MANAGEMENT OF ALCOHOL DEPENDENCE:

A COMMUNITY BASED MULTI -MODEL APPROACH

L. Sam S. Manickam

  Introduction
  De addiction Centres
  Counseling Centres
  Treatment Models
  The Vellore Model 
  Bodhi Experience
  Extension to the Community
  Social Support Person and the Community based Model
  References

Introduction

Alcohol and drug abuse has been showing an increasing trend in India. However, there is very little systematic data on the extent of use and abuse of alcohol. National Sample Survey data is the only available data source for a countrywide analysis on consumption of alcohol. The NSS third round (1987-1988) provides details of number of households consuming alcohol beverages per thousand households state wise (Sarvekshana, 1991). These data are based on the response of the households to the question whether the household consumed alcoholic beverages on the month of survey. The data do not provide details on the quantity of consumption. But it gives an idea of the percentages of households consuming alcohol beverages. It appears from the NSS data that only four in rural areas and one in six or seven in urban area are given to drinking.

In Kerala, a comprehensive health survey was conducted in rural villages in 1987(Kannan, et. al.1991). It showed that among male population above the age of 15, 10.1 % were using alcohol less than 10 days in a month and 8%were abusing alcohol more than 10 days in a month. Together it constitutes 18.1% of the total male population.

Only 104 women, ie.0.5 % is in the habit of using alcohol. Though the number of women addicted to alcohol is very low in rural areas, in cities, there is an increase in number of women who seek psychiatric help (Selvaraj, et. al., 1997). None below the age of 15 reported using alcohol. Mattoo and Basu (1997) also observed that the first drink of the dependent persons is above 19 years.

Considered against the popular impression of widespread and growing practice of drinking, the above survey figures appear to be underestimated. The number of people who would admit to consuming alcohol is usually low, for various reasons. Hence the magnitude of the problem is much more than what is projected.

 

De-addiction Centers

Considering this fact, the Ministry of Health and Family Welfare, Government of India, sanctioned de addiction centers in different parts of the country in 1988 (Manickam, 1994). The number of centers in 1988 was 18 and in 1998, there are 121 centers. In Kerala in 1988, there was only one centre and in 1998, there are 20 centers. Each centre has bed strength of 15 with additional facility for another three for relapse persons.

The total number of bed strength available at each centre for a year would depend on the number of days of stay of each person at the centre. Generally, each patient stays at a centre for 18 days. The approximate number of people being de addicted would be 255 in a year at one centre. Through all the centers, the number of people de addicted would be 308557. The facilities available at these centers are for a population of more than 90,00 Million, of which around 18 million are using or abusing alcohol. This figure does not include the drug addicts.

Apart from the de addiction centers referred above, both private and government mental health centers do help those who abuse substances. However, the number of centers and the effective bed strength of these places are difficult to gather due to the following reasons:

  1. The centers mainly treat people with mental disorders. Hence, the number of people who undergo treatment for substance abuse may vary.
  2. At present there is no system of collecting data of those who seeks treatment for alcohol related problems at the district or state level.

The figures show the extent and intensity of the need and the availability of services.

 

Counseling Centers

These centers are exclusively for the people who abuse the substances. The number of counseling centers in 1988 in the country was 15. In 1998, there are 217 centers in the whole country. In Kerala, in 1988 there was only one centre and in 1998 there are 19 centers.

Each Counseling Centre has 2 psychologists and 2 social workers. Some of the centers are given a vehicle for community extension work. The counselors have to visit the families of those who are de addicted, visit the dropouts and relapsed persons. In addition, they visit the community to motivate people who are addicted to seek treatment, and they organize prevention programmes in the community.

 

 

Treatment Models

Each centre has developed treatment packages for themselves.

TTK Model, Chennai, South India (Cherian, 1986)

TTK hospital Chennai, (Madras) had done pioneering work in de addiction in the country. This is a private centre, started as six bedded centre and now has facilities for about 45 patients.

TTK Hospital offers a comprehensive in-patient treatment programme. It also includes the involvement of the family of the addict. The treatment programme includes detoxification, intensive psychological therapy, and follow-up. Detoxification is for a period of 7 to 10 days. After detoxification, the patient undergoes an intensive 3-5 week, in-patient therapeutic programme at the hospital. Apart from individual counseling, the treatment package includes lectures, group and family therapy, dietary counseling, relaxation techniques and recreation.

This centre has also developed a day care centre for alcoholics (Cherian, 1986). In addition it started camps for the detoxification and care of persons with alcohol dependence in the sub-urban villages of Tamil Nadu. (Murthy, 1992).

NIMHANS, Bangalore.

This centre has developed two models.

 

  1. Behavioral Model ( Prasadarao &Mishra,1994 )
  2. The behavioral model is based on learning theories, which states that all behavior is learned one. Addictive behavior is a learned one and hence it can be unlearned. The behavioral model envisages multidimensional therapeutic programming at the physical, psychological and social levels. The treatment programme concentrates on the antecedent cues and maintaining factors. Behavioral procedures used in the broad spectrum treatment programmes include relaxation, aversion therapies, covert sensitization, self-control training, social skills and assertiveness training and contingency management.
  3. Behavioral counseling to significant others is also an essential part of the package. This ensures modification of reinforcement pattern to provide adequate positive reinforcement contingent upon the individuals sober behavior.
  4. Medical Model (Murthy & Janakiramaiah, 1996 )

The medical model essentially involves admitting patients to the de addiction centre, and detoxification. Counseling is also an important component of the treatment programme.

NIMHANS also collaborates with voluntary agencies in the community. With the agencies' co-operation, they initiated once a week service to the community. A team of mental health professionals visits the villages for education, counseling and community level care, and action. The target population was mainly those with early features of dependence.

Camp Approach (Murthy, 1992)

In the North Indian states of Rajasthan, at Jodhpur, a community-oriented approach was initiated about 15 years ago. The programme is primarily for opium dependent people, since there is a widespread use of opium by a large proportion of population. The camp lasts for 10 days. About 20 to 30 individuals who are motivated to give up opium are kept in a local school or local building and detoxified initially in a group setting. Group discussion, inspirational talks, and final oath taking to give up the drug use follow this. This programme is cost effective since local resources are used and volunteers are mobilized for conducting the camp.

 

The Vellore Model (Manickam & Kuruvilla, 1990)

This model is based on a multi modal approach. This is essentially a hospital-based model. This model has the following components.

Initial Assessment:

The initial assessment focuses on evaluating the psychiatric status of the patient.

Assessment of motivation

Admission to the mental health centre with spouse or significant relative.

Detailed physical examination and investigations.

Treatment of concomitant physical illness, if there are any significant findings.

If the physical status is satisfactory and if the patient and the family are well motivated, the person gets admitted. The person has to stay for a period of 35 to 45 days.

Detoxification

Most patients do show significant withdrawal symptoms on cessation of alcohol at the time of admission. In such cases, appropriate medications are given to control the withdrawal features. Depending on the duration of drinking and the period of abstinence, the medications are tapered off over a period time, which are usually ten to fifteen days. Once the withdrawal symptoms are controlled, the patient and relatives have a tendency to leave the treatment programme. Therefore, at this stage the patient and relative have to understand that detoxification is not ‘the’ treatment of alcoholism and all that detoxification does is to prepare the person to begin the recovery process.

The different modalities of the package include the following therapies

Individual psychotherapy. Each patient gets around ten sessions of individual psychotherapy.

Family Therapy is provided depending on the need of each individual client.

Group therapy

Though group therapy is an effective method in counseling and providing support to the alcohol dependent persons, it could not be provided to all those who were admitted. In the thirty-five bedded psychiatric set- up, the number of patients who are admitted for the dependence problem is often below five. However, if sufficient number of patients are available, the group functions by including those who are outpatients and who are in the process of recovery. Though group therapy is of great help to the recovering persons, in Vellore situation, it did not work, since most of the patients come from different parts of the country, quite far away from the centre.

Behavioral Strategies

  1. Relaxation training:
    According to learning theories, alcohol pharmacologically reduces conditioned anxiety .In order to get quick and temporary relief of anxiety, many persons use alcohol. Kinney and Leaton (1979) have observed that a recovering alcoholic is likely to face a high level of anxiety. It can be of temporary nature, the initial discomfort with his non-drinking life or a more chronic one, if he is an anxious person. In order to alleviate this anxiety, relaxation training is taught. Once the person learns to relax by self, he or she is asked to practice it everyday. On mastery of relaxation technique, it becomes easier for the person to achieve the relaxation response, which can be called at will. Rather than resorting to alcohol, the same response can help to deal with situations, which provoke anxiety in day to day living.
  2. Aversion Therapy:
    Another behavioral explanation given to alcoholism is that it is a conditioned response associated with a pleasant experience. Therefore, using counter conditioning, alcohol is associated to an aversive event or shock. Different types of aversion therapy including chemical aversion are tried out in different treatment centres (Chakravarthy et. al., 1990). In Vellore setting, the patient has to sip the alcohol. When alcohol is in the mouth, the patient gets battery- operated mild electric shock of 9 volts. The patient spits out, when the aversive stimulus is above his threshold and simultaneously the electric shock is stopped. Using patient’s choice of drink, the patient gets about six to eight shocks in each session. This procedure continues for 21 to 28 sessions, depending on individual patient.
  3. Cue Control:
    A careful behavioral analysis of the person’s pattern of drinking helps to identify the cues, which lead one to drink alcohol. Helping the person to break the habitual pattern eases stress and helps achieve the objective of avoiding the drink. Alternatively, in the presence of cues, the person is trained to generate and perform alternate activity to avoid these cues. Identification of all such cues and handling them result in bringing about significant changes in the daily style of living (Prasadarao &Mishra, 1992).
  4. Covert Sensitization:
    The therapist encourages the patient to imagine a typical drinking situation. As he imagines, the therapist verbally describes to the patient an unpleasant scene, like the patient having nausea and vomiting. The pairing of the unpleasant scene with the imagery of his drinking behavior creates unpleasantness to the latter. The patient learns to use the same procedure to handle the cues, which stimulates a drink.

Occupational Therapy

During the stay in the hospital, the patient and spouse or relative attends the occupational therapy department. In the initial day of recovery, the alcoholic needs his environment to be simplified. In occupational therapy, the patients choose a simple yet creative work, and the occupational therapist supervises the activities. Sometimes a group of alcohol dependent persons takes up a common project, which ensures the participation of all the members. The members attain the ability for accepting each other member and get an opportunity to interact with others. It also helps in developing social skills, decision making, and implementation of assigned tasks and opportunity for recreation.

Drug Therapy

Disulfiram (Esperol) is administered at the end phase of the stay in the hospital. After careful review of the physical status and the liver functions, discussion focuses on initiating disulfiram therapy. After signing the written consent form for administration of the drug by the patient and spouse/relative, an initial dose of tablet Disulfiram 500mg per day is administered for two days. If there is no adverse reaction with the initial dose, it is reduced to 250 mg. per day and is maintained for a period of one to two years.

Follow-up care

The patients with their spouses/relatives are asked to come for follow up counseling once in a week initially. Depending on the maintaining factors of sobriety, the interval of visit to the centre is increased. If the patient is coming from far off places, information about social support networks around their place of stay are given and they come for review after 1 or 2 months, depending on the distance.

At Vellore, the follow up rate was very poor. The reasons are,

  1. The patients and relatives expect an abrupt and radical cure.
  2. The patients have less knowledge about alcohol dependence and the process of recovery.
  3. The patients come from far off places.

However, the model developed at Vellore was instrumental in formulating the treatment package for the de addiction centres in Kerala.

 

Bodhi Experience.

Bodhi De addiction Centre was started in 1988, by the voluntary agency, Abhaya in Kerala. This is a 15-bedded de addiction centre, funded by the Ministry of Welfare, Government of India.

Intake Counseling: During intake, the focus of assessment is on the motivation of the patient to give up drinking. Arrangements for detailed physical examination by a physician ensure attention to patient’s immediate physical problem. Moreover, laboratory investigations aid this process. Admission to the centre is confirmed only if,

  •  
    1. The patient is free from any major physical illness, which requires immediate attention. 
    2. Free from overt psychiatric disorder. 
    3. Motivated to stay as inpatient for the stipulated period of 19 days. 
    4. The patient’s spouse or if unmarried, a significant relative visits the centre and consents to stay with the patient throughout the inpatient treatment period and
    5.  Abide by the rules and regulations of the centre during the stay.

     

    The Setting.

    A batch of fifteen patients with their spouse or relative is admitted at a time. The inpatient stay is for a total of 19 days. The patient and the spouse are to stay in the centre until the completion of the inpatient treatment programme. However, the patient is not permitted to go out of the campus during the treatment programme. The patient and spouse/relative are given the choice to accept the treatment offered. Conforming to the whole package is the first learning experience of every patient. However, they are free to leave the treatment at any moment.

    Family Context as the Base.

    Involvement of the family in the inpatient treatment of various psychiatric disorders have very good impact on the course and outcome of the illness (Varghese, 1988). In the Indian setting, the therapy can be envisaged only in the context of family, in most situations. Bhatti (1982) observed that alcohol dependent persons’ family needs treatment as much as the person who is addicted to alcohol does. Surprisingly, in many cases we experience resistance to family therapy either from the patient of from other members of the family.

    The patient and the spouse living together though for a short span of time, creates a sustained environmental context for learning and change. The situation in addition provides opportunity for resolving the interpersonal conflicts through community nurturing, empathic understanding and control of personal behavior. The atmosphere thus generated within the centre encourages self-disclosure.

    The mini community formed within the centre though lasts only for a short period provides encouragement support and reward for desirable behavior. The family-like community often gives shelter to each individual and at the same time helps to confront personal behavior which could hurt the spouse or any other member staying within the community.

    Distancing themselves from the routine of alcohol abuse in an environment free of external cues helps them to reflect in a different perspective.

    Treatment Package

    The treatment package involves detoxification, individual counseling to patient and spouse, marital counseling, group therapy, and disulfiram therapy. If there is need, the patients undergo family therapy also.

    On admission, the patients are given drugs to take care of the withdrawal features. Usually it takes about a week’s time for the patients to get over the withdrawal features. However some of them take more time and they are given the drugs to get over those.

    Individual counseling

    Each patient gets around ten sessions of individual counseling. Initial session aims at finding out the problem areas of the person. Though the patients discuss various family related problems, some of them are rationalizations, to continue their addictive behavior.

    Structuring of the therapy depends on the assessed problem areas of each person. The problem areas assessed are, physical, psychiatry, personality, personal, marital, sexual, family, social, occupational, economical and spiritual.

    Most of the patients do not know that addictive behavior is a disorder (Rao et. al., 1988). Many are unaware of the health hazards that are caused by prolonged intake of alcohol. The patients’ knowledge, if not adequate, imparting information on the above topics is important.

    Some patients report that their drinking is related to a chronic physical problem they have, which they never thought of revealing it to their physicians. In such cases they are prepared for a consultation.

    Past history of affective disorders if found to be associated with drinking, the information on early signs and symptoms helps the person to consult psychiatrist or mental health professional at the early stage. Co morbid disorders like, schizophrenia, paranoid disorders or delusional disorders and other major psychiatric disorders may surface on withdrawal of alcohol. Kannappan and Cherian (1989) observed that the dependent persons have elevated extraversion and neuroticism traits. Other minor disorders like anxiety disorders, phobic disorders, psychosomatic disorders and other disorders if found are referred for further psychological help.

    Identifying the concomitant personality disorder helps to refer the person for further psychological help or aid in setting the counseling limits.

    Though the individual counseling is not psychoanalytically oriented one, defense mechanisms shown by the patients are carefully dealt with. Denial of their own addictive status and physical health extends to other problems existing in life. The family bonds in our cultural setting are strong. Therefore, the relatives both in the immediate and distant circles are involved in decision making process of the individuals' life. The usual tendency of the patient’s relatives is to force him to face all the facts immediately. The relatives do not realize how painful it is for the alcoholic to look at his own drinking behavior and its consequences. The therapist or counselor deals with this conflict of the patient carefully without provoking undue anxiety in the patient.

    In the personal area, the common problems experienced are guilt, self-blame, inadequacy to control one’s own emotions, passive dependency or excessive independence and not having the sense of ‘real time’.

    It is desirable to mitigate the degree of both guilt and self-blame. However, it is also necessary to avoid the other extreme, rejection of social values and blaming others.

    The therapist helps the person to recognize his emotions and to deal with them appropriately. He needs to learn or relearn that feelings need not be repressed altogether or widely acted out. Recognition and acceptance of the emotions can help develop a healthier reaction.

    A person who has strong dependency needs may resolve his conflicts by resorting to alcohol. Making the person realize this, may help him to find alternate source of meeting his dependency needs. Alternatively, it may be because of his stubborn independence that he resorts to it. In such cases, the person has to realize that every one in the society is interdependent.

    .

    Social problems are related to the individual’s place of living, how the society perceives the individual and how the person perceives the society. Some of them are related to the person’s faulty perceptions while some others are real. The caste structure and the interpersonal relationship based on the caste structure are sometimes stressful for the person and the family. The conflicts related to this problem, the person acts out under the influence of alcohol.

    Problems in occupational area are related to incompetence, sidelining, not getting the promotions for government employees. For the seasonal workers like the fishermen have no alternate work or the middlemen exploit them and it is difficult for them to cope with the situation.

    Sexual problems if identified are referred to counselors who are competent to care. Since long dependence of alcohol can produce sexual disorders, the clients are taken up for the therapy, only after a period of three or four months of abstinence.

    Economic problems are either due to their own drinking behavior or those could have been caused otherwise. Upsets in business, loans and debts incurred, as a result of poor planning or extravagant spending of money requires attention.

    Some of the problems do overlap. Dowry related problems, leads to marital and family problems. Or, money lent by the woman’s family spent unwisely by the man’s family leads to unrest in both the families.

    The spiritual dimension

    The spiritual dimension of the clients requires attention. This aspect assumes more importance if the person’s conflicts are related to the spiritual dimension (Manickam, 1992). During the stay at the centre the clients get the opportunity to take part in prayer meetings. Clients of different faith participate in the prayer meeting.

    During individual counseling, discussion centres on participation in religious activities like attending the worship and prayer meetings with family members. Adopting this has helped many clients to achieve change in life style more effectively. People from Hindu faith, some of them begin attending the place of worship. Similarly, people from Islamic faith, begin their daily prayers and attend the worship. Christians, some of them restart attending Sunday worship and start taking part in various church related activities. Clients who were atheists have started attending religious programmes.

    However, during individual counseling if the clients’ problems are found to be predominantly in the spiritual area, that the counselor cannot help out, they are referred to religious counselors or authorities of one’s own faith.

    Group therapy

    The Groups

    The patient group meets for twelve, 75 to 90 minute sessions. In two of these group sessions spouses /relatives are included (orientation group and disulfiram therapy group)

    A therapist and co-therapist, preferably of the opposite sex conduct each group. The seating arrangement is circular, the therapist, and the co-therapist occupying opposite seats; this placement of the therapists facilitates group communication.

    Orientation Group

    The orientation group meets in the first week of stay, i.e. during the period of detoxification. In this session, emphasis is on regulations to be followed in the hospital, which were explained to them at the time of intake. Need for co-operating with staff at the centre and keeping the time schedule are pre- requisites for successful completion of the treatment programme. Briefing about the different modes of treatment in the package ensures the support of every one staying at the centre.

    From the second week of stay, patients and their spouses are to take up handicraft of their choice, preferably a joint activity involving both the patient and the spouse. Engaging in some useful activity provides the opportunity to utilize the daytime effectively and facilitates communication between the patient and the spouse. (Manickam & Kuruvilla, 1990).

    Disulfiram Therapy group

    Disulfiram therapy group meets in the third week of stay and the psychiatrist or the physician conducts the group along with a co-therapist. Explaining the actions of the drug, precautions required, and the procedure to be followed in case of alcohol intake or allergic reaction helps both the patient and spouse in case of emergency. Patients who had earlier undergone disulfiram therapy are helpful while discussing the limitations of the drug.

     

    Therapeutic Groups

    Twelve major topics or areas are covered over the ten sessions. These areas were identified based on the experience at Vellore and the discussions held with experienced therapists in treating substance abuse (Manickam, et. al., 1994).

    Patients’ group is divided into two subgroups of 6-9 members, after the first therapeutic group. The groups are divided based on age, education, occupation, and ability in communication to attain more homogeneity. The weaker group sometimes functions for a longer time, if it does not meet the objectives of each session.

    Session One: Sharing and structuring

    This session aims at introducing individual members to the group. Each participant briefly narrates the history of one’s drinking behavior and the circumstances, which led him or her to seek treatment at the centre. They describe the periods of abstinence, if any, and the situations which led to relapse.

    The therapists encourage the members of the group to raise questions for clarification, in order to facilitate group interaction. Reassurance by the therapists about confidentiality provides a role model for the participants. Since the patients are living with their spouses, misplaced comments and jokes about any person’s verbal and/or non-verbal behavior are likely to threaten the harmony in the centre. Ensuring confidentiality reduces the chances of occurrence of this problem. They are encouraged to be more open and to give a "true picture " of their problems. Option not to disclose matters, which the participants feel highly personal, reduces the stress. Information that such matters can be discussed with personal counselor gives relief to many. The session gives opportunity for every one to realize that each one’s problem is not too different from that of the other. Hence, no one feels ridicule or rejection, which he or she usually experiences at his or her home or in the community.

    Session Two: Disease/Illness Concept of Alcoholism

    The session starts with the question whether alcohol dependence is an illness. Some patients hold a moralistic view and extreme guilt about their inability to control their drinking behavior. On the other hand, there are many who deny their dependence on alcohol even though they would have described their withdrawal features, psychological dependence, inability to control their drink, craving for increased tolerance and impairment in social functioning. Focusing on their own symptoms helps to educate the group about the disease concept of alcoholism. Without direct confrontation by the therapists, most of the members realize their own responsibility in taking the first drink.

    Session Three: Treatment

    Alcohol dependent persons are unaware of the kind of therapies offered to them (Rao, et al., 1988). Hence, this session aims at imparting information about the different components of the treatment package. The process of detoxification, counseling, group therapy, counseling the spouse and marital counseling are explained. In majority of the situations, educated members who are familiar with these processes facilitate imparting the information.

    The role of the client and that of the counselor are clearly spelt out. Many patients come to the centre with the hope that there is "magical cure" for their problem drinking, which could be achieved through the administration of "some injection" which ‘wipes out the thought of alcohol". The task of changing their belief systems is made easier by drawing their attention to the experiences of members who had taken treatment earlier and who had history of periods of abstinence. Though there are claims by different researches that controlled drinking could be one of the treatment objectives, reports from different centres in our country favor life long sobriety as the goal of treatment (Cherian, 1986, Manickam &Kuruvilla, 1990). And to achieve this objective, change in life style is required. During the stay in the hospital, they need to plan about changes, which are realistic and can be implemented when they get back to their community. Expecting a dramatic cure, some of them express the feeling, "Now that we have decided to give up, you do your best to keep us sober."

    Clinging to such ideas makes the person resistant to discuss about making changes in life style. The realization that the treatment does not help them as they think it would, may lead to feelings of frustration, hostility and rejection. The group atmosphere is very helpful in resolving such reactions. The therapists’ support to help them find the possible ways of changes in life style eases out the situation.

    Session Four: Physical Aspects

    Generally, it is assumed that the alcohol dependant person is aware of the effects of alcohol on physical health. Though many of them know that it affects the health adversely, they tend to rationalize their drinking based on several misconcepts they hold. This rationalization may take the form of "increases work efficiency by releasing extra energy," "is medicinal" "many Ayurvedic and allopathic medicinal tonics contain it" and other similar views. These views may be held even by patients who had undergone multiple hospital admissions for alcohol related problems. Specific information on health, when given by physician is likely to remove misconcepts about the abuse of alcohol (Tulkin, et al., 1989). Moreover, physicians’ description regarding abstinence from all mind-altering chemicals is found persuasive. Therefore, physician at the centre attends this session and explains the effects of alcohol on various systems of the body, with the help of visual aids.

    Session Five: The Family

    Evaluating the cultural and sociological aspects of the family systems in India, Bhatti (1982) demonstrated that dependence and group affiliation are the hallmarks of Indian family system. Therefore, strengthening the dependency and improving the relations are the two main components of this session. Many patients are either ignorant or incapable of taking up the family responsibility. Participation in discussing the role in the family in performing the prescribed duties, nurturing healthy communication within the family, maintaining harmony and cohesiveness of the family help individuals to be aware of these issues. Most of them either discusses their issues in the group or take it up during individual counseling. Inability to provide parental model to children which leads to behavior disorders and scholastic backwardness are issues brought to the fore by the group members. Becoming aware of the adjustment problems of children which are related to the their drinking helps some to modify their behavior (Kodandaram,1995).

    Feed back on their disclosure, helps them realize the effects of drinking on one’s spouse. Many are unaware that excessive drinking leads to psychological problems and psychosomatic disorders in the spouses (Haritha, 1990). When the patients neglect their role in the family, usually the spouse takes it up. The idea of taking up family responsibility on achieving sobriety can be threatening to some. The group sometimes helps individual participants to resolve the conflicts. Otherwise, during personal counseling the clients takes it up.

    Many patients tend to focus on the economic aspects. The therapists intervene to avoid the discussion on economic issues, since other issues of the family system could be sidelined. However, care is taken not to induce guilt in them. The patients often discuss the ways to bring about changes in life style, to compensate for what they missed.

    Session Six: Work and Rationalization

    Many patients deny the impairment in work. Research studies indicated that the occupational adjustment is unsatisfactory in terms of productivity, punctuality, and quality of work and attendance. (Senthilnathan, et. al., 1984). Discussion and confrontation between members of the group help each one to realize the "real" state of affairs, which at times is threatening to the individual. The tendency to present a clean picture disappears when members present their own work record filled with disciplinary actions on them. Manual laborers reveal their own state of not being offered work due to their drinking.

    As elicited by Rao et al, (1988), patients tend to use "presentable reasons" for continuing their drinking behavior. The discussion unravels the defense mechanism of rationalization. The skill to discriminate a " genuine" and "real" problem from a defending reason is imparted. This process helps the patients to focus on their craving for alcohol and to take up the genuine problems during individual counseling.

    Session Seven: Cues

    Explaining the principle of cue and response in the group is not difficult. To make the group more clear about the concepts, the members themselves come up with very good examples. Once the concepts are clear to all the members, each one is encouraged to identify one’s own cue. At times, the group does a careful behavioral analysis of each participant. Following this, the group members propose alternate behaviors to tackle the cues.

    Majority of the clients report that associating with friends who abuse alcohol is a cue (Manickam, 1989). The group members learn the skills to avoid their associates who are likely to invite and persuade them for a drink. Similarly, other cues related to time, place and person are discussed.

    Session Eight: Leisure Time

    The sober life provides extra time, which they were spending with the bottles. Encouraging the clients to make a careful planning of day to day activities reduces the availability of extra time. Each member assisted by the group identifies one’s own leisure time, in accordance with the social and cultural background. It may require reviving one’s hobbies or interests that were nourished during pre-morbid period. Engaging in alternate behaviors help reduce the strength of responses to cues. Positive reinforcement to the suggestion of involving the family members in leisure time activities helps the group members to plan similar activities.

    Session Nine: Life long Sobriety.

    The goal of attaining life long sobriety is viewed as a burden by many patients. It is more so among younger patients. It is considered as a burden since they anticipate a number of problems in making changes in life style. Self-reinforcing of one’s own non-drinking behavior is one of the tips Some of the other strategies suggested by the clients include setting up short-term goals, planning for being sober each day and involving in other alternate activities.

    Session Ten: Follow Up and Relapse

    Follow up of alcohol dependent person is difficult in Indian situation (Mahadevappa, et. al., 1987). Hence, the group discusses its need. Many patients feel that it is to check on their alcohol status. They are to continue to visit the centre for a minimum period of one year. Follow-up is part of the treatment process and the suggestion is to come with their spouse or relative.

    Since many of the clients do not view counseling as a treatment modality, the importance of follow up counseling requires discussion. The fact that sober life cannot be equated to problem free life makes the clients more realistic. The clients learn that they can discuss the difficulties, which they face as they start leading a drug free life with the personal counselor.

    Each patient has to align with a social support person and it is usually discussed during individual counseling sessions. Discussing in the group is helpful for those who do not know the concept and its importance and to the highly independent who is reluctant to accept help from others.

    The possibility of relapse and knowledge of early signs of relapse help them plan their schedule realistically.

    Individual counseling to spouse

    Initial sessions focus on helping them to ventilate their feelings. Providing an atmosphere of trust and confidentiality help them to open up alcohol related problems of their spouses and their own problems. Information provided by them aids in formulating the problem areas of the index patient.

    On assessing the problem areas of the dependent person, those areas, which require the spouse’s involvement, gets priority in the initial sessions.

    Discussion on role reversal, helping the dependent person to take up responsibility in a gradual manner etc, when discussed individually reduces the stress. Similarly, the coping behavior adapted by the spouses on many instances require modification( Chandrasekharan & Chitraleka, 1998)

    The unresolved issues of the family and that of the spouse get attention during follow-up period.

    Marital and Family Therapy

    While working with the family, maladaptive behaviors can be identified as it occurs and support is provided for changing them in the desired direction.

    One of the major objectives is to help the family regain a healthy and harmonious relationship among its members. This requires a change in the style of functioning related to interpersonal relationships (Neeliyara et. al.,1989).

    This causes stress to the therapists too. The hierarchy within the family varies according to the culture, region, caste, and religion. Unless the therapists are aware of the norms of the family culture of the client, an effective intervention is not possible.

    In some cases, it would require the role reversal of the spouses. The patient who is expected to function in the role of the head of the family spends most of his time with the bottle. The neglected responsibility then falls on the spouse. The therapist has to carefully guide the persons concerned to relearn their roles gradually without upsetting the homeostasis of the family unit. Some families require to learn effective problem solving skills, while some other have to learn to accept each person as an individual in one’s own right.

    While communicating within the family, many tend to guess the other person’s intentions and motives and they behave as though the guesses are accurate. This leads to confusion and misunderstanding. The therapists in such occasion’s point out the above immediately and try to stop the "mind reading games."

    The Spouses Group

    . The spouses group meets for four sessions. The first session is meant for sharing. Most of the spouses have the feeling that it is their fate, and their experience is unique. Each one’s self-disclosure of torture and battering and the agony they had undergone leads to a therapeutic atmosphere which is supportive and strengthening.

    The second session focuses on illness, which is taken in similar lines to the one taken for the patients. The spouses group reacts differently to the awareness that it is an illness. Most of them find it hard to accept it, which is also shared by the community. Addiction is most often perceived as a purposeful behavior of acting out and/or neglect targeted to the wife and children or the family.

    The third session on treatment often disappoints the members. The symptom of craving or the desire for alcohol, the members feel should be wiped through some magic formula

    Majority of them is aware of the need for changes in life style of the dependent persons but not in them. The close family members, who act against the wish of the spouses, sometimes complicate this. In such situations, the women experience a conflict. On occasions when the women were battered or send out of the house, her family is the one, which stood with her. Therefore, if she takes a decision, which is against the wish of the family members who had supported her earlier, they may not come forward to help her again.

    The fourth session centres around follow up and relapse. Spouses have a better understanding regarding follow up. Like the patients, they also hold t he attitude that it is just for monitoring their drinking behavior that they are asked to continue follow up. Importance of individual counseling to patient and spouse in helping them maintain their life style changes many women are able to understand. Majority of the spouses shows willingness for follow up and they take initiative in encouraging their spouses for follow up.

    Relapse as part of the recovery process is also discussed. It becomes easier when the group has members whose spouse had abstained earlier. Otherwise, it is hard to discuss about the phenomenon of relapse with spouses.

    In majority of the situations, the spouse takes effort to see that their husbands are free of alcohol. It is mostly due to the social and cultural compulsions. If the husband is the only breadwinner of the family, it is the economic situation of the family that the spouse is worried about. Many women and their families perceive the life separated from husband to be unsafe. Some of them feel that it is better to say that her husband is living with her even though he is totally dependent on alcohol than to say that she got separated. This concern is more among women who have daughters of marriageable age.

    Another interesting observation is that marriage is seen as ‘treatment for dependence". The person who has become dependent on alcohol, the parents, and relatives feel can be freed from alcohol by getting the person married. In most situations, neither the girl nor her family has any information on the drinking status of the individual. Or, the family members of the man do inform that he is a social drinker and justifies drinking saying that it is more common these days. The woman realizes the trap only after marriage and then it is too late for her to react. During the initial days of marriage most of them do not inform their parents thinking not to burden their parents. The parents have already spent borrowed money or their life time earnings for the marriage or ‘getting the daughters married’. In addition, to tell that their choice was not the right one leads to conflict in the woman. Some of them feel hostile to their own parents for getting them such a person. Some of them are worried how their parents and relatives would react and behave to their husbands if they tell them about their husbands’ behavior. There are instances where the woman’s relatives and family members have physically assaulted her husband for his drink- related behavior.

    Some of these issues require involvement of the family too, and is taken up during follow up counseling.

     

    Extension to the Community

    In one of the studies, (Manickam, 1996b) it was observed that patients who have social support offered in the community have better out come when compared to those who did not have. It was observed that a voluntary worker in the community, motivated the people in the neighborhood community to provide social support network. The social support net work thus formed mobilized the recovered alcoholics to meet together regularly at a common place every evening. The recovered persons were provided with recreational facilities and fostered better interpersonal relationship in a drug free environment. Each recovered alcoholic person and their family was contacted regularly and was encouraged to keep the follow up with the de addiction centre. The network, in some instances raised money for meeting the personal expenses of patients during their stay at the de addiction centre. The group could motivate other addicts to seek treatment too.

    Taking lead from this experience, a training programme for community volunteers in preventing alcoholism and drug addiction was initiated (Manickam, 1997a). Twenty three community volunteers attended the programme from the administrative district of Thiruvananthapuram. The objectives of the programme were

    1. To impart knowledge and skill to identify alcohol and drug dependent person in their community
    2. To motivate the person to seek de addiction treatment
    3. To motivate their family members to seek treatment at the de addiction centre
    4. To provide social support to the person and family after the in patient treatment at the de addiction centre, and
    5. To organize prevention programmes in the community

    The programme was a week’s residential one and 21volunteers from the community participated.

    The training module was as follows:

    Day 1

    1. Self Introduction
    2. Participants’ Perception of the problem
    3. Pre- testing
    4. Scope of the training / programme goals
    5. Extent of the problem in the community
    6. Group Work: Alcoholism as I understand

    Day II

    1. Illness concept of Alcoholism
    2. Illness concept of substance abuse/drug abuse
    3. Psychological factors
    4. Role of voluntary agencies
    5. Group work: Identifying alcohol dependent person and Drug dependent person

    Day III

    1. Medical and Psychiatric Aspects
    2. Social implications
    3. Drug abuse among the youth
    4. Effects on Family
    5. Panel discussion: The State scene(Panel included police, legal and public health officials)

    Day IV

    1. Treatment of alcohol dependence
    2. Objectives of counseling
    3. Objectives of family counseling
    4. Importance of follow up
    5. Social support and social support person
    6. How to provide social support/lay counseling
    7. Role of police
    8. Group Work:
  • i. How to motivate an alcohol dependent person to consider treatment
    1. How to motivate the family to seek treatment

    Day V

    Treatment of drug dependence

    1. Rehabilitation of drug dependent person
    2. Problems in the treatment of alcoholism and drug addiction
    3. Prohibition and prevention
    4. Social activation and prevention(role of songs, folk dances, folk drama, street play and public demonstrations)

    Day VI

    1. Role of the community volunteers /participants in the treatment programme and prevention
    2. Initiating self help group
    3. Field visit to the self help group
    4. Evaluation of the field visit
    5. Group work: Exposure to video tape on alcoholism and dug addition and discussion

    Day VII

    1. Educational programme for prevention of alcoholism and drug addiction
    2. Post- testing
    3. Evaluation of the programme
    4. Group work: Charting out future programmes in the community.

    Effect of Training

    After the training some of the participants showed active interest in preventive work and the role expected of them. Five of the trained workers together organized about 24 preventive programmes in the following two years. The programmes were organized at the pre-schools of Church of South India. The target group was the families of the children attending the Pre School whom belong to the low socio-economic level. The counselors from the de addiction centre conducted the programmes. After the talk on dependence and prevention, the spouses and children of alcohol dependent persons meet for the group-counseling sessions. In the groups, the members get the opportunity to ventilate their feelings. Discussion centres on the strategies to motivate the index clients to seek treatment at any of the de addiction centres.

    Two of the trained volunteers later organized a camp treatment in the community. Another set of volunteers from a particular geographical area, Panchayat, where the camp was organized were identified and trained using a shorter module. The objectives of the training programme were to identify alcohol dependent person in the community and to motivate them for treatment. In addition, the training clarified their role in the preparation and implementation phase of the camp treatment. Their role in providing continued support of the dependent persons during follow up also formed part of the training.

    The trained volunteers were instrumental in organizing the camp. The Salvation Army hospital at that Panchayat gave permission to conduct the camp at their hospital premises. The volunteers assisted the professionals of the de addiction centre during intake counseling and during the camp. The camp was of a shorter duration, for 15 days. During the first week, the patients underwent detoxification and counseling could be started by the fifth day since many patients did not have severe withdrawal features. The same group-counseling package mentioned earlier was offered to the clients. Two counselors from the centre conducted the individual counseling and led the two groups. Of the fifteen patients, two of them relapsed after 6 months, one of them died after a year, and the remaining twelve are maintaining sobriety even after 6 years.

    The camp approach evoked much response from the community and there was demand to run the programme in the same geographical area and in the neighboring Panchayat. Unfortunately, the programme had to be discontinued due to several reasons.

     

    Social Support Person and the Community based Model

    The learning from the experiences of the social support persons in the community, what we call as the parasahayi or the community volunteer or the lay counselor can be the pivotal point in the community based alcohol management (Manickam,1999).

    Whether it is a community based camp approach, or a centre based de addiction in patient programme or mental health centre based treatment for alcohol dependence, the community volunteers have a role to play.

    Trained community volunteers or lay counselor or the parasahayi can

    1. Identify the dependent person in the community,
    2. Motivate the person for treatment
    3. Motivate and prepare the family for seeking treatment
    4. Liaison with the treatment centre
    5. Encourage the person and spouse or relative to continue follow up
    6. Provide immediate psychological support or help in times of need. This may be in terms of helping to get over the cues, help engage in leisure time activities or to provide and
    7. Develop a social support network for the person to maintain changed life style.

    In case of relapse, the social support person can repeat the cycle, by motivating the person for treatment again if required or by encouraging the link with the centre.

    The human resource for this type of service is available in the community. Nevertheless, effort to mobilize and train them requires commitment. Sometimes recovered persons may be very efficient in this helper role. Others who have interest and motivation to work for the welfare of dependent persons and who possess non-judgmental attitude can be trained to help the people in the community(Manickam,1988).

    In Indian situation, studies show that there is more number of people who abuse alcohol in the rural villages than the urban places. Even in the rural villages, the people affected are more in the low economic strata. It is expensive for them to seek treatment at the sophisticated mental health centres. Even the cost involved during the treatment period, many people in the low economic strata find it difficult to raise the amount.

    Moreover, it has been observed that the existing number of mental health professionals are not able to cater to the needs of the community (Varghese, 1979). Therefore, there have been a number of initiatives taken at different parts of the country to train lay counselors (Manickam &Kapur, 1985;Manickam,1993; Manickam,1996a). Our research has shown that trained lay counselors do have helper qualities, and can be effectively utilized to help specific problems(Manickam,1990; Manickam,1997b). If the potential people are identified and trained, they can be of great help in combating the problem of drug and alcohol abuse.

    In preventing the problem, there has been many efforts taken at different states (Rao &Parthasarathy, 1997; Kuttappan, 1998). The human resources available in the community have to be used to achieve the objective of a drug free world.

    Alcohol dependence, which has multiple factorial causation and unpredictable course and outcome, requires a multi model approach in treatment. Programmes that are community based is better suited for the developing countries.

     

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