NATIONAL MASTER PLAN J FOR PILOT EXPERIMENTAL PROJECTS
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NATIONAL MASTER PLAN
J FOR
PILOT EXPERIMENTAL PROJECTS - extracted text
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NATIONAL MASTER PLAN
J
FOR
PILOT EXPERIMENTAL PROJECTS
Gabriel Britto
Natasha Zen
Dr.Dayal Mirchandani
February 299 1990
National Addiction Research Centre
5 Bhardawadi Hospital
Bhardawadi Road
Andheri West
Bombay 400 058
--
..
NATIONAL MASTER PLAN
FORi
pilot experimental projects
i F
i
As presented at the:
1
J
HAZELDEN APPROACH TO COUNSELLING AND DRUG PREVENTION
Workshop held in Bombay during August 23-26, 1993
k y
Workshop sponsored by: United States Information Service, Bombay
Cosponsored by: National Addiction Research Centre, Bombay
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February 1990
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NATIONAL ADDICTION RESEARCH CENTRE
Floor 5, Bhardawadi Hospital
Andheri West
Bombay 400 058
Tei. 621 2661, 624 5290
Fax: 91.22,621 1658
email: narc@sangra.ncst.ernet.in
4
PREFACE
This paper focuses on the (re)habilitation process of addicts.
Counseling, Detoxification, After-care And Socialr and Vocationalintegration of addicts are parts of the treatment continuum.
In India, the terms After-care and Rehabilitation are used inter
changeably when referring to the Habilitation Process of addicts.
It must be noted that a large proportion of drug habituesfl do not
enter nor need to enter any formal residential rehabilitation
.LI
process as they do not become dysfunctional either• socially or
compounds, for
Most of the users of Cannabis compounds,
vocationally,
fruitful
lives
performing
all
life
roles and
lead
instance,
the
various
milestones
of
their
developmental
functions past
cycle.
Whereas regular use of heroin is generally addictive, there
appears to 1be a group of users, known as ” chippers”, who are
able to use heroin occasionally over a long period of time
without becoming
In his study of heroin, Stanford
beconing addicts.
University professor John Kaplan maintains:
It is now clear that there exists
a sizable population of non-addicted
but regular heroin users who seem
well integrated into society and in
many ways indistinguishable from the
rest of the population^
Even among heroin addicts, most of them do not enter formal
treatment centres because such centres are too few, stipulate
several conditions, are expensive, or are alienating; and because
some of the heroin addicts quit the drug on their own through a
wide variety of measures including: reverting to
Cannabis
compounds, switching to liquor, taking vows to specific gods/godmen,
establishing satisfying new relationships,
developing
personally-fulfilling philosophy and meaning for their own lives
or taking up jobs which demand intense emotional involvement in
religious cults such as ISKCON or fellowships such as
NA, to
cite examples.
Finally there is one segment of those who do not enter fornal
treatment centres who mature out of addiction after 8 - 12 years
spent in heroin clouds.
in the context of this paper, refers to a person
habitually using/abusing drugs
2. John Kaplan, The Hardest Drug: Heroin and Public Policy, 1983.
1. habitu6(s)
It is equally clear to rehabilitation professionals in urban
of addicts
moved from one treatment
India that a small group c.
------- have
thus
creating
an
illusion regards the(-centre to another,
2
. magnitude of the problem of long waiting lists ...
playing up
one centre against other ... has been one of their hobbies
some
parents of addicts are also perennially searching for yet another
centre to dump their addicted wards for another stretch of time.
At the level of integration of addicts with their social
and society at large, for some addicts a return to the
quo’ ante-addiction is pernicious. As social workers at
Vidyapeeth point out, four of their addicts were part of
of pick pocketeers. SPARC studies indicate that in their
one percent of heroin addicts had criminal records prior
onset of addiction.
context
'status
Shramik
a gang
sample,
to the
For a much larger proportion of,addicts, 'educational rehabilitation ' is unattainable if the aim were to help them to re-enter
the educational stream that they had dropped out of when they
took to drugs, Some of them have remained out of school for so
long that they cannot catch up and per force have to either
abandon the concepts of further studies or chalk out functional training programs.
The purpose of this paper is to present in a
aspects/arguments of different protagonists
thought on the habilitation process.
nut
and
shell, some
schools
of
Assuming that organized professional and self-help interventions
could effectively assist ever greater numbers of heroin addicts,
certain pilot projects are outlined for experimentation in the
field.
GABRIEL BRITTO
4
CONTENTS
PREFACE
ORGANIZATIONAL CONTEXT
PREVENTION OF DRUG ABUSE
SUGGESTED PILOT PROJECTS:
- DEVELOPING PEER LEADERS FOR PREVENTION
- WORKERS EDUCATION PROJECT
- INTEGRATED EDUCATIONAL PROGRAMME
- ADVENTURE GROUPS
- MASS COMMUNICATION '
COUNSELING
SUGGESTED PILOT PROJECTS:
- BRIEF STRATEGIC FAMILY THERAPY
- TOWARD THE DEVELOPMENT OF A COMMUNITY BASE FOR
COUNSELING CENTRES
- COMMUNITY ACTION TEAMS
- BUILDING WOMEN'S ORGANIZATIONS
- DEVELOPMENT OF TREATMENT ZONES
- DROP IN CENTERS
- NIGHT SHELTERS
DETOXIFICATION OF SUBSTANCE ABUSES (HEROIN TYPE)
SUGGESTED PILOT PROJECTS:
r
- COMPARATIVE ANALYSIS OF OUT-PATIENT VERSUS
IN-PATIENT DETOXIFICATION OF HEROIN ADDICTS
- TRADITIONAL SYSTEMS OF MEDICINE
- SELF MEDICATION
- MAINTENANCE ON OPIUM
AFTER CARE
SUGGESTED PILOT PROJECTS:
- VOCATIONAL WORK TEAMS
- INDIGENOUS FORMS OF SELF HELP GROUPS
- ALL INDIA ASSOCIATION OF RECOVERED ADDICTS
- PROGRAMME OF SUPPORT TO EX ADDICTS WORKING IN THE
FIELD OF DRUG ABUSE
SUPPORT PROJECTS
4
SUGGESTED PILOT PROJECTS:
- DEVELOPING AREA RESOURCE CENTERS
- DEVELOPING SOCIAL WORK CURRICULUM
- DEVELOPMENT OF A MANAGEMENT INFORMATION SYSTEM FOR
DRUG ABUSE
- NATIONAL DATA BASE
- DOCUMENTATION PROJECT
4
i
HANABEMENT OF DRUG ABUSE IN INDIA
National Addiction Research Centre
The Organizational Context:
1. The Impetus:
The
inspiration or reasons1 for the setting up of
these
organizations to work the field of drug abuse or to take on
addiction related programs are varied.
a.
International Linkage :
Services clubs such as the Giants, Rotary, Lions, Jaycees which
have regular exchanges through conferences. Their counterparts
have supported the local
initiatives in
abroad
India with
finance and technical inputs developed in other countries when
drug abuse became a problem in India.
They have subsequently set up several counseling centers in
The
city,
Rotarians have moved into counseling in Madras
have set up a centre, in Punar Jeevan. The Giants have set
Forum Against Drugs (FAD) in Bombay as a coordinating body
all NGOs in the city including the Lions,
the Jaycees
the Rotarians.
A member of the Rotary club of Goa set up
Drug Abuse* Prevention Program there in the year 1984.
the
and
up
for
and
the
Likewise,
the churches and their social
services organizations
(like the Samaritans, YMCA, The Catholic Church) which have had
a long
tradition of running social services institutions have
begun to work in this field.
field,
They too have gained
from
their international contacts.
The Junior Red Cross, IOGT and such other
bodies too entered the field.
secular
specialized
Three
international
conferences held in
India brought
in
delegates from a wide range of countries with their
ideas and ,
experiences,
NIMHANS has setup a research project partnership
with ADAMHA, USA. The K.E.M. Hospital, Bombay has
collaborated
with the
British Council to hold a workshop with
external
experts.
SPARC
held several workshops in col 1aboration with
the U.SlI.S. which brought in foreign experts.
Fellowships were offered by the USIS for
Indian delegates to
visit U.S.
based agencies,
the U.N.F.D.A.C.,
International
U.N.F.D.A.C.,
commission on Narcotics, Division of Narcotic Drugs,
the
ILO,
ESCAP WHO and various Western Governments affected by drug abuse
in their countries have invited the G.O.I. to Join the global
struggle against this problem.
b. Field experience :
4
community
Three
were some organizations which were doing
organizational
work
(e.g. APNALAYA, SPARC - Bombay) who came
they
upon
a new problem affecting the youth in Slums and
took on programs in this field.
5 -
I
The affected people :
A few ex-addicts (in Bombay SEVA DHAN - Bombay, LIFE LINE - Pune,
hi^Bangalore
Sahara House - Del hi
,Bangalore - CAIMs, set up organizations to
work in the field. Persons whose close ones were affected such
as, a friend, spouse, or other family member have set up organizations (Ranganathan Foundation - Madras, Andre Faria Memorial
Goa for instance).
Forum
Schools of Social Work, instruments of training service providers
have taken up drug abuse work.
They mainly look at curriculum
development in counseling addicts and research. Pune University
(Development Communication Research Project) TISS Department of
Medical
Psychiatry Social Work, Matru Sava Sangh - Nagpur,
a
School of Social Work has set’up'a counseling center, The school
Work of the Institute of Management in Solapur is
of Social
plan and package for prevention in
preparing a city level
Solapur.
film producers and advertising agencies have been
Commercial
Newspapers advertisements,
serials,
inducted
toi produce T.V.
hoardings ...
Association for Social
Health Associations such as
National
India which have their own branches/chapters in
Health ini
different parts of India have set up counseling/detoxification
centres..
Professional Associations of Social Workers in Tamil Nadu, Orissa
and Andhra Pradesh have taken up training of Social Workers in
low-cost media (Street Play) for drug education.
5
I
Professional support organizations which offer technical service,
such as center for Youth and Social Development offer burgeoning
small media and youth organizations training on a whole range of
subjects
such
as
account-keeping,
account-keeping,
reporting,
technical
information on drugs.
Youth . wings of political parties and allied organizations who
conduct rallies,
protest marches, conferences
(Youth Congress
(I), Anti-Narcotic Cell, Shiv Sena and other parties).
Individuals
(highly connected, sometimes highly qualified)
have
either registered organizations I.C.E. Delhi) or have resurrected
moribund
organizations
(Kashi
Club,
Varnasi).
These
organizations have no prior experience in the NGO Sector as such
but have begdm drug abuse work from the start and do only
addiction-related work.
2. Types of Agencies:
a. State Governments :
Most of the State Governments have ignored this problem except
perhaps Maharashtra, U.T. of Delhi, while the Health Department
of Maharashtra has attempted to incorporate it into three
The Welfare
district level projects on community mental health,
department of Maharashtra is planning to allot some buildings
work.
They ,
Social Housing schemes for drug abuse
from
the
Welfare
Ministry
^or
the
Central
also liaison
with
processing projects.
6 -
The?
DDA
(Delhi
Development Administration)
has
allotted
space/buiIdings to NGOs for drug abuse work (More information
to
. be obtained)•
b. Correctional Administration :
4The Imphal Central Jail, The Yeravada Jail, in Pune,
the Tihar
Jail
in Delhi have set up either counseling/detox centres or a
separate ward for addicted inmates in their jails. One of
them
has invited an NGO to run the program within the Jail
premises.
Children's reception homes, lock ups in police stations are yet
to take up the issue.
The Police department of* Delhi has mobilized their NGO to provide
detox,
follow-up and use the setting for getting information on
the peddlers, apart from rehabilitating addicts.
c. Local Governments :
The Bombay Municipal Corporation, Nasik Municipality,
Nagpur
Corporation, Barmer and three other local governments have become
involved in Drug Abuse work.
B.M.C.
has provided space to
purpose Nasik Administration held a week
several NGOs for the purpose,
long blanket campaign drugs and started a -detox and follow-up
center with local contributions. The Central Government has
funded six corporations in a small way.
d. Mental Hospitals, General Hospitals,
Clinics and Non-profit NGO Hospitals.
Commercial
Hospitals
e. Some
mental
hospitals have begun a separate
ward for
addicts,
The general hospital which great addicts, allot 3-5
beds in their psychiatric department. However,
a considerable
number of
<
such hospitals are averse to admitting addicts due to
DANA,
recidivism and other administrative problems in treating
addicts.
f. There
are a few private commercial Hospitals such as the
APOLLO group of hospitals which have started separate trusts/
NGOsj,
(APOLLO started ADDART for e.g.) or keep a separate ward.
Similarly,
several psychiatric and general nursing homes treat
addicts.
These are expensive.
g. General Practitioners s
Whose
dlients are close to their clinics often
get
whom they treat with nutrient fluids and sedatives;
little about addiction.
'
patients
knowing
ESIS Practitioners, Industrial Psychologists, Welfare Officers,
Unions,
Union support organizations ...
have no orientation
whatsoever to this problem.
h. Journalists :
and
A
few journalists have taken keen interest in drug abuse
have written columns on a regular basis in the media,
So have
several
psychiatrists and social workers.
But the quality of
they
reporting,
scrutiny of data available are very week
and
need perspective and training.
7 -
I'
Religious Leaders :
They have either no clue to this problem or they are responding
by setting up extremely costly rehabi1itation centres to cater to
a token number of addicts.
Some Comments:
5
A. One of the important phenomena in the field of drug
is the
birth and death of several
organizations or branches of
organizations.
in
The DAIRRC for instance started a day-care center at Dongri
Bombay and closed it down a year* later apparently for want of
funds.
SPARC started a day-care center with the Cooper Hospital
at Vile Parle and ran it for a year and four months.
The
arrangement was that the therapist would be selected,
appointed
and supervised by the Department of Psychiatry which would
provide the space for group therapy and individual
counseling
reasons
sessions.
This arrangement broke down for a variety of
Nirmala
and therapist was relocated into SPARC research program.
Niketan started out on preparing a manual for parents through
conducting training programs for parents.
Apparently, it has not
pursued
the objectives for want of timely release of grants by
NISD. While SPARC has successfully partnered HOPE in Bangalore
for
research
and training
activities
with
the
SNDT
University
for
with Women's Graduate Union for running
a
Brief Strategic Family Therapy center for addicts ...
It can be said that by and large, SPARC has learnt through trial
and error, the parameters of’ networking and partnering with other
Its attempt to partner with the another agency
organ!zations.
due
to
the
iadequacies of the staff member of
failed
SPARC assigned for the task.
b. There is a tendency to call anti-alcohol work addiction work
because there is money for drug abuse programs today and very few
grants are available for the prevention of alcoholism since most
of the State Governments make their revenue by the taxes on
alcohol and most political parties consider issuance of license as
one of the post-election bonanzas for their party activists.
1
i
t
c. Cross Subsidy:
The Vivekananda Education Society at Calcutta supports its drug
through the surplus generated by their schools.
related workj
Kr ipa and Seva Dhan charge fees at their rehabilitation centres
to maintain the centres and when poor addicts approach
patients
No one is
them they raise sponsors for their treatment period,
(he
I.I.
Ranganathan
money.
The
T.T.
turned away
for wants of
Clinical z
Researchi Foundation charges fees for 45 out of 50
mostly paid for under the State Employees
beds which
are
However
it
maintains
the industries,
Insurance program of
i
pay
the the
five beds for poor patients who cannot afford to
is fully paid for by the
fees.
Their after—care center
Ministry of Welfare, G.O.I.
d. The seeds of youth-to-youth programs can be
organizations such as the SPYM, 'Motivation'
college, Calcutta, Adam, Madras.
- 8 -
in several
seen
Xavier's
- St.
Another trend one sees in the
emergence of organizations working
in the field of drug abuse1 in India deserves
attention;
governmental organizations iregistering a r
separate body under the
Societies Registration ACT fto deal " with the
-- ► problem of drug
abuse.
The Institute of Mental
-1 IHealth ( Ki 1 pauk
Madras),
the
Institute of Mental
Health (Yeravada,
(Yeravada,
Pune),
the
Municipal
Corporation of Nasik.
e. Women Writers:
There is another phenomenon of i---the field n-f
‘
L' WDmen writers getting involved
in
the field of drug abuse,
abuse.
Mrs. Sugathakumari
Sugathakumari is a
Mrs,
well-known
poet author from
spearheaded
from Kerala
Kerala who
who successfully
successfully
the
movement through powerful
of
scientists and
the denr^H^+i™
-.-J concerned citizens to prevent
pr
and
denudation of the Silent Valley virgin forests.
forests
1
a mental hosnital
about WO(nen patients
mental health problems, policy makers, c--concerned citizens and the
courts.
A committee was set up to review the'
condition of mental
ospitals in Kerala and the government brought
about several
changes in the funding and administration
of
all
the four
government-run mental hospitals in the State of Kerala.
Inspite
nIedttforsettina5unrELSU9atl?aKUmari
hBr c°liea9“es felt
the
colleagues felt
cZrfj J
9 P 3 transit home
women in distress and they
called it appropriately
’Athani' (Roadside pillars erected for
fheP vic?n?lOCe ^his hGad;°ad on the pillar5.*nd
take rest in
hinh
These pillars are a common sight alono the
a "s^Xs1" dr:,raLTatmil NadU and Kerala)When
a^e becamZ
XT" JT"4 tJrOU?h P°"er,Ul ‘■o.-. .nd XiJzXn
.bout
"’"n?1
p.tl.n?r
community co^elln^^pr^1’ ^^h^Tt^ni^?
X
*
Mrs. :
Both Athani
and^Mrs ^Suglthak
’
headed
Surend^anJth
!»
Jheaded by Mr.
Sugathakumari
.
In ha'v^no'^appLX
principle, Abhaya does r^istr^Ton'
foreign - donation andXthey
so they have not appliedI for
-- 1 Regulation Act. They find
contribution to government grant.
Mrs.
Sivasankari, Madras:
She identified the emerging
problem of drugs,
interviewed some
addicts
and wrote a serial in a popular Tamil
weekly
with
a
iurne Ci7UlatiDn—
Later xu
it was
was released
released as a book which was in
turn made into a
a television
television serial
serial in Hindi of
P«rts were shqwn on the
the national
network and then which thirteen
national network
stopped.
In
the meantime,
with the offer of the
Ministry
the
support to her prevention work, she reoistered^ of Welfare of
work j,
a Society,
Agni .
Agni has printed
leaflets and
and stickers,
leaflets
film.,
produced a
resc-rcZ S^2atL,re campaigns
ca,r,pai9n5 ...
has also participated in a
*
ese«rch study on ithe
rate of incidence
of addiction
among
the
Hoppit.?’ pangalore and Madras
organized
by
the Apollo
Pvt.
Ltd.
f. Churches:
Church - based organizations were among the first to re^oond
among the first to respond to
the problem of addiction in the country apart from p
Padmashree
unraaa2erin9h?1anaklaD at JodhP^.
The Samaritans in Cai^ta
—i set
into a acenter
fuFl tO-frdH1CHS elghteen Y^cs ago,
which has now grown
1
fledged
addicts fulTh
^ledg^d residential rehabilitation center
for
The
Jesuits
have .assisted
... alcoholics and addicts
center -+ Z w
in a
1979.'
supportino P-Mot ’ Bombay since 1<?79
Asha BhaVan in G°a
been
supporting Pallotine Priests
Priests who
who provided
the premises
provided the
for
both
the rehabi1itation centre run by Seva Dhan in Goa.
9
t
Likewise, the YWCA and the YMCA networks have provided space and
funds to different organizations such as the Seva Dhan and DAIRRC,
the Lions clubs
...
The Marthoma Church created a day care
The
center in collaboration with DAIRRC in Bandra,
Bombay.
Xavier Institute of Communications, in Bombay produced the first
slide program 'No Sugar Tonight*, which has been re-produced as a
video-cassette.
The Sisters of St. Paul have produced a film in
collaboration with Seva Dhan 'Is Anybody Listening Sir'. Kripa is
one among the oldest rehab centres for alcoholics and addicts,
the
It
is now setting up rehab centres in different parts of
country.
I
I
personalities are characteristic of any •set of NGOs
Charismatic
The field of dkug abuse is no exception,
and organizations.
Here one finds a professor o'f Hindi from Bihar going to his home
He witnesses a
town in Rajasthan for the summer vacations.
function . in which several peasants and farmers are being given
loans for the purchase of cattle.. In order toi enhance
their
incomes.
After a year, he sees that none of them have retained
their assets purchased from the loans and most have squandered it
teaching
of
job
away
on
opium-drinking. He resigns his
to work with
Hindi in Bihar and sets up an organization
opium drinkers of Rajasthan in 1979.
i
I
to the
Narayan Singh Manaklao remains central
Though Mr.
proper
i
t
organization,
it
has
acquired
functioning
of his
with
the
apparatus and is professionally managed
organizational
governing
body,
guidance of industrialists and others in their
His movement is attaining maturity. However, the same cannot be
* ' *by' charismatic
personalities.
said of all organizations headed
latter type of’ organizations in this field are
While many of the
L
able to enthuse volunteers for specific activities or programs,
they remain essentially a single—person organization»with all the
strengths arid weaknesses of such organizations.
The training
needs
and
possibilities
of offering
training
to
such
organizations would naturally vary.
i
h. The Ministry of Welfare has a large program for the development of women and children and has funded several NGO in the
is
logical
to expect that some of
these
country.
It
with explicit goals of child/women's welfare or
organizations
be inducted into the field of drug
abuse
development would
program of the same Ministry
which has also become a central
Government level.
Their training needs in
at the
Central
this field would be different from those of youth organizations.
i
*
i
ANNEXURE:
ON TRAINING MANUALS AND MATERIALS :
♦
I
The ILO has prepared a kit for drug abuse prevention in the
workplace.
The WHO has produced a handbook for community health
workers in the field drug abuse. The NIMHANS has produced a
manual for community mental health workers which has incorporated
research
drug abuse as one of its chapters.
The TTR clinical
this
foundation has developed a manual for community workers and
Government
manual has been published by the Ministry of Welfare,
of
India.
The Spicer Memorial College, Pune,
is preparing a
handbook
for teachers to facilitate them to incorporate drug
without
abuse while teaching biology, botany, bio-chemistry
10 -
expanding
teaching.
the- size of the text books or the number of
hours
or
The ILO is launching a
action project in the SAARC region
for developing a manual on the vocational integration
of addicts.
The UNESCO is reported to have produced
a manual
for youth
workers on drug abuse prevention.
The ESCAP is <engaged in developing
curriculum for community
workers throughi a workshop process in India
i and would
probably
set up some field projects to test the ’
validity of
sue h a
curriculum.
Through
the seven projects being set up by
the GDI
in
col laboration with the UNFDACj, the several manuals
are expected
to emerge in the next two or thr^e years.
SOME PROBLEM AREAS ;
The are practices of
< ' some organizations
require public debate :
in
the
field
which
Very few organizations declare the •*
fee they charge.
The public
has a right to know the fees and services
. ---- > provided.
Some of the
organizations dec 1 are that they provide free
services but on
account .of the number of persons seeking admissions,
waitlist ..
corruption, •speed money to skip
Some ’
*. the
“ ‘ queue enter the scene.
scene
.
justify
the high fees by saying that it is not paid by the
paid by
patient anyway but by the sponsors or the not
companies..
Some
companies
parents prefer to go to costly treatment centres because they
because
want good services.
It is not at all clear to
us
what
is
to
us
what
is the
.best * treatment in terms of medication
for addicts.
There are
organizations which charge just two
rupees per detoxification and
there are also organizations which apparently charge
apparently charge anywhere
rom Rs.
9,000 to 35,000 for a ten day detoxification
in the
country which in strict terms should not cost beyond Rs.
300.
In
suoolt th Z an?!ySi*’ “ 15 the ^onomic principle of demand and
systematical!^ i
t
r°DSt
S° SOme °^^izationE have
H T 1 5 lly be9<-in training general practitioners of medicine
in detoxification of heroin addicts.
Thus, if in each area wh^rZ
counseling
a
center is located,
practitioners
are trainedI in detoxification of about 200 general
addicts, then, it is>
possible
for the
counselors to identify addicts in early stages,
to
detoxify addicts on
out-patient basis or in
their
homes,
Naturally there will be some addicts who require
hospitaiization
or
in-patient care.
Their proportion to the total number
of
addicts who seek help is very small.
In this manner, the load on
the de—addiction centres can be reduced.
There is a 1 ready a
sma 11
manual for detoxification of
patients
addicted
to heroin
type of drugs.
♦
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F
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Prevention of Drug Abuse in India
■>
A Status Paper with Outlines for Pilot Experimental Projects
ii
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National Addiction Research Centre
5 Bhardawadi Hospital
Bhardawadi Road
Andheri West
Bombay 400 058
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y
PREVENTION OF DRUG ABUSE
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PREVENTIVE MEASURES
The general objective of any demand reduction activity is to control
use/abuse of all illicit drugs specific drugs and the number of new
cases of illicit use.
Attainment of the goal is dependent on formulation and implementation
of activities focusing on four specific areas; preventive,
treatment,
(re)habi1itation and social/vocational-integration.
Preventive
measures are undertaken under the
assumption
that
informational approach, educational, programmes, personal developmental
programmes,, health educational programmes and community based inter
vention can control the problem through culture specific methodology
of intervention.
PREVENTION IN INDIA
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Philosophy:
The preventive measures in India are based on the philosophy that
addiction to drugs is a new phenomenon that can be tackled by magnify
ing the adverse effects of drug use and abuse.
Concepts:
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Prevention concepts are restricted to modification of the behaviour of
the user,
high-risk groups; identification of users/abusers by the
family, friends,concerned individual and providing information on the
treatment facilities.
7
Strategy of Intervention:
;■
The organisations involved in the field of prevention have adopted the
fear or scare approach to deal with the behaviour pattern of the users
and abusers, the psychological inclination of the high-risk population
and to encourage the involvement of support groups.
J
Actvities Undertaken:
In the country out of 161 organizations working in the field 105
organizations h^ve undertaken information based preventive measures to
deal with addiction.
The informational approach is implemented through talks?group discuss
ions,
lectures,group discussions,seminars,workshops,distribution of
pamphlets and
leaflets, poster, essay and elocution
competition,
holding public meetings, conducting walkathons, morchas,
exhibition,
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' . The organizations
street plays and producing films and audio-visuals,
etc.
posters,
pamphlets
and talks etc.
form
which utilize audio-visuals, |
workshops
and
seminars
are
conducted
by
thirty
the majority and
organizations. At present a large number of information based programs
are based on fear or scare approach in isolation, in order to tackle
the problem, There is a lacuna of conducting other forms of preventive
measures along with awareness building programs.
1
There are several groups in the field of drug abuse today, who believe
in preventive campaigns.
a. Political parties and their cells for the
Narcotics.
control of
I
individuals with perhaps the rudiments of an
b. Concerned
are in the process of
organizational shape ( some
registering their organizations).
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c. Registered NGOs.
d. City administration with the Public
taking the initiative.
Health Department
i
e. Public sector and private sector industrial houses.
f. Prohibition Department.
i
9- Films division.
h. Television.
i. Radio.
a. Political Parties:
The Anti-Narcotics cell of the Congress party has been active in
cycle
different parts of the country,
organizing mass meetings,
morchas to the offices of the Commissioner of Police to put pressure
on them to control trafficking.
They also arrange talks and exhibitions on college campuses.
I
It is not enough if one or two political Parties enter the campaign.
Heroin trade shduld become a common platform for all Parties. Each has
to act as a watchdog of the other and to conduct joint campaigns.
I
Rotarians, Lions, Jaycees and Giants have promoted a similar series of
youth
lectures and
exhibitions targeted at the college youth,
conducted
mostly in English.
The DAIRRC has initiated a campaign against drug
abuse in the slums in Bombay.
14
b.Public and private sector Industries :
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Bharat Petroleum; Rashtriya Chemical Fertilizers, Hindustan Petroleum
and a few other public corporations have also supported campaigns
through hoardings and films. The films "Manas" and•"Sankalp" have been
sponsored by the Corporate Communications Department of
Bharat
Petroleum and have been widely used in English, Hindi and Marathi,
In
the private corporate sector, one sees the Ad club of India taking a
leading role, They had launched a nation-wide competition with awards
of Rs. 2,00,000/- and have developed prototype campaign material for
seven segments of target-audience in all media. This preparatory work
(However this entire campaign
for campaigns has been titled "FAIDA".
was based on evoking fear -psychosis and it has remained in their
godowns ) .
Groups like "Enterprise" in Bombay and some other groups have
developed street plays on drug abuse. Though the actors are middle
class youth, they have adopted several folk lores in their plays which
appear to be more proximate.
>
A student group in Calcutta,“Motivation",launched a campaign
drugs and also undertook referral functions.
against-
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It would be more practical to mobilize the slum youth to develop
<
programs, document them, analyze and understand their appeal toi their
peers from their response to these performances.
It is with this thrust that organizations such as Apnalaya, “SUPPORT'
and “SVP“ (Bombay), have facilitated the local youth to come together
and develop and perform street plays on drug addiction.in the slums.
d.City Administration:
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The mobilization of the entire administration of the city of Nasik and
their week-long blanket campaign in all parts of the city using multi
media
is
another important development in this
field. ✓ The
participation of leading labor unions, ex-addicts, the poor, the
unemployed as well as college * students was a special characteristic of
this campaign.
This unique model can be an example for
the
administrators in other cities. (More details can be had from the
Secretary, Public Health Department, Government of, Maharashtra).
The Nasik city administrators had also mobilized resources for setting
up
a detoxification facility and follow-up unit.This is necessary,
for creating | public awareness on dealing with the drug problem,
without providing the necessary treatment and follpw-up facilities,
The
would lead to mass frustration and endanger credibility,
Rotarians in Madras too, found that running campaigns alone is not
enough. They have thus set up a counseling -center (Punar Jeevan) for
addicts. In Bombay, the Lions too are running two counseling centres
for addicts and they conduct a detoxification camps.
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The principle must be : No awareness campaign should' be conducted
without providing appropriate service facility. We do not want to
repeat the situation after the T.B. campaign when patients were given
cough syrups and sent away.
Critical Factors In Preventive Measures:
Differential pattern of Drug Abuse:
The problem of Heroin/Brown Sugar .addiction is predominantly an urban
phenomenon except in North Eastern India, the border villages in North
West
India and in the fishermen' colonies on the coastal
tip of
Southern India.
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It has also become clear that the problem of Drug Abuse varies of from
city to city.
In 1987., pervasive use of crude Heroin was seen in
Bombay, Pune, Goa and Delhi.
Heroin had also made significant inroads
into Calcutta, Madras, and Kashmir while the soft drugs such as ganja,
bhang, charas), were dominant in Cuttack,
Bhubaneshwar,
Hyderabad,
Coimbatore and the tribal areas.
On the other side, we have
Imphal
and Ukhrul were white Heroin is injected,
a mode of consumption
reported practically nowhere else.
Demand reduction activities should be State—specific/city specific
depending upon the configuration of the drugs of abuse,
profile of
abusers... opium drinkers of Rajasthan are of a higher age group than
heroin users of Bombay. Thus the appeals for prevention have to be
differently selected. Even within a State, variations are visible as
illustrated in the following report of two
rapid studies.They
indicate a need for bottom up. planning of demand reduction activities.
At the time of the present writing, all planning is done centrally at
the national level by a small group of•overworked administrators for
whom drug abuse is one of twenty odd subjects to dispose of(See
annexure).
Socio-economic Factors:
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Preventive activities should be formulated after an analysis of
the
social customs of the area or target population. In our country use of
natural forms of drugs has been prevalent for centuries and an attempt
to ignore or avoid it would lead to the justification of
patchwork
attempts by publicity and non-professional individuals.
In certain pa^ts of the country the basic necessities of existence
wou 1 d be a major problem than addiction. And addiction to soft
forms
of drugs is the only way for the population to deal with stress and
continue
their cycle of life. Invariably this fact has been utilised
by individuals with vested interest to market synthetic forms of drugs.
t
Addiction to heroin has found to be related directly or indirectly to
urbanisation and thus dealing with the problem should consider
the
role of other resultant problems of industri1isation.
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Culture:
posters and
<
When preventive measures utilise audio-visuals , films,
symbols
and
style
of
pamphlets.,
under
the
assumption
that
gestures,
pamphlets <.
intervencommunication to be universal would result in disfunctional
the
It is vital to formulate the activities after analysis of
tions.
and
customs
by
experienced
anthropologist
and
linguist.
culture
Limitations of Present Intervention:
Informational
approach is not effective in modifying ‘the behaviour
patterns of users/abusers.
Thus scare or fear approach can .be
justifiable as an excuse for publicity, funds and effortless profes
sionalism. Through fear/Scare technique would negate the impact of the
programme on high-risk population ' as the messages conveyed are
contradictory to the reality and even factual data may be ignored .by
the target population.
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prevention cannot be achieved through information—dissemination nor by
evoking fear of death, impotence ... Such strategies have failed
elsewhere and we have no empirical evidence of their success here,
This is one area where professionals and policy makers need not
attempt to re-invent the wheel but learn from the evolution of
preventive strategies in the West where enormous human and monetary
resources have been invested for the purpose.
Media professionals are largely drawn from the commercial advertising
world.
Their principal thrust has been to sell some product.Theirs
is an attempt to bring about1 a positive attitude towards a new product
and to make the viewer/audience accept that product or adopt a new
procedure.
Similarly, most of the family planning campaigns are
smal 1
intended along the lines of promoting the concept of a small
family
norm and to adopt family planning ’measures.
On the other hand, the current thrust of the anti-drug campaigns seek
to bring about a negative attitude toward socially accepted drugs such
as alcohol, tobacco, charas, ganja, bhang, opium, and also against the
not-so-accepted brown sugar/heroin.
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social
Here,
the .differentials of commercial advertising
and
against
advertising need to be understood when preparing the campaign
drugs.
Promotional campaigns aimed at developing a positive attitude
towards a drug free life is more akin to commercial advertising than
when they attempt to evoke antipathy to drugs.
We can introduce participatory production-processes.
Poster,
essay,
speech and drama competitions...
among youth is a useful exercise
to generate ideas and to gain insight into the vocabulary range of the
youth population in different cities at different levels.
17
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Campaigns must motivate people to come for early treatment, to promote
abstinence and lead a drug-free life.
It is clear then that each state has to develop its own action-plan
depending on the particular pattern of drug abuse in that state.
DIMENSIONS OF PREVENTIVE MEASURES
Preventive measures are various depending on the area cjf focus and
target population, Inspite of these differences there are certain
principles to be adhered to, which would determine the effectiveness
of these programmes.
GENERAL PRINCIPLES:
I
These measures cannot be carried out in isolation from control on
traff icking of the specified drug(s). Countries that cultivate poppy
its
need to focus on crop substitution; methodology of cultivation,
role
in
international market and its
cost-effectiveness,
scope for -----------facilitating trafficking.
Demand reduction activities have to be varied:
specific, culture-specific and cost-effective.
Area-specif ic/drug
of
of
the
use
long
term
The first step in planning, designing and implementation
program is the selection of objectives, depending on pattern
and related problems.
Effective
basis.
measures
have to be sustained and planned on a
Those
involved in demand reduction
activities with clearly defined roles.
need
to
i
co-ordinate
h
their
PREVENTIVE- PROGRAMMES
Prevention programs may be either motivational or deterrent in nature.
Motivational programs focus on competence development. Deterrent
programs emphasize the harmful consequences of drug use to thej user;
illegal cultivation, manufacturing/
l-----Suppressive measures against
distribution and enforcement of controls on pharmaceutical products.
measures for prevention can be
Alternatively,
informational, educational and community measures.
of
three
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types:
Prevention concepts:
i
It is evident from studies that knowledge by itself cannot bring about
a change in attitude. Even if a particular intervention process
manages to achieve this goal, it does not mean that change in attitude
will head to a change in behavior pattern.
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Information approach can be targeted at various groups:
policy makers in the department of revenue, education, health,
labour and tourism, the media personnel, labour welfare and
welfare,
personnel officers, law enforcement officials, organizations working
in social
J-------- problems, educationists, agronomists, the funding organizations, action groups, youth, teachers and parents.
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‘ ’ i through information should offer balanced knowledge about
Prevention
the
effects
of drugs, nature and extent of the problem, relationship
the i---of drug abuse to other social problems, physical, psychological social
and economic costs of illicit use to the individuaK1), symptoms of
addiction,- help available and their drawbacks, initiatives which can
minimize harmful effects of drugs, the need for crop substitution,
legal status/changes required in the law,, the extent to which the law
supply,. to stigmatize and to marginalize
has been iutilized
------- to
_ - curb
—
addicts,
the marketing strategies utilized in order to substitute
soft drugs with harder forms for higher profits, the role of NDPS Act
in facilitating
the marketing strategy of the traf f ickers, the
circumstances under which an abuser resorts to peddling, the inhumane
facilities provided to the vulnerable groups in the correctional
settings and options available to them.
Information programs should have pre and post evaluation. Analysis of
the reports and articles on the program with regard to their frequency
and content are necessary measures along with awareness building
programs.
Educational Measures:
1) Programmed teaching approaches
2) Integrated drug educational program
3) Health educational programs and
4) Programs for personal development.
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Programmed teaching in drug addiction can be carried out through short
term Courses, study circles, individual studies/postal courses, Such
courses per se cannot change attitudes and behavior but their iutility
-will depend on the content, the context and by whom the matter is
presented within the broad framework of the academic curriculum, The
topics covered in the course should be sequential and the use of
appropriate audio visuals might create a better impact. Emphasis being
laid on responsibility for one's own decisions and rational attitudes
toward use or abuse of drugs. A caution however is necessary, Taking
responsibility for one's actions and the right to make decisions are
not highly respected values in our country where authoritarian life
style is emphasized in all institutions whether it be the family, the
school, or political parties or industrial establishments...
Before venturing into developing courses for the youth or students,it
is vital that a course for the trainers of youth should be conducted.
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Trainers should have skills for modifying the course accurding to the
requirements of their particular setting.
The selected trainers
should be those with whom uhe students are able to relate. Individual
study/postal courses should take into account the age,
level of
awareness of trainees. The availability of trained individuals in the
vicinity is important to clarify doubts.^
Study Circles:
The group participation approach might have advantage over inflexible
pre-determined courses. It will capture the interest of the target
group,
facilitate their critical thinking and clarify their doubts.
Opting for participatory approach indicates the preference for non
norms. It will also improve
authoritarian life-styles and democratic norms.
inter-personal skills and communication between the trainer and
learners. This approach also has the advantage of working out personal
problems of trainees as they surface in discussions.
Integrated Educational Program Within The Curricula:
Drug education program will have to be a part of the regular
curriculum in the educational institutes. It will have to be contiit can be implemented through illustrations and discussions
nuous,
allied
law, chemistry, civics and
during lectures on biology,
subj ects.
a specially prepared curriculum and teaching
It would require
materials, trained teachers and oriented administrators for program
co-ordination.
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Health Education Program:
well-being. Health
Health refers to mental, physical and social well-being.
education is a necessary component of health promotion. Drug education
is more effective when integrated with general health education
programs.
It can be
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targeted at health education workers, youth/ students,
community workers. and trainers of youth. When its prototype is
developed, it is vital that a multi-disciplinary team of professionals
should be involved. They should test the appropriateness of teaching
materials and curricula for each of the target age groups, their
experience with drugs...
.
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The cost of the activity will be minimal where there is
health educational system. In India we have the Central
Health Education Bureau with technical staff, equipment...
already a
and State
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program
f or per won «a 1 deve 1 opmon 11
personali ty
1.
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of
“^contradictory
is
activities. The emphasis is on the individual who uses or
creative «-in
use drugs, rather
than <on creating awareness on
drugs
rather than
or
likely
■to They facilitate him to re-examine or
h
facilitate him to re
into
general.
him to accept positive ones or to have better insight
encourage or
in
to
utilize
his
interest and
need
to
take
part
himself,
that can improve his self-esteem and to prevent alienation,
tivities
the
suit
to
(should not be undertaken to modify him
These
programs
faith
have
to
but should enable him to stand by his views,
what
society
with
deal
abilities and to
develop inner strength to
the
that
of
in
his rc®u 1 t
between
his
goals
and
f rom d ioc rep&nc i g?w L —---- might
s ocietyThe target group
those who have s
might call for changes
from creating a stagnated
stream
of
future
socialization The/^ctlvity
process
should be undertaken along
with
community
wi
th
generation .
approaches such as adventure groups and action groups.
for
value
assertiveness,
for
be
training
also
Programs
can
acknowledge,
to
making,
to
decision
rational
for
consciousness,
without
feeling
in
public
„
---------------making
decision
one' s
acknowledge
inviduality
and
about the decision made. They promote
uncomfortable
their
decisions,
about
support individualst becoming responsible
and
drug abuser to abandon the use
of
But it might not necessarily lead a
experimentation.
prevent
mind-altering substance or
inter
decision making
skills,
The
above programs
above
programs would strengthen
self
The
offer
situations
and
personal skills, ability to anticipate drug
i
perception.
aspects
not
will
These
programs
■."b;..b=< 5”£cbut
associated with use or
with
use
or
associated
on
the
feelings
situations.
The
important
abuse
and
drug
drua
conditions for these programs are :
program
and
---- 1 of the
Periodical
assessment
of the cost e
ec.
the
affected
consultant and members of
involvement of an international
interested
their own and are <capable and
a
critical
population who left drugs on
the field to take
in facilitating professionals involved in
of interventions.
view of the methodology
in
» extensive resources, time and energy the
would
require
imp1emen t
programs 1
These
of others
to
training c.
and subsequent
Lformu1ationi
the
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‘ ,
which
They cannot• ■be» substituted by posters, campaigns,etc.
program.
» more publicity for
ror t
those
social
labor
intensive,
provide
---might be lets® 1 ---- -of
their
figures
who thrive on them being less
1--- accountable in terms
figures
utility and cost-effectiveness.
poster
It
is
important
to
of
campaigns,,
to realize that the utility
important
models
is
competitions,
talks,
films, audio-visuals and commitment
talks
communi
ty
“
based
minimal
when
conducted
without being
followed
by
c_.
condue
ted
tend to
programs.. Preventive
Preventive measures
measures conceptualized by professiona
of
the
aim' at
at satisfying
satisfying their
their need
need to modify the behavior patterns
affected
affected
population
to
the
needs
of
the
socie y.
e
ffee ted
population
to
the
need
the
population consists of' a percentage of individuals who feel
their
express
to
rebel
against
option
to
society and their best
creative
of
discomfort
about
the
societal
values,hypocrisy,lack
societa 1
for them
1
set
options etc.,and they might prefer not to accept th. goal
a 1 so
__
_
__
,
Preventive
measures
by
the
society and their representatives. Preventive
n.
and
that offer alternate forms of activities
need to include programs L..
the
of
population to tackle the
problems
facilitate
the
targeted
society and change society.
i.
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to
should not be restricted
It
is
is evident that preventive activities
educational
approaches
and
campaigns
but
should involve community
programs.
as
abuse campaigns must communicate to the target population in
Drug
found
Since
addicts
were
languages as are found in each city .
many
abuse
Here
again,
drug
all
language
groups (SPARC reports).
in
Planning
in
the
Family
from
the
lessons
can
benefit
campaigns
campaign .< its leaders and the established infrastructure.
1
faci1itative,
and
the Family Planning campaigns, only persuasive,
In
in
drug
abuse,
have
been
used.
But
strategies
educational
of
1988,
legal
after
the 1985 Act and ‘its amendment
particu1arly,
strategies
have
Hence,
power
sanctions are attendant upon drug abuse,
been used which can be built into the campaign.
not
Drug free values need to be introduced in the educational system,
subjec
ts
’ 1 in
I as illustrative material
a separate subject but used
as
life
and
social
aspects of personal <topics that touch uponi those
-and
covered
in
educational
curricula.
of individuals <-- - -- and
transmitted
drug abuse should not be
prepared
The
program on
advanced
forms of
Otherwise, we would be introducing more
nationally,
and
accustomed
only
to
charas
drug
abuse in areas which are til? now
ganj a.
It is a fact that only a few abusers begin addiction with brown sugar,
them have been on tobacco and/or alcohol and/or
charas/ganja
Most
of
or
Thus,
though
not
all
smokers
are
likely
to
take
charas
for years,
the
brown
sugar,
we
still
do
not
know
precisely
ganja
or
In
of
those
who
do
'graduate
to
higher-order
drugs.
characteristics
22
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We need to set up a national program to periodically monitor through
the
research techniques such as "sounding" in all urban areas,
rapi^
ban k
patterns and trends in drug abuse and provide this research data
to the media people and the practitinners and professionals and
vo 1 un tee r s who he 1 p i n 111 e ac tua 1 wo r k .
target
thei r
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media programs,
including TV and radio should
thei r target
audience and use appropriate time slots depending on
be
audience.
For example any program aimed at adolescents would
missed, if projected for 0 p.m. in cities like Bombay.
The anti-drug
are
campaign can be projected when serials, popular among the youth,
popu
1ar
relayed. Anti-Drug Abuse campaigns can also be published in
youth magazines, and programs can also be made to educate the paren ts
regarding the signs and symptoms of addiction and the causes and need
for a support system.
Media people ought to remember that even the most effective preventive
can
education
program aimed at students, sustained for many years,
tackle only a third of the problem since addiction occurs for the
A
majority only after they have left the* portals of education,
considerable number of the addicts have either never entered school or
have dropped out at the primary level itself.
Thus,
the scope of preventive action needs to be broadened.
The
vocabulary,
idiom and setting, dress, demeanor of media presentation
should be tailored to the non-students, the marginalized youth..
Any reduction in drug-use or abuse may probably be more due to family
or community pressures, political mobilization, increasing costs of
Heroin and deaths or addicts, than due to our anti—drug campaigns
which often have a negative impact.
a.
Heroin/Brown
feared.
Sugar ?
being new. is
not
known
but
is
An exaggerated
Our campaigns may remove the fear.
if
made
in
a sensational
stress on the negative aspects,
aversion
for
form,
might evoke curiosity rather than
drugs among the youth.
b.
Public campaigns aimed at publicity and fanfare may tend
to push abusers to more clandestine locations.
c.
The increasing invisibility of the problem is certain,
But we need to clarify the specific impact of our
campaigns -
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trade and
Some countries appear to have come to terms with the drug
Campaigns
have 1 aid the burden of addiction squarely on their youth.
"War on Drugs" have gradually yielded to
"just say No"
such as
Journalists and other media personnel should not end up
programs.
23
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the absence of a clear understanding of these parameters which might
help us to predict which smoker would switch to higher—order drugs, we
should NOT use the TV.
Damage caused by a program projected
to an
unintended
audience of children or villagers who have never heard of
brown sugar cannot be remedied.
Eng 1ish/Hindi
programs on brown sugar on the national network of
the
TV must be stopped at once as the use of drugs follows varied patterns
in our country.
infrastructure has to be developed for regrouping
The
transmissions.
Programs on Heroin .should be broadcast only in Delhip
Bombay,
Pune,,
Goa,
the North-East,
Calcutta and Madras.
Other areas should be
included only upon empirical evidence of Heroin use in those cities.
The injectable mode of consumption of drugs is common in the case of
Fortwin,
Pethidine,
Brown Sugar and White Heroin.
However,
use of
Pethidine and Fortwin occurs only sporadically, except in Tamil
Nadu
and
Kerala,
Not more than 1.6 % of brown sugar addicts
have ever
resorted
to injecting brown sugar in Bombay, Delhi, Goa,
Madras or
Calcutta.
Thus,
media programs and all publicity (except in
the North-East)
including exhibitions and posters should not depict' injections or the
injectable /node of drug consumption because it is
like educating
people on a mode of addiction that usually comes on after several
years of •’chasing” brown sugar.
i
The impact of presenting a well built, tall young man as a hard core
heroin addict, indulging in criminal, homicidal activities needs- to be
studied.
We are trying to show a hard core addict losing all
values
in desperation for funding his habits.
Heroin addicts withi rare
exceptions become very sick in six months time.
We see brown sugar
addicts with respiratory problems, anemia, infections and
loss► of
weight and it is farcical to see perfect models acting as hard icore
heroin addicts in the nationally transmitted anti-drug program.
On
for
the other hand, there are regular consumers of charas/ganja
over thirty years or more whose physical health has not broken down <t
though their-achievement orientation may have become blunted.
brown
Drug induced psychosis is possible not only in the case of LSD,
sugar but also charas and ganja.
However, to what extent it has been
brought out by drug consumption requires clinical research.
While creative writers and professional media persons and
performing
artists have an extremely important role in
the Anti-Drug Abuse
campaigns,the programs need to be developed on the
basis of
their
grass root level experiences/expo^ures and the empirical data needs to
be built up.
1
24
I
the entire blame of addiction on youth and their parent®;
nor
hould
they
make
it
an
individual
problem
of
the
affected
people
when
si —
in’ reality it is a systemic problem.
putting
Community Campaignsa
Turning to community campaign®, we may again cite the example®
the peripheral areas.
•from
Fa 1 ah
we have the
United
the Jammu . and Kashmir region,
(at Urdu Bazaar, at Gantmullah and at Badami Bagh,
committees
Baramulla District);
the Samaj-Sudhar Committee at F’unipora
Sopore,
the
Welfare
Committee at Dalgate as examples of
Tarzoo,
Sopore and
local mobi1ization.
In
Aam
The TMNL Youth council at Ukhrul has included drug abuse a® one of the
themes of deliberation in its annual general council meetings normally
attended
by over a thousand youth (see SPARC
:
a note on noninstitutional forms of campaign).
Such community effort® are also Been in the metropolitan citie® though
on a smaller scale.
J
I
s
I
1.
Ways must be found to sustain such popular participation and we have
to emphasize the role of established organizations, who do not take on
the work themselves but facilitate the affected people themselves to
take up the issue.(A pilot project to set up area resource centres in
in
proposed
different parts of the country for the purpose has been
*
Supportive
heading
the final section of this master plan under the
Projects').
The emphasis is on utilizing the forces in the community to tackle the
problem, facilitating them to act as support groups, involving them in
preventive activities,
the process of social
re-integration,
in
facilitating them to understand the merits and demerits of the present
preventive activities,the lacunae in terms of
treatment facilities,
alternate forms of activities available, the options available and the
method of implementation, the funds available for various J^tivity^
need for accountability among professionals, the role of community
the
sustaining the activities of groups1 that are involved in tackling
understanding
create
problem,
understanding the
the need
i--- for a committee that will
Such
a
committee
should
consist
of
professionals,
accountabi 1i ty.
individuals, ex-addict
professionals openi to assessment of
committed
individuals,
ex
wqrk,, communitv
leaders, members from social organizations
their own wcjrk
community leaders,
working in other fields.
geographic
The term community does not mean people from a specific
who are
but people in
the neighborhood, village or town
region
The community
about
the
quality
of
life
in
their
locality.
concerned
. attitude
be the best force that can bring about a change in the
will
the
in
questioning
of
the society towards the marginalised force,
25
State machinery tackling
the possibility of curbing
the problem
through coercion and authority, when its attempts on these lines have
till
today have not managed to curtail
the activities of
the
underworld nor create a harmonious existence among people,
Probab1y
coercion might succeed in throttling the marginalised section of
the
society
in the name of Justice and welfare of the people as the
they
are not equipped like the underworld to deal with the powerful, rigid,
hypocritical system called society.
!
i
It is a romantic
Western concept that such caring communities exist
in
the developing countries such as India. Our own experiments in
rural development, panehayatiraj, community development
development,F
cooperative
movement,
electoral
politics,
communal
conflagration®,
tribal
movements,
peasant revolts,
cohesive communities have been
rent
asunder by the structural inequalities and political
mobi1ization
processes set in motion by the democratic institutions of India.
It is in this context that we need to look at the types of
organizations working with the poor in the country, These
grass—root
workers have insights into the methodology of coalescing distinct p
often divided
populations along the lines of
pr'imordia 1
sentiments
into a common area of concern, overcoming the obstacles posed by
the
political
and other vested interests which thrive on
divided
communities,
It took even the industrial and commercial
groups wel 1
over fifty years in India to emerge as a single entity under the
banner of Federation of Indian Chamber of Commerce and Industry,
This
formation was preceded by the chambers of commerce and
Industry
under language, caste and other divided considerations.
grouping
It
will
take mature community work to bring in the poor on a common
platform of dealing with the problem of drug abuse.
drug abuse is a problem whi’ch affects all
Besides,
classes,
The
tendency is to enter into multi-class mobilization. From a review of
mass movements in the country where the rich and the poor have been
simultaneously mobilized for a common cause, It is the poor who bear
the brunt of the movement-making while the elite groups within
the
movement walks away with the benefits of the Movement, whether it is
non-brahmin
the freedom movement under Mahatma Gandhi,
or the
movements under Periar in Tamilnadu or the Phule's movement in
movements under
Maharashtra or the Assam Movement or the Farmers*
Sharad Joshi or other Agrarian leaders. Only token
benefits trickle
of
the movement
dflwn to the masses who lose out on the control
planning and negotiations.
Thus,, sectroal mobilization is indicated as the key word for community
work.
Even when multi-class mobilization is taken up, the organizers
ski Ils,,
have
to consciously
train the poor in
leadership skills,.
in
communication systems in their cconstituencies,
on s t i tuen c i es,
include
setting up
them in negotiations, giving them access► to information on the problem
and assisting them to generate data on the problem through community
self-surveys and through
throuqh analysis of existing data from all sources.
1
26
I
I
A
jt is surprising that none of the government funded deaddiction
centres nor the counselling centres employ even a single community
organizer as a part of the treatment team. It is even more surprising
that there are practically no community development organizations
being funded to take up drug abuse work.
This is one set of
organizations which not only have the theoretical framework of social
development and social
problems for tackling the problem of drug
abuse, but actually have created communities out of disparate indivi
or
duals and mutually antagonistic groups which stay divided on real
The
imagined or propagated reasons for staying divided for survival.
collective insights these organizations have built up through years of
working with Community based Organizations should be capitalized upon.
The principle is building upon what is available within the system.
The simplistic notion that giving a van and even appointing a social
worker as part of the counselling and, deaddiction centres would not by
is
themselves give these institutions the community orientation that
bo thoroughly missing in them.
Before venturing into community-based approaches or facilitating or
strengthening already prevalent community based programs. The steps to
be taken in order to ensure that program activities are facilitated
and impact made realistic are? identification and mobilization of
re
sources which already exist which include youth organizationP
the
mediap
voluntary organizationswelfare organizations
organizations,,„
educational
institutions?
industrial
sectors, labor unions
unions,<
religious organi
zations,
leisure activity and facilities; the assessment of the size
and characteristic of the problem in the community; the development of
mechanisms for co-ordination existing services and those which might
be developed in the future; establishment of mechanisms for obtaining
funds, volunteers, facilities and technical expertise.
J
I
27
I
Building an Integrated Community
Broad Objectives;
social
social,,
political
1. To help communities at large to understand,
economic factors that create and sustain problem of drug abuse.
i
indentifi—
2. To create public debate and positive atmosphere towards
cation of drug affected persons and creation of a support network.
3. To equip and train community volunteers to gain control over health
care techniques. •
Identification,
referral
detoxification, treatment 9
follow-up - specific to drug abuse.
b) Develop skills of analysis and application (survey analysis - action - feedback).
c) To develop and sustain area resource centers.
d) To act as trainers for spread of anti-drug education
and action.
4. To develop
deve1op strong local forums/groups of concerned individuals,
organization/pol itical representatives., in order to mobilize public
opinion and provide support to community groups and maximize use
public/community resources.
a)
administrative
5. To interact with and lobby for change in
legal,
environment with reference to adopting new approach towards drug
abuse•
I
f
5
A
- 28
r
I
II
In f o r m
patterns and
understood.
s
5 -
I
i
variations in the spread of drug abuse are
not
Within the country, state
state,ji city/village there is a varied pattern
of drug abuse.
Traditional forms of opium consumption,
consumption
use of
Ganja, Charas etc. on an everyday basis and currently the use of
heroin/brown sugar etc. reveals the need for deeper understanding
of causation? availability of drugs, its spread among urban rural
communities,
role of addiction in personal life and potential
for
addiction among certain 'sections of the-poor.
□pium/heroin addiction is a group/community phenomena often
social and cultural sanctions which need to be reviewed.
Drug addiction as a phenomenon is a complex web which
and destroys established belief and val4ue systems.
!
<
■
yet
with
eccompasses
Process
3i:
Key persons in the community and families of affected persons have
intrinsic understanding of the causes of drug addiction and how
affects the individual, family and community.
Every drug addict is a person first and a member of his/her
therefore his/her responsibility extends towards community.
an
it
community
Addiction is a group phenomenon.
Training would be an outcome of an assessment which identifies clearly
the following:
a) directily affected persons
b) indirectly affected persons
c) support/interested members
d) area/community resources
e) key communicators
f) members of the drug abuse chain
g) extent availability of drugs in the community
h) belief and customs
life style;
i) role of drug use in current
patterns of addiction.
•” acceptance of the drug abuser and his/her integration in
communi ty.
- community members - especially those affected would be
the best persons who can define community goals/vision
29
I
■
ANNEXURE
PILOT PROJECT : 01: DEVELOPING PEER LEADERS FOR PREVENTION
Project Justification:
A
Effective preventive measures are participatory.
Innovations are
poster
necessary since preventive measures are limited to
campaigns, walkathon morchas. We have to assess the effectiveness
of "Just Say No" campaigns (which simplify the problem of
addiction to intra-psychic factors). We need to develop training
programs for interested, capable youth to assist their peers in
tackling isolation and alienation associated with addiction, A
properly designed pre-project and on-going training program for
volunteering youth leaders would increase the probability of
tackling addiction given the paucity of resources and trained
personnel.
J
"My friend gave me" is an soft-heard phrase in our* interviews
with addicts when discussing their initiation into drugs. Friends
are also cited as significant sources of support for giving up
addiction by former addicts. Establishing a satisfactory new
relationship has been an important milestone in the total
recovery of many addicts. Thus training peer leaders can be an
important step towards prevention of first experimentation with
drugs. Such trained peer leaders will be our important local
resource to identify drug abuse among colleagues.
*
■■
■*'i*.*
*...
The specific advantages of relying on peers as prevention
are:
a.
b.
c.
d.
i
agents
Being of the same age group, they speak the same idiom
and language.
They are going through similar difficulties and joys
arising out of the roles and functions they have to
perform in their stage of the developmental cycle.
They are in daily contact.
They know each other's lives:happy moments, sad events,
situations. They
how each one responds to different situations.
reach out to each other in crisis and they have fun to
gether.
Peer leaders can be chosen from a group of friends in a given
institution/community or a trained youth can be placed in an
already existing group of friends provided that the trained youth
is compatible with the group he is entering.
X
30
Community Project - Goal*
s
£
■■
1. To ensure that ’’community management” mechanisms are set up
deal with social addiction (drug and alcohol).
to
2. To ensure voluntary treatment and integration
community processes.
in
of
abusers
increase community
3. To generate action processes which in turn
participation and decision-making of
key issues in
the
environment.
4.i To increase the use of public resourcesp establishing mechanisms
of direct feedback and dialogue with the
local,
city,
state
governments.
5. To build and strenthen "shared"
operative structures.
community
assets
and
co-
i
I
i.
I
6. To increase interaction building < federations of settlement
committees of the poor in cities/towns sub regions and regional
level.
7, To train ex-abusers and youth as a cadre of change agents in the
community.
ON-GOING/ PROPOSED PROJECTS
i
■
I
Th* UNFDAC funded Project in Delhit
This project has been conceived both as a step toward sharpening
the
technology of communication in .the Indian context and at the same time
to develop community participation in the management of drug abuse in
a city.
Jagran,
a non-governmenal organization based in Delhi has been using
their mime plays to act as catalysts to rouse community consciousness
to convince individuals that they have options available in solving
their essential problems and to create in immigrants the self concept
of being potential initiators of a progressive change for the better.
ba lek
Among
the issues handled are untouchability,
nutrition,
marketing drug abuse,dowry, sanitation, family planning,
evils of
alcoholism etc.
In view of the drug
problems,
JAGRAN has been
working in educating and motivating the slum dwellers in Delhi on the
_► as prevalent today in the slum colonies.
harmful effects of drug abuse
The method io-? JAGRAN has been through the Pantomime theatre which
involves the
local
people of the resettlement colonies to act as
animators.
■
Ii
j
i
31
The project aimc :
i)
to produce through isurveys
---and communication with |people
_r_:
in the resettlement areas^i pantomime plays that aim both
at primairy and secondary pprevention target groups.
ii)
to train animators,
in <contacting slum
dwellers,
transcribing their discussions
-- 1 into new ideas for plays
development mimes, rehearsing them intesively and performing them.
ill)
to evaluate the first year of project implementation to
assess the impact of the project.
The two main activities of the project will be the .election
and
training of a group of animators who will work in the slum areas,
and
secondly
the production of plays.
These two activities are
closely
intar-related
-- 1 and part of a particular methodology that
JA0RAN has
developed over the last decade.
The animators play a key role both through their u_.
contacts
with si urn
dwellers
but also through the development of ideas
„
i
into
pi«y« and
through the^actual rehearsals
' i and performance of the pantomime pl.y..
be
>
FUTURE NEEDSx
1• Informational approach need to be targeted at support
groups.
2.
Intergrated
implemented.
Educational
programmes have
to
be
formulated
and
3. Health <educational
'
Programmes involving community • level
health
workers have to established
----------- 1 depending on the needs of the specific
region.
4. Organisations
involved in prevention should network with other
orgaisations involved in treatment,, (re)habi1i tation, social integration and law enforcement.
5- Each city have to develop an action plan specific for their region.
32
»
>
ate Objectives one
I mm*2di
'evaluate
the role of peer leaders in prevention
To '
ddiction.
auAc tivities
Output
■
An action group
consisting of peer
leaders trained in
\ preventive education.
I
I
drug
abuse
Selection of a group of youngsters who
are interested and capable.
Assessment of the selected trainees
knowledge of drugs and attitudes towards
drug abuse and abusers.
- Orientation of the group on various
aspects of addiction, types of pre
ventive measures and their drawbacks.
■
■
A sounding study-interview with.small
groups of addicts, law enforcement
officials and key informants carried out
lay by the group.
■
I
I
of
- Formulation of subgroups to conduct
following activities:
i'
Sub-group A
- Documentation of organizations working
in the field and assessing their lacunae
or shortcomings.
Sub-group B
in-depth interviews with addicts who dis
continued treatment and their view
about support systems
Sub-group ,C
- interview with support groups with the
view of creating a dialogue between
support groups, affected population and
the group of trainee-peer—leaders.
Sub-group D
■
- study
of legal aspects of addiction and
relevance/the drawback of NDPS Act.
Sub-group E
Independent survey of the problem in
a <given educational institution
1
Formulation of policies for the insti
tution and conducting dialogues with
administrators of the institution.
- Facilitation of the peer leader trainees
to identify drug offer situations,
tutorials and assignments on review of
33
literature drug offer-situations encoun
ter meetings with recovered addicts on
drug-offer situations and on ways of
coping with it in a positive manner.
Value clarification program
peer-leaders trainees.
-5
for
the
I
I
Role play on drug offer situations.
- Training in leadership functions.
Collation of all information collected
and forming guidelines for further field
work-specifically for preventive work
with various target groups.
- Assisting one or two of the sub-groups of
trainee peer-leaders to develop positive
alternative programs for their peers.
I
i
&
- training of other youth by these
trained youth.
PROJECT
: 02 : WORKERS EDUCATION PROJECT
Development objective :
Alcoholism and drug abuse have penetrated all segments of society in
Urban and Rural India. The purpose of the current project is to
understand those segments of society which have been, sign if icantly
affected by alcoholism and drug abuse.and to develop mechanisms for
demand reduction with a view to strengthen the human resource base of
the country.
Justification of the Pro.iects
S'-
Among the urban workers especially men addiction cuts across highly
paid professionals, middle management workers, workers in . factories
and workshops hotel and tourism sectors, construction, transport, dock
textile - garment workers; and among the unorganized sector, low paid
‘casual labor, petty traders, ragpickers, hotel and restaurant workers,
prostitutes and victims of drug - heroin addiction especially in the
large cities. A long list of categories of workers affected by brown
sugar addiction in 11 cities of India has been prepared by SPARC.
Urbanization, commercialisation, faster growth of cities seem to pre
conditions for availability of drugs. Street corner joints, video
clubs, country liquor clubs, ^jylanes, vacant lots etc.
usually
located near the work place offer easy access and exhaustion. mental
;;
t-
I
Ii
i
34
-
r
n®ions and congested homes within slums?
access to police is
offitric-t^d
an d often public toilets, clubs and shops are locations
and
liere pu
pushers
in
tho
unlu^rw and drug users meet. And barely 10 7. who work
local government departments of conservancy in hospitals - assigned to
tasks - sweeping, garbage collection, cleaners in hospitals
menta1
both
men women, abuse drugs/alcohol.
again
5 yhe
recycling and hotel industries absorb a majority of
scrap
migrants
who-rarely are able to graduate in their Jobs or
youth
These
segments are vulnerable and are often caught in
the street.
of
addiction
stealing,
pushing and drug addiction.
web
the
off
t he
workers,
slum
It Is apparent that both unions and organizations of
dwellers,
will
have to use innovative techniques to understand . the
dimensions of drug abuse among workers, evolve education that reac hes
out and at the same time is rooted in collective action.
Irregular jobs, work schedules and sometimes major/minor family crises
add to indifferent health, social isolation and frustration which can
lead
to seeking a constant
'drugged'
state.
Several
addicts
interviewed
have confessed that both un-employment and sometimes
the
very nature of employment leads to addictive behavior.
Similarly categories of rural Opium
use has been prepared on
urban workers and laborers affected by
the basis of records available.
■
!
Very little effort has been made to systematically identify which are
the occupations most affected. Nor has any attempt been made to
the ^xisting curricula for worker's education or to train
understand
the labor welfare departments in organized sector industries where
for
staff
they are statutory avai1able.by law with professional
counseling therapy etc...
Practitioners
approved under the ESI scheme are several
Medical
I
law on
the
and
require
training in these aspects. Given
thousands
heroin
by
type
of
behavioral
modifications
brought
about
NDPS,
the
addicts
,
on
given
the
negative
image
created
by
media
campaigns
use,
and
orientation
of
the
employers
would
themselves
need
maj ori ty
for treatment,
Early case finding, peer and union support
training .
after—
detoxification counseling and re -entry into the work place and
pi lot
issues
to
be
addressed
on
a
are
care
(slips, lapses, relapses)
basis to begin with.
Strategy of
I
implementation
A benchmark survey in a given city through participatory process or
trained professionals sensitized to this problem and key workers in
factories and workshops and through any other appropriate methodology
be carried out in
- identification of most affected industries need to
t_ Lthe first place.
35
w ‘‘ ‘ * i one or two units of th® most affected
Through a process of negotiation
affected
industries should be selected to identify the
and
the least
nonto
which
and
the
factors responsible for the spread and
ex ten t
addictive
behaviors
will
have
to
be
determined
.
spread of
Again
through a process of negotiation and active participation of
workers, management and a team of helping profes-siona1s; education on
the dimensions of drug abuse,
provision of treatment
for affected
abuse
workers can be made, involvement of co-workers in after care and
re
integration. The Welfare department of the industry, workers education
boards and all
the other systems concerned with
labor welfare
industrial safety and productivity need to be trained through properly
drawn up manuals so that the existing system can be geared to deal
with the problem of drug abuse in the country.
y
the
Reaching out to the unorganized sector. In the country on 1 y
we
11
and
large/medium industries have a provision of labor welfare
the
in
organized unions - which cover about 18 7. of all
workers
country. However as can be seen the pattern of drug abuse cuts across
several
worker segments - engineering workshops,
transport workers ,,
reaching
out to these
hotel workers and ragpickers. The methodology of
can
constitute
a
segments of workers has to ba carefully planned and
through
organizations
and
unions'
and
unions
which
separate exercise
work among them.
Immediate Objective One:
early
prevention
To integrate alcoholism and drug abuse information, reintegration of
treatment and
procedures,
case identifications,
affected workers as part of the workers education curriculum.
Output
Activities
1.1 Identification of po
tential resource ins
titutions and indivi
duals for carrying out
the project and to
develop a working
methodology for the
organized sector.
Review of Literature on
workers education.
l.*2 Specific agencies and
industries identified.
key informants Negotiat
ions with Unions and
Management.
1.3 Development of a
curriculum integrated
with the manual on
workers health and
safety.
Identification of key
trainers of trainers,
wit+i national outreach.
<
Personal Visits.
A Workshop.
A participatory Survey
Data collection from
36 -
I
Orientation of these
key trainers of trainers
on all aspects of drug abuse.
Production of a manual and
teaching aids for trainees.
Pre-testing it with <a
group of trainers.
$
Modification of the same
in terms of vocabulary
and immediate relevance/to
their lives, Predominant
substances of abuse.
Immediate Objective Two
workers
I tribal
To identify those» segments of rural/agricultural and
alcoholism
Who are affected by
and workers/in the unorganized sector.
manner and to understand the socioabuse
in
any
significant
and drug l-•for
factors that are responsible
situational
cultural-economic
alcoholism and drug abuse.
I Output
I
2.1 Specific Geographic
areas* identified.
I
J
Activities
Review of Gazetteers and other his
torical and contemporary documents
to identify geographic areas/States/
U.T.s/Tribal/pockets/unorganized
industries.
National Conference of organized
national unions with outreach
to unorganized sector.
2.2 A networked methodology
data collection
formulated.
- Sampling of areas/industries.
- Identification of organizations
to undertake filed data collec
tion, Division of labor.
- Procedure and tools of data
col lection.
2.3 Most affected rural
unorganized sector
labor identified.
Data Analysis and report
production.
37
2.4 Methodology of reaching
the rural/unorganized
Jabor identified.
A working of researchers, workers
Education groups, Radio, T.V. teams
NGOs of the area/close to the
affected labor.
2.5 A program of drug/
alcohol education for
the rural/unorganized
labor developed.
Selection of three segments of the
most affected rural/tribal/urban
unorganized labor affected by
drug abuse.
2.6 A group of Key
trainers trained. A
manual produced.
Train a group of key trainers in
the unorganized sector on drug
abuse, alcoholism.
- Through such training material,
develop a manual.
PILOT PROJECT NO:03 : INTERGRATED EDUCATIONAL PROGRAM :
Drug education will be a part of the regular curriculum in the educational institutes. The program would be continuous, it can be implemented through presentation on the physiological effects of drugs
during lectures on various related subjects in the school.
Since the students are one of the segments of society on whom public
resources are spent and much hope is placed. A large number of 4
prevention programs do already target at students. In any case they
are a captive audience so long as the heads of institutions permit
drug workers to organize programs for them. However quite a few
principals have expressed nervousness at the direct drug awareness
that it might stimulate some of their
programs. Their fear is
students to experiment. Though such a position can be disputed there
is no clearly thought out scientifically conceived well researched
method of student education in the field of drugs.
Some of the drug workers have attempted to incorporate drug education
as part ”of overall personality development courses in which presen
tations are made to parents of students on '’abnormal" child/adolescent
behavior and at appropriate moments they incorporate drug related
information q.s well. Such sessions often lead to a good number of
parents seeking help.
Thus any such process of student education should make provisions to
include information about where and what type of services are
available. In those cities,
areas, neighborhoods where no such
facilities are available such educational processess should not be
initiated at all.
I
3
38
I
abuse
paragraphs, it is proposed to incorporate drug
along with other health messages without expanding already
text books.
oveirsized
in the
1 '5
following
suggested that to begin with suchi an exercise should be carried
It
institutions, one each in Kerala,
Calcutta,
Pune and
four
out by
has
other
Hindi
speaking
city
where
Brown
Sugar
usage
Lucknow or any
in
T hus manua 1 s in four different languages can be produced
spread .
the next three years.
also think of other combination such as incorporating drug
One can
the
through
other social problems of national importance
abuse and
examination of existing text books.
attempt to undertake preventive measures within
Any
setting should be preceded by certain steps such as;
the
educational
of
the teachers, adminstrators, parents or other
addiction and its
individuals to the problem of
responsible
various dimensions.
Orien tation
- Facilitating and formulating a network of professionals working in
community
law enforcement officials,
supportive
the
field;
interested
teachers,
other
staff
and
parents.
nr'leaders, L.._
- the policy of educational institutes towards
should be evolved
of
abuse
students
and
drug/s
the decisions on policies should be stated to the
their support groups before admission
the policies should consider factors such as;l need for treatment,
knowledge regarding various
v... 1-- treatment approaches available and
constrains,
need
for professional confidentiality in order
their i__
facilitate individuals to seek\ the service provided.lt should also
parents in treatment is dependent on
state whether involvement of
<
the desire of the concerned individuals.
Immediate objectives
them to
To develop a set’ of graded teacher manuals to assist
botany,
biology,
of
subjects
incorporate health
hea1 th messages in the
students Vlth
history
cienue,
u.j.vu.v.=»
-----for
civics
and
chemistry,
soc i a 1
social
science
messages
standard upwards and to
1— introduces specifically drug related
in the tenth standard.
I
k
39
Output
A set of teacher
•«
manuals
Content analysig < "
°f text books
in
the
following
jbiology,,
lotany, chemistsubjects
social^^science, civics -ryi.
and
histo
r
identifying
topics which lend
themselves
^o lead
a discussion
or> health Elated
messagesj.
A weorknhop
•
or
consultation
meeting
healu? _■ between
pedagogues,
neaith educators
Bducators
community
ealth experts
experts to and community
^entity
which
'nassages
can
be
built•"
-I can be
curriculum by "av of
in to
-•»
the
-- 1 by^way
tlo„,.nocdot
“«v Of illustratutorials,
group
u-1 scussion
o e=e-4
audio-visLlai«
®nfnents, f i 1 ms j)
• ids.
•l3Llals and other
teac hing
Product!
on of the manual "for"
specific c lass
one
and
teachi n9 aids.
f^equisite
Orientation
f
I
i
Of
a group
of
th?
Cted
teache
r
8
on how to
cne manual•
Ii
use
Pield testing the
for lts usability manual both
by
and <etfectivr--__
teachers
eness and
of the students.
acceptance
Based on the
modifying the above
manual.
I
experience
Orientation
teacher
■institutions
On
the
—°Priate’
"" aPPr
use
of
tr>e manual
for
batc hes of teachers.
future
““ State
level tseminars
— •
for key
teac her trainers
-• -> in the relevant
subjects,
who in
turn
organize
trainin 9 program wou 1 d
other teac hers
for
!n their respective idistricts•or
towns
4
40 -
I
PILOT PROJECT NOs
II
I
5 8 MASS COMMUNICATION
evident from the projected and prevelant
preventive measure®
from the media tend to concentrate on
limited
that,
This
of addiction without placing it within right frame work.
aspects
leaves
out
certain
important
dimensions
of
the
problem.
tendency
It
iB professiona1s
professionals need to be aware of the probability of adverse
□f
preventive measures due to lack of correlation between
'pattern
of use/abuse within the community and
projected
*xisting
.
They
need
to
consider
the
cultural
variations
when
producing
messages
Jo-visua 1 s which focus on gestures and other form® of non-verbal
*Ummunications
lunications to
to bring
bring about
about change,
change, the acknowledgement of their own
limitation due to their specific background,
background, the relationship between
and other social problems. The need for sensitizing
addiction
by their professional
role of
is further indicated
personnel
to the notice of the general public the changing trends and
bringing
support
aspects of addiction. They would be a good
other crucial
aystem for the community and the marginalised population.
'5 Media
The curriculum would include the following :
i* History of abuse to mind-altering substances in India.
Steps taken at the international levels and the contribution made
by the involved parties in terms of monetary contribution and
in any other form.
The norms formulated by the Organizations set up by the United
Nation-s in order to tackle the problem of addiction and drug trade
the
in the developed and developing countries; the focus being
assumptions and the criteria selected in the formulation of norms
- and their implementation.
a
Analysis of the problem faced by the UN agencies in terms of their
operatonal function and implementation of specified target■; goals.
It will
also include the difficulties they faced with their
funding governments and other international agencies within and
outside the UN system.
Analysis of the international laws against drug abuse, role of the
Interpol,
national
laws, with specific reference
to the years
these
where major changes were made and the relation
between
changes and cultura
cultural'
factors of our country, international
1
trends
pressure,
changing trends in opium cultivation and trade
in the global market,- how they affect the drug abuse pattern in a
given country.
1 aws
and
technical course on cannabis and
1 egal
A capsule
and
its
control
in
the
countries
that
cultivate
pertaining
to
those
which
do
not
cultivate
but
consume.
consume cannabis and
41
The debate on legalizing drugs and the operant variables
actually pressurize the legislators into making the kind of
that. I hey f-'iiacl.
laundering
techniques and
Money
international
agencies
in tracing
these properties of drug dons.
] <"IWM
the
strategies adopted by
and
prosecuting/confiscating
*
?!
of
the
community
by
Investigative skills used by Journalists in other parts
countries in the field of drug trade and abuse reportage.
Developing accountability within
objective reporting of their work.
that
the
treatment
Linkages of social development processes to drug abuse
in different countries with specific focus on India.
JE
epidemics
Roles of media personnel in the field of drug abuse s
Prevention? mobilization of parents and the opinion leaders of
the country and any given community. Lobbying
support
for
the abusers and the treatment professionals for the creation
of humane facilities and for the protection of the human
rights of the abusers. Making objective appraisal of public
policy and programmes funded by the government and NGOs.
Immediate Objectives
£
To facilitate the role of media personnel in the field of
education through sensitizing them to the problem.
preventive
.p
ACTIVITIES
OUTPUT
To
identify
interested
individuals in the field.
Selecting from among those
who have already published
or produced any communica
tion aid in the field.
To train the personnel
involved in the field of
mass communication.
To conduct a training pro
gram for the individuals
on drug addiction.
!=
Documentation of the
programme inorder to
assess modifications
required in terms of vari
ables such as culture,
history of opium culti
vation in. India, develop-1
ment processes and how
i
- 42
1
they interact
drug abuse.
wit h
Evaluation of the
effectivenes of the
measures and the concept©
©elected by involving
addicts as the part of
the of the evaluation
team Production of a training
manual in ©elected
1anguages
r
>
43
ANNEXURE
TWO STATE LEVEL CASE STUDIES
A.Drug Abuse in Karnataka
SPARC-HOPE Eitudy (1900) indicates the fol lowing j
1.
cannabis,
AlcoholF
Drug abuse has a varied pattern in Karnataka,
petroleum
heroln/brown
sugar p cocaine, dexedrineji calmpose and
were substances abuse in the different towns of the State.
2.
Ganja had been seized from ten ci ties/townsb
Chickmag lore,
Raichur n Kolar, Mysore <i
Hassan, Davangere, Manipal, Raichur,
have been
persons
..J Mandya.
Ninety four
Belgaum and
Karwar,
have
often
However,
police
However,
the
arrested
in
this regard.
indicating
the
prosecuted the offenders under the Customs Act,
the NDPS
need
to provide adequate information to the police on
Act.
3.
Brown Sugar abuse has been seen in the following placess
Mysore,
Mangalore,
Manipa1,
Bangalore has brown sugar.
respondent.
Davangere v Need less to point out
by a
i
Tumkur was a 1 so mentioned
The inquiry indicated that brown sugar had not percolated to
It appears to have two nodal points:
parts of Karnataka.
all
configuration :/
Bangalore
and Mangalore with the
following
De-addiction
Bangalore-Tumkur-Mysore
and
Mapgalore-Manipal.
centres or facilities for drug addicts such as counseling services
should be optimally located in Bangalore and Mangalore.
!
4.
In
Karnataka,
there appears to be a
link
between centres of
Karnataka <,
Manipal
are
education
and. drug abuse.
abuse.
Bangalore,
Mysore,
Manipal
is
a
educational centres and they show brown sugar abuse,
about
36
Institutions
educating
10,500
students
small
town
In the last four decades, 50,750 students have passed
annual 1y.
engineers;
4700 doctors; 600 dental surgeons and 950
out
(4400
graduates.
The
annual salaries of the teaching staff
pharmacy i
is
$.67
crores;
and
the assets of the institutions at
alone
current market value is over 100 crores.
Drug abuse in Kerala
another rapid study carried out by HOPE
in col 1aboration
L i k ew i se j,
with SPARC in 2.1 towns of Kerala brought out the following pattern of
drug ^buse in that State.
44
-
j
i
Findings:
sugar was either seized or media reports were obtained or
the
in
sugar abusers were interviewed or were treated
Cochin n
Trivandrum, Idikki, Malappuram, QuiIon,
following towns:
Pa 1gha t„
Alleppey, Ernakulam, Tellichery,
Kottayam,
Calicut j,
Cannanore, Kovalam and Kasargod.
Maip
Brown
1. brown
2<
3.
&
P®r the Police and Customs data made available in 13 town® (for
January 1988-May, 1989) 662 raids were conducted
in
the period
I
293
persons
were
arrested
and
2019.711
Kgs
of
Ganja
was
which
seized. Though brown sugar" was also seized, the exact quantity was
to the
present
not always specified in
J~
•the
Ll“- data provided
4-4 •
of opium
researchers.
Likewise, the quantity seized in the case
and charas is also not specified In some of the districts and so
totalling was not possible.
The following substances were abused in the towns studied:
Fortwin,
Calmpose,
Alcohol,
Ganja,
Charas, F’ethidin, Morphine,
Opium, Brown sugar and White herion.
A case of 'Snake-bite' addiction was reported in the district of
Pathanamthi tta.
4.
data available to us did not often discriminate between
Hospital
for
Hospital
alcoholics and addicts treated. Trivandrum General
the year
instance,
treated
1006 patients of substance abuse in
not
records
did
1988-89.
While
the Trivandrum Hospital
in
hospitals
distinguish between alcoholics and drug abusers,
patients
other towns
listed
below did not have breakdown of
treated for other drugs such as ganja/charas, opium , brown sugar,
36,
Alleppey
morphine,
and pethidine.
The statistics:
Iddiki “ 20,
Malappuram - 33,
Kottayam - 56, Calicut - 99,
Cannanore - 3, Palghat - 15.
5.
Eleven specialized centres/NGOs working with addicts have
in two years a total of 955 patients.
6.
of
The psychiatrists interviewed were asked to rank the drugs
<
•
average
abuse among their patients on a scale of 0—10 points. The
weightage by the respondents is given in the Table below:
■"
*
treated
$
-
I
Brown
Alcohol:
10.00, GanJa/Charas: 7.00, Ca1mpose/Va1ium: 4.00,
Sugar/heroin: 3.00, Pethidine/Fortwin : 1.75 and Opium: 1.00.
interviewed for this study,
Thus according to the psychiatrists
a,
following closely by Ganja.
alcohol is the most abused drug in Keral
L-..
1
it
is
the
introgenic
form
of
addiction that ranks the
Interestingly,
(including
calmpose/valium/pethidine/fortwin) with a score of
third
(
5.75. The professiona1s need to examine their practice.
45
-
ANNEXE II
The "high-risk Population":
The
media
lias
to recognize tliat certain
vulnerable to drug abusei
a.
Educated but unemployed youth.
b.
Youth
employed in weary Jobs or
employed
in
polluted
environs
staff...).
categories
of
youth
a re
r
I
those
(porters,
conservancy
c.
Youngsters who began smoking cigarettes and
childhood.
d.
Youngsters with a petty criminal
e.
Youth
with low stress-management skills and
esteem.
f.
Youth who
have an
alcoholic
or
absentee
father or a
father
with' a criminal record or youth
who
have
lost
their father in their childhood.
g-
Youth who
had a surfeit of pleasures, drifting through
life without
having
to worry about
money
and without
any meaningful pursuit in life.
beedies
in
record.
low
Be 1 f-
The cost* of addictioni
Media
should
addiction.
highlight the economic,
social and
personal
costs
1
of
Economic loss:
Economic loss is very apparent when we note that:
a.
The money spent on
DOO/per day per
Bombay alone would
there ar6 one lakh
b.
for
The money, spent on detoxification and other medical costs
Delhi
in
examples
50 percent of the 178 addicts interviewed
Rs.
about
had
incurred
a per annum private expenditure
of
5,300/— for medical services.
c.
returns
Most addicts drop out of education leading to lowered
they
had
1 ahour
might
get
in
the
labour
markets /than what they
their
1 ose
addicts
completed
their
courses. Most employed
buying drugs ranges from Rs.
3/to
user.
The value of drugs consumed
in
be between Rs. .179 300
crores
if
addicts in the city.
A
I
46
l
jobsj
alternatively they slide from permanent/secure Jobs to
temporary ones or to casual or become self employed and end up
unemployed. Staying in addiction for several years makes some
of them unemployable as well.
The opportunity
calculated.
costs
lost
to
addiction
cannot
be
eaBily
Social and personal costss
a.
Breakdown of the family-
b.
Erosion of values or the absorption of the subculture
addicted peers and onset of psychopathology.
c.
Loss of self-confidence, self esteem due to public
taken
ignominy following arrests, non repayment of loans
etc .
d.
A host of respiratory and other illnesses such as Eczema <,
suicidal
anemia,
mental illness (psychosis, depression)
attempts and suicides.
e.
Wholesale dehumanization.
47
|
1
of
Counselling in India
1
i
A Status Paper with Outlines for Pilot Experimental Projects
National Addiction Research Centre
5 Bhardawadi Hospital
Bhardawadi Road
Andheri West
Bombay 400 058
ADDICTION COUNSELING
State of the Art
t
3
a
I
i
tv
i
I he role of therapy as an intervention programme lias not
established its utility in isolation, for the process of social
reintegration. Inspite of adhering to various schools of thought
in
the field of mental health, developed countries have yet to
identify relevant schools in dealing with addictive behaviour, to
the extent of making the individual
functional
for his own
satisfaction. •The
The dynamics of addiction counselling have yet to
be perceived as relevant for further analysis and in-depth
thinking.
Demand reduction continuum,- of which therapeutic intervention is
a part, would be effective only i'f the activities undertaken are
related
to
cultural
variations and
implemented
through
networking with organisations involved in dealing with other
aspects of the malaise of a given social milieu.
the number of therapists are few and
country,
1 n a developing country,
only a handful of them are interested in working in the field of
Professionals who enter this field
come from the
addiction.
fields of social work and mental health. JThere is a group .of
people who in spite of lack of theoretical
knowledge,
commited
reasons
participate in demand reduction activities for personal
and have developed their own methodology for dealing with
addiction. Their methodology tends , to be based on their personal
charisma, their relationship with the target population and their
philosophy of life.
Under the circumstances one has to focus \on the existing pattern
pilot
of intervention,
its merits and drawbacks, on—going
future
projects,
dynamics of addiction counselling, lacunae and
steps to be taken.
Counselling in India
■
i;
i
I
I
trends of the counselling processes used in
India were
Genera1
analysed through documented case studies of psychotherapists and
psychiatrists in Bombay, Pune, Goa, Vellore and Delhi and through
workshops conducted by SPARC in Bombay and Madras.
The trends' that came to the forefront call for further discussion
in order to refine these therapeutic interventions.
In certain cases, it is apparent that the individual is brought
for treatment by concerned family members who consider his
to be problematic behavior.Under these circumstance
addiction
becomes
the rationale for setting drug-free life as the goal
questionab1e.
the
inadequate motivation of addicts to give up drugs or to become
socially functional by appropriate strategies of life management.
Most
counsellors emphasise level o'f motivation and assess it
based on subjective criteria, but consider it irrelevant when
dealing with other health problems.
Counselors have not developed a methodology for dealing with
49
I Iie
pi (.•l.<abi 1 i ty
of
impact
of
any
intervention
f >i i
based
psyc I io 1 og ica 1
aspects tend to be handicapped in the
absence of
oi lier
suppor t groups within the immediate community and
soc iet.y
at 1 a r g e . I lie dli.Hidlion of the target popul ation due to
adver so
pr oven I ion
would hf' rectified through involvement of
t tierapist s
w.i th
ui guiiisal.imr undertaking prevention or by the
| if
riE.d.wor I i ng .
in certain parts of the country the problem has been ignored
i or
poli t ica1
reasons. The lack of intervention for long
period
of
time
and the resultant spread of the problem makes
counsel Jiiiq
in iso I a lion an
PXl.Pill
important technicqur? satisfactory to the
of
attempting
to
be concerned to avoid
bringing
the
drastic
differences
to
the
fore front. In these
parts
any
concerned
individual would facilitate an'd orient other relevant persons
in
the community to deal with the problem.
Goals of counselling
Analysis of the case studies of various counsellors in the field
that were documented by SPARC raises several issues
the
about
state of ttie art.
One fact that stand out is that the goal/s of
always decided by the therapist or the center.
counselinq
The following have emerged as the broad areas of
concern
counseling drug addicts i.e. developing skills in addicts:
are
in
To be drug free
To make decisions
lo handle stress (death, failures...)
To develop a positive integrated view of life, of one's own place
in his social network of re1ationship... (raison d'etre)
To
relax, to attain
mental control, K to
assert. oneself,
assert,
to
progressively bring the focus of control of one's
one' s living to the
inner self.
To re~ehte£ academic or employment streams.
To re-build relationships with
family members, with his non
addicted former ri/iends...
events(crimes,misdeeds,misdemeanors)
To
deal
witn all
the
committed at the time of
addiction.
To develop a non-escapist attitude to reality, and to promote the
his
addict
to grapple with
the
reality of
his
life
and
environment.
. To acquire a pragmatic attitude towards money.
To learn to internalize certain minimum norms, lest he gets
into
1 aw
more frustrating situations particularly in dealing with the
and the police.
in
settings
However j,
Counseling of addicts occurs in different
is
a
1
so
India
and
so
the specific objectives of
counselors
For
agency.
the
circumscribed
by
the setting and policies of
of
example,
in day care centres, and half—way homes, the goa 1 s
the
counseling addicts are somewhat specific as can be seen f rom
following i1 lustration:
- 50
H
I
I
s
<
I
It appears that the causes for addiction as perceived by the
counselor are dependent on their own ^ducation/specia1ization and
are not person-specific. Thus, a clinical psychologist is likely
to cite malfunctioning of the ego as the cause of addiction in
over 70 % of her/his patients; while another counselor with some
training in T.A. is likely to cite intra-familial dynamics.
Thus
their approach to therapy is based on their school
of thought
or training. Each person is unique and so counseling cannot be
done according to some pre-meditated causation and pre-packaged
sets of in terventions.
The causes stated by
professionals are:
faulty communication pattern*in the family
absent father figure
unemploymen t
academic failure
traumatic experiences
sexual problems and
financial crisis etc
parameters
Given
the above brief account of the type generic
propounded in various handbooks of addiction counseling, one
with
wonders whether even these guidelines are adequate to deal
the problem of drug abuse in India. In the following paragraphs,
some of the drawbacks of the contemporary counseling
practices
are outlined in order to argue a case for setting up pilot
experimental projects in.psychotherapy for addicts.
However, it is most important to identify the roles and functions
being performed by counselors' in this field today and to identify
those roles which can be routinized, simplified and delegated to
the volunteers.
(SPARC has begun a small study on the -subject).
It is evident that a majority of heroin addicts have relapsed
frequent
with
even
after
af ter a year—long counseling process
hospitalization and rehabilitation either at a residential center
or as outpatients. Even change of environment has not prevented
relapse.
Professionals
also
fail
to
distinguish
between
slip,
1 apse,re 1 apse and readdiction and thus apply the term relapse to
an individual who has slipped even once.
This confussion of
preception might result in a slip actually becoming relapse or
readdiction.
to set up a concerted search among practitioners to
We need
identify those aspects of counseling heroin addicts which are
*/ different from general counseling processes and to
specifically
generate an indigenous body of knowledge in this specialized area
of intervention.
Some counselors focus on specific areas of counseling such as
some have moved from family therapy to
spouses of addicts,
some
of them have sharpened their practice
community counseling,
therapy
with
addicts,
rely on religion as a strong
of group
element
in
counseling,
while some focus on coping
supportive
mechanisms others on environmental Manipulation.
3717
5»S-333
- 51 -
o < LIBRARY
>
’<
AND
$1
I. documentation ) !-
¥
Some
counse1ors
have deve1 oped comprehensive
systems
of
counseling processes, with their own philosophies,
princ i p1es,
str a teg i es, and caveat s.
Thus counseling requirements will have to be varied and will have
to be segment specific and person specific-
r
India is a vast country with a complex matrix of drugs of abuse.
It is
logical
to assume that users of cannabis,
have
to be
treated differently from users of opium, or from heroin addicts.
The principles of counseling the mentally ill
who have a
concurrent drug problem would have to be distinct from counseling
women addicted to painkillers and
pind obesity control tablets.
Similarly,
chi 1dren who inhalec rubber
children
fumes need different type of assistance.
so1ution
or
petroleum
In
India,
we have addicts who are well
placed in
terms of
employment and thos£ who are sliding from good jobs into less
paying,
less secure and less respected jobs to utter under—
employment,
unemployment
unemployment and unemployability. Some move from
being self employed to penury.
We also have student addicts, drop outs, and addicts who
never entered the portals of an educational institution.
have
As can be seen from the background of the addicts, atleast sixty
per cent of them cannot speak English,
whereas most college
education in psychology and counseling/psychotherapy
is
in
Eng 1ish.
Very little work has been done to develop indigenous
vocabulary of the terms used in the therapy process in the Indian
languages.A good number of addiction therapists canpot even
speak
local
languages properly, so- th^ probability of them
effectively counseling addicts who come frocp non-english- speaking
categories of the population is very low. Thus there is a need to
develop the Recording of counseling processes recording in
different settings in the country and to evaluate which aspects
of the present day practice need modification.
Besides,
the bulk- of counselors come from the middle income or
upper classes whereas atleast fifty per cent of- addicts come from
low income groups.
The critical variables between the therapists
and their clients and how they affect the therapy process has to
be examined in a scientific manner.
Methodology utilised
process in India tends to fall under two major
The counselling
fami 1y
counselling, group therapy and
categories;
individua 1
therapy.
Individual Counselling:
sc hoo1s of
Th» bulk of theoretical assumptions of the various schools
psychotherapy/counse1ing/socia1 case work are based on western
phi 1osophies and are a product of the social systems where they
were born. For instance, the concept of individual autonomy has
muc h value for children in western society and the -earlier the
becomes economically and emotionally is , dependent of
child
£
1
indicated.
Each
parents, the more social acceptance is
his/her
and
to
encouraged to assert their personal
objectives
one
is
them. Whereas in our society, a good number of us wou 1 d
ac h i eve
of
make a decision only after taking into consideration the good
the whole
which are
w li o .1 e family.
f a m i 1 y . These
T h e s e and
a n d other cultural
c u 11 u r a 1 variables
v a r i a b les
charactei is lie of de/?loping or developed nations will impinge on
counseling practice.
One counselor,for instance,points out
that
n i versa 1 r
e c] u i r e m ent
though the principle of acceptance is a u
universal
requirement
in
to. take
on
all
therapeutic
interactions,
counselors tend
a
Some
"Parental"
role when
they
work
with addicts.
others
indicate certain guidelines for dealing with a client who
enjoys
being on heroin and who has no motivation to quit except for
the
fact that his mother is suffering.
1
In India, we have never had welfare system in classical sense of
not
basis j,
clear that on a one-to-one
the
term, It has become
experienced
single
than 50-100 addicts can be helped by a
more
counselor in one year.
I
t
Most
the developed
of
social
deve1 oped countries have a large network
ou t
security
systems and
functionaries
to carry
out
individual
counseling. In a
small
sola 11 province in Canada, the government alone
employes over four thousand counselors/case workers to administer
the official welfare system. Since the rise of the Reagan variety
of conservative right-wing politics in the developed countries of
the world,
there
has been a systematic campaign
to undo
the
welfare
system of the Beveridge model and a massive
theoretical
system
debate
has ensued to de-legitimize the welfare
itself.
happening
Welfare state as a concept is dying and what is
there
is a search for
practical methods to remove the functions of the
thousands of employees who ran this mechanism for years.
I
■
hel p
The general
thrust in these countries is to develop self
groups and to generally transfer the responsibility for the care
but
a
of
citizens onto
the citizens themselves with nothing
modicum of support services.
us
of
Since drug counseling is a nascent subject and since few
is
it
have
had the resources to conduct longitudinal research,
fiard
somewhat premature to make any categorical statements. Only
of
empirical
data generated
by action—research in
all
types
settings
and
with varied
clients
can
provide
a
concrete
background.
In India,We have not even asked the question whether counseling
can bring about any change in addicts. We have assumed that oneto-one counseling
services can be
provided
to all
addicts,
without even considering the costs, training and support services
required.
1 ack
of follow up is limited to postcards,
The methodology
for
adapting
this
approach.
the reason
adequate staff was
of
J®
Group Therapy
bl
■
:
of
and
the
paucity
In the face of the large number of addicts
of
in
which
a
group
counselors,another approach is group therapy,
20 addicts can be simultaneously reached by a single therapist.
53
counseling is still not a popular form of assistance. for
Group
example, in centers in Calcutta.
In Bombay, Bhatia and
Cooper
11()spi ta .1 s
used
used to
to offer
group therapy
but
it
has
beer i
discontinuod
due to staff turn over. KEN Hospital and the
YWCA
center in Bombay and Asha Bhavan in
Goa
day care
offer
group
Iheiapy.
r
therapy
session
involvesnot
more
than
twenty
Lach
group
individua 1s. The sessions consist of individual sharing,
dealing
experiences prior to addiction
and
with
specific
vurnerable
after addiction and written assignments.In
situation
the group
each individual gets support from the other
si tuation
members,
also play a crucial role in makeing critical evaluations of
who
the
experiences and responses of the individual
to attain
the
set goal of drug free existence.
The
probbable grey areas in group therapy are : the problems
of
handling
individuals
from different walks of life at
the
same
time; dealing with language, religious and cultural barriers; and
behaviour
the cost -effectiveness and utility of it to deal with
adaptation acceptance of reality. At times there would
be a need
aspec ts
for individual counselling or therapy to tackle in-depth
group
of
an
individuals
life
that cannot
be
tackled
in
a
situation.
from
of case studies of counseling
addicts
drawn
An
analysis
need
counselors
in different parts of the country indicates the
addicts.
clarify and systematize counseling practices with
to
that
would facilitate the analysis of counselling
nuances
This
are culture .specific and viable in terms of different dynamics of
counselling
determined
by
socio-economic
and
political
circumstances.
Family Therapy
The methodology
is based on the assumption that
abuse
is
the
ssystem .
result of
thb contribution of the family as a
ssystem.
The
problem has to be tackled at that level and not be limited to the
individual. Professionals go to the extreme pf refuseing to
take
on
individuals unless the family takes part in
the
therapeutic
process.
street
would be irrelevant for
This
intervention
a family to play a role in their lives.
never had
addicts
who
ONGOING PROJECTS:
proj ec t
the
Keeping
the
above
fac tors
factors
in
mind,
following
for
the
proposals
have
been made for co-funding by the UNFDAC
program
a coherent
Ministry
of
Welfare to launch and develop
programs
country" s
which can
atleast do as well as any other
towards demand reduction.
of
pi lot
In this context, what is needed
in
India
is a
set
case
for
experimental
projects
to develop appropriate manuals
Wei fare
work. Towards this end, under the. UNF^AC-GOI-Ministry of
projects, the consultant has prepared two projects.
54
4
De ve 1 o p i ng a c: oun se 1 i i i q man u a 1 f or r u r a J Iie r o i n ad d i c t s i n
U11. a r
Pradesh. fiie purpose of such a project is to develop appropriate
vocabulary meaningful for the rural
addicted
counseling
youth.
bulk
of
counseling
courses
are
in
English
since
no
e
f for t
I he
b
eei
)
m
ade
to
de
v
e
1
o
p
a
g
1
ossary
of
technic
a
1
words
in
Hindi
has
their
app1icabi1i ty to i11iterate\semi
i terate\semi
1i terate youth
in
and
of
J his project would also help to clarify the doubts
I j.mi ted.
of
ru
11 as
the pa11erns
ur
r a 1 you
ou 1
111
a s expr
e >! p r esse
e s s e d in
in c
c ou
o u nse
n se 1
1 ing
i n g ses
ss
s ions,
i on s
their
II o n ~ v e r b a 1
c:
communication
o m m u n i c:: a t i o n
aadopted
<J o p t e d
by
rural
y
youth
o u t h an d
of
meaning,
their defense mechanisms with counselors, the types
helping
transference/counter
transference that
occur
in
the
process and their insecurity, societal rejection and the type o t
of
legal
problems
that arise in a rural context in
the
field
. addiction, and also throw' light on several issues on the concept
and pr3c:: tice o f cou 11 se 1 irig addic ts in India.
<
Though
the manual
being produced as a result
of
a
two
year
supervised counseling in Varanasi would be relevant for the Hindi
belt.,
it would also throw light on the modalities of
developing
manuals .in other languages.
Similarly in the ICE project in Delhi., another handbook is sought
to be developed for counseling addicts drawing upon the practical
experience
of
counselors with expert
assistance/
supervision/
conceptualization.
Here, the addicts who come for treatment
are
college -going youth as well as slum youth. There is a mixture of
baggage
patients.,
same who are new migrants with
the cultural
Delhi.
of
their place of birth, and those born and broughtup in
all
Delhi
being highly cosmopolitan with population drawn
from
upon
parts of India, the critical variables specifically hinging
can
our
mores and customs as they affect the counseling process
be identified.
■
I
fcarticu1 ar
However,
in
neither project have we suggested
any
suit
school
of psychotherapy to be adopted, tested, modified to
to
Indian
conditions.
These
two manuals
are
only expected
and
indicate the rural/urban differentials in counseling addicts
the cu1tural*constraints in the choice of
strategies/techniques
effective in our context.
I
si
In the view of leading rigorous practitioners, general counseling
in
practice of
the pastoral type is of little practical
value
in
assisting
addicts.
There are
over
two
hundred
schools
We
psychotherapy
some of
which have
their
own
sub—schools,
recommend
the practitioners to read the list of
psychotherapies
and
examine
them as to their suitability to the field
of
drug
abuse.
f
identified one such therapy which itself has
SPARC
has
variations in practice in the West.
over
twenty
Brief Therapy Models :
I
than
30
more
The
fact
that a IXrqe city like Bombay does not have»
long
term
o
f
fer
i
n
g
against
the
possibility
of
<
counselors goes
psychothc?rapy.
The
options are to leave a large number of addicts to
their own devices or to evolve brief intervention models.
95
SPARC
has
slated
a series of
training workshops
on
brief
I /
therapy
with drug addicts,
These workshops have been
conducted
by
experts
drawn from within and outside the country,
An
experimentaJ
center has be€?n set up to try out this model,
11 lough it lacks c.pr lain
f or
equipment
for
recm ding and
transcribing/viewing
1 or
super vis< it y f
purposes,it
is
being recorded manually and will also
be
rigorous1y
evaluated*
by
a
third party for its applicability
i 11
the
Indian
context, specially amongst the poor.
Such experiments are far too few in the face of the enormous
problem
that
the country faces.
The Ministry of Welfare and the Ministry of
Health need to entrust this task of experimentation in different parts
of the country to NGOs and government centers.
Dynamics of addiction counselinq
1.
2.
3.
4.
5.
6.
Practical drug concepts
Social sanction and pattern of use
Interventions
Role of support groups
Goals of counselling
follow-up programme
Practical Drug Concepts
The definition and preconceptions of drugs and related
addiction
defines
the goals and methodology of counselling,
Awareness
of
the effects of drugs defines the perception and
perspective
of
abuse/use.
There is no such thing as a single effect of any drug.
All drugs
have multiple effects and these vary from dose
1 eve 1
to
dose
level, from individual to individual, from time to time, and from
setting
to
«setting in the same individual. Drug effects
are a
function
of the interaction between the drug and the
individua1
defined physio-logically , psychologically and socially.
When
one ’ "considers the use of the term drug abuse,
one
should
keep
in
mind the definition of the word drug. Also
one should
keep
in mind effective dose, toxic dose, lethal dose,
feelings,.
moods,
perceptions,
pharmacological effects,
tolerance,
legal
versus
i1 legal
use,
physical
dependence and
psychological
dependence.
i
!
1
>
Considerable
confusion exists regarding the meaning of
"Drugs",
"Drug Abuse" and related terms in the field of "Addiction".
Because of
the confusion,
any
effort
to
communicate
effectively should
avoid
traditional
labels
and
use
descriptive,phrases. This is stated for two major reasons:
more
more
a)
To
separate
scientific facts, which
are
the
same
across
cultures and national boundaries, from value judgments, which
are highly culture relevant and often culture-specific, and
b)
To
try to establish a common ground
cultures and across languages.
for
discussion
ac ross
I'
Such definitions will themselves be controversial for, in
areas
where belief, values and feelings are strong, neutral terms
seem
56
to
be almost
a denial of these beliefs.
Values,,
beliefs
Vai Lies j,
and
feelings
are
important. Without them, life would
wou1d be empty
and
meaning .1 oss,
liut
they must be considered
separate
from <d rugs
separate
wh ic h a
r
c
pha
rmac
o 1 oq i c a 1 ag
en ts , and from the actions of
arc? pharmacological
agents.,
drug s.
I heir
supposed reasons for using them determine the nature and
e>: ten I.. or their responses mure than tlw substances consumed.
Social Sanctions and Patern of use:
I ' a L C e r 11 of use is related to
I
* ‘
sanctions
through culture, r i.?l igium .
c1imate, economic status and
.social
----- 1 control .
Thus a familiar p i* ■ ac I i c e due to e x ten s i ve use lias to be viewed by
t.he a f f ec ted popu 1 a t i on as ’ a problem to be dealt with., as in
the
c a s e o f 111 e u s e o f o p i u m among tKe peop1e o f Raj as than,especia 11y
the?
farm laborers, to increase their work potential and to deal
with stress or to celebrate social events..
The
accepted
consumption
of Bhang in
different
parts of the
country especially on certain occassions and
the use of qanja by
certain
segments of society such as the fsanyasinys,
labourers,
upper
class etc. are again a case in point. This behaviour when
termed
or viewed
viewed as anti-social tend to enchance the chances of
substitution
by synthetic drugs and to alienate’it
from social.
control 1.
This would be inevitable in the absence of other ways
and means to deal with life and philosophy of existence.
In
certain parts of the country opium is used for its medicinal
value, especially amongst certain tribes, The decision to
tackle
addiction
would
be
irrelevant
as their
need
to
it
can
be
considered essential.
Occasional
use of stimulants by students in order to stay
awake
to study for an examination or to finish a term paper, the
abuse
of
tanquilizers
by
middle aged
women
which
starts
wi tli
prescribtions
are, other areas of addiction
to mind
a 1tering
substances which
bring to light humanity's dependence on certain
substances for dealing with and continuing the life cycle.
In
other cases, the problem status of a particular kind of
df;ug
use represents.the emergence of particular patterns of use in new
segments of
the population, notably the youth (in
contrast
to
and
adults)
in
jroups other
than
the
lower
classes
and
minori Lies.
The
existent patterns of use through planned marketing
strategy
becomes
a
platform
for individuals with
vested
interests
to
market synthetic forms of drugs.
The counselling aimed at a fanatic clubbing together of different
drugs
might
become a hinderance. And the
perceived graduation
process
tends
to
aggravate the chances of
slips
leading
to
relapses with regard to synthetic drugs.
In still other cases., as a result of instant communication
among
the nations of
the
world,
the
problem prevalent
in
other
preva1en t
countries
is perceived as a threat that will occur at
home
in
the near future. For instance, cocaine is prevalent in
the USA
and other countries of the Northern hemisphere. A good number of
demand reduction activities in Indi^ incorporate cocaine although
cocaine is involved in
less than one in a thousand instances
of
addic tion.
3;
a
solution
case,
a problem is pei reived and
the
Whatever
often
emotional
initial
responses
are
hasty,
Many
souqht.
irr ational. imi tat ive and seldom either wise or productive.
is
or
I
11 u?
Effective
problem solving requires careful
definition of
problem Cin descriptive rattier than conclusive terms), evaluation
to
of
the methods utilized, fields and strategies relevant
the
progress
,
problem
stated,
and
constant
evaluation
of
new
for'
identification of
errors,
and
willingness
to opt
so
approaches when old ones fail. Drug problems have been
little
def ined , in such global and value-laden terms, that it is
problem
The
that disagreements and controversy prevail,
wonder
using
is
must
be defined in objective, descriptive terms: who
with
what
frequency
and
for
what
reasons?
what substances
There
are three basic elements in the use of any drug,
illicit, medical or non—medical use:
a)
c)
1 icit
t
I
I
or
b) the individual who uses it, and
the substance,
the use occurs.
and cultural context in which
the social
all
Any approach to deal with the problem must take into account
probably
one
will
factors. An action based exclusively on
three
fail .
‘ r
with
element is complex; the relative degree of complexity
Each
experience
,
each
is
perceived
usually depends
on
which
interests
of
training and personal or professional
background,
the viewer.
Interventions perceived and undertaken!
<1
The analysis of various case studies of counsellors bring forth
the tendency for selective perception 'of
caustory
factors
and
uniform utilisation
of
the same methodollogy
or
strategy of
intervention.
c
The
result being a co-dependent therapist, stagnated approaches
and clubbing together of the target population.
The intervention required during pre and post treatment is varied
and its mergence leads to the emmergence? of further confusion and
society.
inappropriate preparation of the individual to deal with socie
y.
Any
training
process for counselors in
the field of addiction
should also incorporate information on the legal implications of
neglected
drug
use and abuse. This important factor tends to be
selective
by counsellors, due to ignorance, lack of emphasis and
perception.
Role of Support Groups:
We need to develop training packages to orient trainers
in
the
State/Centra1
Health Education
Bureau;
the
NSS State
leve
coordinators; the Military & Police training centers, the Workers
all
Education Boards; trade unions , t\he personnel departments m
industries, community workers and immediate support groups.
58
4
Day Care centre
I ri Bom b a y <, t he Y WUA day care center provides individual counseling
to
prepare the addicts to go in for detoxification
and
r e ha bi J i t a t i on .
I hey also act as a hal f way home for per sons who
come out of fthe
'
rehabi 1 itation center after six montfis of stayin-g
away
from normal social1 life.
In this context counseling has
certain Specific objectives, such as :
helping the addict to strengthen his motivation to enter
detoxification and treatment.
4
helpi'ng him to make concrete plans of how he
with his former addicted colleagues.
will
how to deal with associational memories, and
•factors that might be conducive to relapse.
situational
deal
how to deal with nagging and continuous reminders of the
fact that he had been on drugs.
Lingering suspicion by
drugs,
other his rectitude in handling money and their hesitancy
Family members often
giving him responsibi1ities.
in
do not realize that their gestures and attitudes may not
to recovery.
The addict has to develop
recovery.
be helpful
skills to deal with these situations and not lose his
equilibrium and equanimity.
status
- the etiology of drug abuse often has inter-sibling
If the family pathology
discrepancy and family-pathology.
has not been handled by the therapist through family thethen the addict has to be prepared to gain an in
rapy,
sight into the family dynamics and learn not to take a
self destructive stance while dealing with his pathological family setting.
tendenaddicts often tend to develop depression/suicida1
become
They
also
tend
to
cies in the period of recovery.
comments
and
anxious and disturbed at rather innocuous
them.
Helping
gestures and actions of people close to
addicts at such moments entails being available to t'hem,
reassuring them, clarifying issues that are immediate
tendencies are perceived,
problems and, where suicidal
inducting professional help.
1
Half-way Home
The purpose of these half way homes and follow up programs are to
help the addicts to a gradual re-entry into society. These day
care centers provide a drug free atmosphere during the day and
have prayer, group discussions T.A. sessions in the company of
recovering or ex-addicts, They also have gaqies, reading material
One such center in Calcutta (Antara Drug
and referral services.
includeds
occupational
therapy-cand1e making,
carpentry
Center)
etc. Half way Homes help the addicts in their transition from the
totally sheltered atmosphere of the rehabilitation centers to a
vulnerable
life in the open community.
Arunoday Midway Home
performs such a function together with rehabilitation.
A
59 -
Counseling Centers :
Here again
one
finds
professionals
offering
ppsychotherapy
__
offering
,
psycho-analysis,
fami 1y
therapy and group therapy both
--..n
in
I;
he
non-profit
and
commercial
-.1
setting as well
as
in
the
as
Pub1i (
Sec tor.
r
lhe Ministry
of
Welfare
has
funded
86 counseling
centres,
Practically none of these has a
community base;
nor
11 o r do they have
an outreach program.
Hospital
administrators
are yet to issue circulars
to
soci a 1
workers
and clinical psychologists and psychotherapi
sts
stating
that
house-cal1s to the homes of addicts
to meet
thei r
par eiits
and
for
the collection
for
of detailed
background
in
f
orma
tion
requisite
for
treatment
is a
permitted
expendilure
.
In
the
absence of
such
support,
follow up and
invo1vement
of
the
relatives, friends and neighbours for the
recovery of the
addict
is not possible.
The
concept
of preventive
counselling would be
relevant
as
a
demand
reduction
activity
for youth.
The
establishment
of
counselling
centres
within
educational
institutes or
their
envirans areas would increase their
utility.
In
two workshops
SPARC f
certain
issues
in
students in col 1eges.
They felt that a cluster of colleges in
a
given area should pool
.
money to set up a common center for career
guidance, <--Intervention tor their
TtiX".
They also felt that
---- r
the couneelors end the records should be out
be
of bounds, for principal
Is and the teaching faculty.
Other dimensions
of <setting up these centres and.
required were high-lighted
J through prior attempts.
1
precautions
audits
It
appears
that
due to the overwhelming
attached
to
female-addiction r it is not advisable to set stigma
up centers with such
obvious names,
It would be better to start centers
for "women in
crisis", network with other
organizations working withi women
and
train/orient the staff of women
.'non ' s organizations
--to the phenomenon
of
addiction
among women,
Women 's crisis centers
should
have
specialized
facilities for female addicts while they would
also
attend to other problems.
f
The centre was converted
to cater 1to male addicts.
Subsequent 1y,
rea1i zing
the need to give occupational
--- 1 t r a i n i n q
to
recovering
addicts,
this center
was converted into a work
center
where
addicts
coming
out. of
another center
were
admitted
for
occupational training.
A
Follow-up Programme
In
the
field of addiction any 'intervention
undertaken
has
to
involve
foilow—up
programmes
for
identification • of
1acunae,
modification
—»
required
and
documentation
for
assessment
of
60 -
I”
I
utility.
At present in India the follow-up programmes arc limited tn I
1
cards, involvement in self-help groups and regular visits to
the
centre.
ik
Ther e is a need for systematic documentation of the
fol low-up
programmes undertaken.
This concept can be facilitated through
the
establishment of a group of objective and
commiLied
individuals who besides assessing the lacunae of
the present
interventions will undertake the responsi1 bi 1ty of implementing
follow-up programmes.
Lacunae
Interventions made:
I
I
■'
V
I
The guesstimates of journalists and professionals regarding
the
number of abusers tend to be exagerated for obtaining funds and
supporting organisations catering to their vested interests,
But
the existent methodology of approach would be inappropriate
for
tackling 1/4 of the guesstimated population. Hence there is a
need for identifying the requirements of tackling addiction
besides counselling.
1. The need for drop-in centres that can provide a drug milieu
after detoxification.
2. The
need for drop-tn centres that can faci1itate
the
probability of interupting the stereotyped behaviour pattern
of addicts.
3. The need for night-shelter to cater to the individuals from
the lower strata, to identify critical cases of the poor/
street addicts for providing immediate medical attention and
to identify new cases inorder to provide
treatment
before
further complications.
4. The need
for
community based counselling centres whi'ch can
tackle the drawbacks of centres situated
in areas away_from
the affected
population,
the lack of support groups for
faci1i tating
the rehabi1itation
process and creating
a
probabi1ity
for emergence of para professionals through the
invo1vemen t of community
<
workers
and
other
interested
indiyiduals.
5.
Trained persons in different schools of therapy after they i t
have been
evaluated through
pilot projects
under
the
consultancy of international therapists.
6. Facilitating the creation of courses within accademic
institutes that are practice oriented.
7.
The need for systematic follow-up programmes inorder.to assess
and modify the therapeutic interventions made.
61
Future Needs
Training
:
is unique and while counseling
is
per t,on
W h i I < f a c h p a t i»• n t
common par ame lers/charac ter is tics exist w i thoul. wh.i • h
specifie,
would remain an art restricted a few
practitioners.
counseling
up knowledge and skills in any
field begins with case
Bui Iding
yield
for
further
testing/
studies which
working hypotheses
validation.
In India, we do
a
few
acceptance/rejection/
have
wi th
counselors who have developed personal insights and skills
by
addicts.
iAbout two hundred case studies have been documented
De1hi,
• SPARC., based on the work of fifteen counselors drawn from
Bombay, Coimbatore and Pune.
'
i
a
In the field there also exist individuals who over the years have
be
hampered
their own methodology of work, but might
developed
the rape* it i c
to lack of futher information on various
other
due
rea1ise
the
that can enhance their approach and also
tec hnique
f
r
critical
evaluation
of
their
methodology
merits
of
bf?
individua1s
Training
programs for these
individuals
would
refinement .
developing
the state of the art
in
in
ou
our
r
country.
crucial
for
of
of relevant schools from the e>:isteing number
Iden tification
in
innovative
psychotherapies would
take us a
step
further
of
dealing
with
the problem. This would involve
the
training
their
consellors
in
specific schools that would be useful
and
subsequent
evaluation
in -terms of their utility
for various
target populations and cost-effectiveness. Subsequent training of
others in the field with
emphasis on to modifying the techniques
to suit the cultural requirement for its effectiveness as a tool.
The need
for creating practice - oriented training courses
in
therapy that can be intergrated with relevant accademic fields or
provided
as seperate courses for interested individuals exists.
is
The
SPARC
- SNDT workshop was organized to articulate what
col laboration
involved,, in
counseling drug addicts. The UGC
in
with the Association of Schools of Social Work organized a series
of workshops through Jamia Millia Islamia college of social
'work
for
and
Madurai
School of social work to develop a
curriculum
of
training
counselors in the field of drug abuse. The Ministry
no
Welfare
invited, the Christian Counseling Center
which
has
exposure or experience in the field of drugs, being situated in a
training
remote village in Tamilnadu, to evolve a curriculum for
addiction counselors.
and
so
The
problem of heroin addiction is rather new to India
practical
with
there are very few practitioners in the country
the
with addicts,whi1e
the demand
on
in
working
ex perience
therapists
has been heavy. A considerable amount of the time of
and
routine
on
fund-raising
practi tioners
is
spent
co/nmun
icab 1 e
a
systematized,
In the absence of
administration .
have
to
body
of
knowledge,
know1 edge, the new professionals in the field
Indian
develop
their
own,
a method which is workable
to
the
conditions often through trial and error.
b
What
is needed is a network plan to develop a cadre of counselors
selecto*
re-training interested professionals and training volunteers
from both middle and working classes and ex—addicts.
-
r
*
Little effort has been made to identify the process of counsel.run
specific to addicts.
1 here are well
of
There
wei I. over two hundred schools
psychotherapy.
In India, only two or three organizations use any
model.
systematized model.Most
practitioners claim to use eclectic
mod< ? .1 d i aw i 11 q f i (• m d j f f erent sc hou 1 s.
Y
However <,
ec .1
not work.
no one
has tested which
aspects
of
the
amor pl »dus
system works with drug addicts and which dimensions
cl <'
PROPOSED PILOT EXPERIMENTAL
PROJECT NO: 01
: BRIEF
PROJECTS IN COUNSELING ADDICTS
STRATEGIC
FAMILY
THERAPY
Brief
Therapy (BT) had its origins in the work of
Erickson
who
was a pioneer in using the clients resistances in a positive, and
effective manner.
Jay Haley, a master in the use o f
pa r adox ica 1
techniques
in
strategic family therapy, widened
the scope of
Brief Therapy.
Brief
Strategic
Family
Therapy (BSFT) focuses on
solving
the
clients
presenting problem within the framework of
the
family.
This
is
in
keeping with the two basic
assumptions about
the
nature of families in the BSFT model, which are:
i)
ii)
the family and its members are a system, and
the family interaction occur in typical patterns called.
Structures:
one.
A family presents one member as the "problem" or the "sick"
The
This
person ‘ is referred to as the Identified Patient (IP),
to
be
family's expectations of
therapy is that the IP needs
a1 though
changed.
The BSFT therapist however, recognizes that,
psyc hotic
one of the members manifests some symptom (drug abuse,
entire
behavior etc.)
these symptoms are maintained because the
interac tion.
family
participates
in mal-adaptive
patterns of
rather
Therefore,
the treatment targets the family as a whole,
than focusing on individual behavior in isolation.
members,
A family tends to repeat typical interactions among its
behavior patterns.
These typical
or
habitual
forming ( typical
interaction
define
a
family's
structural
patterns
of
A dysfunction results when the family attempts
to
organization.
resolve a problem applying a mal-adaptive pattern of interaction.
That
is,
when
a problem arises, the
family
responds with
a
particular
set of interactions, not because it will be effective
in
resolving
the problem, but because that particular
type
of
interaction
has become habitual.
The purpose of therapy
is
to
facilitate new
patterns of interaction which
resolve
problems
effectively; i.e. to change the family structure.
BSFT is strategic i.e. problem focused and pragmatic. A "problem”
between
defined as " a type of behavior that is part of acts
is
to
(Haley) The first task of the therapist is
several
people”.
be
presenting problem in such a way that
it can
redefine* the
redefining or reframing, as it
is
called,
solved.
Successfu1
cc
into
ariot.hf?r
] i fts the problem out of the "symptom" frame and
immu
tabi
1ily.
not
carry.the
implication
of
does
that
frame„
on
any
other
the
therapist
doesn't
just
pin
r
ef
raminq
,
While
those
but takes into account the conceptual framf?work of
frame,
tie
reframes
the
problem
in
whose problems are to be changed, i.e.
their language.
Most often, during the therapist's attempts to create this I iPW
that
problem and so 1 ve it, changes occur in the interaction,
] C’.t( l
the fir oh 1 em or i f.i in a 1 1 v
tn thr? solution of
sol »*.< -qiK *n I .1 y
presented by the family.
It is possible to accomplish BSFT goals (i.e. reduction of drug
abuse or symptoms, and improved functioning of the whole fami 1y)
while working
working primarily
primarily with
with one
one person
person in
in therapy,
therapy.
This is
be
called
One
Person Family Therapy (OPFT).
This
can
accomplished, based on the assumption that if the behavior of one
person in a family changes, then the other family members also
have to change their behavior. They will have to change because
" if
’
a system is to maintain itself and its typical patterns of
be
the behavior of each member must co-ordinate with,
behavior,
an
d
and be contingent on the behavior of each
maintained by,
by j,
every one of the family member."
BSFT is present and future oriented.
The goal is not the- exploration
of the past, but rather the manipulation of the present, <as a tool for’
change (Minuchin).
with approximately 12 to
BSFT is time limited,
This is made possible by the therapeutic
sessions.
employed which are:
J. 5
weekly
strategies
i)
The use of Joining, for entering the family system in a
manner designed to avoid systemic resistance, to change,
Once the therapist has successfully joined the family
system, he quickly establishes a leadership position to
bring about change.
ii)
He then diagnoses * the family structures based on
After this
interactions that occur in his presence,
interventions
assessment is done, he plans a series of
restrue ture
that
are
strategically designed
to
dysfunctional patterns of interaction.
This planning focuses the therapeutic process thereby
shortening it.
Immediate Objective :
To develop alternative forms of psychotherapies to
problem of addiction.
tackle
Output
Activities
Professional trained
in various innovative
forms of psychotherapies .
- Analysis of the existing psychotherapies and their drawbacks.
the
1
- Analysis of culture of the community
earlier forms of help therapies
that existed.
@@@@@@@@@
fiA
-
PRUJLCI
Ob
:DEVELOPMENT OF TREATMENT ZONES
Immediate Objective:
In (at ill Late 1 hr emergence of treatment zones in areas which arr
highly affected.
Uli l.putt
Ireatment Zones
Activities
Identification of highly aftected at t-<.asin the given city/community.
- interviewing addicts in their dens
and establishing a rapport.
- identifying their needs for treatment,
recreation, environmental change.
- Providing detoxification facilities in
their dens
- Providing recreational facilities
- Providing opportunities for alternate
life styles for those who want.
— involvement in community projects.
I
- maintenance of their area localities.
- setting up a 1ibrary
- setting up a night shelter
- alternate occupation
- Assessing after a period the extent of
involvement in treatment and activities
chosen by the target population.
- Providing an opportunity for individuals
to learn skills required to exist in the
society.
— Doing a follow up study to assess the no.
of individuals who have given up addiction,
who have slipped, relapsed and those
whose Ijife-styles have not changed.
- further analysis, through interviews of
individua1s who have remained aloof.
~ Collecting their views, reasons.
Modification of the methodology of inter—
vention made.
- facilitating the affected population to
handle the operational details of the
zones?
*
— Providing information on treatment to
the affected population or friend of
affected population.
- Lobbying for more treatment f ac i 1 i t i
at low cost.
- Lobbying for facilities for re-integration of addicts.
- Tackling the stigma attached to addic
tion .
- Facilitating reintegration of addicts.
- Analyze the hazards faced during the
process of providing preventive
measures.
Documentation of whole process.
- Training of other women s organizations
by the trained persons.
-r
Immediate Objective :
Io facilitate the process of re-in tt^gr atioi i of the addicts
the community to their advantage.
Illi Li
Y
OU I I U f
bevelupmen L of <.c
manual of guidelines for
establishing a drop-in
center.
AC I IVI TIES
Analysis of LJio
ing
facilities for recreation,
personal development and
vocational or non-academic
training.
- Conducting a follow-up of the
affected after detoxification
in various treatment centers,
camps or rehabi1itation centers
for assessment of the following:
- reason for relapse
- duration between slip, relapse
and addiction.,
- the attempts made or options
selected to deal with these
stages.
- the modification required
as per the affected population.
Analyse the problems faced by
individuals or organisations
already involved in various
stages of dealing with the
problem.
X
Identifying capable and
interested persons from the.
affected population and those
individuals who were addicted
but have totally left the field
after being drug free.
Involving the target population
in establishing a drop-in center.
formulating the rules as per the
views of the target population and
individuals interested in the, field.
I
Assessing the utility of the centre
after a period of six,twelve and
eighteen months.
Modifying the activities and
methodology of intervention.
— creating a co-operative run by the
a f f e c t e d p o p u 1 a h i <□ n .
members of the population will take over
11 a n d 1 i n q o f t r e a tm ent z or i e a Ion g w i. 111 a i j
NGO.
- Training of others to set up separate
treatment zones.
PILOT PROJECT :06 DROP IN CENTERS:
It is recommended here that some of the counseling centers be
converted into drop in centers with counseling services and otherfacilities for addicts.These centres will be located in different
for
geographical
areas.
Informal centers with
facilities
counseling and other activities can facilitate individuals to
become involved in activities outside their drug-using milieu.
These drop-in centres should be run by individuals who are
flexible by temperament and innovative and would utilize
this
opportunity
to rehabilitate addicts by involving them
in
developing a methodology of conceptualizing a drop in cen ter
suitable to them and their colleagues.
A typical drop in center would perhaps include the following:
Basic f aci 1 ities ‘for toi 1-et/bathing .
Facilities for addicts to involve themselves in physical,
intellectual or recreational activities.
Counseling and career guidance facility
The focus is to provide opportunity^for
individuals who have
completed detoxification/rehabi1itatiqn programs to be involved
in activities besides drug consumption, to provide opportunities
for high risk population to be involved in activities and seek
counseling services as a preventive measure. A casual atmosphere
might facilitate individuals who use or abuse drugs to drop-in at
first due to the facility for involvement in
interesting
activities and at later stages seek treatment for themselves or
for.their colleagues.
The partici pation of the community is vital because the funds
required for the implementation of the program and to faci1i tate
the support groups to take part in the functioning of the cen ter
house
specifically to facilitate the evolution of a democratic
committee to take care of the center. The initial preparation of
the center and subsequent maintenance of the center can be done
by the target population.
-r
I
NIGH I
FILUr PROJECT MO: 08
bntLTERS:
PROJECT JUSTIFICATION
As in the case of drop in centers, some
to be converted into night shelters.
>
counselinq centers
nepci
t tie affected popu 1 a t i on m i q h t be st rec? I
Cer t a in segments of
critical conditions, would require a she 1 ter
addicts who in
even the ten beds
specifically in the present conditions where
not
available
in cities
1
supposed to be set aside for addicts are r I‘
like Bombay.
facilities
whic h
immediate medical attention
Xer^onrcan
^enti’and new addicts early
Xh’f ZroOxde ^aningful service toward their recovery.
There should be facilities for extra-curricular activities wh ich
uf
would provide an opportunity to offer a structure in the life
a stereo typed behaviour
the addict who has been conditioned to
revolving around addiction.
various aspects that might hinder ^Probability of demand
The
activities being effctive are the following.
reduction
over-emphasis on counselling
might• *be» too alien for the
— counselling beingj a western conceptthe
street addicts
lower
strata of
g. the society and t-- attached
to
to. the stigma
an abuser being oversensitive
overcrowded
difficult to travel
in
addiction might find it c----buses and trains
be poin t
. areas
-- will
not
centers
when
located
in
posh
the
abusers might tseek professional guidance
where
with
do not want to deal
that
government
hospitals
the fact
addicts only on paper.
addiction and set aside beds for
interested in the -field.
the lack of trained counsellors who are
f or night
that the pro j ect
It is under these circumstances
shelter can be justified.
Immediate Objective:
lower strata of the society.
To establish a night shelter for the
activities
OUTPUT
MEFRAME
1. A night shelter
Analysis of the pattern
• .1
(?', l ab J isht?d
of use if required
specif ic ’ areas
A manual on
out reach
pr (igr amine
pub1i shed
1 d en t i f i c a t i oi • of th e
organisation involved
in dea L ing with addi ct i ori
amonci the poor and the
str-ee t addic: ts
Identification of
volunteers involved or
interested in the
field from the same
areas or otherwise
j 11
Orientation of these
persons on various
aspects of addiction
and the role of support
groups
Purchase of a Vitl i
taking night rounds to
identify critical cases
who need immediate
medical attention
Identifying those
cases who have just
started taking.drugs
I
Creating facilites
for activities to
break stereotyped
patterns of addiction
contacting other agencies
who are involved in
( re ) ha bi 1 i ta ti on or
social integration of
drug abusers
Contacting day care center
or drop-in centers for those
who have started taking drugs
i
Involving the target
group if possible
in the operation of the
centre
d oc u nien t a t i on o f the whole
process and the hurdles
involved in evolving the
prog ramme
Analysis of the utility of
the programme
72
i
H
-F
Making a draft on the
process
f.
Utilising the view points
of the target population
in order to modify the
programme
Production of a manual on
establishment of a night shelter
i
4'
A
A
- 73 -
$
y
Detoxification of Substance Abuses
J
i
A Status Paper with Outlines for Pilot Experimental Projects
r K
■
■-JK-
I
' *
■
National Addiction Research Centre
5 Bhardawadi Hospital
Bhardawadi Road
Andheri West
Bombay 400 058
i. i
a.
r
DETOXIFICATION OF SUBSTANCE ABUSERS
(HEROIN TYPE)
t'
Dr.Dayal Mirchandani
MD. DPM. FPS.
¥
Drug Abuse is a major problem and is here to stay. It had been
estimated that there are over 700,000 Brown Sugar addicts in
India, with one lakh in Bombay city alone. Drug abuse is rapidly
spreading to the smaller towns and villages of India. The abuse
of brown sugar has cut across all social strata from doctors to
coolies. Today a large proportion of drug abusers are likely to
be from the poorer sections of society.
i
The economic costs of drug abuse are high in terms of man—days
posed to the user and the cost
lost at work, the health hazards nosed
of treatment. It also leads to the diversion of a lot of money
and to the consequent corruption of' 'lawi enforcement agencies,
take to
in order to be able to
——— —— ---— crime
— Additionallyj, many addicts
support the
— habit. Some steal while others get involved in the
drug trade.
II
More important than the economic costs is the "human cost" in
terms of misery, self-destruction and suffering not only of the
__
of those close to him, such as his family,
but also
addict, ___
and
co-workers.
The tremendous suffering caused by drug
friends
cannot
be
quantified
but it far outweighs the economic
abuse <
damage.
I
I
Research shows that current treatment techniques used with heroin
abusers are not very effective and even with years of treatment,
relapse rates as high as 90 % are common. Studies have shown that
over a period of years a number of heroin addicts "mature" and
stop the habit themselves. It has been observed that they stop a
number of times, either in treatment or by themselves,
themselves. before
finally giving up the drug altogether.
I
' ? large
Therefore, from a "public health” point of view, given the
faci
1
ities
—let
addicts and the paucity of treatment
--- 1--.
number of
is
j
'detoxification'
alone effective therapy, -providing effective
step
strategy. Detoxification is the first
in by itself a iuseful
---in the rehabilitation of the addict during which period the
addict is helped to abstain from the drug so that his body can
adjust to a drug-free state.
i'
A
7*'__ ,, addicts use detoxification to keep the cost of their habit
Often
down. Most of them know that once they have developed a tolerance
to heroin, following detoxification, they would require a smaller
amount of heroin to obtain the same effect. So even if the
addict's motivation is not to give up the drug or to enter into
as it
one should not deny him detoxification,
long treatment,
this
helps him to keep his expenditure on the drug down. Often
activity
helps keep the addict from having to resort to criminal
in order to support the habit- It also helps to reduce the total
quantity of the drug ingested and in turn reduces the health
hazards attendant to the use of the drug which are dose
dependent.
75
haphazard 1y
using
Many addicts resort to self-detoxification,
by
medication
or using other unscientific methods which,
. themselves pose a danger to the health and life of the addict, It
is therefore important to provide a cheap, painless, and easily
accessible technique of detoxification which would be acceptable
to the addict. A frequent criticism of this approach has been
that if painless detoxification were made easily available to an
the
addict, there would be little motivation for him to stay off
be
drug once detoxified, because he knows that an addict should
allowed to suffer the withdrawal symptoms, as this would act as a
deterrent to his resuming the habit. However, since 80 7. or more
relapse after detoxification, the thought of undergoing
addicts
and expensive detoxification process frequently makes
painful
them keep on postponing repeat detoxification, This prevents them
on
it is not ethical,
from seeking treatment. Also, as a doctor
c-when
grounds,
to
make
a
patient
suffer,
especially
humanitarian
there is no scientific evidence to show that it helps.
1
BROWN SUGAR
This is a crude form of heroin and has became a major drug of
a small
is a powder, brownish in colour, containing
abuse.
It
percentage
of
heroin and opium alkaloids.
The
percentage of
heroin contained varies with the purity of the drug.
When the drug is originally smuggled in, it has a higher heroin
content than when it reaches the street. As it changes hands from
smuggler to wholesaler to retailer, it is diluted at each stage
to increase bulk and value. Various substances such as talcum,
starch,
glucose,
aspirin and other chemicals are used
as
dilutants.. These by themselves constitute a major health hazard
since they make up the bulk of the drug that the abuser buys from
the retailer, while the heroin content may be merely 10 to 15 7..
Purer forms of heroin known as white sugar are also available at
much higher costs.
1
i
smoked
in cigarettes,
sugar
is mixed with tobacco and
Brown
on
aluminium
foil
mode
of
ingestion
is
heating
the
drug
Another
•
’
chasing".
A
few
the
fumes
—
a
method
known
as
and
inhaling
intravenously
addicts make a solution of the drug and inject it
or intramuscularlyx this method is not popular in India.
i
THE PHARMACOLOGY OF OPIATES
the extract from the seed capsule of the poppy plant
Opium is
such as
__ __
Somniferum). Natural opium contains alkaliods
(Papaver
Morphine and Codeine. The most widely abused narcotic
is Heroin
a simple derivative of Morphine(di-acet1y morphine). A number of
synthetic compounds with similar effects to that of th
the2 natural
opiates are also available. These too, have a high abuse potenDextrotial,
eg. Methadone, Pentazochine (Fortwin), Pethidine,
drugs
propoxyphene and Diphenoxylate (Lomotil). This group of
off
trigger
'opiate receptors' in the brain to f
stimulates the
their effects.
76
A
CLINICAL EFFECTS
When used
for
the first time, heroin and morphine may cause
state).
nausea,
vomiting and dysphoria (an unpleasant mental
addict
These drugs are powerful pain relievers. For the narcotic
the ingestion of the drug usually produces a very pleasant state
pain such as depression
o* euphoric and an talleviation of . psychic
.
and anxiety. The patient may appear slightly drowsy. Flushing and
itching
of skin may be observed in some cases. Pupillary cons
triction,
Hor-macpH
rp^nir^torv rate and constipation are also
decreased respiratory
observed.
tolerance
i
With use,
use 9 a tolerance to these drugs develops, so that the same
The
‘‘ » earlier effects,
dose of
the drug no longer produces the
same
increase
his
intake
of
the
drug
to
achieve
the
addict has to :----- -------- -------- — effects.
Addicts who have developed a tolerance can
take sur—
‘
prisingly large amounts of the drug, which would often be» sufficient to cause death in someone who
i.‘._ has not developed1 tolerance.
acute intoxication
I
This is caused by an overdose of the drug. The patient may be
stuperose with slowed respiration, pin-point pupils, Bradycardia,
hypotension and hypothermia. Opiate overdose should be treated in
the same way as morphine or opium poisoning.
I
I
CHRONIC IN I OX ICATION
and
With use the patient develops tolerance to the physical
the
psychological effects of the drug. He has to keep increasing
amount of the drug he uses to achieve the euphoria and relief of
anxiety
and depression. Once
the
person has become addicted ,to
CU/
QIIU
-------»
drug
and
physical
dependency
has
occurred, the only reason ne
the
continue
to
use
the
drug
is
to prevent the withdrawal
may
symptoms,
since unless he increases his intake he no
longer
experiences the “high".
I
• WITHDRAWAL SYMPTOMS
A physically addicted person develops unpleasant withdrawal symp
toms on discontinuing the use of the drug. The first signs usually appear 10 to 14 hours after the last dose, reach a peak on
the second or third day and gradually subside over the next week.
J-
The symptoms initially consist of yawning, rhinorrhea
(discharge
from the nose), lacrimation (tears), pupillary dilation, sweating
and restlessness. Later, muscular aches and pains, abdominal era
mps,
diarrheoa, vomiting, agitation, profuse sweating,
insomnia
and dehydration may be observed. The patient may complain of mild
aches and pains, as well as insomnia for a few months afterwards.
With proper treatment the addict should experience no discomfort
and withdrawal symptoms when being "detoxifed".
77
CAUTION; One use
Abusers:
of
Buprenorphine (Norphine)
with
Substance
Our experience and anecdotal evidence leads us to believe that
there
is a dangerous adverse drug interaction between Buprenor—
phine and Diazepam with severe respiratory depression and even
apnoea.
This
interaction has apparently only
been noticed
in
India•
the above we would caution you not to
In
view of
use
Buprenorphine with Substance Abusers as in our experience
the
majority of addicts abuse/use Diazepam and other Benzodiazepenes
in addition to the drug they are addicted to. Diazepam has a very
long half life and remains in the body for a number of days after
discontinuation.
Caution is also needed in prescribing
Diazepam
to anyone using Buprenorphine.
I
I1-
CLONIDINE DETOXIFICATION: This is a centrally acting adrenergic
stimulating agent which finds use in the treatment of arterial
hypertension.
It has been found to be highly effective in allevating the signs and symptoms of opiate withdrawal syndrome (Gold
et al 1978, Gangadhar et al 1982). Washton et al in an outpatient
trial
found it to be a safe and effective treatment for opiate
detoxification.
Some of the advantages mentioned by Gold et al
(1980)
are 1)
Rapidity action 2) It is a non-opiate 3)
Noneuphoria producing 4) High success in inpatient and outpatient
doctor-patlent
detoxification
5)
Enhances
the role of
the
few
relationship.
Ginsberg et al (1983)
have reported very
The
adverse effects and no deaths reported in the literature,
and
common side effects noticed were hypotension,
sedation,
rarely the unmasking of other psychiatric disorders. We find that
the sedation and hupentation are an advantage in that it helps
the addict confined to the house.
J
I
*
ADVANTAGES OF OUTPATIENT DETOXIFICATION: It keeps down the cost
of treatment. In Bombay, this can range from a thousand rupees to
sixty thousand rupees in some private nursing homes. We find that
patients are more willing to be detoxified at home. They are more
being
cooperative and find it easier to deal with the boredom of
restricted indoors. Experience has shown that ward boys and other
addicts can be bribed to supply the addict with drugs even when
they are hospitalised. At home it is easier to keep a close watch
the addict and to restrict undesirable visitors. The cost of
on
medication can be kept down to as low as Rs. 20 to 30. The on 1 y
be adminis—
is the doctor’s fees. As treatment can
other cost
down.
be
kept
can
the family physician
this
tered
by
Hospitalisation costs are saved.
fami 1y
the
involving
is that by
Anothcer advantage we
find
actively in the treatment of the patient, they are likely to have
a higher involvement in the rehabilitation and future therapy of
the patient. It builds a strong relationship between the doctor
and
the patient/fami 1y. The family also
gets usedI to the idea
that they have a crucial role :in the therapy of the addict rather
than leaving the patient to the "expert” to cure by magic.
I
4
80
4
I
Y
PROCEDURE: A detailed medical examination and history, history of
drug use,
and a complete medical examination including
patho
logical and Radiological investigations if necessary. The chemi
cally dependent person may be dependent on more than one
substance,
hence this should be enquired about. They may also
abuse tranqui11izers, hypnotics, methaquelone and even alcohol.lt
is also useful to elicit a history of previous attempts to stop,
severity of the abstinence syndrome and behaviour of the patient
during
this
period. Past history of
psychiatric
illness i.e.
psychosis, depression should be obtained. The question of suicide
should
be openly discussed with the patient's relatives and the
patients.
If
there is any risk, however small,
a psychiatrist
should be involved in treatment.
Fol lowing
this the patient can be assigned to either Outpatient
Inpatient treatment. He is a person who is ill and suffering and
uses the drug
to relieve his psychological pain and suffering.
The addict is psychologically and interpersonally very skillful
in manipulating people and may appear compliant or aggressive to
get his own way. Dealing with the addict is like playing chess
with a chess master who appears to be mentally retarded, but is
full of surprises.
CRITERIA FOR INPATIENT TREATMENT:
1)
Physical
illness
such as pulmonary tuberclosis,
cardiac
disease,
hepatic disease, gross debilitation and any other
medical illness that is likely to require close
supervisionthese patients should be detoxified under the
supervision of
a physician in a hospital. Pregnant
rregnant women
women should
not be
detoxified with Clondine as
this
medication
as this medication does
does not cross
placental, barrier,
and this
this is
is likely
likely to
to
lead
and
to an
abstinence syndrome in the foetus with disastrous
consequent
ces.
Such patients should be detoxified by a
by a specialist,
Neonates born to mothers who are
«-- --narcotic addicts may also
develop an abstinence syndrome after
—
birth and should be
treated by an expert.
2)
F 'syc I io 1 < jcj j. c_a 1
Disorder s Severe depression
with
suicidal
in ten t
(patient has made suicidal threats or says he is
considering
suicide);
past history of
severe psychiatric
i11ness
(psychosis/severe depressive i1Iness);
history of
Attempts
the
suicidal
attempts in
past-such patients should
be
detoxified under the care of a psychiatrist , as should be
any
patients addicted to more than one drug.
3)
o.ial and Other Reasons racients
Patients without anyone responsible
to look after them while they are
are being
detoxified;
patients
being detoxified;
whose relatives feel that they* cannot
control
and
keep
the
—
— —- - —n cj
patient at home while he is being detoxified; past history of
t e patient being uncontrollable and troublesome while
being
detoxified - such patients may be detoxified under the super
vision of a General Practitioner in a "Detoxification Camp"
or honpi la I/nur B irig home.
Adequate nursing staff
and ward
boys should be available to keep watch on the patient. Any of
the scientific
techniques described can
be used
in
the
inpatient setting.
7
i
81
OUTPATIENT DE I OX IF-'I CAI I ON
The majority of patients can be detoxified on an Outpatient basis
* (except for those previously described as requiring
Inpatient
treatment).
r
the patient is chosen for Outpatient treatment the procedure
If
be explained to the patient and least one or two responshould
A contract should be made with the relatives
sible relatives.
the house,
that that they will not allow the patient out of
immediately.
Do not
fai1ing which treatment will be stopped
underestimate
the time required for this process or promise to
try and cut down the time required as a means to motivating
the
patient to enter into treatment.
Ten days to two weeks should be
allowed for, although close supervision may only be required
for
the first week or so.
If the relatives feel that they cannot
'control'
the addict or enforce the agreement he has made,
then
friends, neighbours or even hired guards may have to be involved.
Alternatively,
inpatient treatment can be suggested.
A history
of difficulties encountered in the past is useful at this time.
CLONIDINE DETOXIFICATION
Clonidine should be started 8 to 10 hours after the last dose of
the narcotic, when the addict starts experiencing mild withdrawal
rhinorrhea•
symptoms such as yawning, piloerection (gooseflesh),
Relief is usually rapid with a total abolition of all withdrawal
symptoms within an hour or two.
r
three
We usually start with two tablets of•100 mcg(microgrammes)
this
times a day.
If withdrawal symptoms are well controlled
dose is continued for two more days.
From the fourth day onwards
start reducing the Clonidine gradually tapering down at the rate
In some cases which give a history of
of one tablet per day.
using
small
quantitites
of heroin for a short period,
one
only
tablet three times may suffice on the first day.
In other cases,
be
6 tablets per day may not suffice, in which case the dose can
microgrammes
increased to one mg.per day (ie. 10 tablets of 100
each)
in
three or
four divided doses.
(The maximumi dose
With these patients it is iuseful
recommended is 20 mcg/kg/day).
Once the wi thdrawal
to give a slightly higher ose at bed time.
symptoms have been controlled the dose can then be reduced after
tapering
While
a day or two at the rate of one tablet per day.
first f
off Clonidine, it is helpful to reduce the afternoon dose
With
then s top the morning dose and finally stop the night dose.
med
ipatien
t
'
s
experience it is possible to individualise the
of
the
cation on the basis of body weight, amount and duration
withdrawal
abuse and previous history of severity of
narcotic
symptoms.
FRECAUI IONS
the first day it is necessary to record the patient s blood
On
the second
two hours after the first, or preferably,
pressure
the
standing
blood
pressure
fall
below
90/60
mm Hg,
Should
dose.
the next dose can be postponed.
The patient is restricted to bed
If the blood
the next day's dose reduced to half.
pressure
and
remains below 90/60 mm some other technique of detoxifistill
be used.
Rtandino
be
Standing
blood oressure
pressure should
cation should
82 -
A
recorded daily.
If it is below 90/60 mm then reduce the dose and
confine the patient to bed.
Hypersensitivity to the antihyper—
tensive effect of Clonidine is rare and we have not had
to
discontinue treatment because of this.
Some patients complain of
giddiness and unsteadiness on standing up.
This is due to postual hypotension.
Therefore all patients should be warned not to
stand up suddenly but to sit down for sometime and then stand up
with support.
Bathroom and other doors should not be locked
in
case the patient slips and falls. Abrupt discontinution of Cloni
dine may cause rebound hypertension.
Hence the drug should tapered off gradually.
This effect is usually only noticed
after
Clonidine has been used for 30 days and therefore should not be a
problem.
f
SIDE Ef-FECTS
I
1) Hypotension 2) Postural Hypotension 3) Sedation - this could
be an advantage even though patients may complain about
this.
This sedative gradually lessens each day.
;•
DRUG INTERACTION
I
i-
I
I
■
I
Tricyclic antidepressants interfere with the effect of Clonidine
and should not be used until the patient has withdrawn from
Clonidine.
Antipsychotic medication like Chloropromazine poten
tiate the hypotensive effect of Clonidine and may also cause a
confusional state when used with Clonidine. Hence they should not
be used,
ADJUVANT MEDICATION
additional
Most patients become quite anxious and require
Diazepam 5 mg.TDS or Lorazepam 1 mg.TDS usually
tranqui1isers.
suffices, the dose can be safely doubled if required. Insomnia is
HS or Phenargan
usually a problem and Diphenhydramine 50mg.,
50mg. at bedtime usually suffice, If required lOmg. of Nitrazepam
be
can
be given as required. The anti-anxiety medication can
Drug abusers are
gradually tapered off after the fourth day.
Ditranqui1isers.
liable
to become addicted to Nitrazepam and
may be
phenhydramine
(Benadryl)
or Phenargan
(Promethazine)
continued fob sometime to help induce sleep.
ALTERNATIVE MEfHODS OF DETOXIFICATION
1.
Acupunture
:—
This has been found useful
in controlling
withdrawal
symptoms during the detoxification phase. It can
also help in reducing discomfort during the post detoxifi
cation phase. Unfortunately, frequent sessions are required
(every
few hours during the detoxification
phase),
making
treatment expensive.
Though it has often been touted as a
“cure” for drug addiction, there is no evidence that acupun—
ture influences the long term outcome of drug addiction.
2^
Electrical
Methods
Various techniques such as NeuroElectro Therapy (N.E.T.) and Electrosleep exist where a sma11
electrical current is passed across the brain. This con tro1s
be
the withdrawal
symptoms effectively. Such mediums can
for
constructed
for a few hundred rupees but are often sold
83
large sums.
One should be careful in using such
unless the safety for human use is certified by the
Government agency.
3jl
machines
required
Herbal Remedies
Herbal remedies have been tired, many of
them containing opium. There is little scientific documen—
tation about the efficacy of such remedies. High doses of
Vitamin C have also been tried, with some success.
r
SPECIAL PRECAUTIONS WITH MEDICATION
All
medication should be locked up and given to the addict only
as and when prescribed, by a responsible person. (Some patients
take an overdose,
by manipulating
the family or with
may
suicidal intent or because sometimes the patient is confused and
may forget that he has already taken his medication).
is
When medication
to dispense medication.
It is advisable
of
the
patient
and
relatives
do
not
know
the
name
dispensed and
if
the*medication, the doctor can withdraw treatment at any time
follow
not
required,
especially
if
the addict or family do
properly.
It
also
prevents
unsupervised
use byf the
instructions
advise
commonly
the
future
if
he
relapses.
Addicts
patient
in
they
so
that
addicts about medication they have received
other
can detoxify themselves.
I
I
I
SUPERVISON
the
Daily home visits by the treating physician are necessary in
first few days. Vital signs and standing blood pressure should be
family
recorded.
Some time spent talking to the patient and the
out
enhances rapport and
helps them follow up and carry
chart
instructions.
Doctors should review the intake/output
maintained by the relatives and also the medication chart- It is
advisable not to call the patient to the Doctor s Clinic after
it then
first few days when the patient has stabilised, as
the
becomes difficult to restrain and keep him at home, the patient
assuming, then, that he can now go out.
1
I
I
Regime I I : Di phenoxy late (Lomoti 1 )
This has been used in the detoxification of opiate addicts quite
successfully (Gurmeet Singh et al, 1984).
this technique addicts can be stabilised on between ov
In
30 to 60
mg.. of Diphenoxylate per day irf three to four divided doses for a
tapered off.
few days when the the medication is gradually
tranqui1isers,
e.g.
Diazepam,
Adjuvant Medication or Minor
or
Lorazepam are used to control anxiety and Diphenhydramine
Promethazine and Nitrazepam are given at night to induce sleep,
With experience, these can be used for Inpatient or Outpatient
detoxification.
Note:
T
Tablets contain 2.5 mg of
Diphenoxylate and
Lomoti1
has
0.05 mg of, Atropine to prevent abuse. Our experience
or
treatment
that Atropine does not interfere with
been
level
suggested
cause excessive side effects. At the close
patient receives 0.75-1.5 mg of Atropine per day.
- 84 -
4
r
Many addicts and families have the mistaken notion that detoxification
is a "cure” for narcotic addiction. It should be repeated ly emphasised that this is not so and that psyhotherapeutic
help should
snouio be
oe resorted to as soon as possible
for specialised
treatment and rehabilitation.
*
The family should be educated about their role in the treatment
of
the addict and in preventing the addict from relapsing,
by
keeping a close watch on him and holding him responsible for his
actions. When available, the family can be directed to Families
Anonymous - a group of-the families of drug abusers, which will
give
them support and which can teach them the techniques other
families have used with their chemically—dependent members,
They
may also
be guided to Alcoholics Anonymous,
a group
for
alcoholics,
for they can learn a lot about drug abuse in. these
groups as well. Siblings may attend Al-Teen groups.
Personally, I have strong reservations about Narcotics Anonymous
as it socialises the addict with other addicts, and some of the
other addicts who have relapsed may initiate the patient to start
using the drug again. Alcoholic Anonymous may be a better option,
if at all.
;■
■!
I:
i
If
psychiatric facilities are not available the treating doctor
may
be tempted to treat the addict with psychotropic medication
for relief of symptoms such as anxiety and depression.
Minor
tranqui1 leers such as Diazepam, Lorazepam and hypnotics such as
Ni trazepam should be avoided as the substance-abuser may become
chemically-dependent on them. Vigorous exercise and relaxation
training, yoga and religion are useful ways of dealing with minor
psychological difficulties. The clinically-depressed addict may
benefit from adequate doses of trycylic Antidepressant medication
much as Amitryphy1ine, Imipramine, Doxopin - these have a
low
abuse potential.
task
The
psychosocial rehabilitation of the addict is a complex
left . to the professional. The referring doctor should be
best
caretu1 about who he refers his patients to as there are a number
of practitioners with dubious qualifications in the field. In our
experience Family Therapy has been the most effective form of
therapy with addicts. Results of therapy all over the world are
poor and placing the addict in a rehabilitation centre for years
has not been found to be very useful.
■
85
PILOT PROJECT NO:
COMPARATIVE ANALYSIS OF OUT-PATIENT
VERSUS
I N-E 'AT I EN‘I DET OX IFI CAT I ON
OF ADD10 IS
01 :
WMnBBOnnx=nEnnnnnssnE:s:=E = =====: = =: • — ~ — =:=: = = = = =: = = = = = = = = = = = = = =ss= === = = = = = =
PROJECT JUSTIFICATION
I
I
interested
in
In
our
country,
the
number
of
professionals
work
dealing with addicts is very limited, which has led others
finds
ing in the field to charge exorbitant fees. This tendency
on 1 y
support
in
the general view held by
professionals
that
assemotivated individuals should -be treated and their tool for
to
ssment is subjective
perception and inability of the addicts
assert themselves regarding their right for treatment just as any
other
patient
and
not be blamed totally for
lack
of
result
through
practitioners
who refuse to document
their
work
and
create
accountability-
Out-patient treatment would facilitate the family to get involved
in the treatment, to reduce the expenditure incurred, to
facili
tate
the
individual to deal with reality and not be
forced
to
adjust after being detoxified in a conducive environment.
The Project period should be three years,
follow up and report-writing.
inclusive of two
years
IMMEDIATE OBJECTIVE'
r
inpatient
To analyse the cost and effectiveness •of outpatient or
by
each
treatment
and
the
target groups who
would
benefit
modali ty•
OUTPUT
I
ACTIVITIES
!
A manual for
detoxification.
Select a particular hospital or centre
offering
in-patient or out-patient
treatment or two hospita1s/centres in the
same locality offering either in-patient
or out-patient treatment.
Formulating the methodology for data
collection; inclusion and assessment
follow-up criteria.
Selectidn of a study sample.
sample at
Fol low—up of the study
intervals of two years or for a period
not exceeding two years.
Areas covered during follow-up
should
not be restricted to successful cases
only but also involve cases of relapse,
lapses and slips,DAMA, etc.
86
4
E
Identification of problems and modifi
cation in terms of operational details
suggested by the patients a
delay in receiving OPD services, extent
of influence of external factors or
inter-persona1 relationships that inter
fere with out-patient treatment proce
dure and promotes DANA self-medication
opted for by the patients.
Y
The evaluation of the cost and effective
ness
of the
treatment; if benefiting
target
population; and the psycho-social
factors that*faci1itated the outcome.
Production of report based on the
findings.
Production of a manual on guidelines for
low cost detoxification.
>
87
f
PILOT PROJECT NO:
02: TRADITIONAL SYSTEMS
OF MEDICINE
PROJECT JUSfIFICATION
civilization has coursed through several millenia
with the
Joaa^’s5^6 O*traditiOnal
medicine.
Ayurveda
Sidd^ and Unani medical
systems together with i and
folk
medicine and Homeopathy have developed effective treatment
regildate,
=/
?*ture
:ns
-ndiu™" ?o
bY th*
GanJa’ Bh*na and other mind-altering substances
widespread use and their abuse must have been not have been
XV81
"ethods
treatment for ovZrdose of uncommon.
poisons.
aooli2Ib?if? u"earth traditional practices and
their
pplicability to contemporary problems such as strengthen
heroin abuse.
in
IMMEDIATE OBJECTIVE :
To <-the cost and effectiveness < '
of various traditional
systerns of medicine _.i
in comparison with other
allopathic modalities.
OUTPUT
ACTIVITIES
Production of a manual
on the effectiveness c
of
application of various
approaches.
F
‘
Selection
of traditional systems of
medicine to
_ be
—? used for detoxifying
addicts.
I
Selection of particular centres who have
been using traditional methods
<
.
Methodology of data
i
collection .
Decoding the study sample.
Review of 1iterature/documentation on
oral traditions from senior practitioners.
Documentation of the process.
I
The following medical systems are
suggested here: Acupuncture, Homeopathy,
Ayurveda, Siddha, Unami.
In the evolution of TSM in India, one of
the efforts has been to develop an in tegrated medical system and for a while
degrees were also given under the inte
grated curricula though puris.ts have
opposed such exercises. (For an account
of the development of TSMs in
India, of
K.N. Udupa, 1958, G.A.A. Britto, 1985).
- 88 -
4
There exist in the field of drug abuse 9
some centres use acupunture — WHO has
promoted it in Asian countries. In
India, BPT and a few private centres use
acupuncture.
X
A few doctors have started using Homeo
pathy (Delhi Police Correctional
Foundation, Dr. Jerajani). Kashi Club
through a contract to Dr. Udupa, would
test the regimen for Ayurveda under the
UNFDAC — Government of India funded
Project, at Varanasi .
Some projects should be set up
a regimen for treating addicts
of the traditional systems and
test out the feasibility of an
regimen.
to develop
in each
also to
integrated
Selection of sample undergoing other
forms of treatment such as allopathic
medicine for comparative study.
Evaluation of the approaches.
Follow-up at intervals for both the
samples.
Production of report based on the study.
Training of other professionals in the
modalities found useful.
t
>
89
4
■■■■■BaBBassaanasesssxcKKCscecscessssssBSKseKSSssccBeasccneB
PILOT PF^OJECT
N(J:
03:
SELF- ME-DI LA I ] UN
SBBBBBBeeBBBcaaBeEaaaBBxaaaaBsaaeanaeacaaasaanaeaea
Pfx'CJJECri
y
JUSl IF- 1UA I ] UN
It is evident from studies that-a certain section of addicts
are
able to deal with their addiction through self medication, but no
further attempt has been made to understand the phenomenon or its
utility.
In
a
developing country where there is a lack
trained
profes
sionals to deal with addiction, where the cost of
detoxification
is
currently high, where soft forms of drugs like cannabis
have
been
used for centuries, where social control along with
rather
than
stigmatization
played a major role and
where
at
present
stigmatization has received social and legal sanction, one
needs
to
look
at the possibility of devoloping
modalities
for
self
medication
and
have
the , probable
adverse
effects,
due
to
ignorance, could be avoided.
Whether anyone likes it or not, addicts the world over resort
to
self-medication and it is important to provide technically
sound
advice and guidelines to addicts and their peers.
OUTPUT
To produce a manual
on steps for selfmedication .
ACTIVITIES
Selection of different areas where drugs
are prevalent or where hard drugs are
replacing soft forms of drugs (conducting
a study on the pattern of use, if needed).
Collection of data on methods adopted by
addicts to deal with health problems
arising out of their addiction.
J
Analysis of various forms of self medi
cation utilized and the complications
faced.
■:
Analysis of the
positive aspects of the
method and its cost-effectiveness.
Production of report on the study.
Circulation of the report to professionals
for their suggestions and to ex-addicts.
Production of a manual on guidelines for
self medication.
4
90
I
■mm
~n»ii TircWi
1
pi1o t P ro j ec t 04: M ai n ten ance on 0p ium
ss>c8a=>aaiz=z3X3asasx=sis3xis3= s=3 = =:=:s3=3 = = = £= = = s= = 2s= = =: = = =: = = = = =: = = =3 = = =s=s=:=: = = s5=: = s==z=3=:s
i
I
jjf,' ■
!B
I
1-
Coming to the methods of medication, one of the options available
to us purely the political economy of opium cultivation
in
the
country
is to use opium tincture for maintenance and detoxifi
cation or substitution of drugs. The world's demand for raw opium
from India for medicinal purposes has shrunk by over 40 per cent
in
the
last decade resulting in unsold stocks of
mountains of
opium
being
guarded by a couple of hundred of
armed
security
personnel
leading to a hike in th^ cost of production of
opium,
which in turn makes our opium uncompetitive in the world
market.
If we can develop a proper regimen for the use of opium (raw and
tincture)
in
the treatment of heroin addicts and
aggressively
market
the
same in the place of methodone and
other
synthetic
compounds being used in the West for maintenance and Substitution
/treatment, then, not only would our Revenue Ministry be happy to
earn
precious foreign exchange/ contribute to reduction
of
the
imbalance
in
the hard currency trade, but it would
reduce
the
anxiety of some of us working in the field of demand reduction of
the
possibility of the emergence of an Indian source of
heroin.
So far the world has not devised a methodology of convincing
the
opium growing
community
to give up opium cultivation
and
switching over to orchids/pisciculture or other means of earning/
enhancing their incomes. In India, we have not even looked at the
problem in
any systemic manner but have assumed
that
issuing
administrative
fiats
to the farmers to
reduce cultivation
of
opium
by 10 percent of the acreage each year would
bring
about
the' reduction of the amount's of opium produced in
the country.
Alternatively, we have assumed that by reducing the commission of
the
collect opium from farmers and deliver it to
Lambardars who
I
impel
the
purchasing agencies would automatically
government's
The
third
to produce less on a fewer number of acres,
peasants
kilogram
being
followed is the reduction of
the
per
strategy
that
the
likely
price
,of
opium
from
farmers.
It
is
purchase
number
of
same
who
continue
to
produce
opium
on
the
farmers
hectares, hoard the quantity they do not manage to sell or do not
looking
need
sell
to se
11 in order to continue to remain in farming,
for customers to buy their opium at higher rates.
91
OUTPUT
Development
of a set
of guidelines
for the appropriate use
of Yoga,
Ayurveda and
homeopathic
medical
system* in
the treatment
of drug
abusers.
ACTIVITIES
PARTY
RESPONSIBLE
Determination of and appli
cation of criteria for
inclusion of patients for
treatment under traditional
systems of medicine (TSM).
To be Contracted
out
(sub contract B)
TIME FRAME
(MONTHS)
r
3-18
Recording of Clinical and
Medical team
laboratory data of patients
as per allopathic procedures.
Development of prelimnary
treatment regimen according
to TSM.
Development and utilization
of a set of formats for re
cording data of patients as
per the TSM requirements.
The Contracted
team of TSM
experts.
The Contracted
team oT TSM
experts.
Follow up of patients upto
a minimum of six months
after SM treatment.
Recording of data as per
medical team allopathic
systemi post treatment and
after six months.-
Medical team
Development of final regimen
for the use of TSM for the
treatment of addicts.
The Contracted
team of TSM
experts.
92
4
I
21-24
I
I
1
!
Re(habilitation) of Addicts
Y
at
A Status Paper with Outlines for Pilot Experimental Projects
I'.
National Addiction Research Centre
5 Bhardawadi Hospital
Bhardawadi Road
Andheri West
Bombay 400 058
1
(REHABILITATION OF ADDICTS
INTRODUCTION
The management\ of drug abuse in India is asi new a concept as
- order to create a
large scale heroin abuse in urban India is. In
professionals
and
policy
makers
on the most costdebate among ]
the following
and
efficient
methodologies
and
services,
effective
team
of
researchers
at
SPARC:
papers have been produced by a 1--- -Prevention of Drug Abuse
-Counseling Addicts
-Medical Management of Drug Abuse
-Habil)tation of Addicts .
with
The structure of the above named papers deals largely
following :
1. Theoretical considerations of the
of management of drug abuse.
2. Description of the current
different organizations.
3
particular
practice
in
the
aspect
India
in
of the prevalent practice in the light of the
A critique
c*-magnitude of the problem and other criteria
4. Outlines for a set of pilot experimental projects in
order to sharpen the technology of intervention in the
management in the Indian context.
field of drug abuse
i-In
this paper the authors dwell
residential rehabilitation centres.
at
length
on
long-term
DEFINITION OF TERMS
(Re)habilitation can
can be defined as a process that attempts to
aid addicts to physically, psychologically
and socially cope
with situations likely to be encountered after detoxification
and thus utilize the opportunities that are available to
others of the same age group in society.
Detoxification, After care. Social- and Vocational integration are
parts of a continuum,
which aim at assisting people
m their
transition to a meaningful way of life.
The starting point of
this continuum is when a drug-dependent person seeks to overcome
his habit.
Detoxification is an important adjunct to the
longer
efforts needed to integrate him into society. Thus,
After-care,
Vocational- and Social-integration go well beyond the scope of
detoxification.
After-care services meet the medical requirements
detoxified patients.
(re)
is functionally a part of the
used in its broadest sense. It is probable
111 individuals in the affected population, the term
that for certain
reintegration" will refer to their first "integration
“social
street children.
into society (as in the case of delinquents,
Social
reintegration
c=
habilitative process
etc ) .
94
■
Two general objectives
habilitation are :
that
apply to
all
efforts
at
(re)-
1. To modify the attitudes, values,
values, behavior
and skills
of former drug-dependent persons so
as
to
encourage
their ftransition to, and maintenance of.
a drug-free way
of life.
2. To provide jsocial
* ‘ supports needed to esLaonsn or
establish
reinstate these. . individuals
in- the
— —
--- community in roles they
find more satisfying than in their former life
pattern.
where they could function with greater self-assurance.
SOME GENERAL CONSIDERATIONS:
While setting up rehabilitation programs,
we need to consider the
following :
a) Since Drug dependence is often a recurring pattern of
recurring pattern
behavior,
t.ls_vltal that rehabilitation
personnel set
-----1 personnel
realistic goals ---for the
—• program lest their morale decline/
they get burnt out/they give up their jobs or the
program
itself collapses.
b) Long-term residential ]—‘of’add-'j C°ti*
n«dseot certain
between
a ^ear^ c°uld cater to the~ i
’
:
; they are not at all
as they are certainly not the sole
or rehabilitation
_.i any
any proven
proven sense
sense whatsoever.
whatsoever. It
It is
--- m
not even clear what types of heroin i
nnf
v • x j!from
-------------------------------could or could
not best benefit
suchJ ]residential
’ ’ - - addicts
- -long-term
rehabilitation programs. The major goal of any approach needs
to
be the reintegration of the individual to society.
Retaining the addict
in
..
institutions
for long stretches
of
time may further enfeeble his weak moorings in the family,
neighborhood and his work place/educational settings; thus
eroding norms and alienating him further.
c) It is evident that rehabilitation programs do not
n ,
--------- r-^0 4.uu iiuu
require
large, elaborate
physical structures to carry out their
activities. Therefore existing buildings should be
should
utilized. They
should be located in affected areas cor at
least be within
— the
-- j reach of the targeted population.
d) Considerable persuasion
persuasion might be :required to motivate
individuais to enroll for rehabilitation'
programs. The
Pk
°f ofindividuals dropping out of
the program
should be borne in mind.
t
e ) Networking
with other organizations is
facilitating individuals to enter
the
detoxification.
crucial
for
program after
f) Assessment
of
the individual's
treatment
history,
personal iand social factors, his vocational
history
and
health
isJ
important while planning a
program
of
rehabilitation and social reintegration.
95
w
*
.1
g) Programs of social reintegration should incorporate a
follow-up phase to ensure that the client does not
encounter unforeseen difficulties in the community.
successful community program of rehabilitation will
depend on positive attitudes of that community towards
drug-dependent persons.
h) A
i) The success of any community rehabilitation is
on successful job placement.
dependent
’, adjusting
j) Drug craving, developing a new social network,
J satisfaction from
to drug-free activities an/d deriving
them, dealing with stress and pain, maintaining relationships. and dealing with slips and lapses are some of the
important aspects of recovery.
reintegration will be difficult for individualss who had
deviated from the set path of life, specif ically those who,
besides depending on drugs, had also neglected their academic
life, training or social skills.
Social
The effectiveness of rehabilitation programs would have to be
determined through a set of outcome criteria which take into
account the ways in which the individuals develop roles for
themselves in the community both socially and occupationally.
and not be limited to their behaviour regarding drugs.
The areas in an individual's life that need to be verified are.
1.
2.
3.
4.
5.
6.
Subsequent use of drugs
records/attendance
at acadenic or training
Employment l
----courses
Involvement in criminal activities
Relationship with family and community at large
Attitudinal changes
General state of the client's health.
At present, the focus of various rehabilitation centres has been
limited to individuals who had accepted the set processi of change
in order to arrive at a drug-free state. There are others who
have quit drugs without ever entering into any treatment program
or without recourse to professional help. They have either
their
utilized
self-medication
or found alternatives
to
or
have
activities which reinforced their stereotyped behaviour;
and merged with the general public in a
left the addiction circle
<-------new city or under a new name.
The maintenance of a drug-free status is related to :
An opportunity to.partake in interesting activities,
in turn breaks the stereotyped pattern of behaviour
dated with addiction.
This
asso-
Self-help groups are able to sustain their role in the
deaddiction process as they are devoid of stigma, This is
‘ > addiction
the
important, as the stigma attached’ to
?------- -hinders
-7
into
individual from re—integrating himself
l.-»——— —
- - society.
96
f
Therapy sessions often tend to focus on
intra-psychic
problems and ignore social issues that
facilitate
or
hinder the person's reintegration into
society.
Research studies show ti.__
that at times individuals who have
opted' out of drug addiction? f
-- ? addictive behavioral patterns such as ga^bling^overeatiig
etc.
. ----- * such as gambling.
Rehabilitation institutes
Institutes
utilize religious
...
faith and
group pressure to motivate the addict
to remain drug-free.
Pfiority of rehabilitation1 centres
that their
centres that
patients continue to remain drug-free in order to
sustain
Program or professional career.
Several add icts
hfi?nLnOt Manb t0 reach a totally drug-free status but
to
oTthme soclally and vocationally functional, if needed,
instance6 aSS1Stance of soft dru«s such as Cannabis,
for
In the 7Indian context, the facilities <
currently
addicts to seek professional
------ - help are limited.
available
The methodology currently adopted 1
by these centres cater to
snail segment of the universe of addicts.
a small
for
just
In order to justify the large :
investment in terms of professional
inOney and space- and also to increase
-• their chances of
-2f ?uccess> th®y screen out and accept only - highly
motivated individuals.
To illustrate, ia residential rehabilitation centre catering to 20
addicts for six
— months, would require a spacious building,
recreational area, staff, cooking arrangements... 7‘
all of these centres charge a high fee when not fullyThus, almost
J subsidized
by the government.
hab\litation centres would Bombay
neeS^keepinriJ^iAd^hJ^h
hArn-in
Paa' 4.
nin<^ that the lowest estimate puts the number of
iSm.tr o.mt::rdTh‘°-°r r "onid
1
This? ■ o
country
cannot
methodology exceptcentres
by
°“ntr>’ .cannot
afford
such
J way of a token symbolic political
gesture.
The expressed goal of professionals in the
field of
rehabilitation tends to be social reintegration
while
their activities do not
facilitate the process nor can
they support it. Certain rehabilitation
centres which are
also :*involved in preventive activities utilize
the Fear
Approach
—1 I
the shortcoming of this approach is that it
does not eliminate
— the
-- j stigma attached to addiction.
Thu , tendency
y®I.iaen^y to perceive prevention, detoxification and
reintegration0
isolation tends to ----hinder• the social
The lack of r;_
_
‘
systematic
documentation in the field of
rehabilitation could
— lead
-- to exaggerated statistics as
rate
of success lof their methodology. This lack to
of
documentation and its
—j monitoring does not help in adapting
Western models to l
_1_ the local conditions in the Indian
suit
cultural context. Further, there is little accountability
and much self-delusion regarding the best methods of
working with addicts.
97
y
i
The staff have invested heavily towards establishing rehabili
tation centres. Being keen on maintaining the program, they are
apt to succumb to the pressure to increase the rate of success of
the program and so ignore or fail to meet the challenges
of recovery. They may not consider social or vocational reintegra
tion as a component of the theory and practice of rehabilitation.
Conceptually, readdiction is a process that has several stages:
lapse, relapse, readdiction. If counselors misinterpret
slip,
slips as readdiction, difficulties could arise which would cause
the counselor to either underrespond by ignoring or denying the
signs of a slip, or overrespond by trying to rush the person for
preliminary treatment focusing only on drug-use.
When rehabilitation services are peing planned,
measures should be undertaken :
the
following
A. Resource Inventory:
An assessment of existing resources in the community or those
which can be made available through national. State, or Municipal
programs must precede or be a part of the preparation for setting
up rehabilitation programs. Such a survey would avoid delay in de
veloping the program as also in curbing unnecessary expenditure.
The
resource
inventory should include information on:
Local labour market
Vocational training opportunity
Education up-gradation programs
Job placement services
Facilities for post-treatment observation
Counseling and half-way homes or drop-in centres.
B. Hunan Resource:
A resource inventory would identify persons or groups in the
community who can assist in the process of rehabilitation and
social reintegration. They may be professionals skilled in the
relevant disciplines; executive personnel with management skills;
persons with special skills within the community; or instructors
in trades that are appropriate to the needs of the client; or
community leaders and local authorities who are interested and
knowledgeable. The involvement of the community in the design of
the program would motivate them to an sustain optimal level of
performance.
The Measures for rehabilitation and social reintegration are:
1) improving
educational
qualifications and skills.
2) expanding job opportunities and
3) social support
These
are
each other.
naturally interdependent and hence tend
- 98
to
overlap
PROGRAMS FOR IMPROVING EDUCATIONAL QUALIFICATIONS AND SKILLS
Educational Upgrading and Vocational Training is imparted
imparted to
to the
client to pave the way for his entry or return to the educational
stream and to cultivate skills or improve ones qualification
This would prove beneficial to young clients who have dropped out
of formal education but who have the requisite motivation
motivation to
enhance their educational level. The operational cost
cost of
of the
program may increase as educational needs and career goals are
variables.
To provide training in skills relevant to the local
economy or to the informal sector, the design of the program
should be congruent with the local labour market as also with the
economy of the community'. It should be tapered realistically to
industrial and commercial parameters. An attempt should be made
to inculcate attitudes which will improve the clients social
functioning and career; and to deal with societal attitudes
towards addiction and to develop self-confidence.
A survey should be undertaken to determine the needs of the local
labour market; an assessment of the training courses available;
their strengths and criteria for admission; the development of
required non-existent courses through recruitment of relevant
competent instructors, provision of equipments and other training
requirements.
Finally, a working icommittee consisting of representatives from
the labour force, industry,
-> the educational system and the affected population should work, in liaison with the community and
assist in co-ordination.
THE INDIAN CONTEXT
In India, under
i
the Ministries of Education and Labour, we have
several ITIs
IJ . and 46 Shramik Vidyapeeths to offer training for
post-Matriculation courses as ialso for high-school dropouts. In
addition, innumerable apprenticeship
~ and- self-employment
— - — ———•• w programs
operate both under Government and private commercial or industrial auspices.
- _. A / large number of Non-Governmental Organizations
(NGOs) have also specialized in offering vocational
-------- training
courses.
Thus it is not at all necessary for new NGOs in the field of drug
abuse to set up new technical training institutes exclusively for
addicts.
It would not only be a duplication of efforts but they
would be draught with failure when undertaken byr nascent NGOs in
the field of drug abuse. Educational planning is an
an extremely
complex exercise best left to experts in that discipline.
However, educational planning in the country has been lopsided
and has been made to suit certain vocal segments of the country.
It does not cater to the requirements of this vast country's
teeming millions. Hence, a group of NGOs in the field of drug
abuse may uuninixssion
commission studies or act as t.a pressure group for a
national/regional/city appraisal of educational and job-oriented
training opportunities for the current number of youth who need
them and projected for the future needs of youth in their areas
of concern. The Ministry of Welfare and the proposed Association
of recovered addicts
may impress upon development planners,
policy makers (commencing with the Planning . Commission, and
leaders of various political parties to name a few) to look into
the basic question as to how our youth may participate in our
99
i
politico-economic
and economic structures.
PLACEMENT SERVICES
<
Change agents have on many an ocassion, used their personal
contacts with influential people to secure jobs for addicts, but
these efforts have often failed to achieve their purpose largely
due to inadequate preparation of both addicts and employers.
The effectiveness of job placement will depend on the following
concurrent requirements: local labour conditions, attitude of the
community to employ the treated addicts and adequacy of training.
Job placement and counseling services would help the target group
to find employment\ and to deal with related problems,
problems. An
evaluation of the effectiveness of the program could be under
taken by following up on a client's performance.
The criteria for job placement should pivot on thes interest of
the client. Concurrently, the services of counselors need to be
employed so as to deal with problems of the client or would-be
the long list of registered
unemployed youth at
employer. Given
—
exchanges,
it
aDoears
that
little
relief would come
employment
appears
to addicts from that quarter.
Whereas a large number of addicts are either unemployable or
unemployed and probably became addicts due to the enormity of
pain that they have had to undergo in their struggle for
survival, there is a segment among addicts who are basically
social rebels. They need to be identified and assisted to become
social change agents.
INCOME-GENERATING
PROJECTS FOR ADDICTS
A few NGOs have attempted without any previous experience toi set
up production-cum-training units for addicts, Far from reality is
it that all addicts can be made into tailors or leather-goods
craftsmen or candlemakers!
Other organizations venturing into income-generating
have faced the following problems:
a) Difficulty in maintaining Quality Control.
activities
skills are woefully inadequate-understanding
b) Designing
buyer-preferences is a specialized skill and discipline.
c) Cash-flow
_.r
problems are perennial since wholesale buyers
delay payments for as long as possible. Charity oriented
organizations and social work professionals do not possess
the acumen to make a business viable.
d) Developing
markets, securing orders, ability to
quality goods on time, are all failure-prone areas.
supply
e ) Product-diversification is necessary to sustain continuous
Skills
to adapt to market fluctuations.
production
the
for
new
products
may
not
be
available
with
necessary 1,
target group for whose benefit the lproduct ion-unit has
been set up in the first place.
(see Appendix for Pilot Project for developing a placement service)
1
1 nn
t
f) The
overhead costs of administering the
training units become so high that without production-cuma large subsidy
available each
would receive
a
pittance
>
g) There is also an r
-; to be
economy
of~ scale
considered. The
critical volume needed for viable
product to product.
production varies from
h) Whether
export market is available makes a difference
to the viability/ of income-generating products.
The
The
supporting
agency
would
need
for the export goods?"
t0
faBiliar with licensing
i) Accounting, audit and placing of r~
an appropriate quantum of
raw material
material are areas where trainees
raw
’flounder
-? and disrupt
business.
For the above and other y*----field of drug abuse wouldreasons
do wellnot listed here, NGOs in the
--to avoid income-generating
projects until they have:
- Adequate risk- r_
L
or venture-capital
~ The expertise needed for such projects
- An outright grant of a recurring nature for
the government or iany other charities towards every year from
underwriting the
annual losses as social costs.
COMMUKITY WORK PROJECTS
ILO consultant Hans Galver has Cdeveloped
the concept and
practice of Work Teans through pilot
experimental
projects in
several countries. These pilot projects
are funded by the ILO.
The overall purpose of community work teams f
is to provide inoomegenerating activities for i
*
recovering
addicts,, to
-j enhance their
participation in society and to create
more
receptive
attitude
in the community towards them.
This program is tailored to the needs of
will be usefql to that segment of the a specific community and
cannot fit into the conventional labour younger population who
The work chosen 1has to be in line with or educational stream.
the interest of the
targeted population.
The program can be implemented
“
through a group of repre
sentatives of the clients^ <
,
or
voluntary
organizations involved
with the support of the -local
1 government.
Methodology:
Addicts are first identified in
given slum/locality.
Background information on them isa gathered.
They are facilitated to enter detoxification/therapy
In the post-detox period, homogeneous groups of process.
treated
addicts are formed.
Through a p-process of community organization, tasks useful to
the community are identified.
Matching of groups with the tasks is undertaken,
Resources to carry out the task are identifi-ed
within and
- 101
ioi -
>r
jbrarv
AND
' r-
1
outside the local community.
Group processes and group norms are developed. Responsibility
for the group is entrusted to two or three levels of
leadership.
Training or orientation is imparted to the group.
On going after-care for medical needs if treated addicts.
Counseling is continued.
Differential quota of
c- work is allotted to addicts depend ing
on their health Status.
a given-day x—the
Should anyone does not turn up for work on
and
find
out
the reason for
look
him
up
co-addict-workers
absence.
to
kept
kept somewhat below the market rate in order
Wages are
work
of
encourage recovering addicts to .become independent
other are
work-team
sheds
some
members,
each
as
teams and
taken in.
who have wasted some
The <Community which sees their youth,
gradually beg ins to
years are
are now
now doing productive work,
‘
»
the
maintenance
of
such
work
teams,
contribute to
the
work
teams
consolidate,
then,
they are g iven
If some of t..
ef f ect ing
in
maintaining
accounts,
handling
cash,
train ing
own
f irm/
relations...
and
assisted
to
form
their
pub lie
company to carry on business,
In some countries, such work teams have grown into fu11fledged transport corporations.
'ksee Appendix)
pilot
It is with this understanding that a field
of
drug
abuse
in India.
is proposed for NGOs working in the f--- -—
A. SUPPORTIVE SOCIAL APPROACHES:
to
with
and
Placement in foster families can be a means to deal with adverse
effects of disturbed family background during the period of
rehabilitation,
thus helping them to form social links at an
early stage.
The steps for implementing this program are :
matching of a
fostering families,
Ident if icat ion
particular client to a particular family , acquainting the
family with the needs and potentials of the client,
an on-going relationship with the staff
estab 1ishing
member, the foster family and the client.
to lack of adequate number of
Comp 1ica t ions can arise due
foster
avaliable
information
available
to
insuf ficient
and
families
The
likely to be encountered.
families regard ing problems
fami 1ies°would~need to be adequately prepared.
fostering
In India, we
we have not yet attempted to develop foster parents
a
■ ffbgrains even : for children in any systematic manner or on
of
years
severa
large scale
scale..
There are some NGOs who have l
_-- 1
dialogue
A
experience in developing foster parents for children,
on the
these agencies
agencies and
and NGOs
NGOs in
in the field of drug abuse
between these
the
way
nuances of setting up foster parents' program could pave
for pilot experimental projects in this regard.
102
1
'3 85
B. HALF-WAY HOKES
The purpose of Half-way, Homes is to assist habitues to gradually
sever ties with residential rehabilitation centres and
to
face the challenges and demands of society in a graded
manner.
The immediate objective is to identify employment
in society, to assess the skills and capacities of
to cement contacts between clients and employers.
opportunities
clients, and
Half-way Homes should provide living accommodation for eight to
twelve persons in the neighbourhood away from the drug-using
population.
The residents .would be collectively responsible
for
the operation and maintenance of the Half-way House, with a staff
in charge of the overall management. The location needs
to be
close to academic institutions, training centres and places of
work.
The utility of the program would be determined by the length of
stay,
the efforts made to provide an opportunity for the c 1 lent
for a phased reintegration into the society and preventing
dependence on Half-way Houses.
C. DROP-IN CENTRES
Drop-in centres are akin to Half-way Homes except that drop-in
centres do not offer an eight-hour structured program nor do they
compel recovering addicts to spend the whole day in nor insist on
regularity of attendance. It is a place which is run in such a
manner as to make addicts feel they are welcome there anytime
as
also to attract them whenever they, feel the urge
to return
to
drugs.
The objective of drop-in centres is to help the client
to
maintain a drug-free life outside institutional settings
and
to support their reintegration in society.
An informal social environment and counseling services could be
a point of reference for the client
with
relatively
few
acquaintances in a drug-free milieu. The centre should preferably
be located in a. central area and have recreational facilities
for counseling sessions.
Operational costs depend on assistance from the community and
maintenance of the centre should largely be the responsibility
of the clients. For effective functioning a democratic
committee should establish rules for the use of the centre and
decide on their enforcement.
These day-care centres could be places where, in the post
detoxif icat ion
phase,
occupational therapy project could be
implemented.
The objectives of occupational therapy projects are
limited to ass'isting the addicts to structure their time, develop
concentration,
learn to deal with authority and the other
routines which- are essential parts of work life. A sketch of
a pilot project for this purpose is outlined in the Appendix. The
staff requirement for such a project are
an Occupational therapist,
a career guidance person and an assistant to take care of clerical
duties.
103
>
D. RESIDENTIAL PROGRAMS
4
therapeutic
In
this context, it ip vital to distinguish
recommunities from other approaches to rehabilitate and
integrate addicts. In the therapeutic community program, the aim
without
is to keep the former drug user in a drug-free state,
necessarily returning him to the larger society.
Therapeutic communities
This approach views recovery as the total responsibility of the
the centre provides a conducive environment for
individual1 and
J
it. The
’... individual is viewed as ah immature person whoi requires
help, The period of stay to achieve this varies from centre to
centre.
The
close contact with professionals, ex-addicts
and mature
people sensitive to the
problem
is
supposed
to
be
part
of the
1
process. The methodology of behavioural modification iinvolves
confrontation,
loss of privileges or status, group pressures,
acceptance, praise, advancement in social structure; the response
of the
recovering
of the group depends on manifested behaviour cf
tl.
addict.
The program intends to create abstinence from mind-altering
substances, develop a new life style which is non-violent.
positive, spiritual and socially acceptable.
The program's time frame is laid down depending on the processes
to re-structure behavior patterns or to deal with immediate
psychological or social problems, to facilitate their re-entry to
the main stream. The therapeutic community is usually run by
persons with previous addiction history or by professional staff
or by both.
The individual passes through three phases: self-examination and
confession; development of appropriate attitudes, values and
self-image; and reinforcement of these changes, Encounter therapy
for self-examination and shifts of one s belief system is
achieved and maintained through group praise.
The criteria for- admission and removal is based on the level of
motivation. At times, to test motivation. admission is made
difficult.
Communities which attempt to create group cohesiveness between
the staff and target population through shared decision-making
are less harsh.
The facilities and equipment at the centre are relatively simple
or
and these centres are either financed by the government
l
by private sources.
Institutional Rehabilitation in India
The objective of residential programs is to improve the quality
of inter-personal relations, develop responsibility, and maintain
a drug-free life.
The program is designed to avoid relapse by providing. a sheltered
104
r’
•
environment and restricted contact with the outside world. There
should be facilities for counseling and detoxification. The
operation and maintenance of the centre are the responsibility of
the affected population with support from change agents.
This approach is expensive in comparison to other approaches,
It
may prove useful to persons with long-standing addiction who
have been recently detoxified and specifically to those who have not
had the experience of living compatibly with others.
>
In India, the term rehabilitation denotes an approach to tackle
the problem of addiction by providing a conducive environment for
the affected population, in an institutional
setting, for a
period of one to six months.
At present in India, there are five Government funded After-Care
centres in the country. Non-governmental
organizations
like
Kripa,
Bombay;
Good Samaritans, Calcutta function as
rehabilitation centres. The methodology followed by these centres
is not identical. (”
“A case study of a rehabilitation centre”
(SPARC 1986), which is a documentation of Asha Bhavan does bring
to light the method selected by the centre to deal with
addiction. (Requests for copies should be addressed to SPARC
Documentation centre on Addiction).
MINNESOTA MODEL
This model refers to a treatment program for alcoholics and drug
habitues with a specific ideology related to the Twelve Steps of
Alcoholic Anonymous and Narcotic Anonymous. It includes
a
comprehensive and multi-professional approach but the emphasis
is on self-help therapeutic community, utilizing lay therapists
who are themselves recovering from chemical dependence.
i
The model does focus on' the value of 'multiprofessional' approach
in the management of addictive behavior. In particular, the value
of the ex-alcoholic or ex-habitue is upheld in this approach. The
model actively involves the individuals in their own treatment
within the parameters set by the program. This approach utilizes
group therapy , stress on the sharing of life histories, written
assignments, encounters and peer evaluation.
1
This model attempts to provide a spiritual, psychological, social
and physiological rationale comprehensible to the patient,
To
maintain the newly acquired life style and belief system,
it
draws on AA and NA services.
The Minnesota Model receives support from studies, which claim
success for two-<thirds of the treated population over a period of
one year s follow-up. But these follow-up studies have been
criticized on their:
i)
2)
3)
4)
methodological criticisms call for further research
incorporating inclusion criteria
lack of control groups
duration of follow up
assessment-procedures and diagnostic outcome criteria.
To recapitulate the foregoing, the
Minnesota Model are :
1
W’
components
comprising
the
j
J
the time of discharge and follow-up.
No control group or
comparison group was included. The behavioral areas examined by
Rossi, Stach and Bradley appear to be highly subjective. Further
operational definitions of these areas were not provided.
X
At Hazelden, during the years between 1973 and 1975, Laudergan
conducted a study - another study was carried out by Gilmore
during the period 1978-83. The methodology followed by both these
researchers was to collect data through questionnaires from all
patients who gave consent and stayed in treatment for a minimum
of five days. The questionnaires were sent to them at the end of
the Fourth, Eighth and Twelfth months after their discharge from
the treatment program. Those individuals who did not respond to
questionnaires were contacted by telephone wherever possible. The
study period included all patients discharged during the period
June 1, 1973 to December 31, 1975.
The total number of patients admitted for treatment was 3638, in
cluding those in the study, which was 1652. The 'study population'
was selected on the following criteria:
1) Those who had successfully completed the program and were
discharged with a medallion.
2) Those who returned the questionnaire
Eighth and Twelfth months.
after the Fourth,
(Note: Patients who returned to Hazelden for treatment or went to
any of its extended care units were excluded from the study).
y
Other methodological defects of the above study were that:
1) Classification regarding problems with either alcohol or
alcohol and drugs at the time of treatment was determined
solely by the self-report of the respondent to the question
naire.
2) Details of the number of patients who could not be
as also those who withheld consent are not given
authors.
traced
by the
If we exclude the number of persons who came 'shopping', and also
those who went through part of a treatment program and then sought
Discharge Against Medical Advice for one or the other reason,
then the computation of the rate of success is illusory. There is
to suspect that at least 80 per cent of those who
every reason
]
withheldJ consent had relapsed. Excluding them, too, from the
purview of the total number of persons treated makes the rate of
statistics
generating
false
success an exercise at
particularly when the reasons'for withholding consent are not
taken into consideration.
THE UTILITY OF INSTITUTIONAL REHABILITATION:
There is a slim chance of a particular modality, catering to an
aspect of addiction, being adequate to tackle the problem.The
approaches selected need to be culture-specific and related to
other social problems.
Institutional rehabilitation might be a
useful model for a small
4
Alcoholic Anonymous/Narcotics Anonymous
Disease concept of addiction
Group therapy
Ex-addicts/alcoholics as counselors
Family therapy
There have been extravagant claims of success rate of the
Minnesota Model of rehabilitation without it being substantiated
through systematic, serious follow up studies. Among the centres
adopting it, the Hazelden Foundation has attempted to evaluate
its own program. The need for further systematic research will be
evident from the following brief account of their lacunae:
I
During the period 1955-56, Willmar State Hospital conducted a
follow-up study of all patients living in rural areas by the
following methodology:
A counselor interviewed the patients and other informants such as
probate judges, Sheriffs, County Attorneys, police departments,
welfare agencies and AA groups.
In 1957, a sample of 20% of patients was chosen for a follow-up
on the same lines as the '55-'56 study. Based on these
studies, it has been concluded that at best, the effectiveness of
the program was then limited to 45 per cent of the patients.
I
In the year 1963, Rossi, Stach and Bradley published their findings after conducting a further detailed study over a period of
f ive years. The authors stated, that there was no appreciable
change in their program in the given period. A sample of 12% of
all admissions was selected. Thus, 208 male alcoholics were traced who, at the time of research, had completed 21.3 months after
treatment. Interviews were conducted with the patients by the
research team or by specially trained County social workers.
A
Five-point rating scale of drinking behavior was utilized but the
validity of the rating scale was not established. Out of the sam
ple of 208, 83% were traced. It was found that 11 patients were
institutionalized and 13 had died. Out of 149 patients located
in the community 49 patients(24% of the original sample) had
abstained from alcohol for six months or more and 35 of them (17%
of the original sample) had improved on their previous longest
record of abstinence for six months or more. One year of further
follow-up was done for those found to be drinking with mild
effects. It became evident that out of 45 patients,
patients, only one
continued drinking with "mild effects" and only three had stopped
drinking, whereas the remaining 41 were by that time suffering
serious effects as a result of their continued drinking.
The study also considered "behavioral areas" such as self ques
tioning attitude, belief problems within self, sibling relations,
budgeting, employment, harmony at work, and income. Patients who
continued to be abstinent after discharge showed improvement in
16 out of 20 areas, while those drinking with "mild effects"
improved in only 11 areas. Patients drinking with "serious"
effects showed even poorer outcome, but a certain improvement had
occurred in all groups.
v
.
II
I
*
These studies might show valuable impress'ive results but are
methodologically deficient. The results cannot be causatively
related to the treatment provided by the treatment centres. No
account was taken of other forms of treatment received between
X
*
Past histories of unpatterned social behaviour is a common factor
among heroin habitues and delinquents. Several studies which
compared delinquents and habitues with control groups of non
delinquents and non-habitu6s matched for relevant variables (such
as social class, place of residence, intelligence and ethnic
background)
showed
that young urban habitues
cannot
be
distinguished from young urban delinquents (Glueck and Glueck,
1950, Chen et al., 1964, Vaillant, 1966a and c).
Alcoholics had a significant incidence of parental addiction,
Lack of patterned behaviour noted on admission was often secon
dary to unemployment and marital instability which in turn were
themselves consequences and not contributory factors to alcohol
abuse. Only five percent of alcoholics evinced
delinquent
behaviour prior to abuse. The alcoholic is rendered susceptible to
relapse
because alcohol dependence destabilizes
patterned
activities.
The habitue begins his drug-seeking behaviour more due to lack of
opportunity in other forms of competing independent activities
than due to morphine or heroin per se being a powerful reinforcer or temptation.
A study noted that New York habituds had spent only 20% of
their adult life actively addicted and 80% of their life was
spent being unemployed by the time they reached the age of 40
(Vaillant, 1966 b).
For an individual who does not have employment, addiction does
provide a patterned form of behaviour, though stereo-typed. Having
been a misfit both in school and during adolescent periods, the
habitue finally achieves social reinforcement, addiction becomimg
an absorbing occupation.
Among alcoholics, dependence can be defined by the degree to
which alcohol seeking and consumption becomes the individual's
most salient and preoccupying source of gratification(Hodgson and
co-workers, 1978).
It is probable that addiction might be reinforced through the
fear of discomfort during withdrawals, imagined or real, and
through non-pharmacological factors.
It is a fact that the
conscious
chronic use of. narcotics provides little or no
gratif ication and early in the alcoholic's drinking career,
alcohol ceases to become an effective tranquilizer. The non
pharmacological reinforcements might be friends, syringes, pubs ,
rituals of drinking or injection etc.
Withdrawal symptoms might also'be related to past experience and
not be dependent totally on the drugs. Physiological response to
withdrawal of the chemical has been noted in research wards when
an individual who has been abstinent for months experiences
withdrawal
while watching another habitue go through it. This
phenomenon has been noted in different detoxification centres and
camps in India and has been called conditional withdrawal.
It is also probable that an individual who believed himself to be
a hard core habitud and expected to go through heavy withdrawals
actually suffers severe withdrawals although his peddler had been
selling
him milk sugar in the few months prior to
the
detoxif ication.
percentage of the addicts-particularly those who took to drugs
due to inadequate/inappropriate ego development in spite of
coming from economically and socially sound families
with
adequate educational and career opportunities.
Such residential centres may be useful for another set of addicts
who have a hopeless family situation.
For some addicts, such a program could be counter-productive.For
example, if we took a rag-picker and put him away in such centres
for six months or a year, then, on being put back on the streets,
his survival skills would have been blunted and his network of
social contacts for surviving there would have withered away,
even to the extent of his body not being able to withstand the
occupational health hazards of rag-picking, leaving him susceptible to illness.
However, these are only our hunches and there is no research
study to indicate what types of addicts need long-term residential rehabilitation programs, nor who may benefit the most from
such programs.
As per the study it was found that only 3% abstinence for a year
resulted in 100 cases with 770 detoxifications via voluntary
hospitalization or short term imprisonment. (George E. Vaillant 1966)
Studies and literature reviews show that the effectiveness of in
patient treatment in comparison to out-patient treatment or brief
detoxification is not significant (Edwards and Gutherie 1966,
Edwards and Grant 1980) among alcoholics. A comparison of in
patient treatment to out-patient treatment for alcoholics showed
no variation in effectiveness after a period of two years.
(Vaillant*1980).
Denial of detoxification because of uncertainty regarding its
long-term effectiveness would be as inhumane as denying treatment
to diabetics.
diabetics. Detoxification does reduce the person's suffering
and mortality and no justification can be given f or exclusion
fromi medical coverage, from treatment centres or from shelters
for the homeless.
Research in the USA has indicated that the number who gave up
heroin had increased over several years. The number of habitues
with a marginal adjustment, however, remained more or less
constant. They either continued substance-abuse intermittently or
were institutionalized for illness or crime related to abuse.
The data collected from the follow-up of alcoholics also showed a
similar trend. The habitues, as per the study, did recover slowly
but it could not identify reasons for the change.
NON-PHARMACOLOGICAL FACTORS IN RELAPSE
It is probable that focus on non-pharmacological variables would
enable us to answer some pertinent questions: Why does
addiction begin? Why does relapse occur ? Why does relapse not
occur? These questions might help us to understand the possible
interventions required.
*
Parole and AA do not expect an individual to give up his
addictive behaviour without providing him with an alternate set of
behaviour patterns. The AA methodology which facilitates the
preventive process are: busy schedule of social and service
activities with supportive former drinkers, especially at times
of high risk like holidays. AA encourages its members to return
again and again to group meetings and to sponsors, who provide an
external conscience.
Among both alcoholics and addicts formation of a new relationship
with a non-blood relative was associated with abstinence.
But couples therapy was not particularly useful in facilitating
abstinence among alcoholics. An old dyadic relationship with a
long history of suffering would re-awaken old guilts and old
angers which can be conditioned reinforcers to alcohol abuse.
(Orford and Edward, 1974).
The study among heroin habitues showed that mothers often
gratification through their child's addictive behavior.
gained
The formation of new relationships associated with abstinence
often involved another person's total dependence on the reco
vering addict or a person who trusts him to be independent and
does not nag him on his erstwhile dependence on drugs. This could
be compared with the twelfth step in AA.
membership could facilitate abstinence due
Group
to
the
conversion process which occurred through 'strangely trivial'
significant incidents that often triggered remission (Knupfer
1972). Group membership also provided the 'new non-stigmatized
identity which was cited as important by Stall and Biernacki in
1986. This could not be compared with the study of heroin habitues
at Lexington as they belonged to an historical cohort (1950-1960)
which preceded the popularity of self-help groups and Narcotics
Anonymous in America. In the case of alcoholics among the 29
abstinent for three years or more, 14 had attended 300 or more AA
meetings. Adherence to treatment regimen is at times the result
and not cause of abstinence. It has been documented that when
pre-morbid characteristics of alcoholics are controlled, then
the apparent superiority of various treatment interventions
disappear.
Addiction viewed as a constellation of conditioned, unconscious
behaviour could explain the reason for success of
parole,
maintenance and AA over conventional forms of therapy, Community
intervention can serve to impose a structure in the life of the
habitues. Voluntary hospitalization has not been as effective as
a year of parole. The probable reason for lack of effectiveness
through voluntary hospitalization many be because it occurs in
the presence of many conditioned reinforcers (other habitues,
peddlers, community stress, etc.).
i
If the treatment we offer does not seem to be more effective than
natural healing processes, then there is a need to understand
the natural healing process better.
Since Alcoholics Anonymous and Narcotics Anonymous are
helpful
to alcoholics and addicts in the Judes-Christian countries their
applicability to Indian context cannot be automatically assumed.
Hence we recommend a pilot experimental project. (See Appendix).
5
▼
The fact that relapse can be brought about through icondition
11.1^.. ing
to non-pharmacological factors brings to light the possibilityJ of
return ing to drugs even after abstaining from it for a long
returning
duration.
It is evident that poorly-patterned social behaviour may
contribute
to use or abuse of drugs and that behavioural patterns
that are adopted during the period of addiction could be
associated with relapse.
Factors
that had
restructured
the
hab itu6s
life
in the community such as parole,
methadone
maintenance and AA were able to sustain abstinence. There
is a
need to realize that relapse and not dependence
is the maj or
hurdle.
. The severity of prior-addiction does not predict
relapse,
Individuals who manage to remain drug-free are those who
attained a structured form of behaviour developed alternate
competing source of gratification established new relationships.
Among alcoholics and addicts two or more of the following factors
aid abstinence:
-compulsory supervision
-experiencing a consistent aversion towards drinking (e.g. use of
disulfiram or a painful ulcer);
-finding a substitute dependence to compete with
addictive
behavior(e.g.
meditation, compulsive gambling,
overeating);
-obtaining new social supports(e.g. satisfactory employment, new
relationship)
-inspirational group membership that provide sustained source of
hope, motivation and self-esteem (self-help groups
and religion).
In the USA, a year of parole was found to be effective in the
case of heroin habitues. In fact, individuals who were awarded
<
parole were severe
offenders and their past histories d id not
contain favorable prognostic factors (Vaillant, 1966).
These
successful cases had previously relapsed after other
forms of
treatment.
Parole was not useful as an intervention strategy because
it
offered a form of punishment but due to its ability to alter and
reinforce
habitue's schedule of daily routine. The change may
have been due to:
the
reqpirement of proof on weekly employment,
alterations in the friendship ne two r k,
external source of vigilance against relapse.
Work provides an copportunity for structured behaviour which in
turn interferes with addiction.
I
I
It was found that a jstructured
*
laboratory setting could moderate
...drinking
in alcoholics who,, in a community setting tended to
binge uncontrollably.
• Interventions like AA and parole t
Id. a substitute for d rugs.
provide
In
the absence of competing dependency,, disulfiram alone cou Id
not prevent relapse.
110
i
APPENDIX
ft
ft
i
1
Innediate Objective:
To establish an All-India Association for addicts.
4
OUTPUT
Fornation of All
India Association
for addicts.
ACTIVITIES
Identification of NGOs capable of
functioning in a democratic manner.
Identification of recovering addicts
or ex-addicts interested in bringing
about societal change.
Orientation workshop on global
trends of addiction, global issues denand reduction activities,
legal restriction story of drug abuse,
and other allied social and political
problems.
Selection of any particular field of
action by the participants
Detailed study in the artfa of interest
under guidance of thinkers in that
area such as:
legal problems, drawbacks and merits
of detoxification methods, preventive
measures, rehabilitation processes
etc.
Formulation of an action plan in that
particular field.
Establishing contact with Government
officials and other concerned persons
to bring about change.
Analysis of the utility of involvement
in these activities.
Documentation of various activities
undertaken in different fields.
Modification of the training
methodology if required.
production of pamphlets on their
experiences
Trained individuals who subsequently
sensitize other interested
individuals
Production of a manual on the process
the NGOs who were involved.
▼
I
PILOT PROJECT : FORMATION OF AN ALL-INDIA
ASSOCIATION
OF
RECOVERING ADDICTS
PROJECT JUSTIFICATION :
In India, the management of drug abuse is somewhat new and while
some
projects are good, some are extremely well run
on
professional lines and some are marked by deep commitment. One
also finds some projects are commercial ventures. There is little
public accountability. There is a need for a watchdog body of
committed and informed people drawn from various walks of life.
There is a likelihood of medico-legal problems
and ethical
battles emerging between treatment centres and
enforcement
machinery. Often human rights of addicts are violated blatantly.
The entire ire of society arising out of the addiction problem is
sought to be privatized and the addicts are penalized for the
failures of society to develop a caring community where the youth
feel
they
belong.
Inequalities
and
regional
imbalance
characterize our country where a few lobbies manage to corner the
maximum fruits of all developmental investments.
In either case, the basic reason for supporting recovered addicts
is that they understand the implication of addiction, how society
responds to addicts and how addicts are exploited at different
levels by different groups (from the peddler to policemen and
sometimes even helping professionals).
But it does not automatically follow that recovered addicts
automatically that they are familiar with various approaches to
the management of drug abuse in the world today nor would be all
be capable of assessing the applicability of some of the Western
models or even experiments done in developing countries in this
field as to their applicability to the Indian context. Some of
non-government
them
would need training in management of
organizations (fund raising, accounting, office maintenance.
writing skills, team building ...).
It is in this context that we invite NGOs to innovate in this
regard: One, to set up a national association of recovered
addicts and another pilot project, to set up a fellowship for a
group of carefully chosen recovered addicts which would induct
them to work in the field of drug abuse.
- 113
PILOT PROJECT : ADVENTURE GROUPS
PROJECT JUSTIFICATION
4
> in the field of
An analysis of research studies done by NIDA,
fact that
follow-up and after-care 1brings to the forefront the
of
provision
addiction could be best tackled through the l
competing occupations which could:
- sustain the interest of addicts,
- increase hope,
- eliminate stigmatization of addicts and
- aid their re-integration.
I
f
I
I
1
the
At present preventive measures undertaken do not consider
not
which
is
target
group
various kinds of needs of the
of individuals who have
homogenous. A section of addicts consists
c
have
accepted
addiction as a
rebelled against society and may
means to cope with the stress that arises from an attempt to
assert one’s individuality.
The aim of this pilot project is toi assess the utility of
of habilitation of addicts.
alternate activities as a measure cThere exists such a group begun by some highly talented and
educated youth recovered habitues in South India.
In Thailand, where ex-addicts have been1 attached and subsequently
programs
certified by
L, Universities
---------- - to - take . up . government-funded
------as counselors, the methodologies
adoptedj i___
by j-i
them
are those of the
classical casework and other institutional welfare management
procedures.
There are those who leave drugs on their owni and who, by their
Due to this
own creative methods quit the drug scene altogether.
j--for the management
the repertoire of skills and methods
i------ available
of drug abuse remains restricted.
counselors
ex-addict/ex-alcoholie
of
Case-history analysis
out. The Burnt-out
many of them get burnt out.
have revealed that
1--- --relapse to
Syndrome might express itself in ways other than
drugs (Freudenberger,1986).
; available to a
In India and
-- often elsewhere too, the options
becoming
an
ex-addict
to
recovering habitue is restricted
bring
to
fruition
his own
counselor which offers limited scope to
to
"potentials
in
different
fields.
Even
while
he
choses
innate
limits
work in the field of addiction, the job of the counselor modify
his options.' Self-help groups condition the addicts to
peer
attitudes to
to suit
suit the group-ideology
through
their
attitudes
_l_.j of experiences which create ^uiit and
evaluation, the recounting
conditional to behavior modif ication.
by offering group support
.*
in the
management of drug abuse can be traced to
Poverty of ideas i...
--- -addicts who enter the field as
socialization
of
recovering
such
change agents.
have set up
In those rare cases in India, where ex addicts possible when
UU addlvls,
agencies to cater to
addicts it has been made
sustained
large institutions and powerful contacts have provided -; (such
support to the former• over a period of five or more years
notices the
as Churches, industrial houses, etc.). Even here, one on Western
tendency of these
----- ex-addicts to set up institutions
Models and they
institutions.
become professional
managers
of
estab1ished
are recommended,
It is in this context that adventure groups
four cities to be chosen for the experiment. In each city, a
organization may set up such an adventure group. Membership to
this group should be restricted by precisely laid down criteria.
All NGOs working in the field of drug abuse may select the most
talented social rebels out of their patients and refer them to
the agency running the adventure group(Organizing
Agency).
Naturally, the 0. A. should aggregate compatible individuals into
the group to foster cohesion and other group processes.
The
functions of the Organizing Agency are
a)
To form groups among the selected members of the adventure
group.
b)
To organize group discussions among the members regarding
various group activities, and to analyze the pros and
cons of each option, and to recognise the
implications
of each for all the members and for the organizing agency
in terms of resources to be identified and committed.
c)
To ensure democratic functioning of the
group, lest
its own staff take it over wholly or control the group in
a rigid fashion, holding the whole venture to ridicule by
its members.
d)
To progressively reduce its own role in the
of the adventure group.
e)
Over a period of time, to assist the adventure group to
register itself into a Society with norms developed by
senior members and to continue the activity independent
of the organizing agency.
functioning
The fact that this project is aimed at a particular section of
addicts (who might not be willing to be conditioned totally by
the society), it is vital that the organization selected to help
the group, should consist of individuals receptive to and
interested in alter-native non-conventional activities,
The
members will have the right to put forth their views and modify
the methodology of implementation.
CAVEAT:
At each stage of the process described below, the members of the
action group(may drop out or may have to request those who have
lost interest to quit the program, failing which the group itself
may evict those members.
-
1
Immediate Objective:
To evolve adventure groups for individuals who have rebelled
the system as a specific preventive measure.
OUTPUT
4
Formation of Adventure
groups.
■
I
I
I
against
ACTIVITIES
Identification of recovering addicts
interested in alternate forms of acti
vities in the habilitation period.
Survival training - involving trekking,
hiking, martial arts etc. <NCC or
defense personnel may support this
activity). Others may be interested in
studying philosophy, astronomy, occult,
permaculture, socio-economic cultural
variations in the country, anthropo
logy, etc.
Organizing for this adventure group,
an orientation to the problem of addiction,
the methods of intervention and their
drawbacks. Existing forms prevention and
their possible alternatives.
Activities in which the adventure groups
can be involved are:
|
I
Documentation of organizations working
in the field.
Training the adventure group in societal
analysis.
Interviewing abusers or ex-addicts,
eliciting their views of society, its
institutions catering to maintain the
system and alternatives perceived.
II
i
g
■
3
*1
Analysis of the existing system, its
methodology by which it is sustained,
adapted, how it integrates innovations/
change and how the society pursues some
goals, who sets these goals (Basically
the attempt is to facilitate the members
to take up structural analysis of our
society ) .
Conducting an exercise on "The India of
My Dreams" wherein each of the members of
the adventure group:
Those who show interest specific social
issues will be assisted to undertake a
detailed study of that social problem and
to become an expert critic.
PILOT PROJECT:
A PROGRAM OF SUPPORT TO EX-ADDICTS WORKING IN
THE FIELD OF DRUG ABUSE
PROJECT JUSTIFICATION:
It is well known that recovered addicts have been effective
agents of change in the field of drug abuse in various countries.
too,
In India too,
a few ex-addicts have been assisted by NGOs,
Churches and individual philanthrophists to set up registered
organizations to run services for demand reduction, These ex
addicts have often employed other recovering addicts to run their
centres.
There are several other recovered addicts who for want of min imum
survival support, are unable to put all their skills in the
service of drug abusers. Hehce the present project proposal of
training and fellowship.
However, due to lack of exposure and adequate training
train ing the
predominant model that has emerged in India through ex-addicts is
the residential, high cost, long term, rehabilitation centres.
Suggested Areas for Training Recovered Addicts
Assessment of the pattern of use of drugs in places
study has not already been done.
where
the
Analysis of the treatment history including self-medication,
attempts made in order to tackle addiction through involvement in
various activities or drug substitution.
Identif ication of facilities already available in the field and
organizations involved in other social problems who• can be
facilitated to take on drug abuse related work in <different
capacities.
Documentation
addiction and
the following:
of various action groups in the
other social fields. In order to
field
of
facilitate
Facilitating and supporting action groups who are
already
involved in the field.
The action groups would also
f ield.
be
facilitated to take on preventive work focusing on target groups
such as parents youth and peers.
Introduction
to law and analysis of the jurisprudence of the Law.
Assessment of various vocational training facilities and academic
courses available in the city/area. Identification of alterna
tives possible and expressed ndeds of affected population.
Identification iof the requirements of the high risk population
and to formulate viable
-- -- and
----cost-effective
--------- • preventive measures.
Identification of various youth groups and analysis of their
activities in order to identify the modifications required and
the roles they could play in the field of demand reduction.
Assisting the trainees in the skills required for networking with
other organizations in order to facilitate them to take up
various
demand reduction activities
as
prevention.
such
▼▼
1
4
Some of the areas for foremost National
concern are:
a. Communalism - National integration
b. Development of tribal population
c. Environment
d. Women's development
e. Mass Movements
f. Political economy of drug abuse
and alcoholism
g. Educational system
Each group will be provided clues on re
source perspns/institutions and supported
with necessary assistance for collating,
editing, publishing etc. They would also
be given training in various methodologies
of bringing about social change. Some of
them will be made apprentices with leading
persons working in their areas of interest.
Dialogue with policy makers and
administrators and giving talks, writing
articles in news papers based on their
experience.
Follow up study to assess the extent of
changes in the individual in terms of
assertiveness, optimism, experimental to
use with drugs, use or addiction the
same .substitution of drugs, extent of
impact of addiction on their activities.
Subsequent training and facilitation of
other individuals to form adventure
groups by the trained individuals, the
individual or group will take on specific
activities they are interested in and
establish their own groups.
5l
Setting
(re)habi1i tation.
detoxification,
counseling,
organizations or groups to meet the needs or correct the
that exist.
up new
1acunae
their city
Facilitate organizations to evolve action plans for
in
through discussions with other groups such as; INGOs working
enforcement
1
aw
the field,
concerned government officials,
community support
officials,
legal
advisors, media personnel,
the
affected
groups,
interested individuals from the affected population,
action groups and educational institutes interested in the field.
The implementation of the action plan would be discussed with
individuals
the IGovernment by the NGO representing the group and
these individuals
f romi the affected population. Involvement of
to establish a
wou 1 d empower them to aquire skills required
platform for direct dialogue with government officials.
Training them in the methods of evaluation of preventive measures.
Creating awareness among various target groups such as parents,
1abour unions,
community workers, industrial sectors,
labour
friendsr,
religious heads, educational institutes, policy makers,government
officials, organizations working in related fields, professionals
working
in related fields, media,
law enforcement officials,politicians,
funding organizations, officials of correctional
institutes, administrators of hospitals, action groups,
documen
tation centres, Judiciary, agricultural labourers where opium is
cultivated.
Identification of instructors or training institutes that could
disseminate information,on prevention and treatment.
training
Conducting
instructors.
programs
for
the
instruc tors
of
4
future
Assisting them to evolve different approaches/moda1ities of
psychotherapies (from among the 200 or more schools of counseling
in vogue worldwide today).
Orienting
them to different data sources and methods
of
documentation and generating primary data on drug related areas.
120
L
Immediate Objective One:
To train a select number of ex-addicts in all aspects of
reduction.
OUTPUT
demand
ACTIVITIES
4
1.1 A number of recovered
addicts committed to
work in the field
identified.
Through the NGOs working in the
field, recovered addicts are
identified.
SeTection is made out of them.
1.2 Their current level of
knowledge, skills and
exposure assessed. And
an appropriate training
plan made.
To test their administrative and
organizational skills to run an
NGO
To upraise their understanding of
prevention, treatment and
recovery
process.
To develop a training program.
1.3 A number of fellow
ship established.
To place the trained addicts in
positions of responsibility in
selected organizations.
To provide monthly fellowships.
In the meantime to assist them
to register their own societies.
To assist them in project
formulation.
To assist them in times of organizational crisis.
To act as r'esource persons and
to periodically evaluate their
evaluate their programs.
The subsequent training of
others by the trained persons.
121
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PILOT PROJECT : DEVELOPING PLACEMENT SERVICE
Immediate Objective:
To develop a placement service for addicts.
ACTIVITIES
OUTPUT
Placement service
Analysis of the facilities
existing form of vocational
training technical education,
career opportunities.
Analysis of their utility for
the target population, to
facilitate social re-integration
and the extent to which the
addicts or ex-addicts utilize
them/can utilize them.
Providing career guidance and
job placement after taking due
care to match the patient and
the job,
Identification of addicts with
potential to become social
change agents
>
Placing them with social change
agents such as Sundarlal
Bahuguna, Baba Amte, Narayan
Singh Manaklao, Dr. Arole
and other charismatic leaders in
various social settings.
d
123
.1
PILOT PROJECT : WORK TEAM
Immediate Objective:
To
facilitate the process of rehabi1itation through
in community projects.
OUTPUT
Work team.
invo1vemen t
ACTIVITIES
selection of CBOs or action groups
in project areas.
An orientation workshop for these
groups on various aspects of
addiction, specifically on
rehabi1itation process.
Identification of individuals who
require vocational rehabi1itation.
Selecting a group of individuals
who have been detoxified but lack
skills and qualification which
can aid their rehabi1itation.
Forming the identified treated
addicts into a work team.
Work team develops norms taking
up contracts, roles for each
member towards after care needs
of co-members, norms for division
of profits, wages, attendance,
dismissal of members from the
group, admission of new members
to the group... passing out of
work group.
Identification of community
projects, which are considered
important by the community.
Involvement of the group in the
community projects.
Follow up of these
individuals
after their involvement in the
community project for an year.
Assessment of the intervention
made through systematic documen
tation and by members of the work
team.
Production of a manual based on
the process of intervention.
124
A
<
APPENDIX
A
II
1
I
PILOT PROJECT
: INDIGENOUS FORMS OF SELF-HELP GROUP
PROJECT JUSTIFICATION:
to give up his
Self-help groups do not expect an individual
addictive behaviour without providing him with an alternate set of
The AA methodology which facilitates the
behaviour patterns.
process are:
busy schedule of social
and service
preventive
ac tivi ties with supportive former drinkers, especially at times
high risk like holidays. AA encourages its members to return
of
again and again to group meetings and to sponsors who provide an
external conscience.
The cultural hurdles faced when 'attempting to imitate the West
are the lack of attempt to analyze the adverse impact of alien
language,
the need for integrating the cultural
variation and
philosophy,
utilizing premises other than church settings for
conducting the meeting, the need for understanding the perception
of
the drug abusers about the group meetings. The tendency of
may
Narcotics Anonymous to insist on a total drug—free state,
various
clash with the views held by the target population of
cultural backgrounds.
3
125
Immediate Objective:
To evolve indigenous forms of self-help groups.
OUTPUT
Indigenous forms of
self-help group.
ACTIVITIES
Identification of 2 self-help groups.
Keeping one group as a control
on the classical AA/N.A. model.
group
groups analysis of the experimental
group.
A
studying the culture of target popu
lation, the symbols used, language
idioms, philosophy of life,
life style.
Analysis of philosophy, symbols,
life style emphasized by the
groups. (Observers with expertise in
Vipassana, Indian philosophy, Islam,
and Hinduism.)
Interview addicts who are partici
pating in the group and those who
have left the groups who
discontinued.
Formulating guidelines for the
formation.of a self help group that
is culture specific.
Integrating this variation in the
experimental group.
Interviewing the target population to
assess the appropriateness of the
modifications to be made and documen
ting their views on further change.
Follow up documentation of both the
groups for a year after the changes
are made in the experimental group.
Comparing the utility value of
modified groups with earlier
existent groups.
Training others to develop groups
relevant to the culture.
Documenting NA meetings in 2 groups
for a year.
N.B. The turn over in N.A. r
groups is very high and. principles
of Anonymity have to be maintained.
- 126
I
5
i
ASHA BHAVAN
I
t
is for a minimum period of six
months,
Treatment
at this cen
during which period dr<iv abiiusers live in a secluded and conducive
them to modify unacceptable
environment
aimed at facilitating
behavioral patterns adopted
in addiction.
their
The
staff
of
this centre are selected on the
basis
of
of
interest in working with the drug abusing population. As most
of
them
are
individuals
who
have
had
a
previous
history
the
addiction,
their experience is use—worthy. The
staff
and
extra
affected
population
are
involved in daily
chores
and
curricular activities to promote group-feeling.
rule
The centre
stipulates that motivation is the
ground
for
admission.
Verification of the client's level of
motivation
is
the first step of the program. It does not provide detoxification
faci1ities-medical
management of
the
affected
population
is
carried out in hospitals. The program covers spiritual, emotional
and psychological aspects. Modification of one's belief system is
sought to be achieved through group pressure, loss of
privileges
in
or status within the group, praise, acceptance or advancement
the authority structure within the centre.
Life at the centre may be divided into three stages, In the first
restricted.
stage, the movement of addicts outside the centre is
maintain
they
are not permitted to handle money
or
Second,
terms of
The third stage includes rewards in
contact.
outside
a
short
handle money, to leave the centre
for
permission
to
seeking
patients, however, are
prohibited
from
the
duration,
in
entering
the- academic
stream.
Involvement
or
employment
outside activities is discouraged to maintain their concentration
on themselves.
The follow-up program is dependent on the individual's desire
to
maintain
contact while evaluation of the program is
limited
to
the expressed opinion of the target groups during house meetings.
CALCUTTA SAMARITANS:
The
Arunoday centre in Calcutta is based on the Minnesota
Model
and
hinges
on
the
role of
love
and
affection
within
the
parameters of discipline set by the centre in order to facilitate
the
abuser
to re—discover his identity. Treatment consists
of
detoxification
for a period of upto thirty days
and
subsequent
stay at the centre for rehabi1itation, for six months.
group
therapy,
The
process
consists of individual counseling,
behavior therapy, psycho-drama weekly sessions on rehabilitation
spiri tua1
readjustment
and motivation, occupational therapy and
therapy.
The
his
individua1 is urged to take care of personal
own bed, wash his own linen and to maintain
The printing press attached to the centre.
- 128
hygiene,
make
the dormitory.
the vegetable
garden,
_ J
I
a
small-scale fishery project
painting, clay molding and- other
handicrafts provide different avenues for occupational therapy.
Spiritual therapy includes meditation,, devotional group
activity
and group singing.
I
*
Group
therapy aims at facilitating individuals to explore
their
experiences
and
associated
feelings so as to
gain
a
better
insight about themselves.
These exercises assist them to analyze
a particular attitude or impression that surfaces in a given day.
Behavior
therapy and psychodrama are used to
inculcate
respon
sible behavior patterns which exclude the portrayal of dependence
on chemical substances.
The centre feels that a relapse to drugs (specifically to heroin)
can
be prevented through abstaining from nicotine and all
other
forms of drugs.
In order to facilitate integration with 'society', the
recovered
habitues are encouraged, in the latter part of the rehabi1itation
to assist in a school for under-privi1eged children, or in a home
for
abandoned boys and to
take to recreational
activities
and
games.
DELHI POLICE FOUNDATION:
The
Delhi
Police Foundation for
Correction,
De-addiction
and
Rehabi 1itation
(DPFCDR), established Navjyoti clinics at
police
stations
to
detoxify habitues in order to decriminalize
them.
These centres cater to youth in Delhi and the suburbs.
Their process consists of detoxification, rehabilitation and
reintegration
of
the individual in society.
The
individual
is
fac i1i tated
to establish positive and constructive
relationship
with his family and restablish
his
career.
The centre utilizes Allopathic and Homeopathic medicine,
recreational activities.
Yoga and
The
follow-up process is carried out by Special Police
Officers
(i.e.
members of the public who volunteer to assist Navjyoti
in
its after-care work) through home visits. If the habitu£ does not
report
to the centre, Navjyoti sends out a post card asking
him
to repor^ regarding his well-being either personally or by
mail.
Coming
from a police related centre, the rate of
compliance
is
rather high.
KRIPA FOUNDATION
Kripa has adopted the Minnesota model (Hazelden) for the
treatment. Two of its centres use this methodology.
purpose
Admission to the program is scheduled for a specific month of the
year. The entire treatment process continues for a minimum period
of
12 months. The in-patient program and preliminary care
1 asts
for
a
period
of three months.each
with extended
care
being
provided for six months.
The program is based on spirituality, discipline,
129
group cohesive-
<4
i
a
sharing of individual experiences and restricted
contacts
ness,
family
members.
The influence
of
external
stimuli
are
with
controlled through limited reading materia1(handbooks and related
literature on AA and the NA magazine "Grapevine"). The individual
is ’’taught" to be satisfied with his or her life. The program al
so involves Rational Emotive Therapy' and spiritual
disciplines
like 'Yoga' and 'Zen'. The Kripa Foundation collaborates with
an
employment assistance scheme.
program intends to instill a feeling of se1f-worthiness
and
The
the process of social
reintegration.
faci1itate
Counseling
to
are
sessions
aimed, at identification of personal
problems
and
behavior patterns. Family service is conducted once
modifying
a
dependence of 'even one
person
week 9
as chemical
affects
the
family. After completion of the year—long treatment,
entire
the
individual
is
expected to continue his or her participation
in
NA meetings for life.
r
not
Kripa
has
yet undertaken any long
term
follow-up
activity
is dependent wholly on the
subsequent involvement in NA and AA meetings.
i
evaluation.
ex-inmates'
The
own
MANAKLAO TRUST:
■
L
’
I*
<
a
4
Opium
deaddiction
Treatment,
Training
and
Research
Trust
(The Manaklao
Trust) emphasizes
community-based
therapeutic
approach with detoxification.
The
individual is viewed as
a
product of the cultural
socio
psycho-economic
environment.
environment.
Elimination
of
addiction
is
undertaken in this framework. Addiction is viewed as conditioned
behavior
which
is
sustained
through
the
behavior of
the
individual and his interaction with the society.
They
feel the major causes for addiction in certain segments
of
the
affected
population
are
: lack
of
faith
in
humanity,
rebellion
against the hypocritical,
seif-centreed,
competitive
and
mechanical life style of the present society. The
important
factors that might have contributed to the spread of addiction in
Rajasthan
are:
the
social sanction for
consumption
of
opium
during
rituals like birth, death, festivals and soon the
belief
that it is impossible to give up addiction, utilization of
opium
to increase the number of hours of work of agricultural labourers
by
rich
farmer^
and
public
works
contractors;
paucity
of
remunerative
occupation
for
a
large number
of
agricu1tura1
labourers
in
the
desert
conditions
that
mark
the
Western
Rajasthan
Thar
region, the habit of mothers to ingest
or
feed
opium to the infants when they go to work in order to put them to
s1eep.
Apart
from
the treatment centre at Manaklao, mobile
camps
are
organ i zed
in
order to treat patients in their own area
and
to
organize
support groups. Community surveys have
been
undertake
done
to
assess the availability of volunteers
compatible
with
varied
ethnic
and religious community
groups
of
habitues
in
order to enhance the effectiveness of change agents.
Candidates
for
the camps are selected on the
basis ’ of
their
will ingness
to discuss their addiction and associated
problems.
130
nurses, social workers, community
Physicians,
psychiatrists,
workers,
ex-habitu£s,
parents and friends participate on a
voluntary basis during the camp, A trained nurse provides medical
care at night.
During the detoxification camps the organizers provide emotional
support which they perceive as one of the major factors for
Besides detoxification which
consists of
preventing relapse,
they
giving tranqui1izers to deal with symptoms of withdrawal,
conducive
utilize
’hug therapy'
to create an
emotionally
environment of acceptance and love.
I
(consisting
After the withdrawal symptoms subside, music therapy
activities
are
of folk and devotional songs) and recreational
utilized to maintain the drug,free state.
At the end of the ten-day camp, the individuals are obiiged to
support groups
take a vow to abstain from drugs and the local
give them encouragement and facilitate their re-integration into
society. The support group continues to provide positive peer
pressure even after discontinuation of the treatment, by warning
ex-habitu^s not to participate in opium-offering ceremonies.
first of the approach of the Manaklao Trust is
dependent upon the charismatic, affable and dynamic
of the Director, Padmashree Narayan Singh.
The
principally
personality
However, in the post-detoxification phase, the Manaklao system of
habilitation tackles structural issues in the villages and hinges
on the priests and leaders of caste associations to de-legitimize
opium drinking and to ban the public serving of opium during
religious ceremonies and social events in their respective
vi1lages.
4
Under the UNFDAC - GDI scheme to support NGO projects in demand
an integrated comprehensive, district-wide commun i ty
reduction,
proj ect is being set up which would not uproot the addict from
his social mi-lieu at all, but would have activities covering the
entire spectrum of demand reduction activities.
(For further details contact: Opium De-addiction and Counseling
centre, Rajdadi-ji-ka-nohara , Inside Sojati Gate, Jodhpur,
Raj asthan .f)
Under the same UNFDAC - GUI scheme, in the urban context, the Dr.
Vidyasagar Kausha1yadevi Memorial
Health centre in Delhi is
developing work teams for vocational rehabi1itation of addicts as
part of community — based integrated demand reduction project.
(For further details contact; Dr.
Vidyasagar Kaushalya Devi
Memorial Trust, Nehru Nagar, New Delhi - 110 065.)
T.T, RANGANATHAN PROGRAM;
TTR
Hospital
has adopted a residential
mu 1ti-disciplinary
therapeutic program to tackle the problem of addiction.
Addiction is viewed as being a chronic and progressive
that leads to physical, emotional and social problems.
131
disease
’<1
The program is tailored to achieve the goals set by
the
centre
namely,
to attain total abstinence from alcohol and drugs
for
1 e and to instill positive changes in the behavior and
the
attitudes of the patients.
I ■
■ f
The treatment program which lasts from
four
to
six weeks
provides medical
help for physical
addiction and associated
problems. A therapeutic program for psychological problems
consists of individual counseling, lectures, group
<
therapy,
relaxation techniques,
recreational activities -and1 educative f i1ms.
Individualized care and attention are provided.
lr
A
follow-up program is maintained for a period of five years
..rOU?^ Participation in after-care programs held every week
at
the hospital,
visits to their doctors or counselors
within a
period of fifteen days in the initial stages and monthly followup visits after three months.
f
The «social support program of the centre aims at exploring the
exploring
possible support the recovering patients could receive from the
society m their process of recovery. The contact with support
people, family members (other than the spouse) with co—workers or
with friends facilitates in establishing recovery
and ensuring
regular follow-up.
I
The hospital also has a two-week program for the family,
based on
the concept that addiction is a "family
that
family illness
illness””
that affects
members of the family apart from the
concerned individual.
The
program provides necessary information
to the parents while the
therapistsj provide them with emotional support to
• cope with
stress when dealing with addicted
individuals,
The program
consists of
lecture sessions, group discussions, assignments,
relaxation techniques and AL-Anon.
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