GETTING CONVICTED: THE PENALTY BOX

GETTING CONVICTED: THE PENALTY BOX

The penalty laws of most states and countries are built on a series of leg­islative acts that happened over a long period of time, and thus, they are complicated and not easily summarized. Possession of modest amounts of marijuana can result in a slap on the wrist in some places and serious jail time in others. The same is true for other drugs, although they are usually taken more seriously, even in very small amounts. Often the prosecuting attorney has some leeway about the level of crime with which to charge an individual. The problem is that it is difficult to be sure of (1) the latest changes in the law, (2) the attitude that the prosecu­tor is taking toward drug crimes, and (3) whether that individual will be charged under state or federal statutes. Thus, conviction for the posses­sion of a small, recreational amount of heroin or cocaine could result in either a modest sentence or a huge fine and a long prison term, depend‑

ing on the exact circumstances and the mood of the legal officials over­seeing the case.

It is important to recall that in some states and in the federal system there is structured, or guideline, sentencing. That means that once an individual is convicted of some drug crimes, the sentence is regulated by law and might not be alterable by the judge no matter what the circum­stances. Coupled with the fact that there is no parole in the federal system (and increasingly in the state systems), a conviction can mean long prison time, even if the prosecutor and judge wish it were otherwise.

Here's an example of how things can go terribly wrong as a conse­quence of alcohol, a prescription drug, and harsh laws. One of us (WW) testifies as an expert in legal cases, and a recent one illustrates how the law, the prosecutor, and the courts can interact to ruin the life of an indi­vidual. A man was at a party with his neighbors outside of his home. He consumed a modest amount of alcohol throughout the evening, but at some point he decided to go to bed and took his nightly medicine, which included the sleeping pill zolpidem (generic for Ambien). Before going to bed, he came back to the party but soon appeared intoxicated. He then prepared for bed and went to sleep. Shortly thereafter, he awoke and came out of the house without his shoes, false teeth, or hearing aid, clearly hav­ing just awakened. But he had a gun, which he had retrieved from his bedside where he kept it. He fired twice as he yelled an obscenity to the individuals at the party. No one was hurt. The police were called, and he was arrested.

The man was charged with aggravated assault, and everyone thought he was intoxicated with alcohol. In the law of most states, that is consid­ered "voluntary intoxication" and thus is not a defense against any charges. His defense team argued that he was not intoxicated with alco­hol, but with his prescribed zolpidem, which is known to produce odd behaviors such as sleep driving, sleep sex, sleep shopping, sleep eating, and so forth. If it were the zolpidem, that would be "involuntary intoxica­tion," and that is a defense against such charges.

The jury heard the case and decided that he was intoxicated by alcohol and was therefore guilty. Now, here is where the disaster occurred. In that state, commission of many crimes (such as aggravated assault) with a gun is a mandatory ten-year sentence. If the gun is fired, the mandatory sen­tence is twenty years. In this case the prosecutor chose to charge the man for each of the six people present at the party, and the law requires that the mandatory sentences apply to each charge and be served consecu­tively. This means the man (who has not been sentenced at this writing)

must, by law, be sentenced to 120 years in prison. The judge has no discre­tion in this case.

This is a terrible example of the interaction of intoxication, harsh laws, vigorous prosecution, and finally, the presence of a gun where a sleepy, intoxicated person could access it and fire it. This man had no history of behavior like this and was a decorated soldier. It is very likely that the zolpidem produced the bizarre behavior, but the prosecutor and jury did not see it that way.

The lesson from this is that if a person chooses to intoxicate himself and then commits a crime, that intoxication is usually not a defense against any crime he committed, no matter how impaired he was at the time of the crime.

Designer Mescaline-like Drugs

Designer" Mescaline-like Drugs

A large number of variations on the structure of mescaline were first "designed" during the original chemical studies of mescaline. The names sound like an alphabet soup: DOM (2, 5 dimethoxy-4-methylphenyliso­propylamine, also known as STP), MDA (methylenedioxyamphetamine), DMA (dimethoxyamphetamine), MDMA (methylenedioxymethamphet­amine, or Ecstasy). All of these drugs are less specific than mescaline and produce strong amphetamine-like effects in addition to hallucinations. As a result, all are more toxic than mescaline and appear much more rarely on the street today. Ecstasy provides a unique profile of effects, dis­cussed in the "Ecstasy" chapter.

'fhe spices nutmeg and mace deserve a final note as we discuss the mescaline-like hallucinogens. Someone who takes several teaspoons of nutmeg (if he can figure out how to avoid the overwhelming taste) might experience a very mild hallucinogenic state that includes perceptual dis­tortions, euphoria, and sometimes mild visual hallucinations and feelings of unreality. The active compounds in nutmeg and mace are myristicin and elemicin, compounds with structures somewhat like mescaline. These compounds are very weak hallucinogens, and the dose required to evoke changes in perception causes a number of unpleasant side effects including vomiting, nausea, and tremors. Furthermore, an aftereffect of sleepiness or a feeling of unreality can persist into the next day.

OTHER LSD-LIKE HALLUCINOGENS

OTHER LSD^-LIKE HALLUCINOGENS

There are many other molecules with chemical structures that resemble serotonin (tryptamines) or amphetamine (phenethylamines) that scien­tists or bootleg drug preparers have made. 2C-B is one example, but there are many, and odd variants pop up all the time. Those that have been stud­ied scientifically owe their hallucinogen properties to the same mechanism as LSD. However, each one has the potential to exert additional effects due to interactions with multiple receptor types, and so the effects can be indi­vidual and perhaps not what the user expects. A former synthetic chemist, Alexander Shulgin, and his wife published two books that describe the synthesis and use of these drugs, which some use as a guidebook. Those with amphetamine-like structures often have amphetamine-like activities along with their hallucinogenic properties, which can lead to dangerous levels of sympathetic nervous system stimulation and increased heart rate and blood pressure, for example. All such drugs are illegal in the United States (see the "Legal Issues" chapter).

DMT

Dimethyltryptamine (businessman's special) is one of the other serotonin­like hallucinogens that appear on the drug scene in North America. The compound originally derives from the beans of the tree Anadenanthera peregrine (sometimes referred to as Piptadenia peregrine), which grows in northern and central South America, and related species in southern South America. It has been used by South American tribes as a halluci­nogenic snuff called yopo or cohoba. However, it is most often available today as the pure compound, which users prepare as a tea or smoke by itself or in conjunction with marijuana by first soaking the leaves in a solution of DMT and then drying and smoking them. The drug takes effect very rapidly: the entire experience develops and finishes within an hour. Probably because the onset of action is so fast, DMT causes anxi­ety attacks much more frequently than LSD, although the basic experi‑

ence is similar.

Some serotonin-derived compounds, such as 5-methoxy dimethyl­tryptamine (5-Me0-DMT) or bufotenin, are found in the skins of some toads, including the Colorado River toad. Milking the glands on the back of the toad to obtain the hallucinogens, which are then smoked or ingested, was an old Native American trick that has been repopularized to the extent that the Wall Street Journal reported it. The high that is produced is extremely brief and accompanied by much worse side effects than most hallucinogens, including increased blood pressure and heart rate, blurred vision, cramped muscles, and temporary paralysis. These are due mainly to the bufotenin. The same compounds also appear in the seeds of a number of trees that grow in the Caribbean, Central America, and South America (Piptaclenia peregrina). The powdered seeds provide the basis for hallucinogenic snuffs used by indigenous peoples and have been identified as a component of voodoo powders. DMT, 5-Me0-DMT, and some other variants including 4-Acetoxy-DMT and 5-Me0-DiPT (N)N^-diisopropy1-5-methoxy-tryptamine) also show up in pill form. The basic effects of these drugs are similar, although the duration of action varies.

Peyote Cactus (Mescaline)

The peyote cactus has likely been used as a hallucinogen by native tribes in Mexico for thousands of years, and its use by North American tribes is an accepted part of their histories. The species that is typically the source of hallucinogens in the United States is a cactus that grows in northwest Mexico: Lophophora williarnsii. It produces mescaline, the active halluci­nogen, as well as many other compounds. The dried "button" of the cac­tus is the usual form in which the drug is sold, although it also appears in other dried forms (powders, etc.), as well as in a tea. While it can be smoked, the button is usually swallowed without chewing, and the active agent is absorbed from the stomach and intestine. There are other cacti that produce hallucinogens, including the San Pedro cactus (Trichocereus pachanoi), which grows in the Andes Mountains of South America.

Mescaline's chemical structure does not resemble LSD or psilocybin and the other serotonin-like hallucinogens. Instead, the structure looks more like amphetamine. The physical effects also resemble those of amphetamine—dilated pupils, increased heart rate, and increased blood pressure. The mental effects as described by ritual and recreational users, however, are surprisingly similar to LSD. Nausea and vomiting are com­mon, especially soon after ingestion of the cactus buttons. After a user ingests a number of cactus buttons, he often feels an increase in sensitiv­ity to sensory images and sees flashes of color followed by geometric pat­terns and sometimes images of people and animals. Time and space perception are distorted, as with LSD, and people often feel that they are outside themselves. The effects of ingesting pure mescaline versus the cac­tus button are similar but not identical, because there are at least thirty other compounds in the cactus.

The ritual use of this cactus by the shamans of native tribes, such as the Huichol in Mexico, persisted into recent times, and North American tribes adopted it in the late nineteenth century. The ritual use by North American tribes was then integrated with a number of Christian prac­tices in the form of the Native American Church. The use of peyote as a part of this church's religious rituals has been protected by the First Amendment and then later by the Religious Freedom Restoration Act (1993). The act states that the government can limit a person's exercise of religious freedom only if "it is in furtherance of a compelling govern­ment interest, and is the least restrictive means of furthering that com­pelling interest." Although the 1993 law was declared unconstitutional by the US Supreme Court in 1997, some states have since enacted protective legislation for religious use to replace the protection no longer provided by federal law.

GOALS OF FAMILY TREATMENT

GOALS OF FAMILY TREATMENT

It is best to negotiate the goals for therapy with the family at the very outset of treatment. This is because (1) it provides family members with the sense that treatment will have direction, rather than wander-ing about aimlessly or having as an endpoint the uncovering of personal pain or feelings; (2) it indicates to them that they may get some return for their efforts, that their energies will not be expended fruitlessly; (3) they can take some satisfaction that the therapist at least seems to know what he is doing, thus possibly instilling in them a sense of hope. All of these features serve to both increase the as red herrings by the therapist—as ways of pulling therapy off track and diverting its thrust. Thus the therapist should question their relevance and require that the members who raise them justify their pertinence to the primary goal. (For example, a discussion of the addict's getting a job would only be considered appropriate if it were seen as important in keeping him off drugs.) The general rule is for the therapist to keep sessions focused on drug use until stable im-provement has been achieved.

It is crucial that the therapist form an alliance with both parents or parent surrogates in this stage so that they may take an effective stance toward the addict around the chosen goal. The therapist must keep the parents working together in the early phases, even siding with them against the addict upon occasion. Sometimes therapists, especially young therapists, are uncomfortable in treating a young adult in this manner. For example, such a therapist might feel uneasy suggesting that the parents negotiate a time when their 27-year-old son should be in the house and off the streets in the evening. What one finds, however, is that the IP is often surprisingly cooperative, even though he may protest the fact that he is being treated as a child. This cooperation can be explained as gratitude in many cases. The addict is secretly grateful for the fact that the parents' relationship is being attended to by the therapist. In general, it is very difficult for the addict to significantly improve his situation and remain that way unless there appears to be some tangible evidence that the therapist is addressing the needs of the parental subsystem.

If freedom from drug taking has been maintained for a month or more, it may be possible to shift emphasis to other treatment goals. Two common ones have been mentioned—gainful employment or schooling and getting the addict out of the home. Underlying both topics are issues of separation—either physical separation or separa-tion through increased competence and the resulting independence of functioning. The therapist should be sensitive to the meaning of such separations for the family and restructure therapeutically in such a way that alternative supports are provided for members who are likely to feel the greatest loss.

Similarly, as progress occurs in all the goals relating to the addict, it becomes possible for the therapist to move flexibly toward dealing with other family issues. As is amply demonstrated in suc-ceeding chapters, such a broadening of goals is important at this stage illegal drugs, but it is necessary to get this issue on the docket as early as possible.* Then a process of negotiation can be started as to a date for detoxification and how the family is to prepare for it.

Often questions arise about the feasibility of having the addict become totally drug-free. We have found it critical for the therapist to be committed to this goal and to recognize that as long as the addict is on any drugs, including methadone, he is still labeled as an addict and the basic situation is unchanged (see Chapter I ). It is tempting to think of an addict as similar to a diabetic, implying that he will always need methadone. It is Haley's experience that working from such a

• model with schizophrenics almost never leads to cure.-j- Similarly, the therapist working with an addict is hopelessly hamstrung if he sees his job as helping the family to cope with a handicapped person suffering from an inherently chronic, incurable condition.

It needs to be underscored that the goals are negotiated with the family rather than being foisted upon them by the therapist. Thus the agreed-upon goal must be one that makes sense to them. This process begins by first assessing the priorities and competencies of the client and family, then reaching closure on a realistic and achievable goal. Although the therapist recognizes that the family may be ambivalent about a goal, he seeks to have the goal stated publicly in order to urge the family to action and, in a sense, to call their bluff. If, however, a family is extremely resistant at the outset to the idea of having the IP get off drugs (including methadone), the therapist might be better advised to postpone family treatment and obtain an agreement with them to reconvene when they have decided they do not want an addicted member. Otherwise, the purpose of therapy becomes unclear and the chances for retention of the family in therapy and for any real change are very slight.

Once an agreement has been reached about goals for the IP's drug use, family members may raise other issues or problems. As noted in Chapter 4, some other, crisis-laden issue may even underlie the addict's move to initiate treatment (e.g., he might be about to get married). While these problems may be real, they should be regarded as red herrings by the therapist—as ways of pulling therapy off track and diverting its thrust. Thus the therapist should question their relevance and require that the members who raise them justify their pertinence to the primary goal. (For example, a discussion of the addict's getting a job would only be considered appropriate if it were seen as important in keeping him off drugs.) The general rule is for the therapist to keep sessions focused on drug use until stable im-provement has been achieved.

It is crucial that the therapist form an alliance with both parents or parent surrogates in this stage so that they may take an effective stance toward the addict around the chosen goal. The therapist must keep the parents working together in the early phases, even siding with them against the addict upon occasion. Sometimes therapists, especially young therapists, are uncomfortable in treating a young adult in this manner. For example, such a therapist might feel uneasy suggesting that the parents negotiate a time when their 27-year-old son should be in the house and off the streets in the evening. What one finds, however, is that the IP is often surprisingly cooperative, even though he may protest the fact that he is being treated as a child. This cooperation can be explained as gratitude in many cases. The addict is secretly grateful for the fact that the parents' relationship is being attended to by the therapist. In general, it is very difficult for the addict to significantly improve his situation and remain that way unless there appears to be some tangible evidence that the therapist is addressing the needs of the parental subsystem.

If freedom from drug taking has been maintained for a month or more, it may be possible to shift emphasis to other treatment goals. Two common ones have been mentioned—gainful employment or schooling and getting the addict out of the home. Underlying both topics are issues of separation—either physical separation or separa-tion through increased competence and the resulting independence of functioning. The therapist should be sensitive to the meaning of such separations for the family and restructure therapeutically in such a way that alternative supports are provided for members who are likely to feel the greatest loss.

Similarly, as progress occurs in all the goals relating to the addict, it becomes possible for the therapist to move flexibly toward dealing with other family issues. As is amply demonstrated in suc-ceeding chapters, such a broadening of goals is important at this stage of therapy, whereas it would have been inappropriate in the initial, acute phase of treatment.

Approaches to Fathers

Approaches to Fathers

As might be expected, fathers were the most difficult family members to recruit. However, the lore in the field may be exaggerated on this point. We have heard other therapists complain, 7We can't get the fathers in,- when they never contacted these men directly and left the recruiting to someone else. What these therapists may really mean is they cannot get other family members to bring fathers in. As other authors have stated," 86 contacting fathers directly can make a dif-ference.

Even granting the above, however, the fathers in our sample presented special problems. At least 72% of them had drinking problems1" and did not want this brought to light in a therapeutic situation. Some were rarely at home, and asleep when they were. Still more common was a family pattern in which the father was shut out from communications about the IP or his treatment. The family structure was tight and rigidly channeled. It was not unusual for the rest of the family to agree to participate and then come in without  telling the father where and when they were going, or for what reason. On more than one occasion a therapist called a father to confirm an appointment, only to get a -What are you talking about?”

response. Again, preappointment contact with fathers became a necessity.

Engaging fathers was one of our more demanding tasks and often one requiring the most creativity. At one time or another we used all of the guidelines (summarized earlier) that L'Abates6 has presented for enlisting fathers. The following vignettes give some

idea of the latitude and innovation that can be applied to this endeavor.

Vignette 5. The therapist (Paul Riley) tried numerous times to reach a

father at home, but to no avail. Finally, he made a visit to the father at

his place of work in order to foster trust and explain the treatment program.

Vignette 6. Three home visits were made. On the first, the therapist (Jerry I. Kleiman) commiserated with the mother while she cried and talked about how things were. The next night he returned to the home and sat with the father in the den, where he had numerous pictures on the wall of his son as a Marine. The father lamented about what his son "could have been." The two of them talked and drank beer together. The following morning Kleiman went over and brought the family in for treatment.

Vignette 7. In this case the therapist (Paul Riley) sensed that the father was suspicious and jealous because this strange man (Riley) had come to his house to talk to his wife. Consequently, Riley brought his own wife along for the next visit. This reduced the threat, because now Riley had his woman and the father had his.

Vignette 8. In a case seen by Sam Kirschner, PhD, the father was adamantly against coming and said his son didn't deserve the effort. Drawing upon his clinical knowledge and experience, Kirschner sized up this situation as one in which, unless change occurred, the addict was in danger of "going off the deep end." He sensed that the young man was feeling desperate and that something had to be done to avert a tragedy. It became clear that a harsh reality was being ignored and that the father's (and family's) denial had to be con‑fronted directly. Because the stakes were so high he decided to take a gamble, which required two steps. First, he moved to counter the father's resistance by referring to a pattern that is typically seen in addicts' families and one that was suspected in this particular family: he made a joining pitch by connoting positively that the father really cared more about his son than he let on, and that if something happened to the son, father would be the flrst to help him out. The second move was to confront the denial. Kirschner left the father with the prediction that if he did not come into treatment, his son would either be dead or in jail within 2 weeks. The son obliged by getting arrested 3 days later, and the father took out a second mortgage on his home to raise the bail money. These events ob-viously gave Kirschner considerable power from that point on.

While Kirschner's prediction might seem extreme, or even absurd, it should not be mistaken for a paradoxical intervention. Rather, he was rubbing in a harsh reality. The probability for disaster was high, and this was not being recognized by the father. It needs to be emphasized that these addicted young men die or become im-prisoned at rates that are many times higher than for similar men in their age group (see Chapter 1). From our own data (see also Chapter 17) 10% of a matched group of clients (who were not assigned to family therapy) died over an 18- to 48-month follow-up period (average 31 months). This mortality rate was five times higher than the 2% of deaths that occurred during the same period for cases that engaged in family therapy. Our therapists were aware of the threat to life or other dangers extant when the addictive process was allowed to continue unchecked, and Vignette 8 presents one response to this exigency. In this context a sense of -mission-was hardly inappropriate.

Vignette 9. Therapist Samuel M. Scott encountered a case where the father worked two full jobs and was only at home and awake for 15 minutes of each day. Father's routine was to arrive home, wolf down a meal, and go immediately to bed. Scott made several telephone attempts and missed the father by 5 or 10 minutes. When he finally did catch him, he opened by being extremely contrite, recognizing how busy the father was and how hard he worked, and apologizing for interrupting his schedule. He was so apologetic that the father's curiosity was aroused, and the conversation turned into one with the father asking Scott questions about his son's program and about how he and the family could help.

An important ingredient of this vignette was the way Scott intuitively responded to signals from the father about the latter's personal space. He let the father know immediately that he was sensitive to issues of -turf,- in a sense saying, respect your boundaries and your privacy.- Establishing such respect early allowed rapid joining and a smooth transition into the matters of treatment.

Vignette /O. This was a situation in which the mother and siblings agreed to participate, but they claimed that there was no way the father would become involved. Mother said she had petitioned her husband about it several times without results. She conveyed to Sam Kirschner, the therapist, the pain and frustration she felt at her husband's intransigence—she could not move him. She noted how badly things were going, both in general and with her husband. It was clear to Kirschner that she hoped he would do whatever was necessary to budge her husband from his position, and that the information she conveyed might provide Kirschner with momentum. After several attempts, he finally reached the father by the telephone. The following is a reconstruction of that conversation.

Approaches to Mothers

Approaches to Mothers

Compared to fathers, there seemed to be more variability in the difficulty entailed in engaging mothers. More mothers than fathers responded positively to the opportunity to become involved in their son's treatment. Some appeared to want to control what happened to their sons, especially if the sons were improving. They wanted to know what was going on, so they could take charge of it. This was fine with us. We could "fly" with it. Our main concern was to get them in, no matter what their motivation.

On the other hand, there were mothers whose resistance equaled or exceeded that of their husbands. They might not oppose the idea openly, but instead would use the intransigence of their husbands as an excuse for not participating. Some techniques that could be used for recruiting mothers have been described. Others are discussed in the next section. Only one vignette will be presented here, partly due to its uniqueness.

Vignette        In this case the addict had a 6-year history of drug

problems. He started heavy drug use at age 16, injecting ampheta-mines and taking barbiturates regularly. By age 19 he was addicted to heroin. He had failed two prior treatment attempts and at intake was still addicted to heroin (10 bags per day), supplementing this with regular use of barbiturates and marijuana. It also appeared that the family had many problems and was clearly making the situation impossible for the addict to improve. Samuel M. Scott, the therapist, determined from his conversations with the addict that the family members were downplaying their importance for therapy. The addict was about to drop out or be pulled out of treatment and the family was scared. The sense that they were slipping away and had lost any notion of urgency prompted Scott to give it his best—and perhaps last—shot.

The family was a large one, with seven children. For such a sizeable group, the payment for participating in the evaluation ses-sion gained salience. This unusual aspect provided the therapist with a means for (1) gaining attention, (2) downplaying the possible nega-tive implications of family involvement in treatment, and (3) under-scoring the urgency of the situation. The following is a reconstruction of Scott's first phone call to the mother.When the mother called later, she was given more details about the evaluation session. By that time, the decision had been made to

participate, however, so she was not looking for reasons to back out.

The humor in this vignette should not obscure the sound theo-retical base underlying Scott's approach. It derived from his prior

knowledge of the family. Scott was aware of their increasing re‑

luctance. He attempted to create a sense of urgency and surprise in

order to catch them off guard and cause them to focus on a positive aspect of their participation.

The money served as a convenient vehicle for taking the family's side against an "impersonal- institution. While financial incentive

seemed important in this case, a similar tack could have been taken using a different source of leverage.* For instance, the therapist could have called with a different scenario, saying, "It's finally come through! They're gonna let us do it!" [-Do whatfl " They're finally gonna let the family help with the treatment! It's fantastic! We've been trying to convince them for years that they should let the family know what's going on. My God, let's get it set up before they change their minds. We can't lose this opportunity! I'm really glad for you,- and so forth. This particular variation of the approach might be appropriate for a family who had previously experienced treatment for their son and had felt closed out. It should be recognized that the specific content chosen should be in response to a given family and its

situation, rather than an indiscriminate application of a series of -pat" or -canned- phrases.

An important point in this handling of the recruitment process is that it reframes as positive an event that has the potential to be viewed negatively by the family. Instead of presenting them with the

prospect of having their dirty linen examined by a -bunch of shrinks,-

 they are presented with an opportunity. This opportunity is portrayed as beneficial and no blame is attached to it. Consequently, the -reality- is shifted. The tone of urgency, enthusiasm, or concern only supports the importance and the positive features of the event, thereby fortifying the shift.