OF ALCOHOL DEPENDENCE:
BASED MULTI -MODEL APPROACH
Sam S. Manickam
De addiction Centres
The Vellore Model
Extension to the Community
Social Support Person and the Community based Model
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
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.
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
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:
- The centers mainly treat people with
mental disorders. Hence, the number of people who undergo
treatment for substance abuse may vary.
- 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.
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.
Each centre has developed treatment
packages for themselves.
TTK Model, Chennai, South India (Cherian,
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,
This centre has developed two models.
- Behavioral Model ( Prasadarao
- 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
- 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.
- 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
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.
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
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.
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.
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.
- 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.
- 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
patients 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
- Cue Control:
A careful behavioral analysis of the persons
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).
- 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.
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.
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.
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,
- The patients and relatives expect an
abrupt and radical cure.
- The patients have less knowledge about
alcohol dependence and the process of recovery.
- 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 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 patients immediate physical
problem. Moreover, laboratory investigations aid this process.
Admission to the centre is confirmed only if,
- The patient is free from any major
physical illness, which requires immediate attention.
- Free from overt psychiatric disorder.
- Motivated to stay as inpatient for the
stipulated period of 19 days.
- The patients spouse or if
unmarried, a significant relative visits the centre and
consents to stay with the patient throughout the
inpatient treatment period and
- Abide by the rules and
regulations of the centre during the stay.
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.
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
weeks 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.
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 patients
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
ones 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
Social problems are related to the
individuals place of living, how the society perceives the
individual and how the person perceives the society. Some of them
are related to the persons 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
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 womans family spent unwisely by the mans
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
persons 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 ones own
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
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
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,
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.
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 ones 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 persons 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
ones 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
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 ones 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
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 ones 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
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 ones own leisure time, in accordance with the
social and cultural background. It may require reviving
ones 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 ones 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
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
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 spouses
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 ones own right.
While communicating within the family, many
tend to guess the other persons intentions and motives and
they behave as though the guesses are accurate. This leads to
confusion and misunderstanding. The therapists in such
occasions 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 ones 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
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
womans 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
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
- To impart knowledge and skill to
identify alcohol and drug dependent person in their
- To motivate the person to seek de
- To motivate their family members to
seek treatment at the de addiction centre
- To provide social support to the
person and family after the in patient treatment at the
de addiction centre, and
- To organize prevention programmes in
The programme was a weeks residential
one and 21volunteers from the community participated.
The training module was as follows:
- Self Introduction
- Participants Perception of the
- Pre- testing
- Scope of the training / programme
- Extent of the problem in the community
- Group Work: Alcoholism as I understand
- Illness concept of Alcoholism
- Illness concept of substance
- Psychological factors
- Role of voluntary agencies
- Group work: Identifying alcohol
dependent person and Drug dependent person
- Medical and Psychiatric Aspects
- Social implications
- Drug abuse among the youth
- Effects on Family
- Panel discussion: The State
scene(Panel included police, legal and public health
i. How to motivate an alcohol
dependent person to consider treatment
- Treatment of alcohol dependence
- Objectives of counseling
- Objectives of family counseling
- Importance of follow up
- Social support and social support
- How to provide social support/lay
- Role of police
- Group Work:
- How to motivate the family to seek
Treatment of drug dependence
- Rehabilitation of drug dependent
- Problems in the treatment of
alcoholism and drug addiction
- Prohibition and prevention
- Social activation and prevention(role
of songs, folk dances, folk drama, street play and public
- Role of the community volunteers
/participants in the treatment programme and prevention
- Initiating self help group
- Field visit to the self help group
- Evaluation of the field visit
- Group work: Exposure to video tape on
alcoholism and dug addition and discussion
- Educational programme for prevention
of alcoholism and drug addiction
- Post- testing
- Evaluation of the programme
- 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
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
Social Support Person and the Community based
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
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
- Identify the dependent person in the
- Motivate the person for treatment
- Motivate and prepare the family for
- Liaison with the treatment centre
- Encourage the person and spouse or
relative to continue follow up
- 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
- 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
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
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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