DESAFOS Y AVANCES EN LA PREVENCIN Y EL TRATAMIENTO DE LAS DROGODEPENDENCIAS

RESPONSABLE EDICIN Lino F. Salas Director Comunicacin y Marketing EDICIN Y REDACCIN EN ESPAOL Isabel Garca DISEO Y MAQUETACIN Rosaura Marqunez y Francisca Bonet FOTOS PORTADA Nicols Terrasa, Alejandro Vanrell, archivo Proyecto COLABORADORES Albert Sabats Presidente Asociacin Proyecto Hombre Elena Goti Consultora drogas. Modesto Salgado Presidente Comunicacin y Marketing Isabel Garca Departamento Comunicacin y Marketing Francisca Bonet Departamento Comunicacin y Marketing ngela Dale Phipps Voluntaria Projecte Home Balears Andreu Company Voluntario Asociacin Proyecto Hombre

ASOCIACIN PROYECTO HOMBRE Declarada de utilidad pblica el 29/12/1993 C/ Osa Mayor, 19. 28023 Aravaca (Madrid) Tel.: 91 357 09 28 www.proyectohombre.es ISBN: 84-88930-10Depsito legal: Marzo 2004

NDICE/INDEX
GEOPOLTICA/GEOPOLITICS NARCOTRFICO, DELINCUENCIA ORGANIZADA Y TERRORISMO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 DRUG TRAFFICKING, ORGANISED CRIME AND TERRORISM Garzn Real, Baltasar LA GUERRA CONTRA LAS DROGAS Y LOS INTERESES DE LOS GOBIERNOS . . . . . . . . . . . . . . . . . . . . .17 THE WAR AGAINST DRUGS AND THE INTERESTS OF GOVERNMENTS Labrousse, Alain RETOS DE LA INFORMACIN SOBRE DROGAS EN EL SIGLO XXI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25 CHALLENGES OF INFORMATION ON DRUGS IN THE 21ST CENTURY Pueyo Ruiz, Begoa del TRATAMIENTO/TREATMENT CUIDANDO EL JARDN DEL CORAZN. LAS MUJERES EN LA COMUNIDAD TERAPUTICA . . . . . . . .33 TENDING THE HEARTS GARDEN. WOMEN IN THE THERAPEUTIC COMMUNITY Arbiter, Naya TRATAMIENTO DE LOS TRASTORNOS DE LA PERSONALIDAD Y DEPENDENCIA A SUSTANCIAS: ESQUEMA DE TERAPIA CON DOBLE FOCO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43 TREATMENT OF PERSONALITY DISORDERS WITH CO-OCCURRING SUBSTANCE DEPENDENCE: DUAL FOCUS SCHEMA THERAPY Ball, Samuel A LA PERSONA ADICTA Y LOS FUNDAMENTOS ANTROPOLGICOS DE SU REHUMANIZACIN . . . . .69 THE ADDICTED PERSON AND THE ANTHROPOLOGICAL APPROACH TO REHUMANIZATION Caas, Jos L. EL ESPRITU DE LA COMUNIDAD TERAPUTICA. TRASCENDENCIA Y ESPIRITUALIDAD EN EL SENDERO DE LA HUMANIZACIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .89 THE SPIRIT OF THE THERAPEUTIC COMMUNITY. TRANSCENDENCE AND SPIRITUALITY ON THE PATH TO HUMANISATION Carvajal Posada, Jorge Ivn LOS RIESGOS DE LA REDUCCIN DE DAOS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .95 THE RISK OF HARM REDUCTION Castao Prez, Guillermo Alonso PSICOTERAPIA INTEGRATIVA EN TRASTORNOS ADICTIVOS: INTROVISACIN A TRAVS DE LA AUTOBIOGRAFA, TCNICA PARA EL REPROCESAMIENTO DE LA FUNCIN DE SIGNIFICACIN DEL SELF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .101 INTEGRATIONAL PSYCHOTHERAPY IN ADDICTIVE DISORDERS: INTROVISATION THROUGH THE TECHNICAL AUTOBIOGRAPHY FOR REPROCESSING OF THE FUNCTION OF THE SIGNIFICANCE OF THE SELF Guajardo Sinz, Humberto y Kushner Lanis, Diana COMUNIDADES TERAPUTICAS: RECIPROCIDAD INVESTIGACIN-PRAXIS . . . . . . . . . . . . . . . . . . . .113 THERAPEUTIC COMMUNITIES: RESEARCH-PRACTICE RECIPROCITY Leon, George De

ENFOQUE DE GNERO EN EL TRABAJO CON MUJERES RESIDENTES EN NUESTRAS COMUNIDADES TERAPUTICAS ESTNDAR PARA TOXICMANOS . . . . . . . . . . . . . . . . .157 GENDER APPROACH IN THE WORK WITH FEMALE RESIDENTS IN OUR STANDARD THERAPEUTIC COMMUNITIES FOR DRUG ADDICTS. Martens, Johanna PREVENCIN DE RECADAS DESDE UNA PERSPECTIVA LOGOTERAPUTICA . . . . . . . . . . . . . . . . . .135 PREVENTION OF RELAPSES FROM A LOGOTHERAPEUTIC PERSPECTIVE Martnez Ortiz, Efren LAS FRONTERAS VARIABLES EN LAS COMUNIDADES TERAPUTICAS . . . . . . . . . . . . . . . . . . . . . . . . .157 THE CHANGING BOUNDARIES IN THERAPEUTIC COMMUNITIES Mereki, Portia EL ROL DE LA COMUNIDAD TERAPUTICA PARA DROGODEPENDIENTES EN EL CAMBIO DE CONDUCTA DEL DELINCUENTE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .177 THE ROLE OF THE THERAPEUTIC COMMUNITY (TC) FOR ADDICTION TREATMENT IN CHANGING OFFENDER BEHAVIOR Muehlbach, Britta; Mattina, Dominick RESULTADOS POSITIVOS EN LA INICIATIVA PARA EL TRATAMIENTO DE ABUSO DE SUSTANCIAS DEL DEPARTAMENTO CORRECCIONAL DE CALIFORNIA . . . . . . . . . . . . . . . . . . . . . .191 POSITIVE OUTCOMES FROM THE CALIFORNIA DEPARTMENT OF CORRECTIONS SUBSTANCE ABUSE TREATMENT INITIATIVE Mullen, Rod TICA Y COMUNIDAD TERAPUTICA: EN BSQUEDA DE UNA AUTOCRTICA . . . . . . . . . . . . . . . . . .197 ETHICS AND THERAPEUTIC COMMUNITY: IN SEARCH OF SELF-CRITICISM Palacios Herrera, Juan EVALUACIN DE LA EFICACIA DE PROGRAMAS DE PROYECTO HOMBRE . . . . . . . . . . . . . . . . . . . . . .207 THE EFFICIENCY OF THE PROYECTO HOMBRE PROGRAMMES Proyecto Hombre: Deben, Ofelia et al CONSTRUCCIN DE UN PROCESO INTERNO DE EVALUACIN DE PROGRAMAS DE TRATAMIENTO DE ADICCIN A LAS DROGAS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .223 CONSTRUCTION OF AN INTERNAL ASSESSMENT PROCESS FOR DRUG ADDICTION TREATMENT PROGRAMME Proyecto Hombre: Yubero Fernndez, Arantza ALTERNATIVAS DE TRATAMIENTO DE PROYECTO HOMBRE EN LOS CENTROS PENITENCIARIOS . .229 PROYECTO HOMBRE ALTERNATIVES FOR TREATMENT IN PENITENTIARY CENTRES Proyecto Hombre: Comisin Jurdica LA FUNCIN DE LA COMUNIDAD TERAPUTICA, AYER Y HOY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .239 THE FUNCTION OF THE THERAPEUTIC COMMUNITY, PAST AND PRESENT Roldn Intxusta, Gabriel UN ENSAYO ALEATORIO QUE COMPARA LOS TRATAMIENTOS DE TOXICOMANAS EN RGIMEN DE DA Y EN RESIDENCIA: RESULTADOS DE 18 MESES . . . . . . . . . . . . . . . . . . . . . . . . . . .255 A RANDOMIZED TRIAL COMPARING DAY AND RESIDENTIAL DRUG ABUSE TREATMENT: 18-MONTH OUTCOMES Sorensens, James L. et al

RESULTADOS DE LA GESTIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .265 OUTCOME MANAGEMENT Walburg , J.A. PROGRAMAS DE TRATAMIENTO DE TOXICOMANAS EN CORRECCIONALES DE CALIFORNIA: UNA PERSPECTIVA HISTRICA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .277 CORRECTIONAL SUBSTANCE-ABUSE TREATMENT PROGRAMS IN CALIFORNIA: A HISTORICAL PERSPECTIVE Wexler, Harry K. y Prendergast, Michael L. PREVENCIN/PREVENTION EL MITO DEL CONSUMIDOR INTELIGENTE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .301 THE MYTH OF THE INTELLIGENT CONSUMER Calafat, Amador UNA PERSPECTIVA CONTEXTUAL PARA LA COMPRENSIN Y LA PREVENCIN DE ENFERMEDADES DE TRANSMISIN SEXUAL / SIDA ENTRE ADOLESCENTES . . . . . . . . . . . . . . . .311 A CONTEXTUAL PERSPECTIVE FOR UNDERSTANDING AND PREVENTING STD/HIV AMONG ADOLESCENTS DiClemente, Ralph EVALUACIN Y DIFUSIN DE RESULTADOS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .325 ASSESSMENT AND DIFFUSION OF RESULTS Gil Carmena, Enrique EL NIO MALTRATADO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .337 THE MALTREATED CHILD Mele, Francisco QU ESTILOS DE VIDA GLOBALIZADOS SON IMPORTANTES PARA LA PREVENCIN? . . . . . . . . . .343 WHAT GLOBAL LIFESTYLES ARE OF IMPORTANCE FOR PREVENTION? Prez-Gmez, Augusto ENTRE TODOS: DEL TRATAMIENTO A LA PREVENCIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .351 ENTRE TODOS: FROM TREATMENT TO PREVENTION Proyecto Hombre: Comisin de Prevencin EL VOLUNTARIADO EN DROGODEPENDENCIAS: LA EXPERIENCIA EN PROYECTO HOMBRE . . . . .359 VOLUNTEERS IN DRUG DEPENDENCIES: THE EXPERIENCE OF PROYECTO HOMBRE Proyecto Hombre: Comisin de Voluntariado COMPORTAMIENTOS RESILIENTES Y DE RIESGO. CONSUMO DE SUSTANCIAS PSICOACTIVAS EN ADOLESCENTES LATINOAMERICANOS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .363 RESILIENT AND RISK BEHAVIOURS. CONSUMPTION OF PSYCHO-ACTIVE SUBSTANCES IN LATIN AMERICAN ADOLESCENTS Rojas Valero, Milton J. PREVENCIN TEMPRANA EN NIOS DE 4 A 6 AOS: MODOS DE INTERVENCIN . . . . . . . . . . . . . . .377 EARLY PREVENTION IN CHILDREN FROM 4 TO 6 YEARS OF AGE: FORMS OF INTERVENTION Salazar Ascencio, Jos

PARA PROYECTO HOMBRE ES MOTIVO DE SATISFACCIN CONTAR CON LA COLABORACIN DE UN SELECTO GRUPO DE EXPERTOS A NIVEL INTERNACIONAL PARA LA EDICIN DE ESTE LIBRO. CON SU PUBLICACIN TRATAMOS DE OFRECER UN MANUAL DE BUENAS PRCTICAS, REFLEJO DEL TRABAJO QUE MUCHAS ORGANIZACIONES ESTN LLEVANDO A CABO EN EL ABORDAJE DE LAS DROGODEPENDENCIAS Y EN EL CAMPO DE LA PREVENCIN.

LA GLOBALIZACIN DEL FENMENO DE LAS DROGAS NOS OBLIGA, CADA VEZ MS,

TANTO A LAS ORGANIZACIONES P-

BLICAS COMO A LAS ONGS, A COMPARTIR LOS XITOS Y FRACASOS, LOS AVANCES Y RESULTADOS, AS COMO A TRAZAR ESTRATEGIAS COMUNES A MEDIO Y LARGO PLAZO. POR ESTE MOTIVO, HEMOS DIVIDIDO EL LIBRO EN TRES APARTADOS: LA GEOPOLTICA DE LAS DROGAS, LOS MODELOS DE TRATAMIENTO Y LAS INTERVENCIONES EN PREVENCIN.

DESDE DIFERENTES FRENTES, ACADMICOS Y ASISTENCIALES, CADA UNO DE LOS COLABORADORES TRASMITE SUS REFLEXIONES Y EXPERIENCIAS. DE ELLAS PODEMOS SACAR ENSEANZAS QUE NOS ORIENTEN Y FACILITEN NUESTRO TRABAJO DIARIO. ESPERAMOS QUE SIRVA, ADEMS, PARA CONOCER QU SE EST HACIENDO Y CMO SE ABORDA ESTE FENMENO EN OTROS LUGARES Y PASES.

FINALMENTE, EN ESTE AO QUE PROYECTO HOMBRE CELEBRA EL VIGSIMO ANIVERSARIO DE SU IMPLANTACIN, DESEAMOS REFORZAR LA UNIN Y COMUNICACIN DE TODOS LOS QUE DEDICAMOS NUESTROS ESFUERZOS A LA PREVENCIN, TRATAMIENTO Y REHABILITACIN DE DROGODEPENDIENTES.

ALBERT SABATS PRESIDENTE ASOCIACIN PROYECTO HOMBRE

WE AT PROYECTO HOMBRE ARE PLEASED TO HAVE THE COLLABORATION OF A SELECT GROUP OF INTERNATIONAL EXPERTS FOR THE EDITING OF THIS BOOK. IN PUBLISHING IT WE HOPE TO OFFER A GOOD PRACTICE MANUAL, REFLECTING THE WORK MANY ORGANISATIONS ARE CARRYING OUT IN THEIR APPROACH TO DRUG DEPENDENCIES AND THE FIELD OF PREVENTION.

THE GLOBALISATION OF THE DRUGS PHENOMENON INCREASINGLY OBLIGES THOSE OF US IN BOTH PUBLIC ORGANISATIONS
AND NGOS TO SHARE SUCCESSES AND FAILURES, PROGRESS AND RESULTS, AND TO TRACE OUT MUTUAL STRATEGIES FOR THE MEDIUM AND LONG TERM. BECAUSE OF THIS, WE HAVE DIVIDED THE BOOK INTO THREE SECTIONS: THE GEO-POLITICS OF DRUGS, MODELS OF TREATMENT AND INTERVENTIONS FOR PREVENTION.

FROM DIFFERENT FRONTS, BOTH ACADEMIC AND IN CARE, EACH OF THE COLLABORATORS TRANSMITS HIS OR HER REFLECTIONS AND EXPERIENCES. FROM THEM WE CAN EXTRACT TEACHINGS TO GUIDE US AND MAKE OUR DAY-TO-DAY WORK EASIER.

WE ALSO HOPE THAT IT HELPS US DISCOVER WHAT IS BEING DONE AND HOW THIS PHENOMENON IS BEING APPROACHED
IN OTHER COUNTRIES.

FINALLY, THIS YEAR, WHEN PROYECTO HOMBRE IS CELEBRATING THE TWENTIETH ANNIVERSARY OF ITS INTRODUCTION, WE
HOPE TO REINFORCE THE LINKS AND COMMUNICATION BETWEEN THOSE OF US WHO DEDICATE OUR EFFORTS TO THE PREVENTION, TREATMENT AND REHABILITATION OF DRUG ADDICTS.

ALBERT SABATS PRESIDENT ASOCIACIN PROYECTO HOMBRE

GEOPOLTICA/GEOPOLITICS

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NARCOTRFICO, DELINCUENCIA ORGANIZADA Y TERRORISMO

DRUG TRAFFICKING, ORGANISED CRIME AND TERRORISM

Garzn Real, Baltasar Magistrado. Audiencia Nacional. Madrid. Espaa

Las organizaciones terroristas y las organizaciones mafiosas (como el narcotrfico), con estructuras y objetivos similares, ponen en peligro, desde distintos frentes, la estabilidad de los sistemas democrticos y cuestionan las instituciones bsicas del Estado. Por tanto los esfuerzos para la erradicacin de ambos deben emprenderse bajo un mismo prisma. Para ello sera necesario un organismo superior que aglutinara tales esfuerzos a nivel internacional y la suficiente ambicin para abordarlo globalmente con el esfuerzo coordinado de todos.

Terrorist organisations and mafias (like the drug trafficking mafia), with similar structures and objectives, endanger the stability of democratic systems and question the basic institutions of the State on different fronts. Therefore efforts to eradicate both must be embarked on using the same perspective. In order to carry this out a superior organisation would be n e c e s s a r y, g r o u p i n g t o g e t h e r e f f o r t s o n a n international level and with sufficient ambition to deal globally with the coordinated efforts of all those involved.

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Es preciso establecer inicialmente que aunque las organizaciones terroristas no van a constituir el punto central de mi exposicin, no es menos cierto que, en gran medida el terrorismo ha dejado de tener un mvil exclusivamente poltico y, aunque a veces est relacionado con reivindicaciones polticas, es cierto que en los ltimos aos ha pasado a ser una forma ms, las ms violenta y terrorfica, del crimen organizado. En efecto, no es extrao encontrar casos de narcoterrorismo, como asociaciones de la mafia con organizaciones terroristas a travs del suministro de armas, material nuclear o de la venta y compra de droga y blanqueo de dinero para financiarse; o bandas armadas o de mercenarios que actan guiados por estmulos estrictamente econmicos al servicio de organizaciones criminales. En otro sentido, las organizaciones de corte mafioso no dudan en utilizar medios de destruccin propios de organizaciones terroristas (bombas, subfusiles, granadas, etc.), es decir, mtodos cada vez ms eficaces que aseguran el resultado y, adems, a veces, buscan fines netamente polticos. Por lo dems y si bien no pueden equipararse o identificarse absolutamente bajo una misma rbrica todas las organizaciones terroristas y las organizaciones mafiosas, es lo cierto que unas y otras hoy por hoy, y salvo determinadas excepciones, tienen una estructura parecida; y utilizan medios similares, persiguen objetivos comunes que sirven a su propia supervivencia y engrandecimiento. Asimismo ambas atacan, desde distintos frentes, a la estabilidad de los sistemas democrticos y ponen en cuestin las instituciones bsicas del Estado. Por todo ello la forma de actuar frente a ambos tipos de delincuencia debe ser similar dentro del mbito de la investigacin y represin y emplear similares medios y tcnicas policiales y jurdico-procesales asimismo homogneas, y, hacerlo precisamente bajo un mismo prisma de coordinacin

superior tanto en el rea de la informacin como en el de la actuacin operativa de alcance internacional. Entre el da 12 y 15 de diciembre de 2000 ms de un centenar de pases firmaron en Palermo (Italia) la Convencin sobre la delincuencia transnacional organizada. (Espaa la ha ratificado el da 29 de septiembre de 2003). Sin embargo y a pesar de que la misma supone un avance fundamental y necesario, se muestra insuficiente en algunos puntos en los que aborda, en una forma ms remisa que el Convenio de Asistencia Judicial en Materia Penal de la U.E. firmado el 29 de mayo de 2000, las cuestiones objeto de regulacin. Es preciso ir ms lejos. Es el momento de apostar por iniciativas ms ambiciosas pero que resultan imprescindibles. Un Sistema compacto de comunidad de inteligencia que aglutine y recoja toda la que se produce en los diferentes pases, para elaborarla y explotarla operativamente, extrayendo su mximo rendimiento para la comunidad internacional, exige un Organismo Superior que dirija dicha coordinacin y que implemente los medios necesarios para hacerla realidad. Hoy por hoy, es cierta la afirmacin de que en el inicio del siglo XXI si bien es cierto que se ha alejado el riesgo de confrontacin nuclear y que las guerras actuales tienen un alcance ms bien local, aunque no por ello menos cruentas, no lo es menos que el peligro que amenaza con ms insistencia a la comunidad internacional es el del Crimen Organizado entendido en sentido amplio, de ah la necesidad vital que exista de una Convencin Internacional en la materia como la que se firm en Palermo. Hoy, tres aos y pocos meses despus de su existencia y aplicacin se ha hecho mas necesaria. Los terribles atentados terroristas del 11 de septiembre de 2001 han evidenciado que el tiempo perdido en la elaboracin de los tratados internacionales que regulan

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las relaciones jurdicas y judiciales entre los pases ha sido demasiado largo y las interminables incomprensiones e intereses de unos y de otros han causado demasiado dao a la propia humanidad, que asiste inerte a una deriva difcilmente justificable. Y esto sucede en los diferentes mbitos a los que se expande la criminalidad y sus mil formas que cada vez ms fagocitan nuestra convivencia. Es verdad que la mayora de los Gobiernos de los pases han reaccionado en los ltimos aos, mucho ms desde aquella fecha, y se han dado cuenta de aquella realidad contradictoria, pero todava existen demasiadas reticencias entre las diferentes naciones y autnticos enfrentamientos a la hora de definir los conceptos y de establecer las pautas sobre las cuales ha de versar el discurso, por ejemplo en lo relativo al trfico de armas. Mereciendo un apartado especial las cuestiones derivadas de la interpretacin y aplicacin del principio de soberana. En el marco de la ONU se han suscrito varios convenios para perseguir el narcotrfico y el lavado de dinero, con menor o mayor mbito territorial de aplicacin; se han realizado reuniones para hablar de la criminalidad organizada y de la peligrosidad de la misma; insistentemente se aboga por la creacin de espacios ms amplios que los estrictamente nacionales para combatir ms eficazmente el fenmeno y su manifestacin principal, aunque no la nica, (vase la criminalidad asociada a la inmigracin y al trfico de seres humanos para su explotacin sexual, cuyos beneficios anuales, segn la ONU se aproximan e incluso sobrepasan a los del narcotrfico). Por todo ello es preciso tener la suficiente ambicin para abordar, quizs en forma revolucionaria, todos estos temas y as y tomando como punto de partida el espritu universal, por encima del localismo clsico, tal como se ha indicado en la Unin Europea, a partir de la Cumbre de Tampere (octubre del 99) y

del Convenio de Asistencia Judicial en Materia Penal de 29.05.00 donde se tom la iniciativa que conduce la situacin por buen camino: a) Apostar por la Unificacin Legislativa, tanto en la definicin de las conductas como en el diseo para su persecucin e investigacin, resulta esencial para afrontar eficazmente el fenmeno. b) Perseguir la desaparicin de los parasos fiscales, o cuando menos reducir seriamente su mbito mediante severas restricciones a los sistemas jurdicos que lo profesen, es absolutamente necesario. En este sentido la resolucin del Parlamento Europeo. Aquellos constituyen focos de delincuencia permanente. c) Iniciar el diseo de una poltica de investigacin criminal y asistencia poltica en el seno de unas Naciones Unidas radicalmente renovadas, que la haga una organizacin operativa y que sirva para este nuevo desafo, dara sentido a ese organismo. d) Conseguir un espacio judicial nico, universal en este campo, como se acoge en el Estatuto de la Corte Penal Internacional de 1998, sera la meta mnima. Es cierto que la ONU se cre y dise como consecuencia de una Guerra Mundial y pensando en un mundo dividido en bloques de presin poltica y, por tanto, con la vista puesta en la nica amenaza que se presuma posible para el mundo en ese momento: la guerra. Sin embargo, la situacin mundial producida como consecuencia de la cada del Muro de Berln, las grandes masacres y violaciones de derechos en la dcada de los 90 y los atentados del 11S han configurado un panorama totalmente diferente, de modo que la nica amenaza capaz de poner en peligro la estabilidad de los pases es el crimen organizado y el terrorismo. No verlo as es desear estar ciegos ante una realidad meridiana y, de hecho, favorecer el desarrollo e implantacin de las organizaciones criminales o terroristas.

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Es cierto que la mayora de estas Organizaciones existan antes, pero tambin lo es que sus entramados se han ido extendiendo y afirmndose a la par que se han relajado los controles polticos y jurdicos para favorecer el libre mercado, la libre circulacin de personas, mercancas, o la desaparicin de fronteras interiores. Frente a esta eclosin de organizaciones criminales la nica ventaja que de momento existe por parte de la Comunidad Internacional de Naciones representada por Naciones Unidas, es que aqullas todava no han llegado a estructurarse globalmente y en forma permanente y generalizada. Si esa mnima ventaja se pierde asistiremos en un futuro no muy lejano a una situacin de desestabilizacin permanente fruto de la accin del crimen organizado. A primera vista esta visin parece un tanto apocalptica. No obstante, si se analiza la situacin existente hace 10 aos y se la compara con la actual, se comprobar el cambio sustancial experimentado y cmo ha evolucionado el fenmeno no slo en el aspecto cuantitativo, sino especialmente en el cualitativo; utiliza el fenmeno de la delincuencia organizada con nuevas tcnicas, nuevos mbitos de iniciativa, blindajes mucho ms sofisticados, tecnologas ms avanzadas, utilizacin de todos los adelantos cibernticos e informticos. Cualquier organizacin criminal, ya se dedique al trfico de drogas o al trfico de armas, ya al lavado de dinero o al fraude, ya al terrorismo o a todas ellas a la vez, no respeta ni normas legales ni derechos de las personas, ni tampoco perodos de sesiones o perodos de vacaciones oficiales y, desde luego, no va a cumplir requisitos burocrticos interminables y absolutamente intiles, ni va a discutir indefinidamente sobre qu hacer, sino que precisamente va a aprovechar todas esas disfunciones y deficiencias del sistema legal para que acten en su favor facilitndole la

obtencin del fin perseguido y consiguiendo de paso el descrdito de las instituciones. Este dinamismo es el que hace necesario no descansar en la adopcin de medidas nuevas partiendo de las actuales que traten de interpretar y colocarse a la altura de las nuevas tcnicas de la empresa criminal. Expuesto lo anterior, y adems de llamar la atencin sobre la incidencia internacional del crimen organizado y la necesidad de tomar medidas en el mbito del trfico de drogas, lavado de dinero y crimen organizado en forma permanente, para acomodarnos a las formas cambiantes de este tipo de delincuencia, era necesario un instrumento legal de actuacin. En este escenario es en el que los diferentes pases y en especial la Unin Europea, y Naciones Unidas, sin olvidar EEUU, han desarrollado una serie de normas para tratar de remediar el caos existente. Sin embargo, y a pesar del trauma del 11 S, lo cierto es que todava se est muy lejos de hacer efectiva esa legislacin. Es decir falta voluntad poltica, y desarrollo judicial de este tipo de iniciativas. Si se establece que las organizaciones delictivas buscan, como fin de su existencia la obtencin de pinges beneficios, y que utilizan para ello sistemas de defraudacin transnacionales en detrimento de los presupuestos nacional y comunitario. Se precisa, como antes se deca, la aproximacin de legislaciones, adopcin de instrumentos jurdicos que fomenten la cooperacin judicial con el fin de llegar a una represin homognea y una coordinacin eficaz para obtener las pruebas necesarias. (En este sentido el Convenio de 29 de mayo de 2000). Cualquier sistema de este tipo tiene que partir, para su xito, de una serie de premisas imprescindibles: 1. Que el fenmeno del crimen organizado ha de ser abordado globalmente, sin perjuicio de las peculiaridades de sus manifestaciones concretas, y que toda accin contra el mismo ha de apuntar a

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la estructura de la organizacin o empresa criminal y no tanto a los hechos delictivos concretos que s e c o m e t a n , e n e l s e n t i d o m a rc a d o p o r l a Convencin de Paler mo sobre el Crimen Organizado y otros instrumentos internacionales que dan forma al nuevo concepto universalizacin de las formas de luchar contra la delincuencia transnacional organizada que supone una previa unificacin de criterios sobre el crimen organizado, labor asumida por la Convencin de Palermo y tambin en forma avanzada por la Unin Europea, que ha creado no slo nuevas instituciones como EUROJUST, para coordinar las diferentes acciones policiales y judiciales, sino tambin la Orden de Detencin Europea, que ha supuesto la desaparicin de la Extradicin y la interferencia poltica en la relaciones entre jueces a travs de la cooperacin jurdica internacional. Ntese que cuando hablamos de este tipo de delitos, como por ejemplo, el trfico de drogas, habr un pas en donde se cultiva la materia prima, otro que fabrica los precursores, otro a travs del que se transporta y otro a donde llega la sustancia estupefaciente ya elaborada para su distribucin. En estos casos de delitos complejos, al menos territorialmente hablando, resulta esencial que aquella coordinacin exista, so pena de que la ineficacia se aduee una vez ms de la situacin. Por eso resulta extrao que a veces se constate como determinadas legislaciones, con una visin bastante miope de la realidad se inclinen por una visin nacionalista absurda. Nadie est a salvo de la accin de la delincuencia organizada, de ah que los esfuerzos deben ser facilitadores y respetuosos con los derechos de los ciudadanos, pero a la vez protectores de la vctimas. El hipergarantismo, cuando se trata de este tipo de formas complejas de delincuencia organi-

zada, terrorismo, trfico de drogas, lavado de dinero, puede ser tan pernicioso como la ausencia de garantas. En todo caso se impone una reflexin en profundidad sobre este tema. 2. En la lucha contra la delincuencia transnacional organizada resulta muy conveniente, la desaparicin del principio de doble incriminacin, como planteamiento positivo para facilitar la cooperacin jurdica internacional. Es ms, dicho principio se convierte en una necesidad (slo se mantendra si es el pas del imputado y no existe en l el delito que ste cometi),como tambin lo es que en la cooperacin jurdica internacional se aplique la legislacin del pas requiriente y no del requerido. 3. Debe existir la conciencia de que las Instituciones se enfrentan a un problema de muy difcil y compleja solucin. Por ello el esfuerzo coordinado de todos, en la forma aqu expuesta, o en cualquiera otra, es vital para ofrecer una alternativa coherente que permita tomar la delantera y prevenga los efectos del problema, y la conciencia de que si no se consigue, se habr perdido la ltima posibilidad de controlar y encauzar el fenmeno dentro de unos cauces razonables o, lo que es lo mismo, aceptables por la comunidad internacional.

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16

LA GUERRA CONTRA LAS DROGAS Y LOS INTERESES DE LOS GOBIERNOS

THE WAR AGAINST DRUGS AND THE INTERESTS OF GOVERNMENTS

Labrousse, Alain Socilogo. Asociacin de Geopolticas de las Drogas (AEGD)

Contenido
- Lmites de la Guerra contra el Trfico - Actividades Mafiosas y Corrupcin Policial - Las Drogas en un Conflicto Global - Europa, el Plan Colombia y los EE.UU. - La Lucha contra las Drogas, un Arma Poltica y Econmica - Conclusiones

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In the introduction to the last reports1 of the Office for Drug Control and Crime Prevention (ODCCP)2, the organizations Director, Pino Arlacchi writes that "the psychology of despair has gripped the minds of a generation" [in the area of drugs]. There follows a series of facts and figures intended to support the idea that substantial progress has been made in the fight against the production and trafficking in these drugs. Mr. Arlacchi further notes: "The end of the Cold War and the emergence of real processes for peace in a number of hitherto insoluble conflicts have softened these tensions within the international system; making cooperation a more practical enterprise."3 We that in fact the end of the Cold War fostered the appearance of pseudo-states within which political corruption became institutionalized, it also triggered new local conflict. Lastly, the fight against the drug trade is complicated by the economic and geopolitical interests of states, particularly rich countries which establish themselves as leaders in the war against drugs and are inclined to be indulgent with their allies or clients. LIMITS OF THE WAR AGAINST DRUG TRAFFICKING The claim made in the ODCCP report that illicit drug production is declining appreciably is based on a selective use of data. For example, the ODCCP reports that coca cultivation declined in Bolivia and Peru between 1995 and 2000 (from approximately 150,000 hectares to 50,000 hectares), but fails to mention that this reduction was offset by a virtually equivalent increase in areas under illicit cultivation in Colombia (from 40,000 h to 160,000 h)

I n t h e c a s e o f o p i a t e s , t h e i n c re a s e i n w o r l d production (from 4 000 t to 5,000 t between 1998 and 2000) is so high that mafia themselves have probably asked for a freeze in Afghanistan for fear of a price collapse. In July 2000, Mulla Omar, leader of the Taliban, ordered the complete eradication of poppy crops, in a country which was hitherto the world's number one opium producer ahead of Myanmar. In October, when poppy seeds are planted, technicians from European NGOs observed that emissaries of the Emir4 were touring the villages spreading the message that the terrible drought that had struck the country was a punishment from heaven for cultivating that impious plant. Uncooperative peasants were imprisoned in Djelalabad, capital of the province of Nangahar. A field survey conducted in the eastern part of the country among Pakistani and Afghan opium traders suggests that the central Asian Mafia paid the Taliban in order the market was not to be flooded w i t h e n o r m o u s a m o u n t s o f o p i u m a n d h e ro i n accumulated from the record harvests of 1999 and 2000.5 It is said they offer financial compensation to the Taliban for halting production for one or more years. My field contacts confirmed that part of the Shinwari tribe which resisted the Taliban decree received money from them in order not to cultivate The production of cannabis derivatives is constantly growing to supply markets where their consumption is becoming commonplace. In 1999, Spain alone seized more than 400 tonnes of hashish from Morocco, where crops may cover 120,000 hectares in the Rif mountains and beyond. Around the world, authorities are also seizing large quantifies of hashish from Pakistan,

1World Drug Report 2000 Published early this year. 2Which absorbed the United Nations International Drug Control Programme (UNDCP). 3World Drug Report 2000 P~ 4. 4 Title adopted by Mulla Omar. 5 4,500 t in 1999 and 3, 200 in 2000.

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Afghanistan and Nepal, as well as marijuana exported by Mexico, Colombia, Jamaica, Trinidad y Tobago, Cambodia and all the countries of sub-Saharan Africa. Although the replacement of natural drugs with synthetic substitutes is not yet on the agenda, the production of and trafficking in synthetics are growing exponentially. One can only observe that, in Europe, the number of seizures increased by 38% between 1997 and 1998, with an annual average of nearly three tonnes of pills in the United Kingdom, 1.5 tonnes in the Netherlands. France is the hub for amphetamine and ecstasy exports to the United States which are controlled, in particular, by Israeli rings. Several eastern europen countries like Poland, Ukrainia are also important producers. In the United States, where annual seizures reached 1.7 tonnes in 1997-1998, the number of admissions to treatment centres rose spectacularly between 1992 and then stabilized in 1999 and 2000. However, in Southeast Asia and the Far East in particular, the phenomenon is constantly on the rise. MAFIA ACTIVITIES AND POLITICAL CORRUPTION Since no other illegal activity is as lucrative, drug trafficking has increased the ability of criminal organization to penetrate the economic and political structures of certain states. Economically, they have followed the globalization movement, when they have not anticipated it. However, faced with an offensive by various states, the major organizations (so called "Colombian cartels", Italian and Chinese " M a f i a " , P a k i s t a n i a n d Tu r k g o d f a t h e r s ) f i r s t decentralized their structures in the mid-1990s to be less vulnerable to law enforcement. Where there were three or four major "cartels" in Colombia, there are now at least 40 medium-size organizations in that country. Similarly, in the 1980s, there were a

dozen groups of the Camorra in Naples; the number is now approximately 100, with 6,000 affiliates. These organizations simultaneously diversify their activities (trafficking in human beings, diamonds, protected species and so on) and delocalize them while strengthening their business ties with their counterparts on other continents. When the Turkish government forbed casinos, the babas (godfathers) began to delocalize them to the Caribbean (SaintMartin in particular) and in Africa6 in a country like Tanzania. The Sicilian Cosa Nostra which has been hard hit by the law in the past decade, has stepped up its inter national presence, in par ticular in Brazil, Canada, Easter n Europe and South Africa. According to South African anti-Mafia services, the Sicilian Mafia is solidly established in Cape Town and Johannesburg. Its operations range from money laundering - dummy corporations, real estate dealings - to cocaine trafficking, in cooperation with Colombian groups and aiding escaped Italian m a f i o s i . I n t h e C a p e To w n r e g i o n , t h e m o s t prominent godfather is Vito Palazzolo, for mer banker for the Pizza Connection. Having escaped from Switzerland and sought refugee status in South Africa, where he first put his abilities to work for the apartheid regime before rendering services to the Mandela government, he remains one of the Cosa Nostra' s leaders and an important business man in this country. He is currently under house arrest on the sole charge of obtaining a South African passeport falsifying its nationality. Probably other speakers will deal with the presence of Russian mafia in Latin American countries.

6 On this point see "La maffia diversifie ses activits" in La Lettre Internationale des Drogues no. 4, March 2001, published by the Association de gopolitiques des drogues (AEGD).

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These activities are fostered by the relationships which criminal organizations maintain with the political powers. This is true not only in "banana republic dictatorships" (Myanmar and Equatorial Guinea) and non-states such as Afghanistan, Paraguay and Liberia, but also in countries that play a key geopolitical rote in their region such as, for example, Turkey in Europe and Mexico in North America: I dont insist on them, because both countries are going to be considered by other speakers. I just want to mention that in Turkey 16% of the popular vote, the MHP, the presentable faade of a not so presentable organization, the Grey Wolves, of which a lot of members are incarcerated for criminal activities across Europe, has filled the positions of Deputy Prime Minister and Minister of the Interior after the April 99 election. DRUGS IN A LOCAL CONFLICT The third element in the current situation is the effect of increasing local conflicts on criminality and drug trafficking, a by-product of the end of the Cold War and of the turbulence caused by the collapse of the Soviet Union.7 During the Cold War, the major powers whom nuclear deterrence prevented from confronting directly, did so through their Third World allies. The drug money used by the belligerents thus enabled certain countries to avoid drawing on secret funds to finance their allies. Far from putting an end to these local conflicts, the end of the Cold War merely revealed that in most of the cases they lacked ideological basis, thus triggering ethnic, national, religious and other confrontations. As the belligerents could no longer rely on financing from their powerful protectors, they had to find alternative resources in various forms of trafficking, including drug traffick-

ing. 8 In some 30 conflicts, open, latent or in the course of being resolved, the presence of drugs in various forms and levels is apparent:9 Half of them are taking place in Africa. Some of these conflicts in Colombia, Afghanistan and Angola pre-date the Cold War, but, with the withdrawal of sister parties and powerful protectors, they changed character, gradually sliding into predatory activities. In addition, the downfall of communist regimes was at the origin of the conflicts in Yugoslavia, Chechnya, Azerbaijan-Armenia and of the Georgian civil wars. 10 The combatants in these conflicts dabble in all areas in their search for funding, trafficking in oil, drugs, strategic metals a n d s o o n . S p i r a l l i n g p ro f i t s m a k e d r u g s 1 1 a particularly promising source of financing. The amount of taxes which the Taliban collect annually on drugs was estimated at $100 million." 12 This figure may be multiplied by three or four in the case of the FARC in Colombia. In a micro-conflict such as that of Casamance, in Sngal, the cannabis taxes l e v i e d i n 1 9 9 5 b y t h e M o u v e m e n t d e s f o rc e s dmocratiques de Casamance (MDFC) amounted to several millions of dollars."13 This helps explain why these several hundreds of barefoot combatants have acquired increasingly sophisticated weapons

8Jean Christophe Ruffin [ed], conomie des guerres civiles Paris : Hachette, 1996, 593 pp. 913 See OGD, "Conflicts, Drags and Mafia Activities", communication to the Hague Pence Confrence, May 11 to 15, 1999. On most of the countries cited, the last three annual reports of the OGD may also be consulted.(www.ogd.org). 10Michel Koutouzis, "Drogues l'Est : logique de guerres et de march", IFRI politique trangre 195, pp. 233-244 11From producer to consumer, prices are multipled 1,000 to 2,500 times. See Alain Labrousse, Drogue un march de dupes Paris : ditions Alternatives, p. 78. 1216 OGD, "Afghanistan" chapter in "World Geopolitics of Drags 1998-1999". 131' OGD, "Senegal" chapter in "World Geopolitics of Drags 1995-1996" and "World Geopolitics of Drags 1997-1998", op.cit.

7Alain Labrousse ; Michel Koutouzis, Gopolitique et gostratgies des drogues Paris : Economica, 1996, pp. 23-32

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over the years, and, despite the peace accord signed with the government, groups continue to confront the army and fight against them, particularly in the cannabis harvesting season. One of the most significant recent examples of the use of drugs in a triggering conflict and in the obstacles raised to its resolution is that of Kosovo. In April 1999, The Times of London reported that Europol was preparing a report for European ministers of the Interior and justice emphasizing the connections between UCK and drug traffickers. Those links are regularly confirmed by Italian police and justice. EUROPE, THE "COLOMBIA PLAN" AND THE UNITED STATES In the context of contemporary local conflicts, The "Colombia Plan" should be carefully considered because it marks a very appreciable difference in approach between Europe and the United States. AU the elements of a lasting crisis are found in Colombia: internai conflict between Marxist guerrillas and extreme right wing militia members whose control of drug production is one of the reasons; a state attempt to restore civilian peace and resume control of the territory; the U.S. desire to intervene to put an end to drug trafficking at the risk of jeopardizing peace negotiations. The official objective of the "Colombia Plan" is to combat drug trafficking, suppor t the peace negotiations which began in 1998 with the main guerrilla movement, the Revolutionary Armed Forces of Colombia (FARC), 14 and more recently with the National Liberation Army (ELN),z915 and to promote the country's economic development, in particular for

the most modest segments of the population. The overall cost of the plan is $7.5 billion. The Colombian government's contribution should amount to $4 billion. The United States has decided to contribute $1.3 billion. The rest is expected to come from bilateral cooperation (Spain, Japan) and multilateral cooperation, in particular with international financial organizations (World Bank, International Development Bank, Andean Financial Community, BIRR, etc.) and from the European Union. In Colombie, the plan has come under criticism, not only by guerrillas, but also by development NGOs and human rights defence organizations. The criticism is based on the fact that approximately 70% of U.S. financing ($1 billion) will go to reinforce the military potentiel of law enforcement forces. In particular, 60 helicopters, including 18 Blackhawks, were purchased from the United States. The FARC and ELN thus believe that, under the guise of fighting against drag trafficking, the U.S. government, by reinforcing the Colombien army, in fact aime to sabotage the peace process and that it is the target of a genuine "act of war". The Colombien and international NGOs (Amnesty International, American Watch, WOLA and others) denounce what they consider "a logic of war", which can only exacerbate the unsafe circumstances in which the population is living. The plan is also disturbing and dividing Colombias neighbours, which cannot help likening it to a plan for which the United States flew trial balloons while officially denying it to create a multilateral Latin American army to intervene in Colombie where the guerrillas and drag traffickers jeopardize regional security. Such a plan, which had been approved by Peru urider former President

14Approximately 15,000 men. No cease fire was reached with this organization and military operations thus continue during the negotiations. 151,500 to 2,000 combatants.

Fujimori, has met with strong opposition by Venezuela (whose nationalist President Hugo Chavez does not conceal hie sympathies for the

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FARC), Panama and Brazil, which takes a dim view of any initiative that might compete with its role as a regional power. The countries bordering on Colombia (Ecuador, Peru, Brazil, Venezuela and Panama) fear that a violent offensive against drug production in that country will scattter not only the population, but also guerrillas and drug traffickers across the Amazonien regions along their borders with Colombia. At a meeting of the countries supporting the fight against drugs held in Bogota on October 24, 2000, the European Union, upon completion of a process in which France played a decisive role, clearly distanced itself from the "Colombia Plan". The EU's financial contribution of $871 million will essentially be allocated to the "institutional reinforcement" and "social development" program. However, this financial assistance is clearly outside the framework of the "Colombia Plan". The Unions s p o k e s m a n , R e n a u d Vi g n a l , f ro m t h e F re n c h Department of Foreign Affairs, informed the meeting, "European aid is different from the Colombia Plan," and added, to avoid all ambiguity: "European assistance includes no military component For the European Union, there is no alternative to the peace process; there is no military solution to restore a sustainable peace." The Unions official responsible for Latin America, Francisco de Camera, hammered the message home: "We want to contribute to peace, not increase tension." On March 8, 2001, a meeting was held between the diplomate of 26 states and the FARC in the demilitarized zone conceded to the guerrillas. The United States refused to attend,16 even though the new administration affirmed its "unequivocal support" for the peace process and that it "does not ride out taking part"

in the second round of talks with the guerrillas. The European Union and most of the countries of the Schengen Area were represented, as were the Vatican, Switzerland, Canada, Japan, Mexico, Brazil, Venezuela and others. Following the meeting, a communiqu signed by all the countries present reiterated their support for the peace process. In addition, since May 2000, five countries Cuba, Spain, France, Norway and Switzerland have been members of the group of countries that are "friends" of the peace process together with the other guerrilla group of the National Liberation Army (ELN). The European Unions rising opposition to the "Colombia Plan" facilitated the change in strategy of the FARC, which was previously opposed to the presence of any international commission in the demilitarized zone and put the seriously compromised negotiations back on the rails. THE FIGHT AGAINST DRUGS, AN ECONOMIC AND POLITICAL WEAPON The various types of compromises which the rich countries make with drug trafficking states are so widespread that their characteristics can be modelled. The most widespread stems from economic interests. During the 1990s, China and Poland readily agreed to be paid for the weapons they sold to Myanmar with heroin money. Rangoon in particular spent nearly $1 billion to purchase combat aircraft from China at a time when its currency reserves did not exceed $300 million.17 Members of the intelligence services of the French Embassy in Pakistan I met, did not rule out the possibility that drug money might at that time have been involved in the payment of France 's weapons sales to that country.

16The pretext used is that the FARC did not deliver up the guerrillas who had murdered three American cooperants in February 1999 to the United States.

17This affair in particular was covered by Bertil Lintner, a journalist with the Far Easter Economic Review, whose articles where reprinted in gurma in Revoit, Opium and Insurgency Since /948 Boulder, Westview Press.

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The World Bank and International Monetary Fund ask no questions about the origin of the fonds enabling certain countries in particular, Colombia during the 1980s to pay their foreign debt. Certain European states and the Union itself close their eyes to the official protection granted for cannabis cultivation in Morocco because it contributes heavily to that country's economic equilibrium and it would be extremely costly to replace it.18 However, drugs may also be used as a diplomatie weapon to destabilize or discredit a political adversary. An example of this attitude is the U.S. drug policy towards Iran. Throughout the 1990s, despite its efforts against the transiting of Afghan heroin (Iran lost nearly 3,000 men in these fights over 20 years), Iran was "decertified" by Washington. When I questioned a State Department representative he simply answered that Iran had been placed on the list just because it was a terrorist state. In December 1998, President Clinton announced that he would remove Iran from the list of "decertified" countries. The reason given was that "Iran is no longer a significant opium and heroin producer and that it had stopped being a transit country for drugs destined for the United States." There was general understanding that this was a goodwill gesture in response to the policy of openness displayed by President Mohamed Khatami since 1997. The U.S. use of drugs as a political weapon has its imitators. Many Third World countries now use it to fight their political opponents or ethnic and religious minorities living within their borders. The situation of Timor has received extensive media coverage, but there is at least one other Timor in Indonesia, and that is the province of Aceth, where fierce repression of the population of that region of northern Sumatra has given rise to a movement of armed revolt over the past 20 years. In the early 1990s,

the Indonesian army's pretext for intervening massively in that region was to conduct cannabis eradication campaigns supported by the United States. It is true that the region was a traditional producer of drugs, but this in no way justified the deployment of such significant military resources, which proved to have murderous effect. Another example is that of the Sudan, where the fight against cannabis, this time supported by the UNDCP, has enabled the Islamic government at Karthoum to intervene in recent years against the animist Beja tribe.19 The last factor concerning the manipulations in which drugs are an issue is diplomatic in nature. In this instance, a country conceals another state's involvement in drug trafficking in order to blackmail it into putting an end to it or to force it to comply with a policy desired by the first state in another area. [The United States"20 has simultaneously pursued these two objectives in the case of Syria, whose troops were deeply involved in hashish and heroin trafficking in Lebanon. In this way, the United States forced eradication campaigns on illicit drug crops on the Bekaa plain and Syrian participation in the Middle East peace negotiations]. The same strategy is currently being used by Washington with General Hugo Banzer, elected president of Bolivia, whose military dictatorship (1971-1978) not only engaged in serious human rights violations and the assassination of opponents in foreign countries as part of the "Condor Plan", but also contributed to Bolivia's specialization in cocaine production."21The virtually complete eradication of illicit coca crops by the end of last year, was indeed obtained through the blackmail (and silence) of the United States

19 See on this subject the "Sudan" chapter in OGD, "World Geopolitics of Drags 1997-1998 20The Israeli secret service also had files on Syrian military involvement in hashish and heroin trafficking

18Eradication without any development alternative would result in an increased flow of migrants in Europe.

21Alain Labrousse, La drogue, l'argent et les armes Paris : A. Fayard, 1977, pp. 366-370.

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and the international community. Now, every Latin American dictator will now be able to think, on the basis of this example which is well known across the continent, that he can engage in drug trafficking today and will need only become a drug eradicator for everyone to forget the source of his wealth and power. CONCLUSION The United States has just lost its seat on the board of the International Narcotics Control Board (INCB). This reverse is probably the result of a combination of various interests. But one of the reasons might be the vote of Latin American countries which have always opposed the U.S. Colombia Plan and "certification" process. In addition, isolated phenomena such as the virtual disappearance of opiate production in Afghanistan, or more structural phenomena such as the development of synthetic drug production in the developed countries, will undermine some of the United States' arguments in its crusade against the producer countries. With regard to substance abuse, the advance of "harm reduction" policies, to which France, in particular, has rallied since the late 1990s, to the detriment of policies in favour of the U.S. policy of a "drug-free world", of which Sweden remains one of the last European supporters,22 is another sign of change. But the United States retains as allies two major specialized U.N. organizations in the fight against drugs ODCCP and INCB which has developed under their influence. Also the position of developing country in Asia and Africa are at times even more extreme than those of the United States with regard to national policies on substance abuse and the international fight against drugs. There are a number of reasons for this attitude. For some, it stems from the fact that these are non-

democratic societies China, Malaisia, Saudi Arabia and Iran which punish all visible deviants very harshly. For others, this is simply the consequence of the fascination exercised by the "American model" or of an opportunism which pushes them to join in what is perceived as the dominant position of the richest countries. An other motive is through punitive measures, they raise a smokescreen to trafficking activities engaged in by their leaders. These countries are prepared to support all anti-drug crusades, as long as they or their elite are not, the target of them. Its the reason why I consider as very positive the European position not to support the Colombia Plan. But the attitude of european countries is not always so clear, for example in relation with money laundering centres such as Jersey for the United Kingdom and SaintMartin/Sint Marteen for France and the Netherlands. These ambiguities and contradictions are not only a barrier to the fight against serious drug crimes, but they can also be the cause of new threats, as suggested by the U.S. attitude in the case of Colombia.

22See "Sude : inflchissement de la politique anti-drogues" in OFDT Drogue Trafic International no. 2, March 2001.

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RETOS DE LA INFORMACIN SOBRE DROGAS EN EL SIGLO XXI

CHALLENGES OF INFORMATION ON DRUGS IN THE 21ST CENTURY

Pueyo Ruiz, Begoa del Periodista. Coordinadora de Todos contra las Drogas. Protagonistas Onda Cero. Cruz al Mrito del Plan Nacional sobre Drogas.

En los aos 80 del siglo XX los primeros periodistas que intentaban hacer informacin sobre drogas en Espaa se encontraban con escasez de fuentes de informacin: el 90% de las noticias las proporcionaba la polica y hablaban de incautaciones y robos protagonizados por toxicmanos. En el aspecto social, haba pocos interlocutores fiables. En cambio, los escasos profesionales que trabajaban con rigor, recelaban de los medios de comunicacin, acusndoles de banalizar la problemtica de las drogas en aras de la espectacularidad. Esa desproporcin de noticias policiales y sociales cre el ambiente de alarma social que propiciaba la imagen de drogodependiente-delincuente. El acceso poco a poco a los medios de comunicacin de profesionales multidisciplinares para explicar a la poblacin este fenmeno ha ido difuminando ese tpico. Actualmente, uno de los retos fundamentales para el periodista est, paradjicamente, en contrastar la avalancha de informaciones procedente de fuentes muy diversas (el caso del Dr. Ricaute publicado por "Science" es el paradigma de esa falta de contraste informativo). Ms difcil todava es mantener el rigor a la hora de abordar cuestiones relacionadas con drogas legales como el alcohol y el tabaco. El mayor reto, sin embargo, est en conseguir que la normalizacin social de las drogodependencias que ya no provocan alarma, no haga caer a este colectivo en el olvido informativo. La frmula ms eficaz para conseguir una informacin contrastada y de calidad est en la estrecha colaboracin entre los profesionales de las drogodependencias y quienes elaboran esas informaciones que permite ganarse mutua confianza. Pero no basta con el esfuerzo de los periodistas, hay que exigir el compromiso de las empresas de medios de comunicacin para formar profesionales especializados en este problema, cuya magnitud social as lo exige. Esa es una demanda, que tienen que hacer suya tambin los colectivos que trabajan en drogodependencias.

In the 1980s the first journalists who tried to inform on drugs in Spain found that there were few sources of information available: 90% of the news was provided by the police and spoke of confiscations and thefts carried out by drug addicts. There were few reliable interlocutors with regards to the social aspect. Moreover the few professionals who carried out rigorous work were suspicious of the media, accusing them of turning the drug problem into a banal news item in the interests of spectacular reporting. This disproportion between police and social news created an atmosphere of social alarm which led to the image of the delinquent-drug addict. Little by little the access of multi-disciplinary professionals to the media to explain this phenomenon to the population has gradually helped the clich fade. Currently, one of the fundamental challenges for the journalist is, paradoxically, to contrast the avalanche of information from extremely diverse sources (Dr. Ricautes study case published by "Science" is the paradigm of this lack of information contrast). And it is even more difficult to maintain a rigorous approach when dealing with matters related to legal drugs such as alcohol and tobacco. The greatest challenge, however, lies in achieving a situation where the social standardisation of drug dependencies which no longer give rise to alarm does not lead to this group of persons being forgotten by the media. The most efficient formula for achieving contrasted, quality information is the close collaboration of drug dependency professionals and media professionals, enabling mutual trust to grow up between them. But the effort of journalists alone is not enough, we must also ask for a commitment from the media companies, who should train professionals specialising in this problem, something its social magnitude demands. This demand should also be made by groups working on drug dependencies.

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Ya en 1972, cuando las drogodependencias comenzaron a constituir un problema social generalizado, la UNESCO seal que los medios de comunicacin representan un poderoso medio de accin para fomentar actitudes y transmitir conocimientos en materia de drogas. Pero tambin advirti que una informacin transmitida inadecuadamente puede llegar a propagar el uso de las drogas o agravar la reaccin de la sociedad para con los drogodependientes, traumatizar a los padres y provocar el aislamiento de los individuos dependientes. Afortunadamente, ms de tres dcadas despus, el panorama es esperanzador en cuanto a la aceptacin social de los drogodependientes, aunque sobre los periodistas pende todava la asignatura pendiente de transmitir una informacin veraz que se ajuste a la autntica magnitud del fenmeno. Hace tiempo ya que los colectivos sociales han asumido que lo que no aparece en los medios de comunicacin es como si no existiera. Por eso demandan de los periodistas que contribuyan a la prevencin, tambin a denunciar situaciones injustas y a crear estado de opinin. Por otra parte, se critica de los medios la tendencia a primar las informaciones negativas sobre las positivas, de magnificar la realidad y de fijar estereotipos respecto a las drogas y sus consumidores. Para contrarrestar estas distorsiones del mensaje informativo es imprescindible que los colegios de periodistas y asociaciones de prensa asuman en sus cdigos deontolgicos la necesidad de producir mensajes constrastados. Pero lo fundamental es que el colectivo interdisciplinar de profesionales que trabajan en drogodependencias (terapeutas, psiclogos, socilogos, educadores, antroplogos, etc.) colaboren estrechamente con los informadores.

LA PRESENCIA EN LOS MEDIOS NO PUEDE SER A CUALQUIER PRECIO En los aos 80-90, el mayor hndicap al que tuvieron que enfrentarse los periodistas para informar sobre drogas fue la escasez de fuentes. La mayora de las noticias provenan del mbito policial, referidas a alijos o delitos cometidos por drogodependientes. Eso contribuy a crear alarma social, al fijar el estereotipo de drogodependiente delincuente. A eso se uni el recelo mutuo entre los escasos profesionales rigurosos que trabajaban en drogodependencias y los periodistas. Los terapeutas rehuan aparecer en los medios de comunicacin por la amenaza de que se vanalizara su trabajo, dada la espectacularidad de algunas informaciones, en tanto que los periodistas tampoco acababan de encontrar los interlocutores vlidos, ante la proliferacin de centros cuyo origen se asociaba con sectas que eran justo los que mayor disposicin tenan a aparecer en los medios. La complicidad actual que existe entre la mayora de los periodistas que informan asiduamente sobre drogas y los profesionales de las drogodependencias corre el peligro de romperse ante la proliferacin de estudios que no siempre pasaran los ms escrupulosos controles. Ver reflejada una investigacin, un estudio o una terapia en los medios de comunicacin garantiza subvenciones o la confianza necesaria para conseguir el apoyo en un proyecto. En este sentido, no slo ONGs, sino instituciones y quienes trabajan en investigacin al ms alto nivel han pecado en algunas ocasiones de precipitacin a la hora de publicar conclusiones de sus resultados, prematuramente, para verlos reflejados en la prensa. Por parte de los periodistas la premura de tiempo y la escasa especializacin de los informadores hace que, a menudo, se publiquen estas informaciones sin contrastar. Uno de los casos recientes ms esclarecedores de esta decepcionante realidad es el estudio del

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Dr. Ricaute de la Universidad John Hopkins, a propsito del dao neurolgico irreversible provocado por el MDMDA. Dos aos despus de difundida la investigacin, el propio autor reconoca que las conclusiones eran falsas, por un defecto en las muestras de laboratorio. La publicacin de esta investigacin en la prestigiosa revista Science dio la vuelta al mundo, sin mayor contraste informativo por parte del resto de los medios de comunicacin. En la mayora de los casos, los periodistas se limitaron a informar sobre esas desmesuradas conclusiones, sin solicitar la opinin de otros expertos. Un fenmeno que se repite a menudo cuando se trata de poner de manifiesto el peligro del consumo de drogas, a veces, con resultados excesivamente alarmistas. Otro de los retos ms importantes a los que se enfrenta la prensa del siglo XXI es a la obligacin de crear mensajes que no resulten contradictorios, en torno a dos drogas legales como el alcohol y el tabaco. LO QUE SE DICE Y LO QUE SE ENTIENDE Las reglas de la comunicacin, en ocasiones, pueden provocar indeseadas distorsiones del mensaje. - El primer impacto es el que se fija con mayor intensidad. Eso explica, aunque no justifica, por qu todava la herona sigue siendo la manifestacin grfica con la que se representan las drogas, cuando en estos momentos el consumo de hachs y cocana ha superado al nmero de consumidores de herona y sus consecuencias resultan igualmente destructivas para el individuo. - El efecto magnificador de los m.c. puede provocar alarma social al advertir de un fenmeno, amplificando su importancia y minimizando los efectos de otro. Una muerte por consumo de xtasis en una fiesta adquiere un protagonismo que no alcanzan las 13.000 vctimas por accidente que se atribuyen al alcohol.

- La heterogeneidad de los receptores de los mensajes puede provocar que una misma noticia sea percibida con preocupacin por los padres y al tiempo fomentar el espritu trasgresor de los jvenes. - La necesidad de trasformar el lenguaje para que sea accesible a toda la audiencia, especialmente cuando se trata de informar sobre conceptos cientficos, puede provocar distorsiones como la que se produce al explicar las propiedades teraputicas de los principios activos del cnnabis, que algunos jvenes acaban simplificando con la sentencia de que el porro cura. - Los testimonios que se asoman a los medios de comunicacin no siempre reflejan la autntica dimensin del fenmeno. Es frecuente que en radio y televisin aparezcan slo vctimas de las drogas que provienen de ambientes desestructurados. Es su modo de echarle en cara a la sociedad que no les ha ayudado. En cambio, las experiencias de los socialmente integrados difcilmente pueden ser recogidas. - El fenmeno de los padres coraje, popularizados por los medios de comunicacin, pueden provocar la frustrante sensacin de ineficacia de la justicia y al tiempo acomplejar a los familiares de un drogodependiente que no asume una postura beligerante contra las drogas. Otro tanto sucede con los barrios escenario, donde la denuncia de los puntos de venta puede llegar a estigmatizar a todos sus habitantes. - Ofrecer el precio en mercado de las drogas incautadas puede inducir a los ms jvenes a plantearse una ilusoria manera de conseguir dinero fcil. - El lenguaje verbal y grfico no son inocentes. Una simple fotografa de jvenes acodados en una barra para ilustrar una informacin sobre las fiestas de un pueblo o denominar a las drogas de sntesis como drogas de diseo o droga del amor distorsionan el mensaje.

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- Es imprescindible que los periodistas entiendan programas como los de reduccin del dao y reduccin del riesgo (folletos para consumo responsable, intercambio de jeringuillas, narcosalas, etc.) para evitar que fuera de contexto puedan ser percibidas como una amenaza, en lugar de transmitir su funcin normalizadora. LAS NUEVAS TECNOLOGAS NO TIENEN QUE SER LA UNICA VA DE COMUNICACIN CON LOS JVENES Un reciente estudio sobre jvenes realizado por la FAD revela que los adolescentes tienen una progresiva tendencia a la homogeneizacin. Su estereotipo de ser joven significa necesariamente ser rebelde y vivir el ocio a veces de una manera extrema, consumir determinados productos, incluidas las drogas. Los medios de comunicacin a menudo recogen las ideas preconcebidas de los jvenes y las devuelven a la sociedad, reforzadas e institucionalizadas. Eso explica que pese mucho ms en el imaginario de adultos y adolescentes el 26% de jvenes que consumen xtasis que el 974% que no las emplean en su tiempo de ocio, por ejemplo. Es importante resaltar la tarea de los medios de comunicacin como altavoz al servicio de los profesionales que pueden dar pautas de comportamiento a los padres respecto a sus hijos. En otras ocasiones la prensa permite apelar a la responsabilidad que tienen los adultos en su educacin, tal como sucedi con el Congreso sobre Jvenes y tiempo Libre que realiz el PNSD en el ao 2001. Lamentablemente, no resulta igual de sencillo conseguir que los jvenes accedan a los medios de comunicacin convencionales para explicar su visin del fenmeno. Sabiendo que los jvenes son ms sensibles a teleseries, radiofrmulas e Internet se corre el riesgo de excluirles de los medios de comunicacin convenciona-

les, sin darnos cuenta que estamos cerrando la puerta a un instrumento til para facilitar la comunicacin intergeneracional. No podemos obviar que Internet ha crecido un 370% en los ltimos aos y se ha convertido en el segundo medio de comunicacin, slo superado por la televisin. Es cierto que se estn haciendo magnficos programas destinados a adolescentes a travs de la red, pero tambin debemos recordar que es precisamente a travs de Internet como se refuerzan muchos de los tpicos sobre legalizacin de drogas, formas de elaborar sustancias sintticas, smart shops, etc. Otra asignatura pendiente para los medios de comunicacin es advertir a la sociedad y ms concretamente a los jvenes, sobre los peligros que entraa el abuso de las nuevas tecnologas, sin por ello demonizar unos instrumentos tiles a la sociedad como Internet o los mviles, que ya figuran a la par que las drogas entre las adicciones juveniles. LA NORMALIZACIN SOCIAL UN ARMA DE DOBLE FILO Cuando en los aos 80-90 los profesionales que trabajaban en drogodependencias luchaban, con la complicidad de los medios de comunicacin, por acabar con la alarma social que generaron las drogas, poco podan imaginar que esa normalizacin poda poner en peligro su tarea. Los drogodependientes ya no provocan vergenza en las familias, ni intranquilidad en el resto de los ciudadanos, pero se corre el peligro que esa normalizacin se torne indiferencia. El barmetro del CIS del mes de febrero de 2.004 fue suficientemente esclarecedor: las drogas no figuraban entre las diez mximas preocupaciones de los espaoles, que atribuyen al paro, el terrorismo y la violencia de gnero los mximos problemas a los que enfrentarse. A pesar de que las estadsticas nos revelan que cada vez hay un mayor nmero de afectados por drogas

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que precisan tratamiento, la normalizacin del fenmeno acarrea el peligro de que desaparezcan paulatinamente de la prensa. Y como decamos al comienzo lo que no aparece en los medios de comunicacin es como si no existiera, con todo lo que comporta: disminucin de la conciencia social, reduccin de recursos por parte de los organismos pblicos y de iniciativas privadas... Cuando en 1993 naci el Comit Drogas No y organiz una fiesta del ftbol a favor de Proyecto Hombre, bajo la presidencia de honor de Su Majestad La Reina e impulsado por el juez Baltasar Garzn, el periodista Luis del Olmo y por el actor Emilio Aragn (inicialmente estaba tambin el entrenador Johan Cruyff), el objetivo fundamental de estos encuentros deportivos fue aportar calor humano a las familias que sufran en silencio un problema del que se culpaban y frente al que no encontraban respuesta social satisfactoria. En esa poca en la que las drogas causaban alarma social, reunir a ms de un centenar de personas de todas las edades y profesiones en el csped del estadio, para llenar los graderos de solidaridad, fue un hito relevante para la integracin de los drogodependientes en nuestra sociedad. En pleno siglo XXI es ms necesario que nunca mantener un acontecimiento que llame la atencin, aunque sea una vez al ao, sobre la necesidad de seguir luchando por este objetivo. Una tarea que no se lleva a cabo sin los recursos econmicos y humanos que, a falta de difusin, podra parecer a los ciudadanos que ya no es necesario preocuparse porque el problema est resuelto. Resulta paradjico constatar que los mismos medios de comunicacin que se vuelcan a la hora de transmitir el mensaje de solidaridad del Partido Drogas No, con insercin gratuita de la campaa publicitaria de promocin del partido, no resulten tan activos a la hora de buscar sus propias informaciones sobre drogas. Por eso, HAY QUE APROVECHAR ESA BUENA DISPOSICIN

DE LOS MEDIOS DE COMUNICACIN AUNQUE EXIJA UN DOBLE ESFUERZO POR PARTE DE LOS PROFESIONALES QUE TRABAJAN EN DROGODEPENDENCIAS. Con estudios rigurosos y con-

trastados, con sus sugerencias a los periodistas ms concienciados, se puede mantener viva la llama de la informacin sobre drogas. BIBLIOGRAFA Medios de comunicacin y drogodependencias. Actuar es posible. PNSD 2000. Isabel M. Martinez Higueras/ Miguel A. Nieto / Begoa del Pueyo Jvenes y Medios de Comunicacin. FAD INJUVE 2001. Elena Rodrguez / Jos Navarro / Ignacio Megas Tratamiento periodstico de las drogas y las drogodependencias. Coordinadora de ONGs que intervienen en drogodependencias. 1996 Los medios de comunicacin social y las drogas: entre la publicidad y el control social. Revista Especial Drogodependencias 1995. Amando Vega Fuente.

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T R ATA M I E N TO / T R E AT M E N T

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CUIDANDO EL JARDN DEL CORAZN. LAS MUJERES EN LA COMUNIDAD TERAPUTICA

TENDING THE HEARTS GARDEN. WOMEN IN THE THERAPEUTIC COMMUNITY

Arbiter, Naya Amity Foundation & Extensions, LLC

La invisibilidad de las mujeres - Cmo obtenemos las experiencias de nuestros participantes que se hallan fuera de las experiencias de los profesionales de las CT? - El acuerdo tcito para excluir aquello que no comprendemos, o aquello que es demasiado perturbador para ser tratado por el personal y los participantes. - Denominar, reivindicar, utilizar e integrar experiencias. Hallar valor en experiencias consideradas como degradantes. Eliminar el rol discriminatorio; abuso, violacin, prostitucin, encarcelamiento Desarrollo del rol frente a parlisis del rol. Hacerse ms grande que la herida. Ir ms all del estado de supervivencia. El acuerdo social para sobre-medicar (silencio) a las mujeres. El testimonio fundado, utilizando el paradigma de Alice Miller - Redefiniendo el grupo de encuentro como un complemento del testimonio fundado. Utilizar el currculo. - Currculo basado en la comunidad y en el individuo en su integridad - La CT en torno a las inquietudes de las mujeres da cuenta tanto de hombres como de mujeres. - El desarrollo de un lxico de refugio, donde la adecuada confrontacin y otras herramientas tradicionales de la CT puedan utilizarse. La relacin entre la recada crnica y la auto-revelacin. La Historia de la Handless Maiden. - Compresin de la alfabetizacin emocional. - Autenticidad frente al cumplimiento de las normas de la CT. - Proporcionar una oportunidad a las personas para influir en otras, lo que ofrece autntica curacin interna. Desarticulacin y Rememoracin de China Galland. Hallarse en el proceso de conducir frente a la orientacin hacia la meta. Comunidad viva frente a conformidad.

The Invisibility of Women. - How do we elicit the experiences from our participants that are outside the experiences of the TC practitioners? - The unspoken agreement to exclude that which we do not understand, or that which is too upsetting to deal with for the staff and participants. - Naming, claiming, utilizing, and integrating experiences. Finding value in experiences seen as degrading. De-rolling from victimization; abuse, rape, prostitution, incarceration Role development vs. Role parlisis. Growing larger than the wound. Moving beyond survival status. The Social contract to over-medicate (silence) women. The informed witness-using Alice Millers paradigm. - Redefining the encounter group as an adjunct to the informed witness. Using Curriculo. - Curriculum that is community & whole person based. - The women centered TC provides accountability for both women and men - The development of a vocabulary of sanctuary, within which appropriate confrontation and other traditional TC tools can be used. The Relationship between chronic relapse and selfdisclosure. The story of the Handless Maiden. - Understanding emotional literacy. - Authenticity vs. meeting norms of the TC. - Giving people an opportunity to make a difference for others which offers real internal healing. Dismemberment and Re-membering China Galland. Being on the road process vs. goal orientation. Living Community vs. conformity.

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In Native American lore, there is the story of the Black Lodge, a holy and most sacred place. When a man has acquired all the masculine skills, and has fulfilled the expectations that the tribe has of a man according to the ways of his people, then and then only, he may be invited by the elders of the tribe to enter the Black Lodge. He enters the Lodge as an accomplished warrior, hunter, husband, father; he is skilled in all the masculine ceremonies and rituals of the tribe. But when he enters the Black Lodge he dresses as a woman, he learns the lore, the customs, and the skills of women. He lives in the Lodge with woman as a woman until he has acquired their knowledge and their ways. When he emerges from the Black Lodge, there is a great ceremony and he is recognized by the tribe and the elders as having obtained his true and authentic masculine self. For a woman to obtain her true womanhood, she too, having fulfilled the common expectations of woman, must enter the Lodge and live as a man. Daisy Utemorra, an elder of the Wandjina people of the Kimberleys in Northwest Australia is reported to have said that after men have obtained the highest degrees of male initiation only then do they become eligible for initiation into womens law. It was said that oftentimes a mans hair was gray before he was ready and it was the same for women. These tribal people were ancestors of todays world. The teachings of people who understood the heartbeat of community are teachings that the Therapeutic Community movement would be wise to heed. For these ancient cultures lived community and wholeness and authenticity were their highest values. If we profess to provide whole person education for wounded women and men today, our path is not honest without striving for understanding, acceptance and compassion amongst all of us. How many TC practitioners today would be eligible to enter the Black

Lodge? How many men and women would be eligible for initiation into the ways of the opposite gender? In the dreamtime of the therapeutic community (before funding, bureaucratic interference, clinical oversight, and risk management) there was a love story; a love that was as politically incorrect as it could be. 1958 in the United States; a love between a white man and a black woman. He was educated but a hopeless alcoholic, and she a prostitute, a criminal addict. They both had strong voices and dreams. They are our ancestors in this work. He said: None of the accredited professions have been successful with addicts. They dont address the whole person. The pharmacologist and the physiologist will deal with the chemical nature of addiction, the internist will supervise the withdrawal, the psychologists will measure mental and emotional capabilities; the psychiatrists will try to unearth the resolve the traumatic events that brought on the addiction; the anthropologists will study cultural factors; and sociologists will try to determine a social setting that will contribute to recovery. We propose something new: is a program for wholeness. The purpose of this is to give everyone who comes into it a glimpse of the vision that life is a gift not to be wasted. His partner the tall, proud, elegant, African America woman with Cherokee blood in her veins looked at his processes, his ideas and the early encounter groups. She said: We have a great vocabulary for hostility; but we need more ways to say I love you. Receiving affection throws people into more of a crisis than being yelled at. People need both, it is the sound of two hands clapping. We need to teach, She said, teaching is an act of love, it is the most important function of the adult human being. To communicate your own truth, THAT is the act of love.

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And so they both dreamed. He developed structure and accountability and selfsupporting businesses, and spun webs of ideas that spilled out into the world, and she developed encounter groups based on affirmation, ceremonies and rites of passage. She created hope and that hope spilled out into the world and his ideas floated on the hope that she made.. She entered his lodge, and he entered hers they crossed the barriers of race and class, religion and experience. She included children and made special places for women and families. Together with their circle of castaways; alcoholics, convicts, addicts, Muslims, Jews, and gentiles, they created a new foundation. It was a garden of the hear t. It was the first Therapeutic Community. After time passed men began to come from all over the world to see this place and the circle of people that stood in it; but the men who came could only hear what He said because they were men, and they had only learned to hear mens voices. And so it came to pass that her voice faded and the wind took her voice back and blew it away. When her voice was blown away she died, and his heart cracked with regret knowing that he had not helped her voice be heard. He returned to his madness, his alcoholism until he died. It was a love story. And so the Therapeutic Community grew and grew without the feminine vision. The history was written, like most of our histories, as His Story, written and told by men about men and for men. China Galland writes: Fierce compassion is the transformation of anger into compassion. The divine feminine can rise up when the world is in danger, help can come from forgotten quarters, from what has been cast out, lost rejected and marginalized and what we have cast out is what saves us and what becomes the cornerstone for a new foundation.

Women and their children remain lost, rejected and underserved internationally. The anger, revulsion and fear women have for themselves, and that society has for them must be transformed into fierce compassion should we wish to improve the pathway for women from degradation to dignity. Stigma remains greater for the fallen women than for her male counterpart; it is more acceptable to be a male ex-convict than a female exwhore. Voices representing the addicted, alcoholic and incarcerated woman have emerged yet there remains resistance to full disclosure by women of their experience. Both clinical and political arguments abound regarding why the addicted woman doesnt need to go into detail. The TC practitioner confronts the unnamed experiences of the woman herself; the customs and policies unfriendly to women; and the astounding denial that has been maintained supporting the silence of both male participants and male practitioners in the TC regarding the reality of the impact of men on women and vice versa. Twenty years ago in the United States, the National Institute on Drug Abuse published a survey taken from U.S. treatment programs for women. Many were TCs. Although most of the women reported severe abuse prior to and during their addiction, less than 10% of the programs addressed these issues. The hue and cry was raised that womens issues; rape, molestation, childbirth, domestic violence, abortion, prostitution must be addressed. Yet no one raised the issue that the male participants in the Therapeutic Communities were the counterparts to these feminine experiences. It has seemed that those men who raped, abused, sold, bought and tormented women as well as those men who were themselves molested, raped, beaten, and abused, who prostituted, served as prostitutes or pimp were elsewhere. If we are to do the work of authentic healing for women, the men must do their work as well.

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For thirty years women have maintained the status of a special population with special issues in hundreds of conferences, and thousands of academic pages. The drug-using prostitute panders to the least exalted needs of the men that buy and sell hera transaction which metaphorically travels through all of the manifestations of a womans addiction. Yet, if women were to universally state their experience in detail; would that not lead us to examine the reality of mens lives? Does not the silencing and separation of the womens experience ultimately support the repression of the men who have come to the TC to be healed? The recovered role model is one of the fundamental concepts upon which the TC has been built, consistent with its Alcoholics Anonymous heritage. Yet many male recovered TC practitioners have not, as part of their own recovery, dealt with the issues of pornography, adultery, sexual abuse, molestation, child abuse, prison sexuality, homosexuality and prostitution in their own lives. Thus they both wittingly and unwittingly serve as a significant barrier to opening the TC to be an informed witness to the feminine experience and they continue to relegate the feminine to a special population. If the ideal that we strive for in our TCs is whole person education, then we must transform anger into compassion for our own and each others experiences and create dialog to understand each others suffering. Gender responsive treatment is not gender exclusive treatment. As we learned a generation ago during the civil rights movement, separate is inherently unequal. 1. ACCOUNTABILITY TO GENDER Accountability. Every one of our TCs has it; miles of structure boards, millions of pull-ups, endless distractions over the often-mundane details of here and now behavior. Our own accountability systems frequently obfuscate our ability to be accountable as practitioners to those issues, which wound our souls.

How accountable are our Therapeutic Communities to gender; starting with our workplace and our practitioners? It is a lie to pretend that we are promoting whole person education if we develop projects that are gender responsive for women: but within our same agencies do not provide arenas for men to address these same issues. Men and women need their own space, place and time; but after being in their own Lodge they need some time together in sanctuary, facing each other before leaving the TC. Men and women need to practice using their voices to tell their truths. 2. ACKNOWLEDGING A CULTURE OF DEGRADATION The culture of addiction for women is a culture of degradation that exists beyond ethnicity. It is a culture of sexuality divorced from relationship, of motherhood without nurturing, association without friendship, childbirth without celebration, rape without comfort and infection without medication. It is a culture of manipulation, being used and using others cycling through shades of despair. Regardless of socioeconomic background it is a culture whose seeds flourish through silenced experiences of sexual abuse. It is a culture of pornography rather than erotica the story of female slavery rather than romantic love. It is a culture of exploited children, shattered dreams; industrialized crisis nurseriess and foster care; a culture that maintains the emotional climate of lonely hours in the abortion clinic. It is a culture divorced from our most common mythology: this is no period of sowing wild oats; girls will be girls, or proving womanhood though sexual prowess and numerous partners. There are no celebrations and feasts when the prodigal daughter returns from the street corner after servicing thousands and renounces prostitution. In the end, the culture of the addicted woman, she who has been soundly rejected, rejected herself, been

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shuffled between programs, prisons, psychiatrists, who has been ridiculed, arrested, urine tested, hair t e s t e d , b re a t h a l y z e d , e v a l u a t e d , a n d d u a l l y diagnosed, this culture may hold a special meaning for us. In the cracked and dirty mirror that bears her reflection if we have the courage to look we may, as the great Jungian Helen Luke has stated, see the suffering that contempt to the feminine values has brought to all women through the ages, a contempt to which not only many men have been guilty but also large numbers of women, we may see the most despised and repellent things in our own psyches, that we refuse to acknowledge, and in which we turn often in disgust. Evidence that we have turned in disgust from these women can be seen in a 230% increase in the womens prison population in the U.S. in the past decade. Most of those incarcerated were alcoholic and drug addicted women most of them mothers. Their status as a special population continues the mythology of stigma. 3. CREATING SANCTUARY: EMOTIONAL CLIMATE AND PHYSICAL ENVIRONMENT Cultures through the ages have had spaces, places and ceremonies that represent sanctuary; a prerequisite for vision, celebration, transition, and healing. From the dreamtime of the aborigines, to Asklepioss temenos in Epidaurus; from the dances of the Kalahari bushman to soul catching, the sweat lodge, and the rites of passage of the American Natives, we find spaces created for sanctuary followed by ceremony. We cross centuries to industrialized nations where thousands of us seek sanctuary in obsessions, relief in behavior modifying drugs, therapy for anxiety disorders; we study meditation, practice yoga often alone. Our global progress has decimated and degraded sanctuary, and this has contributed to the wounded feeling function

of our time. The woman who comes to us has sought sanctuary and found her synthetic version in a bottle, pill, spoon or pipe. We need to teach her how to reach sanctuary authentically. Sanctuar y is not without boundaries, rather a psychological space supported by physical environment wherein boundaries are created with the intent of repelling lower forces of our nature, and inviting that which is sacred to enter. With the entry of the sacred comes transformation. It is sacred to learn to know thyself. It is sacred indeed to come home to ones own heart after a long and arduous journey. To develop the vocabulary of sanctuary we must start with ourselves and acknowledge in our own lives what constituted our sanctuary as children, as adolescents, as adults. What are the elements that we need to be able to disclose, to feel safe? The climate of sanctuary starts with the TC practitioners; for a staff without sanctuary amongst themselves is one without authentic community. Practitioners cannot indulge in sloppy emotional habits of gossip, backbiting, and resentment. For the woman in the TC the physical and emotional climate needs to present a dramatic contrast to the world from which she comes. It must be safe enough to name her experience, to discover who she is, safe enough to change her sexual preference without shame if she wants to, safe enough for her to declare all of herself. The physical environment sets an example of selfexpression, creativity and comfort. We are not teaching a woman to live in our TC; rather our TC should serve the role of teaching her to live in the world and to have the ability to create a world for herself and those she loves. 4. WOMENS CIRCLES Women are guardians of the feeling function of the heart. To validate the feminine experience is to validate the quality of connection, of feeling, of intuition. Womens circles need to be small enough

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to fully name experience; develop different roles, reform street relationships, grieve, laugh and form relationships that will last beyond the treatment episode. Circles should foster community rather than destroy it. Participants in circles need to serve the role of both helping witness and informed witness as Alice Miller eloquently describes in her work. The process of witnessing is critical allowing each woman not only to teach but also to serve and comfort. Sanctuary circles accelerate growth needed around trauma; they are not re-traumatizing. She has survived the experience talking about it enables her to overcome it, to integrate it. Hope starts with a story, and when told in detail, hope becomes contagious. The teller grows beyond the wound and the listener can find a path for herself out of a circle of despair. Sanctuary circles foster real meeting between participants and they are able to find both forgiveness and humor in the human condition. 5. CREDIBLE MENTORS/TC PRACTITIONERS The practitioners need to be credible to the women and operate from the position that every woman entering the community has an inherent strength for having survived no matter how long the winter of her addiction. Mentors need to have the emotional literacy to help women face not only their victimization but ways in which they have been predators. That she has survived indicates that a springtime, a flowering possible. Too often practitioners, horrified by the feminine experience lover their expectations for women, inadvertently supporting an attitude of learned helplessness, it is the dark side of empathy. Women need credible female mentors who are willing to talk about obstacles they have overcome, who are not frightened of hearing pain, who are willing to serve as midwife and mentor to the reawakening feeling function; to the emergence of voice.

6. CEREMONY When life has lost its grace one way of regaining it, and the attendant dignity we all need is through ceremony. Ceremony creates the pause that gives our lifes dance beauty. It is a method for honoring and recognizing connections to all life through the expression of gratitude with ritual, talk, sharing, dance, writing, and gifts. Ceremony can acknowledge a womans anniversary dates of grief and celebration; her transitions. How each group is opened and closed can be a ceremony; the formation of an authentic friendship, the anniversary of a death of a loved one, the birthday of a child one has lost, the knowledge of discovering that one is HIV positive, the reunification with children, the divorce long awaited, or the courage of self disclosure that constitutes a rite of passage. To take the time to acknowledge and affirm the movement that occurs in each of our lives with authentic community participation restores grace, and allows dignity to replace false pride. 7. PROCESS RATHER THAN STRUCTURE Women do not need yet another experience of being in a male paramilitary, overly structured environment. Women need an opportunity to experience other women and develop their voice. They need to hear their own experiences through voices of other women so they can begin to put their experience in context. Our effort towards whole person education should give as much credence to the feminine values of connectedness, to the feeling function, to hearth, home and relationship as it does to structure. Where there is conflict, process prevails over structure. Structure is the masculine contribution to the Therapeutic Community; process is the feminine contribution. Let us resist the temptation to replace process, and spontaneous community building with cognitive re-structuring and other curriculums not friendly to feminine values.

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8. OPPORTUNITY TO WORK Women are frequently the sole caregivers of their children and need to be exposed to opportunitys to develop marketable skills. In many countries women are co-opted into the drug trade through economic need. There is no opportunity to develop natural talent, or even to discover ones talent. This is as true for the wealthy as for the destitute, those who are born into a set of expectations that do not fit their talent or personality. The TC needs to be an arena of exposure for the woman. As she grows she will be able to feel what she resonates to, she will create or rediscover her dreams and move towards them. 9. AFFIRMATION We have become proficient at catching people doing the wrong thing and holding them accountable The societies from which we come are adept at it as well. Do we have the courage and the fortitude to develop the skill to catch people, starting with women, doing something right? Are we able to acknowledge what is right about a woman, her life, her strength, her ability to survive and reinforce that message giving her a chance to grow into herself? Oftentimes the inherent quality of affirmation leads us to the intimacy of real friendships and we become afraid. To be critical is to create distance, to maintain appropriate professional space, to create isolation. As TC practitioners get licensed, improve their counseling techniques; are we becoming more emotionally literate? Or are we starting the process of fragmentation that will prevent us in the end from providing whole person education? 10. NAMING, CLAIMING AND USING EXPERIENCE If you cant name it, you cant claim it; if you cant claim it, you cant use it. Women need to name their experiences if they are to understand how they

responded; understand the coping skills they developed, and understand how they can use the energy from these experiences for transformation. Each woman needs to discover for herself the importance of story, her story, her pilgrimage; and t h e t h re s h o l d s s h e h a s c ro s s e d . W i t h i n e a c h wounding is a seed of the larger story into which she can grow. If she is not given an opportunity to name her wounds and the wounds she has inflicted we are cheating her out of her larger story. As you read the vignettes below, ask, what was the larger story? - For the woman stuffed into a trash can in New York City, beaten for 10 years, all of her teeth pulled in the interests of prostitution, her parental rights severed from all three children when she served 7 years in prison doing time for a male partner? - For the woman held by her mother and raped by her stepfather, who ran away, had a baby. and then spent years in prison for aggravated assault against the man who turned her on to heroin, beat her and tried to kill her child? The woman who gave birth to two more children and lost them? - For the woman in the large city addicted to heroin covering herself with dirty laundry as a blanket in a tenement, waking up to the boyfriend holding a loaded gun to her head and then shooting her up with more heroin so she would be nice? - For the woman who was brutally raped and then was arrested by the police for aggravated assault because she had a criminal record and her rapists did not they were allowed to go free? - For the woman first dumped out of a moving car then chased, captured, and urinated on in a public street under the street lamp by her pursuer? - For the woman whose first rape was by her family doctor, subsequently she spent years on the streets homeless, keeping in the winters warm by hiding in

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elevators and subway stations, shooting dope with dirty needles in public bathrooms? Today one is a highly respected director of a TC in one of the most notoriously violent mens prisons in the United States; another has her PhD, married to a prominent professional and a loving mother of three children; another a successful musician with many albums to her credit; another an acknowledged expert at family reconstruction work, having rescued hundreds of families; Another found her children got them out of the system and today they have college educations and one wrote this paper for you. THE LARGER STORY The story then develops when that which is cast out saves us and becomes the cornerstone for a new foundation. When we cease to participate in the creation of shame, when we rebuild what we have destroyed, sew what we have torn, plant where we have set fire, embrace that which we have scorned and scorn that which we embraced. Love is needed to create authentic community. We desperately need community in our world today, people who are willing to love when it is not politically correct, to sacrifice when no one notices. We need to embrace feminine values. What will be the larger story for the Therapeutic Community? Will we be able to metaphorically create the Black Lodge where men and women begin the process of understanding each other after they understand and accept themselves? Will the elders in our communities continue their own process of growth and initiation? Or will they devote themselves entirely to the corporate side of the TC? Will we be able to fulfill the vision of whole person education? Will the TCs be able to develop new roles for itself instead of just the job of self-perpetuation? What is the role of the Therapeutic Community in todays world? What is our larger story? Will all practitioners over time cease to

personally participate in community will the tools that we have developed be relegated for use only when someone is in treatment? Will we be able to continue to notice and include those who have been cast out and learn from them how to continually create new foundations? The larger story, to be able to see women, who need help and to remind ourselves that they are representatives of younger brothers and sisters, children born and yet to be. Can we provide them with whole person education, so they can be honorable ancestors? Can we extend a strong hand to those amongst us who have been discarded, or who have thrown ourselves away? The fallen woman: may we have the courage to console her, the patience to understand her, the strength to love her and the generosity to include her so we can all grow into our larger story.

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THE ROSE ENDURES: Fossil evidence dates the rose at 35 million years Roses were depicted in Egyptian texts, revered in Greece and Rome, and referenced in the most ancient literature of Buddhism and Confucianism. Muslims believe that the rose was born of a drop of sweat from Mohammed; They considered roses symbols of perfection. In 1187 Saladin defeated the Crusaders, and ordered 500 camel loads of roses distilled into rose water to cleanse the Mosque of Omar from the infidels. Jewish lore states that Mount Sinai was covered with roses when the Torah was received; Many still decorate the Torah with rose wreaths and sprinkle rose water on congregants. Jews associate roses with mitzvoth, humility and the ability to cope with adversity. The scent of the rose was thought to call Gods attention to Jewish rituals. Christians saw the five wounds of Christ in the five petals of the Rosa Sancta, and consider red roses symbolic of martyrs blood. The Rosary derived is name from rose hips strung as prayer beads by monks. In 1485, after the War of the Roses, England adopted the rose as its national flower Since that time giving white and red roses together symbolizes unity. In Europe the rose was so valued, for a time it was used as legal tender. In December of 1531, the Virgin Mary appeared to the indigenous Juan Diego in Mexico. To prove the authenticity of her appearance, she gave him Castilian roses to show the Spanish Bishop. Since that day Our Lady of Guadalupe has been the Patroness of the Americas. The rose was adopted as the national flower of the United States of America in 1987. Would that all persons and cultures that have embraced the rose find ways now to embrace each other.

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42

TRATAMIENTO DE LOS TRASTORNOS DE LA PERSONALIDAD Y DEPENDENCIA A SUSTANCIAS: ESQUEMA DE TERAPIA CON DOBLE FOCO.

TREATMENT OF PERSONALITY DISORDERS WITH CO-OCCURRING SUBSTANCE DEPENDENCE: DUAL FOCUS SCHEMA THERAPY

Ball, Samuel A Yale University School of Medicine. Department of Psychiatry

Contenido

L o s p a c i e n t e s d u a l e s Tr a s t o r n o s d e l a Personalidad y Abuso de Drogas son atendidos frecuentemente en los Programas de Tratamiento de Drogas donde consumen una cantidad desproporcionada de tiempo del personal y tienden a responder menos favorablemente a las intervenciones habituales para Abuso de Drogas. Este captulo resume 5 aos de un nuevo Programa de Investigacin cuyo foco ha estado puesto en la evaluacin de las implicaciones del Tratamiento de Trastornos de Personalidad y Abuso de Drogas.

Some sections of this chapter are abstracted or reprinted from previously published work and reprinted by permission of the publishers: Ball and Young (2000), copyright by the Association for Advancement of Behavior Therapy; Ball (1998), copyright by Elsevier Science Ball and Cecero (2001), copyright by Guilford Press. Research summarized in this chapter was supported by a National Institute on Drug Abuse behavioral therapy development grant (R01 DA05592) to me and diagnostic (R01 DA05592) and psychotherapy center grants (P50-DA09241) to Bruce Rounsaville. I acknowledge the mentoring I have received in diagnostic and psychotherapy research by Bruce Rounsaville and Kathleen Carroll specifically as to therapist training procedures and the development of treatment manuals and adherence/competence rating systems. I also acknowledge the invaluable guidance and encouragement of the originator of the schema therapy model, Jeffrey Young, who also trained all therapists in the research to date and consulted on my adaptation, development, and implementation of the Dual Focus schema Therapy manual. Correspondence concerting this article should be addressed to me at: Yale University School of Medicine, VA CT Healthcare (151D), 950 Campbell Avenue, West Haven, CT 06516 Or by electronic mail ([email protected]).

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THE SPECIFICATION OF PSYCHOTHERAPY MODELS FOR PERSONALITY, DISORDER RECENT REVIEWS OF the empirical literature (Perry, Banon, & Ianni, 1999; Sanislow & McGlashan, 1998 indicate that individuals with personality disorders improve over time and benefit substantially from intensive psychosocial interventions. Clinical reports and uncontrolled study designs suggest that cognitivebehavioral therapy may be effective for some personality disorders, but controlled outcome studies are very limited (Shea, 1993). Several cognitivebehavioral therapy models have been described (A. T. Beck, Freeman, & Associates, 1990; J. S. Beck, 1998; Young, 1994) that focus specifically on the problematic beliefs, assumptions, or schemas that underlie the symptoms of personality disorder. As with most approaches described in this volume, these treatment models have been developed and actively disseminated but have never been subjected to the rigors of a controlled, empirical study of their efficacy, and none have developed detailed, time-limited treatment manuals necessary for such an investigation. Treatment manuals and training programs have become a virtual requirement in the technology of psychotherapy research (Carroll, 1997) because they allow for the specification of therapeutic ingredients, therapist behaviors, and intervention strategies so therapists can deliver treatments as intended by the developer. By far, the most developed, promising, and popular manual-guided approach has been dialectical behavioral therapy (DBT) for Borderline Personality Disorder by Linehan (1993). However, no well-specified treatment manuals exist for the wder range of personality disorders, and no individual therapy has been fully articulated that integrates a dual focus on the diverse personality disorders and their commonly cooccurring Axis I disorders, such as Substance Abuse and Dependence. This is an important limitation

because personality-disordered individuals rarely seek psychotherapy specifically for their personality disorder. Typically, it is a cooccurring Axs I disorder or strong environmental pressure that provides the motivation to seek help. This chapter describes dual focus schema therapy (DFST; Ball, 1998; Ball & Young, 1998, 2000), a manualguided individual cognitive-behavioral therapy that integrates a schema-focused approach (Young, 1994) with symptom-focused relapse prevention coping skiIls interventions (Kadden et al., 1992; Marlatt & Gordon, 1985; Monti, Abram, Kadden, & Cooney, 1989) to treat the interrelated symptoms of substance abuse and personality disorders. After providing background on the important link between personality disorder and substance abuse, the treatment model is summarized, ongoing research is reviewed, and important training and dissemination issues are considered. THE PERSONALITY DISORDER-SUBSTANCE ABUSE CONNECTION Over the past 50 to 60 years, theoreticians have attempted to conceptualize the complex association between personality disorder and substance dependence. Psychoanalytic conceptualizations of addiction influenced the first and second editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM; Arnerican Psychiatric Association [APA], 1952,1968) and classified drug addiction and alcoholism under the category of "Sociopathic personality disturbance" or the broader category of personality disorders." Substance use disorders: achieved differentiation from antisocial and other personality disorders only with the shift to a multiaxial system in the last three DSM revisions (APA, 1980, 1987, 1994). Once this diagnostic distinction occurred, it became meaningful to evaluate the Cooccurrence of these disorders.

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Rates of Cooccurrence As a broad diagnostic group, the Axis II personality disorders are the most common co-occurring disorders in treated substance abusers. Median prevalence rates of Axis II are especially high among treated opiate (79%) and cocaine (70%) dependent patients and somewhat lower in alcohol-dependent samples (44% see reviews by DeJong, van den Brink, Harteveld, & van der Wielen, 1993; Verheul, Ball, & van den Brink, 1998). Although studies that evaluate all Axis II disorders indicate that Cluster B disorders are the most prevalent (Antisocial, Borderline, and, less often, Narcissistic and Histrionic), both Cluster C (Avoidant and Dependent and, less often, ObsessiveCompulsive) and Cluster A (Paranoid and, less often, Schizod and Schizotypal) disorders also seem to be highly prevalent among substance abusers. The wide range of prevalence rates seen in moor than 100 comorbidity studies seems to be related to differences in the substance abused, the setting, and the method of assessment. An important feature of the program of research on personality disorders and substance abuse at Yale Medical School's Division of Substance Abuse has been the simultaneous attention to characterizing this substantial, complex dually disordered group of patients and developing and testing a promising treatment approach. Early work (Kosten, Kosten, & Rounsaville, 1989;, Rounsaville, Kosten, Weissman, & Kleber, 1986) determined high rates of DSM-III personality disorders and their association with worse prognosis among methadone maintained patients. More recently, the prevalence, reliability, and validity of DSM-Ill-R and DSM-IV personality disorders and the major dimensions of personality were evaluated in a sample of 370 opiate, cocaine, and alcoholdependent outpatients and inpatients and 187 community controls. The majority of substance

abusers (70%) met criteria for one or more personality disorders. Cluster B disorders were the most prevalent (61%) followed by Cluster C (34% and Cluster A (22%. Antisocial (46%), Borderline (300%), and Avoidant (20%) were the most common specific, personality disorders (Rounsaville et al., 1998) In addition to finding substantial rates of personality disorders in the treatment samples of substance abusers, Rounsaville et al. (1998) established guidelines for distinguishing between personality disorder symptoms that are related to substance abuse versus symptoms independent from substance abuse. This diagnostic approach helps identify individuals whose Axis II conditions may be more likely to endure even when the substance use disorder is in remission and thus require additional intervention for better long-term outcome. The interview method involves allowing a two- to three-week stabilization period following treatment entry and then inquiring into each positive personality disorder symptom to deter mine whether it should be considered independent from the acute or chronic effects of substance abuse (e.g., intoxication, withdrawal, drug craving or seeking behavior). Symptoms are counted as positive only if they persist during drug-free periods. This more conservative diagnostic approach resulted in a 13% decrease in the rates of overall personality disorders (i.e., from 70% to 57%). Cluster B disorder prevalence was particularly reduced by the exclusion of substance-related symptoms (from 61% to 46%). Of the specific personality disorders, Antisocial (from 46% to 27%) and Borderline (from 30% to 18%) were more affected than Avoidant (from 20% to 18%). Symptom Severity and Outcome As to treatment response, the impact of reduction of substance abuse was evaluated on baseline-to-oneyear follow-up remission rates of mood, anxiety, and

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personality disorders (Verheul et al., 2000). Reduction in substance abuse was associated with improvement and recovery from mood and anxiety disorders, but not with significant changes in personality disorder symptoms. The failure of Axis II pathology to diminish with abstinence from drugs and alcohol suggests that personality disorders are independent entities requiring additional therapeutic intervention. Other investigators have found that the co-occurrence of substance abuse and personality disorders is associated with greater substance abuse and psychiatric symptom severity (Brooner, King, Kidorf, Schmidt, & Bigelow,1997; Rounsaville et aL 1986; Ruther ford, Cacciola, & Alter man, 1994) and increased risk for suicided hospitalization, repeated treatment admissions, overuse of medical care, employment and legal problems, victimization or perpetration of abuse, and HIV infection (Links, 1998; Target, 1998), These dual disordered patients appear to be more susceptible to relapse in the presence of craving, negative physical and emotional states, and interpersonal conflict (Kruedelbach, McCormick, Schulz, & Grueneich, 1993; Nace, Davis, & Gaspari, 1991i Smyth & Washousky, 1995). Studies have found that personality disorders are usually associated with worse outcomes when provided routine or less intensive addiction treatment (DeJong et al., 1993; Griggs & Tyrer, 1981; Kofoed, Kania, Walsh, & Atkinson, 1986; Kosten et al., 1989; Nace & Davis, 1993; Rounsaville et al., 1986). At one year following standard inpatient treatment, 94% of patients with personality disorders relapsed in cornparison to 56 % of those without personality disorder (Thomas, Melchert, & Banken, 1999). However, Borderline Personality Disorder patients benefit at least as much as nonBorderline patients when provided an intensive, psychiatrically oriented inpatient alcoholism treatment (Nace & Davis, 1993; Nace, Saxon, & Shore, 1986).

Although Antisocial Personality Disorder (ASPD) is widely considered to be a robust predictor of negative outcome, several studies find little evidence of worse prognosissis when psychotherapy, potent behavioral incentive contingencies, or at least moderately intensive psychosocial treatments are provided (Alterman & Cacciola, 1991; Brooner, Kidorf, King, & Stoller, 1998; Cacciola, Alterman, & Rutherford, 1995; Cacciolal Rutherford, Alterman, Mckay, & Srlider, 1996). Alcoholdependent individuals with greater sociopathy tend to have better outcomes with cognitive-behavioral coping skills treatment than with an interactional group therapy (Kadden, Cooney, Getter, & Litt, 1989; Longabaugh et al., 1994). Woody, McLellan, Luborsky, and O'Brien (1985) have shown that methadone patients with ASPD and a lifetime diagnosis of Major Depression were able to benefit as much from individual psychotherapy as patients without ASPD. Type A and B substance abusers Research evaluating the validity of multidimensional addiction typologies has integrated personality traits and disorders with other dimensions relevant to the etiology, symptom presentation, and prognosis of substance use disorders. Type B substance abusers are characterized as having an earlier age of onset of substance abuse and greater family history, childhood conduct problems, impulsivity or sensation seeking, addiction symptom severity, polysubstance use, and co-occurring psychiatric disorders (especially depression and Antisocial Personality Disorder; Ball,1996; Ball, Catroll, Babor, & Rounsaville, 1995). Type As have a later onset and less severe form of substance abuse. Type B substance abusers also have higher rates of diagnosed personality disorders than Type As and seem to exhibit general personality pathology and secondary psychopathy (Ball, Kranzler, Tennen, Poling, & Rounsaville, 1997). This finding has relevance to the treatment development process

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because Type B (i.e., personality-disordered) substance abusers have more severe problems, higher psychological distress, relapse faster, and seem to benefit more from a cognitive-behavioral coping skills approach (Litt, Babor, DelBoca, Kadden, & Cooney, 1992). These subtypes are strongly related to outcome and to the major dimensions of normal personality that contribute significantly to the prediction of personality disorder severity above and beyond substance abuse and depression symptoms (Ball, Rounsaville, Tennen, & Kranzler, 2001; Ball Tennen, Poling, Kranzler, & Rounsaville, 1997; Ball, Young Rounsaville, & Carroll, 1999). Through this work, a psychotherapeutic focus on personality trait dimensions (temperament and coping) was conceptualized that has informed the developing treatment approach (Ball, 2001; Ball & Schottenfeld, 1997; Ball & Young, 2000 Verheul et al.,1998). TREATMENT CONSTRUCTS AND MODEL Dual Focus Schema Therapy hypotheses that two broad cognitive-behavioral constructs interact and form the core pathology observed in personality disordered individuals. These two constructs (early maladaptive schemas and maladaptive coping styles) are the primary targets for a series of interventions designed to lessen the intensity of the schemas and develop more adaptive coping strategies. The overarching goal of DFST is to help individuals achieve behavioral control a n d f u l f i l t h e i r c o r e h u m a n n e e d s . Va r i o u s psychoeducational, cognitive, experiential, behavioral, and relational techniques are employed to accomplish these goals via Axis I and II symptom reduction. Early maladaptive schemas A. T. Beck et al. (1990) and Young (1994) have defined maladaptive or dysfunctional schemas as enduring, unconditional, negative beliefs about oneself, others, and the environment that organize an individual's experiences and behaviors. These schemas are very

broad, pervasive themes that are learned early in life and then reinforced, elaborated, and perpetuated in adulthood. Over time, these mental structures become dysfunctional to a significant degree and highly resistant to change in persons with personality disorders (Young, 1994; Youngl Klosko, & Weishaat, 2003). Early maladaptive schemas share the following characteristics: . Develop from the interaction between temperament and repeated early negative experiences with parents, siblings, and peers. . Generate high levels of affect, self-defeating Consequences, or harm to others. Interfere with meeting core needs for autonomy, connection, and self-expression. . Are deeply entrenched, central to self, selfperpetuating, and difficult to change. . Are triggered by everyday schema-relevant events or mood states (Young, 1994; Young et al., 2003). In contrast to Beck's approach, Young (1994) does not connect specific schemas to each DSM-IV personality disorder but rather describes 18 core s c h e m a s , o n e o r m o re o f w h i c h i s p re s e n t i n personality-disordered patients. The 18 early maladaptive schemas (listed in parentheses) are grouped into five broader domains of: 1- Disconnection and rejection (abandonment/instability, mistrust/abuse, emotional deprivation, defectiveness/shame, social isolation/alienation). 2 . Impaired autonomy and performance (dependence/incompetence, vulnerability to danger, enmeshment/ undeveloped self, failure to achieve). 3- Impaired limits (entitlement/domination, insufficient self-control/self-discipline). 4. Other directedness (subjugation, self-sacrifice, approval.seeking).

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5. Overvigilance and inhibition (vulnerability to error/negativity, ovetcontrol/emotional inhibition, unrelenting standards, punitiveness (Schmidt, Joinet, Young, & Telch, 1995 Young, 1994; Young et al., 2003). Maladaptive coing styles Because the thoughts, feelings, impulses, and memories associated with early maladaptive schemas are distressing to the individual or others, the individual typically develops strategies to cope. These longstanding, overlearned, usually unrecognized, cognitive, affective, interpersonal, and behavioral responses to the triggering of a schema are called maladaptive coping styles. Although these behaviors may effectively reduce the negative affect associated with schema activation, they are self-defeating and impede the meeting of basic needs and the change process (Young, 1994 Young et al., 2003) Coping styles are categorized as schema surrender, schema avoidance, or schema compensation. Schema surrender represents a complying or giving in to the person or situation (or the associated affect) that evokes the schema. Schema avoidance includes various forms of escape or avoidance from people, situations, or mood states that activate the schema, for example, social withdrawal, excessive autonomy, compulsive stimulationseeking, addictive self-soothing, and psychological withdrawal. Schema compensation involves different forms of fighting off or counterattacking the schematriggering stimuli and includes aggression or hostility, dominance, excessive self-assertion, recognition or status-seeking, manipulation, exploitation, passiveaggressive rebellion, and excessive orderliness (Young, 1994; Young et al., 2003). Dual focus schema therapy (Ball, 1998 Ball &Young, 1998, 2000) recognizes active addiction as a primary disorder, but also conceptualizes schema activation and maladaptive avoidance as heightening the

ongoing risk for relapse among individuals with s i g n i f i c a n t p e r s o n a l i t y p ro b l e m s T h e m o d e l hypothesizes that substance use can occur as a direct behavioral expression of the activation of impaired limits schemas (entitlement, insufficient self-control) or when an other-directedness schema (subjugation, selfsacrifice, approval-seeking} gets triggered within a substance-abusing or otherwise dysfunctional relationship. Another potent relapse risk factor is the patient's overreliance on avoidance as a maladaptive means of coping with the affect or conflict associated with the activation of schemas (and associated memories) around themes of disconnection and rejection (abandonment, mistrust/abuse, emotional deprivation, defectivenessl social isolation) or impaired autonomy/performance dependence/incompetence, vulnerability to danger, enmeshment, failure to achieve. Dual focus schema therapy (DFST) model and manual As described in this chapter, DFST (Ball, 1998; Ball & Young, 1998, 2000) is a 24. week, manual-guided individual therapy consisting of a set of core topics, the specific content and delivery of which are determined by an assessment and conceptualization of the individual's early maladaptive schemas and coping styles. Session topics are shown in Table 18.1. DFST includes symptomfocused relapse prevention coping skills techniques for interpersonal, affective, and craving experiences (Kadden et al., 1992; Marlatt & Gordon, 1985; Monti et al., 1989) and schema-focused techniques for the maladaptive schemas and coping styles (Young, 1994; Young et aI., 2003). Cognitive-behavioral therapy appears to be an excellent choice for developing an integrated treatment strategy that has a dual focus on substance abuse and personality disorders. It was developed initially and found to be effective for the treatment of depression and, later, substance abuse, which are the two most common Axis I disorders in

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personality -disordered patients. DFST interventions are focused on addictive behaviors and personality disorder symptoms through an integrated series of core techniques. For example, functional analysis is used to understand recent episodes of substance use and craving as well as maladaptive schemas and coping and their triggering events. Selfmonitoring, problemsolving, and coping skills training occur similarly for both the addiction and personality problems. Assumption of dual focus schema therapy Dual focus schema therapy hypothesizes that a broad range of the patient's difficulties can be subsumed by a single or few early maladaptive schemas and coping styles. Targeted change in substance use and core schemas can have a significant impact on a broader range of behaviors by disrupting some of the behavioral and interpersonal chain of events that perpetuate the dual disorder in adulthood. DFST does not have the unrealistic goal of curing a chronic, lifedefining personality disorder through a 24-week manual-guided treatment. Realistic goals are extremely important, such as improving selfesteem, relationships, work, and symptoms through improved retention and exposure to a substance abuse treatment that explicitly addresses the personality functioning of the patient. The model assumes that the treatment of personality disorders is best viewed ultimately as a longterm process of controlling substance use and other coexisting Axis I disorders through the combined approaches of psychotherapeutic, psychosocial, pharmacological, and self-help experiences. Another important assumption of the treatment model is that a therapist's ability to promote cognitivebehavioral change and symptom reduction depends on his or her empathic understanding of the origins and reasons for maladaptivity, the confrontation of the patient's addiction and personality (schemas, coping)

TABLE 1 List of Core and Elective Topics for the Dual Focus Schema Therapy Manual
Core Topics Topic A Identification and analysis of current problems. Topic B Understanding historical patterns. Topic C Defining personality, schemas. and coping. Topic D Schemas education. Topic E Schema assessment through imagery. Topic F Early origins. Topic G Maladaptive behavioral and coping patterns. Topic H Problem conceptualization and focus. Topic I Topic K Schema evidence and coping pros and cons. Flashcards. Topic J Schema confrontation and disputes. Topic L Confronting past/parents through imagery. Topic M Schema reattribution through imagery. Topic N Writing lettersTopic O Changing relationships. Topic P Skill building and behavior change. Topic Q Termination and continuing change. Elective Module Topics-Axis I Relapse Topic 1 Internal and external triggers. Topic 2 Coping with high risk situations. Topic 3 Coping with craving. Topic 4 Activity planning. Elective Module Topics-Mode Work Topic 5 Schema modes. Topic 6 Vulnerable child and detached protector. Topic 7 Confronting the punitive parent. Topic 8 Coping with the angry or impulsive child. Elective Module Topics- Therapy Interference Topic 9 Therapeutic relationship. Topic 10 Traumatic memories of abuse. Topic 11 Self-injury. Topic 12 Managing boundaries and limits. Elective Module Topics-Community Adaptation Topic 13 Introduction: Upsetting and uplifting situations. Topic 14 Understanding current and historical problems and patterns. Topic 15 Problem solving. Topic 16 Personality; Conflicts and opportunity within a new community.

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p ro b l e m s , a n d t h e q u a l i t y o f t h e t h e r a p e u t i c relationship (Linehan, 1993; Young, 1994). Attempts at cognitive disputes or rapid behavior change will be ineffective if they fail to appreciate the historical origins of these problems, the reasons certain coping styles developed, and the rationality of the self-defeating behavioral cycle that forms the core of personality pathology and the resistance to change. A therapist can push for significant behavior change and recovery after the patient feels that his or her resistance to change is empathically understood Stages of dual focus schema therapy In the first stage of PFST, the therapist integrates early relapse prevention Work with an identification and education about early maladaptive schemas and coping styles and their association with substance use and other presenting life problems. This educational stage is meant to accomplish at least three important goals; 1. Initiating abstinence or significantly reduced substance use. 2. Establishing a strong therapeutic alliance. 3. Developing a detailed case conceptualization. The development of a strong therapeutic alliance is dependent on both the patient's experience of the therapist's limit setting and focused attention on addictive behaviors as well as the therapist's interest in understanding the patient's personality (temperament, schemas, coping style) and its origins (reactions and behaviors of significant others). The first few months of therapy include a discussion and analysis of the patient's presenting problems and life patterns, particularly as they are related to substance dependence. Maladaptive schemas and coping styles a re a s s e s s e d t h ro u g h t h e c o m p l e t i o n o f f o u r questionnaires developed by Young and associates to measure: (1) schemas; (2) parental origins; (3) avoidant coping, and (4) compensatory coping. Reactions to

homework readings, insession behaviors and discussions of schemas, imagery exercises, and the nature of the therapy relationship provide additional information to identify those schemas and coping styles that are central to the patient. As such, the assessment process is complex and relies on several different sources of data. Patients develop a sense of trust and collaboration through the therapist's interest in obtaining and providing information and personality feed-back and developing a highly individualized conceptualization of their past and current problems. Once the therapist completes this detailed assessment and develops an empathic appreciation and conceptualization of the history of the patient's current life problems, the stage is set for changing the maladaptive schemas and coping styles that contribute to the personality and addiction problems. The individualized case conceptualization guides the development of a technically eclectic, but theoretically integrated, series of change strategies for the schemas and coping styles (Young, 1994): 1 . Cognitive (schema validity, disputes, and dialogues, flash cards for healthier internal voice, reframe past to create distance, identify and confront validity of schemas and usefulness of coping style, substance abuse as avoidant coping). 2. Experiential (imagery and inner child work, role play, ventilation about past and toward caregivers, work on schema origins, letter writing). 3. Behavioral (change self-defeating behaviors maintaining the schemas, identify life change and overcoming avoidance, insession rehearsal, graded task assignment, individualized schema relevant coping skills training, empathic confrontation). 4. Therapy relationship (confront insession schemas and coping styles, limited reparenting).

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During either the first (assessment or education) or second (change) stage of treatment, other elective module session topics may be used to address persistent, treatment-interfering substance use; extreme avoidance; boundary violations and limit setting in the therapeutic relationship; working with traumatic memories of abuse; managing suicidal crises and self-injurious behavior and working with schema modes. Although the focuss on initiating or maintaining abstinence from substances is continually integrated within the framework of DFST, therapists may shift to a primary focus on relapse prevention when clinically indicated. This work includes identification of intrapersonal and interpersonal relapse precipitants, coping skills training for highrisk situations, resisting social pressures to use, assertive communication, coping with cravings, and developing pleasurable activities. Over the course of treatment, the depth of focus and relative emphasis (i.e., substance use versus maladaptive schemas and coping) in any single therapy session are guided by clinical judgment, supervision, and an ongoing evaluation of substance use. Other special problems frequently occur in the treatment of personality-disordered patients. When intractable avoidance of the therapeutic work is encountered, the therapist may shift to a focus on schema modes. A mode may consist of several linked early maladaptive schemas combined with a predominant affect and coping style and is experienced and expressed as broader (typically unintegrated) components or sides of the patient's personality (i.e. similar to an ego state). In mode work, these various sides or states of the patient are identified and labeled (e.g., detached protector, vulnerable child, punitive parent), and their origin and functions are explored and targeted for change through cognitive disputes, empathic confrontation,

imagery, and empty chair techniques. Mode work appears to be especially useful when working with borderline or highly avoidant, overcompensating, or selfcritical patients. The concept of modes seems to be easily gasped by substance abusers who may have split off an addictive, antisocial, acting-out" personality from their recovering, vulnerable, emotional" identity. DUAL FOCUS SCHEMA THERAPY FOR PERSONALITY- DISORDERED OPIATE ABUSERS Through the collaborative effort of several individuals, most notably Jeffrey Young who created the original schema therapy model, we have successfully developed a detailed treatment manual and are in the process of evaluating its efficacy in four different projects and a planned fifth project. Much of this treatment development and evaluation work has been funded through the National Institutes of Health. Manual development pilot project Ten individuals participated in the pilottesting phase of a behavioral therapy development project funded by the National Institute on Drug Abuse (NIDA), which focused on the development and refinement of a treatment manual for personality-disordered substance abusers. Study inclusion criteria were: (1) DSM-IV diagnosis of opioid dependence, (2) receiving a stable dose of methadone at least one month, (3) not participating in additional psychotherapy other tham drug abuse counseling at the methadone clinic, and (4) no evidence of acute psychosis or suicidality/homicidality. Outpatients were recruited from The APT Foundation'sOrchard, Park Hill and Women in Treatment methadone programs New Haven, Connecticut. Two patients dropped out after four months of therapy, and two were highly symptomatic and chaotic at baseline and dropped out after one appointment. The o

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outpatients with the best attendance were both employed full time. It is interest that the three patients with the lowest retention or attendance all had a primary Axis II diagnosis of Avoidant Personality Disorder (with secondary Antisocial). Because the two patients who dropped out after one appointment were discharged soon thereafter from the methadone treatment program and could not be located, these monthly follow-up assessments could not be completed. Although the monthly assessment results are biased because they exclude the two poor outcome patients, they do provide a gross estimate of the effect of the psychotherapy being developed on those eight who received an adequate "dose." An inspection of the aggregate data indicated that patients had decreases in the frequency of their substance use, the severity of their psychiatric symptoms, and ratings of dysphoria. An observed increase in primary substance use frequency at six months was accounted for primarily by one of the patients who dropped out of the study after four months and had resumed daily benzodiazepine use by the time of the termination assessment. Ratings of dysphoria (depression, anxiety, hostility) creased by the fourth month to the point of equaling positive affect ratings (which remained fairly stable across the study). Fnally, although subjective in nature, all eight patients reported at study termination that they found the therapy very useful and were disappointed that it could not continue. Randomized controlled pilot trial Through this NIDA funding, a group of therapists were trained and a randomized pilot study was completed involving 30 methadone-maintained patients comparing individual manual-guided DFST to 12.step facilitation therapy (12FT; Nowinski, Baker, & Carroll, 1992). Urines and self-reports of substance use were collected weekly. Measures of addiction-related psychosocial impairment, psychiatric symptoms, affect states, and the therapeutic alliance were

assessed monthly, and various personality indicators assessed at baseline were repeated at treatment termination. Study Sample Characteristics. The trial sample was predominantly Caucasian (85%, 13 % African American; 20% Hispanic) men (46%) and women (54%) with a mean age 37.4 (SD = 5.9). Patients were mostly single (46%; 32% separated or divorced; 22% married or cohabitating) and high school educated. Patients met structured interview criteria for an average of 3.3 personality disorders with Antisocial Personality Disorder present in more than 70% of the cases, and Borderline and Avoidant Personality Disorders present in more than half of the cases. Paranoid and Dependent were present in more than 10% of the cases, and the remainder of the Axis II disorders were less prevalent (Ball et al., 1999; Ball & Cecero, 2001). At the time of screening for study eligibility, approximately one-third of the sample selfreported significant symptoms of depression, anxiety, violent behavior, suicidal ideation or attempts in the past 30 days, and the majority had experienced these symptoms in their lifetime. Onehalf of the sample reported engaging in at least one HIV-related risky behavior in the past three months, and 15% reported being HIV positive. The majority (85%) reported experiencing emotional abuse as children, and a significant number reported past physical (49 %) and sexual (27%) abuse. As to their addiction, patients averaged more than 10 years of substance abuse, with polydrug abuse common. The length of patients' current methadone treatment episode was varied with a mean of 23.1 (SD42.1; range 1 to 180) months in treatment. Patients were mostly injection drug users by history (71%; intranasal 27% oral 2%), and 47% of the sample repor ted using heroin in the 30 days before assessment (37% used alcohol, 34% cocaine, 27 %

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tranquilizers, 6% cannabis in the prior 30 days). Multiple treatments in substance abuse (Mean= 7.5) and psychiatric (Mean = 5.0) programs and criminal arrests (Mean = 16.2) and incarcerations (Mean = 25.2 months) during adulthood provided further evidence for considering this a chronic, difficult-treat sample of dual-disordered individuals. As to the assessment of maladaptive schemas and coping styles, avoidant coping was highly common, and the mistrust/abuse schema was related to 8 of the 12 personality disorders assessed and seemed to be common to all except the Cluster C disorders, which often had subjugation and self-sacrifice schemas (Ball & C e c e ro , 2 0 0 1 ) . P e r s o n a l i t y a n d t r a i t a ff e c t dimensions and specific interpersonal problems (e.g., vindictiveness, domineering, nonassertiveness, exploitable) provided further differentiation of the personality disorders. Neuroticism or negative affect appears to serve as a common risk factor for most Axis II disorders whereas the traits of extraversion agreeableness, conscientiousness, and sensationseeking differentiate specific disorders (see also Ball, 2001; Ball, Kranzler, et al., 1997). Treatment Outcomes. The principal analyses for the effects of study treatments were: (1) analysis of variance for continuous summar y variables at ter mination (e.g., retention measures, urines, abstinence) and (2) random effects regression for continuous outcome variables, which were measured monthly. Significant Treatment (12FT versus DFST) x Time (six monthly assessments) effects were found for the percent of days per week of primary substance use; dysphoria ratings, and strength of the therapeutic a l l i a n c e . P a t i e n t s a s s i g n e d t o D F S T re d u c e d substance use frequency more rapidly over the 24week treatment than did patients assigned to 12FT. Further inspection of the data suggested a difference beginning to emerge at the third month, which

corresponds to a point in the manual where the treatment is shifting from an assessment and education focus to an active change focus (Ball et al., 1999). Analyses of the dysphoria ratings favored the 12FT condition in which patients exhibited steady decreases in this summary measure of negative mood (as distinct from psychiatric symptoms) over time in comparison to DFST patients who showed no change in dysphoria. As it turned out, however, this sustained dysphoric mood was not related to relapse or drop out. ln fact, the reverse seemed to be true, that is, substance abuse symptoms decreased and the working alliance strengthened despite the lack of change in negative mood over time. This ver y preliminary finding was consistent with a longstanding clinical belief that mobilizing negative affect may be critical to sustain productive work and effect change in personality disordered patients. As stated, DFST patients reported an increase from a good early therapeutic alliance to a very strong alliance over the subsequent months of treatment whereas 12FT patients demonstrated no such increase. Consistent with this finding, DFST therapists reported feeling as though they had a stronger working alliance with patients than did 12FT therapists. There were no treatment-related adverse events involving the randomized pilot patients, and there were no retention differences between the treatment conditions. The mean number of weeks completed was 13.5 for DFST and 14.7 for 12FT (nonsignificant), suggesting that any outcome differences could not be attributed to the confounding influence of one group receiving more treatment. Proposed stage II study in methadone-maintained patients Having accomplished all of the major goals for a behavioral therapy development project (see Rounsaville, Carroll, & Onken, 2001), a more ambitious

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randomized clinical trial of this promising psychotherapy for personality-disordered drug abusers has been proposed, specifically to: (1) conduct a definitive comparison of the efficacy of the two 24-week manual-guided individual therapies (DFST versus 12FT) in 120 methadone-maintained patients with personality disorders; (2) evaluate changes in primary and secondary outcomes from baseline, monthly during treatment, at treatment termination, and 3, 6, 12, and 18 months posttreatment. Secondary analyses will: (1) evaluate post hoc whether the presence or absence of the more common personality disorder categories (Borderline, Antisocial, Avoidant) are related to differential response to the two treatment conditions and (2) evaluate process dmensions related to discriminability of treatments and treatmentspecific changes. Primary outcomes will be: (1) frequency and severity of substance use (cocaine, alcohol, marijuana, benzodiazepines) as measured by both self-report and urine testing and (2) severity of psychiatric symptoms as measured by the self-report and interview assessments. Secondary outcomes include: (1) changes in personality dimensions that may be associated with changes in personality disorder. (personality traits, affective states, interpersonal problems, HIV risk behaviors) and (2) general (therapeutic alliance) and treatment specific (schemas or coping styles, 12.step meeting attendance) measures of therapy process. Although most of the manual development work occurred with the first 10 pilot patients of the earlier study, several minor changes were incorporated based on experience with the subsequent 30 methadone patients. Several of the DFST experiential and relational change techniques seemed to heighten affective distress (self-reported sadness, anger, anxiety) and the use of avoidant coping (i.e., missed appointments,

resistance to imagery or role play) by several patients. These reactions were not a complete surprise given the theory that DFST would work by targeting painful past and current emotional and relational themes while also trying to remove substance abuse as the patient's dominant method of avoidant coping. However, several adjustments were made because of concerns about heightening risk for relapse or decompensation: 1. Shifting the more affect mobilizing techniques to later in the manual and implemented only after several months of abstinence. 2. Movement of coping skills sessions earlier into the manual during treatment and incorporating a 5- to 10-minute "decompression" period into the more affectively charged sessions. 3. Development of the special problem modules for the manual discussed previously. Dual focus schema therapy in a drug.free therapeutic community Premature dropout remains the major problem undercutting the effectiveness of drug-free residential therapeutic community (TC) treatment, and this problem has been exacerbated as TCs have admitted individuals with higher levels of psychopathology. Personality disorders are the most common psychiatric conditions in inpatient addiction programs, and TCs view significant personality disturbance as common to all patients and a core component of addiction. In this ongoing study, I hypothesize that retention in a TC (The APT Foundation's Residential Services Division in Bridgeport, Connecticut) will be enhanced by the application of DFST because it targets the maladaptive cognitive, behavioral, interpersonal, and emotional processes that interfere with the accommodation and assimilation of the patient to the processes and core elements of a TC. I n a t h e r a p y m o d e l a d a p t e d t o t h e c o n t ro l l e d residential environment of a TC, DFST first focuses on

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improving engagement in a therapeutic process through psychoeducation on the patient's personality (symptoms, traits, schemas, coping) and the suitability, relevance, and utility of a TC for addressing these individual differences and needs. Early dropout risk is assumed to be high because the TC immediately expects behaviors (e.g., self-disclosure, delay of gratification, ruletrary, accepting strong feedback, sociability, cooperativeness) that are contrary to the patient's personality style and addictive behavior. The patient's reaction to this stressful experience is normalized, coping with this challenging treatment environment is emphasized, and potentially problematic personality traits are identified. Thus, this first stage of DFST treatment provides a form of psychological inoculation for why the TC may be a difficult form of treatment (given the interaction of the patient's core issues and themes with the program's confrontational atmosphere). In such a situation, the impulse to escape, avoid, or act out can be viewed as normal but must be restrained to achieve benefits from the TC model. The behavior change techniques used in the second phase of DFST (two to six months) are conceptualized as working synergistically with the TC methods, processes, or elements. For example, schemas and maladaptive coping are triggered through job (adult patients) or school (adolescent patients) responsibilities, community incidents, rules, consequences, and groups and the TC is a specialized, safe, and therapeutic learning laboratory in which this can be worked through more adaptively. Enhanced by such a psychotherapeutic context, a TC can be viewed as a milieu in which the patient's personality problems can be expressed, contained, and confronted by the peer community, but with acceptance and support of the person-as-a-whole. Patient acting out can be viewed as an expected

method of communicating internal conflicts that can be addressed with firm support and confrontation. Reactions to the TC rules, techniques, group experiences, or structure are used as opportunities for observation, discussion, understanding, and confrontation. Here-and-now confrontation of patient's maladaptive patterns of coping and relating to others is considered one of the Cornerstones of the TC resocialization and rehabilitation process (Chiesa, 2000) and are consistent with DFST. The purpose of this recently funded NIDA study is to: (1) compare the efficacy of two manual-guided individual behavioral therapies (DFST versus individual drug counseling [IDC)) delivered to 100 adult and adolescent substance abusers as an enhancement to the first 24 weeks of the standard TC treatment program; (2) evaluate differences in retention on a monthly basis as the primary outcome of interest; and (3) evaluate changes in psychological indicators related to personality disturbance (personality disorder symptoms, Axis I psychiatric symptoms, interpersonal conflict, negative affect, HIV risk, maladaptive schemas, and coping styles) and treatment processes related to the TC (therapeutic alliance, perceived TC suitability, value of 1C core elements, treatment atmosphere) as secondary outcomes at 6 (therapy termination), 12, 18, and 24 months postenrollment. In addition, exploratory analyses will evaluate several Attribute (patient characteristics) x Treatment (DFST versus IDC) interactions. For example, there will be an evaluation of whether baseline severity of Axis I and Axis II symptoms predicts differential response to the two treatment conditions concerning both primary (retention) and secondary (psychological and treatment process indicators) outcomes. It is hypothesized that severe personality disturbance causes significant problems with an individual's initial adjustment and effective utilization of TC processes and techniques and that a therapy that targets personality

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pathology will result in better early retention, engagement and symptom reduction than will the more general or standard addiction counseling approach. Dual focus schema therapy for homeless personality-disordered substance abusers In another randomized clinical trial currently underway, D F S T i s b e i n g c o m p a re d t o a s t a n d a rd d r u g counseling group for homeless drop-in center clients with substance abuse and personality disorders (Langeloth Foundation; Patricia Cobb-Richardson). Like many urban homeless social services program, the Neighborhood Coalition for Shelter in New York City historically has been unable to engage a large number of individuals who constitute their long-term homeless population. This population has a history of substance abuse and psychiatric symptoms that significantly impede their ability to access social services Members of this population also appear to have lower success rates in housing and vocational placements because their personality disorders compromise their ability to develop positive living and working relationships with peers, co-workers, and supervisors and, consequently, significantly hinder the development of functional independent living skills. Sixty homeless clients meeting structured diagnostic interview criteria for substance abuse and personality disorder at the drop-in center are being randomly assigned to one of two on-site 24-week treatment conditions: (1) substance abuse counseling (SAC) group and (2) individual DFST. It is predicted that this population will experience improved outcomes when a targeted psychotherapeutic intervention is combined with case management, vocational training, and educational services. It is predicted that therapeutic attention to the symptoms (personality disorder will reduce behaviors such as relapse, depression, anxiety, and disruptive behaviors that lead to drop out or removal from homeless programs and

substance abuse treatment. It is also predicted that clients who participate in DFST will be more likely to remain in treatment and increase their ability to follow through successfully with other social services referrals than clients who participate in the SAC group. Substance abuse, attendance, retention, psychiatric symptoms, employment, housing eligibility, and interpersonal problems will be assessed at baseline, throughout 24 weeks of treatment, and at a threemonth posttermination assessment. Both therapy conditions are delivered by licensed social workers with more than 10 years' experience in the field of substance abuse. The DFST therapist received two weeks (beginner, advanced) of training in the schema therapy model by Jeffrey Young and is employed at Young's Schema Therapy Center in New York. In addition, he receives weekly supervision facilitated by my weekly review of session audiotapes. Although outcomes of these two trials are not yet available, preliminar y impressions confir m impressions from the prior methadone study. Although DFST is not a standard form of treatment in these settings, clients report finding it acceptable and comprehensible. In fact many of these chronic, treatment refractory patients report that it is the first of many therapeutic experiences they have found relevant to their specific struggles related to addiction. Dual focus schema therapy for depressed women with childhood sexual abuse histories There are a number of effective pharmacological and psychosocial treatments for major depression, but a substantial number of patients do not respond to these treatments either through insufficient response, noncompliance, or frequent relapse. Research suggests that depressed individuals with poor treatment response are most often those with histories of childhood sexual abuse, post-traumatic stress, and personality disorders. Childhood sexual abuse is

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significantly associated with major depression in adulthood, especially in women, and is believed to be associated with a more chronic course of depresson (Brown & Moran, 1994), including lower initial recovery rates and higher subsequent relapse rates (Brown, Harris, Hepworth, & Robinson, 1994; Zlotnick, Ryan, Miller, & Keitner, 1995). In an exploratory treatment research project, DFST is being modified for depressed women with histories of childhood sexual abuse and compared to pharmacotherapy and clinical management (National Institute of Mental Health; C. Zlotnick). The major goals of this outpatient study conducted at Butler Hospital in Providence, Rhode Island, are to: 1. Modify the DFST manual for patients with current major depression and histories of sexual abuse and pilot its use on 11 women. 2. Implement a therapist training program. 3. Conduct a randomized controlled pilot study of the efficacy, feasibility, and acceptability of schema therapy plus clinical management/ pharmacotherapy in comparison to clinical management, pharmacotherapy alone in a sample of 24 women. Primary outcomes are treatment retention and depresin symptoms. A schema-focused therapy is hypothesized to be useful for this population because of its careful use of exposure techniques (i.e., controlled activation of schemas and childhood events through imagery), emphasis on coping skills, and targeting of the maladaptive schemas believed to underlie the depressive symptoms. It also targets for change cognitive and affective avoidance as defenses against overwhelming memory-driven affects and specifically addresses schemas of mistrust/abuse and vulnerability to harm and their reenactment in current relationships. It focuses on dysfunctional cognitions originating in traumatic childhood

experiences, emphasizes safety and stability within the therapeutic relationship; and emphasizes the development of self-care, affect stabilization, and stress management skills. Zlotnick has developed an affect management module that is integrated into the early stage treatment process. Rather than using experiential techniques to elicit intensely painful affects and memories, early emphasis is placed on the management of negative affect (e.g-, through distraction, selfsoothing, distress tolerance, crisis planning skills) without resorting to maladaptive behaviors such as selfharm or dissociation. TRAINING AND IMPLEMENTATION ISSUES Attendance at schema therapy workshops conducted by Dr. Young and requests for the DFST manual suggests that there is significant interest among clinicians in the field. Most practitioners appear to be attracted to the approach because of its integration of different therapeutic techniques, its skill sets for managing and treating complex p s y c h o p a t h o l o g y, a n d i t s c o h e re n t t h e o r y o f personality disorder which clinicians appear to g r a s p m o re re a d i l y t h a n s o m e o t h e r m o d e l s . H o w e v e r, t h e r e i s a b i g d i f f e r e n c e b e t w e e n understanding an approach through workshop participation or manual reading and delivering the therapy with skill and fidelity to the model. At this point in the development of DFST, I recommend that i t b e d e l i v e re d w i t h i n t h e c o n t e x t o f a n o t h e r treatment modality (e.g., pharmacotherapy, partial hospital, and inpatient/residential) by a skilled clinician who has received intensive training and supervision. Dual focus schema therapy as a treatment enhancement Unlike many of the psychotherapy models described in this volume, DFST has not been conceptualized as

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a standalone therapy. Undoubtedly, this reflects the obvious differences between the patients from the series of studies discussed here and those seen in the office-based practices of other personality disorder therapy models. Given the complicated, severe, and long-standing problems associated with personality disorders and cooccurring Axis I conditions, the optimal delivery of this manualguided psychotherapy may be within the context of a structured, longer term or open-ended treatment experience. In all studies conducted or being conducted, DFST is being added as an enhancement to standard services that range from moderate to intensive. In New York City, DFST is being added to a drop-in center that provides meals, emergency housing, case management, psychiatric consultation, and vocational and educational activities. In New Haven, DFST is added to methadone programs, which provide this highly effective agon this medication in addition to group counseling, primary medical care, case management, and psychiatric consultation. In Bridgepor t, DFST is added to a residential therapeutic community that provides this powerful milieu treatment in combination with group counseling, education, vocational training, case management, and medical and psychiatric care. In P ro v i d e n c e , t h e m o d e l i s b e i n g a d a p t e d a n d integrated with clinical management and pharmacotherapy provided by a psychiatrist. All of these treatment programs are conceptualized along a long-term or chronic care model for the presenting Axis I condition. Implicit in this model is the assumption that a certain level of psychological containment and psychiatric symptom stabilization is optimal for DFST to be administered with a level of efficacy and fidelity to the original schema therapy model as developed by

Young (1994; Young et al., 2003). The background treatment helps provide this as well as the ostensible reason for treatment for a personality disorder for which the patient would be unlikely to seek treatment if not so distressed. From a research integrity perspective, this level of standard treatment platform also helps retain patients in treatment and reduces the likelihood of differential attrition between the treatment conditions that might confound the interpretations of findings. The receipt of these concurrent services by all patients does represent a potential confound for determining specific treatment efficacy. However, regular individual psychotherapy is rarely provided in these settings so that the addition of this service can be evaluated and the receipt of other services can be controlled for in analyses. Appropriate comparison conditions for clinical trials A critically important issue when evaluating psychotherapy for personality disorders is the treatment condition to which it will be compared in a clinical trial. Given the number of competing treatments now being marketed for these disorders, it is no longer sufficient to present a model with a few illustrative cases. Instead, the treatment needs to be specified in a manner in which it can be evaluated against another credible form of treatment. In all of the previously described studies, the use of placebo or delayed treatment controls was considered unethical because of the level of acute problems these patients experience. In addition, the empirical question of whether (any) treatment is better than no treatment has been answered, and the field should now compare innovative treatments to some standard form of care. Such comparisons are also important because they control for nonspecific factors (e.g., general support, empathy, advice, attention) that contribute to positive outcome and must be controlled

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to conclude that a treatment being developed provides some specific (and added) benefit. Another option considered was to compare DFST to treatment-as-usual however the patient chose to pursue this. This was the approach used by Linehan in her original DBT study, but it has some serious problems, not the least of which is that the powerful effects of one condition receiving significantly more treatment can never be ruled out. It is no longer considered a contribution to the literature to find that treatment is better than no treatment or that intensive treatment is better than minimal treatment. The standard now should be higher than what has been used in DBT studies, and newer treatment models should have the burden of proving themselves superior to some standard active reference treatment either in the management of the primary (e.g., substance abuse) or secondary (e.g., depression) Axis I symptoms or in the management of these problems in patients with more severe personality pathology. Ultimately, a complex psychotherapy model for complex patients should not be adopted in standard clinical practice unless it demonstrates its superiority over more easily trainable or already popular models. This is obviously a fairly stringent test of DFST. For this reason, DFST is being compared to standard for ms of counseling (individual or group drug counseling, 12-step facilitation, psychiatric case management) to evaluate whether an individual therapy that targets personality problems leads to better outcomes for personality-disordered drug abusers than a standard active reference therapy. For example, individual drug counseling (Mercer, 2000; Mercer & Woody, 1999) is a common synthesis of many recovery topics used in standard inpatient and outpatient addiction treatment programs across the country, and its manualized version is one of the first

three treatment manuals In the NIDA "Clinician Toolbox series. Thus, IDC provides a credible psychotherapy control and allows an evaluation of the efficacy of adding DFST therapeutic content to the standard treatment content while controlling for time and attention provided by individual sessions. In comparison to the equal emphasis DFST places on personality dysfunction and addiction, IDC remains more narrowly focused on addiction as a disease and views personality dysfunction as secondary manifestation and not a major focus of treatment. The primary role of the IDC therapist is to help patients admit their addiction, teach recovery tools, motivate patients, encourage the development of drug-free social supports, promote abstinence, review self-help philosophy, and encourage meeting attendance. Likewise, DFST has been compared to 12-step facilitation treatment because this is a standard form of counseling with little theoretical or technical overlap with DFST. Some of the other manualized comparison treatments considered (e.g., standard cognitivebehavioral coping skills, interpersonal psychotherapy, supportive-expressive therapy) have too many areas of overlap with DFST . The studies in Providence and New York City also make use of a comparison condition employing a standard reference therapy. In the drop-in center study, DFST is being compared to a substance abuse counseling group available on-site several times per week that includes addiction psychoeducation, 12step principles, and relapse prevention concepts. In the study of depressed women with childhood histories of sexual abuse, the comparison is to regular clinical management provided by a psychiatrist who is prescribing an antidepressant. Thus, DFST is being evaluated as an enhancement to what has become the standard form of psychiatric treatment for depression in the United States.

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Therapist selection and training procedures Although therapist training for Axis I disorders requires time and effort, effective training for a personality disorder psychotherapy such as DFST and the other t re a t m e n t m o d e l s d e v e l o p e d b y m a n y o f t h e contributors to this volume is best described as burdensome. Developing treatment manuals greatly facilitates the process of working with very challenging patients, but it cannot substitute for an intensive training period followed by close supervision of some ongoing cases. DFST therapists typically receive two to three full days of training by Jeffrey Young for schema therapy; then I provide an additional day of training specifically in the use of the DFST manual. The t r a i n i n g m a t e r i a l a n d p ro c e d u re s h a v e b e e n developed through Youngs extensive training series and through the original FST study. Didactic material is integrated with videotaped case demonstrations and role plays. The review of the therapy manual is intended to allow therapists to understand the demarcation between the internal and external boundaries of the treatment approach and specific t h e r a p i s t b e h a v i o r s t h a t a re p re s c r i b e d a n d proscribed as a means of reducing overlap between approaches. After the training workshop, therapists treat one or more pilot patients, and videotapes of these sessions are reviewed and rated. I provide detailed guidance and feedback as well as evaluate the therapist's adherence, competence, and readiness to participate as a therapist. In addition to supervising the DFST therapists in the NIDA methadone study, I have served as a consultant to the other studies described in this chapter, listen to and rate audiotapes, and hold phone or in-person supervision sessions weekly. Another important issue is the training criteria for selecting who is qualified to deliver DFST. Regardless of level of education, therapists must be highly

competent because the training and treatment manuals are not designed to teach basic skills to novice therapists, but rather to augment existing skills for the treatment of this specific dual-disordered population. The treatment development study used a more select group of doctoral-level clinical psychologists specializing in therapy with substance abusers with advanced training in cognitive-behavioral or psychodynamic therapies. It was believed that highly trained clinicians were needed to provide therapy because of the comp]ex, challenging psychopathology that is often found in this population and the negative reactions these patients often elicit in clinicians without advanced training in psychotherapy and exposure to theories of psychopathology and personality. Adherence or competence measures indicated that the training and ongoing supervision plan was effective in transmitting the skills and techniques to therapists who were able to both adhere to the DFST manual as well as perform it with adequate skill. The degree to which less educated or experienced clinicians can provide this approach with the fidelity necessary for a clinical trial is an empirical question currently being addressed. All three ongoing studies are using masterslevel clinicians, but in all cases these are individuals with substantial clinical experience working with their respective target populations. A more sophisticated question is whether clinicians of diverse professional backgrounds and levels of education and experience are able to provide all components of the treatment model with equal fidelity or whether only some components can be delivered by a broad range of clinicians (e.g., psychoeducational material, but not cognitive or experiential change strategies). Until research can answer these questions, it is recommended that clinicians considering use of this model have formal education and advanced training in theories of

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psychopathology, psychotherapeutic techniques, and, specifically, experience in treating the commonly cooccurring Axis I conditions. Clinicians should have several years of experience treating individuals with substance abuse, severe mental illness, or dual diagnosis. Clinicians should be familiar with cognitivebehavioral approaches, willing to learn and follow a manual-guided approach, and participate in an intensive training and supervisory process. SUMMARY AND CONCLUSIONS Patients with cooccurring personality disorders and substance abuse are frequently seen in treatment p r o g r a m s ( Ve r h e u l e t a l . , 1 9 9 8 ) , c o n s u m e a disproportionate amount of staff time, and may be less likely to respond favorably to standard substance abuse treatment interventions (Griggs & Tyrer, 1981; Kosten et 31, 1989; Nace & Davis, 1993). This chapter summarizes a new program of research that has focused over the past five years on the assessment and treatment implications of personality disorders in substance abusers. During this time, our research team has developed considerable expertise in the complexities of diagnosing personality disorders in substance abusers, particularly the ability to separate drug-related behaviors from personality disorders and to evaluate the reliability and validity of personality disorder diagnoses. A diagnostic procedure has been established that minimizes the likelihood of finding spurious changes in personality disorder symptom severity. Diagnostic research has mapped out the association between categorical personality disorders and underlying personality trait, cognitive, affective, and interpersonal dimensions. These dimensional constructs, and especially maladaptive schemas and coping styles, are thought to translate better into more specific interventions for personality-related problems than the Axis II categorical constructs

Through both diagnostic and therapy development research, the ability to recruit sufficient numbers of p a t i e n t s w i t h p e r s o n a l i t y d i s o rd e r s h a s b e e n established. A cognitive-behavioral approach has excellent potential for integrating the treatment for substance abuse and the diverse range of personality disorders, and a NIDA-funded treatment development study has: . Determined the feasibility, safety, and acceptability of DFST . . Developed a detailed session-by-session treatment manual with prescribed and proscribed techniques. . Developed comprehensive, effective training packages for therapists. . Conducted a small randomized pilot trial demonstrating the promise of DFST. .Developed adherence/competence scales and a rater guide and established treatment discriminability. The success of this project has led to three (and, it is hoped, a fourth) separately funded clinical trials evaluating DFST in different clinical populations. The individual therapy model described in this chapter and elsewhere (Ball, 1998; BalI & Young, 2000) is only one of a growing number of promising, time-limited treatment approaches for personality disorders. The field of personality disorder treatment has been separated historically into groups that questioned the existence of personality and its disordered expression (behavioral), had developed short-term, symptomfocused techniques that seemed ineffective for difficult-to-treat" patients (cognitive), or had viewed treatment as a very long-term process with unclear outcomes for a fairly narrow functional range of character disturbance (psychoanalytic). Limited clinical success combined with major shifts in the delivery of psychotherapy under managed care stimulated each of these major individual therapy

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models to adapt their traditional methods to respond better to the needs of this complex population in a challenging health care environment. Shorter term psychodynamic approaches were developed, which f o c u s e d i n c re a s i n g l y o n c o n s c i o u s t h o u g h t processes, core conflicts or relational themes, and confrontive techniques, whereas longer ter m cognitive-behavioral approaches began to focus on the origins of maladaptive behavioral patterns and cognitive themes, their expression in the therapeutic relationship, and the impor tance of empathic understanding. These are major theoretical and technical changes. Although the language used to describe psychopathology and psychotherapy remains different, the underlying similarities of constructs and approaches is evident in the different theoretical and clinical writing and videotaped demonstrations of cases. Although there is now some excitement about conducting personality disorder treatment research, it is not a time for unrealistic optimism. Although many approaches appear promising, empirical support for their efficacy is almost non-existent. The major exception to this is Linehan's (1993) DBT, which shows targeted effects on reducing parasuicidality and hospitalization (Linehan Armstrong, Suarez, Allmon, & Heard, 1991; Linehan, Heard, & Armstrong, 1993) and for which there are few efficacy studies. For the field to continue to advance, it will need to value these improvements in focal life areas rather than expect deeper, structural change as the major outcome of interest. Realistic goals are necessary when treating s e v e re p e r s o n a l i t y d i s o rd e r s a n d s u b s t a n c e dependence (e.g., improving selfesteem, emotional functioning, relationships, psychiatric symptoms) through improved retention and outcome in a treatment that explicitly addresses the Axis I and II problems of the patient. For an empirically supported

treatment literature to develop, clinicians and theoreticians will need to articulate their approaches in ways that permit independent investigators to replicate promising single case studies through controlled clinical trials. As previously discussed (Ball, 1998), research in this area struggles with a number of practical problems, including: . Diagnostic reliability and stability of DSM-IV personality disorders. . Recruitment of sufficient sample sizes . Need to address the Axis I symptoms that typically motivate the individual to seek treatment. . Controlling for additional treatments. . Training therapists in a complex psychotherapeutic approach. . Treatment time frame. As to the last point, six months is probably an inappropriately short period within which to expect change in this population, yet it stretches the duration beyond that of most clinical research and managed care plans. It is hoped that relatively short-term approaches such as DFST will show enough promise that a more extended course of therapy may be justified on the basis of longer term cost-effectiveness or as an effective means to prevent relapse of a presenting Axis I disorder. From the standpoint of personality disorder treatment, even one year is probably an unrealistically short time for addressing longstanding, maladaptive patterns of viewing self and relating to others and severe addiction. Metaanalytic (Perry et al., 1999) and literature reviews (Sanislow &: McGlashan, 1998) suggest that symptomatic improvements must be measured over a long follow- up period when evaluating change in a chronic condition such as personality disorders (and drug dependence). The originator of cognitive-behavioral therapy for personality disorders (A. T. Beck et al., 1990), the

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theorist and investigator of the only empirically supported treatment for a specific personality disorder (Linehan, 1993), and the author of a meta-analysis (Perry et al, 1999) all argue that separate treatments are needed for the different DSM-IV personality disorders. In fact, the. developer of schema therapy (Young) now believes that the original model may be less appropriate for some personality disorders (especially Borderline, Narcissistic, and Avoidant patients) than a modefocused approach. However, the evaluation of separate manuals for each disorder is impractical in clinical trials and in clinical practice, especially because the number of mixed, "not otherwise specified," or co-occurring cases of personality disorders greatly outnumbers the "pure cases." Such approaches also afford these categorical diagnoses a status that is unjustified based on reliability and validity research. Rather than using a different approach for each of the 10 personality disorders, DFST consists of a series of core topics, the specific content and delivery of which are determined by an assessment and conceptualization of the individual's maladaptive schemas and coping styles. DFST focuses on theoretical constructs with treatment implications that cut across and below the surface of the syndrome and symptom-focused DSM system. Although the clinical conceptualization (e.g. schemas, coping styles) necessarily varies from case to case, use of a common core of cognitive, expetiential relational and behavioral techniques for all disorders should facilitate a more efficient evaluation of the therapy's effectiveness by other investigators in the substance abuse field as well as for other Axis I disorders commonly seen in personality-disordered individuals (e.g., depressive, anxiety, eating, somatoform, trauma-related disorders). Nonetheless, the issue of treatmentspecific focus (i.e., categories or dimensions) may be resolved only through empirical study. Although results using a single, integrative DFST

manual were promising, such smallscale studies do not permit an analysis of outcome for patients who meet different categorical personality disorders. In the larger scale study proposed in the methadone program, exploratory analyses will be conducted on the basis of the presence or absence of Borderline, Antisocial and Avoidant Personality Disorder. Because this group of individuals rarely present for treatment for their personality disorders per se , researchers invariably study and treat these disorders in the context of alleviating a presenting Axis I disorder or significant pressure in the patient's environment. For this reason, a treatment manual for personality disorders should be integrated with an Axis Isymptomfocused approach. One advantage of DFST is that it targets both overt symptoms (e.g., substance use, depressed mood, interpersonal problems) and underlying themes (e.g., schemas, coping styles) and transitions from behavioral symptoms to internal and external determinants of psychopathology in a manner that is theoretically consistent for the therapist and, more importantly, comprehensible to the patient and responsive to his or her needs. Several factors may limit the adoption in clinical practice of many of the innovative psychotherapy models that have been developed for the personality disorders. First, with rare exception (Linehans DBT being the best known), none have been evaluated in a clinical trial and are many years away from achieving recognition as an empirically supported treatment. In fact, many either do not hold this as a goal or are conceptualized at a level of complexity that makes such a goal unachievable. Second, and again with DBT as the exception, few if any of these approaches have developed a sufficiently detailed treatment manual to facilitate effective training and dissemination. Third, most models are based on work with Borderline, Narcissistic, and, occasionally, Avoidant patients, and the techniques used for these

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individuals may not always be relevant to the broader range of specific or mixed/unspecified personality disorders or their co-occurring Axis I conditions encountered in clinical practice. DFST is a promising approach on all three counts. Although research support is still preliminary, ongoing or planned randomized clinical trials should have an answer to the efficacy question in five years. DFST has a highly detailed therapy manual, and the feedback by providers who have reviewed it after completing an intensive training has been very positive. In addition, the approach cuts across the current Axis II categories (and thus would not be affected by inevitable changes to the DSM nomenclature) and is flexible in its ability to incorporate a treatment focus on the common presenting Axis I conditions. Stone (2001) has raised the important (elated concern that very little has been written about the multiply disadvantaged borderline and other personality disordered patients existing on the margins of societyfor example, the poorly educated, unemployed, substance abusing, traumatized, homeless individuals with histories of repeated hospitalization and incarceration. Although the higher functioning personality-disordered patients on whom most current models were developed are certainly troubled and deserving of treatment, they are not necessarily representative of the kinds of chronic patients that most practitioners encounter in mental health clinics, hospitals, or another nonpsychiatric settings (addiction treatment programs, social service agencies, shelters, vocational programs). The growing number of professional and lay books for personality disorders may be less relevant to lower functioning patients because they fail to account for the significant additional Axis I, case management, and ancillary service needs that must be integrated with the personality disorder therapy. In contrast,

DFST (like DBT) has been developed, initially tested, and is currently being evaluated on a variety of lower functioning patients with difficultto-treat Axis I and II disorders and often severe problems with daily living. REFERENCES Alterman, A. I., & Cacciola, J. S. (1991). The antisocial personality disorder diagnosis in substance abusers: Problems and issues. Journal of Nervous and Mental Diseases, 179, 401-409. American Psychiatric Association. (1952). Diagnostic a n d s t a t i s t i c a l m a n u a l o f m e n t a l d i s o rd e r s . Washington, DC: Author. American Psychiatric Association. (1968). Diagnostic and statistical manual of mental disorders (2nd ed.). Washington, DC: Author. American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC; Author. American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed-, rev.). Washington, DC: Author. American Psychiatric Association. (1994)- Di4gnostic And statistical manual of mental disorders (4th ed.). Washington, DC: Author. Ball, S. A. (1996). Type A and B alcoholism: Applicability across subpopulations and treatment settings. Alcohol Health and Research World, 20, 30-35. Ball, S. A. (1998). Manualized treatment for substance abusers with personality disorders: Dual Focus Schema Therapy. Addictive Behaviors, 23,883-891. Ball, S. A. (2001). Big five, alternative five, and seven personality dimensions; Validity in substance dependent patients. In P. T. Costa Jr. & T. A. Widiger (Eds.), Personality disorders and the five-.factor model of personality (2nd ed., pp. 177-201). Wa s h i n g t o n , D C : A m e r i c a n P s y c h o l o g i c a l Association.

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Chiesa, M. (2000). Hospital adjustment in personality disorder patients admitted to a therapeutic community milieu. British jour nal of Medical Psychology, 73, 259-267 DeJong, C., van den Brink, W., Harteveld, F. M., & van der Wielen, G. M. (1993). Personallity disorders in alcoholics and drug addicts. Comprehensive Psychiatry, 34, 87-94. Griggs, S. M., &. Tyrer, P. J. (1981). Personality disorder, social adjustment and treatment outcome in alcoholics. Journal of Studies on Alcohol, 42, 802805. Kadden, R. M., Carroll, K. M., Donovan, D., Cooney, N. L., Monti, P., Abram, D., et al. (1992). Cognitivebehavioral coping skills therapy manual; A clinical research guide for therapists treating individuals with alcohol abuse and dependence. In M. E. Mattson (Ed.), NIAAA Project MATCH Monograph Series (Vol. 3, DHHS Publication No. ADM 92-1895). Washington, DC: U.S. Government Printing Office. Kadden, R. M., Cooney, N. L., Getter, H., & Litt, M. D. (1989). Matching alcoholics to coping skills or interactional therapies: Post-treatment results. Journal of Consulting and Clinical Psychology , 57,698-704. Kofoed, L., Kania, J., Walsh, T. & Atkinson, R. (1986). Outpatient treatment of patients with substance abuse and co-existing psychiatric disorders. American Journal of Psychiatry, 143,867-872Kosten, T. A., Kosten, T. R., & Rounsaville, B. J. (19B9). Personality disorders in opiate addicts show prognostic specificity. Journal of Substance Abuse Treatment, 6,163-168. Kruedelbach, N., McCormick, R. A., Schulz, S. C-1 & Grueneich, R. (1993). Impulsivity, coping styles, and triggers for craving in substance abusers with borderline personallity disorder. Jour nal of Personality Disorders, 7,214-222.

Linehan, M. M. (1993). Cognitive behavior therapy for borderline personality disorder. New York: Guilford Press. Linehan, M. M., Armstrong, H. E., Suarez, A., Allmon, D., & Heard, H. L, (1991). Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48, 10601064. Linehan, M. M., Heard, H. L., & Armstrong, H. E. (1993). Naturalistic follow-up of a behavioral treatment for chronically parasuicidal borderline patients. Archives of General Psychiatry, 50, 971974. Links, P. S. (1998). Developing effective services for patients with personality disorders. Canadian Journal of Psychiatry, 43, 251-2S9. Litt, M. D., Babor, T. F., DelBoca, F. K., Kadden, R. M., & Cooney, N. L. (1992). Types of alcoholics. II: Application of an empirically derived typology to treatment matching. Archives of General Psychiatry, 49,609-614. Longabaugh, R., Rubin, A., Malloy, P., Beattie, M-, Clifford, P. R., & Noel, N- (1994). Drinking outcome of alcohol abusers diagnosed as antisocial personality disorder. Alcoholism; Clinical and Experimental Research, 18,410-416. Marlatt, G. A., & Gordon, J. R. (1985). Relapse prevention. New York: Guilford Press. Mercer, D. E. (2000). Description of an addiction counseling approach. In J. J. Boren, L. S. Onken, & K. M. Carroll (Eds.), Approaches to drug abuse counseling . Bethesda, MD: National Institute on Drug Abuse. Mercer, D. E., & Woody, G. E. (1999). An individual counseling approach to treat cocaine addiction: The collaborative cocaine treatment study model . Therapy Manuals for Addiction (manual 3). Bethesda, MD: National Institute on Drug Abuse.

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Monti, P. M., Abram, D. B., Kadden, R. M., & Cooney, N. L. (1989). Treating alcohol dependence; A coping skills training guide. New York: Guilford Press. Nace, E. P., & Davis, C, W. (1993). Treatment outcome in substance abusing patients with a personality disorder. American Journal of Addictions, 2, 26-33. Nace, E. P., Davis, C. W., & Gaspari, J. P. (1991). Axis II comorbidity in substance abuser American Journal of Psychiatry, 148, 118-120 Nace, E. P., Saxon, J. J ., & Shore, N. (1986). Borderline personality disorder and alcoholism treatment. A one-year follow-up study. Journal of Studies on Alcohol 47, 196-200. Nowinski, J., Baker, S., & Carroll, K. M. (1992). Twelvestep facilitation therapy manual; A clinical research guide for therapists treating individuals with alcohol abuse and dependence. NIAAA Project MATCH Monograph Series (Vol-1, DHHS Publication No. ADM 92-1893). Washington, DC: U.S. Government Printing Office. Perry, J. C., Banon, E., &: Ianni, F. (1999). Effectiveness of psychotherapy for personality disorders. American Journal of Psychiatry, 156, 1312-1321. Rounsaville, B. J., Carroll, K. M., &: Onken, L. S. (2001). NIDA's stage model of behavioral therapies research; getting started and moving on from Stage 1. Clinical Psychology: Science and Practice, 8, 133-142. Rounsaville, B. J., Kosten, T. R., Weissman, M. M., & KleberJ H. D. (1986). Prognostic significance of psychopathology in treated opiate addicts. Archives of General Psychiatry, 43, 739-745. Rounsaville, B. J., Kranzler, H. R.J BallJ S. A., Tennen, H., Poling, J, & Triffleman, F.. (1998). Personality disorders in substance abusers: Relation to substance abuse. Journal of Nervous and Mental Diseases, 186, 87-95. Rutherford, M. J., Cacciola, J. S., & Alterman, A. I. (1994) Relationship of personality dis. orders with

problem severity in methadone patients. Drug and Alcohol Dependence, 35, 69-76. Sanislow, C. A., & McGlashan, T. H. (1998). Treatment outcome of personality disorders. Canadian Journal of Psychiatry, 43, 237-250. Schmidt, N. B., Joiner, T. E., Young, J. E., & Telch, M. J. (1995). The Schema Questionnaire: Investigation of psychometric properties and hierarchical structure of a measure of maladaptive schemas. Cognitive Therapy and Research, 19, 295-321. Shea, M. T. (1993). Psychosocial treatment of personality disorders. Journal of Personality Disorders (Special Suppl.), 167-180. Smyth, N. J., & Washousky, R. C. (1995). The coping styles of alcoholics with Axis II disorders. Journal of Substance Abuse, 7, 425-435. Stone, M. (2001). Natural history and long-term outcome. In W.J., Livesley (Ed.), Handbook personality disorders (pp. 259-273). New York: Guilford Press. Ta r g e t , M . ( 1 9 9 8 ) . O u t c o m e re s e a rc h o n t h e psychosocial treatment of personality disorders. Bulletin of the Menninger Clinic, 62, 215-230. Thomas, V. H., Melchert, T. P., & Banken, J. A. (1999). Substance dependence and person-ality disorders: Comorbidity and treatment outcome in an inpatient treatment population. Journal of Studies on Alcohol, 60, 271-277. Verheul, R., Ball, S. A., & van den Brink, W. (1998). Substance abuse and personality disorders. In H. R. Kranzler &: B. J. Rounsaville (Eds.), Dual diagnosis and treatment: Substance abuse and comorbid medical and psychiatric disorders (pp. 317-363). New York: Marcel Dekker. Verheul, R., Kranzler, H. R., Poling, J., Tennen, H., Ball, A., & RounsavilleJ B. J. (2000). Axis I and Axis II disorders in alcoholics and drug addicts: Fact or artifact? Journal of Studies on Alcohol, 61, 101-110.

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Woody, G., McLellan, A. T., Luborsky, L.J & O'Brien, C. P. (1985). Sociopathy and psychotherapy outcome. Archives of General Psychiatry, 42, 1081-1086. Young, J. E. (1994). Cognitive therapy for personality disorders: A schema-focused approach. Sarasota, FL: Professional Resource Exchange. Young, J. E., Klosko, J. S., &: Weishaar, M. E. (2003). Schema therapy: A practitioner's guide. New York: Guilford Press. Zlotnick, C., Ryan, c. E., Mller, I. W., & Keitner, G. I. (1995). Childhood abuse and recovery from major depression. Child Abuse and Neglect, 19, 15131516.

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LA PERSONA ADICTA Y LOS FUNDAMENTOS ANTROPOLGICOS DE SU REHUMANIZACIN

THE ADDICTED PERSON AND THE ANTHROPOLOGICAL APPROACH TO REHUMANIZATION

Caas, Jos Luis Universidad Complutense. Madrid

Se presenta aqu una visin antropolgica de la persona que hace posible superar el fenmeno de las adicciones y fundamenta el fenmeno de su rehumanizacin posterior. Desde el mtodo fenomenolgico, pretendo mostrar las claves filosficas, psicolgicas y educativas que subyacen en la persona adicta y en la persona rehumanizada. Sustituyo los conceptos de sujeto, individuo, usuario, etc., empleados en el lenguaje de la ciencia objetivista, por el concepto de persona (persona adicta o persona rehumanizada) ms propio del lenguaje empleado en la ciencia humanista. Por ltimo, planteo la necesidad de superar la actual Comunidad Teraputica Rehabilitadora mediante el ideal de una Comunidad Teraputica Rehumanizadora.

An anthropological vision of the person is presented that makes it possible to overcome the addiction phenomenon by inspiring the rehumanizing process. From a phenomenological approach I attempt to show the philosophical, psychological and educational underpinnings of the life of addicted and rehumanized persons. Instead of the concepts of subject, individual, user, etc., appearing in the language of objectivist science , I use the concept of person (addicted person or humanized person) more appropriate to the language of humanist science . Finally, I state the need of going beyond the present notion of a Rehabilitating Therapeutic Community by adopting the ideal notion of a Rehumanizing Therapeutic Community.

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En este artculo presento en sntesis las conclusiones a las que he llegado sobre el fenmeno de las adicciones y la rehumanizacin, ideas desarrolladas y fundamentadas en mi reciente obra Antropologa de las Adicciones (Dykinson, Madrid, 2004). Mi propuesta empieza y finaliza en una premisa sencilla: slo una antropologa esperanzada puede fundamentar a la persona adicta en la esperanza. Para alcanzar este objetivo no estamos solos, contamos con la poderosa luz de la antropologa filosfica y con el peso especfico de la amplia tradicin humanista a lo largo de la historia. Estas conclusiones las recojo ahora en diez postulados: 1. La persona adicta no es el sujeto (mucho menos el objeto), ni el individuo, ni el paciente, ni el usuario, ni el consumidor, etc., tal como se la trata no ya en el plano coloquial sino en el discurso acadmico y en los manuales cientficos. Ciertamente puede querer decir todo eso, pero desde luego es mucho ms que eso: la persona adicta ante todo, y antes que adicta, es persona. Y en esta afirmacin encontramos ya que el mundo de las adicciones es una des-personalizacin, y que para salir de este mundo y provocar un cambio de vida definitivo no basta con utilizar unas tcnicas del modo adecuado, es necesario una visin integral de la persona esperanzada. Y eso, en principio, no lo pueden aportar las ciencias particulares por s solas. Necesitan de un fundamento antropolgico previo. 2. Buscando las causas de los fenmenos adictivos llegamos a la conclusin de que sobre todo son causas existenciales que estn en la persona adicta, pero no son constitutivas de su ser ntimo. Las adicciones estn de muy variadas formas instaladas en las personas esclavas de s mismas, por ejemplo como enganche a la realidad virtual, como trabajo adictivo o como ortorexia, como sectadependencia y/o sexodependencia, como adiccin al alcohol, al tabaco o a

psicofrmacos, o sobre todo como drogadiccin, etc., pero no forman parte de la estructura constitutiva de la persona fatal e inexorablemente. Antes bien, son los efectos visibles del vaco existencial y de la falta de recursos personales y de estancamiento del desarrollo personal. 3. Si la persona no est condicionada en su ser de forma absoluta ni determinada irremisiblemente, ello nos lleva a afirmar la existencia de procesos evolutivos de maduracin o perfeccin, por un lado, y de regresin o imperfeccin, por otro, en su estructura constitutiva. Slo partiendo de la afirmacin de la libertad esencial podemos entender que la persona elija construirse (procesos de madurez), o destruirse (procesos de regresin). Pero no puede elegir no ser persona: a este nivel de fundamento, por ejemplo elegir ser animal slo sera una metfora literaria. Se es persona, se quiera o no serlo. Se sea adicto o no. 4. Adems, ser persona tambin equivale a ser para las otras personas, lo cual quiere decir que ser persona es lo mismo que ser relacional, o ser-de-encuentro, consigo misma y con los dems. 4.1. Una primera nota constitutiva del ser relacional es el amor : ama y desea ser amada. La persona puede no amar, como de hecho hace la persona adicta, pero eso demuestra que es libre no que no sea un ser-para-el-amor. 4.2. Igualmente podemos afirmar de la comunicacin, que la persona es un ser-para-la-comunicacin no para la in-comunicacin. Es decir, puede incomunicarse o encerrarse en s misma porque es libre, pero su constitucin revela que est hecha de y para la apertura comunicativa. 4.3. De la misma forma, la persona tambin es un serpara-la-esperanza, est orientada constitutivamente por un principio radical de esperanza en lo ms profundo de su yo. La esperanza sera el fundamento existencial que la mantiene viva en la

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existencia, aunque libremente pueda optar por caminos de desesperacin como cuando se entrega al mundo de las adicciones, lo cual no hace sino confirmar de nuevo su libre albedro. 5. Estas notas constitutivas esenciales de la persona nos llevan a dibujar el siguiente perfil tipo de la persona adicta: persona joven encerrada en s misma que no ha conocido antes el amor ni el autntico afecto en su vida, ni tiene razones para la esperanza, a quien se le ofrecen y acepta las adicciones para olvidar su drama ntimo existencial. 6. Para ayudar a la persona adicta a explicarse a s misma primero, y a salir del fenmeno adictivo despus, necesitamos acercarnos a sus fundamentos antropolgicos desde las tres perspectivas clsicas de las Ciencias Humanas: la filosfica, la psicolgica y la educativa. Desde la Filosofa, la Psicologa y la Pedagoga llegaremos a comprender, por ejemplo, que lo visible de la persona adicta no es la totalidad de su persona. 6.1. Al echar una ojeada filosfica a los comienzos de la filosofa contempornea (siglo XIX), nos encontramos con dos grandes pensadores con dos modelos de persona polarmente opuestos, que van a marcar dos estilos o tendencias contrarias de vida: la persona trascendente de S. Kierkegaard, por un lado, y la persona inmanente segn F. Nietzsche, por otro. Despus, de entre las grandes corrientes del pensamiento actual, particularmente tiles para nuestro propsito seran la Fenomenologa, el pensamiento existencial con sus dos grandes tendencias: la filosofa de la existencia y el existencialismo, y la filosofa dialgica y el Personalismo. Todas estas Filosofas aportan la visin ms universal y global del fenmeno adictivo y de su superacin posterior. 6.2. La segunda perspectiva, la psicolgica, aporta las claves del comportamiento de la persona adic-

ta y, sobre todo, las tcnicas psicoteraputicas ms eficientes en orden a la re-estructuracin de su "paisaje del alma", que dira Unamuno. Despus de acercarnos a los problemas epistemolgicos de la psicologa, entre los aspectos psicolgicos de la personalidad adictiva nos fijamos en su complejo mundo consciente e inconsciente, en su mundo emocional y en su dolor y sufrimiento, as como tambin distinguimos entre su placer adictivo y el placer personal. Para ello pasamos revista a las principales escuelas psicolgicas y a los grandes abordajes o psicoterapias, estableciendo una divisin clara entre psicoterapias ms excluyentes, como los abordajes de psicologa profunda y los abordajes conductistas-cognitivos, y psicoterapias ms integradoras, como los abordajes sistmicos y los abordajes humanistas. 6.3. Y en tercer lugar, las ciencias de la educacin, que nos ponen ante la perspectiva de la prevencin. Los distintos modelos y programas de prevencin de las adicciones hacen posible una tarea especfica tanto por parte de la Comunidad Educativa, como por parte de la familia como primera y principal sociedad preventiva. La perspectiva educativa-preventiva, en fin, entre otros perfiles nos va a mostrar al terapeuta-educadorvoluntario, una figura coherente con el modelo de persona que revela una antropologa personalista. 7. En efecto, una antropologa personalista explica no slo el fenmeno de las adicciones, sino que sobre todo hace posible su superacin total, lo cual se explica muy bien mediante el concepto de rehumanizacin . Este concepto nos permite superar la actual Comunidad Teraputica (CT) Rehabilitadora por una CT Rehumanizadora, como situacin educadora ideal no slo para la persona adicta, sino tambin para las personas en general y la sociedad en la que todos vivimos inmersos.

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8. De todo ello surgira un supraparadigma integrador en la actualidad, apuntado ya por distintos autores desde mediados del siglo pasado como Viktor E. Frankl, Ken Wilber el paradigma hologrfico, o ms recientemente Martin E.P. Seligman con su Psicologa Positiva, supraparadigma que denomino Filosofa de la Rehumanizacin. Sera sta una lnea investigadora fecunda para establecer unas slidas bases esperanzadoras de dejar de ser persona adicta o esclava y llegar a ser persona rehumanizada, o persona sin ms. Si consideramos que la persona adicta es una persona des-humanizada, la lgica evolutiva de la perfeccin que supone dejar de ser dependiente y esclava nos permite concluir que, si lo consigue, es una persona nueva re-humanizada. 9. Adems, esa persona nueva no slo se construye a s misma sino que tambin, de algn modo, construye la historia. Igual que la persona adicta no slo se destruye a s misma sino tambin a la sociedad, porque ayuda a des-estructurar la comunidad social en la que est inserto, la rehumanizacin se la puede ver tambin desde una perspectiva historiolgica esperanzadora para el futuro de la Humanidad. Entre otras razones, porque la persona adicta est incrustada en la cultura actual como nunca antes lo haba estado en la historia. 10. Finalmente, estas ideas tan utpicas como posibles sirven de corolario a una antropologa filosfica de las adicciones con decidida vocacin prospectiva. Mediante la educacin para la rehumanizacin de la persona, ponemos de relieve que el ser humano es un ser orientado hacia la esperanza, constituido hacia la esperanza de llegar a ser persona en un mundo contradictorio capaz de generar, a la vez, las adicciones y su posible superacin. Incluso en las circunstancias ms adversas y en las situaciones lmite, a la persona adicta siempre le ser posible hacer la experiencia de la esperanza y forzar a su propio destino.

Si, como dijo el poeta alemn Friedrich Novalis, las teoras son redes y slo quien lance coger, en ltimo trmino mi propuesta intenta lanzar una red para ayudar a las personas esclavas de s mismas a hacer posible el sueo de su rehumanizacin total y, por aadidura, el sueo de una sociedad venidera en la cual al menos siempre nos quepa la utopa de soar.

...

A continuacin presento brevemente las principales coordenadas del fenmeno adictivo integral, es decir a la persona adicta y su posible rehumanizacin, as como algunas claves metodolgicas que hacen posible acercarnos a sus fundamentos existenciales. Apoyndome en mi libro De las drogas a la esperanza (San Pablo, Madrid, 1996), donde ya intent desbordar los lmites de la rehabilitacin a favor de la rehumanizacin a travs de la Comunidad Teraputica Proyecto Hombre (Espaa), ahora intento fundamentar el fenmeno de las adicciones y el trabajo teraputico para ayudar a salir de ellas. Como continuacin de aquel primer ensayo propongo ahondar en la quemadura del fenmeno adictivo desde planteamientos ms acadmicos, pero igual que entonces tampoco ahora presento un mtodo ms para prevenir y curar. Trato de construir un trabajo terico con decidida vocacin teraputica, que propone como fundamento un modelo de persona humana con profundos valores, nicos capaces de llenar la vaciedad de la existencia. Precisamente por ser persona, el ser adicto, antes y despus de ser adicto, est revestido de esa dignidad nica que le viene de su propia condicin o razn de ser. Vengo proponiendo (Caas, 1997, 2002) la idea de que los actuales Centros universitarios de Drogodependencias y los Institutos de Investigacin y Formacin sobre Drogas1 pasen a llamarse sobre

1 El Instituto de Investigacin y Formacin sobre Drogas (PND) en Espaa. El National Institute on Droug Abuse (NIDA) en EE.UU. Los Centros dependientes de La Comisin Interamericana para el Control del Abuso de Drogas (CICAD). Etc.

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A d i c c i o n e s , y n o s l o s o b re D ro g a s o d e Drogodependencias, porque el fenmeno adictivo es bastante ms amplio y ms real que slo la dependencia de las drogas. Uno de los objetivos prioritarios de estos Centros que imparten ttulos profesionales (Experto, Master en Drogodependencias, etc.) debera ser una slida formacin humanista que permita conseguir cambios duraderos en las personas adictas respecto de actitudes y de convicciones profundas. La compleja estructura de la personalidad adictiva es tan arcana que difcilmente se logran resultados duraderos en su rehumanizacin si no se apunta a lo ms profundo y a lo ms alto de la persona, es decir a su fundamento existencial y a su esencial dignidad y finalidad. En los Institutos y Centros sobre drogas efectivamente se estudia con detenimiento todo tipo de teoras y de instrumentos teraputicos ms eficaces, pero no siempre se tiene una visin de conjunto de a quin van dirigidos dichos instrumentos, esto es, una visin humana global del ser-en-el-mundo-adictivo. Hasta llegar a descubrir que en la problemtica de las adicciones el principal problema no es prioritariamente la adiccin sino la persona adicta, y despus ser coherente con este principio fundante en las teraputicas que se apliquen, en primer lugar hace falta un conocimiento terico antropolgico previo que explique esencial y existencialmente quin es el ser adicto, y cul es la lgica interna de los procesos de su regresin y de su maduracin, y en segundo lugar hace falta ejercitar una teraputica que rehumanice de verdad y a la vez respete la libertad de la persona adicta. Si podemos distinguir entre la persona y su adiccin ello es posible porque la persona es un ser ms real, ms profundo y ms ntimo, visto desde un conocimiento tpicamente humano, que el ente objetivo de su adiccin, con lo cual estamos priorizando a la persona frente a su objeto de deseo adictivo merced a un

fundamento antropolgico previo. Y ello nos pone bien en claro que el mero-objeto-adictivo es una tentacin de la persona adicta de reducir toda su rica y compleja realidad personal a algo dominable, algo posible de verificacin y control, y, por tanto, manipulable. Al contrario, toda persona posee caractersticas propias que superan las condiciones de lo espacio-temporal que ostentan los objetos, tal y como han puesto de manifiesto las mejores corrientes filosficas existenciales y humanistas contemporneas como el personalismo y la filosofa dialgica, entre otras. Esta visin humanista inicial de las adicciones, que se fija primero no en qu es la adiccin sino en quin es la persona adicta, podemos llamarla visin antropolgica personalista porque prioriza a la persona y no al objeto droga. Diramos que las ideas de la antropologa personalista ms actual (Burgos, 2003, 19 ss.) estaran perfectamente adaptadas para explicar la realidad de la persona adicta hoy da porque ya no podemos dudar de que el problema es la persona y no la droga (De Leon, 2000, 35). Priorizar la conducta adictiva, y las perturbaciones psquicas o el deterioro fsico que la adiccin puede originar, al poner el objeto-droga (sustancia o conducta) en el centro de la problemtica lo que hace es dar lugar a una visin reduccionista de la persona adicta invirtiendo el enfoque cultural y profesional del problema, entre otras cosas porque es ms fcil de adoptar. La gran mayora de la investigacin experimental sobre las adicciones que se lleva a cabo actualmente en las Universidades y Centros Superiores de Investigacin no sale del unvoco mtodo emprico sin tener en cuenta la grave parcelacin de las personas y del mbito personal del mundo adictivo que ello implica. Ya en el ao 1935 Edmund Husserl, sin duda una de las mejores inteligencias del siglo XX, advirti a la comunidad cientfica de su tiempo que meras ciencias de hechos hacen meros hombres de hechos, porque exclu-

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yen por principio precisamente las cuestiones relativas al sentido o sinsentido de la entera existencia humana (1991, 6)2 . El resultado de esta exclusividad analtica tan extendida en la investigacin y en la prctica psicoteraputica contempornea es fruto de una visin antropolgica reduccionista de la persona (adicta o no). El problema no es que en la actualidad no exista una visin antropolgica previa, es que la que existe est generada por una concepcin de la persona mutilada de raz. La visin antropolgica personalista de las adicciones, al contrario, la eleva hasta lo mejor de s misma porque es una visin de totalidad y de unidad y, por tanto, es la visin ms realista de la persona precisamente porque est fundada en aquello que la trasciende. Cierto que las personas estamos inclinadas por una parte irracional que vive en nosotros, y que la ciencia y la literatura universal se encarga de amplificar. El gran escritor hngaro en lengua inglesa Arthur Koestler pensaba que el cerebro consta de dos mitades, una pequea parte tica y racional, y otra enorme trastienda animal y territorial, cargada de miedos, de irracionalidades, y de instintos sexuales y violencias3 . Pero ello, aparte de ser magnificado en la creacin literaria y la cultura audiovisual actuales, a lo sumo indica que la persona que quiera dar prioridad a su ser racional tiene que realizar de entrada un esfuerzo mayor que si elige priorizar su ser irracional, pero no que una de las dos mitades siempre e irreversiblemente prevalezca necesaria y fatalmente sobre la otra, o dependa de la otra, ni que por s sola y de por vida haga dependientes a las personas.

Y cierto que todas las personas tenemos fantasmas. El miedo, por ejemplo, no es ms que el fantasma de la simple anticipacin anmica de un mal posible o probable que, atenindose a las estadsticas, pocas veces llega a cumplirse de verdad. Pero al miedo, como a la adiccin, se le puede y se le debe plantar cara. Qu son el susto y el terror, sino fantasmas virtuales que, en definitiva, slo existen en nuestra imaginacin? Toda persona, por muy equilibrada que sea en los tres dominios de cuerpo, mente y espritu, tiene miedos, fantasmas que Freud acertadamente situ en el inconsciente. Quiz el miedo ms caracterstico de la persona adicta sera el miedo a toda verdad, segn la acertada expresin de Gianni Vattimo en El Pensamiento dbil, que no es sino el miedo a enfrentarse a su realidad adictiva. El miedo sera el sustrato de su esclavitud existencial, y lo evidencia la destruccin de su personalidad a la que se ve sometida. Por este camino, enseguida concluiremos que todos somos susceptibles de seguir alguna conducta de tipo adictivo. Pero la diferencia entre dejarse llevar y autodominarse estriba en saber someter los fantasmas que nos obsesionan al crisol de la razn y espantarlos. Toda persona alguna vez en su vida siente el miedo del instinto adictivo, pero cuando no lo consiente es porque de hecho prev que lleva enroscado en sus entraas una radical desesperanza. De igual modo, la persona adicta en vas de rehumanizacin experimenta que puede luchar y vencer a sus fantasmas ms ntimos cuando se posicionan sobre ellos los destellos de la esperanza. El miedo, en definitiva, dibuja el proteico mundo del fenmeno adictivo, entre otras razones porque perte-

2 La crisis de las ciencias europeas y la fenomenologa trascendental, publicada postumamente en 1954 proviene de una conferencia escrita en el ao 1935 con el ttulo de "La filosofa en la crisis de la humanidad europea" (Husserl, 1991, 323-358). 3 Cf. El loto y el robot (The lotus and the robot, 1960), El fantasma en la mquina (The ghost in the machine, 1967), Las callgirls (The Call-girls, 1972), etc.

nece al mundo humano. Nuestras vivencias cotidianas, desde la satisfaccin de las necesidades bsicas como comer o dormir hasta las ms complejas como las relaciones personales, en general varan poco, y desde que nacemos dependemos de estmu-

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los internos y externos que en su mayora son predecibles porque se repiten con regularidad. El psiquiatra Luis Rojas Marcos (2000) repara en que las personas somos por naturaleza dependientes de muchas cosas y que la mayora de nuestros hbitos nos aportan una cierta dosis de seguridad en nuestra vida cotidiana y representan dependencias y usos constructivos y benignos, a la vez que nuestra naturaleza nos proporciona la capacidad para aprender, para cambiar, para adaptarnos a circunstancias diferentes y para superar los contratiempos de la vida. El problema estara cuando esas dependencias se convierten en compulsivas o adictivas. La frontera entre la dependencia adictiva y la dependencia no adictiva o la no-dependencia estara en hacer girar todo nuestro ser en torno a algo o a alguien que nos anula como personas. Vistas las cosas bajo este prisma podemos sostener que en potencia todos podemos llegar a ser adictos, en mayor o menor grado. Hemos sido adictos de alguna forma por ejemplo cuando hemos experimentado el vrtigo de una ambicin econmica desmedida, o de alcanzar poder para manipular a los dems, o el deseo de obtener un placer irracional compulsivo4. Cualquier situacin incitadora de placer autonomizado puede acabar generando dependencia, y la mayor parte de las conductas compulsivas nacen de hbitos de comportamiento de los que la persona es responsable en ltima instancia. Las caractersticas psicosociales de cada persona son las que determinan y modulan la va concreta y particular hacia un tipo de adiccin.

De la vivencia particular de estas experiencias adictivas se desprende ya una idea antropolgica clave, que se nos ir apareciendo cada vez ms clara, de considerar la libertad personal mayor de lo que normalmente se le atribuye, o al menos en la misma proporcin que normalmente se le atribuye al fatalismo. Efectivamente, desde la experiencia del ejercicio de la libertad personal estamos en mejores condiciones reales de poder llegar a establecer los fundamentos de las personas adictas, y sobre todo de conocer los procesos de su rehumanizacin. La humanidad comparte la misma tierra (humus), y ello nos permite comprender por qu bajo ciertas condiciones biolgicas psicolgicas y sociales patolgicas que interfieren con nuestras cualidades adaptativas y nuestros instrumentos naturales de defensa, una proporcin de hombres y mujeres pierden la capacidad de controlar su comportamiento y desarrollan dependencias adictivas. Independientemente que el objeto de adiccin sea la droga, el alcohol, la comida, el hambre, el juego, el sexo, el poder, la televisin, el trabajo, internet, una relacin, o incluso la violencia sdica, los adictos se sienten movidos por una fuerza compulsiva, irracional e irresistible de satisfacer una necesidad inmediata (Rojas Marcos, 2000, 29). Esto son las adicciones. Con el aadido de que, pasado cierto tiempo inicial, la persona adicta se lanza por la pendiente autodestructora de su hbito adictivo en busca de adormecimiento ms que de placer. Socialmente la ms escandalosa de todas las adicciones es la drogadiccin, aunque para cada persona particular la adiccin ms grave siempre es la suya. Ahora bien, lo mismo que podemos afirmar con absoluta seguridad que no se sale de las drogas hablando de las sustancias que las producen sino de las personas que las padecen, y que slo se cambia de verdad atajando las causas existenciales profundas de las personas y no centrndose en la sintomatolo-

4 Podemos imaginar lo que puede ser estar obsesionado continuamente da tras da por un mismo tema, porque pasamos por momentos en la vida en los que parece que no podemos dejar de pensar en algo o alguien que nos llega a quitar el sueo. La raz del comportamiento adictivo sera entonces la enajenacin mental y fsica propia de esa esclavitud existencial.

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ga, eso mismo debemos sostener respecto de cualquier tipo de adiccin. Muchas personas siguen pensando que una adiccin es el resultado inevitable de consumir alguna sustancia -una droga-, pero tal concepcin limitadora es peligrosamente errnea dado que un proceso adictivo puede sustentarse slo en la repeticin de una conducta sin que medie ningn consumo de sustancias. El fenmeno de la drogadiccin ciertamente es un mal particularmente grave porque muchos jvenes han muerto o van morir por su causa, pero en el resto de las adicciones tambin es muy grave porque los jvenes se hallan muy disminuidos en su ser ntimo, y esto en principio no se ve. En los momentos ms delicados del crecimiento de los jvenes la adiccin es el sntoma de un malestar existencial, de una dificultad para encontrar su lugar en la sociedad, de un miedo al futuro y al compromiso de la vida adulta, y de una fuga hacia una vida ilusoria y ficticia: Numerosos jvenes piensan que todos los comportamientos son equivalentes, pues no llegan a distinguir el bien del mal y no tienen el sentido de los lmites morales (Pontificio Consejo, 2002, 175). En todo caso, las adicciones (de todo tipo) no deben ser tratadas como un problema exclusivo y preferentemente sanitario ni psiquitrico. El "dependiente" no es slo un enfermo que padece una enfermedad fsica y mental: su tratamiento nicamente sanitario-psicolgico est abocado al fracaso si se renuncia a la rehumanizacin de su persona, que es la verdadera perspectiva global aportada por la antropologa filosfica sobre la condicin humana. Ya F.G. Schelling, desde su romanticismo, intuy perfectamente que el enfermo, como todo hombre, es inagotable (Jaspers, 1955, 322), lo cual quiere decir que el ser adicto no es slo una entidad patolgica es ante todo una persona y, por tanto, un ser con posibilidades de cambiar el rumbo de su existencia en cualquier momento merced

a su libertad. La teraputica actual ms valiosa generalizada demuestra que las adicciones son un problema existencial, pedaggico y preventivo antes que sanitario, judicial y policial, y que se ha de afrontar prestando ms atencin al sufrimiento de cada persona adicta, de su familia y de su entorno prximo, antes que a la intervencin paliativa aunque lgicamente esta sea necesaria. Dicho de otro modo, si de verdad se quiere atajar la raz del problema se han de aplicar tratamientos farmacolgicos, sanitarios y psicolgicos de forma rehumanizadora. La persona (el hombre) era definida por Gregorio Maran como una unidad estructural y funcional, ser vivo racional que siente, padece, sufre y quiere ms que odia; y la enfermedad como una anormalidad que altera dicha unidad y el equilibrio fsico-psquico. Por eso diramos que la cura en sentido heideggeriano de la persona adicta y de todas las personas desestructuradas en general, hoy da atae a todos los terapeutas (padres y tutores en primer lugar) y a todos los profesionales (mdicos, psiclogos y profesores, principalmente) que trabajan rehumanizando a quienes han cado, y educando y haciendo prevencin, o sea ayudando a no caer, a los dems. Aqu est la clave de por qu los Estados no avanzan en este terreno proporcionalmente a los enormes recursos y esfuerzos que ponen en marcha de todo tipo. Si no se tienen en cuenta los fundamentos antropolgicos y existenciales que se encuentran en el principio y en el final de las personas adictas, como mnimo no se capta la complejidad del fenmeno adictivo. Lo expresa poticamente Mario Picchi (fundador de Progetto per l'uomo en Italia, y pionero en Europa de una teraputica humanista de las personas adictas), cuando nos invita a contemplar a la persona en su integridad y en sus infinitas posibilidades de rescate y de riqueza interior, en clave preventiva y de rehabilitacin [rehumanizacin], [lo cual] resulta ser la nica

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estrategia que permite hacer continuas opciones en funcin del amor a la vida (Picchi, 1998, 74). Perspectiva que es la ms eficaz y, desde luego, la ms humana. Y, adems, la ms rentable. Esta visin antropolgica personalista de las adicciones se apoya en las filosofas humanistas y en las psicologas integradoras, lo cual proyecta una fundamentacin existencial que lleva a conclusiones del tipo teora, prevencin y teraputica de las adicciones. El ttulo lo tomo prestado de Viktor Frankl, quien en 1956 present a la sociedad de su poca una sistemtica de su pensamiento, confirmada con una amplia casustica teraputica ya entonces (Frankl, 19925) . A la bsqueda del placer (Luststrebigkeit) que Sigmund Freud estim como el principal motor del ser humano, opuso Frankl la voluntad para encontrar sentido a todas las situaciones humanas (Wille zum Sinn), incluidas la enfermedad, la depresin y la muerte, as como en la trgica situacin de las adicciones. Lo cual, entre otras consideraciones, inicialmente quiere decir que tambin la persona adicta tiene ms participacin en su destino de lo que a simple vista se la quiera atribuir, como un ser que crea el mundo y determina lo que ella es y lo que ella quiere que sea. A mi juicio, lo que destilan las mejores teoras humanistas filosficas, psicolgicas y pedaggicas de las ltimas dcadas, es un nuevo giro antropolgico respecto del llamado giro antropolgico de los pensadores antihumanistas del XIX. Estamos ahora en los umbrales de una nueva poca para que el pensamiento d el autntico giro? Est por hacer el autntico giro antropolgico? Es posible que esta pregunta, largo sueo acariciado por tantos humanistas a lo

largo de los ltimos cien aos (la filosofa fenomenolgica, la filosofa de la existencia, el pensamiento dialgico-personalista,), an no halle respuesta definitiva. Pero una cosa es segura, la tremenda realidad actual del ser adicto nos pone en la pista cierta de la necesidad de una re-humanizacin si la Humanidad quiere tener futuro. Efectivamente, para entender a la persona adicta es preciso una inversin de la visin antropolgica determinista y desesperanzada por una concepcin antropolgica de la libertad y la responsabilidad personal fundada en la esperanza. Eugenio Fizzotti, discpulo de Frankl, escribe: visto en la dimensin notica, el hombre trasciende el plano biolgico, psicolgico y sociolgico. No es determinado; ms bien determina todas las cosas, se determina a s mismo. La existencia es, pues, subjetiva, nica, singular e individual (Fizzotti, 1977, 179). Dicho de otro modo, slo una concepcin de la persona esperanzada puede fundamentar a la persona adicta en la esperanza. Nadie puede dar lo que no tiene. Una persona, por lo dems, que es libre y autnoma porque puede, dentro de sus limitaciones personales, escoger y ordenar los derroteros de su propia existencia. Las condiciones genticas y sociales estn ah, pero estn ah generalizadas, despus cada quien las jerarquiza a su modo. Diramos que la persona adicta no es una persona especial por sus genes heredados o por su marginalidad familiar o ambiental. Estar influenciado gentica o materialmente no quiere decir estar determinado inexorablemente, entre otras razones porque tambin influencian a otras muchas personas que en las mismas circunstancias no derrotan adictivas. Y, en todo caso, una predisposicin gentica no anula la capacidad ltima personal e intransferible de acercarse o distanciarse de la rea-

5 T h e o r i e u n d T h e r a p i e d e r N e u ro s e n : E i n f h r u n g i n Logotherapie und Existenzanalyse (Teora y terapia de la neurosis: iniciacin a la logoterapia y al anlisis existencial).

lidad. Slo visto desde la perspectiva de la rehumanizacin de las personas adictas podemos llegar a

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saber por va de experiencia que en ltima instancia la conducta adictiva es una grave inmadurez personal, fruto del ejercicio de la propia libertad y la propia (i)responsabilidad personal. Si nos preguntamos qu consecuencias se derivan de considerar a la persona adicta como un ser esencialmente libre en su decisin radical podemos ver, desde este principio, muchas ms ventajas y posibilidades explicativas que de la otra forma. Por ejemplo, la persona adicta desde la inicial libre eleccin de su adiccin es esclava de s misma porque enajena su libertad en algo o alguien que le tiraniza al extremo de no poder controlar su yo mental y personal. Independientemente del tipo de adiccin que le someta podemos encontrar en todos los adictos el denominador comn del tipo de persona que ya en 1849 Kierkegaard llam el hombre inmediato (1969, 110), y que hoy se correspondera perfectamente con la persona adicta. La visin del mundo del "hombre inmediato" sera una clave de interpretacin muy vlida para explicar la conducta del buscador de placeres continuos y compulsivos, no slo en el presentismo de una vivencia que necesita ser satisfecha ya, sino en el sentido de quien no es capaz de ganar distancia de perspectiva alguna de su vida, ni pasada ni futura. Comprender al hombre-inmediato y la "inmediatez existencial" en la que vive el ser adicto nos va a aclarar sobremanera su estructura personal y vivencial. Al avanzar un poco ms en estas indagaciones podemos preguntarnos: De dnde le viene a la persona el deseo de ser adicta? Los dos procesos globales ms opuestos de la libertad humana, las experiencias de vrtigo y las experiencias de xtasis como los denomina el profesor A. Lpez Quints (1981), se producen al salir de s la persona para trascenderse a su propio yo. Merced a las experiencias de vrtigo que lleva a cabo la persona adicta, difumina las fronteras de su yo, rompe los lmites de la conciencia para en-

trar en un ms all por la va rpida de la anulacin personal, e incluso de la muerte anticipada. El vrtigo le tiende una trampa existencial que la devuelve a la caverna desnuda de su realidad, una y otra vez, con dolorosa obstinacin. Despertar para volver a dormir, alargar el sueo artificial para volver a lo real, para volver a empezar un ciclo sin solucin de continuidad. Las personas as condicionadas a menudo siguen llevando con naturalidad su vida diaria, aunque desarrollen una prctica adictiva ms o menos frecuente o pasajera, hasta el da en que caen en la situacin lmite de una nica realidad obsesiva: vivir para la adiccin. La persona adicta ir ordenando progresivamente su existencia hacia la bsqueda de esa obsesin y, en cierto sentido, vivir casi exclusivamente para ella. Aunque al principio comience por curiosidad, para evadirse o para eliminar un malestar de la vida, la adiccin llegar a ser el nico centro de inters de su existencia. Es decir, un crculo en el que la falta de proyectos y la ausencia de ideales hacen que la persona se encierre en s misma. La voluntad de sentido de que nos habla Viktor Frankl se trueca, en el caso de la persona adicta, en voluntad de adiccin por la necesidad de autotrascendencia que, en ltima instancia, necesitamos experimentar todos los seres humanos sea como sea. Es tan fuerte ese deseo de desaparecer de lo real que, cuando no enajena a la persona, la pone en contacto con la trascendencia mediante un proceso no de vrtigo, sino de xtasis. Tanto las experiencias vertiginosas como las extticas slo cabe entenderlas cabalmente desde el deseo de trascendencia que toda persona lleva dentro de s misma, y que eminentes autores actuales como George Steiner llaman nostalgia del Absoluto, o autntica felicidad (Mar tin Seligman), que no slo se da en las experiencias religiosas o msticas sino que tambin puede ser traducida en trminos de hambre de lo trascendente, que

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observamos en las mitologas, en las metforas totalizadoras de la utopa marxista, de la liberacin del hombre, en el esquema de Freud del sueo completo de Eros y Tnatos, en la punitiva y apocalptica ciencia del hombre de Lvi-Strauss (Steiner, 2001, 22), etc. Es decir, estamos ante un fundamento existencial que explica la estructura de los seres personales. En Viktor Frankl encontramos una explicacin filosfica de las neurosis, que se puede aplicar perfectamente a las adicciones, cuando descubre que las neurosis se dan no tanto en una esfera psquica sino en una esfera notica o espiritual, debidas a problemas espirituales o conflictos existenciales y morales. Es ms coherente pensar que no existe una inclinacin especfica en la persona a la adiccin, sino que existen situaciones y ocasiones propensas que conducen a caer en ella. Lo cual nos lleva a la imposibilidad de trazar una lnea ntida entre el ser normal y el ser adicto, entre otras razones porque todos podemos caer en la adiccin. El deseo adictivo de la persona sera explicable por una voluntad de ser feliz pero sin reconocerse a s misma, algo as como si el yo no fuera el propio yo, sino el yo de otros yo. La paradoja est en que la persona adicta al afirmar el yo mediante su acto libre de elegir ser dependiente, precisamente porque quiere ser yo, est negando su yo porque lo destruye al hacerlo depender, no del yo, sino de algo (un objeto, una conducta) o alguien (otro yo) que no es su yo. La persona no adicta, al contrario, sera la persona independiente que sigue un proceso de crecimiento personal, como fundamenta muy bien el esquematismo kierkegaardiano: el yo es una relacin que se relaciona consigo misma, [] que en tanto se relaciona consigo misma, est relacionndose a otro, [] y que al autorrelacionarse y querer ser s mismo, el yo se apoya de una manera lcida en el Poder que lo ha creado (Kierkegaard, 1969, 47-49).

Otra hermenutica que explica muy bien el modo existencial de vivir de la persona adicta la encontramos en el ser humano que dibujan la literatura y la filosofa del absurdo, con obras desarrolladas originalmente hacia la mitad del siglo XX6. El hombre absurdo, en efecto, desemboca tambin en el tipo de ser humano inmediato que elige entregarse a toda clase de vrtigos existenciales que desembocan en la prdida del sentido de la vida. En ltima instancia sera esta, la prdida del sentido de la vida lo que desemboca en lo absurdo de la existencia, claves que explican el ser profundo del adicto y su des-estructuracin esencial personal como veremos. Pero la persona nunca puede dejar de ser persona. Convertirse en animal, por ejemplo, slo sera una metfora literaria como hace magistralmente Franz Kafka de Gregorio Samsa, el protagonista de La metamorfosis. Como tampoco puede elegir la vida infrahumana del ser vegetal, segn desea por ejemplo Calgula al final de su vida en la obra homnima de Albert Camus7. Ni siquiera deja de ser persona Gregorio Samsa cuando toca la sima de la nada, como da a entender Max Brod comentando el hecho de que Kafka rebaja a la persona a la condicin de animal: El hombre debe hundirse ms profundamente an, all donde slo exista el todo o nada (Kafka, 1977, 11), porque incluso en esa situacin Samsa es capaz de pensar

6 A mi juicio son paradigmticas tres obras: El extranjero, de A. Camus (Ltrangere, 1942), La cantante calva, de E. Ionesco (La cantatrice chauve, 1950), y Esperando a Godot , de S. Beckett (En attendand Godot, 1952). 7 A propsito de la soledad, Camus hace exclamar a Calgula en dilogo con Escipin el deseo de una vida vegetal subhumana: La soledad! Acaso t conoces la soledad? [...] T no sabes que propiamente solo no se est nunca! Y que a todas partes nos acompaa el mismo peso de porvenir y de pasado. Los seres a quienes uno ha matado estn con nosotros [...] Solo! Si al menos en lugar de esta soledad envenenada de presencias que es la ma pudiera gustar la verdadera, el silencio y el temblor de un rbol! Mi soledad est poblada de un crujir de dientes y en toda ella resuenan ruidos y clamores perdidos (Camus, 1957, 90, s.n.).

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en los dems, es decir ser persona es lo mismo que ser relacional, como lo ve muy bien la filosofa contempornea a partir de Sren Kierkegaard. La persona es especficamente un ser-de-encuentro. Por todo ello, las mejores ideas para la prctica teraputica (mdica, psicolgica y social) provienen del anlisis de los fundamentos de las adicciones desde las perspectivas holistas y globales. Desde la Filosofa, la Psicologa y la Pedagoga, los grandes paradigmas tericos clsicos de las ciencias humanas que nos llevan al conocimiento profundo del ser personal, nos acercaremos al ncleo de ideas que siempre estn ah y que lo nico que cambia con los aos son las estrategias de las terapias. Ese ncleo humanista es el fundamento antropolgico de la persona. Desde estos enfoques tericos, en fin, ya se atisba cmo emergen modelos que ejemplifican desde la prctica diaria y la accin concreta la amplia perspectiva filosfica, psicolgica y educativa humanistas. Una de las mximas preferidas de Spinoza, siguiendo a Platn, repite que la cosa excelente ha de ser muy difcil, lo cual proyecta hacia lo alto la teora de la rehumanizacin y sus consecuencias teraputicas y educativas prcticas, porque hoy casi todas las terapias son terapias de facilidad, que terminan en terapias-placebo, no de superacin real de las dificultades. Y sin embargo, educar en la lucha por la superacin de la dificultad es ensear a las personas adictas a luchar por resolver sus problemas cotidianos de manera efectiva y real. Es decir, que para trabajar en la rehumanizacin de las personas desestructuradas por las adicciones se necesita tener una idea previa antropolgica de excelencia, porque es la ms ajustada a la realidad existencial del ser adicto, igual que toda psicoterapia vlida tiene que apoyarse forzosamente en una concepcin antropolgica previa fuertemente arraigada en la consecucin de un ideal, el ideal de la persona

"sana", que es la postura ms real. James Hillman, director del Instituto Carl G. Jung en Zrich, en su obra El mito del anlisis (2000), muestra cmo la psicologa ya naci desde un principio como psicopatologa, es decir como ciencia de la mente enferma, pero ese perfil es el que presenta la persona adicta, no la persona sana en general ni en primer lugar. De ah que la rehumanizacin, como paradigma de la persona sana, nos lleva sin pretenderlo a una antropologa filosfica aplicada al abordaje psicolgico de las adicciones. Es momento, por tanto, para dar pasos adelante en psicoterapia. Yo vengo proponiendo sustituir el gastado concepto de rehabilitacin por el de rehumanizacin (Caas, 1996). Rehabilitarse se confunde con abandonar el hbito o el consumo de sustancias adictivas, mientras que rehumanizarse, adems de dicho abandono, se vincula a transformar conductas personales y mbitos de sentido asociados a esa esclavitud existencial. Bajo el concepto de rehumanizacin pretendo abrir lneas de investigacin que establezcan fundamentos claros y seguros para comprender las adicciones en todos sus aspectos tericos, y en sus correspondientes prcticas teraputicas esperanzadoras. Por la misma razn, si la rehumanizacin plena de la persona se perfila como el objetivo especfico y prioritario de la intervencin en las Comunidades Teraputicas (CT) de autoayuda para adictos, entonces sera preferible hablar ya de Comunidades de Rehumanizacin , en vez de Comunidades de Rehabilitacin, pues en el momento presente debemos pensar con M. Picchi que ya no se puede hablar de lucha contra la droga [y las adicciones] si cada uno de nuestros gestos no tiende a promover la dignidad humana, el derecho a la existencia, un reparto ms justo de los bienes, la fidelidad a unos deberes ciudadanos, la solidaridad, la responsabilidad compartida (1998, 85). Esta perspectiva educadora global, apo-

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yada en las mejores teoras antropolgicas humanistas desarrolladas a lo largo de la historia sera hoy, a mi juicio, la ms realista, la ms efectiva y la nica que posibilita un programa completo de rescate de la persona des-humanizada capaz de abrir perspectivas esperanzadoras para la humanidad venidera. Quiz la conclusin ms optimista de la rehumanizacin es que hay esperanza en la humanidad. La afirmacin de que el ser-persona-en-el-mundo puede salir de la esclavitud existencial de las adicciones, y llegar a ser libres de verdad. La rehumanizacin, en definitiva, respondera a las ms altas aspiraciones utpicas del ideal de la unidad de todas las personas en la historia, y, como ya escribi Karl Jaspers, la Historia no es ms que el movimiento orientado por la unidad mediante representaciones e ideas de la unidad (Jaspers, 1994, 321 y 339).

Heidegger,...), se nos presenta aqu y ahora como un camino actualizado para comprender el mundo de las adicciones y, sobre todo, para conocer la estructura de la persona adicta en su esencia. Dicho brevemente, este mtodo nos va a permitir eliminar todo tipo de prejuicios y el mundo fenomnico de las adicciones y de la rehumanizacin est saturado de ellos- para intentar ver lo que la realidad personal adictiva y la realidad personal rehumanizada presentan sin ms, anulando los aspectos irrelevantes del fenmeno tal y como se presenta a la conciencia de la persona, y as hasta llegar a su fundamento, es decir, a la intuicin de su esencia como dira Husserl. El mtodo fenomenolgico de momento revela, por un lado, que nuestro conocimiento de la vida (terico y prctico) siempre es intencional, es decir que conocemos porque tenemos una intencin previa de conocer, y por otro que es esencialmente similar para todos, lo cual constituye un fundamento vlido para un conocimiento de la vida personal objetivo y universal. Husserl, que llama al mtodo "fenomenologa trascendental", lo concibe como una tarea de clarificacin para poder llegar a la esencia de las cosas mismas partiendo de la propia subjetividad, pero no como una descripcin emprica o meramente psicolgica, sino trascendental, es decir constitutiva del conocimiento-de-sentido de lo experimentado, porque se funda en los rasgos esenciales de lo que aparece a la conciencia de la persona. Despus de Husserl, muchos de sus seguidores del Crculo de Gttingen emplearon el mtodo fenomenolgico para emprender una vuelta a las cosas mismas (zu den Sachen Selbst), que ser a partir de entonces el mejor camino para hacer filosofa partiendo de la experiencia9.

...

Si volvemos ahora la vista a las cuestiones metodolgicas, observamos que las conclusiones alcanzadas en el presente trabajo han sido posibles gracias a una fenomenologa de las adicciones y de la rehumanizacin, tal vez la aportacin terica ms personal al estado de la cuestin8. Con el doble objetivo de fundamentar todo tipo de adicciones, por un lado, y de explicar la rehumanizacin de la persona adicta, por otro, a lo largo de la obra aplico el mtodo fenomenolgico mediante el cual se pretende describir objetivamente esas dos experiencias contrarias y llegar a comprender que estamos ante fenmenos humanos polarmente opuestos. Este mtodo iniciado por Edmund Husserl hace casi un siglo, y desarrollado posteriormente por sus continuadores de la escuela fenomenolgica (A. Reinach, E. Stein, E. C o n r a d - M a r t i u s , R . I n g a rd e n , M . S c h e l e r, M .

8 Aunque espero que no contenga nada fundamentalmente nuevo, segn la advertencia de Robert Spaemann: "cuando se trata de la vida recta slo lo falso puede ser realmente nuevo" (1989, 9).

9 Adolf Reinach destaca de la fenomenologa su aspecto metdico como la aportacin definitiva husserliana a la historia del pensamiento: la fenomenologa no es un sistema de proposiciones y verdades filosficas -dice- sino un mtodo de filosofar que viene exigido por los problemas de la filosofa (1986, 21, s.n.).

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Y tanto las adicciones como su posterior superacin de las mismas, comparten el simple y primordial estatuto de ser, ante todo, experiencias personales. Hoy por hoy a mi juicio la fenomenologa, con sus desarrollos posteriores y los complementos de otras teoras, se posiciona como el mejor mtodo -no un mtodo ms-, el ms vlido para captar la esencia de fenmenos personales tan complejos como los fenmenos adictivos. Porque adems de poder fundamentar objetivamente los fenmenos adictivos en general y alcanzarlos en teora, el mtodo fenomenolgico tiene una aplicacin prctica inmediata subjetivamente, es decir puede ser aplicado por la persona tanto en fase adictiva como en fase rehumanizadora, porque en definitiva lo que se posibilita mediante la comprensin del fenmeno es un camino vlido para que la persona se vuelva hacia su realidad, mire dentro de s misma, y reflexione sin juicios preconcebidos sobre su vida y su ser personal real, y pueda por ltimo prever su destino futuro. As, la persona entra en contacto directo con su experiencia ntima, con sus vivencias en el aqu y ahora, nica forma de que no se evada de ellas (ni de sus pensamientos, ni sensaciones reales) mediante una especulacin intil. Comprender la realidad partiendo de esta experiencia universal, una experiencia que la pueden hacer todas las personas, eso es algo que se puede erigir en fundamento, es decir, en saber terico y prctico cientficos. Algn ejemplo de categoras rehumanizadoras de la persona que intenta dejar de ser adicta nos ilustra ahora estos comienzos metdicos. La vivencia de la categora de la verdad por parte de un exadicto, por ejemplo, surge del anlisis fenomenolgico de la experiencia tica de una persona que encuentra ante s valores de honestidad (no mentir, respetar a los dems) y estos valores la mueven a la accin prctica para llegar a ser persona veraz y honesta. La categora de la relacin, otro ejemplo, surge de la expe-

riencia de la intersubjetividad o encuentro interpersonal a travs de la palabra o de cualquiera de los lenguajes humanos, o del amor que, como bien subraya Ferdinand Ebner, procede de una relacin que no se establece entre un sujeto y un objeto, sino entre dos seres personales. Estas categoras tericas (verdad, relacin) slo se entienden cuando se viven como experiencias prcticas (de amor, de respeto, de fidelidad a una palabra dada, etc.) a las cuales slo cabe aproximarse concretamente, como descubri Gabriel Marcel tambin por esta poca de entreguerras10. Observemos que se trata de experiencias personales, en plural. Para autores personalistas contemporneos como Maurice Ndoncelle, el punto de partida de toda filosofa sera la experiencia (fenomenolgica) de la conciencia de s misma percibida por la persona en comunin con otras conciencias de otras personas. Segn esto no se puede concebir a la persona como una entidad aislada y luego se le aade la relacin interpersonal, porque esa relacin estaba ya dada desde el principio como fundamento esencial. En La reciprocidad de las conciencias, la obra principal de Ndoncelle, afirma que el yo pienso tiene antes que nada un carcter recproco y que la comunin de las conciencias es el hecho primitivo (1942, 310), de modo que la persona tomara conciencia de s misma precisamente teniendo presente la existencia de otras conciencias, es decir, que se encuentra desde el inicio en relacin con los dems. Todo esto indica que la idea de ser persona surge esencialmente no deducida de una teora o teoras, sino de la experiencia radical de verse a s misma como un ser al que se le puede calificar de personal.

10 Puede verse su importante obra metodolgica del ao 1933 Position et approches concrtes du Mystre Ontologique (Aproximacin al misterio del ser. Encuentro, Madrid, 1987, trad. J.L. Caas).

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En efecto, desde que el ser humano piensa por vez primera en s mismo, tiene conciencia de ser-yomismo, es decir desde que tiene memoria de la primera vez en su existencia en que se capta como ser nico existente, en torno a los tres aos de vida, su idea de ser persona le surge del anlisis fenomenolgico de una experiencia personal radical. Entonces, el ser humano encuentra en s, no frente a s, la razn esencial de su ser-en-el-mundo mediante la experiencia de unicidad, esto es ser persona, experiencia de s unvoca y fundamental que ya no le abandonar jams a lo largo de su existencia. Esta experiencia radical, pues, se convierte en punto de partida de la filosofa, esto es, de la reflexin fundamental y universal que lleva a cabo cada persona sobre los hechos de experiencia, por ejemplo de los hechos adictivos, hechos que encuentra sin dificultad dentro de s misma mediante la toma de conciencia de s, de los dems y del mundo que le rodea. De todo ello podemos concluir que a la realidad del ser personal se accede no tanto desde un pensamiento subjetivista que se encierra en s mismo, ni desde un planteamiento objetivista-cientificista incomprometido, pues la persona no es un objeto y slo se definen los objetos exteriores al hombre y que se pueden poner ante la mirada", como bien escribi Emmanuel Mounier (1962, 6), sino desde la experiencia del misterio de ser persona , como reducto ltimo de su ser. Por consiguiente, la fundamentacin del fenmeno adictivo encuentra un suelo firme de partida en la tematizacin de la primera vez que la persona adicta se experimenta a s misma como persona, y a partir de entonces conoce que ese yo, que permanece esencialmente invariable y que la permite establecer y fundar la identidad y continuidad de su ser persona, es el sello de la unidad y la singularidad que la acompaa siempre, no de forma esttica antes bien en continua evolucin cre-

adora, como seala Bergson, hacia la perfeccin y a lo largo de su existencia. As, pues, mediante la aplicacin de esta metodologa fenomenolgica ponemos a las personas adictas ante su experiencia radical de ser-persona-adicta y ante la reconsideracin de su posicionamiento en el mundo y su autodestructivo modo de acceso a la realidad, as como su posible rehumanizacin posterior o ser-persona-rehumanizada. Para ello he seguido de cerca el desarrollo del mtodo fenomenolgico llevado a cabo por el filsofo personalista A. Lpez Quints a travs de los que denomina tringulos hermenuticos, una metodologa de comprensin de las experiencias personales mediante el anlisis de la interaccin de las categoras de inmediatez (vrtice a), distancia (vrtice b) y presencia (vrtice c) plasmadas en forma de distintos tringulos11. Pueden parecer al principio conceptos difciles de captar, pero siguiendo con atencin su despliegue vemos cmo efectivamente sirven para explicar los fundamentos de las experiencias personales de todo tipo, es decir tanto de las conductas adictivas como de las de rehumanizacin. En efecto, esta metodologa triangular intenta mostrar que la realidad es dinmica y flexible y que para cada fenmeno o experiencia personal existe una presencialidad bien de tipo cerrada o bien de tipo abierta, y cmo los diversos tipos de experiencias que la persona tiene o puede tener han de ser matizados convenientemente segn su modo peculiar de ser. As, combinando los diversos modos de inmediatez y

11 Hay tres categoras decisivas en todo anlisis filosfico relativo al proceso humano de conocimiento: inmediatez, distancia y presencia [] De la interaccin mutua de cada forma de inmediatez con cada forma de distancia surge un modo especfico de presencialidad (Lpez Quints, 1971, 59-60, s.n.). Mediante los tringulos que podemos llamar cerrados (pp. 7786) matizamos las distintas experiencias que subyacen en la vida de las personas adictas , mientras que los tringulos abiertos (pp. 87-109) nos permiten comprender las experiencias bsicas de las personas en vas de rehumanizacin.

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distancia a que puede situarse la persona adicta o la persona rehumanizada respecto a su mundo, se explican los diversos modos de experiencia o presencialidad cerrada o abierta. Hemos de tener siempre muy presente que la realidad personal est repleta de hondura y flexibilidad en su estructura, y como tal es necesario estudiar estas categoras y verlas en interaccin dinmica. Se necesita entonces hacer orfebrescos anlisis metodolgicos de estas experiencias adictivas cerradas y, sus contrarias o experiencias abiertas rehumanizadoras. Ello nos va a permitir distinguir y matizar las relaciones bsicas que se dan de modo superficial sensible o, por el contrario, de modo profundo o suprasensible, tanto con las cosas como con las personas. Por ejemplo, en las experiencias adictivas la persona se relaciona de modo superficial inmediato (vrtice a) fusionado con su objeto adictivo, mientras que en las experiencias rehumanizadoras se relaciona de modo profundo a la distancia (vrtice b) ajustada con su realidad personal. La inmediatez, primera de las tres categoras de los tringulos hermenuticos, ayuda sobremanera para comprender las experiencias llevadas a cabo por las personas adictas. La inmediatez de fusin es el modo de unin ms intenso de dos realidades pero el menos perfecto: justamente lo que le pasa al adicto con su adiccin, que ambos se funden adiccin y adicto como dos trozos de cera y entonces la persona termina confundindose con una cosa. De forma indirecta captamos que esa inmediatez fusional entre dos realidades tan distintas degrada a la persona de nivel, la cosifica. Es decir, que la persona adicta se queda reducida a su vertiente cosificable. La experiencia del encuentro personal que acontece en la rehumanizacin, por el contrario, responde a la presencia ganada merced a la distancia personal oportuna, es decir que potencia a la vez a los seres personales y no los disuelve fusionalmente en una

nueva suma cuantitativa. Segn la filosofa existencial, y las filosofas personalista y dialgica, hacer la experiencia del encuentro interpersonal implica en esencia un compromiso (engagement), como hace la persona en vas de rehumanizacin que experimenta que su realidad personal est constituida ms bien por mbitos que se interrelacionan con otros seres personales, por ejemplo en una CT, que por cosas que se manipulan, por ejemplo en el mundo adictivo. Lgicamente concluimos que no se pueden dar autnticas experiencias de encuentro entre las cosas o los meros objetos. Lo meramente objetivo permanece exterior a la persona y en este sentido no puede haber creatividad. Lo mismo sucede cuando la atraccin interpersonal es muy fuerte: la forma de unidad entonces es la de fusin y, por tanto, de la indebida distancia de respeto. Ello, llevado al extremo anulara la autonoma propia de los seres personales y, al contrario, vistos los seres [personales] ms como mbitos que como meras cosas, puede afirmarse que el Infinito se patentiza en el espritu humano y que ste queda sobre-cogido por l y elevado a un nivel de plenitud (Lpez Quints, 1971, 270). Lo cual nos lleva a concluir, entre otras perspectivas, que el descubrimiento colosal de la estructura esencial de la persona se debe a su posibilidad de poder hacer la experiencia singular y nica de la trascendencia. Previo al anlisis de las experiencias concretas del seradictivo o del ser-rehumanizado, interesa analizar las experiencias constitutivas de la estructura del ser humano en general, y por tanto describir los fundamentos antropolgicos esenciales como la libertad y la responsabilidad, la verdad y la mentira, o como el lenguaje y la incomunicacin, experiencias propias de los fenmenos del encuentro personal relacionadas con el rico mundo de los sentimientos como el amor o la esperanza. Todas ellas, en fin, experiencias clave para comprender todo tipo de relacin persona-objeto, o

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como se relaciona por ejemplo la persona adicta con su droga, y persona-persona, o como se relacionan por ejemplo las personas en vas de rehumanizacin con los dems compaeros de una CT, etc. Estas y otras conclusiones metodolgicas propias del campo de las ciencias humanas o ciencias del espritu, seran complementarias a las aportadas por la investigacin bsica de la ciencia emprica o ciencias de la naturaleza, segn la clsica distincin diltheyana. Pero no siempre se hace ni se ha hecho este esfuerzo integrador, antes bien hoy da asistimos a muchos desenfoques cientficos por culpa de esta radical escisin metodolgica. A mi juicio, para avanzar de verdad en la teora y en la teraputica de las adicciones es necesaria la integracin de ambos paradigmas, y ello slo lo consiguen el cientfico y el humanista de talante abierto que saben apoyarse en el contraste y no en la contradiccin de sus respectivas metodologas, entre otras razones porque son conscientes de sus propios lmites. A modo de ejemplo nos puede servir ahora la siguiente investigacin neurobiolgica sobre una determinada conducta adictiva: A partir de la existencia de un sistema cerebral propio donde interaccionan los principios activos de la marihuana, y en especial el Tetrahidrocannabinol (THC) los neurobilogos han identificado piezas que participan en la adiccin a cannabinoides y opioides, con dos visiones del mismo fenmeno: si varias adicciones confluyen en unos puntos comunes del sistema cannabinoide se produce la vulnerabilidad adictiva, es decir el consumo de una droga altera las piezas que son utilizadas por el mecanismo de otra droga. Esos puntos de confluencia pueden representar dianas farmacolgicas mediante las cuales disear estrategias paliativas y teraputicas (Navarro y Rodrguez, 1999, 28-29, s.n.). Hasta aqu este tipo de discurso cientfico. Podemos comprobar con facilidad cmo este modelo, en este

caso aplicado al campo de la neurobiologa, no sale del estrecho reducto del lenguaje mecanicista: piezas, sistema, mecanismo, dianas Lo interesante es comprobar cmo partiendo de este paradigma tan mecanicista los mismos cientficos concluyen que las sustancias actan en el cerebro a travs de los mismos sustratos bioqumicos, y aunque todas las drogas de abuso tienen sus particularidades, el mecanismo por el cual modifican el llamado sistema de recompensa es la base neurobiolgica comn del fenmeno adictivo. Subrayemos el concepto de fenmeno adictivo del prrafo anterior, porque parece que este cientfico tiene necesidad de dar el salto a la universalidad de un fenmeno que es mucho ms complejo que lo meramente neurobiolgico, segn hemos apuntado mediante el mtodo fenomenolgico. Pero inicialmente su objetivo es slo comprender los mecanismos celulares y moleculares implicados entre los estados que provoca el consumo de una droga, as como de los estados transitorios a los que dan lugar entre ellos mismos. Ante este modelo explicativo es evidente la ventaja del modelo antropolgico personalista porque aporta la visin total o global de la persona, no slo de una parte, por muy fundamental que sea, como en este caso la bioqumica o la somtica. De modo que el cientfico-humanista (con guin), apoyndose en esos mismos datos que le suministra la neurobiologa, no tardar en concluir que el fenmeno adictivo no es cambiante, como pudiera parecer por ejemplo si se piensa que los cannabioides ya desplazaron a los opioides, y que la tendencia es que las anfetaminas y las drogas sintticas desplacen a la cocana y el cnnabis. Pero esto son variables sociales aleatorias, es decir igual que vienen se van para despus volver, etc. En realidad lo que cambian son las sustancias, no la experiencia adictiva de las personas, y esto es lo relevante para el cientfico humanista tal y como le

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muestra el mtodo fenomenolgico. Lo relevante, en suma, para poder hacer una fundamentacin aquilatada del fenmeno de las adicciones. Desde un modelo antropolgico personalista, en fin, llegamos a la certeza de que se puede salir del mundo adictivo para volver a encontrar el camino de la confianza en la vida. Eso es, en esencia, la rehumanizacin. Abordar la rehumanizacin de la persona adicta desde el esfuerzo de conocerla y comprender su mundo interior es llevarla al descubrimiento o al redescubrimiento de su propia dignidad, mediante una confiada reactivacin de los mecanismos de la voluntad orientada hacia ideales seguros y nobles (Pontificio Consejo, 2002, 32). La novedad de una antropologa rehumanizadora consiste en ver que la persona es un ser que busca perennemente el significado de la propia vida en la autotrascendencia. Todo esto encierra el emergente paradigma de la rehumanizacin. Un paradigma, en fin, que tiene la doble garanta de recibir la herencia de la filosofa desde la antigedad, por un lado, y de la ciencia ms actual, por otro. Quiz el modelo que ms le convendra es el paradigma hologrfico, en la propuesta integradora de filosofa y ciencia (psicologa y religin) que vienen haciendo desde hace dos dcadas autores como Ken Wilber, David Bohm, Fritjof Capra, Marilyn Ferguson, Rene Weber, Karl H. Pribram, etc. Mi punto de vista es ste: se est o no de acuerdo con el (los) nuevo(s) paradigma(s), hay una conclusin clara: como mucho, la nueva ciencia requiere espritu; como poco, deja un amplio espacio para el espritu. En cualquier caso, la ciencia moderna ya no niega el espritu. Y eso es lo que hace poca (Wilber, 1987, 11). Espritu y ciencia, a la vez, se anan esplndidamente en la actualidad en el paradigma de la rehumanizacin. No olvidemos que las adicciones tienen un gran poder esclavizante del corazn y de los sentimientos humanos, y que, en definitiva, no pueden dar la felici-

dad. Esta sera, a mi juicio, la gran aportacin al futuro de la humanidad: que una parte importante de la felicidad personal puede venir a la sociedad actual indirectamente a travs del mundo de la rehumanizacin de las adicciones. REFERENCIAS BURGOS, J.M. (2003) Antropologa: una gua para la existencia. Palabra, Madrid. CAMUS, A. (1957): Teatro. Calgula (4 ed.). Losada, Buenos Aires. (Caligula, 1945). CAAS, J.L. (1996) De las drogas a la esperanza. Una filosofa de la rehumanizacin. Ed. San Pablo, Madrid. CAAS, J.L. (1996a) El hombre adicto: una hermenutica del sentido existencial. En Cuadernos de Pensamiento 10 (1996), 193-209. CAAS, J.L. (1997) Educar para rehumanizar. En Boletn del Colegio Oficial de Doctores y Licenciados, 82, 33-35. CAAS, J.L. (2002) Antropologa de las adicciones. En Revista Proyecto, 41 (Dossier n 41, 27-38). CAAS, J.L. (2003) Soren Kierkegaard. Entre la inmediatez y la relacin. Trotta, Madrid. DE LEON, G. (2000) The Therapeutic Community: Theory, Model, and Method. Springer Publishing C o m p a n y, N e w Yo r k . ( Tr a d . L a C o m u n i d a d Teraputica, Descle de Brouwer, Bilbao, 2004). FIZZOTTI, E. (1977) De Freud a Frankl. Interrogantes sobre el vaco existencial. FRANKL, V. (1979) El hombre en busca de sentido. Herder, Barcelona. ( Ein Psychologe erlebt das Konzentrationslager, 1946). FRANKL, V. (1992) Teora y terapia de las neurosis: iniciacin a la logoterapia y al anlisis existencial. Herder, Barcelona. ( Theorie und Therapie der N e u ro s e n : E i n f h r u n g i n L o g o t h e r a p i e u n d Existenzanalyse, 1956).

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HILLMAN, J. (2000) El mito del anlisis . Siruela, Madrid. ( The Myth of Analysis, Three Essays in Archetypal Psychology, 1992). HUSSERL, E. (1991) La crisis de las ciencias europeas y la fenomenologa trascendental . Crtica, Barcelona. (Die Krisis der europeischen Wissenschaften und die transzendentale Phenomenologie, 1954). JASPERS, K. (1955) Schelling, Grsse und Verhngnis. Piper Verlag, Mnchen. JASPERS, K. (1994) Origen y meta de la historia . Altaya, Barcelona. ( Vom Ursprung und Ziel der Geschichte, 1949). KAFKA, F. (1977) La Metamorfosis (Versin de A. Reyes). Prisma, Mxico D.F. ( Die Verwandlung , 1915). KIERKEGAARD, S. (1969) La Enfermedad Mortal o de la desesperacin y el pecado (Trad. D. G. Rivero). Guadarrama, Madrid. ( Sygdommen til dden, 1848). LPEZ QUINTS, A. (1971) Metodologa de lo suprasensible II. El tringulo hermenutico . Editora Nacional, Madrid. LPEZ QUINTS, A. (1981) La juventud actual entre el vrtigo y el xtasis, Narcea, Madrid. (2 ed. ampliada en Ed. Public. Claretianas, Madrid, 1993). MARCEL, G. (1987) Aproximacin al misterio del ser (Trad. J.L. Caas). Encuentro, Madrid. (Position et approches concrtes du Mystre Ontologique , 1933). MOUNIER, E. (1962) El personalismo (Trad. A. Aisenson & B. Dorriots). Ed. EUDEBA, Buenos Aires. (Le personnalisme, 1949). NAVARRO, M. y RODRIGUEZ, F. (1999) Estudio de la adiccin. El cnnabis como droga de abuso. En Revista Proyecto, 29, 27-38. NEDONCELLE, M. (1977) La reciprocidad de las conciencias: ensayo sobre la naturaleza de la persona

(Trad. de J.L.Vazquez y U. Ferrer). Caparrs, Madrid. (La rciprocit des conciences, 1942). PICCHI, M. (1998) Un proyecto para el hombre. PPC, Madrid. (Un progetto per luomo, 1994). PONTIFICIO CONSEJO PARA LA PASTORAL DE LA SALUD (2002) Iglesia, droga y toxicomana . Ed. EDICE, Madrid. (Citt del Vaticano, 2001). REINACH, A. Von (1986) Introduccin a la fenomenologa. Encuentro, Madrid. ROJAS MARCOS, L. (2000) La sociedad y el fenmeno de las dependencias. En Revista Proyecto, 34, 27-38. SPAEMANN, R. (1989) Glck und Wohlwollen. Versuch ber Ethik. Klett-Cotta, Stuttgart. STEINER, G. (2001) Nostalgia del Absoluto. Siruela, Madrid. (Nostalgia for the Absolute, 1974). WILBER, K. (1987) El paradigma hologrfico: una exploracin en las fronteras de la ciencia (Trad. D. Gonzlez). Kairs, Barcelona. (The holographic paradigm, 1982).

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EL ESPRITU DE LA COMUNIDAD TERAPUTICA. TRASCENDENCIA Y ESPIRITUALIDAD EN EL SENDERO DE LA HUMANIZACIN

THE SPIRIT OF THE THERAPEUTIC COMMUNITY. TRANSCENDENCE AND SPIRITUALITY ON THE PATH TO HUMANISATION

Carvajal Posada, Jorge Ivn Hogares Claret, Colombia.

La comunidad teraputica es una escuela de vida, un espacio de humanizacin. La droga es seal de una crisis cuya leccin permite reconocer la va que va desde la dependencia hasta la autonoma, la autoaceptacin, la autogestin y la libertad. La dependencia puede ser considerada como un dficit de humanizacin. La espiritualidad est relacionada con la formacin del carcter. Y para que este sea instrumento del espritu habr que trabajar el control, compromiso y autogestin. Se concibe la espiritualidad en el tejido de relaciones. En primer lugar, las relaciones que uno mantiene consigo mismo, cuyos componentes clave sern la transparencia, levedad, consagracin, capacidad de distinguir la cualidad de las apariencias y una decidida devocin. En segundo lugar, las relaciones con los otros que llevan a involucrar la totalidad del ser en cada interaccin.

The therapeutic community is a life school, a space for humanisation. Drugs are the sign of a crisis, and the lesson it provides enables us to recognise the route that leads from dependency to autonomy, selfacceptance, self-management and freedom. Dependency may be considered as a deficit in humanisation. Spirituality is related to the formation of the character. And to enable the character to become an instrument of the spirit, we have to work on control, commitment and self-management. Spirituality is conceived in the tissue of relationships. Firstly, the relationships one has with oneself, the key components of which will be transparency, lightness, dedication, capacity to distinguish the quality of appearances and determined devotion. Secondly, the relationships with others, which lead us to involve our whole being in each interaction.

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Urdimos la vida sobre una trama de relaciones, en la que vnculos y reciprocidades conforman los elementos claves de un tejido de soporte, en el que tenemos nuestra vida, nuestro movimiento y nuestro ser. La esencia de la comunidad teraputica es ese algo intangible que se infiltra como agua en el campo de las relaciones humanas, para llenar silencios, interacciones y palabras de un poder teraputico que no posee ningn medicamento. Esa inmersin total en un espacio de comprensin amorosa, permite reconstruir el tejido de la humanidad en cada quien. A esa reconstruccin la llamamos proceso de humanizacin, cuya esencial esencia es espiritual: Es la esencia de la auto-ayuda y de la ayuda mutua, una espiritualidad cotidiana que se teje en la relacin del residente consigo mismo y con los otros, que reconstruye vnculos y despierta reciprocidades para descubrir el territorio sagrado del nosotros. En esa dinmica de humanizacin, la transparencia, la humildad, la honestidad, la alegra, el perdn, la reconciliacin, la tolerancia y la paz se revelan en cada residente como facetas del diamante del Ser. Ser de nuevo humanos, pertenecer a la humanidad, asumir la responsabilidad de la propia libertad y, en el liberarse de toda dependencia, descubrir el mayor don, aquel de dar que libera en el hombre una infinita capacidad de amar. Es la comunidad teraputica una escuela de vida, en la que se nace cada da al compartir; es un espacio de humanizacin, en el que se recrea el embrin de una nueva cultura de relaciones humanas, de la que surge la experiencia existencial de la hermandad. LA COMUNIDAD TERAPUTICA: UNA VISIN HUMANA DE LA ESPIRITUALIDAD La espiritualidad no es religiosidad, ni tiene que ver slo con algn tipo de confesin religiosa. A escala humana, espiritualidad es aquello que humaniza la

poltica, la educacin, la economa, el arte, la teraputica, todos esos campos relacionales que cualifican nuestra vida. La espiritualidad es la esencia misma del vivir humano. En la comunidad teraputica, esta espiritualidad asume la dimensin de puertas abiertas para entrar o salir; se expresa asumiendo el riesgo de la libertad; se va hollando en el sendero de la responsabilidad; se convierte en inclusividad que elimina todo tipo de discriminacin racial, poltica o religiosa; en fin, a nivel de la comunidad teraputica, la espiritualidad se traduce en un proyecto de humanizacin, generador de esa milagrosa participatividad que involucra individuos, familias y sociedades vctimas de la dependencia, en una refrescante corriente de libertad con responsabilidad. La espiritualidad es aquello que llena de vida el comportamiento y da sentido a la rutina del cotidiano vivir. Aunque la espiritualidad ha sido mirada en general como si slo fuera un captulo de la religin, es en realidad el ms importante de los constituyentes de la vida humana. Est inmersa en la economa, en el arte de vivir la vida, en la fe, en la confianza, en la responsabilidad y la alegra. La espiritualidad es el comn denominador de todo aquello que da sentido a la vida y podramos decir que la espiritualidad es el sentido mismo de la vida humana. No han alcanzado su humanidad los hombres y las mujeres que no ejercen su propia humanidad desde su esencia espiritual. Vivir espiritualmente es posible cuando se comprende que aun las cosas ms sencillas y elementales estn constituidas de la materia prima invisible del espritu; cuando comprendemos que todo, materia, energa e informacin son distintas vibraciones del espritu; cuando en la profundidad de la crisis se revela el potencial constructivo y regenerador del alma. Lo trascendente es inmanente al espritu y el espritu es inmanente al hombre. El hombre es trascendente porque es espiritual, y tal descubrimiento podra poner fin

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a ese nihilismo suicida en el que negamos hasta el presente, porque hemos perdido la visin de futuro. Al mismo tiempo, al vivir espiritualmente o ms humanamente- deshipotecamos la vida anclada a un futuro sin presente: ya la salvacin no es slo en otra vida y se es salvado en cuanto se descubre la ms ntima realidad en la unin con Dios adentro. En uno mismo. Ms all del poder, del placer o los sentidos fsicos, la vida humana tiene un sentido espiritual en el constante ejercicio de aprender, para ascender en el proceso de humanizacin. Este proceso es, en s mismo, una poderosa corriente espiritual que, en la hermandad, nos aproxima a la unidad. (Y esta interdependencia de la hermandad en la unidad es la condicin de una libertad responsable, caracterstica de la ms excelsa de las libertades).1 PREMISAS PARA VIVIR ESPIRITUALMENTE 1- Vivir espiritualmente es a la vez un derecho y un atributo esencial de la humanidad del ser humano. (Teniendo aqu en cuenta que los humanos tienen atributos previos al desarrollo de la humanidad como un componente estrucutural o mineral, vegetativo o animal e instintivo o animal). 2- La espiritualidad se despliega en el marco de las relaciones consigo mismo y con los dems. Estas relaciones constituyen la trama de la vida, que est tejida sobre una urdimbre de naturaleza espiritual. 3- Este tejido de relaciones est hecho de vnculos y reciprocidades, los cuales constituyen las fuerzas de tensin y de compresin que dan a la vez solidez y adaptabilidad al campo existencial.

4- El vnculo trascendental del hombre es su propia alma. A travs del alma se proyectan relaciones humanas fundadas en la hermandad, en las que todos los seres humanos son clulas del cuerpo de la humanidad. 5- Espiritualizar la vida es humanizarla (En una connotacin cristiana el mismo Dios se humaniza para redimirnos). 6- La cada y el dolor forman parte del proceso de humanizacin. Ambos permiten revelar el amor, proyectado en la relacin como comprensin. (Y sta es amor con claridad o discernimiento, un amor que nos hace sensibles a la necesidad del otro. Un amor que nos convierte en Hijos de la necesidad). En el marco de estas premisas, la droga, ms que una enfermedad en s, es un sealador de una crisis, cuya leccin permite reconocer la va que va desde la dependencia hasta la autonoma, la auto-aceptacin, la autogestin y la libertad. Y todos estos son peldaos en el camino hacia la propia humanidad. En sntesis, trascender es humanizarse y la humanizacin es la experiencia existencial de la espiritualidad. En tal sentido la dependencia es dficit de humanizacin. Y el ejercicio responsable de la libertad libre albedro es la mayor evidencia espiritual de nuestra humanizacin. Las comunidades teraputicas son surcos donde germina en la paz de la hermandad la semilla de una nueva humanidad. Son campos de una nueva conciencia, en la que el florecer de nuestra humanidad es amor incondicional, y su fruto maduro es libertad con responsabilidad. LA ESPIRITUALIDAD Y LA FORMACIN DEL CARCTER

1 Es esta una unidad que no homogeniza, que reivindica la individualidad y las diferencias; una unidad que de todos modos conserva los dones preciosos de unicidad e interdependencia. Y stos son requisitos de la autntica libertad: aqulla en la que podemos vivir la paradoja de unirnos desatndonos, para hacernos interdependientes. Libres.

La conquista de esa libertad personal, que excluye automticamente toda forma de dependencia, pasa por el reconocimiento de la bsqueda de un equilibrio relacional que contribuye a la formacin del carcter.

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Tal vez no haya nada ms espiritual para nuestra actual humanidad que el desarrollo de todo aquello que pueda contribuir a la formacin de un buen carcter, es decir un carcter que sea tan firme como tolerante, tan slido como flexible, tan auto-afirmativo como humilde, tan disciplinado como armonioso. Si pudiramos vislumbrar el carcter como un diamante que puede tanto dejar pasar como reflejar la luz del espritu, aceptaramos que el error, la cada o el fracaso, pueden convertirse en preciosos instrumentos para pulir nuestras aristas y revelar la preciosa esencia, escondida bajo la apariencia de la oscura piedra de nuestra personalidad. En el seno de la comunidad teraputica es esa esencia humana que permite catalizar la reaccin hacia la liberacin del fuego interior del amor, lo que permite derretir el hielo de la insensibilidad y la indiferencia y eliminar las barreras de complejos y temores, para subir a nacer a la esencia humana de la hermandad, esa evidencia existencial de la espiritualidad del hombre. Humanizar la vida es avanzar existencialmente, por el sendero de la hermandad, hacia la afirmacin del amor, un fuego transmutador que ha eliminado el no ser, para nacer al ser que vive en nuestro interior. Al construir un buen carcter permitimos la expresin del alma en el ser humano. Y en el alma todos somos hermanos, porque somos hijos del mismo padre: El Espritu. La propuesta para la construccin de un carcter, que sea instrumento del espritu en nosotros, supone la capacidad de control, compromiso y autogestin , que estn en relacin con la capacidad de aceptar la vulnerabilidad y la incertidumbre cuando aprendemos las lecciones del pasado. El CONTROL nos lleva a la dinmica interior de la paz y la serenidad que no se pierden frente a las turbulencias externas. Es la genuina paz del corazn que lleva al

auto-control. Este se afirma en una constante capacidad de aprendizaje, lo cual no es posible sin una buena dosis de humildad. EL COMPROMISO se expresa en la intensa vivencia de un presente que llena la vida de pasin, o de ardiente aspiracin. Supone la consagracin a una causa que involucra, sin clculos ni separaciones, todo nuestro ser. Es bien importante en el caso de la drogodependencia, puesto que buena parte de las drogas desencadenan artificialmente y con todos los efectos destructivos a la vez la excitacin que no se ha podido conseguir en la vida. Si no es apasionante, la vida no merece la pena ser vivida. LA AUTOGESTIN es la tercera condicin de un buen carcter y se refiere a la capacidad de auto-recrearse. Retenemos la palabra recrearse que hace alusin al tiempo libre y creativo tiempo de la libertad un tiempo interior que nos humaniza, al conducirnos a la libertad de ser nosotros, con todos los otros, un TODO humano, en el seno del cual el hilo de nuestro tejido existencial se llena de sentido. Veamos ahora, en el marco de la construccin de un buen carcter a travs del autocontrol, el compromiso o consagracin y la autogestin creativa, la adaptacin de una antigua propuesta, que constituye un mnimo comn denominador para asumir en nuestras relaciones con nosotros y los otros, para llevar una vida espiritual. Esta propuesta trasciende aqu en su alcance el marco de las comunidades teraputicas, si bien en ellas encuentra la plenitud de su vigencia. LA ESPIRITUALIDAD EN EL TEJIDO DE LAS RELACIONES Uno se relaciona con uno y con los otros. Sin el uno no hay dos. Sin el yo no existen ni el t ni el nosotros. Un viejo aforismo o mandato dice: .Y al prjimo como a ti mismo. Ese t mismo se construye de relaciones interiores, a travs de las cuales se elabora una

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imagen de s. Esta es la primera desestructuracin en la personalidad adicta: la de la propia imagen. Y el primer objetivo teraputico es en consecuencia reconstruir la imagen de s2. Las relaciones consigo mismo. Sus componentes claves son: 1- Transparencia, sinnimo de trans-apariencia. Ser el ser que se es sin complejos de inferioridad ni de superioridad. Se refiere al justo sentido de las proporciones y supone, en principio, la conquista de la propia identidad esencial, ms all de toda mscara o apariencia. Supone en la vida la desidentificacin de formas ajenas y externas al ser, y el reconocimiento de sus cualidades internas. Es una forma de economa de la vida que impide el desgaste innecesario producido por la desalineacin y la friccin que llevan a la incoherencia. En la transparencia surge una coherencia que permite enfilar todos los aspectos de la vida en la misma corriente del ser esencial que cada quien es. 2- Levedad, sinnimo de alegra. Se refiere a la elasticidad, adaptabilidad, fluidez y tolerancia de una personalidad que sabe reconocer en su vulnerabilidad, ms que una carencia, una fortaleza real. La levedad viene de la permanente disposicin a la aceptacin de la incertidumbre y de las crisis existenciales, como maestros (que slo son reconocidos desde la actitud humilde leve del aprendiz). Levedad se refiere a abandonar el lastre de lo no esencial para emprender en alas de lo esencial el vuelo de la propia vida. Levedad es alegra, es gracia, es gratuidad, es aquello que en nosotros est siempre presto para

darse; es lo que hace de la vida un don, un presente, un regalo a travs del cual damos y recibimos la Presencia. En la levedad se experimenta la presencia de la paz como un don interior que permite fluir sin resistencia y aceptar lo que somos, con nuestras sombras y dudas, para revelar en nuestro propio centro la levedad de la luz interior. All tenemos un permanente punto de referencia, a partir del cual podemos emprender cada da de nuevo el sendero de la vida. La levedad es aquello que en nosotros siempre se renueva porque no se apega ni se congela en el pasado. Cuando de veras podemos disfrutar la vida es porque vamos ligeros de equipaje. 3- Consagracin. Obsesin y compulsin se convierten en disciplina y dedicacin, guiados por una ferviente vocacin que da sentido y direccin a la vida. La vida tiene sentido en la consagracin, pues una direccin y un propsito iluminan su camino. La consagracin transmuta adiccin y dependencia en participacin libre y responsable en un proyecto de vida, que trasciende la individualidad del pequeo ego, para descubrir el propsito del verdadero Ego o Yo: El alma. Cuando se puede salir de la prisin de la rutina, a travs de la dedicacin libre y consciente a un proyecto de vida, nuestro campo de relaciones se vuelve sagrado como el ms sagrado de los templos. Entonces el lugar del hogar, el lugar del trabajo, todos los lugares de nuestras relaciones humanas se convierten en lugares sagrados, pues en ellos oficiamos con devocin el ritual que nos consagra como discpulos de esa sabidura que mora al interior de cada ser humano. 4- La capacidad de distinguir la cualidad de las apariencias. Supone la capacidad de distinguir el placer

2Esta imagen de s es la clave del auto-reconocerse y auto-recrearse. Tiene relacin con procesos tan aparentemente distantes como la calidad del sistema inmunolgico y la madurez o inmadurez del afrontamiento la manera positiva o negativa en que nos proyectamos al mundo, que a su vez es un precioso indicador del riesgo de morir o enfermar.

de la felicidad, los sentidos del sentido, la realidad de la apariencia. Se adquiere la capacidad de ver ms all del mundo del consumismo y de la ilusin, la capacidad de vencer el espejismo de un pequeo yo

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egosta y separado del universo de relaciones humanas que puede liberarnos. 5- Una decidida devocin por esa sabidura interior que utiliza el instrumento de nuestros pensamientos, sentimientos y comportamientos. Es devocin al alma, la expresin de Dios en cada uno. Las relaciones con los otros Consecuencia de las relaciones con nosotros, las relaciones con los otros constituyen un espejo para reconocernos, y un colchn de seguridad afectiva que amortigua las cadas. Estas relaciones, que pueden darse en mltiples niveles, tienen especialmente una connotacin emocional, que nos lleva a involucrar la totalidad del ser en cada interaccin. 1- Inofensividad. Es el primum non nocere tan caro a la medicina. Es total inocuidad, incapacidad de ofender o de daar tanto por accin como por omisin. Es producto del haberse perdonado y es sinnimo de una paz interior en cuya presencia todas nuestras acciones se llenan de sentido. 2- Verdad. Es la total transparencia en la relacin con otros. 3- Utilizar el poder como un instrumento de la vida y no convertir a la vida que es sagrada en un instrumento del poder. 4- No permitir que nadie se vaya de nosotros peor de lo que lleg. Supone amor exigente, confrontacin comprensiva, capacidad de escucha y acompaamiento exento de juicios y prejuicios. 5- Darle a la vida ritmo y colorido, encontrando tiempos y lugares apropiados para llenarla de sentido con nuestra accin. Vigente en el aforismo Cada cosa tiene su tiempo bajo el sol, un vivir rtmico lleva a la armona de la continencia, en la que dosificamos sabiamente nuestras acciones. As, sin sequas ni inundaciones en nuestro territorio, podemos mantener la fluidez de la reciprocidad y sostener vnculos slidos y flexibles que nos permitan adaptarnos a los retos de

la vida. Todos los procesos en nuestro cuerpo estn sujetos a cantidades y cualidades, que parecen dosificar la corriente misma de la vida. Tambin en la dimensin psquica, el ser humano encuentra en el vivir rtmico una oportunidad de dar y recibir en las proporciones correctas para conservar la armona.

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LOS RIESGOS DE LA REDUCCIN DE DAOS

THE RISK OF HARM REDUCTION

Castao Prez, Guillermo Alonso Magster en Drogodependencias. Coordinador Nacional Postgrado en Farmacodependencia Fundacin Universitaria Luis Amig

Los programas de reduccinn de riesgos y de daos estn plenamente asentados e impulsados en la actualidad. Considerados como parte integral y complementaria de las polticas que buscan reducir y controlar la demanda de sustancias psicoactivas, es necesario conocer los riesgos que pueden surgir al desarrollar y proponer propuestas de disminucin de dao. A lo largo de esta intervencin y para evitar que ocurran muchos de esos riesgos se exponen diversas consideraciones y recomendaciones que se debern tener en cuenta. Unas van dirigidas al enfoque como una etapa intermedia, de modo que posibilite mayor adherencia a los dispositivos asistenciales mientras decide el cambio; dirigida a un perfil preciso de usuarios. Los fundamentos sobre los se debe construir la prctica sern el pragmatismo, la tica profesional, el humanismo y el principio de salud pblica. Controles jurdicos y administrativos. En cuanto a los programas que incluyen tratamientos de sustitucin debern ejercerse con control, seleccin objetiva de sus posibles beneficiarios, con asistencia mdica, psicolgica y social. Seguimiento global. Los programas de reduccin de dao cuando estn enmarcados dentro de acciones que definen muy bien los perfiles de la poblacin de usuarios, tomados como parte de un proceso intermedio e integrados a los dems servicios de atencin, aportan una alternativa eficaz y no antagnica sino complementaria a los programas de rehabilitacin donde la abstinencia total sea la meta y todo ello a pesar de los riesgos expuestos.

Harm reduction programmes are currently fully established and receive a great deal of impetus. Considered an integral and complementary part of policies that seek to reduce and control the demand for psychoactive substances, it is necessary to be aware of the risks that may arise from the development and proposal of harm reduction proposals. Diverse considerations and recommendations which must be taken into account are put forward during this speech, with the aim of avoiding avoid many of the risks. Some are aimed at the focus as an intermediate stage, to make adherence to the care devices possible whilst the route is being decided; directed towards a precise user profile. The base on which the practice must be constructed is pragmatism, professional ethics, humanism and the principle of public health. Judicial and administrative controls. As regards programmes including substitution treatments, these must be used in a controlled fashion, through objective selection of the potential beneficiaries, with medical, psychological and social care. Global monitoring. When harm reduction programmes are taken as part of an intermediate process, integrated into the other care services and within a framework of actions that defines the user population profile well, they provide an efficient alternative which is not antagonistic but rather complementary to rehabilitation programmes whose aim is total abstinence, in spite of the risks exposed.

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Al igual que las mejores y ms probadas tcnicas y medicamentos para atender los males del hombre tienen sus riesgos e incluso provocan reacciones adversas no deseables, los programas y estrategias de Disminucin de Riesgos y de daos no estn exentas de ello. Los nuevos paradigmas propuestos para comprender e intervenir las diversas problemticas que plantean los viejos y nuevos problemas que afectan al hombre y a la sociedad post-moderna, muchos de ellos adecuadamente probados e incluso impulsados por gobiernos y organizaciones.1 (1), plantean tambin peligros que deben ser tenidos en cuenta y reflexionados para ser consecuentes con la premisa Hipocrtica universalmente tica de primum non nocere. Entre algunos de los POSIBLES RIESGOS que se puede incurrir al proponer y desarrollar propuestas de Disminucin de Riesgos y de Daos se encuentran: 1. Proponer los programas y polticas de Reduccin de Dao como panacea. 2. Considerar la Disminucin de Riesgos y de Daos como el objetivo principal de los Programas de Intervencin y Prevencin de las Drogodependencias. 3. Instrumentar polticamente, los programas de Reduccin de Riesgos y Daos como acciones para enfrentar los problemas de seguridad y orden pblico, olvidando los intereses sanitarios y sociales de los consumidores. 4. Crear climas de aceptacin social al consumo de drogas, a riesgo de ser interpretados incluso como estar a favor de la legalizacin. 5. Englobar las acciones en torno a un objetivo mnimo, no inscritas en estrategias integradas a objetivos

ms amplios, enmarcados en el control y reduccin de la demanda. 6. Riesgo de caer en una especie de identificacin con los consumidores, incluso en una especie de convivencia. 7. Entrar en conflictividad con el marco legal. 8. Reduccin del nmero de usuarios que optan por la abstinencia. 9. Erosin de lo atractivo de los programas libres de drogas. 10. Transmisin de mensajes de desesperanza y deshaucio a los consumidores de drogas y sus familias. 11. Reacciones adversas no deseadas y daos provocados por sustancias substitutas, empleadas en algunos programas de Reduccin de Daos. Para EVITAR LAAPARICIN y ocurrencia de muchos de estos RIESGOS es necesario tener en cuenta las siguientes consideraciones y recomendaciones: 1. El Enfoque de Reduccin de Daos en los programas de tratamiento de las drogodependencias deben entenderse como un paradigma que le da mayor flexibilidad a los procesos teraputicos, que hasta hace unos aos slo se centraba en la abstinencia total como objetivo, permitindole al consumidor pasar de una modalidad a otra, segn la situacin individual en que se encuentre, tomando entonces esta etapa Reduccin de Riesgos y Daos como una etapa intermedia, de modo que se le posibiliten diferentes alternativas y mayor adherencia a los dispositivos asistenciales, mientras decide el cambio. 2. La propuesta Reducir Daos, dentro del marco de la identificacin y manejo de riesgos, no puede ni debe sustituir a la Reduccin de la Demanda. Esta debe ser complementaria del objetivo principal de toda intervencin y la Reduccin de Daos debe ser considerada como uno de los objetivos especficos(2), e integrarse a

1 Es el caso de las recomendaciones hechas por la Unin Europea, quienes han sugerido que los pases que estn afectados de modo grave por el problema de VIH/SIDA asociado al uso de drogas por va intravenosa, estudien la posibilidad de implementar este tipo de programas.

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los programas de prevencin primaria y secundaria, atendiendo integralmente lo bio-sico-social de los consumidores, sin olvidar los aspectos psquicos, pues la gran mayora de las acciones se encargan de atender lo biolgico y lo social. 3. Los programas de Reduccin de Daos deben establecer y definir claramente los perfiles de los usuarios que se beneficiarn de las acciones. No hacerlo posibilita la emisin de dobles mensajes como las drogas no hacen dao, pudiendo caer adems en la descalificacin de los programas libres de drogas. Slo en la medida que se establezca un perfil preciso de usuarios, se lograr que los mensajes y las acciones las reciba quien las tenga que recibir. 4. El enfoque de Reduccin de Daos debe rechazar cualquier definicin estereotipada y debe entenderse como una poltica y una prctica, construida en torno a cuatro principios fundamentales: a. El pragmatistmo que se opone al idealismo, y que rompe con el paradigma de la curacin (abstinencia total), versus la atencincuidado, que busca mejorar las condiciones de vida y acompaar al usuarios, mientras decide abordar objetivos ms exigentes. b. La tica profesional, basada en la total aceptacin del consumidor de drogas como un ser humano con todos sus derechos. c. El Humanismo, comprendiendo y aceptando que el consumidor es un ser humano que sufre y que necesita y busca ayuda. d. El principio de la Salud Pblica, a travs de la cual se busca preservar el bienestar bio-sico-social de las comunidades. 5. La Reduccin de Riesgos y de Daos no se debe interpretar como una posicin derrotista, induciendo a pensar que la batalla contra las drogas y las adicciones est perdida. Estas estrategias deben presentarse como programas complementarios a aquellos que bus-

can controlar y reducir la demanda de sustancias psicoactivas (programa de prevencin primaria y de tratamiento y rehabilitacin). 6. Definidos claramente los perfiles de la poblacin beneficiaria de los programas de Reduccin de Dao, deben tambin establecerse controles jurdicos y administrativos, sobre todo para aquellos programas que proponen estrategias con sustancias sustitutas y/o dispensacin controlada de las mismas drogas, para evitar que esos consumos afecten a terceros. Respecto a los programas de Reduccin de Dao que incluyen tratamientos de substitucin (Metadona, buprenorfina, hojas de coca2, herona, marihuana )3, si son desarrollados sin control, sin una seleccin muy objetiva de sus posibles beneficiarios, sin suficiente asistencia mdica, psicolgica y social, pueden no justificarse por los riesgos y daos que pueden producir. Cuando los tratamientos de sustitucin son ejecutados y dirigidos por equipos con una seria y slida formacin y disponen de los medios adecuados para asegurar un seguimiento global durante un largo perodo de tiempo, los beneficios para el usuario y para la salud pblica son importantes; pero cuando dichos programas son manejados sin un marco estructurado e integral, el riesgo que se corre, es el de obtener una respuesta pasiva que apenas deja espacio a una relacin interpersonal entre consumidor y su asistente (5), donde puede ser peor el remedio que el problema que se pretende remediar. Tampoco quiere decir esto que los programas de sustitucin y/o dispensacin controlada de sustancias deban reservarse nicamente a acciones de alto umbral de exigencia. No obstante para poder ser utilizados en el marco de programas de bajo umbral de exi-

2 Hur tado J., Institute Research of Drug (Bolivia). Coca Interventions. Simposium Coca. IX Conferencia Mundial de Reduccin de Daos. Sao Paulo, Brasil, 1998. 3Lambriaglian

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gencia, necesitan la creacin de un entorno muy preciso y de perfiles de usuarios muy definidos, con el objetivo de lograr que el usuario avance hacia metas ms exigentes, buscando siempre mejorar su situacin y calidad de vida. 7. La implantacin de Polticas y programas de Reduccin de Daos plantea la necesidad de despenalizar los consumos, idea sta muy diferente a la de Legalizar las Drogas. Una vez resuelto el problema de la criminalizacin del consumo, la teora del comercio pasivo de Francis Caballero(3) y la dispensacin controlada de drogas4, puede ser una alternativa eficaz que permita prescribir sustancias psicoactivas a los drogodependientes, sin entrar en disquisiciones con las propuestas ms liberales como la legalizacin. 8. Uno de los riesgos en que pueden caer los programas de Reduccin de Daos y quizs el ms peligroso de todos, es que, a travs de las prcticas, se

caiga en la pasividad y se transmita un mensaje de desesperanza y de deshaucio a los consumidores de drogas y a sus redes sociales ms cercanas. Aunque los programas de Reduccin de Daos plantean una atencin que por principio cuenta con la libertad y voluntad del usuario, respetando su dignidad y sus derechos por degradada que se encuentre su condicin, por recriminables que sean sus acciones, los programas de Reduccin de Daos deben tener en cuenta el grado de conciencia y la salud mental real y concreta de los usuarios de drogas con respecto a su estado y a su problemtica. Desde el punto de vista tico, una caracterstica de importante consideracin en este tipo de estrategias es la integracin que deben tener los dispositivos de atencin a los otros modelos y programas de rehabilitacin. Una actitud responsable ante el que consume drogas, especialmente ante aquel que lo hace de manera compulsiva y destructiva, ha de consistir en motivarle permanentemente para el cambio, ayudarle a alcanzar metas ms ambiciosas, apoyarle cuando quiera abandonar el consumo y ayudarle a que quiera y puede hacerlo, desarrollando acciones para que sea capaz de lograrlo. La motivacin para el mejoramiento de las condiciones de vida cada vez ms ambiciosas, deben cobrar fuerza a medida que pasa el tiempo y se vayan alcanzando metas intermedias. Junto al concepto de Integracin de modelos, es importante tambin tener en cuenta el concepto de integralidad. Este concepto tiene que ver con la necesidad de considerar los aspectos bio-psico-sociales y transcendentales en la atencin, en donde adems de brindar atencin sanitaria en los aspectos bio-psquicos y atencin social, tambin se les eduque en salud, se les eduque para la vida y se les trate de aliviar su desesperanza, a travs del fortalecimiento de sus potencialidades.

4Segn Francis Caballero, los sistemas de distribucin controlada se sitan a medio camino entre el rigor de los sistemas prohibicionistas y las amplias tesis libertarias. Ellos se caracterizan por medidas diversas tendentes a encuadrar estrechamente el comercio y el consumo de las drogas autorizadas. Las tcnicas de control son variables en funcin de las categoras de las sustancias haciendo una reglamentacin sobre medida. Respecto al Comercio Pasivo, el mismo autor para construir esta teora se pregunta: Cmo reglamentar las sustancias susceptibles de engendrar toxicomana respetando las libertades individuales y salvaguardando los intereses de la sociedad? l mismo responde afirmando que esto es difcil de resolver a travs de una teora general, ya que cada droga presenta una particularidad que exige una reglamentacin especial. Entre los principios fundamentales del comercio pasivo se reconoce que las drogas no son mercancas como las otras. Ellas no estaran sometidas, entonces, al derecho comn de la competencia que tiene por objeto activar la oferta y estimular la demanda. Ellas no podran tampoco beneficiarse de todas las ventajas de la libertad de comercio y de industria, ni tampoco, de los medios clsicos de promocin y ventas. Igualmente, un comercio pasivo de Drogas tendra como principios anexos fundamentales: un principio de informacin a los consumidores (prevencin), un principio de tasacin de los costos sociales de las drogas, y un estatuto del usuario.

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9. Todo programa de Reduccin de Daos que se pretenda llevar a cabo y que directa o indirectamente involucre a la comunidad debe ser conocido por esta. En concreto la comunidad debe conocer y comprender el alcance de los objetivos de los programas. La implicacin de la sociedad en los procesos de Reduccin de Dao, sensibilizndola y educndola, favorece y desarrolla la responsabilidad y solidaridad colectiva, potencia el pluralismo, le permite conocer mejor la realidad, comprender el problema y buscar su transformacin, contribuyendo a la educacin social y cvica de los ciudadanos, fortaleciendo las redes y relaciones sociales (4). Otro aspecto muy importante para conseguir que la sociedad comprenda y entienda las polticas de Reduccin de Riesgos es lograr que sta modifique su visin sobre el consumo y los consumidores de drogas. Una de las necesidades ms inmediatas y necesarias es lograr la conviccin social, sensibilizndola y mantenindola objetivamente informada, de que las drogodependencias son un hecho originado en y por la propia sociedad; que no es un castigo divino, ni una determinacin fatal del destino, y que tampoco es un rasgo maligno de la personalidad humana. Se trata por el contrario, de un fenmeno con hondas races sociales, sobre el que se puede incidir para buscar su modificacin (5). Este es un primer paso para conseguir que la sociedad adopte posturas objetivas y promueva actividades racionales ante estos programas. Por el contrario la informacin parcial o la desinformacin sobre lo que se pretende hacer, deriva de la inseguridad y promueve una serie de respuestas viscerales, deformadas por la angustia y la presin del temor, de pensar que est fomentando el consumo (1). Seguramente todos estos riesgos se corren si los programas no son responsables, ticos y llevados a cabo por profesionales debidamente capacitados.

Mientras los programas de Reduccin de Dao se enmarquen dentro de acciones que definan muy bien los perfiles de la poblacin de usuarios a los que van dirigidos, se tome como parte del proceso de tratamiento y rehabilitacin, entendiendo esta etapa como una etapa intermedia mientras el usuario asume objetivos ms ambiciosos sean integrales y estn integrados a los dems servicios de atencin, no hay por qu descalificarlos pues vistos de esta manera pueden representar una alternativa eficaz y no antagnica, sino complementaria a los programas de rehabilitacin donde la abstinencia total sea la meta, contribuyendo a dar una respuesta integral, plural, pragmtica y ms realista a la problemtica del uso indebido de drogas y sus problemas conexos. CONCLUSIN Es innegable que a pesar de los riesgos y de los obstculos, la Reduccin de Riesgos, considerada como parte de una poltica integral, integrada y complementaria a las Polticas que buscan reducir y controlar la demanda del consumo de sustancias psicoactivas aporta nuevas perspectivas y nuevas prcticas al tratamiento y rehabilitacin de los drogodependientes y una visin ms integral, comprensiva y humanista del fenmeno de las drogas y sus problemas conexos. Estos programas agregan valor al trabajo con los drogodependientes al brindarles esperanza, motivarles para el cambio, acompaarles y estar ah no slo en su rehabilitacin; sino tambin en su sufrimiento. BIBLIOGRAFA (1) Cano P, L., Mayor M, L,. Accin mediadora de la Comunidad en los Programas de Reduccin de Daos con Drogodependientes. Revista Espaola en Drogodependencias. Vol. 23. No. 2, 1998. pginas 149-160.

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(2) Velasco, R., Reduccin de la Demanda Vrs Reduccin del Dao? Revista Proyecto Hombre N. 13, Marzo de 1995, pginas 21-24. (3) Garca, J. Una Escuela de Padres hacia la Participacin. Informacin Psicolgica, pginas 63, 54, 57, 1997. (4) Atutxa, J. La Eficacia de las Normas y el Compromiso de la Comunidad ante las Drogodependencias. Jornadas de Drogas. Desarrollo y Estado de Derecho. Universidad de Deusto. Gobierno Vasco, 1994.

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PSICOTERAPIA INTEGRATIVA EN TRASTORNOS ADICTIVOS: INTROVISACIN A TRAVS DE LA AUTOBIOGRAFA, TCNICA PARA EL REPROCESAMIENTO DE LA FUNCIN DE SIGNIFICACIN DEL SELF

INTEGRATIONAL PSYCHOTHERAPY IN ADDICTIVE DISORDERS: INTROVISATION THROUGH AUTOBIOGRAPHY TECHNIQUE FOR REPROCESSING THE FUNCTION OF THE SIGNIFICANCE OF THE SELF

Guajardo Sinz, Humberto Mdico Psiquiatra. Profesor Titular de Adicciones, Facultad de Ciencias Mdicas Universidad de Santiago de Chile. Subdirector Revista Eradicciones. Kushner Lanis, Diana Antroploga Social. Profesora de Adicciones, Facultad de Ciencias Mdicas de la Universidad de Santiago de Chile.

Se presenta la tcnica de introvisacin a travs de la autobiografa, la cual est orientada a reconocer los principales elementos de significacin del Self que el paciente construy en sus etapas tempranas. Esta tcnica permite comprobar la funcionalidad de la droga generada a travs del proceso de significacin y el condicionamiento de la droga a la realidad construida por el paciente. Se relata un caso clnico tratado por los autores en el Centro Integrativo de Adicciones (CIAD) de la Facultad de Ciencias Mdicas de la Universidad de Santiago de Chile.

The introvisation technique is presented through the a u t o b i o g r a p h y, w h i c h i s o r i e n t a t e d t o w a rd s recognising the main elements of significance of the Self that the patient constructs in his or her early stages. This technique enables us to confirm the functionality of the drug generated through the significance process and the conditioning of the drug to the reality constructed by the patient. A clinical case treated by the authors in the Centro Integrativo de Adicciones (CIAD Integrated Addictions Centre) of the Medical Science Faculty of Santiago de Chile University is presented.

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INTRODUCCIN Desde hace algunos aos los autores hemos venido trabajando con un enfoque integrativo en el tratamiento y anlisis de los trastornos adictivos (5, 12). Este enfoque postula que no hay un solo factor que lleve al proceso adictivo y que los diferentes subsistemas de la personalidad pueden estar afectados en la adiccin. Estos subsistemas son: el ambiental-conductual, el biolgico, el cognitivo, el afectivo, el insconciente y el sistmico. Las bases de este enfoque fueron descritas por los autores en un artculo anterior de la revista Eradicciones y estn en prensa para ser publicadas en el Journal of Psychotherapy Integration. El desarrollo de estos subsistemas confluye en el desarrollo del Self (S mismo) que es el eje central de la personalidad que convierte en estmulos efectivos los diferentes estmulos que impactan al individuo. Se han descrito 5 funciones que integraran los elementos centrales del Self: identidad, organizacin, significacin, control de impulsos y ltimamente los autores hemos incluido la funcin de espiritualidad para efectos del trabajo en adicciones. La funcin de identidad involucra la autoimagen y autoestima determinando una respuesta a la pregunta: Quin soy yo? Pacientes que tengan altos niveles de Neuroticismo o de inestabilidad emocional vern muy interferida su funcin de identidad. Una persona con mucha inestabilidad emocional tendr frecuentes cambios en su autoimagen afectando su funcin de identidad. Las diferentes experiencias nos impactan y tienden a desorganizarnos. La funcin de organizacin del SELF nos permite reconstituirnos despus de cada experiencia. La resiliencia en cierta medida est mostrando la capacidad del individuo para resistir a experiencias de alto impacto. La funcin de control de impulsos tiene que ver con poseer un repertorio conductual asertivo que nos per-

mita satisfacer nuestras propias necesidades, pero respetando el derecho de los dems. En nuestros pacientes adictos es frecuente el deterioro de esta funcin lo que lleva a comprometer la realizacin personal y a generar importante frustracin a la persona. La funcin de espiritualidad (2, 3, 6, 8) no tiene que ver en absoluto con factores de tipo religioso, ms bien tiene que ver con capacidad de trascendencia, bsqueda del sentido, aprender del dolor, capacidad de experienciar vivencias culmines y meseta y aprender a desarrollar el sentido de atribucin de causalidad. Como se puede observar el adecuado desarrollo de estas funciones en el paciente influir directamente en la calidad de vida del mismo. Hemos dejado para el final y comentaremos ampliamente la funcin de significacin del Self que es el objeto de este artculo y la comentaremos ms en extenso en las siguientes lneas. BASES TERICAS DE LA FUNCIN DE SIGNIFICACIN DEL SELF Desde una perspectiva epistemolgica, nuestro Modelo en Adicciones adscribe a un Constructivismo Moderado en cuanto al acercamiento a la realidad por parte del paciente lo cual difiere de las aproximaciones idealistas en las cuales la realidad slo es producto de nuestros sueos y pensamiento, y del realismo que plantea que generamos un acceso directo a la realidad la cual es nica y captada como verdaderas fotocopias por nuestro sistema biolgico (4, 10, 12). Desde una perspectiva constructivista diremos que las caractersticas de nuestro sistema nervioso determinan la forma en que percibimos los diferentes estmulos que nos impactan. Experiencias tempranas que en el embarazo o parto impacten al sistema nervioso pueden determinar formas particulares de experienciar. Hay que recordar que un alto porcentaje de los pacientes en tratamiento en adicciones tiene antecedentes de proble-

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mas en el embarazo y en el parto, los cuales aunque pequeos pueden determinar diferentes sensibilidades en el sistema nervioso. A medida que el individuo va creciendo y desarrollndose las diferentes experiencias que generan el desarrollo evolutivo cognitivo y afectivo van determinando las particulares formas en que cada persona va construyendo su significacin personal y otorgando una explicacin a sus diferentes vivencias. El significado creado va siendo puesto a prueba por el individuo y buscando siempre comprobarlo a travs de sus actos y conductas. Se forman as verdaderos argumentos de vida que se van cumpliendo con el pasar del tiempo. Cada experiencia de vida va siendo integrada a este proceso de significacin de la experiencia y cuando se producen experiencias violentamente opuestas o contrarias al significar de la persona se generan crisis emocionales y existenciales que afectan violentamente al individuo. Algunos principios de la construccin de significados De acuerdo entonces a lo sealado diremos que la construccin de significados involucra una sntesis continua de informacin. Este significado subjetivo da el sentido subjetivo de la realidad y la evaluacin del significado de los acontecimientos (5). Esto determina que constantemente estamos creando y generando significados y por lo tanto la construccin del s mismo es continuo, crendose por la interaccin del organismo y el medio. De lo anterior se desprende que estamos influidos por nuestros esquemas y experiencias pasadas. Si aceptamos lo anterior significa que podemos utilizar la atencin en terapia focalizando y significando en forma diferente la experiencia interna. Esto nos permitira sealar que si atendemos adecuadamente el flujo de la experiencia, podemos crear es-

tructuras esquemticas que generen formas automticas positivas en el procesamiento de nuevas experiencias. Es decir podemos generar reflexiones sobre la experiencia y crear nuevos significados. Elementos de significacin en Psicopatologa Diferentes son las experiencias que se han mencionado como posibles productoras de una significacin que genere patologa. Las experiencias de apego percibidas como desatencin o rechazo (por ejemplo la prdida de un progenitor) pueden generar una tendencia automtica a experimentar dolor y a bloquear la expresin emocional de la persona. Esto desde luego genera menos refuerzos, lo que puede ser interpretado como desatencin. Experiencias de prdida, abandono o rechazo, generan rabia o tristeza automtica y el mundo es interpretado como poco fiable e incontrolable. La experiencia de soledad lleva slo a confiar en uno mismo. Los acontecimientos incontrolables son atribuidos al s mismo en forma estable y global lo que da coherencia interna a la psicopatologa. Aspectos cognitivos de la construccin de significados Un primer aspecto cognitivo que influye en la construccin de significados es que la atencin es un primer elemento que limita los procesos que se experimentan y controlan. Esto ya produce un cierto sesgo en la informacin que el organismo utiliza para la construccin de significados. Es indudable que existen procesamientos automticos no dirigidos por la persona y que por lo tanto hay un procesamiento paralelo de la informacin fuera de la conciencia. Desde esta perspectiva el subsistema inconsciente tendra una importancia fundamental en la funcin de significacin. El subsistema cognitivo determina que existan procesamientos esquemticos que controlan la memoria. Los

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esquemas se caracterizan por ser un conjunto almacenado de conocimientos con el que interacta la informacin entrante; son modulares y la activacin de una parte activa el todo y actan fuera de la conciencia guiando la percepcin, la memoria y la experiencia. Teraputicamente podemos facilitar la memoria centrndonos en las caractersticas especficas de un acontecimiento. Esta caracterstica ser utilizada en la tcnica que describiremos posteriormente. Aspectos afectivos de la construccin de significados La emocin resulta un elemento muy importante en la construccin de significado ya que gobierna los objetivos de las personas e influye en sus intenciones. Influye rpidamente en la conducta muchas veces sin un procesamiento conceptual. Los afectos se integran con la cognicin para producir la experiencia e influyen en el procesamiento cognitivo. Las emociones complejas incluyen evaluaciones cognitivas del s mismo. Por tanto emocin y cognicin estn en un juego permanente en la construccin de significados del individuo. Cmo la construccin de significados genera disfunciones? Los significados de la experiencia pueden determinar una conducta inadaptada y patolgica. Por ejemplo, un individuo que experiencia falta de apoyo tender a hacer emerger la experiencia nadie me quiere procediendo a aislarse, sentirse desolado, experimentar vaco y deseo de ser consolado. La atencin selectiva de la informacin lleva a buscar confirmar los esquemas disfuncionales: quien se considera indigno de ser amado busca minuciosamente signos de rechazo de manera que el apoyo es visto como falta de apoyo o crtica. Los individuos estamos autodeterminados por los significados que hemos entregado a nuestras experiencias tempranas.

Principios de cambio generados en la tcnica que proponemos La tcnica que proponemos se realiza cuando se ha generado un fuerte vnculo teraputico lo que determina que una relacin teraputica segura permita incrementar la capacidad de procesamiento y cambiar esquemas. La tcnica busca dirigir la atencin hacia los rasgos reales de la experiencia. Busca evocar los esquemas de significacin a objeto de ofrecer nuevas significaciones o interpretaciones. Por otra parte se busca ensear a contactar con experiencias nuevas que se evitaban por ansiedad. Cuando la persona logra expresar lo que siente genera nuevas experiencias. La interaccin con el grupo teraputico permite generar nuevas experiencias interpersonales que permitan modificar las estructuras nucleares de significacin. Nuestro objetivo teraputico ser facilitar la construccin de un nuevo significado personal. IMPORTANCIA DE LA FUNCIN DE SIGNIFICACIN DEL SELF EN EL PROCESO ADICTIVO El trabajar con un Modelo Integrativo en Adicciones implica asumir que la alteracin de la funcin de significacin es una causa ms en la etiopatogenia de los cuadros adictivos, pero que su trabajo en la terapia puede resultar fundamental para controlar el cuadro adictivo y en especial en el trabajo de prevencin de recadas. Los pacientes que presentan alcoholismo y/o adiccin a drogas tienen por lo general historias y experiencias de vida intensas y dolorosas que en la mayora de los casos tienen mucha importancia en el desarrollo del proceso adictivo. Los autores pensamos que hay al menos dos elementos fundamentales que considerar en la relacin que se establece en la relacin de la droga con la funcin de significacin del paciente:

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a) La droga es funcional a las experiencias de construccin de significados del paciente (1). b) En algunos pacientes existira un condicionamiento entre la funcin de significacin y el uso de drogas de manera que la evocacin de la significacin requerira el inmediato consumo de drogas para cumplir con el significado otorgado al consumo. Este elemento a nuestro juicio resulta fundamental en el trabajo de prevencin de recadas en el tratamiento de las adicciones. De lo anteriormente expuesto podramos sealar que, por ejemplo, pacientes con significacin de evitacin al dolor podran tender a consumir drogas relajantes que disminuyen ansiedad como alcohol o benzodiazepinas, en cambio pacientes con significacin de caractersticas enfrentadoras (ser exitoso) o agresivas podran tender a estimulantes como cocana. Creemos que trabajar con la significacin y las experiencias tempranas del paciente adicto tendr un efecto importante no tan slo en el manejo de la adiccin, sino tambin en el desarrollo de un Self ms armnico en el paciente (11). TCNICA DE INTROVISACIN A TRAVS DE LA AUTOBIOGRAFA Los pacientes trabajan con esta tcnica luego de aproximadamente un mes de haber ingresado al proceso teraputico (13) y una vez que en opinin del equipo clnico se ha estructurado un buen vnculo teraputico (7) y el paciente ha eliminado totalmente el consumo de drogas. Esto es fundamental para asegurar una capacidad de anlisis cognitivo ms racional. El trmino introvisacin lo definimos como un mirarse dentro de s mismo, no utilizamos el trmino instrospeccin porque significa inspeccionarse desde una funcin cognitiva y esto lo dejamos para ser realizado por el grupo y el terapeuta, slo nos interesa que el paciente se observe.

Se deja en claro que para los propsitos de la terapia no es importante si el recuerdo es un recuerdo de un acontecimiento real. En la primera etapa se solicita al paciente que trabaje escribiendo una historia de los hechos dolorosos ms importantes que recuerda entre sus 0 y 10 aos de vida. Slo debe enfocarse en sus hechos dolorosos, ya que los acontecimientos felices se trabajan en las ltimas etapas del tratamiento. Los acontecimientos felices grabados tienden a ser muy similares en la mayora de las personas. Como se trata de su construccin de significado se le solicita al paciente que no le pregunte a nadie sobre lo ocurrido (los aportes de los padres y familiares estn contaminados por sus propias significaciones personales). Cuando el paciente informa que ha terminado esta autobiografa de sus diez primeros aos, en forma solemne debe exponerla al grupo, tras realizar alguna experiencia de relajacin, motivacin o de concentracin para el trabajo. Una vez terminada la exposicin, el terapeuta ofrece la palabra a los miembros del grupo, los cuales generan durante un rato una ronda de preguntas que buscan aclarar y focalizar la atencin en los elementos ms relevantes de la experiencia. Terminado el proceso de aclaraciones, el equipo clnico destaca los elementos de construccin de significados observados y las creencias y mandatos que se observan. Estos elementos son registrados por el coterapeuta y entregados al final de la sesin al paciente para que los guarde consigo. Posteriormente en la sesin los miembros del grupo entregan al paciente diferentes alternativas u opciones que estiman pueden ayudarlo a modificar su significacin. La exponencia termina con un abrazo que cada uno de los miembros del grupo entrega al compaero que expuso como una muestra de afecto y refuerzo por el trabajo realizado.

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A medida que el paciente contina en el proceso teraputico debe ir trabajando su autobiografa por perodos cada 5 aos hasta llegar a la etapa actual de la vida. Una vez terminado este proceso se indica realizar introvisaciones dirigidas a ciertos aspectos del desarrollo personal, de la relacin familiar, de pareja u otros que se consideren de inters para comprender la significacin del paciente. CASO CLNICO Se trata de un paciente de sexo masculino de 37 aos, soltero con estudios universitarios incompletos. En la actualidad es comerciante. Tiene antecedentes de un tratamiento en una Comunidad Teraputica hace cuatro aos. Recado hace un ao. Es poliadicto con consumo de alcohol, cocana y marihuana. Inicia su consumo a los trece aos con marihuana. A su ingreso est consumiendo 3 gramos diarios de cocana. Asume que ha perdido la alegra, el dinero y la responsabilidad. Sus motivaciones para tratarse son sus problemas econmicos, sus problemas fsicos, su familia y resolver su identidad sexual ya que tiene un trasvestismo. Est muy angustiado por cuanto en su tratamiento anterior se le inst a asumir una condicin Gay. Su grupo familiar consta de padres separados, una hermana mayor de 40 aos, un hermano de 34 y una hermana por parte de su padre que tiene 24 aos. Refiere a su padre como dictador, avaro, fro y autoritario. Su madre es descrita en forma contradictoria como protectora, preocupada y cariosa, pero por otro lado como maltratadora. Estuvo casado durante un ao. El paciente tiene antecedentes de un dficit atencional, con hiperactividad, e impulsividad no tratados. Delinque entre los 12 y 14 aos, es detenido y va 20 das a una correccional de menores. En el examen se ve lcido, orientado y un poco ansioso.

Resultados de la Ficha de Evaluacin Clnica Integral de Adicciones (FECIAD) La aplicacin de esta ficha entreg resultados alterados en las escalas de: Neuroticismo, Extroversin, Psicoticismo, Autoimagen, Autoeficacia, Ansiedad, Alexitimia, Intolerancia a la frustracin, irracionalidad cognitiva, Perfeccionismo, Perturbacin emocional y Repertorio conductual. A los seis meses de tratamiento al ser pasada la ficha haba corregido y normalizado todos estos valores. Llama la atencin lo alterado de los valores en un paciente que haba hecho un tratamiento completo en Comunidad Teraputica. Primera exponencia de 0 a 10 aos de vida Me castigaban por comerme las uas. Me senta extrao por una conducta que no saba por qu tena. Me ponan aj en los dedos, guantes y me golpeaban las manos si las llevaba a la boca. Tena dolor en los dedos y sentimientos encontrados por no saber por qu me las coma. Recuerdo largos castigos porque no quera comer, me amarraban a la mesa con silla includa, senta que estaba con personas dspotas ya que si no coma al ritmo del reloj y no terminaba a la hora indicada, me enviaban a una pieza por un par de das sin comer. Quizs en esos momentos aprend a masturbarme. En esa etapa senta ganas de mirarme al espejo y mirar todo mi cuerpo. Senta una profunda desolacin por esas horas interminables de castigo y hambre, donde mi padre era mi salvacin de los pesados suplicios que me haca pasar mi madre. Siento una etapa muy castigadora, no me escuchaban y la respuesta era un grito acompaado de un golpe. Escuchaba que era muy rebelde y travieso a tal extremo que no escuchaba y era muy desobediente. Dorma en la pieza con mi hermana. Debamos estar en silencio, si nos escuchaban mi madre sacaba una

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correa del closet y golpeaba mi espalda en medio de gritos y dolor, me senta muerto. Mi hermana curaba mis heridas y llantos del alma, algo indescriptible y de mucha agresin. Mi hermana era bella, hermosa y alta. Mis padres nunca la tocaban. No tengo recuerdos de mi madre acogedora. Mi padre comparta sus decisiones, pero en una posicin ms flexible y conservadora. Senta ausencia total de mi madre con una presencia que no quera ante sus maltratos e histeria. Mi padre trataba de justificarla con la ms top y repetida de sus frases: Tu madre es una histrica. Recuerdo que si nos orinbamos en la cama, al da siguiente mi destino sera un largo consumo de mi misma medicina: El Pich. Tuve que asumir que era una ficcin e irrealidad lo que estaba pasando. En un lugar de mi infancia conoc el silencio de mi familia cuando mis padres no se hablaban y se mandaban mensajes que me caan muy desagradables. Tuve que aprender que esta era mi realidad y que no me importaba ni dola. Vagamente recuerdo haber tenido una relacin del mismo sexo cuando invit a un nio al bao de mi casa para ensearle a masturbarse. Hay detalles que no recuerdo bien. Elementos de significacin en esta primera exponencia - Soy malo por algo me abandonan. - No soy querido. - Las mujeres mams son malas tienen poder y mandan. - Hay mujeres intocables, son lindas, te calman el dolor y nunca sufren. - Los hombres son como mi padre poco definidos. - Frente al dolor puedo producirme placer (autoestimulacin). - Con un amigo se puede compartir ocultamente.

- Mandatos: No mostrar emociones. No te equivoques, hacerlo cuesta caro. - Creencia: Las mujeres bellas no sufren. Los hombres son protectores y las mujeres autoritarias. Vivir en pareja no resulta. Se observa que ya en estos primeros elementos de significacin hay factores que sern facilitadores del futuro proceso adictivo. Por ejemplo, Soy malo, ante el dolor puedo autoestimularme y producirme placer. Se hace dependiente del placer para combatir el dolor, compartir ocultamente, etc. Su trasvestismo se asocia con la visin de su hermana calmndole el dolor, cada vez que consuma o recaa en drogas se vesta de mujer. Al hacer la autobiografa y ver su significacin, el paciente hizo un awareness en el sentido de que no era gay y tuvo una fuerte sensacin de alivio. Nunca ms ha vuelto a vestirse de mujer. Conversando con su hermana posteriormente, ella no recuerda situaciones tan difciles ni que ella curara ciertas heridas, no obstante lo importante para la significacin es lo que el paciente grab. Exponencia de 10 a 15 aos En medio del caos familiar, no saba qu ocurra. Los recuerdos de maltrato y violencia se tornaron en el pan de cada da. El ltimo episodio que me dej muy confundido fue ver a mi madre golpeando a mi padre y junto a ello actitudes histricas de mi madre. Sin justificacin mi madre anunciaba cambios de casa y de ciudad. Con mi hermana nos preguntbamos por qu, nadie saba, secreto, prohibido comunicar. No haba respuesta de mis progenitores, slo porque s. Los primeros das de colegio tuve buena recepcin de mis compaeros, me sent muy bien. Sin embargo llegaba a mi casa y todo cambiaba. Aunque mi padre ya no estaba, mi madre lo traa con sus quejas. La queja que se repeta eran sus pagos atrasados, en esos minutos me senta muy mal. Mi vieja amenazaba con prostituirse si mi padre no le

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mandaba dinero. Cada da me alejaba de casa, abandonaba todos los buenos amigos y comenc a juntarme con malos, ellos se la jugaban por m. Comenc a delinquir y no lo pude parar, form parte de una banda de robos, asaltos, estafas y falsificaciones. Siento poder y la posibilidad de obtener mucho dinero. Comenc a vivir una vida de promiscuidad, siempre de noche con alcohol, drogas y sexo, veo a homosexuales teniendo relaciones. Termino en la crcel de menores, me siento indefenso, yo no conoca esto, me amenazan y me quieren violar, sufr mucho. Me envan a vivir con mi padre, pero lo que ms recuerdo es un subterrneo lleno de zapatos y un espejo muy grande. All empec con el juego de usar los zapatos y mirarme al espejo, sent nerviosismo, dolor y alivio, casi placer. A mi madre la sent lejana, lo que me produca mucho dolor, pero la marihuana me haca sentir bien y se me olvidaba mi madre. Elementos de significacin - El caos produce angustia y desconcierto - La casa (el hogar) es desagradable - El poder me resuelve muchos problemas, yo escojo, nadie me hace sufrir y me otorga dinero. - Soy malo, el mundo es malo, me castigan y sufro. - Las drogas alivian la pena - Imitando a las mujeres alivio mis dolores, me siento bello, limpio e intocable. - Soy malo y no querido - Soy distinto y raro - Tengo sentimientos de abandono Es importante notar cmo en esta exponencia se van repitiendo y confirmando elementos de significacin de la primera de 0 a 10 aos. Adems es notorio cmo se establece el nexo y condicionamiento con la marihuana como droga que le alivia el dolor. Se repite constantemente el sentir ser malo y no querido.

El paciente genera poca discriminacin valrica entre lo bueno y lo malo. Tiene baja autoimagen y empieza a generar problemas en su identidad sexual, la cual se torna difusa. Los dolores le llevan a una alta alexitimia y como un paliativo el deseo de buscar emociones (la cocana llegar como consecuencia). Exponencia de 15 a 20 aos (resumida) Sigo siendo un fracaso, nada me resulta. No quiero volver a delinquir, pero hago muchas cosas indebidas, no veo a mi madre, el consumo contina, ya no le intereso a nadie. Me transformo en un ser muy solitario, con mucho odio al xito de mi padre, siempre quiero desafiarlo. Cuando me voy a enfrentar a la Universidad me fugo y no quiero saber si fui aceptado. Me voy al extranjero, mi objetivo es slo ganar dinero y lo consigo. Al regresar trabajo con mi padre y estudio, pero soy un explotado por mi padre. Elementos de significacin - Soy malo y un fracaso - Nadie me quiere - Necesito poder y dinero - Mi padre me explota - La droga me da poder, obtengo dinero y puedo competir con mi padre. A pesar que hemos resumido esta exponencia por razones de espacio, podemos observar que se mantienen los elementos de significacin y la justificacin para el uso de drogas. Resumen de exponencias de 20 a 30 aos Me caso sintindome muy enamorado, pero nada funciona. Una persona que conozco y es gay me sentencia que yo llegara tarde o temprano a lo mismo. Esta idea me asusta y no me deja tranquilo. No dejo de consumir drogas, parece que estas me hacen vivir en otro mundo, ms tranquilo, sin miedos ni problemas, me hacen olvidar todo. Hago negocios y fracaso, cada fracaso es recordado dolorosamente por el exitoso y avaro de mi padre.

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Me enredo en negocios sucios, estafando. Establezco una relacin laboral con un homosexual que me acosa, pero yo lo domino y sigo el juego con la finalidad de obtener beneficios econmicos. Aqu me comienzo a enganchar con la cocana. Ya no s quin soy ni qu quiero. Veo a mi madre y no soporto el dolor que me produce. Elementos de significacin - Los matrimonios no funcionan. - Indefinicin sexual. - Las drogas me alivian. - Mi padre es poderoso y debo desafiarlo. - Soy malo. - Las mujeres madres son malas y producen dolor. Es importante mencionar que se siguen repitiendo significaciones de otras exponencias. Su matrimonio era casi esperado que fracasara dado su significacin. Por otra parte cabe mencionar que su padre no es un hombre exitoso ni poderoso econmicamente, incluso hoy depende de su hijo, todo fue una construccin del paciente. Exponencia final Mi relacin con la droga es intensa y de mucha locura. Vestirme con zapatos y tacos de mujer me hacen sentir placer, con episodios de fetichismo y locura, siempre bajo los efectos de la droga. Ya no puedo andar por la calle slo pienso y miro a las mujeres, no s si quiero sentirme ellas. Fracaso y fracaso, todo lo hago mal, estafar me angustia y me da miedo, pero tengo que conseguir dinero, tengo que mostrarle a mi padre que soy mejor que l. No puedo ms, me internan en una clnica y vivo un proceso de tratamiento por cuatro aos. Elementos de significacin - Soy malo - La droga me proporciona placer - Sentirme mujer y vestirme de mujer me da placer - Debo superar a mi padre

El paciente durante todo el proceso fue resignificando sus experiencias y tomando conciencia que mucho de los elementos de significacin fueron desarrollndose a partir de su propio anlisis de realidad, que no siempre fue coincidente con la verdad de lo que ocurri. Hoy el paciente ha establecido una nueva relacin sentimental con una mujer y est planificando comprar un departamento para establecer su hogar, concepto que hoy es visto como deseable y apetecible. Constructos que se repiten durante todo el proceso - Soy malo por algo me abandonan. - No soy querido. - Las mujeres mams son malas, tienen poder y mandan. - Hay mujeres intocables, son lindas, te calman el dolor y nunca sufren. - Los hombres son como mi padre poco definidos. - Frente al dolor puedo producirme placer (autoestimulacin). - Con un amigo se puede compartir ocultamente. - No muestres emociones. - No te equivoques, hacerlo cuesta caro. - Las mujeres bellas no sufren. - Vivir en pareja no resulta. Carta final a sus compaeros de grupo Los tacos de zapatos de mujer me han hecho sentir un placer muy extrao, con episodios fetichistas, de lujuria y lujuriosa elegancia. Para m, entre otras cosas han representado el medio de ver cmo la mujer puede sobresalir, por destreza y altura, cautivando la atencin y la mirada de mi persona frente a un gran grado de erotismo y placer. Lo fastuoso, tal vez comience por sentir la desnudez a flor de mirada, la fragilidad de andar en puntas caminando hacia la vida, el dolor de espanto por terminar el da y bajarse de los altos, la suciedad del cami-

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no que se te pega en las plantas, y a modo de huella, las marcas de los hilos que te amarran por todo el da, eso es sentirse mujer. Tal vez comience, por tener un parto y vivir el dolor que trae la vida, dolor que sin duda, yo he querido pertenecer, aferrado como si no existiera la otra cara de la moneda, o el otro sexo de la vida. No s ni cuando, ni cmo comenz, lo que s s, es que en algn rincn de mi vida pasada, adopt lo femenino, quizs, como una manera de relacionarme a oscuras, de descargar lo que no era capaz, de enfrentar tal vez aquello que tuvo relacin con los falsos miedos a desarrollarme en un mundo intenso, quin sabe Lo que s hoy, es que me doy cuenta y me hago responsable de esos tiempos de terror y confusin, movido supongo por una frustracin o imitacin, por un reto o una alegra. Sin embargo hoy, sigo con penas y alegras y frente a mis fantasas, no tengo esa herramienta de hervir como mujer pretendiendo adormecer la vida y de rechazar mi cuerpo, ensuciando mi alma, sin que me permita disfrutar de mi sangre y de mis venas masculinas. El seor se me hizo hombre, casi sent no tener silencio o instancia para escuchar y ver lo que soy. Tard muchos aos para concientizar los roles y responsabilidades de un hombre y los de una mujer. Hoy siento que la vida me tom y me toc este tema, como la causalidad de los momentos y que a partir de hoy nunca me dejarn de impresionar. El sentir los espejos del pasado, revelan cuanto me veo diferente y que los tiempos han pasado y que no todo ha de continuar he aprendido que a ciertas cosas se les ha de poner fin. Hoy siento que mi fortaleza es sentir el presente asumiendo las responsabilidades del ayer, y como consecuencia aliada, me olvido de los llantos del pasado y del nio mimado. Siento que es la oportunidad de ver lo que deseo ver, pues ya tengo in-

cubadas las ganas de caminar descalzo, entregarme a mis pies y el seor sabr qu hacer con ellos. Obsesin, adrenalina, pudor, fantasa y algunos significados ms me han hecho sentir estar ciego, encerrado en una irrealidad de ver lo que no soy, y que en palabras y sentidos, me han tenido bastante confundido. Por muchos aos he sentido una falsa percepcin, de extremas fantasas corporales; de la piel a las piernas, del pelo a la cara, de la voz a la palabra, del dolor a la calma, de la pintura a la luz, de la mujer al hombre, de lo personal a la identidad, de lo poco a lo mucho, de lo mucho a lo mucho ms, y ms que varios trastornos, asociado a una bsqueda personal y a sentir placer, emanado quizs, de una adrenalina desubicada. Hoy me siento ubicando mis fuerzas, orientando desplegar mis emociones, tras el encuentro de esa libertad de estar cmodo, de sentir que poco a poco estoy nadando entre calma y tormenta, en ese mar de emociones; tengo fe de que mi pasado pase a ser slo un recuerdo que tuve alguna vez. .....Cuando duele el alma y el cuerpo, siento que es el momento, dentro de otros, para el cambio. Comentario final La carta final del paciente ahorra muchos comentarios, puede apreciarse su comprensin respecto a muchas de las significaciones ya comentadas y destacando una nueva construccin de significados. Es muy importante sealar que se observan en la carta muchos elementos de terapia espiritual (9), en especial factores de causalidad que esperamos comunicar en prximos artculos. Hoy el paciente en una slida abstinencia ha dejado atrs todas sus significaciones de identidad sexual ambigua y est desarrollando un trabajo honesto, ayudando a su padre econmicamente dado que est muy enfermo.

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BIBLIOGRAFA 1. Bateson, Gregory. Espritu y Naturaleza. Biblioteca de Psicologa y Psicoanlisis. Amorrortu Editores. Argentina, 1997. 2. Frankl, Victor. Logoterapia y Anlisis existencial. Editorial Herder. Barcelona, 1994. 3. Frankl, Victor. El hombre en busca del sentido ltimo. Editorial Piads. Barcelona, 1999. 4. Greenberg L, Rice L y Elliott R. Facilitando el Cambio Emocional. Editorial Paids. Espaa, 1996. 5. Guajardo H, Bagladi V, Kushner D. Evaluacin de Trastornos Adictivos en Sistema Teraputico Comunitario. Revista Eradicciones N 4 Marzo/Junio 2001. Santiago de Chile. 6. Guttman, David. Logoterapia para profesionales. Editorial Descle de Brouwer. Espaa 1998. 7. Kleinke, Chris L. Factores comunes en Psicoterapia. Editorial Descle de Brouwer. Bilbao. 1998. 8. Kushner, Harold. Dar sentido a la vida. Emec editores Argentina, 2002. 9. Maslow, Abraham H. La amplitud potencial de la naturaleza humana. Editorial Trillas. Mxico, 1999. 10. Maturana, H. El Sentido de lo Humano. Dolmen Ediciones. Santiago Chile, 2000. 11. Moreau, A. Ejercicios y tcnicas creativas de gestalterapia. Editorial Sirio. Argentina, 1999. 12. Opazo, R. Psicoterapia Integrativa . Ediciones Icpsi. Chile, 2001. 13. Yalom Irvin. El don de la terapia. Emec Editores. Argentina, 2002.

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COMUNIDADES TERAPUTICAS: RECIPROCIDAD INVESTIGACIN PRAXIS

THERAPEUTIC COMMUNITIES: RESEARCH-PRACTICE RECIPROCITY

Leon, George De Doctor en psicologa. Director del Centro de Investigacin de Comunidades Teraputicas (CTCR), profesor de Psiquiatra en la Universidad de Nueva York.

Contenido
La Comunidad Teraputica (CT) ha probado ser un abordaje poderoso para el tratamiento del abuso de drogas y sus problemas asociados. Siendo fundamentalmente un abordaje de auto-ayuda, la CT ha evolucionado hacia una modalidad sofisticada de servicios humanos, como lo evidencia el amplio rango de sus servicios, por la diversidad de la poblacin asistida, y por el volumen de Investigaciones que las sustentan. Actualmente, las CT atienden en los EE.UU. a miles de individuos y a sus familias anualmente. Las CT han sido implementadas en varias modalidades diferentes, residenciales y ambulatorias (por Ej. hospitales, prisiones, escuelas, casas de medio camino, clnicas con centros de da y clnicas ambulatorias). La CT ofrece una amplia variedad de servicios: social, psicolgico, educacional, mdico, legal y social.
Partes del Artculo

1- La CT Residencial Tradicional Quin viene buscando Tratamiento? Son las CT Efectivas? Qu se sabe sobre la Retencin en los tratamientos en CT? Reciprocidad Investigacin-Praxis: Son las CT contemporneas Efectivas y Costo / efectivas para el Tratamiento de la Diversidad Actual de Abusadores de Drogas? 2 - Qu es el Abordaje Actual de Tratamiento de las CTs y por qu da resultados? Reciprocidad Investigacin- Praxis Datos de la Ciencia Tratamiento y Datos sobre Polticas Retencin Prctica Clnica y una nueva Agenda de Investigacin

Some of the material in this chapter is drawn from George de Leon (in press), The Research Context for Therapeutic Communities in the USA, and is adapted with permission from the copyright holder, Jessica Kingsley Publishers. The work involved in developing this chapter was supported in part by National Institute on Drug Abuse Grant P50-DA07700

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The therapeutic community (TC) has proved to be a powerful treatment approach for substance and related problems in living. Fundamentally a self-help approach, the TC has evolved into a sophisticated human services modality, as is evident in the range of its services, the diversity of the population served, and the substantial body of supporting research. Currently, TC agencies in the United States serve thousands of individuals and families yearly. TC programs have been implemented in various other settings, both residential and nonresidential (e.g., hospitals, jails, schools, halfway houses, day treatment clinics, and ambulatory clinics). TCs offer a wide variety of services, including social, psychological, educational, medical, legal, and social/advocacy. THE TRADITIONAL RESIDENTIAL TC Much of what is known about the TC approach and its effectiveness in based on the long-term residential model, also termed the traditional TC. Traditional TCs are similar in planned duration of stay (12-15 months), structure, staffing pattern, perspective and rehabilitative regime, although they differ in size (306 0 0 b e d s ) a n d c l i e n t d e m o g r a p h y. S t a f f a r e composed of TC-trained clinicians and other human services professionals. Primary clinical staff are usually former substance abusers who themselves were rehabilitated in TC programs. Other staff consist of professionals providing medical, mental health, vocational, educational, family counseling, fiscal, administrative, and legal services. The TC views drug abuse as a deviant behavior, reflecting impeded personality development or chronic deficits in social, educational, and economic skills. Thus, the principal aim of the TC is a global change in lifestyle: abstinence from illicit substances; elimination of antisocial activity; and development of employability, prosocial attitudes, and values.

The quintessential feature of the TC approach may be termed community as method (De Leon, 1998, 2000). What distinguishes the TC from other treatment approaches (and other communities) is the purposive use of the peer community to facilitate social and psychological change in individuals. Thus, in a TC all activities are designed to produce therapeutic and educational change in individual participants, and all participants are mediators of these therapeutic and educational changes. Although the TC emerged outside of the medicalscientific mainstream, its evolution has been advanced by the reciprocal contributions of both research and practice. This chapter illustrates this reciprocity across some 30 years of TC research. During this period, policy and practice issues shaped research agendas, which in turn influenced treatment practice and programming. The main lines of TC research in the United States are organized into two eras, or phases: (a) the early phase (circa 1970-1989) and (b) the current phase (1990present). For each phase, I summarize the key treatment and policy questions and research conclusions and offer examples of practice-research reciprocity. In the last section of this chapter I explore some of the insights of both research and practice learned from the evolution of science in the TC. PHASE 1 (1970-1989) Beginning in the 1960s, the heroin epidemic and its crime consequences launched an expansion of drug treatment resources and research activities. TCs had emerged as alternatives to conventional medical and mental health treatments for opioid abusers, but their doors were open to alcoholics and other substance abusers. The TC perspective of the disorder, the client, and recovery different from that of other major treatment modalities (see De Leon, 2000, part 2). The

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residents in TCs were usually the most severe substance abusers, with wide-ranging personality problems in addition to their drug use, and many displayed histories of antisocial behavior. Thus, treatment focused on the whole person and on changing lifestyle and identity rather than simply achieving abstinence. These broad goals could be achieved only through an intense, 24-hour-a-week treatment in a long-term residential setting. The TC approach was not well understood but, more important, it was viewed as expensive, particularly compared with outpatient counseling and pharmacotherapy such as methadone maintenance. Furthermore, dropout was the rule, suggesting that the broad impact of the TC was limited when defined in terms of the number of clients completing treatment. These issues were fundamental to the survival of the TC as a bona fide health care modality that deserved continued public funding. They framed three key lines of inquiry in Phase 1: (a) the description of the social and psychological profiles of TC admissions, (b) documentation of the effectiveness of TC treatment, and (c) illumination of the phenomenon of retention in treatment. The main issues and conclusions in each line of inquiry are summarized next. Who Comes for Treatment? The broad issue underlying this line of inquiry was the validation of the TC perspective of the disorder and recovery, that is, that the individuals served required long-term residential treatment. Studies describing the social and psychological characteristics of admissions to TC programs documented that substance abuse among TC admissions is a disorder of the whole person (e.g., de Leon, 1984, 1985; Hubbard, Rachal, Craddock, & Cavanaugh, 1984; Simpson & Sells, 1982). In addition to their substance abuse, the drug abusers who enter TCs reveal a considerable degree of psychological disability, which

is further confirmed in diagnostic studies. Despite the TCs policy concerning psychiatric exclusion, the large majority of adult and adolescent admissions meet the criteria for coexisting substance abuse and other psychiatric disorders (De Leon, 1989, 1991; Jainchill, De Leon, & Pinkham, 1986) Are TCs Effective? The unique recovery goal of the TC is changing lifestyle and identities. Thus, it was essential to document the effectiveness of long-term residential TC particularly as compared with other treatment modalities. A particular issue was the clarification of outcomes among individuals who do not complete treatment, as dropout occurs in the majority of admissions. The main findings from outcome studies document that long-ter m residential TCs are effective in reducing drug abuse and antisocial behavior, particularly in opioid abusers (De Leon, 1984; De Leon & Jainchill, 1981-1982; Hubbard et al., 1989, Simpson & Sells, 1982). The extent of social and psychological improvement is directly related to retention in treatment. In the studies that have investigated psychological outcomes (e.g., depression, anxiety, self-concept), results uniformly showed significant improvement at follow-up (e.g., Biase, Sullivan, & Wheeler, 1986; De Leon, 1984; De Leon & Jainchill, 1981-1982; Holland, 1983). What Is Known About Retention in TC Treatment? Length of stay in treatment is the largest and most consistent predictor of positive post-treatment outcomes. However, as with other drug treatment modalities, most TC clients leave long-term treatment prematurely. Thus, understanding retention was, and remains, crucial for improving the impact and costbenefit of TC treatment. Studies show that temporal overall levels of retention vary, but the temporal pattern of dropout is uniform across TC programs (and other modalities). Dropout is highest in the early days of

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treatment and characteristically declines thereafter. Thus, the probability of remaining in treatment increases with time in treatment itself (e.g. De Leon & Schwartz, 1984). For example, approximately 60% of all admissions to community-based, long-term TC residential programs remain 90 days; of these survivors, 60%-70% will complete 12 months of residence1. There are not reliable client characteristics that predict retention, with the exception of severe criminality and severe psychopathology, that are correlated with earlier dropout. Studies point to the importance of dynamic factors in predicting retention in treatment, such as perceived legal pressure, motivation, and readiness for treatment (e.g., Condelli & De Leon, 1993; De Leon 1988, De Leon, Melnick, Kressel, &Jainchill, 1994; Hubbard, Collins, Rachal, & Cavanaugh, 1988; Simpson & Joe, 1993). The main conclusions from this research indicate that although retention is a legitimate concern, it should not be confused with treatment effectiveness. TCs are effective for individuals who remain long enough for treatment influences to occur. Obviously, a critical issue for TCs is maximizing holding power to benefit more clients. Research-Practice Reciprocity Overall, Phase 1 research confirmed that TCs were serving the most difficult substance abusers. Moreover, findings consistently supported the validity of the TC perspective on addiction and recovery, namely, that substance abuse is a disorder of the whole person and that long-term treatment is needed to achieve the TC recover y goals of changing

lifestyles. The Phase 1 research also contributed to changing practices in several ways. First, TCs now focus on retention: TCs were (and to some extent still are) criticized for their high dropout rates, particularly early in treatment. Critics viewed this as an evidence of the limited impact of this treatment approach. The TC view of dropout was complex: It made the individual primarily responsible for getting ready for treatment. TC staff defended this view on the basis of clinical experience, arguing that dropout were simply not ready to change, that motivational and readiness factors changed only as a result of the negative life experiences associated with addiction. Dropouts had to have another run and hit bottom, which would lead to death or readiness for change. Moreover, TC programs accepted high dropout rates as an inherent selection process that was necessary to sustain a healthy program. This view resulted in little systematic effort to modify the treatment approach to reduce dropout, much less enhance motivation. Based largely on the Phase 1 research, staff no longer blame the client for early dropout, recognizing that motivational/readiness factors should be assessed and enhanced as part of the treatment plan. Many TCs currently incorporate strategies within the basic TC regimen to sustain motivation in treatment (e.g., family involvement, individual counseling and senior staff seminars, medications; see De Leon, Hawke, Jainchill, & Melnick, 2000). Second, TCs also focus on assessment. Admission practices have become elaborated to address clients psychological suitability for the TC as well as risk for early dropout, and an increasing number of programs monitor clinical progress and motivational changes. There is an increased awareness of the importance of client-treatment matching. Multisetting TC agencies attempt to assess which clients are appropiate for longer and shorter term TC residential treatment as

1Retention (and outcome) comparisons with other modalities such as detoxification or 28 day rehab centers are invidious for various reasons. These modalities reflect wide differences in the clients served (e.g., social-psychological-health profiles, their sources of referral and treatment history), and the diversity of the treatment approaches (e.g., setting, source of funding, philosophy and goals of treatment).

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well as for TC-oriented day care and outpatient treatment. Matching strategies have been primarily conducted by clinical assignment. However, as described in the subsequent discussion of Phase 2, researches have developed client-treatment matching protocols as tools to assist in these assignments (e.g., Melnick, De Leon, & Thomas, 2001). The shortening of residential treatment for some clients has encouraged the use of continuing care programs in non-residential settings. This has reflected clinical and research experience that underscored the need for sufficient involvement in treatment, regardless of setting, to maximize effectiveness. To date, however, TC programs, and the drug treatment field in general, await convincing research documenting the impact of client-treatment matching on both retention and outcomes. An indirect effect of Phase 1 research has been increased affirmation and morale. Research has confirmed the perspective of the TC and its advocates clinical views with respect to outcomes and retention. This has generally strengthened perceptions of the credibility of the TC approach. As a result, TC clinical staff and program management articulate with confidence what they do and how well TCs work. PHASE 2 (1990-PRESENT) Phase 2 witnessed a considerable increase in federal support for TC research. This reflects not only the scientific gains in Phase 1 but also the persistence of the drug problem and the evolution of the TC itself. T h e f a c t t h a t d r u g t re a t m e n t w o r k s d o e s n o t necessarily solve societys drug problem. Substance abuse and related problems remain pervasive in terms of the diversity of populations and drugs of abuse. In response to this, TCs have modified their practices and adapted the approach for special populations, settings, and funding requirements.

Illustrations of these modifications and adaptations have been described elsewhere (De Leon, 1997, 2000, chapter 25). Current applications include TC programs for adolescents (Jainchill, 1997), homeless substance abusers, mentally ill chemical abusers in communitybased and institutional settings (Sacks, Sacks, & De Leon, 1999), inmates in correctional settings (Inciardi, Martin, Butzin, Hooper, & Harrison, 1997), women and children (Coletti et al. 1992; Stevens & Glider, 1994), and methadone-maintained clients (De Leon, Stainess, Sacks, Brady & Melchionda, 1997). Patient differences, as well as clinical requirements and funding realities, have encouraged the development of modified residential TCs with shorter planned durations of stay (3, 6, and 12 months) as well as TCoriented day treatment and outpatient ambulatory models (e.g., Guydish et al., 1999). Current modifications of the TC practices are those that can be incorporated into the TC model itself. Family services approaches include family therapy, counseling, and psycho-education. Primary health care and medical services are offered for the growing n u m b e r o f re s i d e n t i a l p a t i e n t s w i t h s e x u a l l y transmitted and immune-compromising conditions, including HIV seropositivity, AIDS, syphilis, and Hepatitis C. Screening, treatment, and increasing health education have become more sophisticated, both on site and through linkages with community and primary health care agencies. Aftercare services involve linkages with other service providers. Relapse prevention training (e.g., Lewis & Ross, 1994) has been incorporated into the TC day. Twelvestep components may be introduced at any stage in residential treatment but are considered mandatory in the re-entry stages of treatment and in the aftercare or continuance stages of recovery after the client has left the residential settings. Mental health services

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include psycho-pharmacological adjuncts and individual psychotherapy (see De Leon, 1997, for illustrative adaptations and modifications). The evolution of the TC caused basic policy issues, such as the feasibility, effectiveness, and cost-benefits of its various adaptations, to resurface. In particular, managed care pressures to reduce the cost of treatment have challenged the necessary for long-term residential treatment. However, a second issue that emerged from the adaptations and modifications of the TC concerned the fidelity of the approach itself. The wide diversity of TC-oriented programs has raised a variety of theoretical and quality assurance questions. These issues associated with the diversity of clients served and the fidelity of the TC adaptations have directed two main lines of inquiry in Phase 2 : (a) evaluation of the effectiveness of standard TCs serving the new generation of drug users as well as modified TCs for special populations and (b) conducting studies to clarify the essential elements of the TC approach. Federal funding of research on these questions has included support for studies conducted at the Center for Therapeutic Community Research on special populations and large-scale multimodality surveys such as the National Treatment Improvement Evaluation study (Preliminary report, 1996) and the Drug Abuse Treatment Outcome Study (Simpson & Curry, 1997). The following section summarizes the findings and conclusions of the main Phase 2 questions. Are Contemporary TCs Effective and Cost-Effective for Treating the Current Diversity of Substance Abusers? Studies have addressed the client admission profiles of both standard and modified TCs. These have focused on psychiatric comorbidity, retention characteristics, short- and long-term outcomes, and cost analyses. Special populations that have been studied are mentally ill chemical abusers,

adolescents, the homeless population, criminal justice clients, and mothers with children, as well as methadone-maintained clients. The findings and conclusions regarding the admission profiles and the effectiveness of standard and modified TCs are briefly summarized in Exhibit 2.1. The weight of the evidence from the Phase 2 studies indicates that current standard and modified TCs provide effective treatment for the current generation of substance abusers who reveal a wide range of social and psychological problems. Based on their unique self-help perspective, TCs provide a favorable cost-benefit alternative to traditional institutionalb a s e d t re a t m e n t s i n m e n t a l h e a l t h , h o s p i t a l , correctional, and community-based settings. What is the TC Treatment Approach, and Why Does It Work? TCs are complex programs that are considered difficult and costly to implement relative to other treatment modalities. Specification of the active ingredients of the method and an understanding of the treatment process are critical to substantiate the validity of the TC approach, to justify its costs, and to improve the approach itself through research and training. Studies clarifying the treatment approach have mainly been conducted by the Center for Therapeutic Community Research at the National Development and Research Institutes, Inc. These have focused on elaborating the theory and method of the TC approach, developing instruments for assessing client motivation and readiness for treatment and clinical progress, defining and validating the essential elements of the TC model, identifying TC treatment environments that relate to risk for client dropout, and providing a conceptual formulation of the treatment process. The main findings and conclusions from these studies are briefly summarized in Exhibit 2.2.

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EXHIBIT 2.1 Phase 2 Research: Effectiveness of Standard and Modified Therapeutic Communities (TCs)
Standards TCs - National, multimodality survey studies uniformly show that community-based standard TC residential programs were serving the most severe substance abusers compared with other treatment modalities (Simpson & Curry, 1997). Client admission profiles indicate that contemporary TCs are serving individuals who reveal a considerable degree of social and psychological dysfunction in addition to their substance abuse. - Long-term residential programs obtain positive outcomes in drug use, criminality, employment, and psychological adjustment that are comparable or superior to other modalities that treat less severe substance abusers (Preliminary report 1996; Simpson & Curry, 1997). Also, cost-benefits for long-term residential treatment exceeded those of other treatment modalities, particularly benefits associated with reduction in crime (Flynn, Kristiansen, Porto, & Hubbard, 1999). - The planned duration of residential treatments in generally shorter than in earlier years; however, outcomes are still favorable among the clients who complete or stay longer in treatment. The differential effects of longer and shorter planned durations of residential stay remain to be clarified. In initial studies that have attempted to match clients to settings (residential-outpatient), evidence points to improved retention. Modified TCs - Drug use and criminality declined along with improvements in employment and psychological status for various special populations (De Leon, 1997; De Leon, Sacks, Staines, & McKendrick, 2000; Simpson, Wexler, & Inciardi, 1999). Again, improvements were correlated with lengh of stay in treatment (Inciardi et al., 1997; Jainchill, Hawke, De Leon, & Yagelka, 2000; Melnick, De Leon, & Thomas, 2001; Simpson, 1981). Aftercare services beyond primary treatment in the residential TC- is a critical component of stable outcomes. Thus, regardless of planned duration of primary treatment, individuals must continue in the treatment process for some undetermined time beyond the residential phase - Aftercare models must be integrated with the primary treatment model in terms of philosophy, methods, and relationships to provide effective continuity of care (e.g., De Leon, Sacks, et al., 2000). Studies in progress on samples leaving prison-based modified TC treatment suggest the superiority of TC-oriented vs. non-TC-oriented aftercare (Sacks, Peters, et al., in press). - Fiscal studies indicate that TC-oriented programs reveal favorable cost-benefit gains, particularly in reduction of expenditures associated with criminal activity in mental health services (e.g., French, Sacks, De Leon, Staines, & McKendrick, 1999; French, Sacks, McKendrick & de Leon, 2000).

Note. From The Research Context for Therapeutic Communities in the USA, by G. De Leon, in press, London : Jessica Kingsley Publishers. Copyright by Jessica Kingsley Publishers. Reprinted with permission.

Research-Practice Reciprocity Phase 2 research has documented the fact that standard TCs continue to serve the most serious substance abusers as compared to outpatient and other residential modalities. More important, it has provided empirical evidence for the feasibility and effectiveness of implementing modified TC programs into various institutional settings (e.g., mental hospitals, homeless shelters, prisons, methadone

clinics). These scientific gains have advanced initiatives to extend TC-oriented programs further into mainstream human services. The Phase 2 witnessed how the reciprocity between practice and research unfolds. TC agencies initially responded to the diversity of clients entering treatment by modifying and adapting the model. Evaluation research followed practice in providing empirical data as to effectiveness and cost-effectiveness. In turn, these

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EXHIBIT 2.2 Phase 2 Research: Clarifying the Therapeutic Community (TC) Approach: Findings and Conclusions
Program Diversity Empirical studies have identified the essential elements of the TC program model. TC programs have been differentiated in terms of standard and modified types and with respect to environmental factors that relate to dropout (e.g., Jainchill, Yagelka, & Mesina, 1999; Melnick, De Leon, Hiller, & Knight, 2000). Motivation The role of motivational and readiness factors in entry and retention in TC treatment has been assessed (e.g., De Leon, Melnick, & Hawke, 2000; Simpson & Joe, 1993), and initial studies have measured the contribution of these factors to the treatment process in the TC (Melnick, De Leon, Thomas, Wexler, & Kessel, 2001). Clinical assessment An array of related instruments has been developed to measure client progress in the TC assessed by the clients, staff, and peers (e.g., Kressel, Palij, & De Leon, 2001; Kressel, Palij, De Leon, & Rubin, 2000). Theoretical Framework Research has contributed to the development of a comprehensive theoretical framework of the TC approach. This framework is used to guide clinical practice, program planning, and treatment improvement as well as empirical studies of treatment processes and client-treatment matching (De Leon, 2000).
Note. From The Research Context for Therapeutic Communities in the USA , by G. De Leon, in press, London: Jessica Kingsley Publishers. Copyright by Jessica Kingsley Publishers. Reprinted with permission.

scientific gains have advanced initiatives to extend TC programs further into mainstream human services. An impressive illustration of these advances in the expansion of TC-oriented programs in the correctional system and, to a lesser extent, into community residences for people with mental illness and homeless shelter settings. Finally, research confirmation of the adaptation of the TC for special populations and settings encouraged the cross-fertilization of clinical practices among TC and traditional mental health, correctional, and human services professionals. The second line of inquiry to clarify the essential e l e m e n t s o f t h e t re a t m e n t a p p ro a c h h a s h a d impor tant practice and policy effects. The elaboration of the theoretical framework of the treatment approach and the supporting research have facilitated significant to improve TC treatment through quality assurance and clinical practice training. National standards for prison and

communitybased TC treatment have been developed and promulgated. Efforts are underway to establish a process for program accreditation and s t a ff t r a i n i n g b a s e d o n t h e s e s t a n d a rd s a n d grounded in theory (e.g., Therapeutic Communities of America, Criminal Justice Committee, 1999, 2001). SOME INSIGHTS AND ISSUES In the fields of conventional medicine and mental health, research generally precedes the widespread implementation of evidenced-based treatments or clinical practices. For example, in addiction treatment randomized, controlled trials launched methadone detoxification and maintenance. Contingency contracting, cognitive-behavioral approaches, and motivational interviewing were borrowed from mainstream psychological treatment research, modified for addiction treatment, and evaluated under controlled designs.

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In the evolution of the TC, however, research has generally followed practice, as has the formulation of its theoretical underpinnings. In turn, theory and research have informed changes in TC program management and clinical practice. This unique reciprocity of research and practice in TCs over the years contains insights for both science and treatment. Science Insights Self-Selection For drug treatment research in general, and TC studies in particular, the issue of selection has clouded the interpretation of treatment effectiveness. Length of stay in treatment has been identified as the most consistent predictor of post-treatment success. However, selfselection factors may influence those who seek, remain in, and complete treatment. In the past 10 years, fieldeffectiveness studies have confirmed a long-held clinical understanding that selection factors, such as motivation and readiness, contribute to treatment retention and outcomes (De Leon et al., 1994; Joe, Simpson; & Broome, 1998; Melnick, De Leon, Hawke, Jainchill, & Kressel, 1997). This body of work supports a perspective outlined in other writings in which selfselection in viewed as a prerequisite for treatment effectiveness (e.g., De Leon, 1998; De Leon, Melnick, & Hawke, 2000). Clients who are more highly motivated are more likely to use treatment differently than clients with less motivation to change themselves Such an interactional view of self-selection in the treatment process has important clinical and research implications. For example, good treatments and clinical practices are those that identify, increase, and sustain motivational factors for change. With respect to research, client motivational/readiness factors must be routinely measured and their contribution to retention and outcomes assessed in studies of treatment effectiveness. Moreover, comparative treatment designs must assure that motivational/readiness

factors are equally distributed across treatment conditions2. Practice, Research and Theory Since its inception, TC treatment was grounded in its own native theory, consisting of the TCs common practices, beliefs, and assumptions concerning selfhelp recovery. However, the cumulative knowledge base from the reciprocity between research and practice over the years has recently fostered the elaboration of a more formal theory of the TC. The latter reframes the TC its essential elements, practices, beliefs and assumptions into a unique socialpsychological treatment approach (see De Leon, 2000). The validity of this theoretical framework is currently being explored in studies that focus on improving treatment effectiveness through process oriented research (e.g., De Leon, 2001; Kressel, 2000). Treatment and Policy Insights Retention Time in program has been the most consistent predictor of successful outcomes. However, TC clinicians have emphasized that time alone is a proxy for dosage of treatment: Individuals must remain in a program long enough for time-correlated interventions to work and for treatment benefits to occur. Thus, present cost pressures to reduce planned durations of residential treatment must consider client factors in relationship to treatment intensity. Policy and Research Paradigms Effectiveness studies, such as those conducted on TC treatment as it is practiced in the field, have established the benefits of TC treatment before efficacy studies, that is, those conducted in controlled conditions. The

2A sample assessment tool to measure motivational/readiness for TC treatment is reflected in the CMRS scales (De Leon et al., 1994). The increasing use of these scales illustrates a useful dissemination of knowledge from research to practice.

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evidence from the field studies remains compelling based on the numbers of clients studied and the replication of findings across years, samples, and investigative teams. From a policy perspective, the fieldeffectiveness studies have provided the main empirical justification for continued federal funding for drug treatment expansion and for treatment services research. Moreover, the field-effectiveness studies constitute a knowledge base to guide efficacy studies of treatment improvement. This point is illustrated in the National Institute on Drug Abuses (NIDAs) current emphasis on controlled studies of why and how TCs work rather than on whether they work. A ResearchPractice Utilization Model A key insight emerging from the years of reciprocity between TC research and practice underscores the need for appropriate models of technology transfer. Successful reciprocity depends on how effectively programs use research to improve treatment. The experience in TCs indicates that involvement in research projects, the use of scientific information, and the value of research itself must be reinforced through its application to program needs. However, the use of research in human services settings in general, and in TCs in particular, has typically been impeded by the communication difficulties and perceptual distortions that often exist between research and nonresearch people (De Leon, 1979, 1980). For example, program evaluation may be viewed as hidden threats to the funding or survival of treatment agencies. Data systems are viewed as remote substitutions for face-to-face interactions rather than as technological extensions that could facilitate human services. Service program staff often perceive data people as removed from the realities of delivering day-to-day treatment. Research activities (such as completing forms) are seen as uncompensated burdens that are not relevant to service delivery. Researchers may view program

people as inflexible in their beliefs and lacking objectivity concerning the work. Often they find line workers recalcitrant to participating in researchdictated boundaries, such as random designs, or not open to learning research-relevant skills (such as record keeping) that will increase accountability. Researcherclinician communication is often impeded by different vernaculars an issue that is critical to translating the meaning and value of research for practice. These issues have shaped an approach to maximize research use that has evolved over the years of reciprocity in TC programs. The premise of the approach is that the use of research for clinical practice and programming is optimized when treatment programs themselves are completely involved in the purpose, design, and conduct of research. In Exhibit 2.3, key components of the approach that illustrate the theme of researchpractice integration in relation to use are outlined. CLINICAL PRACTICE AND A NEW RESEARCH AGENDA The evolution of the scientific knowledge base has gradually shifted the research question from whether TCs work to how they work. To a considerable extent, this shift reflects both policy and scientific issues. TCs work for serious substance abusers, for special populations, and in various settings. The weight of the outcome research accumulated over 30 years has established the TC as an evidenced-based treatment, researches must isolate the components of the approach that are critical to its effectiveness. Identifying the active treatment ingredients of the TC approach remains a compelling question for improving treatment, funding policy as well as science. Reducing the costs of treatment by limiting its planned duration, for example can be rationally implemented only if the necessary and sufficient TC interventions are known.

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EXHIBIT 2.3 Maximizing Utilization of Research for Practice

Assessment Treatment agencies are more likely to use research for practice when they are ready to change their customary administrative or clinical practices. Thus, before research projects or findings are introduced into treatment settings, evaluations are essential to assess agency (organizational) readiness to engage and use research to charge its practices. Preparation Treatment agencies (and practitioners) need to be prepared to engage in research efforts, and use findings for clinical practice. This involves planning sessions that represent a cross-fertilization of research, clinical, and administrative staff in the purpose, conduct, relevance, and impact of the research project. Clinical and administrative input are essential to define the questions and address the issues of design and data collection. Project personnel should be composed of agency-based research and externally based research teams, and funding should be sufficient to support agency participation in research. Dissemination A variety of strategies and products are used to advance research use. These include research-practice-management seminars in which all participants contribute to the interpretation of the findings, recommendations, and limits of a study. Appropiate written, audio, and video formats are developed for describing findings, conclusions, and implications. Research personnel are effectively used as educators in translating scientific findings into curricula for training in program management and clinical practices.

These issues are shaping a current focus of research on the treatment process in therapeutic communities. Illuminating the treatment process in the TC, however, underscores the necessity for continued practiceresearch reciprocity. In contrast with evaluation of treatment outcomes, which involves minimal intrusion into the activities of the treatment program, studying the treatment process in the TC often requires research strategies that perturb the process itself. Program management and, in particular, clinical staff, must be completely supportive of research activities that can alter standard procedures, practices and, possibly, the treatment environment. Such support is particularly compelling considering the unique nature of the TC treatment approach. T h e T C i s a g l o b a l t re a t m e n t t h a t c o n s i s t s o f m a n a g e m e n t a n d c l i n i c a l p r a c t i c e s t h a t a re embedded in the programs daily regimen of formal activities (e.g., planned meetings, groups, work assignments) and informal activities (unplanned, spontaneous peer-per and peer-staff interactions).

Each activity is potentially an intervention, and all activities are interrelated to produce individual change (De Leon, 2000, see chapter 24). Research strategies that attempt to study the active ingredients of this global approach may be deconstructive or enhancive. Deconstructive strategies attempt to isolate the necessity or sufficiency of a hypothesized ingredient (e.g., peer groups) by subtracting it from the treatment regimen. Enhancive strategies intensify a specific activity or practice (e.g., formal training of residents in the factory of peer roles) to improve their treatment impact. The intrusive character of both strategies requires an extraordinary cooperation among researchers, program management, and clinical practitioners as to the goals, significance, and conduct of the research itself. Indeed, the success of this cooperation may generate innovative strategies for studying treatment process as well as improve treatment practices. Finally, the maturation of the reciprocity between research and practice in TCs is dramatically illustrated

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in two cooperative initiatives between NIDA and the Therapeutic Communities of America, the North American association of TCs. One initiative addresses the elaboration of a TC treatment process research agenda, as discussed previously. This has resulted in a recent NIDA request for research applications dedicated to understanding and improving TC treatment. The second initiative focuses on disseminating a NIDA project that is in preparation and that outlines TC principles and practices grounded in clinical theory and supported by research (NIDA, 2002). These products reflect the cross-fertilization of the TC treatment field workers (practitioners and program managers), researchers (program based and independent), and the federal funding agency. They also signify an evolutionary landmark in how reciprocity assures the success of both research and treatment objectives. REFERENCES Biase, C:V:, Sullivan, A.P., & Wheeler, B. (1986). Daytop Miniversity Phase 2 college training in a therapeutic community: Development of self concept among drug free addicts. In G de Leon & J.T. Ziegenfuss (eds.), Therapeutic communities for addictions (pp. 121-130). Springfield, IL: Charles C. Thomas. Coletti, D.S., Hughes, P.H., Landress, H.J., Neri, R.L. Sicilian, D.M., Williams, K.M., et al. (1992). PAR village: Specialized intervention for cocaine abusing women and their children. Journal of the Florida Medical Association, 79, 701-705. Condelli, W.S. & De Leon, G. (1993). Fixed and dynamic predictors of client retention in therapeutic communities. Journal of Substance Abuse Treatment, 10, 11-16. De Leon, G. (1979). People and data systems. In Management information systems in the drug field

(National Institute on Drug Abuse Treatment Research Monograph Series, DHEW Publications No.ADM-79-836, pp. 107-120). Rockville, MD: National institute on Drug Abuse. De Leon, G. (1980). Therapeutic communities: Training self evaluation . Final report of project activities (National Institute on Drug Abuse Grant No. 1H81-DAO). New York: National Development and Research Institute. De Leon, G. (1984). The therapeutic community: Study of effectiveness (National Institute on Drug Abuse Treatment Research Monograph Series ADM-841286). Washington, DC: U.S. Government Printing Office. De Leon, G. (1985). The therapeutic community: Status and evolution. International Journal of Addictions, 20, 823-844. De Leon, G. (1988). Legal pressure in therapeutic communities. In C.G. Leukefeld & E.M. Tims (eds.), Compulsory treatment of drug abuse: Research and clinical practice (NIDA Research Monograph 86, DHHS No. ADM-88-1578, pp. 160-177). Rockville, MD: National Institute on Drug Abuse. De Leon, G. (1989). Psychopathology and substance abuse: What we are learning from research in therapeutic communities? Journal of Psychoactive Drugs, 21, 177-188. De Leon, G. (1991). Retention in drug-free therapeutic communities. In R.W. Pickens, c:g: Leukefeld, & C.R. Schuster (Eds.), Improving drug abuse treatment (NIDA Research Monograph 106, pp. 218-224). Rockville, MD: National Institute on Drug Abuse. De Leon, G. (Ed.). (1997). Community as method: Therapeutic communities for special populations and special settings. Westport, CT: Greenwood. De Leon, G. (1998). Commentary: Reconsidering the self-selection factor in addiction treatment research. Psychology of Addictive Behaviors, 12, 71-77.

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De Leon, G. (2000). The therapeutic community: Theory, model, ad method. New York: Springer. De Leon, G. (Principal Investigator). (2001). Treatment process: Enhancing peer mentor performance. Unpublished grant proposal, Center for Therapeutic Community Research, National Development and Research Institutes, New York. De Leon, G. (in press). The research context for therapeutic communities in the USA. In J. Lees, N. Manning, D. Menzies, & N. Morant (Eds.), Researching therapeutic communities. London: Jessica Kingsley. De Leon, G., Hawke, J.; Jainchill, N., & Melnick, G. (2000). Therapeutic communities: Enhacing retention in treatment using senior professor staff. Journal of Substance Abuse Treatment, 19, 375-382. De Leon, G., & Jainchill, N. (1981-1982): Male and female drug abusers: Social and psychological status 2 years after treatment in a therapeutic community. American Journal of Drug and Alcohol Abuse, 8, 465-497. De Leon, G., Melnick, G., & Hawke, J. (2000). The motivation/readiness factor in drug treatment research: Implications for research and policy. In D. Mcbride, R. Stephens, & J. Levy (Eds.), Emergent issues in drug treatment: Advances in medical sociology (Vol. 7, pp. 103-129). Greenwich, CT: JAI Press. De Leon, G. Melnick, G., Kressel, D., & Jainchill, N. (1994). Circumstances, motivation, readiness and suitability (the CMRS scales): Predicting retention in therapeutic community treatment. American Journal of Drug and Alcohol Abuse, 20, 495-515. De Leon, G., Sacks, S., Staines, G., & McKendrick, K. (2000). Modified therapeutic community for homeless mentally ill chemical abusers: Treatment outcomes. American Journal of Drug and Alcohol Abuse, 26, 461-480.

De Leon, G., & Schwartz, S.(1984). The therapeutic community: What are the retention rates? American Journal of Drug and Alcohol Abuse, 10, 267-284. De Leon, G., Staines, G.L., Sacks, S., Brady, R., & Melchionda, R. (1997). Passages: A modified Therapeutic community model for methadonemaintained clients. In G. De Leon (Ed.), Community as method; Therapeutic communities for special populations and special settings (pp.225-246). Westport, CT: Greenwood. Flynn, P.M., Kristiansen, P.L., Porto, J.V., & Hubbard, R.L. (1999). Costs and benefits of treatment for cocaine addiction in DATOS. Drugs and Alcohol Dependence, 57, 167-174. French, M.T. Sacks, S., De Leon, G., Staines, G., & Mclendrick, K. (1999). Modified therapeutic community for mentally ill chemical abusers: Outcomes and costs. Evaluation and the Health Professions, 22, 60-85. French, M.t., Sacks, S., Mckendrick, K., & De Leon, G. (2000). Services use and cost by MICAs: D i ff e re n c e s b y re t e n t i o n i n a T C . J o u r n a l o f substance Abuse, 11 (2), 1-15. Guydish, J., Sorensen, J.L., Chan, M., Werdegaar, D . , B o s t ro m , A . , & A c a m p o r a , A . ( 1 9 9 9 ) . A randomized clinical trial comparing day and residential drug abuse treatment: 18 month outcomes. Journal of Consulting and Clinical Psychology, 67, 428-434. Holland, S. (1983). Evaluating community based treatment programs: A model for strengthening inferences about effectiveness. International Journal of Therapeutic Communities, 4, 285-306. H u b b a r d , R . L . , C o l l i n s , J . J . , R a c h a l , J . V. , & Cavanaugh, E.R. (1988). The criminal justice client in drug abuse treatment (NIDA Research Monograph No. 86). Research Triangle Park, NC: Research Triangle Institute.

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H u b b a rd , R . L . , M a r s d e n , M . E . , R a c h a l , J . V. , Harwood, H.J., Cavanaugh, E.R., & Ginzburg, H.M. (1989). Drug abuse treatment: A national study of effectiveness . Chapel Hill: University of North Carolina Press. Hubbard, R.L., Rachal, J.V., Craddock, S.G., & Cavanaugh, E.R. (1984). Treatment Outcome Prospective Study (TOPS): Client characteristics and behaviors before, during and after treatment. In F.M. Tims, & J.P. Ludford (Eds.), Drug abuse treatment evaluation: Strategies, progress, and prospects (NIDA Research Monograph No. 51, DHHS No. ADM-84-1329, pp. 42-68). Rockville, MD: National Institute on Drug Abuse. Inciardi, J.A., Martin, S.S., Butzin, C.A., Hooper, R.M., & Harrison, L.D. (1997). An effective model of prisonbased treatment for drug-involved offenders. Journal of Drug Issues, 27, 261-278. Jainchill, N (1997). Therapeutic communities for adolescents: The same and not the same. In G. De Leon (Ed.), Community as method: Therapeutic communities for special population and special settings (pp. 161-178). Westport, CT: Greenwood. Jainchill, N., De Leon, G., & Pinkham, L. (1986). Psychiatric diagnoses among substance abusers in therapeutic community treatment. Journal of Psychoactive Drugs, 18, 209-213. Jainchill, N., Hawke, J., De Leon, G., & Yagelka, J. (2000). Adolescents in TCs: One-year post-treatment outcomes. Journal of Psychoactive Drugs, 32, 81-94. Jainchill, N., Yagelka, J., & Messina, M.(1999). Development of a Treatment Environmental Risk Index (TERI): Assessing risk fot client dropout. Unpublished manuscript, Center for Therapeutic Community Research, National Development and Research Institutes, New York. Joe, G.W., Simpson, D.D., & Broome, K.M. (1998). Effects of readiness for drug abuse treatment on

client retention and assessment of process. Addiction, 93, 1177-1190. Kressel, D. (Principal Investigator). (2000). A protocol to improve therapeutic community training . New York: Center for Therapeutic Community Research, National Development and Research Institutes. Kressel, D., Palij, M., & De Leon, G. (2001). The predictive validity and clinical utility of instruments measuring client progress in therapeutic community treatment. Unpublished manuscript, Center for Therapeutic Community Research, National Development and Research Institutes, New York. Kressel, D., Palij, M., De Leon, G., & Rubin, G. (2000). Measuring clinical progress in therapeutic community treatment: The Client Assessment Inventory (CAI), Client Assessment Summary (CAS) and Staff Assessment Summary (SAS). Journal of Substance Abuse Treatment, 19, 267-272. Lewis, B:F., & Ross, R (1994), Therapeutic community: Advances in research and application, NIDA Monograph 144 (NIH Publication No. 94-3633). Washington, DC: Superintendent of Documents, U.S. Government Printing Office. Melnick, G., &De Leon, G. (1999). Clarifying the nature of therapeutic community treatment: The Survey of Essential Elements Questionnaire (SEEQ). Journal of Substance Abuse Treatment, 16, 307-313. Melnick, G., De Leon, G., Hawke, J., Jainchill, N., & Kressel, D. (1997). Motivation and readiness for therapeutic community treatment among adolescent and adult substance abusers. American Journal of Drug and Alcohol Abuse, 23, 485-507. Melnick, G., De Leon, G., Hiller, M. L., & Knight, K. (2000). Therapeutic communities: Diversity in treatment elements. Journal of Drug Use and Misuse, 35, 1819-1847. Melnick, G., De Leon, G., & Thomas, G., (2001). A client-treatment matching protocol (CMP) for

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therapeutic communities: First report. Journal of Substance Abuse Treatment, 21, 119-128. Melnick, G., De Leon, G., Thomas, G., Wexler, H. K., & Kressel, D. (2001). Treatment process in therapeutic communities: Motivation, progress and outcomes. American Journal of Drug and Alcohol Abuse, 27, 633-650. National Institute on Drug Abuse. (2002). Therapeutic community (Research Repor t Series, NIH Publication No.02-4877). Rockville, MD: U.S. Department of Health and Human Services, National Institutes of Health. Preliminary report: The persistent effects of substance a b u s e t r e a t m e n t O n e y e a r l a t e r. ( 1 9 9 6 , September). Rockville, MD: U.S. Dept. of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment. Sacks, S., Peters, J., Sacks, J. Y., Wexler, H. K., Roebuck, C., De Leon, G. (in press). Modified therapeutic community for MICA offenders: Description and interim findings. Criminal Justice and Behavior. Sacks, S., Sacks, J. Y., & De Leon, G., (1999). Treatment for MICAs: Design and implementation of the modified TC. Journal of Psychoactive Drugs, 32, 19-30. Simpson, D. D. (1981). Treatment for drug abuse: Follow-up outcomes and length of time spent. Archives of general Psychiatry, 38, 875-880. Simpson, D. D., & Curry, S.J. (Eds.).(1997). Drug Abuse Treatment Outcome Study (DATOS) [Special issue]. Psychology of Addictive Behaviors, 11(4), 211-337. Simpson, D. D., & Joe, G.W. (1993). Motivation as a p re d i c t o r o f e a r l y d ro p o u t f ro m d r u g a b u s e treatment. Psychotherapy, 30, 357-368. Simpson, D. D., Sells, S.B., (1982). Effectiveness of

treatment for drug abuse: An overview of the DARP research program. Advances in Alcohol and Substance Abuse, 2, 7-29. Simpson, D. D., Wexler, H.K., & Iniciardi, J.A. (Eds.). (1999). Drug treatment outcomes for correctional settings, Parts 1 and 2 [Special issue]. Prison Journal, 79(4). S t e v e n s , S . , & G l i d e r, P. ( 1 9 9 4 ) . T h e r a p e u t i c communities: Substance abuse treatment for women. In F. M. Tims, G. De Leon, & N. Jainchill (Eds.), Therapeutic community: Advances in re s e a rc h a n d a p p l i c a t i o n ( N I D A R e s e a rc h Monograph No. 144, NIH No. 94-3633, pp. 162180). Rockville, MD: National Institute on Drug Abuse. Therapeutic Communities of America, Critical Justice Committee. (1999). Therapeutic Communities in Correctional Settings: The prison Based TC Standards Development Project, Phase II (final report prepared for the White House Office of National Drug Policy [ONDCP]. Washington, DC: Author. Therapeutic Communities of America, Critical Justice Committee. (2001). Therapeutic Community Standards Development Project, Phase III American Correctional Association Version (final report prepared for the Center for Substance Abuse Treatment). Washington, DC: Author.

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ENFOQUE DE GNERO EN EL TRABAJO CON MUJERES RESIDENTES EN NUESTRAS COMUNIDADES TERAPUTICAS ESTNDAR PARA TOXICMANOS

GENDER APPROACH IN THE WORK WITH FEMALE RESIDENTS IN OUR STANDARD THERAPEUTIC COMMUNITIES FOR DRUG ADDICTS

Martens, Johanna Director T.C. De Spiegel, Belgium.

El enfoque orientado en funcin del gnero en el trabajo realizado entre mujeres residentes en nuestras comunidades teraputicas estndar ha estado presente en las conferencias que tuvieron lugar en Oslo (1997) y en Varsovia (2001). En Oslo, analizamos y discutimos nuestra experiencia belga, en marcha desde 1995 (Vase nuestro artculo en www.eftc-europe.com). Ms tarde, Espaa y Noruega iniciaron su propio enfoque en torno a las mujeres y su interconexin, inspirados en la experiencia belga. Las CTs espaolas y noruegas estarn presentes en este taller belga, y compartirn sus experiencias locales con mujeres residentes. El enfoque de gnero en el trabajo con mujeres residentes se centra en: 1. Residentes y personal 2. Comprensin de los problemas de gnero de las mujeres a nivel conductual, emocional y cognitivo, y su situacin como grupo minoritario en la CT. 3. La solucin de interconexin, con un da de intercomunicacin entre las CTs dedicado a la mujer y de frecuencia mensual para el grupo minoritario de mujeres residentes, donde algunas herramientas teraputicas bsicas de nuestro trabajo en la CT puedan utilizarse: intercambio, apoyo, autoayuda, modelo de rol, reflexin y actuacin. Adems de los participantes europeos, esperamos dar la bienvenida a participantes experimentados de otros continentes para comentar este trabajo europeo y compartir sus propias experiencias.

The gender-oriented approach in the work carried among female residents in our standard therapeutic communities has already been in the picture during the conferences that took place in Oslo (1997) and Warsaw (2001). In Oslo we discussed our Belgian experience which has been going on since 1995 (See our paper on www.eftc-europe.com). Later, Southern Spain and Norway began their own women-centred approach and network, inspired by the Belgian experience. In this workshop Belgian, Spanish and Norwegian TC's will be present and will share their "local" experiences with female residents. The gender oriented approach in the work with female residents focuses on: 1. resident and staff 2. understanding the gender-connected problems in women on the behavioral, emotional and cognitive level, and their situation as a minority group in the TC. 3. the network solution with a monthly inter-TC women's day for the minority group of female residents where some basic therapeutic tools of our TC work can be used: sharing, support, self-help, role model, reflection and action. In addition to the European participants,we look forward to welcoming experienced participants from other continents to comment on this European work and to share their own overseas experiences.

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THE BELGIAN EXPERIENCE SINCE 1995 To give you some idea of the concrete work going on with the female residents, well go back to the paper mentioned earlier with the highlights of the Belgian experience. Belgium is a small country and is divided into three cultural parts, each with its own language (Dutch, French and German). In the Dutch-speaking part, there are five therapeutic communities for drug addicts. Only 20% of the residents of these TC's are women (Noels and Wydoodt, 1996). These TC's are characterised by a male life style, with a lot of hard work, sports activities and confrontation going on. Because of this situation, female residents get little support and lack a role model. In contrast with the gender of the residents, nearly 50% of the staff members are women. Different hypotheses can be formulated to explain the low occupation rate of women in the TC's. Some of these hypotheses have to do with society, others have to do with the TC's themselves. First we have to take into account that women prefer medicine and alcohol rather than hard drugs. These first substances are easier to get, or are easily prescribed by medical doctors. They are consumed within the context of a very different subculture or scene, and the hard illegal drug scene may frighten many women. Second, it is not difficult to understand that a long-term residential programme is hard for women with children to enter. It's painful for them to be separated from their children and not easy to find a good solution if other family members are unable to look after the children. We also have the impression that addicted women are able to maintain themselves quite well on the drug scene. Usually they have a boyfriend who is also their drug dealer. When the police catch the couple, the man admits to being responsible and goes to jail while the woman remains free, visits him and takes him the drugs he needs. Women earn the

necessary money for the drugs by prostitution rather than by committing theft. And we know that the judicial authorities are more tolerant towards prostitution than towards burglary. Women are also less pressured by the judicial authorities to enter a TC. But the TC itself is also responsible for the fact that women have difficulties entering and staying in the TC. As mentioned before, the TC is characterised by a male life style. Some women may experience sexual danger because of the macho seduction going on, or feel oppressed as members of a minority group. WHO ARE THESE WOMEN IN THE THERAPEUTIC COMMUNITY? How can we describe the women who stay in our TC's? First of all we have to think of people with a character disorder (Kooyman, 1993) and a traumatised sexuality (Martens, 1996). Most of the women have been sexually abused during their youth and /or have prostituted themselves during their drug career. They have a lot of physical problems and tend to neglect themselves in that regard. Some of the women have eating disorders such as anorexia and bulimia or eat a lot of sugar. Their psychological problems can be characterised as following. At the behavioural level they are sub-assertive, having difficulties saying no, setting limits and accepting positive feedback. They are uncomfortable with intimacy without sex and sex without drugs. At the emotional level it is obvious that they have problems with feeling and expressing anger. At the cognitive level they have a triple negative selfimage: as a person with a character disorder, with an addiction problem and as a woman in society. SURVIVAL STRATEGIES The women in our TC's tend to use typical survival strategies that were functional on the drug scene but tend to hang on and are very hard to drop inside the

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T.C. This certainly confirms the hypothesis of a macho subculture in the TC (and perhaps in society?). The two extremes of these strategies can be described as the macha-rejector style versus the doormat-acceptor style. The macha seems to be very strong and able to live by herself. In fact, she is only tough and afraid of intimacy. The doormat cannot live by herself and would do anything not to be alone. She seems to be lacking self-respect. Other possible strategies women can use, are flirting with men or choosing a pimp that protects them from the other males. These strategies can be understood as a way of attempting to control the situation and of maintaining themselves as a minority of women among men. WOMAN-CENTRED APPROACH To be able to do something about the described situation and to give the addicted women more possibilities to benefit from a fruitful stay in a TC, we have been developing a so-called woman-centred approach in the TC's. We decided to pay attention to the female residents as well as to the female staff. In our work with the residents, the focus is womancentred throughout the therapeutic programme and we also give the women extra activities and privileges. On a behavioural level we encourage them to drop their survival strategies, take care of their bodies (e.g., hygiene, dentist, gynaecologist), control their eating patterns, be assertive (e.g., acquire status and privileges), say no (set limits), accept positive feedback, and experience intimacy without sex, and sex without drugs. At the emotional level we encourage them to express anger, especially within the safety of the encounter group or the bondingpsychotherapy. At the cognitive level we help them to think about themselves in a positive way. The extras that the women get, are the following. First of all we make sure that they have a godmother among the

resident group and among the staff from whom they can get the necessary support. Secondly, we organise a weekly group session exclusively for women where they can discuss their problems in a safe environment without having to take care of, or trying to seduce men. FORT-techniques can be used and will be explained further in this paper. We also have the monthly inter-TC womens day. More about this will also be described later. Specific hygienic facilities are provided as well as accessories in their own toilet and bathroom and more time allowed for private hygiene. If necessary, a separate corner is organised in the living room where the women can sit and relax without being approached by the men. For the female staff members of the TC's we have been organising a training day every year. This is an opportunity to exchange experiences, discuss and hear a lecture by some expert. MONTHLY WOMENS DAY The purpose of this womens day is to make the TC more suitable for female addicts by encouraging solidarity among them and giving them support for their minority position in their own TC. We want them to benefit from the role model function that is available in a larger group with older women and with women who have been par ticipating in a therapeutic programme for a longer time. The spirit of the meeting is that the residents choose and organise their own programme for the day and get support from staff members, if necessary. Every TC takes turns being the host. Staff members (one from each TC) participate on a personal level as a woman and supervise at the same time. The programme of the day starts with a coffee and getting to know each other. This is followed by a group discussion on an issue chosen by the residents. At lunch there is a buffet prepared by the different TC's

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and much informal chatting. This is followed by activities connected with the issue of the day. Finally, the group sits together to evaluate the day and to make proposals for the next womens day. Some of the discussion issues and activities can be found in the following list. Issues: relationships with men, sexual abuse, hobbies, mother and daughter, being a woman in the TC, healthy eating and cooking, taking care of my body, dressing in the TC, being a parent in the TC, assertiveness, how to spoil our bodies, gynaecology, aggression in the TC, being in love in the TC, the child within ourselves, feminity and sensuality, friendship and love, the feminist movement, women with a male job etc. Activities: healthy cooking, creative art, swimming, sauna, visit to a fashion museum, assertiveness training (two days), baseball, massage, shiatsu stretching, belly dancing, African dancing, role playing, hair styling, visit to a fitness centre, skating, horseback riding etc. FORT-TECHNIQUES FORT means Feministische Oefengroep voor Radicale Therapie. This is Dutch for "women self-help groups". The discussion techniques are inspired by Transactional Analysis and Radical Psychiatry and stimulate the emancipation process of the participants not only as a person but also as a member of society. The techniques are made to address womens problems here and now in the group (negative selfimage, difficulties expressing anger, receiving positive feedback etc.). The FORT-movement has been going on for many years in the USA, The Netherlands, Belgium and other countries. In the TC work, we use their techniques but change the self-help aspect to a staffdirected one. The session generally takes two hours and is divided into different parts. The first session starts with several rounds where every woman takes the necessary time

to answer the following questions and shares her answers with the rest of the group: "How do I feel here and now? What is recently good and new in my life? Is there anything standing in our way to have a good group session (negative ideas, resentment)?". Then the personal working time starts where the women who want to, can discuss or work in their own way on some problem they may be experiencing. At the end of each personal working time, the other group members try to formulate some aspects of recognition from their own situation or experience. The sessions end by giving the opportunity for each group member to get a stroke or a compliment. The described exercises may seem easy, but in fact are not at all easy for the participating women if you keep in mind what was described above as typical female problems. A group member cannot skip her turn as the group is waiting for a good answer. A female staff member of the TC directs the group session. She also participates on a personal level as a woman. That means that she answers the questions of the starting rounds and gets a stroke at the end of the group. The personal working time, of course, is left to the residents. CONCLUSION Women are a minority group in our standard TCs for drug addicts and they have their own genderspecific problems on the behavioural, emotional and cognitive level. Very often they have a traumatised sexuality and have developed survival strategies that were functional on the drug scene but are hard to drop inside the TC. If our TCs wish to keep and to work with these women, they will have to implement a women-centred approach. This approach focuses on residents and staff, on understanding the genderconnected problems and on developing an inter-TC network exclusively for the minority group of female residents. In the WFTC workshop, experiences with

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the gender approach among female residents in different par ts of Europe will be shared and discussed together with experiences from other areas of the world.

prospective study. Thesis Department of Behavioural Sciences in Medecine, University of Oslo. STOCCO, P. e.a.( 2000). Women drug abuse in Europe: gender identity. Irefrea Espaa, Palma de Mallorca. ISBN 84-607-0775-X. STOCCO, P. e.a. Women and opiate addiction: a European perspective. Irefrea Espaa, Palma de Mallorca. ISBN 84-932947-2-7. WYCHOFF, H. (1977). Solving womens problems . Grove Press Inc., New York. WYCHOFF, H. (1978). Vrouwenpraatgroepen, Feministische Oefengroepen Radicale Therapie. Bert Bakker B.V., Amsterdam.

BIBLIOGRAPHY KARSTEN, C. (1993). Female hard drug-users in crisis. Childhood traumas and survival strategies. Hard druggebruiksters in crisis. Kindertraumas en overlevingsstrategieen . NIAD, Utrecht, The Netherlands. ISBN 90-71187-42-X. KOOYMAN, M. (1993). The therapeutic community for addicts. Intimacy, parent involvement, and treatment success. Swets & Zeitlinger, Amsterdam/Lisse. MARTENS, J. (1996). Harddrugsverslaafde vrouwen in de therapeutische gemeenschap: specifieke problemen en hun aanpak. In: Verslagboek studiedag Vrouwgerichte Verslavingszorg op 15/03/96 te Brussel. VHV-VAD-IMPULS. VAD, Brussel, pp. 67-71. MARTENS, J. (1997). Inter T.C.-work with female re s i d e n t s a n d s t a ff m e m b e r s : 3 0 m o n t h s o f experience in Belgium. Conference book of the Third European Conference on Rehabilitation and Drug Policy, 1-5 June 1997, Oslo. MEULENBELT, A.; WEVERS, A.; VAN DER VEN, C. ( 1 9 9 4 ) . Vr o u w e n e n a l c o h o l . Va n G e n n e p , Amsterdam. NICOLAI, N. (1997). Vrouwenhulpverlening en psychiatrie. Babylon-De Geus, Amsterdam. ISBN 90-6222-332-X. NOELS, B. en WYDOODT, J.P. (1996). Alcohol, Illegale Drugs en Medicatie. Recente Ontwikkelingen in Vlaanderen, VAD, Brussel. PEETERS, M. (1993). Alledaagse Ongelijkheid. Sekseen klasseverschillen in de hulpverlening, Garant, Leuven/Apeldoorn. RAVNDAL, E. (1994). Drug abuse, psychopathology and treatment in a hierarchical therapeutic community. A

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PREVENCIN DE RECADAS DESDE UNA PERSPECTIVA LOGOTERAPUTICA

PREVENTION OF RELAPSES FROM A LOGOTHERAPEUTIC PERSPECTIVE

Martnez Ortiz, Efren Fundacin Colectivo Aqu y Ahora. Colombia.

La presente ponencia pretende exponer los fundamentos bsicos de la logoterapia aplicada a la prevencin de recadas. A travs de una disertacin descriptiva de los elementos que conforman la teora logoteraputica, se pondr en escena el papel del sentido de la vida como promotor de la prevencin de recadas, as como el papel que juegan los recursos noticos (espirituales) el interior de la comunidad teraputica, y especialmente, en el mbito de la prevencin de recadas. Se otorgarn a los asistentes conocimientos sistemticos para el enriquecimiento de los programas de tratamiento, logrando comprender que la recuperacin no es slo la ausencia de consumo de drogas, sino el desarrollo del ser en su esencia y sentido; es decir, salud no es slo ausencia de enfermedad, sino principio de responsividad (posibilidad de caer enfermo y defenderse), dirigiendo as, la prevencin de recadas hacia el ncleo sano de la persona y no slo hacia los riesgos.

This presentation seeks to expound the basic foundations of logotherapy as applied to the prevention of relapses. Through a descriptive dissertation of the elements which make up logotherapeutic theory, the role of the meaning of life as a promoter of relapse prevention will be presented, as web as the role played by noetic ( s p i r i t u a l ) re s o u rc e s i n s i d e t h e t h e r a p e u t i c community and particularly in the area of relapse prevention. Systematic knowledge of the treatment programes will be presented to those attending, helping them understand that recovery is not only the absence of drug consumption, but the development of the being in all its essence and meaning; that is, health is not only the absence of illness, but the principle of responsivity (possibility of falling ill and defending oneself), thus directing the prevention of relapses towards the healthy nucleus of the person and not only towards the risks.

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La logoterapia fue creada por Vktor Frankl (19051997), mdico, neurlogo, psiquiatra y doctor en Filosofa, nacido en Viena. Su nacimiento recoge influencias de personalidades acadmicas como Sigmund Freud, Alfred Adler, Carl Jung, Rudolf Allers y Ludwing Binswanger, as como la filosofa de Max Scheler y Nicolai Harttmann, y en menor grado de Martin Heidegger, Karl Jaspers y Martin Buber. Es la terapia del sentido, definindola a partir del vocablo griego logos en su acepcin de "razn ntima de una cosa, fundamento, motivo"1. Es decir, logos en logoterapia se refiere a sentido. Podramos ubicarla como una perspectiva de pensamiento con influencias humanistas-existenciales, de aproximacin cognitiva (metacognitiva) y epistemolgicamente fenomenolgica/constructivista2. ESTATUTO EPISTEMOLGICO DE LA LOGOTERAPIA La logoterapia sera difcil de ubicar epistemolgicamente dentro de una escuela pre-establecida, pues guarda diferencias y similitudes con todos los intentos de clasificacin que se han realizado hasta el momento. La logoterapia, por lo general, es incluida dentro de la categora de la psicologa humanista (Bhler y Allen, 1972), o bien es identificada con la psiquiatra fenomenolgica

(Spiegelberg, 1972) o la psiquiatra existencial (Allport, 1959; Lyons, 1961; Pervin, 1960). Sin embargo, en opinin de diversos autores, la logoterapia es el nico de dichos sistemas que ha logrado desarrollar tcnicas psicoteraputicas propiamente dichas 3 . Ahora bien, las diferencias no estn slo dadas en el campo metodolgico, pues Frankl realiza crticas tanto al existencialismo como al humanismo que rebasan el terreno de lo tcnico. Se suele incluir la logoterapia dentro de las categoras correspondientes a la psiquiatra existencial o a la psicologa humanstica. Sin embargo, el lector de mis libros quizs est informado de que he hecho algunas observaciones crticas con respecto al existencialismo; o al menos, a lo que es designado como existencialismo. De modo similar encontrar en ste libro ciertos ataques dirigidos contra el as llamado humanismo4. Frente al humanismo dice Frankl: Aun cuando se ha dicho que la logoterapia se ha unido a dicho movimiento (Charlotte Bhler y Melanie Allen, 1972), por motivos heursticos es conveniente separar la logoterapia de la psicologa humanista, a fin de lograr un punto de vista crtico ms ventajosos y comentarla con sentido crtico 5 . En este orden de ideas, en cuanto a la principal crtica al humanismo, Frankl alega, principalmente, que suele ser comn en las orientaciones de la psicologa humanista aplicar un modelo mecanicista, en trminos causa-efecto sintomtico, en el quehacer psicoteraputico6; as mismo y especficamente en cuanto a las propuestas de Maslow, dice Frankl: la distincin estableci-

1Bailly. Dictionaire Grec-francaise. (26 ed.) Librairie Hachette. Citado por: Noblejas, M.A. Logoterapia: Fundamentos, principios y aplicacin. Una experiencia de evaluacin del logro interior de sentido. Tesis doctoral. Universidad Complutense de Madrid. Facultad de Educacin. Departamento de psicologa evolutiva. (indito), 1995, P. 17 2Se utiliza el termino perspectiva, puesto que la logoterapia a pesar de tener un cuerpo epistemolgico, antropolgico y metodolgico claramente definido, no puede constituirse como un paradigma tal como lo definen otros autores, ya que puede ubicarse dentro del postpositivismo, pero no lo supera, ms bien lo complementa. Al respecto Frankl se distancia de la postura positivista al decir en su libro El hombre doliente: Es fcil demostrar que el positivismo es en realidad un nihilismo encubierto. Pg 286.

3 Frankl, Vctor. Psicoterapia y humanismo. Tiene un sentido la vida?. Mxico. Ed. FCE. 1994. P. 127 4Op. Cit. P. 11 5Op. Cit. 71 6Freire, Jose Benigno. El humanismo de la logoterapia de Viktor Frankl. Pamplona. 2002. ed. EUNSA. P. 63

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da por Maslow entre necesidades superiores e inferiores no toma en consideracin que cuando las necesidades inferiores no son satisfechas, puede hacerse ms urgente una necesidad superior, tal como la voluntad de sentido 7 , crtica aceptada y compartida por el autor en mencin. En lo referente a las corrientes humanistas de mayor tono afectivo, la crtica la desarrolla Frankl al mencionar que en lo que se refiere al tema de las emociones, estas no pueden ser intencionalmente provocadas 8 . Ahora bien, Frankl hace ms referencia al llamado pseudohumanismo, pues es innegable que son ms las coincidencias que las divergencias entre la logoterapia y otras corrientes ubicadas en el movimiento humanista existencial. Tambin se intent incluir a la logoterapia en el mbito de la psiquiatra fenomenolgica9, al igual que dentro de la psiquiatra existencial, pues la logoterapia toma las influencias de la fenomenologa de Husserl y especialmente de Max Scheler, as como la antropologa existencialista10, aunque configurando un cuerpo metodolgico diferente e incluyendo la contraparte del tema central existencialista de la libertad: la responsabilidad11. La logoterapia ha recibido crticas relacionadas con la relacin que mantiene con la filosofa existencial, dice Frankl: Se ha puesto de moda culpar a la filosofa existencial de poner excesivo acento en los aspectos trgicos de la existencia humana. La logoterapia, considerada una de las escuelas de la psiquiatra existencial,

se ha convertido en el blanco de estos reproches.12 Sin embargo, ni toda la filosofa existencial es pesimista, ni la logoterapia es una apologa a la tragedia, considerando tal vez todo lo contrario, pues no existe psicoterapia pasada ni actual, que conserve tanta fe en el ser humano y en sus potencialidades como la propuesta Frankliana. Finalmente, se ha intentado definir la logoterapia como una psicoterapia cognitiva13 e incluso como la primera psicoterapia cognitiva, afirmacin hecha por Frankl al escribir: en el artculo presentado en el Segundo Congreso Mundial de Logoterapia, Alfried A. Laengle lleg a afirmar que la logoterapia es la primera terapia cognitiva por sus condiciones y por su programa14. Hoy en da, cada vez ms se relaciona la logoterapia con la psicoterapia costructivista, autores representativos de este movimiento la citan en sus textos ( M a h o n e y, 1 9 9 7 , M a h o n e y & F re e m a n , 1 9 8 8 , Goncalves, 2002, Feixas & Villegas, 2000, Neimeyer & Mahoney, 1998) y otros ms reflejan como se llega a perspectivas casi idnticas desde lugares y pocas distintas, y sin mutuo conocimiento (Semerari 2002a, 2002b). APROXIMACIN COGNITIVA DE LA LOGOTERAPIA La logoterapia no puede definirse como una psicoterapia cognitiva exclusivamente, y menos como una psicoterapia cognitiva estndar a la manera de autores como Beck y Ellis, quienes a pesar de compartir

7Frankl, Vctor. Psicoterapia y humanismo. Tiene un sentido la vida?. Mxico. Ed. FCE. 1994. P. 34 8Op. Cit. P.83 9Freire, Jose Benigno. Op. Cit. P. 62 10Especialmente la de tipo testa. 11Vale la pena mencionar que esta es una crtica parcializada, pues en autores como Buber y Jaspers, el tema de la responsabilidad en lo que se refiere al encuentro y a la comunicacin respectivamente, son argumentos centrales. 12Frankl, Vctor. Psicoterapia y existencialismo. Barcelona. Ed. Herder. 2001. P. 95 13Carelli, Rocco. Logoteoria: assunti Clinici. En: Attualita in logoterapia. Roma. LAS. P. 4977 14Frankl, Viktor. Logos, paradoja y bsqueda de significado. En: Mahoney & Freeman. Cognicin y psicoterapia. Barcelona. Ed. Paids.

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muchos recursos tcnicos15, se diferencian epistemolgica y antropolgicamente de la logoterapia. Sin embargo, s pueden considerarse aspectos cognitivos del proceder logoteraputico y de su concepcin epistemolgica. Al respecto dice Frankl: la logoterapia, que es el nombre con que se bautiz este nuevo enfoque, intentaba significar el desplazamiento del nfasis desde los aspectos afectivos a los aspectos cognitivos de la conducta humana16. Pero la logoterapia va ms all de lo cognitivo, pues la idea de logos estaba slo parcialmente esbozada en los trminos cognitivos clsicos de la cognicin, indicando que durante el desarrollo de la logoterapia (sera mejor decir de la logoteora subyacente a la misma), el logos inclua la cognicin, o la percepcin del significado17. La Dimensin Notica18 comprende los aspectos cognitivos del ser humano. Esta facultad originaria, esta posibilidad originaria del ser espiritual, es la condicin de otras posibilidades: la percepcin, el pensamiento y el lenguaje; y esto significa entenderse unos con otros y ponerse de acuerdo, pero tambin es la condicin del recuerdo y la evocacin, y esto significa estar presente en lo distante temporal y espacialmente19. Y este estar presente es la caracterstica del acto de conocimiento que se lleva a cabo desde lo espiritual-Notico, un acto de conocimiento que supera la escisin sujeto-objeto;

el ser espiritual ni los otros seres estn fuera ni dentro. No al menos en el sentido ntico espacial; en sentido ontolgico ambos se encuentran siempre implicados. Esto crea esta relacin peculiar que se ha establecido desde antiguo entre el mundo y la conciencia: no slo el mundo est en la conciencia, sino que la conciencia est en el mundo, contenida en l: se da pues, la conciencia. El sujeto y el objeto se implican mutuamente de este modo peculiar; una implicacin cuyo nico smbolo es el yang-yin chino20. Esta caracterstica de lo Notico es su fundamento intencional, la posibilidad de que el ser espiritual est presente en otro ser es una facultad originaria, es la esencia del ser espiritual, de la realidad espiritual; y una vez reconocida nos ahorra la problemtica tradicional del sujeto y del objeto: nos libera del onus probandi en el problema de la posibilidad de acceso del uno al otro21. La principal diferencia con el cognitivismo clnico se da a nivel epistemolgico al plantear la logoterapia que la pregunta sobre el modo de acceso del sujeto al objeto (para posibilitar y construir un conocimiento objetivo) carece de sentido porque la pregunta es ya el resultado de una espacializacin ilegtima y constituye, en consecuencia, una notificacin de la verdadera realidad; es superfluo preguntar cmo el sujeto puede salir fuera de s y acceder al objeto que se encuentra fuera, simplemente porque este objeto nunca estuvo fuera en sentido ontolgico, de metafsica del conocimiento. Pero si esta cuestin se plantea a nivel ontolgico y autnticamente metafsico y se entiende el afuera como un modo de hablar, nuestra respuesta es que el denominado sujeto ha estado siempre afuera, por decir-

15La logoterapia y la psicoterapia cognitiva estndar comparten el dialogo socrtico como tcnica principal, as como el autodistancia