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Dr Shanthi Ranganathan

Treatment services and strategies

Dr. Shanthi Ranganathan
T T Ranganathan Clinical Research Foundation
“TTK Hospital”
Indira Nagar, Chennai

Abuse of alcohol is not a problem restricted to metro and cities, it is also rampant in villages and in smaller towns. There is an increased incidence of multiple addiction and incidence of HIV is also high among them.

Uniqueness of this problem
The need for treatment is not widely known or accepted due to denial of the problem by the client and his family members. Unlike other illnesses, not only the addict but other family members are also affected psychologically. A condition where relapse is not uncommon, the clients and their family question the efficacy of and the need for treatment.

Availability of treatment
In India, the Ministry of Social Justice & Empowerment coordinates the treatment and rehabilitation services. Around 393 treatment-cum-rehabilitation centres and 53 counselling and awareness centres are offering services all over the country funded by the Ministry of Social Justice & Empowerment. 100 centres have been empowered to provide preventive support for HIV-AIDS. 15 workplace prevention programmes have been set up in industries and enterprises.

For the first time in social service practice, minimum standards of care to be complied with by the NGOs who are providing rehabilitation services have been introduced. To help the NGOs to follow minimum standards of care, eight Regional Resource & Training Centres have been established in the south, north, east, west and north-east. The responsibilities of the Regional Resource & Training Centres are:

Providing training to NGOs working in this region and helping them improve their quality of service and comply with the minimum standards of care;

  • Preparing training materials in the form of manuals;

  • Undertaking research activities and documenting them;

  • Monitoring drug abuse situation in this zone.

Treatment – Research Findings
Cost of untreated addiction due to morbidity of people of working age, drug related crimes and health care cost are substantial. These expenses are a great burden to the government and society. Hence, treatment interventions are more cost effective than the non treatment criminal justice system.

The theme of United Nations Office on Drugs and Crime for the International Day against Drug abuse and illicit trafficking for the year 2004 was “Treatment Works”. Patients in treatment either reduce or stop alcohol and other drug use. They also make positive changes towards physical health, psycho social functioning, stability in employment, reduction in criminal justice involvement and prevention of relapses.

Principles of effective treatment – NIDA
The National Institute on Drug Abuse USA has recommended the following principles to ensure effective treatment and rehabilitation services:

  • No single treatment is appropriate for all individuals. There is a need to offer a range of services based on individual needs;

  • Treatment needs to be readily available;

  • Remaining in treatment for an adequate period of time is critical for treatment effectiveness;

  • Treatment does not need to be voluntary to be effective;

  • Medical detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug use;

  • Addicted or drug abusing individuals with coexisting mental disorders should have both disorders treated in an integrated way;

  • Counselling and other behavioural therapies are critical components of effective treatment;

  • An individual’s treatment and service plan must be assessed continually and modified as necessary to ensure that the plan meets the person’s changing needs;

  • Possible drug use during treatment must be monitored continuously;

  • Treatment programme should provide assessment for HIVAIDS, hepatitis B & C, tuberculosis and other infectious diseases and counselling to help clients modify or change behaviours that place themselves or others at risk of infection.

  • Recovery from addiction can be a long-term process and frequently requires multiple episodes of treatment.

Addiction treatment needs to be structured in a way that addresses the wide range of issues. Mann (1991) described the principles of treatment succinctly:

Treatment does not cure the disease. The expectation is that, by instituting an achievable method of abstinence, the condition will be put into remission;

All therapeutic efforts are directed at helping the client reach a level of motivation that will enable him / her to commit to abstinence;

An educational programme is necessary to make the client familiar with the addictive process, giving the individual an insight into compulsive behaviour, medical complications, emotional problems and maintenance of physical, mental and spiritual health;

Group and individual therapy are directed at self understanding and acceptance with emphasis on how drugs have affected the client’s life;

The client is indoctrinated into the self-help programmes (AA/NA) instructed about the content and application of the 12 steps of the programme;

The client’s family and other significant persons are included in the therapeutic process to make them understand the problem of addiction and the support they must extend to the client;

Insistence on participation in a longitudinal support and followup programme based on the belief that, as in the management of all chronic disease processes, maintenance is critically important to the ultimate outcome of any therapy.

The popular model of treatment available in India
In India, the majority of the treatment centres provide residential care for a period of 21 – 30 days. Both detoxification and psychological therapy are offered as part of treatment. Some of the components of therapy are reeducative sessions, group therapy and individual counselling. In reeducative sessions, information and practical guidance on addiction, relapse and recovery and issues related to qualitative sobriety are provided. Group therapy is the most important therapy in treatment. Open sharing / mutual understanding and support are the benefits. Individual counselling is provided to deal with personal issues and developing an individualized treatment plan. Some of the goals of individual counselling are developing a therapeutic relationship and strengthening the motivation; assessment of addiction and related problems;identifying needs and resources; helping to develop recovery plans and support in sustaining recovery.

The need for family therapy
Addiction has an impact on each and every member of the family. In the process, trust, love, respect and cooperation are eroded. There is no healthy relationship between husband and wife, parent and children. There is emotional, financial and social damage. A series of escalating crises intensifies over a period of time and reality is denied by blaming, rationalizing. This results in responding to the problem inappropriately and developing co-dependency traits.

Family support is the greatest asset India has.
All treatment centres provide family programmes of short duration. The goals of family therapy are to provide information about addiction and its effects on the family system; help the family understand their inappropriate responses and deal with their defects of character; to provide a safe and acceptable environment for the family to discuss and deal with their problems; to improve interaction among family members; to equip parents with the skills needed to raise adolescents / to improve marital relationship.

The family programme components are re-educative sessions, group therapy, self-help group meetings (Al-anon) and counselling.

Follow-up is an important aspect in the rehabilitation of addiction. The goals of follow-up are to enable clients attain whole person recovery – alcohol / drug free, crime free, gainfully employed and having a healthy family relationship. Followup also helps clients who have had relapses and to assist family members in their own recovery.

Some of the components of followup are medical care and counselling client and family members: Relapse Prevention Programme; self-help groups, home visits and other methods of communication are also used to provide support to clients who are not regular for follow-up.

Factors facilitating recovery

  • Group setting contributes to deeper understanding of the problem and enables support from one another.

  • Medical and psychological issues handled.

  • Structure provides discipline andopportunities to take up responsibilities.

  • Offering emotional support to family members and motivating them to provide support during recovery.

  • Long-term follow-up and recognition of sobriety by awarding medals.

  • Specific programme to deal with relapses.

  • Taking efforts to contact patients who do not turn up for follow-up.

Strategies for improvement

  • Community approach of treatment which is cost effective to be promoted in villages / small towns.

  • Accessibility of treatment through primary health centres which are available in the entire country.

  • Availability of flexible treatment modalities to suit individual needs by networking with other NGOs. Longer treatment for patients with psychiatric problems, poor social support, lack of employment. Longer retention in treatment through short term in patient care followed up by out patient care in the community.

  • Incorporating relapse prevention and long term after care services into existing programmes.

  • Opportunities for vocational rehabilitation / training.

  • Medical insurance to cover treatment cost.

  • Organising regular training programmes to upgrade the knowledge and skills of staff.

  • Documentation and evaluation to be made essential components.