Peer-Led Drug De-Addiction Initiatives in India by Suneel Vatsyayan

Peer-Led Drug De-Addiction Initiatives in India: An Empowering Journey For an Identity Prepared with the support of Mr. Suneel Vatsyayan, Chairman Nada India Foundation

Alexander Hitch Volunteer, Nada India Foundation April 2014

The overcast September skies of Delhi clouded the entrance to the therapeutic community “Nai Kiran,” complementing the damp smell of a fresh rain and the faint scent of the flowers hanging from our necks. As we sat onto our noticeably worn, plastic chairs, I glanced over to a fellow panel discussant as he barked out in a hardened, raspy voice, “hello family,” to the forty odd members of the community. Each responded effortlessly, in unison, and without hesitation, “hello guru.” These members, known to society as drug and alcohol addicts, sat pretzel-legged on a large, worn oriental carpet in columns that resembled a military formation, and gazed attentively toward the group of us that sat facing them. The conversation flowed without one batting an eye or questioning a statement of us in the front, or of one another. I was introduced as an historian from Chicago, visiting the therapeutic community to narrate the link between the current peer-led treatment centers, and their humble beginning many years before. As we exited the main hall after our discussion had concluded, I spoke to individual members regarding their experience. I observed that through much of the pent up emotion – a characteristic of a zero-tolerance, holistic approach to drug and alcohol treatment – there exists a unique warmth and compassion towards one another. Indeed, this type of peer-led treatment bases itself on a community to assist one another through discussion, addiction therapy, relapse, and eventual de-addiction. As a Westerner, my initial understanding of drug abuse in the developing world was, admittedly, non-existent. During my time in India, however, I was exposed to the range of difficulties that afflict nations undergoing major social and economic tumult, such as India. Remarkably, many of their solutions are inexpensive and effective in combating the societal ailments caused by drug and alcohol abuse. An example of this ingenuity is the peer-led, former-addict directed therapeutic community model supported by the National Acupuncture Detoxification Association India Foundation (Nada India), a non-profit cofounded by an Indian native, Suneel Vatsyayan, and American psychiatrist and acupuncturist Dr. Michael

O. Smith.1 Mr. Vatsyayan is a practicing social worker and relationship counselor by trade, and was the co-founder and Director of the non-governmental organization (NGO), the “Delhi Police Foundation for Correction, De-Addiction & Rehabilitation” (also known as the “Navjyoti”), in many ways the precursor to the Nada India supported therapeutic communities (TC).2 From this beginning in the late 1980s, this particular TC treatment modality has grown into a network of rehabilitation centers known as the Association of Recovering Peoples Action Network (ARPAN). This network of therapeutic communities are run by recovered addicts who each have learned counseling and NGO management, but also possess a unique ability to connect with the recovering members as personal survivors of drug addiction.3 The tendency of medicine in the past several decades has been to “privilege expert, large-scale, technical, and technocratic approaches to problems which are often social in nature.”4 Indeed, biomedical approaches can often deemphasize the social dynamics of addiction, especially in India. But this report does not assert the false presumption that medication and pharmacological treatments are inadequate. On the contrary, they are very often integral to the recovery of many addicts. The general understanding of addiction, however, must evolve in order to help change the outlook of government agencies, funding sources, and society at-large. To eliminate this disconnect, we must do-away with the notion that addiction carries with it a behavioral component or learned habit that must be forced out of the patient by 1

Nada India Foundation is part of the larger Nada International non-profit, being first instituted in 1974 at Lincoln Hospital in New York City as the National Acupuncture Detoxification Association United States. Today, independent Nada foundations exist in 20 different countries. The peer-led treatment program, however, is part of the multi-faceted Nada India Foundation network of services. These are meant to serve varied sections of society in innovative and effective ways. Other programs include: the Pehachaan Training Center of female adolescent peer educators for outreach to women and the elderly in the village of Chattarpur on issues of STDs, health matters, and HIV/AIDS; the youth-driven Pehachaan Radio Club; outreach to boys and girls of the Nirzamuddin Train Station and Interstate Bus Terminal in Sarai Kale Khan; a telephone helpline for HIV/AIDS awareness. 2 The report uses the terms TC and therapeutic community interchangeably. A therapeutic community is defined as a welcoming home to those experiencing trauma as a result of addiction, where addicts can relate to one another’s suffering through the assistance of recovering and former addict “peer counselors.” Moreover, the treatment model is holistic and includes concepts such as group counseling, yoga and meditation, homeopathy, and complete drug abstinence. 3

In this report, I use the terms “addiction” and “drug dependence” interchangeably. They denote an individual who is at the mercy of drugs.

4 Roberts, Samuel. “Meeting Needs with Needles: A Review of the 2011 Nada International Conference, Dublin.” Guidepoints: News from Nada November 2011 (2011): 2.

simply, “being tough.”5 Thus, illuminating the accessible and effective resources and services available for those either impacted or vulnerable to drug abuse and its effects in India is of great importance. At its heart, however, this report chronicles the history of how the therapeutic community treatment modality has grown and evolved since its first steps with Mr. Vatsyayan at the Delhi Police Foundation. The success of these peer-led treatment centers and continued growth of the TC treatment modality amid persecution and stigmatization, insufficient funding, and lack of government assistance, is truly remarkable.6 But this report is also meant to serve as a history for those whose humble and selfless actions are often overlooked, and who act as the human infrastructure that fills a gap in a woefully inadequate healthcare delivery system. They unmistakably deserve recognition for their steadfast support of one another. Methodology This research was completed in conjunction with Suneel Vatsyayan, who generously allowed me to sift through many of his personal files on the TC treatment modality, as a way to chronicle the growth of these peer-led treatment centers. The research began in Delhi, India in the autumn of 2011, where I spent much time with Mr. Vatsyayan and interviewed leaders and recovering addicts of the Nada India therapeutic communities. Through review of relevant documents regarding the development and experiences of those involved with the Nada India supported treatment centers, while also incorporating United Nations and Indian governmental documents, a larger theme emerged, compelling enough to convey in a larger report. It was completed in Chicago, Illinois, in 2014. A disclaimer: This report is not 5

The notion that drug dependence could be considered a ‘self-acquired disease’, based on individual free choice, has contributed to its stigma and discrimination. However, scientific evidence indicates that the development of drug dependence is a result of a complex multi-factorial interaction between repeated exposure to drugs, and biological and environmental factors (Szalavitz, Maia. “So, What Made Me an Addict?” Washington Post, August 28, 2007. http://www.washingtonpost.com/wp- dyn/content/article/2007/08/24/ AR2007082401699_2.html (accessed April 6, 2013)). 6 Peer-led treatment centers are named such because of the counseling and group therapy efforts which are led by recovering and former addicts who remain in the therapeutic community to assist other addicts undergoing similar drug dependence-related issues.

intended for academic publication, as it is neither written in that manner nor peer-reviewed. Moreover, it does not intend to compare or recount the existence of other treatment networks or those in other nations, or presume that the Nada India supported ARPAN network is foolproof. Rather, it focuses on the specific example that this network presents, and chronicles its development in a trying environment. Finally, I do not claim to be an expert in drug dependence treatment. But, as this report demonstrates, I believe there is much to be learned from the therapeutic community treatment modality.7

I. History of the Peer-Led Therapeutic Communities In the 1980s, a peer-based model for drug de-addiction had not been established. It would eventually sprout from the guidance of the young co-founder of Nada India, Mr. Vatsyayan. He describes two main events that provided him significant reason to look into the treatment of drug and alcohol addiction. While still a student, Mr. Vatsyayan visited a temporary treatment camp supported by the government named Khanjhawla Village. There he found people enthusiastically volunteering their time, and found drug addicts pleased with their ability to begin treatment. Upon returning to the clinic only ten days later, however, he found that a number of addicts were using alcohol and drugs while undergoing treatment, disheartening the volunteers and their families.8 The second experience occurred near the end of his schooling, when Mr. Vatsyayan met and spoke with a somber mother whose son was staying at an observation home for destitute and delinquent boys run by the government at Delhi Gate. Her son had worked at a motorcycle repair shop, where he became addicted to petrol inhalation. Having traveled to many different clinics, she had no other prospects, and her last hope was this observation home that lacked a drug de-addiction facility. Unbroken, Mr. Vatsyayan realized that upon the completion of his Master’s Degree in Social Work his career needed to center on the drug addiction rehabilitation field. Mr. 7 Throughout the report, treatment centers and therapeutic communities denote the same meaning, representing a center that is led by recovered addicts who act as the peer counselors and administer therapy in many manners which are novel and successful. 8

Vatsyayan, Suneel. Interview by Alex Hitch. Personal Interview. Delhi, India, September 13, 2011.

Vatsyayan initially worked for nine months at an outpatient department run by the All India Women’s Conference in northern Delhi, but relocated to start a residential treatment center at Majanu Ka Teela for the All India Women's Conference. While there, Mr. Vatsyayan began volunteering his time at the police post across the street that housed a rudimentary de-addiction program. The program was formed by the Northern Deputy Commissioner of the Delhi Police, Ms. Kiran Bedi, who was a crusader of a police chief and pioneered a crime-prevention, drug de-addiction treatment program in police posts in northern Delhi.9 As many of the legal offenses in the city could be attributed to drug and alcohol abuse, this was a novel idea and hitherto untested method of crime prevention by police in Delhi.10 Impressed with his commitment, in January 1988 Commissioner Bedi hired Mr. Vatsyayan as the Founding Director of the Delhi Police Foundation for Correction, De-Addiction Rehabilitation, a formalization of the police clinic network. This formalization of the network, colloquially known as the “Navjyoti police clinic,” insured the continuation of both the rehabilitation space and the de-addiction efforts that were proving effective.11 With his new position, Mr. Vatsyayan facilitated the introduction of the counseling approach at each of the eight police clinics that Commissioner Bedi had originally

For many years, Commissioner Bedi was known as “Crane Bedi” for cleaning up the parking problem in Delhi and famously towing Prime Minister Indira Gandhi’s car. (Bedi, Kiran. “Professional – Traffic Police Chief – ‘Crane Bedi.’” www.kiranbedi.com. http://www.kiranbedi.com/trafficchief.htm (accessed May 1, 2013)). 10 Vatsyayan, Suneel. “Police and NGOs: Partnership for Social Correction.” Paper presented by Suneel Vatsyayan at the South Asian Association for Regional Cooperation’s Regional NGO Conference on Developing Sustainable Substance Abuse Prevention Strategies and Utilizing Community Resources in Katmandu, Nepal, 1998. p. 1. (On file with Suneel Vatsyayan). For more information on SAARC visit http://www.mohe.gov.af/saarc.afg/about%20us.html. 11 Vatsyayan, Suneel. Interview by Alex Hitch. Personal Interview. Chicago, IL (Skype), May 14, 2013; Vatsyayan, Suneel (September 13, 2011). Navjyoti became the nominal name for the police clinic. Navjyoti in Hindi means, “new light.” Throughout the report, “Navjyoti,” “Navjyoti police clinic,” and “police clinic” are used interchangeably, all referring to the Delhi Police Foundation for Correction, De-Addiction Rehabilitation.

established.12 Other members of the organization included Dr. J.P.S. Bakshi as the medical director, Mr. S.D. Dwivedi as the yoga therapist, and sixteen trained police officers to monitor the recovering addicts.13 The several police clinics in Delhi were eventually consolidated into one large clinic at the Sarai Rohilla police station, as the expenses were too great for the Navjyoti to split its services across the city. This larger Navjyoti had four full-time doctors, seven full time counselors, and over ten supervisors that served approximately 180 addicts each year.14 However, this consolidation also helped standardize the treatment program, which would evolve into the medico-psycho-social and spiritual model eventually employed by the Nada India supported therapeutic communities. This model included aspects of the twelve-step program from Alcohol Anonymous and Narcotics Anonymous, as well as concepts of a therapeutic community such as group counseling, yoga and meditation, homeopathy, and complete drug abstinence.15 The treatment regimen would begin with an outpatient phase for addicts, followed by a sixmonth residential treatment program, and finally an after-care program for rehabilitation and social reintegration.16 By combining these phases of treatment, they combatted the biological, psychological, and social problems of drug addiction in one holistic treatment model. They recorded that their method achieved nearly a 60% success rate.17

Along with Sarai Rohilla, the seven other police clinics of North Delhi included: Andha Mughal Police Post, Adarsh Nagar, Majanu ka Tilla, Jahangirpuri, Mangolpuri, Sultanpuri and Keshav Puram; Vatsyayan, Suneel. Interview by Alex Hitch. Personal Interview. Chicago, IL (Skype), April 12, 2013. 13

Navjyoti Delhi Police Foundation. “A Decade of ‘Life Again’” Navjyoti News: Help For The Helpless 1 (1997). p. 3.

14 Rajagopalan, Shruti. “Directorate of Prohibition” Centre for Civil Society: CCS Internship Papers 2003. http://ccs.in/internship_papers/ 2003/chap2.pdf (accessed April 1, 2014). p. 15. 15 Ibid. pp. 16-17. The use of homeopathy is incorporated because it is non-habit forming and the dependence is less severe as dosage is very small. 16

Ibid. p. 16.

Ibid. p. 15.

The Navjyoti extended their work beyond the treatment of addicts, as it began to notice the issues inherent in drug abuse in the poverty-stricken slums such as Yamuna Pushta. The police clinic diversified by providing education, health services and vocational training to children, while also working to educate children to keep them from drug and alcohol abuse.18 Moreover, the Navjyoti began a new stage of community outreach with the “Navjyoti Natya Manch,” a theatrical play by drug addicts for informing communities of the dangers of drug abuse. In 1994, Deputy Commissioner Bedi, with Mr. Vatsyayan’s help, began providing services in Tihar Jail, the largest prison complex in South Asia with approximately 12,000 inmates, to combat the drug problem within the jail itself.19 Many of the same treatment procedures that were instituted in the Navjyotis were also employed in the jail, including peer-led counseling, meditation, and yoga.20 The Navjyoti also established women’s empowerment programs in the disparaged communities of Jehangir Puri and Bhondsi. It was yet another novel way to approach drug abuse and crime prevention, and Commissioner Bedi and Mr. Vatsyayan became renowned for their work across the Delhi area. However, funding was not a simple task for the Navjyoti police clinic. Each patient was required to pay Rs. 1,700 ($28.25; £17.00), with the average patient’s costs ranging from Rs. 10,000 to as high as Rs. 15,000 ($166.00; £99.00).21 As a result, the police clinic was primarily funded by community donations that were collected by police volunteers for its first several years. But because of the success of their treatment program, in 1991 the Ministry of Social Justice and Empowerment of the Indian government extended financial assistance to the Navjyoti, a hallmark occurrence that signified the

Vatsyayan, Suneel. “From the Outgoing Convenor” NGO Forum for Street & Working Children (2000). p. 3.

Navjyoti Delhi Police Foundation. (1997). p. 3.

“Ranjan.” “Innovative Project in the Prison.” Navjyoti News 5:1, 1994. p. 4.

Rajagopalan, Shruti. (2003). p. 16.

government’s support of the program.22 By 1993, the National Institute of Social Defence recognized Navjyoti as an official training center for counseling and drug abuse treatment, with professionals and police imparting knowledge on the consequences of addiction, along with a day-care center for recovering addicts for proper monitoring and recovery.23 Through the cooperation of social workers, medical professionals, and police officers, the Navjyoti police clinic had grown to represent a successful and innovative method to policing strategy and crime prevention. The Origination of the Peer-Led Treatment Method The Navjyoti police clinic employed many new types of treatment that would eventually be emulated by the therapeutic communities of ARPAN. This included the service of former drug addicts as peer support counselors, who in 1990 were recognized as official counselors at the clinic.24 The Navjyoti also implemented “Kutir Udyog” (cottage industry) to add the element of economic rehabilitation for addicts, as well as establishing an “after-care-cum rehabilitation” center in 1994.25 This center concentrated on the whole recovery of an individual, incorporating both behavior modification and economic rehabilitation following drug cessation.26 Since nearly the inception of the Navjyoti, Mr. Vatsyayan also sent addicts to visit Alcohol Anonymous (AA) self-help groups as an additional component of treatment. However, the AA members continuously classified the police clinic addicts as the poorer and lower status patients. Alcoholism had a higher social standing as a less-serious illness, as opposed to heroin and cannabis addicts of the Navjyoti 22

Rajagopalan, Shruti. (2003). p. 15.

Navjyoti Delhi Police Foundation. (1997). 3.

Ibid. p. 2.

Ibid.

Ibid. p. 3.

police clinic. Thus, in 1995, Mr. Vatsyayan stopped sending the police clinic addicts to AA meetings and encouraged the creation of an independent Narcotics Anonymous (NA) breakout group, ultimately being established by Rajesh Wig, a founder of one of the future independent therapeutic communities.27 The germination of this new group, however, came in the addicts’ own image, that of a peer self-help group. Indeed, Mr. Vatsyayan had seen the potential of a peer-support counselor and therapeutic community leader in recovering addicts since his early work at the Navjyoti police clinic. The former addicts, having been through great pain and sorrow, were willing to impart the same empathy they had received in the healing process to others who had recently arrived. All they required were the skills and knowledge that would enable them to work objectively and independently. In 1995, Mr. Vatsyayan was invited by the United States Information Agency to visit drugtreatment centers across the United States in an international exchange program of twenty-five social workers, counselors, and medical doctors involved in drug rehabilitation.28 On this visit, Mr. Vatsyayan witnessed how police departments dealt with addiction rehabilitation in the United States, as well as how they worked within prisons. Most notably, however, it became clear to Mr. Vatsyayan that there was not a specific way to treat addiction. Indeed, each program is reliant on other services included in its regimen, as well as the culture in which it resides.29 This lesson was affirmed in 1998, when Mr. Vatsyayan met Dr. Michael Smith of Nada International at a drug abuse prevention conference in Jakarta, Indonesia. Dr. Smith was the head of the substance abuse division of Lincoln Hospital, based in New York City, and worked with addicts at the Lincoln Rehabilitation Center in the South Bronx.30 The Lincoln Rehabilitation 27 At this time a Narcotics Anonymous chapter did not exist in Delhi. NA was founded in 1953, and today NA communities can be found scattered throughout the Indian subcontinent, Africa, and East Asia. (Ontario Regional Service Committee of Narcotics Anonymous. “Information about NA (2007).” www.orscna.org. http://www.orscna.org/english/info.php (accessed May 28, 2013)). 28

Vatsyayan, Suneel. (April 12, 2013).

Ibid.

Dr. Michael Smith was the Director of Lincoln Hospital Recovery Center from 1974 to 2011, when he retired. Currently, he is an Associate Professor of Psychiatry at Cornell Medical School and is certified by the American Society of Addiction Medicine. He is internationally known

Center had been established in the early 1970s as a community-based addiction treatment program. Dr. Smith shared the benefits of the acupuncture detoxification regimen (acudetox), and later visited India to train Mr. Vatsyayan and others at the Navjyoti police clinic in the acudetox regimen.31 From discussions with Dr. Smith, Mr. Vatsyayan also realized there needed to be a certain balance between rigidity and flexibility in treatment centers, another lesson that would be instituted in the future therapeutic communities of Nada India. Moreover, he understood that although he was a trained social worker, the former-addict peer counselors needed to be seen as colleagues, not subordinates or clients.32 This approach transcended the traditional model of director and worker, replacing it with guru-shisha, or a teacher-pupil relationship. This guru-shisha connection would grow into the basis of ARPAN in coming years.33 As a result of the Navjyoti’s growing reputation, in 1998 the United Nations Drug Control Program (UNDCP) provided the police clinic a grant to train twenty individuals affected by substance abuse in the development of a community based treatment center, as a demand reduction measure for drug rehabilitation in Delhi.34 The participants included fifteen former addicts from the Navjyoti and five for developing the use of acupuncture in the field of chemical dependency. More than 2,000 treatment programs worldwide use the Lincoln Hospital model. As the Chairperson of the National Acupuncture Detoxification Association, Dr. Smith provided consultation to city, county, state, federal, and United Nations agencies in more than one hundred settings. (National Acupuncture Detoxification Association. “Board of Directors.” acudetox.com. http://acudetox.com/about-nada/11-board-of-directors (accessed April 21, 2013)). 31 Acudetox consists of trained administers applying three, fine gauge, sterilized stainless steel needles just under the skin of the ear that produces calming effects to the receiving patient. (Acupuncture Today: The Acupuncture and Oriental Medicine News Source. “The Nada Protocol.” www.acupuncturetoday.com. http://www.acupuncturetoday.com/abc/nadaprotocol.php (accessed May 10, 2013)). Yet Nada India would grow into being a non-profit organization that did much more than acupuncture. For Mr. Vatsyayan, a principle reason for bringing acudetox into the TC treatment modality was to mediate the gap between the streets and the facility. He understood the efficacy of acudetox, as a wide spectrum of drug users could be brought into the drug treatment programs in the neighborhoods where they lived. Moreover, acudetox allowed individuals to receive treatment during all stages of drug rehabilitation, as it did not revolve around the drug. 32

Vatsyayan, Suneel. (April 12, 2013).

Nada India Foundation. “Nada India Network Members.” www.nadaindia.info. www.nadaindia.info/network.htm (accessed May 19, 2013).

Vatsyayan, Suneel and T.K. Thomas. “Training of recovering addicts and their family members as peer support educators: An Indian experience.” Mobilizing Communities Blogspot. http://peer-ledcorrectionrehabilitation.blogspot.in/2010/12/training-of-recovering-addictsand.html (accessed June 20, 2013). The full report is on file with Suneel Vatsyayan.

family members of addicts. The training was broken into three phases: Pre-training for three months, a training and developing module for six months, and a post-training for three months.35 These sessions provided preparation in the science of drug dependence, national and international strategies on drug demand reduction, treatment modalities, ethics of social workers, long-term rehabilitation methods, reintegration into the family and society of recovering addicts, and in the principles of AA and NA self help groups.36 Moreover, the program equipped the participants in practical exercises such as in family counseling, client servicing, yoga, communication skills, campaign planning and implementation, community outreach and the use of traditional media, and management skills.37 Most notably, however, was that several of these trainees would go on to establish their own TCs in the vein of this training’s curriculum, independent of the Navjyoti police clinic.38 By 2000, Mr. Vatsyayan had grown into the knowledgeable and respected Director of the police clinic, but Commissioner Bedi’s ambition was just as vital a component to its success. Commissioner Bedi was responsible for the broad range of additional services that the Navjyoti entered, including education, community development, and vocational training. In no small part to Ms. Bedi, the Navjyoti had support from many private donors organizations and the United Nations.39 With these successes and assurances, Mr. Vatsyayan – who was so integral to the Navjyoti’s success, as well as the success of the peer-group method – realized that his services at the police clinic were no longer required. Still, he understood the great need for treatment centers in the Delhi area, and that his work with de-addiction and 35 Ibid; Mr. Vatsyayan’s colleagues T.K. Thomas, a communication trainer and consultant, and Dr. Sanjai Bhatt of the Delhi University School of Social Work, each added new dimensions to the approach towards peer-led treatment centers. 36

Vatsyayan, Suneel and T.K. Thomas. http://peer-ledcorrectionrehabilitation.blogspot.in/2010/12/training-of-recovering-addicts-and.html (accessed June 20, 2013). 37

Ibid.

Rajagopalan, Shruti. (2003). p. 15.

rehabilitation was not complete. He realized it was time to rescind his role as the Director of the police clinic, and grow into a teacher for those willing to establish their own treatment centers. Branching Beyond the Police Clinic Following his move away from the Navjyoti police clinic, Mr. Vatsyayan began to lay the groundwork for future peer-led treatment initiatives. Although he and Dr. Smith’s collaboration originated in their acudetox training at the Navjyoti, their relationship continued to blossom, so much so that in 2000, Dr. Smith co-founded the Nada India Foundation with Mr. Vatsyayan and established a permanent office for South Asia. Mr. Vatsyayan also began advising former addicts who branched out with their own TCs from the UNDCP training.40 These former addicts had established TCs throughout the Delhi area and northern India, often with inspirational names such as “Nai Kiran” (New Ray), “Mukti” (Freedom), “Parivartan” (Change), “Savera” (Morning), and “Ankush” (Restrain).41 A remarkable number of suffering drug and alcohol addicts now had access to a missing component of the healthcare delivery system in India: An affordable and accessible drug and alcohol treatment program in the states of Delhi, Rajasthan, Uttar Pradesh, Haryana, Utteranchal, and Punjab.42 However, with the continued proliferation of these rehabilitation centers, many of the lessons of how to establish a universal and effective standard of care began to be overlooked. Arising primarily because the TC treatment modality was fairly simple to duplicate, the centers competed for patients and prestige, bending the system of care and corrupting its treatment philosophy. The centers’ leaders competed with one another to be held in higher regard by Nada India, and the success of their individual 40 Khisa, Bihita Bidhan. “The Mukti: A Therapeutic Community.” Report submitted to the Delhi University School of Social Work for fieldwork. 2002. p.1. (On file with Suneel Vatsyayan). 41

Hindustan Times. “Stress management: ‘Developer’ Vatsyayan’s mantra for cops under stress.” Hindustan Times. October 28, 2002.

42 Vatsyayan Suneel. “Recovery from drug addiction.” The Hindu. July 6, 2008. http://www.hindu.com/op/2008/07/06/stories/ 2008070651551400.htm (accessed June 15, 2013).

programs became more important than quality de-addiction delivery.43 Concerned for the health of the TC treatment modality he had helped to establish, Mr. Vatsyayan realized the need to streamline and develop a more formalized training program and quality control component as the treatment centers continued to multiply. This would allow for all of the TCs to keep the practices of the peer educators consistent. He commissioned Ms. Shonali Shah, a medical student of Cornell Medical College in New York, and Mr. Bihita Bidhan of the Delhi University School of Social Work, to conduct a third party needs-assessment survey of the Nada India affiliated TCs.44 Their findings of the treatment centers included:

A lack of involvement of professionals such as social workers, psychologists, and occupational therapists

ii.

A lack of Infrastructure and inadequate space in many of the centers

iii.

No permanent premises, as much of the land was rented and they had limitations of independent use45 Ms. Shah and Mr. Bidhan’s analysis also included discoveries that demonstrated the

methodological limitations in the manner of care:

A rigid and generalized program structure with minimum flexibility

ii.

A lack of systematic and scientific management of the cases

iii.

A lack of follow up and outreach programs

iv.

A lack of systematic planning of program keeping in view of the diverse needs and problems of the residents

Inadequate professional/clinical supervision and monitoring

vi. Lack of training in scientific counseling46 43

Vatsyayan, Suneel. (April 12, 2013).

Vatsyayan, Suneel, A. Goswami, Arun Gupta, Om Prakesh, Vinay Singhal, T.K. Thomas. “Proposal for evolving and strengthening of quality care network among peer led drug rehabilitation initiatives with a purpose of reducing risk HIV/AIDS in boarder areas of Delhi.” (2002). p. 4 (On file with Suneel Vatsyayan). This proposal was submitted to the Ministry of Social Justice and Empowerment for funding, but was not accepted. 45

Ibid. p. 5.

Major changes were needed, and as the number of Nada India supported TCs had grown to ten total therapeutic communities, their loosely related and non-allied makeup required a network to keep them all true to the TC treatment modality and to steer clear of any possible illicit treatment methods. Therefore, in 2000 Mr. Vatsyayan, with the TC treatment center leaders, developed ARPAN (Association of Recovering Peoples Action Network), a network under the auspices of Nada India that would work to reduce high-risk behavior and trauma as it related to drug abuse.47 It would work to accomplish the following objectives:

To share common concerns, fears, and innovations

ii.

To resolve differences by inculcating values of cooperation and mutual respect rather than competition and jealousy

iii.

To share best practices among the members such as techniques of dealing with clients with denial, aggression and violence, dual diagnosis, staff burnout and compassion, fatigue, etc.

iv.

To develop service linkages and a feedback system for effective interventions

To provide the members an opportunity of ventilation and validations of their feelings and experiences

vi.

To provide learning opportunities keeping in view their personal growth including personal recovery from addiction in a professional environment

vii.

To seek support and network with other stakeholders like NGOs, law enforcement agencies, district administration, local media, etc. for effective community based interventions

viii.

To appreciate and accept the role of other professionals in the field and establish themselves as another service provider in order to make it a collective effort48

Vatsyayan, Suneel, A. Goswami, Arun Gupta, Om Prakesh, Vinay Singhal, T.K. Thomas. (2002). p. 5.

Peer led drug rehabilitation facilities in ARPAN include, Mukti De-addiction center, Aman Foundation De-addiction center, Ujala De-addiction center, Nai Kiran De-addiction center, Ankush De-addiction center, Sawera De-addiction center, Utkarsh Foundation, Parivartan De-addiction center, Shreyas Foundation, and Carers Foundation. 48 Vatsyayan, Suneel. “Mukti Drug Rehabilitation Center: A Peer Led Initiative and Role of Professional as Mentor or “Guru.” (2001). p. 5 (On file with Suneel Vatsyayan). This proposal was submitted to the Delhi AIDS Control Society for funding of HIV/AIDS prevention efforts by Mukti. “ARPAN” in Sanskrit means to “present or offer in dedication”, and they see their efforts as an “offering” to the community (Nada India Foundation. “Nada India Network Members.” www.nadaindia.info/network.htm. (accessed May19, 2013)).

The network also established a minimum “standard of care,” as per the standard of care guidelines issued by the Ministry of Social Justice and Empowerment. All TCs in ARPAN would be required to adhere to these standards. Some notable items included (see Appendix A for a full list): i.

Referrals must be made within two days for any patient needing a higher level of psychiatric care

ii.

Therapy manual developed detailing clinical strategies and guidelines for all counselors

iii.

Individualized treatment plans for whole person recovery

iv.

Facilitation provides group with a safe space where confidentiality is assured and full participation is encouraged

Rights of client displayed for clients, family members, and visitors

vi.

Properly ventilated, well lit, and cleanly maintained

vii.

Networking with other agencies to share successes, challenges, and strategies of interventions as they relate to client care As a method to maintain these standards of care, regular meetings and training programs were

established with the leaders of member TCs. These meetings’ topics included items such as communication, counseling, acudetox, public relations, and first aid.49 And to keep the standard of care consistent, a “check-up” system was also developed, which stated: “an internal review is expected to take place biennially. Staff and service users will evaluate their service against the service standards. Each member facility will nominate a lead person who will be trained in how to use the standards for internal review and how to interpret and use the results.”50 ARPAN meetings became the regular manner in which Mr. Vatsyayan could stay in contact with the Nada India supported TCs and assess how each was operating. But these meetings also acted as a 49

Vatsyayan, Suneel. (2001). pp. 4-5. Vatsyayan, Suneel, A. Goswami, Arun Gupta, Om Prakesh, Vinay Singhal, T.K. Thomas. (2002). p. 9.

forum in which to iron-out the rivalries, differences, and feuds that had developed in the competition for patients and success. The ARPAN members would also elect a convener and treasurer to maintain efficiency and provide for continual feedback from professionals such as Dr. Smith and the UnderSecretary Arunodya Goswami of the Ministry of Social Justice and Empowerment.51 To this day, Nada India continues to support the ARPAN project through peer-led training, general consulting and support, and advocacy efforts with the Indian government.52 With the successes of the Nada India supported TCs and their methods being controlled by their own self-developed peer network, outside actors were beginning to notice their methods as being possibly beneficial. In 2007 the Indian Military Border Security Forces of Punjab approached Mr. Vatsyayan for assistance in preventing alcohol abuse and suicide within their ranks.53 As the Tribune India quoted concerning the Border Security Forces, “The nature of the job is very demanding with adverse climatic conditions, unperceived hours of work, tight scrutiny, a limited scope for family accommodation status, strict discipline and severe penalties for lapses. Because of these reasons stress takes a toll which may even lead to undertaking of extreme activities like attempt to suicide. Therefore, a need was realized by Nada India to deal with the problem of increasing stress levels in the forces.”54 Nada India began to work with constables in the remote border regions of India, from Punjab to Agartala in the east. They sent Nada International volunteers to work at these camps, and also trained

Vatsyayan, Suneel. (2001). p. 4.

Vatsyayan, Suneel. Interview by Alex Hitch. Personal Interview. Chicago, IL (Skype), April 26, 2013.

The Border Security Force is the paramilitary force charged with guarding India's land border during peacetime and preventing transnational crime. It currently stands as the world's largest border guarding force (Border Security Force: Ministry of Home Affairs (Govt. of India). http://bsf.nic.in (accessed May 23, 2013)). 54 The Tribune India. “Health care programme for BSF.” The Tribune India. January 11, 2008. http://www.tribuneindia.com/2008/20080111/ bathinda.htm#11 (accessed April 29, 2013).

officers in Border Security Forces battalions to administer peer-led treatment themselves, as well as acudetox for stress reduction.55

II. Drug Abuse and Current Treatment Methods in India Drug and alcohol abuse, and the high-risk behavior associated with it, causes a host of wellunderstood health issues for the individual. Perhaps more damagingly, however, is its inherent threat to the social fabric of communities and families in which addiction is prevalent. Testimonies from actual addicts within the treatment centers clearly speaks to this point: “Now the situation became such that I began to cheat and keep back money given by my family to purchase things for the house and spent that on drugs.” “My family began opposing me openly now and there were fights and disagreements in the house but I never used to listen to anyone and kept on getting intoxicated.“ “I sold my mother's jewelry to buy drugs. My ancestors land, property and wealth were also ruined by drugs. I was in such circumstances that… my mother threw me out of the house twice.”56 The Indian governmental body responsible for the control of drug and substance abuse is the Ministry of Finance, acting as the administrator of the Narcotic Drugs and Psychotropic Substances Act of 1985, and the Prevention of Illicit Traffic in Narcotic Drugs and Psychotropic Substances Act of 1988. The Narcotics Control Bureau, falling under the Ministry of Home Affairs, functions as the coordinator of the various offices, while the Ministry of Social Justice and Empowerment organizes training programs and the building of NGOs. The Ministry of Social Justice and Empowerment has also established the 55

Towards Well Being Blog. “Ear acupuncture based alcohol treatment and rehabilitation services in Border Security Force (Punjab Frontier).” towardswellbeing.blogspot.in. December 23, 2008. http://towardswellbeing.blogspot.in/2008/12/ear-acupuncture-based-alcoholtreatment.html?view=flipcard (accessed April 2, 2013). 56

Unpublished case studies courtesy of Suneel Vatsyayan. I have chosen to hide their identities for both their privacy and that of their families.

National Consultative Committee on De-addiction and Rehabilitation to advise both the central and state governments on issues connected to de-addiction, including NGOs funded by the government and those that are private, such as the Nada India supported TCs. Lastly, the Government of India works in demand reduction on a national level, and has a three-pronged strategy for demand reduction: i.

Building awareness and educating people about the ill effects of drug abuse

ii.

Dealing with addicts through a program of motivational counseling, treatment, follow-up and social-reintegration

iii.

Imparting drug abuse prevention and rehabilitation training to volunteers with a view to build up an educated cadre of service providers57

Unfortunately, even with these strategies, no method of assessing the number of people reached from drug prevention mediums or the efficacy of their programs currently exists.58 It is important to appreciate, however, that addiction is an experience of a human being, not a property of a drug or substance.59 Learning to see addiction as an illness, much as we do other major physical illnesses, is integral to challenging the manner in combating it. And in order to treat an illness, it is not appropriate to treat it only with pharmaceuticals, but with changes in lifestyle, behavior modification, and with the empathy and support of others. Although treatment approaches continue to evolve to changing needs, there are five main ways in which to treat drug and alcohol addiction: Outpatient treatment, group counseling, individualized drug

Rajagopalan, Shruti. (2003). p. 11.

Ibid. pp. 2; 6.

For a concise overview of misconceptions of addiction see http://lifeprocessprogram.com/the-meaning-of-addiction-3-theories-of-addiction/.

counseling, short-term residential treatment, and long-term residential treatment.60 Outpatient treatment is mainly centered on counseling and is best for people with careers and extensive social supports. Although it is the least cost-prohibitive type of treatment, it often can offer little more than basic drug education. Group counseling provides a non-residential peer discussion of abuse issues, while individualized drug counseling focuses on the effects of addiction on employment, social relations, and illegal activity, independent of a community setting. Short-term residential treatment usually consists of a three to six week hospitalization period where patients undergo detoxification, individual counseling and psychotherapy, and are expected to participate in outpatient treatment through a self-help group to reduce the risk of relapse.61 However, these four methods rely more heavily on the efficacy of de-addiction medications, and often lack a holistic recovery. The Nada India supported treatment centers in the ARPAN network fall under the long-term residential treatment method commonly referred to as the “therapeutic community” method.62 The TC method provides care around-the-clock, and usually consists of a six to twelve month stay for the addict.63 The treatment model also provides community activities for patients to learn about themselves through emotional conditioning and behavior management, while also helping them understand that de-addiction is possible through challenging one another and sharing common experiences.64 Thus, the activities in a

National Institute on Drug Abuse. “Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition).” www.drugabuse.gov. http://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/drug-addiction-treatment-inunited-states/types-treatment-programs (accessed April 12, 2014). 61

National Institute on Drug Abuse. http://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-thirdedition/drug-addiction-treatment-in-united-states/types-treatment-programs (accessed April 12, 2014). 62

Ibid.

Daytop Village. “About Us.” www.daytop.org. http://www.daytop.org/about.html#wha (accessed June 10, 2013).

TC are designed to produce not only therapeutic strength and full detoxification, but also educational growth for the participants, with the actual individual participants as the mediators of these changes.65 Therapeutic communities, run by peer counselors and former addicts, however, are not unique to India. Numerous other countries have similar organizations and treatment centers, but most suffer from comparable issues, especially underfunded centers in developing nations. Many of the therapeutic communities in Asia – part of the Asian Federation of Therapeutic Communities – are trying to dispel their often-negative reputations, which stem from lack of quality care and occasional issues with poor management.66 This has arisen from the recent proliferation of facilities, which has in turn adulterated the methods of many therapeutic communities.67 Moreover, many of the centers have issues with personnel, including a shortage of adequately trained staff and inabilities to meet governmental requirements of having a post-secondary trained psychologist.68 Accordingly, many of these centers and their employees receive discrimination from the professional world, as many governments and professionals are hesitant to assume that these therapeutic communities provide safe and effective treatment.69 Therapeutic Community Structure and Treatment Regimen Taking an in-depth, comprehensive analysis of how the treatment of the addicts actually progresses within a TC can provide rare insights into how it functions outside of government support. It also illuminates inadequacies and where improvement could prove most impactful. Perhaps the most complete example of a long running and respected Nada India therapeutic community is that of Mukti 65

Vatsyayan, Suneel. (2001). p. 6.

66 Castillo, Eddie. “AFTC Report” Presentation by Eddie Castillo, President of the Asian Federation of Therapeutic Communities at the World Federation of Therapeutic Communities conference in Bali, Indonesia, 2012. (On file with Suneel Vatsyayan). 67

Ibid.

Drug De-Addiction and Rehabilitation Center (Mukti).70 The Mukti TC is directed by one of Mr. Vatsyayan’s first mentees, Rajesh Vig, a former drug addict of nearly ten years who has been drug free for eighteen. The community provides a strong example not only because of its success and continuity, but also because of the number of other therapeutic communities that have mimicked its program and structural model. Since its inception in June of 2000, it has consistently provided services to approximately forty-five live-in clients, belonging to a diverse set of socio-economic backgrounds. It has served over 2,000 addicts to date.71 Mukti’s main goal is to provide a residential rehabilitation program for addicts using the therapeutic community peer-led approach. However, the TC method goes beyond curing the addiction to find the full potential of the individual and reestablish him into the public sphere as a productive, unstigmatized member of society. To accomplish this, Mukti facilitates the social reintegration of the members through a family counseling service, helping their families understand how to reintroduce them into the community.72 Mukti’s leaders also conduct awareness and training programs on drug abuse and its dangers, and organize awareness programs for HIV/AIDS, vaccination programs from hepatitis, and Nada India supported acudetox training programs.73 The leaders include a part-time psychiatrist, five former-addict counselors with experience in rehabilitation, a social work trainee from the Delhi School of Social Work, and several recovering addicts who volunteer as maintenance and service providers.74 The work of recovered addicts as counselors and support staff helps in that the residents easily identify with

Mukti Rehabilitation Centre. “About Us.” www.muktirehab.org. http://muktirehab.org/wp/about-us (accessed June 8, 2013). Mukti was originally located in Mundka Village, but it has since moved to Samai pur Badali Village. 71

Ibid.

Khisa, Bihita Bidhan. (2002). p. 2.

Ibid. pp. 3-4.

them and see an everyday example of success, even though their lack of knowledge and expertise with specialized skills in counseling and psychology can be a limitation.75

Governing Body

General Secretary Director

Social Work Trainee

Ex-‐addict Counselor

Ex-‐addict Counselor Voluntary Staff (6-‐8)

Ex-‐addict Counselor

Family (Recovering Addicts)

Figure 1: Mukti Organizational Structure76 Addicts who come to Mukti abuse many drugs, including cannabis, heroin, alcohol, opium and propoxyphene, and originate from all walks of life and financial backgrounds. The admission process therefore relies on how dire their addiction is, with the fee being based on their financial situation. To determine these variables, addicts undergo a detailed psychological and drug history assessment, and if it is deemed appropriate for admittance, the addict is kept under observation for a few days to justify motivation and commitment to undergo de-addiction and rehabilitation.77 The average monthly fee for 75

Khisa, Bihita Bidhan. (2002). pp. 4-5.

Ibid. p. 2.

Ibid. p. 5.

each addict is Rs. 3,200 ($53.00; £32.00), with the required payment minimum around Rs. 2,500 per month. Addicts in need can receive sponsorship or free treatment, depending on their economic situation or the severity of their addiction.78 Once admitted, the addicts do not engage in any off-site communication during the first week of care.79 They then begin the five steps of recovery, structured so that they acquire living, social, occupational and interpersonal skills.80 The first step centers on physical recovery, denoting the initial absence of drugs. For a chemically dependent person, this initial abstention from the substance is meant to begin a life-long commitment of drug abstinence. During this process of detoxification, they use auricular acupuncture per the Nada India treatment protocol and insert acupunctural needles at three points in the ear. This works to facilitate retention of the addicts in the program, reduce violence, and eventually leads to a greater admission for more commitment-heavy treatment.81 Following the initial detoxification, the second step, or psychological recovery, involves working in structured activities such as morning meetings, group therapy, counseling, relaxation therapy, and open, trust-filled meetings much like AA (see Appendix B). In this step, they concentrate on stress coping and emotional management, and the twelve-step method of drug recovery pioneered by AA acts as a guideline towards recovery.82 In the third step, they concentrate on social behavior and respect for others by employing specialized therapies such 78

Khisa, Bihita Bidhan. (2002). p. 5.

Ibid. p. 6.

Ibid. pp. 7-8.

Bhatia, Richa. “The Support Group Route to Rehab.” The Indian Express. August 18, 2008. http://www.expressindia.com/latest-news/thesupport-group-route-to-rehab/ (accessed June 8, 2013). 82

Khisa, Bihita Bidhan. (2002). p. 8. Originally proposed by AA as a method of recovery for alcoholism is a set of guiding principles that outline a course for recovery from a drug or alcohol addiction. These steps are to be followed in order, beginning with admittance of a problem, that a greater power can restore sanity to your life, and that you decide to turn that will to that higher power, although this is not necessarily religious. The fourth and fifth steps are usually the most difficult, where the addict recognizes and admits bad behaviors and judgment openly. In the following steps (six, seven), the addict concedes that he is ready for recovery, and asks for forgiveness for their faults, while steps eight and nine outline forgiveness from those they have wronged. Steps ten and eleven continue the moral inventory (searching), and the final step is where the recovering addict begins to help other addicts (No Regret: The Addiction Treatment Homepage. “What is the 12-step program?” www.noregret.info. http://www.noregret.info/12-step-program.php (accessed May 13, 2013)).

as anger management training, while also learning withdrawal-coping strategies.83 In the fourth step, they concentrate on social living and responsibility, as well as the inculcation of appropriate social skills. The final step, which often blends with the fourth, consists of establishing skills in an occupational setting where a variety of leisure and learning activities such as art, singing and other basic skills are taught. It is a distinguishing feature of Mukti’s program, as more than 3/5 of treatment centers do not provide educational or vocational livelihood skills in their treatment regimen.84 Being under the Nada India umbrella, ear acupuncture is a very important component of the detoxification and behavior modification of the recovering addict, and is used through all five stages of Mukti’s program. At Mukti, the acudetox process consists of Nada-trained detoxification specialists applying three, fine gauge, sterilized stainless-steel needles just under the skin of the ear, where they remain for approximately half an hour while the recipient relaxes with other group members receiving treatment.85 Addicts and clinicians report that it creates a more optimistic and cooperative attitude toward the process of recovery, as well as reductions in cravings, anxiety, and sleep disturbance.86 The value lies in that Mukti community members receive relief from their withdrawal symptoms, but also that they are more willing to participate in all aspects of treatment, known in Nada India as the “treatment readiness

Vatsyayan, Suneel. (2001). p. 9.

84 Tellis, Eldred and Gary Reid. Situation Analysis of Basic Education, Vocational Education & Development of Sustainable Livelihoods in Drug Treatment & Rehabilitation Centres of India. New Delhi, India: United Nations of Educational, Scientific and Cultural Organization, 2009. p. 14. In 2009, UNESCO funded a study along with the European Commission to review the “status of drug demand and harm reduction strategies” and it found that 61% of facilities did not provide educational or vocational livelihood skills. 85 Acupuncture Today: The Acupuncture and Oriental Medicine News Source. “The Nada Protocol.” http://www.acupuncturetoday.com/ abc/nadaprotocol.php (accessed May 10, 2013). In the mid-1970s, Dr. Michael Smith modified the system of acudetox as a simple technique for the treatment of drug addiction, primarily as an alternative to methadone. In 1985, after ten years of using this treatment for addiction, the staff realized the need to grow into a national organization from the Lincoln Hospital to expand training capacity and awareness of the value of acupuncture as a tool of recovery. It has since spread to many nations around the world, as Nada estimates that they are over 2,000 clinics worldwide where training and treatment have taken root. But it is not a simple procedure, as those who wish to become proficient in the Nada protocol must study under a Nada registered trainer, and complete a 30-hour training course, which is followed by 40 hours of hands-on work in a clinic. (National Acupuncture Detoxification Association. “FAQs.” http://acudetox.com/about-nada/12-faqs (accessed April 21, 2013)). 86

National Acupuncture Detoxification Association. “FAQs.” http://acudetox.com/about-nada/12-faqs (accessed April 21, 2013).

approach.”87 And unlike the TC treatment modality, which is from the outside to the inside, auricular acupuncture helps one to settle internally, and make better choices among peers and other members of society.88 Perhaps most importantly, however, is that recovering addicts often have few skills and low self esteem, but through learning acupuncture, they possess a skill that is both medically beneficial, and self esteem boosting.89 The Mukti treatment regimen, however, does not always fully succeed. At times addicts may step out of line, cheat the system, or become angered by another member of the community. To help regulate behavior in a zero-tolerance facility, Mukti allows for many issues to be aired before they encourage greater concerns. This comes from their “Attitudes,” which exist for members to confront one another via the “encounter box,” where they may “take up matters before the house on days when encounter is held” (see Appendix C).90 More dire types of punishment, such as shaving ones head, have been banned, as humanizing the experience has become a point of focus in treatment after problems arose in some TCs.91 As the addict enters the final phase of overall treatment at Mukti, his family members are given psychological support and treatment through regular meetings, family-counseling sessions and home visits.92 The addicts attend lectures such as “drugs and their effects,” “addiction as a disease,” and “coping with stress,” while also undergoing group therapy sessions that deal with the physical, social and financial 87 Towards Well Being Blog. “Ear acupuncture based alcohol treatment and rehabilitation services in Border Security Force (Punjab Frontier).” http://towardswellbeing.blogspot.in/2008/12/ear-acupuncture-based-alcohol-treatment.html?view=flipcard (accessed April 2, 2013). The Nada protocol is used in over 130 prisons in England, and post-trauma treatments have been given to local community members after 9/11 and Katrina (Towards Well Being Blog. “Physicians, Mental health professionals, Rehabilitation Experts got acudetox training form Dr. Michael O. Smith in Delhi.” towardswellbeing.blogspot.in. May 24, 2012. http://towardswellbeing.blogspot.in/2012/05/physicians-mental-healthprofessionals.html?view=flipcard (accessed April 4, 2013)). 88

Vatsyayan, Suneel. (May 14, 2013).

Bhatia, Richa. (2008).

90 Mukti Rehabilitation Centre. “Attitudes and House Rules.” p. 1. (On file with Suneel Vatsyayan). The “attitudes” which are listed in many TCs across the ARPAN network, come originally from the Daytop Village therapeutic community in New York City. 91

Vatsyayan, Suneel. (May 14, 2013).

Vatsyayan, Suneel. (2001). p. 10.

damages incurred by drug dependence.93 After completion of the program, the client is discharged but encouraged to attend the after-care program and return to celebrate his recovery anniversaries.94 This continued interaction between the recovered addict and the TC is not common, and the leaders at Mukti propagate this support through both addiction awareness campaigns and presentations of the Mukti treatment vision with addicts’ families and communities.95 Drug-Addiction Treatment Outside of the Therapeutic Communities To understand the larger outgrowth of the Nada India supported TCs, it is important to place the growing problem of drug and alcohol abuse in India in context. Rural to urban migration, acute poverty, and youth unemployment are all major factors for this increase in drug abuse. Poverty in particular persists, with 42% of the Indian population – 456 million people as of 2005 – living on Rs. 75.00 ($1.25; £0.76) per day.96 India also has become more urbanized in recent decades, and this massive societal shift from agrarian to urban divisions of labor has adverse effects and loosens established social controls. Compounding this issue, an estimated 57% of young Indians experience some degree of unemployment, either from a lack of marketable skills or the absence of vocational skill training.97 This is especially concerning because youth are the most likely age group to abuse drugs.98 Finally, India is a large opiate producer, and its proximity to large heroin-producing regions acts as a contributing factor to many of these challenges.99 93

Vatsyayan, Suneel. (2001). p. 10.

Ibid. p. 11.

Mukti Rehabilitation Centre. http://muktirehab.org/wp/about-us (accessed June 8, 2013).

Tellis, Eldred and Gary Reid. (2009). p. 19.

Ibid.

Many of the commonly abused substances include opiates such as heroin, various cannabis preparations, and pharmaceutical sedatives.100 A 2004 analysis by the Ministry of Social Justice and Empowerment and the United Nations Office on Drugs and Crime stated that alcohol, cannabis, and opiates such as heroin were the major destructive drugs in India, with 62.5 million, 8.75 million, and 2 million users, respectively.101 Moreover, the majority of those addicted were males in their twenties and thirties, many of whom are illiterate.102 And although rates of alcohol use are relatively low in India – only 32% of the male population and 2% of the female population use alcohol – continued globalization will promote growth in India’s alcohol industry.103 Alongside the aforementioned Narcotic Drugs and Psychotropic Substances Act of 1985, and its later amendment, The Prevention of Illicit Traffic in Narcotic Drugs and Psychotropic Substances Act of 1988, the Ministry of Health and Family Welfare also put forth the Drug De-Addiction Program in 1988, which was modified for individual states in 1993. The main aim of this program was demand reduction, and it provided each of the Indian states a one-time grant of Rs. 800,000 ($13,269; £7,900), for the construction of Drug De-addiction Centers (DACs).104 Currently, there are 122 such DACs throughout the country, which are usually situated in general hospitals, while some are located in the Government Medical Colleges.105 Every DAC must meet a set of requirements which include an outpatient as well as inpatient based service, medications which are required for management of withdrawals and in 100

Tellis, Eldred and Gary Reid. (2009). pp. 19-20.

101

Ibid. p. 20.

102

Ibid.

103 International Institute for Population Sciences (IIPS) and Macro International. National Family Health Survey (NFHS-3), 2005-06, India: Key Findings. Mumbai: IIPS, 2007. http://dhsprogram.com/pubs/pdf/SR128/SR128.pdf (accessed April 10, 2014) p. 13. 104 Ravindra and Vijakrishnan. “Minimum Standards: Care for Dug De-addiction Centres.” Indian Harm Reduction Network Newsletter 1:1 (2013). p.4. http://ihrn.in/wp-content/uploads/2013/05/IHRN-News-Letter.pdf (accessed May 5, 2013). 105

Ibid.

emergencies, access to basic laboratory services for liver functioning, blood biochemistry, HIV screening, chest X-Rays, and basic counseling services.106 Article 47 of the Constitution of India stipulates that the individual Indian States shall work to discourage the abuse of alcohol and drugs, while the rehabilitation of the addicts and their counseling is the responsibility of the Ministry of Social Justice and Empowerment.107 With funds allocated from this legislation, the Ministry of Social Justice and Empowerment provides approximately 400 NGOs with capital to implement awareness and prevention campaigns, as well as counseling and treatment.108 Moreover, various settings have been developed by Indian states for the treatment of substance abuse at the community level. These include the delivery of services from hospitals, establishment of community clinics and drop-in-centers, and mobile clinics. Nevertheless, the growth of substance abuse management owes much of its success to the partnership between governmental and non-governmental actors, such as peer-led TCs.109 As demonstrated in a report by UNESCO, “the use of peers was beneficial, held broad value and appeal and overall should be encouraged to expand with its contribution to address the complex needs of drug users.”110 They continued, “expansion of the peer model should…be scaled up on the proviso that peers were fully recognised for their role and should receive appropriate financial support.”111 Examples of those interviewed by the report stated similarly positive reviews:

106

Ravindra and Vijakrishnan. (2013). p. 4.

107

Bhushan, Rajesh. “Drug De-addiction Programmes in India” in Rekesh Lal’s Substance Use Disorder: Manual for Physicians. Delhi, India, 2005. http://www.aiims.edu/aiims/departments/spcenter/nddtc/Substance%20Use%20Disorder%20-%20Manual%20for%20Physicians.pdf (accessed April 10, 2013). p. 1. 108

Tellis, Eldred and Gary Reid. (2009). p. 22.

109

Sharma, HK. “Community-based Treatment of Substance Use Disorder” in Rekesh Lal’s Substance Use Disorder: Manual for Physicians. Delhi, India, 2005. http://www.aiims.edu/aiims/departments/spcenter/nddtc/Substance%20Use%20Disorder%20%20Manual%20for%20Physicians.pdf (accessed April 10, 2013). pp. 4; 7. 110

Tellis, Eldred and Gary Reid. (2009). p. 37.

111

Ibid.

“[peers] have become the backbone of our intervention, it improves their self esteem, motivation, they consider themselves useful…clients become the staff. They have benefited hugely on this model. We would put this out as something that could fit the national guidelines. One of the strengths of therapeutic communities or residential care programmes is that by default they are managed by drug users.” “We need more of an introduction of the peer model, building capacity of peers, being involved in the training and decision making process.” “…awareness exists among the doctors, nurses, counsellors that they [peers] are important, this is another resource that needs to be tapped” 112 Moreover, as Dr. Rajesh Kumar, Executive Director of the Federation of Indian NGOs for Drug Abuse Prevention, states: “In the early nineties there were around 21 rehab centers in Delhi – which has reduced to just four presently – and there are none for female drug users. The government scheme of assistance for prevention of alcoholism and substance abuse has to be revised if the government is serious about treatment and wellbeing of drug users in the country.”113 With the dearth of government-run facilities, however, many unauthorized treatment centers have exploited the “desperation of drug users and their families.”114 This has partially occurred because there is no actual inspection and oversight from the Narcotic Drugs and Psychotropic Substances Act, which has

112

Tellis, Eldred and Gary Reid. (2009). p. 37.

113

IHRN Newsletter. “Call for Action: Public Hearing in response to death in Drug Rehab” Indian Harm Reduction Network Newsletter 1:1 (2013): p.3. http://ihrn.in/wp-content/uploads/2013/05/IHRN-News-Letter.pdf (accessed May 5, 2013). 114 IHRN Newsletter. “Drug Treatment and the NDPS Act 1985” Indian Harm Reduction Network Newsletter 1:1 (2013): p.2. http://ihrn.in/wpcontent/uploads/2013/05/IHRN-News-Letter.pdf (accessed May 5, 2013).

allowed for these illegal and dangerous clinics to proliferate.115 Those who have suffered the most have been patients of these clinics and their families, as these dark examples demonstrate:

At the Amarjot Drug de-addiction center in 2003, a former addict running the treatment was arrested for beating patients with logs, a baseball bat, and conducting mental torture.116

ii.

In 2008, an addict named Surinder Singh was admitted to the drug de-addiction center in Balongi, and died under mysterious circumstances only four days later, with his mother claiming he was tortured to death.117

iii.

In 2009, a 26 year-old Pondicherry man was declared dead upon his arrival to a government hospital after being admitted to a drug rehabilitation center in Guduvancheri, one that was known to strip their patients naked, and beat them if they turned violent from their withdrawal symptoms.118

iv.

In 2012, a 24 year-old was found dead inside of a de-addiction center in Dwarka, and upon investigation it was determined that he had his hands bound for days, and had died from a head injury.119

Unfortunately, these heinous reports have worked to undermine the public perception of true TCs that provide strong and safe treatment for their clients. To combat these atrocities, the Ministry of Social Justice and Empowerment established minimum standards of care to help curb the many tragedies that have occurred at independent treatment centers. Furthermore, in September 2010, the Haryana government issued the Haryana De-addiction 115

IHRN Newsletter. (2013). p. 2.

116 Tribune News Service. “De-addiction centre inmates ‘tortured’: Thrashed by Director in the name of therapy.” Chandigarh Tribune. August 8, 2003. http://www.tribuneindia.com/2003/20030809/cth1.htm (accessed May 13, 2013). 117 Staff Reporter. “Mystery shrouds the death of drug addict.” The Hindu. August 25, 2008. http://www.hindu.com/2008/08/25/stories/2008082555340800.htm (accessed May 13, 2013). 118

Narayan, Pushpa. “Drug rehab centres strip inmates, beat them up as part of cure.” The Times of India. December 14, 2009. http://articles.timesofindia.indiatimes.com/2009-12-14/chennai/28063807_1_rehab-centre-rehabilitation-centre-addiction (accessed May 13, 2013). 119 TNN. “Youth found dead in drug rehab centre.” The Times of India. October 26, 2012. http://articles.timesofindia.indiatimes.com/2012-1026/delhi/34749561_1_rehabilitation-centre-drug-rehab-centre-post-mortem (accessed May 13, 2013).

Centres Rules, 2010, and in January 2011, the Punjab government enacted the Punjab Substance Use Disorder Treatment, Counselling and Rehabilitation Centres Rules, 2011.120 These rules mandate that all drug treatment and rehabilitation facilities must obtain licenses and are subject to inspections, while also explicitly requiring voluntary admission, free of coercion.121 Moreover, the unlicensed treatment centers and any of those committing human rights violations are liable to closure, as well as prosecution.122 Treatment centers are now required to inform the government of the commencement of operations, have the correct number of beds, sufficient ventilation, adequate number of toilets, and other basic necessities.123 They must also provide a doctor and nurse for every twenty patients, and a counselor for every ten patients, as well as around-the-clock security.124 More stringent laws, however, are needed nationally, and especially in regions similar to Delhi where the number of drug addicts is quite high.125

III. A Way Forward Clearly, the number of government institutions providing drug dependence treatment is too few, as is the proper regulation of private facilities that purport to provide such services. And although the development of successful therapeutic communities has gained attention, these treatment centers need more recognition, support, and funding. Inherently, TCs are very private entities, but Mr. Vatsyayan has consistently exposed people from the surrounding communities, the media, and the government, which 120 Tandon, Tripiti. “Treatment not torture: A case for establishing right based drug dependence treatment regulations in Punjab and Haryana.” Indian Harm Reduction Network Newsletter 1:1 (2013). p.7. http://ihrn.in/wp-content/uploads/2013/05/IHRN-News-Letter.pdf (accessed May 5, 2013). 121

Ibid.

122

Ibid.

123 Expose India Live. “Haryana Government framed the Haryana De-addiction Centres Rules” EIL: ExposeIndia LIVE. November 9, 2010. http://exposeindialive.com/eil/?p=2419 (accessed April 12, 2014). 124

Ibid.

125

IHRN Newsletter. (2013). p.2.

not only desensitizes the visitors, but humanizes the experience for the addicts as well. Along with the establishment of ARPAN, Mr. Vatsyayan has continued his promotion of the therapeutic community treatment modality by making Nada India a member of the Asian Federation of Therapeutic Communities (AFTC). The AFTC promotes this modality to “unite a community of TC advocates within the Asia Pacific Region by building and sustaining a professional organization yet caring environment,” a noble effort that ensures quality care for all TCs in the network.126 Mr. Vatsyayan continues to work with police agencies, psychiatric programs, acupuncture clinics, and HIV/AIDS treatment centers, as well as in the training of recovered addicts, social workers, and physicians in NGO management, acudetox, and counseling. With his wife Pallavi, he has also reached out to women. Unlike the male addicts, a larger percentage of female addicts suffer from pharmaceutical drug abuse. Because of the serious social stigma associated with female addicts in India, this has been a long, hard road to be won for Nada India and the peer-led treatment method. Mr. Vatsyayan is also pushing for the ability for trained peer counselors, social workers and yoga therapists to practice as acupuncture detoxification specialists, as it is often out of reach for marginalized populations without a strong number of caregivers. The simplicity of auricular acupuncture means that outreach workers, peer counselors and social workers can provide these services safely. And, in the process, and at the patient’s own pace, they make connections with the doctors and other service providers and addicts to develop more long-term change. Nevertheless, it is crucially important to the success of the Nada international protocol that it remains a type of treatment that is only administered with the appropriate training. Of course, an abstinence-only method of treatment is difficult, as there is more money in pharmaceuticals, and the philosophical approach of abstinence is being challenged as India continues to 126 The Asian Federation of Therapeutic Communities. “About AFTC.” www.asianfedtc.org. http://www.asianfedtc.org/index.php (accessed June 3, 2013).

change. Still, Mr. Vatsyayan is proud of the network that ARPAN has grown into and what the therapeutic communities have become. As he states, “we may not have a large corpus of funds,” but are “proud of a large corpus of goodwill, credibility, and transparency.”127 And now that the TC treatment modality has established itself in the Delhi region and experienced great success through the support of Nada India, its foremost challenge may be that it again adheres to its principles. Just as post-rehabilitation autonomy is when a former addict can relapse into the doldrums and darkness of his previous life, the Nada India supported TCs and all other truthful treatment programs must be vigilant not to waver as they grow and evolve. They must be wary of their responsibility as peer-led therapeutic communities and their fidelity to the original principles. And as India continues to change, the TCs must evolve as well.

Action Points Aside from its faults, the therapeutic community treatment modality is an effective drug and alcohol treatment method, due in no small part due to its ease of access. The recovered-addict peer support counselors have learned from each recovering addict, as well as from their own experience, of what motivation and guidance one may need. Who other than the peer group can fulfill this requirement more effectively and efficiently?128 And unlike their peers, the Nada India supported treatment centers developed ARPAN to meet minimum standards of care that reflect those of the government-run treatment for all of its members. Moreover, as the parent organization of ARPAN, Nada India’s membership with the World Federation of Therapeutic Communities and World Federation Against Drugs demonstrates

127

Vatsyayan, Suneel. “Police and NGOs: Partnership for Social Correction.” p. 2.

128 Vatsyayan, Suneel. “Recovery from drug addiction: Action network for trauma-related to drugs, HIV/AIDS, violence and crime.” The Hindu. July 6, 2008. http://hindu.com/thehindu/op/2008/07/06/stories/2008070651551400.htm (accessed April 4, 2013).

how steadfast and effective the Nada India supported TCs indeed are, under the scrutiny and supervision of one another, and larger multi-national organizations.129 The legality of credentialing and providing funding for private treatment centers obfuscates the point of how vital these centers are to high-need populations. There are simply too many addicts and not enough safe places for them to rehabilitate, and although it would incur costs initially, leaving untreated addicts on the streets or in prisons guarantees further burdens to the entire society and nation. The scarcity of services provided makes the establishment of treatment centers a virtual necessity, a void that Nada India and the TC treatment modality attempt to fill. Below is a summarization of key themes from this report, or “action points” to consider going forward. i.

Why has the peer-led method of drug abuse treatment not been given legitimacy by the established medical community, most notably with such an absence of available options for the most disadvantaged demographics?

ii.

Addicts have been stigmatized by their experiences with the disease of addiction and mistakes with drug abuse. Their identity has been set by society, and at times by themselves. This permanent stigmatization must be eliminated.

iii.

Access to one another is the key, meaning personal disclosure and identification with fellow addicts. Any further rehabilitation must incorporate this strategy.

iv.

This is a report of only one of the many addiction treatment programs in India. For many of the

129 The World Federation of Therapeutic Communities, of which Nada India is a member, state’s that their goal “is to join together in a worldwide association of sharing, understanding and cooperation within the global TC Movement as well as to widen recognition and acceptance of the Therapeutic Community and the Therapeutic Community approach among health organizations and health delivery systems of international and national bodies” (World Federation of Therapeutic Communities. “Mission.” www.wftc.org. http://www.wftc.org/mission.html (accessed June 7, 2013)). It has six different regional federations, including the Asian Federation of Therapeutic Communities. The World Federation Against Drugs is a worldwide organization, making up a multilateral community of NGOs and individuals that share a common concern that illicit drug use is undercutting traditional values and threatening the existence of stable families, communities, and government institutions throughout the world. Founded in 2009, they “believe that working for a drug-free world will promote peace, human development, democracy, tolerance, equality, freedom and justice” (World Federation Against Drugs. “Introduction.” www.wfad.se. http://www.wfad.se/about-wfad (accessed June 7, 2013)).

treatment centers, regulation and monitoring is needed to protect their integrity, including some described in this report. There is a very fine line between authority and abuse of power; deadly punishment has been an issue in treatment centers and must not be tolerated. v.

It is vital that the Indian government looks beyond the usual medical model and support responsible, independent, non-profit TCs, such as those supported by Nada India. These communities provide strong treatment and are successful in providing vocational training for addicts through counseling, acudetox, and treatment center volunteering.

vi.

There is no “only way” for the treatment of substance addiction. It is contingent on a variety of factors. This report does not take stock in which methods are better, but rather, demonstrates what has occurred and what is occurring in drug and alcohol rehabilitation in northern India, and the several ways in which it is approached. Its intention is not commercial. It is a story for those without one.

IV. References Acupuncture Today: The Acupuncture and Oriental Medicine News Source. www.acupuncturetoday.com. The Asian Federation of Therapeutic Communities. www.asianfedtc.org. Bedi, Kiran. www.kiranbedi.com. Bhatia, Richa. “The Support Group Route to Rehab.” The Indian Express. August 18, 2008. http://www.expressindia.com/latest-news/the-support-group-route-to-rehab/. Bhushan, Rajesh. “Drug De-addiction Programmes in India” in Rekesh Lal’s Substance Use Disorder: Manual for Physicians. Delhi, India, 2005. http://www.aiims.edu/aiims/departments/ spcenter/nddtc/Substance%20Use%20Disorder%20-%20Manual%20for%20Physicians.pdf. Border Security Force: Ministry of Home Affairs (Govt. of India). http://bsf.nic.in. Castillo, Eddie. “AFTC Report” Presentation by Eddie Castillo, President of the Asian Federation of Therapeutic Communities at the World Federation of Therapeutic Communities conference in Bali, Indonesia, 2012. (On file with Suneel Vatsyayan). Daytop Village. www.daytop.org. Expose India Live. “Haryana Government framed the Haryana De-addiction Centres Rules” EIL: ExposeIndia LIVE. November 9, 2010. http://exposeindialive.com/eil/?p=2419. Hindustan Times. “Stress management: ‘Developer’ Vatsyayan’s mantra for cops under stress.” Hindustan Times. October 28, 2002.

IHRN Newsletter. “Call for Action: Public Hearing in response to death in Drug Rehab” Indian Harm Reduction Network Newsletter 1:1 (2013). http://ihrn.in/wp-content/uploads/2013/05/IHRNNews-Letter.pdf. IHRN Newsletter. “Drug Treatment and the NDPS Act 1985” Indian Harm Reduction Network Newsletter 1:1 (2013). http://ihrn.in/wp-content/uploads/2013/05/IHRN-News-Letter.pdf. International Institute for Population Sciences (IIPS) and Macro International. National Family Health Survey (NFHS-3), 2005-06, India: Key Findings. Mumbai: IIPS, 2007. http://dhsprogram.com/pubs/pdf/SR128/SR128.pdf. Khisa, Bihita Bidhan. “The Mukti: A Therapeutic Community.” Report submitted to the Delhi University School of Social Work for fieldwork. 2002. (On file with Mr. Vatsyayan). Mukti Rehabilitation Centre. www.muktirehab.org. Mukti Rehabilitation Centre. “Attitudes and House Rules.” (On file with Suneel Vatsyayan). Nada India Foundation. www.nadaindia.info. Nada India Foundation. “Standard of care for treatment cum Rehabilitation services.” (On file with Suneel Vatsyayan). Narayan, Pushpa. “Drug rehab centres strip inmates, beat them up as part of cure.” The Times of India. December 14, 2009. http://articles.timesofindia.indiatimes.com/2009-1214/chennai/28063807_1_rehab-centre-rehabilitation-centre-addiction. National Acupuncture Detoxification Association. acudetox.com. National Institute on Drug Abuse. “Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition).” www.drugabuse.gov. http://www.drugabuse.gov/publications/principles-drug

addiction-treatment-research-based-guide-third-edition/drug-addiction-treatment-in-unitedstates/types-treatment-programs. Navjyoti Delhi Police Foundation. “A Decade of ‘Life Again’” Navjyoti News: Help For The Helpless 1 (1997). No Regret: The Addiction Treatment Homepage. “What is the 12-step program?” www.noregret.info. http://www.noregret.info/12-step-program.php. Ontario Regional Service Committee of Narcotics Anonymous. “Information about NA (2007).” www.orscna.org. http://www.orscna.org/english/info.php. Rajagopalan, Shruti. “Directorate of Prohibition” Centre for Civil Society: CCS Internship Papers 2003. http://ccs.in/internship_papers/2003/chap2.pdf. “Ranjan.” “Innovative Project in the Prison.” Navjyoti News 5:1. 1994. Ravindra and Vijakrishnan. “Minimum Standards: Care for Dug De-addiction Centres.” Indian Harm Reduction Network Newsletter 1:1 (2013). http://ihrn.in/wp-content/uploads/2013/05/IHRNNews-Letter.pdf . Roberts, Samuel. “Meeting Needs with Needles: A Review of the 2011 Nada International Conference, Dublin.” Guidepoints: News from Nada November 2011. Sharma, HK. “Community-based Treatment of Substance Use Disorder” in Rekesh Lal’s Substance Use Disorder: Manual for Physicians. Delhi, India, 2005. http://www.aiims.edu/aiims/ departments/spcenter/nddtc/Substance%20Use%20Disorder%20%20Manual%20for%20Physicians.pdf.

Staff Reporter. “Mystery shrouds the death of drug addict.” The Hindu. August 25, 2008. http://www.hindu.com/2008/08/25/stories/2008082555340800.htm. Szalavitz, Maia. “So, What Made Me an Addict?” Washington Post, August 28, 2007. http://www.washingtonpost.com/wp- dyn/content/article/2007/08/24/ AR2007082401699_2.html. Tandon, Tripiti. “Treatment not torture: A case for establishing right based drug dependence treatment regulations in Punjab and Haryana.” Indian Harm Reduction Network Newsletter 1:1 (2013). http://ihrn.in/wp-content/uploads/2013/05/IHRN-News-Letter.pdf. Tellis, Eldred and Gary Reid. Situation Analysis of Basic Education, Vocational Education & Development of Sustainable Livelihoods in Drug Treatment & Rehabilitation Centres of India. New Delhi, India: United Nations of Educational, Scientific and Cultural Organization, 2009. TNN. “Youth found dead in drug rehab centre.” The Times of India. October 26, 2012. http://articles.timesofindia.indiatimes.com/2012-10-26/delhi/34749561_1_rehabilitation-centredrug-rehab-centre-post-mortem. Towards Well Being Blog. “Ear acupuncture based alcohol treatment and rehabilitation services in Border Security Force (Punjab Frontier).” towardswellbeing.blogspot.in. December 23, 2008. http://towardswellbeing.blogspot.in/2008/12/ear-acupuncture-based-alcoholtreatment.html?view=flipcard. Towards Well Being Blog. “Physicians, Mental health professionals, Rehabilitation Experts got acudetox training form Dr. Michael O. Smith in Delhi.” towardswellbeing.blogspot.in. May 24, 2012. http://towardswellbeing.blogspot.in/2012/05/physicians-mental-healthprofessionals.html?view=flipcard.

The Tribune India. “Health care programme for BSF.” The Tribune India. January 11, 2008. http://www.tribuneindia.com/2008/20080111/bathinda.htm#11. Tribune News Service. “De-addiction centre inmates ‘tortured’: Thrashed by Director in the name of therapy.” Chandigarh Tribune. August 8, 2003. http://www.tribuneindia.com /2003/20030809/cth1.htm. World Federation Against Drugs. www.wfad.se. World Federation of Therapeutic Communities. www.wftc.org. Vatsyayan, Suneel. “From the Outgoing Convenor” NGO Forum for Street & Working Children (2000). Vatsyayan, Suneel. Interview by Alex Hitch. Personal Interview. Delhi, India, September 13, 2011. Vatsyayan, Suneel. Interview by Alex Hitch. Personal Interview. Chicago, IL (Skype), April 12, 2013. Vatsyayan, Suneel. Interview by Alex Hitch. Personal Interview. Chicago, IL (Skype), April 26, 2013. Vatsyayan, Suneel. Interview by Alex Hitch. Personal Interview. Chicago, IL (Skype), May 14, 2013. Vatsyayan, Suneel. “Mukti Drug Rehabilitation Center: A Peer Led Initiative and Role of Professional as Mentor or “Guru.” (2001). (On file with Suneel Vatsyayan). Vatsyayan, Suneel. “Police and NGOs: Partnership for Social Correction.” Paper presented by Suneel Vatsyayan at the South Asian Association for Regional Cooperation’s Regional NGO Conference on Developing Sustainable Substance Abuse Prevention Strategies and Utilizing Community Resources in Katmandu, Nepal, 1998. (On file with Suneel Vatsyayan). Vatsyayan, Suneel. “Recovery from drug addiction: Action network for trauma-related to drugs, HIV/AIDS, violence and crime.” The Hindu. July 6, 2008. http://hindu.com/thehindu/op/2008/07/06/stories/2008070651551400.htm.

Vatsyayan, Suneel, A. Goswami, Arun Gupta, Om Prakesh, Vinay Singhal, T.K. Thomas. “Proposal for evolving and strengthening of quality care network among peer led drug rehabilitation initiatives with a purpose of reducing risk HIV/AIDS in boarder areas of Delhi.” (2002). (On file with Suneel Vatsyayan). Vatsyayan, Suneel and T.K. Thomas. “Training of recovering addicts and their family members as peer support educators: An Indian experience.” Mobilizing Communities Blogspot. http://peerledcorrectionrehabilitation.blogspot.in/2010/12/training-of-recovering-addicts-and.html.

V. Appendices Appendix A: Standards of Care Adopted by ARPAN 130 NADA INDIA FOUNDATION

Standard of care for treatment-cum-rehabilitation services 1. Activities for assessment and motivation -

Intake form upon arrival of client in treatment Case history within first week/four sessions Meeting with family members support persons within four meetings Consent forms signed for voluntary admission

2. Activities related to detoxification and medical care -

Medicines given for withdrawal symptoms Medical history taken on day of admission Medical emergencies or changes in regiment monitored Blood pressure checked daily for hypertensive patients Temperature recorded for two days for those with fever Stock of medicines monitored once a month Referrals made within two days for any patient needing higher level of psychiatric care Acupuncture given to alleviate symptoms of withdrawal Orientation to program given including assigning a peer in the program to help new client with orientation to rules, schedules and other adjustments HIV/ STD counseling and education

3. Program structure -

Daily schedule developed and followed Rules established and followed by clients Consequences for non-adherence to rules established Timetable established for time in treatment with reasons recorded for stay longer than one month

4. Counseling standards -

Therapy manual developed detailing clinical strategies and guidelines for all counselors

130

Nada India Foundation. “Standard of care for treatment cum Rehabilitation services.” (On file with Suneel Vatsyayan).

Regular attendance and recording of attendance for psychological therapy Eight counseling sessions per month of 30-45 minutes Special attention given to issues such as HIV positive status, extra marital affairs, legal problems, marital separation, gambling or traumatic childhood experiences Individualized treatment plans developed for whole person recovery Client centered counseling strategies using behavioral change communication and motivational interviewing

5. Re-educative lectures standards -

Three education sessions per week consisting of topics such as disease concept, addiction related damage relapse, overcoming personality defects, methods to stay sober self-help/ support group principles, and HIV/AIDS Documentation and standardization of educational sessions Qualities of assertiveness decision making and problem solving skills also to be taught in context of sessions.

6. Group therapy standards -

Five sessions per week of one hour Maximum of fifteen persons per group and minimum of five persons. Language appropriate groups Discuss issues such as damage due to addiction, symptoms of addiction, powerlessness and unmanageability, breakdown of values and character defects as well as selfdisclosure, personal testimony, identification with others Facilitation provides group with a safe space where confidentiality is assured and full participation is encouraged Individual patient observation in group recorded once per week Yoga therapy Daily acudetox therapy

7. Family program standards -

Four sessions for family members to be provided to help family members to achieve personal recovery with respect to their enabling and codependent behavior as well as deal with their feelings of shame, guilt, anger and resentment One education session per week to be given and documented on issues such as the treatment program, medications given the disease process, relapse, recovery, impact of addiction of the family Regular family visits

8. Discharge services Â Â

Identity cards with registration number given upon discharge Discharge made by counselor with consultation of doctor/ project director Letter of endorsements that client has completed treatment Explanation of medicines and treatment given to client and family A manual about the center which is updated yearly and details centerâ&#x20AC;&#x2122;s vision, facilities and functions to be given to patient Half yearly report on patient maintained 43

Discharge plan with supports established in the community and after care treatment plan in place with short term and long term goals

9. Vocational services -

Vocational options in the community given to patient Culturally relevant vocational training given when appropriate Directory of and networking with government recognized vocational centers for referrals for training Mediation with former employer of client who has been dismissed due to addiction

10. After- care/ follow up services -

One session/ fifteen days within first three months conducted and documented One session/ one month from three months-one year conducted and documented One session/ two months from one year-two years conducted and documented Failure to report for visits to be followed up with two letters and one home visit to client and one letter to the family Drug use to be documented at each session Whole person recovery assessed two times per year All patients completing one year get a congratulatory letter All relapses addressed over four sessions Directory maintained of networking after care and vocational services

11. Physical standards -

Quiet locality with adequate space Name of center, complete address, and sponsoring agency prominently displayed Rights of client displayed for clients, family members, and visitors Properly ventilated, well lit, and cleanly maintained Water made available Waiting space with seating arrangements for five persons Reception/ inquiry and registration counters Nursing station with facilities to store drugs, linen, and records of patients Private facilities for individual, group, and family session Chairs, mats, or other comfortable sitting arrangements Blackboard and chalk or the like for educational sessions Recreational facilities Mattresses and pillows for each patient Bed linen changed per once week Each patient has locker or personal storage space One bathroom/ten patients One toilet/five patients Confidential space for patient files Addiction related educational material to be to be prominently displayed Informational pamphlets, handouts, and other educational materials to made available in public space

12. Documentation Â Â

Computerized system use to track data Monthly report of admissions, discharges, and absconds Medical and counseling regularly maintained for each client Treatment plans implemented with input from the client and regularly assessed for client’s compliance and progress

13. Funding -

Grant writing to sustain funding Initiatives to decrease dependence on client fees Account well kept and regularly reviewed Ensure all documentation is funder complaint

14. Supervision and clinical team -

Weekly case review of client’s progress, observations, and recommendations by the clinical team. Each client should be reviewed once per month. Individual in-group supervision to ensure the wellness of the counselor, to assist in clinical difficulties, to make recommendations for clinical work, and to process challenges and successes with clients. Networking with other agencies to share successes and challenges and strategies new interventions as they relate client care. Regular internal audit of all documentation

Appendix B: Work Schedule at Mukti 131 1.

5:55 a.m.- 6:00 a.m.

- Wake up.

6:00 a.m.- 7:15 a.m.

- Fresh up.

7:15 a.m.- 7:45 a.m.

- Prayer and Yoga.

7:45 a.m.- 8:30 a.m.

- Breakfast.

8:30 a.m.- 9:00 a.m.

- Reflection.

9:00 a.m.- 9:30 a.m.

- Medical Check up.

9:30 a.m.- 11:00 a.m.

- Morning Meeting.

11:00 a.m.- 11:30 a.m.

- Department Meeting.

11:30 a.m.- 12:30 p.m.

- Work Therapies.

10.

12:30 p.m.- 1:30 p.m.

- Younger Members’ Group Session.

11.

1:30 p.m.- 2:30 p.m.

- Lunch.

12.

2:30 p.m.- 3:30 p.m.

- Big Brother Session.

13.

3:30 p.m.- 4:00 p.m.

- Sessions.

14.

4:00 p.m.- 5:30 p.m.

- Game Sessions.

15.

5:30 p.m.- 8:30 p.m.

- Confrontation Dealings.

16.

8:30 p.m.- 9:00 p.m.

- Relating Time.

17.

9:00 p.m.- 9:45 p.m.

- Dinner and Wind up.

18.

9:45 p.m.- 10:00 p.m.

- Prayer and Lights off.

131

Khisa, Bihita Bidhan. (2002). p. 9.

Appendix C: Mukti’s “Attitudes” Betraying, breaking house rules, being greedy, bickering, being a skid, block in medication, butting in, back biting, blaming, carelessness, care a damn attitude, challenge, disorganised, defending, defying, give up, having own way, hitting back, holding of guilt, irresponsible, improper statement, lying, laziness, justification, lack of communication, manipulation, making allowances, not following directions, negative filter down, negative contact, negative support, offending, oozing out of confrontation, pushing a trip, procrastination, resentment, react, setting up, stealing, sly and sneaky, smart answer, shirking responsibility, shooting a curve, taking for granted, taking lightly, threatening, tripping, dishonesty, stubborn