusses recruitment principles that also apply to the Family Movie cases and to treatment "refusers,- and Chapter 17 presents outcomes for all four treatment conditions, the major concern is with family therapy. Thus attention will be given here to the 46 cases (21 and 25, respectively) in the combined Paid and Unpaid Family Therapy groups (although two Unpaid cases never did, in fact, attend a family therapy session). This gives a more accurate picture of the patient population with which the treatment principles have been developed. Demographics for the other groups are, of course, quite similar, and are presented elsewhere:-

Of the 46 family therapy patients, 48% were Black and 52% White. Among the Whites, 40% were of Italian, and 25% of Irish extraction. The mean age at intake was 24.7 years and ranged from age 20 to age 34. Some 24% were married and another 11% had been previously married but were unmarried at intake. All had been away from home in military service for at least a brief period in their lives; 32% had served in Vietnam and 5% had been dishonorably discharged from the military for drug use. Of the 46 patients, 61% still lived with their parent(s). Most had completed high school or an equivalency examination, 4% were in school or a training program, and 41%. were employed at intake. The average length of time during which they had used opiates was 6.7 years, while 94% had been previously treated for drug abuse (i.e., they were "repeaters- ). The socioeconomic composition of this (urban) group, as defined by Hollingshead and Redlich's

Two-Factor Index of Social Position,69 was Class III, 8%; Class IV, 66%; Class V, 26%.

Aside from their somewhat worse prognosis (mentioned above and in Appendix C), the major differences between this group and the overall DDTC patient population are probably that this group (1) was slightly younger; (2) had a slightly higher ratio of Whites to Blacks; (3 ) included fewer patients who had ever been married; and (4) included a

somewhat lower percentage of patients in a school or training pro-gram (4% vs. 18% ).

Chronic Alcohol Abuse

Effects on Mental Functioning

Five areas of mental ability are consistently compromised by chronic alcohol abuse: memory formation, abstract thinking, problem solving,attention and concentration, and perception of emotion. As many as 70 percent of people who seek treatment for alcohol-related problems suffer significant impairment of these abilities.

Memory Formation

By memory formation we mean the ability to form new memories, not the ability to recall information that was learned in the past. That is, an individual with a chronic drinking habit might vividly and accurately recall what he learned early in life but not be able to tell what he ate for lunch four hours ago. And the richness and detail of his memories during the past few years of drinking might be significantly less than in those earlier memories. On some tests of mental ability that assess differ­ent kinds of brain functions, chronic drinkers often perform lust fine on most of the categories but perform poorly on the memory sections. This selective and profound memory deficit may be a result of damage to spe­cific brain areas, such as the hippocampus, the mammillary bodies, or the frontal lobes.

Abstract Thinking

By abstract thinking we mean being able to think in ways that are not directly tied to concrete things. We think abstractly when we interpret the meaning of stories, work on word puzzles, or solve geometry or alge­bra problems. Chronic drinkers often find these abilities compromised. One way to measure abstract thinking is to show someone a group of objects and ask her to group the objects according to the characteristics they share. Chronic drinkers will consistently group things based on their concrete characteristics (such as size, shape, and color) rather than on the basis of their abstract characteristics (such as what they are used for, or what kinds of things they are). It is as if abstract thoughts do not come to mind as easily for the chronic drinker.

Problem Solving

We all have to solve problems each day. Some are simple ones, like deter­mining whether to do the laundry or the grocery shopping first. Some are more complicated, like setting up a new personal computer or deciding on what inventory to order for the next month's needs in a business. In either case, one of the required abilities is mental flexibility. We need to be

able to switch strategies and approaches to problems (particularly the complicated ones) to solve them efficiently. People with a history of chronic drinking often have a lot of difficulty with this. Under testing conditions, it often appears that they get stuck in a particular mode of problem solving and take a lot longer to get to a solution than someone who is better able to switch strategies and try new approaches. This diffi­culty could relate to the effects of chronic drinking on the "executive functions" of the frontal lobes.

Attention and Concentration

Chronic drinkers also develop difficulty in focusing their attention and maintaining concentration. This appears to be particularly difficult when related to tasks that require visual attention and concentration. Again, the deficits may not appear until the person is challenged. In casual conversa­tion, the sober chronic drinker may be able to concentrate perfectly well, but placed in a more challenging situation (like reading an instruction manual, driving a car, or operating a piece of equipment), she may be quite impaired.

Perception of Emotion

One of the most important elements of our social behavior is the ability to recognize and interpret the emotions of other people. Alcoholics have a deficit in the ability to perceive emotion in people's language. There is a specific brain function that normally gives us the ability to detect attitude and emotion in conversation. It turns out that chronic, heavy drinking markedly reduces this ability. It is important to realize that this deficit is one of perception and does not reflect the alcoholic's own emotional state. It's as if the subtle things like the tone and cadences of the other person's language that convey attitude and emotion are simply not perceived by the alcoholic. This is particularly interesting because we know that chronic heavy drinkers often have difficulty in social relationships. Per­haps this perceptual deficit causes some of these problems.

Do These Deficits Go Away?

Chronic heavy drinkers who quit recover these functions partially during the first month or two after the last drink. However, once this

time passes, they have gotten back all that they will recover. It is difficult to identify precisely how much recovery occurs, but clear deficits do appear to persist permanently in these individuals. In one study, people who had quit drinking completely after many years of alcohol abuse were examined for seven years. Even after this time they had significant memory deficits. This persistent pattern of memory deficits in previous alcoholics is common enough to have a specific diagnosis. It is generally

called either alcohol amnestic disorder or dementia associated with alcoholism.

SCOTT SWARTZWELDER