The Empowered Community - A Paradigm Shift in the Treatment for Alcoholism

Abstract 
Abuse of alcohol has become a serious public health and socio economic problem in Indian villages. Treatment services are neither available nor affordable. Keeping this in mind TTK Hospital has developed a cost effective community approach of treatment with the involvement of the community. The organization has been conducting six camps each year for the past 25 years.

There are five  steps involved in organizing the camp
1.   Identifying  and empowering a host organization
2.   Preparation
3.   Selection of patients
4.   Action  - conducting a camp for 15 days
5.   Follow-up and maintenance
A local NGO, called host organization plays a key role prior to, during and after the camp. At the end of one year, there are many  benefits to the patients and their family members. Treatment for alcoholism through rural camps is not an individual effort. It is a joint venture-the combined efforts of the treatment team, the host organization and the community.  (Vide Appendix)
 
Abuse of alcohol – A major issue in Indian villages
Abuse of alcohol has become a serious public health and socio economic problem in Indian villages. The harmful consequences of excessive drinking are many. They can be physical problems like hepatitis, gastritis or neuritis, psychological problems like depression and suicide or social issues like violence, break up of marriages and disintegration of families. Apart from these, there are economic problems like neglect of work  and unemployment.  

“The fathers of our students drink excessively. As a result, many students are dropping out of the school” complained an anguished teacher in a village school at Manjakudi in the State of Tamilnadu.  The occasion was an awareness programme organized for the teachers by the TTK Hospital. The intense emotion and deep anguish behind the concern voiced by the teacher brought home to us the full import of the problem and the idea of conducting the first rural camp was born in 1989 at Manjakudi.
 
Taking treatment from the city centers to the doorstep of the villager
Our healthcare system is not equipped to deal with the magnitude as well as the complexity of this problem. Hence there is a need to innovate and try out alternative methods of treatment In the last 30  years, voluntary agencies have tackled other community health concerns  by organizing  camps  in rural areas – eye camps,  immunization, family planning and dental camps. TTK Hospital has  now been seriously considering the issue of handling this major problem of alcohol abuse/alcoholism among villagers who can neither be away from their homes for days together, nor afford the cost of  treatment provided by the  centres  in big cities.

Finally TTK Hospital conceived the camp approach to treatment of alcoholism. This treatment programme concept (which proved to be cost effective) was first put to test by organizing a rural treatment camp at the village of manjakudi itself. The treatment module designed and developed by us proved to be quite effective and the outcome so very gratifying and encouraging that we decided to continue offering  treatment services to other villages in and around Tamil Nadu using this camp approach. From then on, for the past 25 years, we have been regularly conducting treatment camps for alcoholism in rural areas. At the time of writing we have conducted 139 camps covering a predominantly male population of 3268 patients.
 
Organising rural camps - The Concept
The concept of rural camps is to provide treatment at the door steps of villagers – where the people live and work. This enables us to harness existing community support and local NGOs. In a close knit social framework in villages, this can be a powerful force in the recovery of the patient. Another objective of the camp is to make the rural population aware that alcoholism is a serious problem which needs to be tackled in order to improve the quality of life and to demonstrate to them that the problem has a solution and that they have an active role to play in implementing the solution.
 
The  Process
There are five steps involved in organizing a camp. A flow chart is given as annexure.

-    Identifying and empowering a host organization
-    Preparation
-    Selection of patients
-    Action - conducting a camp for 15 days
-    Follow-up and maintenance

The treatment agency (TTK Hospital) identifies a social unit from the community and empowers  them to take up certain crucial roles. The community unit with which the treatment facility works in close coordination is called the host organization. A few examples of host organizations are  NGOs, schools, rural up-liftment societies, self help groups, religious organizations etc. In short  any group of individuals already engaged in some activity aimed at improving the lives of the local population.
 
Selecting the host organization
In identifying the host organization, care should be taken to choose a  local organization which

- enjoys the trust and respect of the community. The organization should have a good track record of services and be transparent in its functioning. The services should be known to the community members.
- feels the need for treatment camp for alcoholism in the community where they work.
- is willing to provide the basic infrastructure to run the camp and provide support to the patients during follow-up.
- is willing to offer its services without looking for any financial or material gains

Time spent in identifying a suitable host organization is time well spent because it can positively impact the effect of the treatment camp.
 
The role of the host organization
Prior to the camp
-    Getting trained to organize camps
-    Identifying alcoholics for treatment
-    Organizing accommodation and other infrastructure
-    Mobilizing resources
 
During the camp
- Active involvement of the local physician and networking with other agencies in case of medical emergencies
- Motivating the family members and support persons
- Organizing logistics such as cooking gas, procurement of vegetables etc
 
After the camp
- Providing follow-up in the form of dispensing disulfiram, counseling, home visits.
- Intervening and providing appropriate support in case of clients who have had relapses
- Arranging for  medical assistance (by the physician) during a relapse or otherwise.
- Networking with other agencies to provide vocational training, job opportunities, medical and psychiatric help
- Documenting the progress of clients and communicating to the treatment centre
- Educating the community on a continued basis

The camps are typically organized either in a  school building / wedding hall / community centre  which is given free of charge by the community. To conduct a camp, we need a hall to accommodate 20 to 25 patients, 2 or 3 rooms to conduct therapy sessions  and 2 or 3 rooms for the staff to stay.
 
Our Manjakudi Experience
The step by step approach – A case study
At Manjakudi the host organization was the school management and the teachers.

Kanniappan was brought to the camp site by a teacher from the school. His daughter was studying in the school.

K, male, 41 years old, illiterate, married and lived in a village near the camp site of Manjakudi. He had three children. His profession was weaving and was earning roughly around Rs.5000/- per month.  His wife Sarala also had the required skill to help him in weaving.

He started drinking at the age of 25, drank on and off for five years and excessively for the past seven years. He was drinking brandy three times a day. 

During the first interview, Kanniappan’s motivation level was assessed and he and his wife were briefed about the treatment process.

During the 2nd round of selection the village doctor gave the patient a medical checkup which included test for blood pressure and diabetes. A talk was given by the *outreach worker of the host organization about what they could expect from the camp. A week later, during the 3rd round of selection which was 7 days prior to the camp, chlordiazepoxide (Librium) was given to the patients to tackle withdrawal symptoms. The medicines were removed from the wrapper to prevent misuse of the same tablets and given to the family member with the clear instruction to administer them in the night after dinner. Besides, vitamins and liver supplements were also provided. The outreach worker made the patients and family members understand that those who come without taking alcohol would be given priority. In case of any other withdrawal symptom they would have to contact  the local physician.

Since Kaniappan’s wife Sarala wanted him to positively attend the camp,  she gave him the  medicines all the seven days, made him stay at home, never allowed him to  go out at all. She was afraid that  he may go and drink as the last  time as he is planning to attend the camp. K followed all the instructions of the counselor – drank a lot of liquids, never kept his stomach empty; avoided meeting his regular drinking friends.

The day before the camp, the ambulance of TTK Hospital loaded with medicines, basic medical equipment, bedding arrived at the camp site. A team of a doctor and an outreach worker from the community, one nurse, three counselors were available to run the camp.

Patients started coming for the camp from 7 am onwards, each with one accompanying family member. They had brought with them personal clothing, a plate, a tumbler and  toiletries. The doctor with the support of the nurse carried out a physical examination and prescribed medicines wherever necessary.  For the first two days, patients were restless and anxious. Interacting with other patients helped them reduce their anxiety.

K was admitted for treatment. He had poor appetite and lack of sleep. He had other problems also. He had been very irregular  for work. As a result, his  wife  had taken up the responsibility of weaving. The patient had even mortgaged the silk thread which had been given for weaving. His son had dropped out of school in order to help his mother.  

On the 3rd day,  patients had stabilized and psychological therapy was initiated. The counselor explained to the patients and their families the goals of the treatment and the days programme. The day starts with simple physical exercise followed by  bath, prayer session and breakfast. At 9.00 am, the programme started with a thought for the day followed by classes wherein information about alcoholism and practical guidance to make positive changes in their lives were given. This was followed by an activity which helped them to translate what was taught in the class. After a simple lunch, the patient assembled for group therapy. Within each group, they shared their experiences, feelings and problems.

The thought for the day was ‘Living one day at a time’.  The anecdote which explained the concept was very interesting.  A clock with a two year warranty period thought to itself – “I have to live up to two years – that is tick one million times. My  God! What a strenuous job. I can’t do that. Let me stop ticking right away”.

His friend, another clock said – “Do not think about the one million times; but just tick for this instant”

The concept of not drinking that day alone appealed to K. It gave him hope that he could also stay away from alcohol on a ‘one day at a time’ basis.

This was followed by a class educating the patients on the fact that alcoholism is a disease and to provide  details of the  symptoms of alcoholism. This is an important session, because when the patient understands alcoholism is a disease, they gain an insight into many of their actions and many are able to rid themselves of their feelings of guilt. At the same time they understand that freedom from alcohol is possible and that they are responsible for their recovery.

K told Sarala “when the counselor talked about the symptoms, it looked as if she was narrating my own life”

After a simple lunch the patients assembled back for group therapy. Each group had 8 to 9 patients facilitated by a counselor. Within each group, they shared their experiences, feelings and problems.

In group therapy K openly talked about the problems he had caused to his wife and children. He shared with a lot of pain, how on one occasion, he went to the school function under the influence of alcohol and embarrassed his son.

The same counselor provided individual counseling for her  group members. She acted as a friend and guide to the patients and motivated them towards leading a sober life.

In the counseling session, K talked about the debts he had incurred due to his drinking. He was worried whether his old employer would trust him and give him a job after the camp. In another session, K was more hopeful and he set two goals for the next three months – I will start weaving  regularly at least 8 hours a day; send my son back to school to continue his studies.

In the evening, the counselor narrated a simple story.
A male and a female elephant got stranded in a desert and were feeling  thirsty. They found some water in a small pond nearby. When the female elephant saw this, she requested the male elephant to drink the water. But the male elephant asked the female to quench her thirst first. Finally they decided to share the water between themselves. They put their trunks inside the pond. But the level of water did not go down. Why? The female elephant waited for the male elephant to drink, whereas the male elephant waited  for the female. This is meaningful life. The happiness of life lies in sharing and  caring for others.

K said, “just as a nail is driven through the wall, these stories get deep into our heads. Hereafter I will try to be helpful to my family members”.

The last session for the evening was sharing by two patients who were treated in the earlier camps (who were sober for more than a year). They shared about their recovery – damage, methods tried to stay sober, benefits derived. This sharing gave patients a lot of hope and an opportunity to meet recovering patients in their community. 

When two or three alcoholics who had undergone treatment and remained sober shared their experiences, K asked everyone of them – “What did you do when you had the craving?”. They explained some of the time tested methods which had worked in their case – take tablet regularly, eat something to fill the stomach, share feelings with a friend, pray to God to give strength.

Disulfiram is a drug which is used in the treatment of alcoholism in order to help the patient to abstain from alcohol. If the patient consumes alcohol while on disulfiram, the body produces unpleasant reactions, hence, disulfiram serves as a deterrent. The patient is advised to take one tablet daily for a minimum period of one to two years. Once he crosses the first / second year without drinking, it paves the way for his future sobriety. Disulfiram is given on the 4th day and the counselor explains to the patients and the families the advantages and also the possible consequences of drinking after taking disulfiram. A card is also given indicating the consequences and the medicines to be given as an emergency treatment in case of drinking with disulfiram.

When disulfiram was given, K felt relieved. To him, the medicine was a protective fence. He told his wife Sarala, “If my friends ask me to take alcohol, I will show them this card. Now they cannot pressurize me to drink”.

The family members undergo a separate programme for 12 days on an outpatient basis. The goals of family therapy are  to make the family understand that alcoholism is a disease;  to enable the family to appropriately express her feelings of shame, anger and  hurt in order to help her to achieve a functional life style; to help her develop a supportive attitude towards the alcoholic. The therapy includes, re-educative sessions, individual counseling, sharing by spouses of recovering alcoholics.

As the camp progressed, the family members accompanying the patients also began to openly share  their problems.

“When my son joined a company for apprenticeship, he asked for a new shirt and a pair of chapels. I had no money, hence I could not satisfy even this small desire of his” – Sarala cried when she shared.

A two hour programme is conducted once during every camp for the support persons of those who are presently receiving treatment in the camp. Support persons are those who have a keen interest in the welfare of the alcoholic. They may be a family member (uncle, sister, brother, father-in-law), a friend, neighbour, any other recovered alcoholic living in the same village or the person who has brought him for treatment. The programme is for a duration of two hours. The support persons are educated on  alcoholism being a disease, total abstinence is the only solution to the problem, need for positive changes in one’s life, disulfiram reactions, importance of follow-up.

K’s neighbor and his employer attended the support programme. The employer was willing to take him back as long as he stayed sober and his neighbor said he would make sure K attends the follow-up programme.

In the rural areas, the community has a particularly powerful influence on the recovering person. Keeping this in mind, we organize lectures in every village from where we had taken more than three patients.

The follow-up was provided for a period of one year – dispensing disulfiram, medical checkup if there is a need and counseling. At Manjakudi one of the teachers was designated as the outreach worker to provide follow-up support. He was given a training  on his role. He also made a visit to their homes whenever necessary.

Two months after the camp, Sarala brought K to see the teacher. K was anxious about paying back  debts. The teacher spent  an hour with him gave him moral support. He guided him on how to budget  his income and repay  debts.

Four months after the camp, K’s daughter shared with the teacher that they had celebrated the  festival of Pongal  with a lot of happiness. “For the first time after many years, we all  ate together and my mother made a sweet”.

On the 9th month of follow-up, K proudly told the outreach worker that he had paid back almost 3/4 of his debts. Since then his son  had joined the school to continue his education. 

At the end of one year, another camp was organized with a new set of patients.

For the subsequent camps, K would make it a point to bring at least two or three patients from his village. He would also visit them in the evenings to give them support.
 
Benefits of this approach
- Reduction in alcohol related problems in the community (crime, violence, etc)
- Mobilizing recovering persons as volunteers in organising camps helps in sustaining the recovery of  new clients
- Community understands the processes of addiction and recovery. Hence is empathetic and willing to support treated patients in recovery
- The feeling of oneness in the community is constructively  utilized. In turn, the responsibility of managing alcohol  problem shared between the professionals and  the community, leading to ‘doing with’ rather than ‘doing for’
 
Recovery Indicators
How individual clients and their families benefit
- Regularity in work, in turn, contributing to the family
- Paying back debts
- Getting the children into school (earlier they would have dropped out)
- Getting their daughters married
- Absolutely no violence
- Getting electricity for the house and repairing the house
- Respect in the community
 
Other factors
Ensuring success when duplicating the programme
- Identifying appropriate host organization and training them to take up the task
- Adequate efforts to make community aware of  the forthcoming camp
- Careful screening process to select patients without serious medical problems
- Structured treatment programme
- Trained staff
 
Staffing
- Medical officer from the community
- Follow-up support with the help of the host organization
- Three counselors
- One Nurse
- One Driver with ambulance for any emergency

What is unique about the treatment for alcoholism through rural camps is that it is truly a holistic approach to the problem. The dynamics of a closely linked community are leveraged to enhance the impact of the treatment and to create an enabling post-treatment environment for the patients who attend the camp. Conducting treatment camp is a joint venture-the combined efforts of the treatment team, the host organization and the community.
 
References

1. Ranganathan. S, 1996, The Empowered Community – A Paradigm shift in the treatment of alcoholism, Chennai, TT Ranganathan Clinical Research Foundation
2. Ranganathan.S, 2011, “Treatment for Alcoholism The Community Approach”, Chennai, TT Ranganathan Clinical Research Foundation

Dr. Shanthi Ranganathan
Honorary Secretary & PadmaShri Awardee, TT Ranganathan Clinical Research Foundation, IV Main Road, Indira Nagar, Chennai-600 020.