The birth of outpatient treatment

How did the idea of outpatient treatment come about?

The idea of outpatient treatment was born many years ago, when I was a resident at the Borda neuropsychiatric hospital. It troubled me a great deal to see how, faced with a crisis, families would leave the patient at the hospital, getting rid of the problem and playing a very passive role before the “expert” professionals. Then, in most cases, they never came back and the patient was left “deposited” there. That is when, with other professionals, we set up an outpatient care programme (1) in which we admitted patients who arrived at the hospital with an indication for hospitalisation. We were thus able to see that most of the patients who were not hospitalised could get through the crisis at home, with their family. In this way we spared them all the harm of a hospital stay and, at the same time, it represented significant savings for the hospital.

Did those who were not hospitalised have a therapeutic companion?

No. It was members of the family structure, friends, neighbours or people of good will who acted as companions, and very effectively at that. One of these members of the extra-familial support network was called in to take part in the family sessions.

What we wanted to prove with this experience was that hospitalisation, very often, was completely unnecessary.

And also how families and their network, properly guided, could take charge of the situation and get through the crises.

The essential thing was, and still is, to support them, to trust them and to convey to them at every moment that they are capable of generating resources to overcome difficult situations.

First contacts with the addict and their family

Was it from this experience that you created a different form of care?

From this experience we created a different form of care, which I put into practice some time later, in 1984-1985, when I returned to the Borda as coordinator of the family sector of the outpatient department and organised a systemically oriented service. I managed to get a one-way mirror installed, a Gesell chamber, and I began to coordinate a team of professionals, many of whom (*) are still with me today.

It was precisely there that I made my first contact with drug addicts and their families, who would come to two sessions and stop coming at the third.

Faced with our therapeutic inability, I decided that we would no longer take on addictions in family therapy. And we organised an internal conference on “therapeutic failures”, where we could speak out and reflect on our mistakes. That got me dismissed from the hospital for the second time (I had already been let go around 1975), but this time I left accompanied by the whole team that was working with me.

The experience taught us that with drug addicts, working in isolation in a family therapy service produced no results, and that individual therapy was not effective either. The therapeutic response to addictions had to come from elsewhere. I do want to make clear, however, putting the experience in context, that in the sessions related to addictions something different was happening from what happened in consultations for other reasons. It was a different dynamic, which did not fit with what I knew or thought I knew; the literature we consulted was scarce and poor: it said, for example, that the addict was a psychopath, but offered no effective therapeutic way out. In short, that is how we came out of university, repeating concepts that bore no relation to what we would later see in clinical practice.

What did you do then?

I tried to find out who was treating drug addicts with more or less positive results. And I discovered institutions that had nothing to do with professionals, coordinated by former addicts. I was curious and wondered what methods they used and what went on there. That led me to make contact with Carlos Novelli (founder and director of Proyecto Andrés), who had just arrived from the United States and who, at that time, in 1986, was beginning to take an interest in working with families.

Trying to find out what went on in these therapeutic communities, I got close to them, I observed on site how the former addicts worked and I discovered a model that generated an intense emotional mobilisation, completely different from anything I had known. I decided to stay there to learn how to work with families, couples and parents’ groups.

Later, I proposed to Novelli, a character full of life, a genuine leader, innovative and affectionate, that we organise an outpatient space.

I believe it was the first programme of its kind carried out in the country. We worked with the addict in peer groups, with family therapy and with groups of parents and other family members. The teams were mixed, made up of professionals and former addicts; we got to the point of having 108 people in treatment, and at the general meetings we could gather between 400 and 500 people.

In two years, we designed an outpatient model, correcting mistakes as we went along, since we had no references and there was as yet no literature.

I was accompanied by that team which had left the Borda with me, joined by other professionals and former addicts. In 1988, we decided to organise our own programme, which we called “Proyecto Cambio” (Project Change), and which I currently run with Susana Barilari.

The beginnings. We started from scratch; growth was not easy at all. In the early years, I found myself obliged to be visible, and I gave courses everywhere. The programme had to be made known. Meanwhile, we were recording and supervising almost all of the work so that we could study it afterwards. I believe that meeting constantly with the team to reflect on every detail of the work allowed us to correct and adjust the technique and to find new resources. That is how we gradually shaped this programme to which, over time, we have made a thousand modifications.

Today, ten years on, is the idea still the same?

Yes; despite the modifications, the important thing is that we have kept the same ideology, giving importance to the group dimension, to work between families and to the mixed team, which for us are the pillars of outpatient treatment.

And what encouraged us to carry on was seeing that the results were highly positive, with very few relapses.

Have you had any other experience?

Yes; as addictions adviser to the Secretariat of Health, I had the opportunity to go round the hospitals of the federal capital, and I saw at close quarters how chaotic the care of drug addicts is there. Fortunately, few of them go there for treatment. Going through these departments, I saw once again that the university does not train professionals who know about addictions, and that individual therapy models such as psychoanalysis are of no use in these cases. We have to think of programmes that include specific group models, with the participation of former addicts and the inclusion of the family in therapy; in short, work that is a whole specialty in itself. We had planned to open neighbourhood centres outside the hospital, similar to those I had seen in Madrid, so that each addict could be treated in their own neighbourhood, sparing them the expense of time and money involved in travelling with their family. These “centres” would also have taken charge of prevention in the schools of the area and of work in public squares. The idea was to decentralise the task by creating concrete people in charge, but unfortunately this project was aborted a few days after it began to operate.

Treatment: weaving the networks of solidarity

The addict sleeps at home and comes to their groups several times a week, because we consider that their family or their social network can accompany and contain them. If an addict’s parents tell me that they both work, that they are alone and have nobody to help them, I suggest we think together about someone who could accompany them, because otherwise they will not be able to be treated here.

I can assure you that most of them discover a family member or a friend, and that afterwards, little by little, the network emerges. Nobody exists alone; there are always human resources ready to lend you a hand. It is sometimes hard to open up and ask for help, but when we do, we discover the solidarity that surrounds us.

When their treatment ends, the addict, now recovered, invites the people who collaborated in their recovery to a very moving ceremony, and it is wonderful to see uncles, cousins, friends, neighbours appear like ants… a real network that took part in helping them. And which, at the beginning, did not show itself, because the family, ashamed or crushed by pain or anger, did not dare to call on it. Then, people gradually draw closer, roll up their sleeves: help very often springs up beyond the limits of the strictly familial.

And what happens with the gang on the street corner?

Which one, the kids he takes drugs with? If I demanded from the outset that a young person drop his friends or stop taking drugs, I would really be crazy, because what reason would he have to do so? Because I tell him to? If he obeyed me, how easy it would be, then, to stop using drugs. That is why, from the very beginning, we have to take sure and effective steps, which are neither an order nor an imposition – which, generally, are not respected. Let us think of it as a process in which norms and behaviours related to self-care and risk avoidance are gradually put in place.

How does treatment begin?

Generally, the relationship with our institution begins with a phone call from a mother or a father (but sometimes it is the siblings or the wives), worried because a family member is taking drugs. A few years ago, I used to receive them all together, and the result was an angry addict, who mistreated his parents and had a provocative or absent attitude. The parents looked at me expecting me to convince their son of the benefits of treatment, and if I tried to do so, the bond I could establish with the addict was tense and totally ineffective. The “circuit” was as follows: the parents delegating the problem to the expert, the expert believing it, and the addict displaying a high level of provocation. Result: it was of no use at all.

Over time, we changed this way of making contact, and today we maintain a different initial relationship: before seeing the addict, I call in the parents on their own and I have a brief interview with them in which I propose, as a prior and necessary condition, that they come to an orientation group attended by other parents in the same situation as them. This group also includes one or two parents from our institution whose children are about to finish treatment, so that they bring their experience and tell what they felt. A group of reflection and exchange of experiences is thus created, where each person talks about what is happening to them and the others give their opinion, helping in a spirit of solidarity. These parents enter into a relationship with their peers in a climate of productive work.

We hear:

“The same thing happened to me as to you, and I did this or that” or “All our children’s behaviours are alike; now I no longer feel I am the only one”. All of this said in an emotional context of pain and helplessness, where they are no longer ashamed to mention lies and thefts that were often kept hidden. What we see is that this father, coming out of the orientation group, is completely different from the one who arrived: he feels more energy, he sees things more clearly, he sometimes has hope in his own strength and he is surely in a position to talk to his son with more conviction and firmness. The parents then learn a few strategies for telling their son to come to an interview, because many say that young people refuse to do so. I assure you that, in most cases, the son accepts and, even if angry, turns up. Once this step has been taken, and with the family’s collaboration, the start of treatment is set.

Is the first interview with the addict individual? Who conducts it?

Yes, it is individual, and it is conducted by a former addict who finished his treatment some time ago, that is, someone who has been through the same thing and managed to get out of it. A kind of melody is established in this relationship between the former addict and the addict; to communicate, they use a unique language, impossible to obtain if the interviewer were a professional. Generally, within a few minutes, the truth about the drug use begins to emerge, and it is far greater than the parents believed. Moreover, coming to our institution for the first time, they see that it is an open house, and they change the prejudiced image they had of it, imagining a place with bars, like a prison, because they may have heard that on the street, or even because they have lived through an experience of confinement.

The stages of treatment. Admission is a process that lasts about a month. During this period, the addict and their family group take part in several weekly sessions: parents’ groups, addicts’ groups, family therapy, etc. Only then can we really assess the family’s capacity for containment and the degree of commitment; in this way, they will be able to determine whether they really find in our institution the help they need. Meanwhile, the addict learns to avoid risk situations, to take on board certain limits, and it is common for them to reduce or suspend their drug use. They are already functioning in a peer group with whom they reflect and begin to question certain behaviours. Once a week, we bring together everyone who is in treatment, and the “old hands” give “tips” (information that may be useful to them) to the “newcomers”, and tell them how they themselves dealt with each obstacle.

What is the next stage?

Once the admission stage is completed, if they decide to stay, the initial phase begins (which we call “A”), where they will continue to attend family therapy, the groups of addicts, parents, siblings or wives, and other activities such as sport or music.

In this stage, we work on compliance with norms, such as getting up and going to bed at a set time, studying or working six hours a day and not frequenting places that involve risks. These are rules of care and order in daily life, intended to allow them to organise their free time while avoiding certain dangers, since it is assumed that at the beginning they do not possess the internal instruments of control and self-care that they will gradually acquire.

This first stage lasts about four months: it is not easy for them to get organised and to comply with the norms in order to get out of disorder and chaos.

Then begins phase “B”, where the norms are now followed automatically. We then work on relationships with work, with studies, with emotions and with mistreatment, a very important theme.

At the end of this stage, outings with fellow group members are encouraged; that way they feel more protected. It must not be forgotten that before, they used to dance while high or with a glass of whisky in hand, or would go and take drugs in the toilets of a bar. They are full of terrible images from other times, which today, treated and accompanied, they dare to face.

After about six months, phase “C” begins, in which the norms to be followed will be those that each family determines: they will negotiate among themselves the timetables, the outings, whatever is needed. Thus, little by little, they learn to discuss properly, with confidence (and even with legitimate fears), the norms of life together in each home.

The final phase is detachment, that is, separation from the institution. Which, in many cases, is the first time in their lives that they manage to finish something properly.

Is the treatment then considered finished?

Yes, but we keep on “evaluating”. At first, once a month; in the second year, every three months; and in the third, every six months. The results of this evaluation are very favourable: only 10 to 15% of those who finish relapse, that is, start using again. With one particularity: these are very brief relapses, because their families, who now know what to do, act quickly. If you compare these figures with the statistics of other places, it is fantastic, but we must not fool ourselves: it is impossible to compare without knowing in what contexts one works and with what population. These figures would be different if we worked with a marginalised population or one without a cooperating family.

Group clinical work

Who coordinates the groups?

They are mixed teams, made up of a former addict and a professional therapist.

Do you use individual therapy?

No. There may be a brief interview in very extreme personal situations, but we avoid material being withheld from the groups and triangle situations being created. Peer groups and family therapy are, I repeat, the pillars of treatment.

And what about leisure?

On Saturdays, they have a compulsory sports activity (football or paddle tennis), where everyone plays, well or badly. We have never had a situation of violence, although there have been some minimal frictions. But young people who cannot control themselves with drugs can control the urge to kick someone, and they gradually discover that, when they want to, they are capable of curbing their impulses.

They also take part in a musical activity coordinated by a musician and former addict who did his treatment here. Most of the young people who come used to play rock at dawn, with alcohol and drugs, and we now offer them the chance to make music at three in the afternoon with soft drinks or water. They all know the lyrics of the songs and many play an instrument: they spend a very special, almost religious moment, doing together something they are passionate about.

What percentage of women do you have?

About 20%. Personally, I do not believe that women use less than men; what happens is that they take more tranquillisers or psychotropic drugs. As they cause less social disturbance, they do not come for treatment. So there is a high percentage of women addicts with no possibility of receiving adequate help. Concerned by these percentages, in 1997 we organised, in collaboration with FONGA and under the auspices of the OAS and other institutions, the first Argentine Congress on the impact of drugs on women and the family, attended by representatives from all over the country. There we found, to our surprise, that their concerns about addiction in women and the difficulties of treatment coincided with ours.

What happens when a couple relationship arises between people in treatment?

It is very rare. But if it happens, we have to ask ourselves to what extent this new relationship blocks the treatment. In general, we think it harms it, because the couple closes in on itself and hides material from the group, which makes the work difficult. The important thing is not to take a compulsive punitive measure, but to ask whether the treatment is going to help them. Only then can we decide whether or not they will continue in the institution.

And do the siblings come?

They are invited to take part from the outset, because they need a space where they can question their role and revise the bond they have with the addict. It is common for many siblings to have a very bad relationship, for there to be a lot of anger, and even rifts lasting several years. As treatment progresses, the siblings learn to relate to each other with a little more trust and collaboration.

Of those who enter the admission phase, what percentage leave, and for what reasons?

Between 15 and 20% leave, because they do not bond with their peers, do not establish good contact, or because the family does not take part and does not enter into a relationship with the other parents. Perhaps, theorising a little, we could think of resistances, or of something that failed on our side, since we did not manage to establish a better relationship.

What happens when, during treatment, the parents stop coming?

In these cases, we call them in urgently and ask for their collaboration, explaining to them that, for us to help them, they must help us, and that at least one of them must come to the groups. If neither of them can, then let an aunt, a sister, the grandmother or a neighbour come, someone who can. It is not possible to work with the addict without the network of collaboration; there has to be someone responsible.

Do addicts who come on a court order stick with it? How do you work with the court?

We work in collaboration with the court, we do not act on our own account. We always try to prevent a triangle forming between us, the family and the court, because that is harmful. To avoid it, we work seriously and as a team, because any crack in the union of the three institutions harms the treatment.

We must form common fronts of help, not competition.

It may happen that there are unclear or contradictory messages: in that case, we go to the court to unify criteria, trying to smooth out the difficulties and to value the relationship. More and more often, we meet court staff overwhelmed with paperwork, but so well disposed that, if we do not compete for power, they end up coming to the end-of-treatment ceremonies.

We must stop believing that we are the owners of the rehabilitation process, because it will be all the better the more people there are helping.

What about the marginalised population – by which I mean someone who is in a borderline situation, on the margins of their group and their family?

In general, marginal behaviours are present in all drug addicts, but I think there are two situations: that of those who were born and live in a marginalised social structure and have absorbed a culture that is itself marginal, made up of promiscuity, theft, alcohol, violence, etc.; and that of those who, belonging to a different social structure, adopt marginal behaviours linked to drugs. In the first case, the work of recovery is difficult; it requires more time and a different methodology. In the second, on the other hand, it is a matter of recovering values that already existed: generally, the resocialisation programme proves very effective. However, in both cases, there is always a social network of collaboration, and we must find strategies to activate it.

Legalising drugs

Legalised drugs: yes or no?

For me, it is a very difficult and complex subject, which must be studied broadly and seriously, so as not to be guided solely by the opinions of the economists or philosophers of the moment. What worries me above all is the point of view from which it is approached, because generally it is approached from the economic angle, where what counts is that, drugs being legal, the tax money will go to the State and not to the drug traffickers.

We should take a look at the results of the legalisation of alcohol: has the rate of consumption gone down or not? How have the taxes been distributed? Have effective prevention campaigns been launched? Quite the opposite: we see that both consumption and the rate of alcohol-related illness have increased enormously, and that people die very badly cared for. Moreover, the State stimulates alcohol production by authorising the setting up of new drinks factories.

In the case of drugs, I fear that, if policies designed solely from the economic angle are applied, the same thing will happen, and that what we think of as a “great change” will be nothing more than a simple change of hands to the benefit of the State.

I am against the circulation of drugs, but it also disgusts me that profit should be made from people’s drama and destruction. This subject is very complex and controversial. In this respect, we should review and establish a state of uninterrupted debate and permanent evaluation of the results obtained.

Horacio Serebrinsky: In Switzerland, where I stayed for professional reasons, the experience of legalised drugs did not lead to fewer addicts, but to better control; harm reduction campaigns are carried out there and the crime rate has fallen.

The serious problem, in Europe, is the type of drug used (heroin), which, fortunately, does not exist here to this day. There too, they are rethinking different models and working methods, because hospital stays are expensive and have a high rate of relapse and readmission. That has made them think about the effectiveness of treatments and other possible alternatives: today they look at outpatient treatment with more openness. In recent years, I have been to Rome, Corsica and Sardinia to give seminars on the outpatient model, and I was listened to with great attention.

Objectives and conclusions

What are the objectives of these outpatient treatments?

One is detoxification, that is, that the person being treated does not start using drugs again, and the other is socialisation, which is what makes treatments longer, and which consists in the development and structuring of social roles and of values such as honesty and respect for the norms of life together.

Another important objective is that they discover that it is possible to control themselves in the face of the impulse to use, and also in the face of the impulse to mistreat and be violent.

We also try to achieve progress in the growth of family members; that is why we say that in this treatment, if they take an active part, the good result benefits everyone’s health. It is common to see, in families that have lived for years in a chaotic climate, that the parents, on arriving in treatment, have not been to the cinema, have not gone on holiday or eaten all together for a long time. Over the course of the therapeutic process, they all come together again, organised in a different way, and the family members themselves often say that not only has the addict changed, but that they too have been able to find a life project that includes pleasure.

In your opinion, what is the essence of the programme?

We attach fundamental importance to resocialisation. I believe that the programmes with a high relapse rate are those that aim solely at getting the addict to stop using. We know that with the help of the group, stopping drug use is sometimes immediate, but also that this alone is not enough: mechanisms of self-care and self-control must be developed, and work must be done with the family and with the values that underpin human relationships. That takes time; that is why we speak of therapeutic processes, and that is also why those who think of pills that cure fail: that is not how addictions are treated.

Is it true, as some say, that the best treatment is the one that does not deal with drugs?

Yes, I believe so. We must think in terms of a process of change, and that does not happen overnight.

Do you work with a Gesell chamber?

Yes, we supervise the work a great deal. It is fundamental to consult on stuck situations by opening up the work to another gaze, which is always enriching. We also meet as a team during the week to update the supervision of everyone in treatment, to see what is happening in each of the therapeutic spaces and, in this way, to allow each coordinator to know what is going on in the other groups. We bring ourselves up to date on what is happening, and everyone has a structural view of each case.

Working as a team in this way allows us to realise whether situations of triangulation, delegation or provocation are occurring, which are so common in this work. Being able to make them explicit prevents them from being acted out within the team.

Once treatment is over, can one continue therapy in the institution?

No. With those who have finished, we hold periodic multi-family sessions, to assess, for example, whether the gains have been maintained or whether there have been relapses.

If a professional refers a young person to you, should they stop seeing them?

Yes, for as long as the treatment with us lasts. If they continued their individual therapy outside, confusing situations of triangulation or blockages would arise that would disrupt the treatment. In this work, which is difficult in itself, it is better to clear the ground than to complicate it. At the end of the programme, the young person can go back, if they wish, to the therapist who referred them.

How are couple conflicts or conflicts of another kind dealt with when they appear during treatment?

Let us bear in mind that about halfway through treatment, or perhaps earlier, conflictual themes begin to appear, arising from the restructuring of bonds. This happens not only in the parental couple, but also with the children, whatever their situation in the family. Our experience did not yield a positive result when we had to refer the problem to another therapeutic context, for example couple therapy outside the institution.

Currently, any conflict that arises during treatment is related to the central focal theme, which is the addiction, trying to see its repercussions in all the group spaces, that is, how the emergence of this conflict impacts on the treatment of this patient and on the members of their family.

What produces change?

In this structure where all the family members are distributed in groups, there is a bombardment of all the bonds, which means, for example, that the father (in his parents’ group) questions his relationship with his son, that the brother, for his part, does the same with his peers, and that the same thing happens in the groups of wives or friends. Then, they all meet again in the family therapy session.

It is impossible to know whether the changes in the bonds originate in the groups, whether the father or the brother changed thanks to what they learned there, or whether it was family therapy that triggered a change in relationships. And that does not interest us.

What matters to us is that change happens. And for that, we create contexts where the bonds can be worked on, and we speak of multiple bombardment. It is like firing a shotgun, from which many pellets fly out: that way, there is a better chance of hitting the target.

Do you work on the intrapsychic?

It is absurd to think of “the intrapsychic” in this state.

In general, the addict’s daily life is so chaotic that at first we set out to achieve some order in family life and in their working life, to avoid risks that are sometimes fatal, and to help them comply with elementary norms of life together. Then, gradually, we approach the emotions.

What other points do you work on?

Violence is an ever-present theme, which appears in the history of these families, but which can also circulate in the relationship of the addict or their relatives with us. Mistreatment can manifest itself in every context, and we must be very vigilant in order to see it, to work on it and, if it appears in our own behaviour, to be able to ask for forgiveness and thus establish a clear model of repair.

Horacio Serebrinsky: How long does treatment last?

On average from a year and a half to two years, because, as I was saying, socialisation takes time. One has to think of the terrible histories that go with the drug addict.

I repeat: stopping drug use is only one objective; the hardest part is integrating social values so that self-care and self-control become solidly structured. Without that, stopping drug use amounts to putting on a simple plaster, which does not last long, and relapses go on destroying them.

We must not repeat the failures of other methodologies.

Applying this model puts us in a position to achieve a more solid and more stable change.

Does everything really end here?

As far as the different stages of treatment are concerned, yes. But, once it is over, we continue to evaluate the effectiveness of what we have achieved.

It is very important to see how families, once the problem of addiction is past, gradually face the normal emotions that we all go through at one time or another.

Values such as responsibility, solidarity, respect, sobriety, good treatment of one another also begin to arise spontaneously in relationships.

And one more thing: the possibility of reflecting in the face of situations to which one previously responded impulsively gives rise to new behaviours, which manifest themselves in a lasting way, even once treatment is over.