DOING YOUR OWN RESEARCH

DOING YOUR OWN RESEARCH

If reading this book has raised your level of interest and you want more specific information, or you want the straight story about a new develop­ment, there is no substitute for doing your own research.

Reading both scholarly review articles and original research papers is much easier than most people believe. In fact, one of the first steps in writing this book was gathering such research. Much of the library work for the first edition was done by two college students, neither of whom had any previous experience using a medical library. Should you decide to investigate for yourself, here are some suggestions about where to begin.

Public libraries are not likely to have the sorts of journals and books you will need. Because there is such a vast amount of medical literature pub­lished, most universities with a medical school have a separate library just to house all this information. Find a medical library at a nearby medical school. If for some reason you cannot get to a medical school, check to sec if there is a college or university biology department nearby and use the

library they use.

Next, go to the library and make friends with the reference librarian, because you will need his or her help until you are familiar with the library and the search mechanisms. The most efficient way of searching the literature is to use MEDLINE or PubMed, databases of the National Library of Medicine, a US government institution that allows you  

search almost all the published medical literature on any subject you can think of related to health. You can search by author, title, subject, key­word, institution, and many other descriptors.

In most cases you will find far more information than you need. A good place to start is with reviews. Reviews are documents that consoli­date and summarize the research and literature available in a given area, and they are usually written in less technical language. Reading several recent reviews about the topic you are researching will help you form a base of knowledge about the subject. Practice using MEDLINE by start­ing out with simple concepts; for example, search for marijuana articles. There are hundreds of them, and many of the titles will be so technical that they might seem indecipherable. So tell the computer to select mari­juana review articles. This will reduce the number markedly.

If you have read Buzzed, then you know that one of the active ingredi­ents in marijuana is THC. Try searching for THC and you will get more articles. Refine your search by asking for reviews of THC and you will get articles different from those you did when you searched for marijuana in general. Play with the database and have fun. Search for all kinds of com­binations of keywords, like THC and learning, or THC and adolescent. You will soon have an idea of the enormous amount of information there is about just this chemical. Understand, though, that no one study tells the whole story.

As a final note, we caution you not to accept everything you read as directly applicable to the human condition. Often scientists employ very high levels of a chemical to test for toxic effects in animals, and sometimes the chemical levels they use in/on animals are hundreds or thousands of times higher than a human would ever use, taking into account the weight of the human compared to the animal. Consequently, some of the toxic effects seen in animals may not apply to humans. On the other hand, ani­mal experiments cannot reveal many subtle effects of chemicals, particu­larly psychological ones, and thus animal studies almost certainly miss some important effects that humans will experience. So, as you read a sci­entific paper, remember that it is just a small part of the literature about a drug, and while the data may be true, it is important to understand that data in the context of everything else known about the drug.

ILLEGAL ACTS

The drug laws are complicated, and the states differ from each other and from the federal system. So, there is no easy way to explain them in detail. However, there are a few very powerful and relatively unknown aspects of the law that should be explained to everyone.

First is the difference between a felony and a misdemeanor. A misde­meanor is a minor crime that might result in a fine, public service, or a short prison sentence—typically less than one year (in the federal sys­tem)—and usually is associated with traffic violations, minor theft, or sometimes possession of a very small amount of an illegal drug. A felony (murder, armed robbery, sale of drugs) usually carries a sentence in excess of one year and is considered such a serious crime that convicted individ­uals lose many rights that ordinary citizens enjoy. This includes the right to hold many kinds of highly paid jobs. A felony conviction is truly a life-changing event. Understanding this is important for drug users because possession of some amounts of some drugs can be considered a misdemeanor, while larger amounts are always felonies.

The law always sets the level of punishment based on the amount of a drug that one possesses or distributes, and in this case size counts a lot.

For example, there is a current public controversy because the federal laws are terribly tough for possession of even a few grams of crack cocaine, but one would have to possess much more powdered cocaine to receive the same punishment. Anyone who contemplates drug usage should under­stand the severity of the penalties that various levels of drug possession invoke. (As we write this, the US Department of Justice has decided to modify the way US attorneys may charge cocaine/crack dealers. Now they can make the charge without stating the amount of drug, so that the pen­alties are more consistent between crack and powdered cocaine. The problem is that this is an executive decision and can be reversed in any case and at any time. The actual law regulating possession and distribu­tion of these drugs has not been changed.)

Most people know that conviction for selling drugs (distribution) results in stiffer penalties than for possession. What they don't know is that sim­ply possessing certain amounts of a drug can be considered an "intent to distribute" and thus may subject a person to the much stiffer distribution penalties. Moreover, money may not have to change hands for distribution to take place from a legal perspective. Simply handing a package of a drug from one person to another can be considered distribution.

Another obscure criminal area is conspiracy. In drug cases, there are many convictions for conspiracy to commit a crime because very often a drug deal involves much more than the simple transfer of money and drugs. The conspiracy laws are broad and powerful, and even people peripheral to the planning of a crime, who may not have participated in the crime itself, are often charged under these laws, sometimes in the hope that they will cooperate with the court officials to convict others. Anyone hanging around individuals involved in drug possession and dis­tribution should be aware of the risk of being charged with conspiracy for seemingly innocent acts, such as lending a boyfriend a car, cashing a check, or allowing a friend who is a dealer to use a telephone if it can be proven that in doing any of these seemingly innocent acts you knew why the person wanted you to do them. From the standpoint of law enforce­ment, drug dealing is considered a business (although it is illegal), and just as in a legal business, different people play different roles and have different levels of importance. In general, being around drug dealing is legally very risky.

Finally, there is the issue of the confiscation of property. Most of us have heard about auctions where the property of drug dealers is sold. This hap‑

pens because of forfeiture laws that allow property used in drug dealing to be confiscated and sold by the government. The particularly devastating aspect of this is that the property of a more or less innocent individual might be confiscated because it was being used in violation of drug laws. Imagine, for example, a student distributing cocaine from his father's home and car. Suppose the father knew something about this and told the student to stop it. If the prosecutor could prove that the father knew some­thing and allowed it to continue, it is possible that both the home and the car could be confiscated as part of the criminal prosecution.

What about marijuana? It's now legal, right? Some states have "legal­ized" marijuana possession for medicinal purposes; others have made the possession of small amounts for recreational use either legal or punish­able as a misdemeanor. But the US federal law makes it a crime in all fifty states. In general, federal law overrules state law, so you might well be in a state in which possession is legal but prosecuted under federal law. As we are writing this new edition, President Obama has asked the Department of justice to refrain from enforcing the marijuana laws in certain circum­stances for states that permit its possession. But that is an executive deci­sion that can he reversed at any time. Moreover, the specific conditions under which the federal law might be enforced may not be crystal clear. So, be aware that no matter what a state law says, federal law still has this drug illegal everywhere in the United States.

ASSESSING COMPETENCIES

ASSESSING COMPETENCIES

The personal experiences, competencies, and ambitions of family members are important both for building trust in therapy and for giving the therapist clues as to the most appropriate direction to proceed. The therapist can use his knowledge in these areas to create arguments in favor of home detoxification and to develop goals of treatment that are tailored to the family. The basic idea is to make use of what the family members know already, whatever skills they already have. This allows therapy to be based on success and strengths.

Strategy evolves by observing the family's reaction to new in-formation. Such new information might be drawn from the addict's knowledge of drug pharmacology and drug use (such as with the cases in Chapters 7 and 10). He is asked to share his expertise with the family. This could show the addict in a competent light, which can create trust between the family, the addict, and the therapist. The therapist's view that the addict is competent reflects favorably on the family's competence. The therapist can point out that in order to obtain street drugs consistently and successfully, the addict must be competent in acquiring and handling money. Discussions exploring this topic can make the addict more competent in his parents' eyes, and this competency reflects back on their skills as parents. Mean-while, the addict's competence on these topics is also being trans-mitted to the family as they become acquainted with the variety of alternatives the addict has at hand to obtain and use drugs. This knowledge places the family in a better position to understand the addiction and consequently help the addict to detoxify at home. It also shifts the structure and power balance from addict to parents; his authority is decreased as they become more knowledgeable. The confidence and expertise elicited through such discussions should be continually acknowledged, labeled, and reinforced by the therapist.

SAMUEL M. SCOTT JOHN M. VAN DEUSEN

STRUCTURAL AND STRATEGIC FAMILY THERAPY

STRUCTURAL AND STRATEGIC FAMILY THERAPY

The theoretical and operational facets of our therapy are derived primarily from structural family therapy and certain aspects of strategic therapy.* While there are differences between these ap-proaches, they also share certain commonalities. As a rule, both schools subscribe to the following view of the family or couple:

1.      People are seen as interacting within a context—both affecting it and being affected by it.

2.      The family life cycle and developmental stage are im-portant both in diagnosis and in defining therapy strategy—a problem family being seen as stuck at a particular stage in its development.

3.    Symptoms are both system-maintained and system-main-taining.

4.  The family or couple can change, allowing new behaviors to emerge, if the overall context is changed. Further, in order for individual change to occur, the interpersonal system itself must change. This would permit different aspects of such family members' (potential) -character- to come to the fore.

Both schools also regard therapy and the therapist in the follow-ing ways:

1.      Treatment is viewed pragmatically, with an eye toward what -works.-

2.      Emphasis is on the present rather than the past.

3.      Repetitive behavioral sequences are to be changed.

4.      While structural therapists may not be as symptom-focused as strategic therapists, both are much more symptom-oriented than psychodynamic therapists.

5.      Process is emphasized much more than content. This includes interventions that are nonverbal and noncognitive—in a sense, -doing away with words.- Such interventions are derived from viewing the system from a -meta- level and recognizing that verbalizations, per se, by therapist or family are often not necessary for change.

6.   The therapist should direct the therapy and take re-sponsibility for change.

7.   Diagnosis is obtained through hypothesizing, interven-ing, and examining feedback.

8.  Therapeutic contracts, which relate to the problem and the goals of change, are negotiated with clients.

9.  Interpretation is usually employed to "relabel- or re-frame- rather than to produce -insight.-

10.    Behavioral tasks (homework) are routinely assigned.

11.    Considerable effort may go into -joining" the family positively and reducing apparent -guilt- or defensiveness. This is more than simply -establishing rapport,- as it is often done selectively with particular family members and in line with specific therapeutic goals.

12.    Therapy cannot usually progress from the initial dys-functional stage to a "cure- stage without one or more inter-mediate stages, which, on the surface, may appear dysfunctional also. For instance, a therapist may have to take sides with a spouse, thereby "unbalancing- the couple in a way opposite from which it entered treatment, in order to restabilize at a point of equality.

13.    Therapy tends to be brief and typically does not exceed 6 months.

It may be apparent that some of these points are shared by other, more active interpersonal therapies also, such as the behavioral and  -communications training- approaches. However, most of them are distinctive of structural and strategic therapy.

THERAPIST FACTORS

THERAPIST FACTORS

Frequently we are asked what therapist variables lead to success in recruiting. The following four principles are devoted to such factors.

Principle 16: An important recruitment variable is the extent to which the therapist shows interest in the family through hir willing-ness to expend considerable effort in engaging thenz. From our experience, there are a number of therapist characteristics and atti-tudes that lead to more favorable recruitment rates. These include the following:

I . The therapist must be energetic. The recruitment process can be demanding in time and effort. Rather than expecting to sit in his office, the therapist should be willing to get out into the field and make home visits.

2.   Enthusiasm for the work is obviously essential. Sager et al.'26 noted a reluctance by many of their therapists to work with -poorly motivated- families.

3.   The therapist must be persistent and able to tolerate rebukes by family members.

4.   Flexibility and lack of rigidity are necessary, since they allow therapists to adroitly counter family resistance moves.

5.   The therapist must be convinced of the value of his endeavor and feel that it will be helpful to the family. This conviction will be conveyed to clients, and will help to change their negative -set.-

Principle 17: Providing incentives to therapists for each success-fully recruited case increaser the rate of success. Early in the life of our project the therapists began to complain that they were paid to do therapy and the recruitment effort was demanding an inordinate amount of their time. If this objection had been allowed to dictate our procedures, we would have been left with an unacceptably small, select sample, composed of -easy- or highly motivated families. Thus we were forced to rearrange our priorities and shift incentives. We did this by making a portion of the therapists' pay contingent upon successfully recruiting families—a bonus system. This had the double advantage of (1) reordering therapists' priorities through tangibly demonstrating the importance we placed on enlisting families, while also (2) providing them with reimbursement for the time they spent in recruiting activities. They were, of course, paid in addition for the time they spent doing therapy. However, money need not be the only incentive, and other programs might be able to establish alternative, nonmonetary procedures (see Chapter 16).

Principle 18: The program must be structured in a way that does not allow therapists to back down from enlisting whole families. This is a crucial point. We are convinced that if we had not held firmly to our requirement that the total family—or at least the IP, both parents, and siblings living in the home—be involved, the therapists would have settled for less. Without this mandate, we estimate that one-third of our families would have arrived incomplete, and treatment would have commenced without one or more important members. It would have been too easy to proceed with only the most willing participants.

Vignette 15. Adherence to Principle 18 sometimes had unexpected benefits. In one interesting example (in a case seen by David B. Heard, PhD) the recruitment requirement prevented a potential problem from developing in our research and treatment design. The addict in this case was in trouble with the law (although we did not know it at the time) and had a court hearing pending. Heard devoted great energy, including seven individual interviews plus numerous telephone calls, toward getting the IP to agree to engage his family. As the situation developed, it appeared that all members except the stepfather would agree to participate (the natural father was de-ceased). However, Heard could not make direct contact with the stepfather. This process went on for approximately 21/2 months with no results. Eventually the addict was caught selling drugs at the treatment center and was discharged for disciplinary reasons. He defected to another program and soon thereafter went to jail. We later learned from a counselor in that program that (1) the addict had been facing serious legal charges for some time, and (2) he had no "stepfather." The person the addict was trying to bring in as his stepfather was his uncle. Apparently the addict was trying to avoid prison by presenting a case to the judge that he was motivated to change, had entered a treatment program, and that his effort was earnest to the point where he could claim, "See, even my family is involved with me in treatment." However, he knew that we would not accept him in the family program without a father figure, so he tried to get the uncle to pose as stepfather. The plan failed because the uncle refused to take part in the masquerade. The point is, if Heard had not persisted in his demand for inclusion of the "step-father," the rest of the family would have come in and treatment would have progressed under the false assumption (by the therapist) that the nonexistent stepfather would eventually participate.

Principle 19: A mechanical approach to recruitment it insuf-ficient to guarantee success—flexibility and skill are crucial if the therapist is to avoid getting deadlocked. While the initial interview procedure described in Chapter 3 can probably be handled by most experienced clinical interviewers, recruitment of the whole family is more difficult. The latter demands a certain level of skill in dealing with families—essentially the kind of experience one gets in per-forming family therapy. Not only must one be able to show proper empathy and effective joining techniques, but one must also be able to respond to family interaction patterns.

The importance of recruiter skill cannot be overestimated. We do not agree that positive results are primarily due to "highly moti-vated therapists.- Therapists must be able to adapt the basic princi-ples of recruitment flexibly and creatively in order to meet the unique requirements of each case. Simply -plugging away- is insufficient. As in Vignettes 10 and 11, a skillfull recruiter can sometimes get results with a minimum of well-directed effort, much like the judo flip succeeds when direct overpowering will not.