Upload
others
View
10
Download
0
Embed Size (px)
Citation preview
CHAPTERl
INTRODUCTION
This chapter on 'Introduction' introduces the theme of paradigm shift in
intervention with substance use from clinical to ecological and reviews research
studies done on the latter.
A PARADIGM SHIFT IN INTERVENTION WITH SUBSTANCE USE
This section on 'A Paradigm Shift in intervention with Substance Use', first
examines the growth and limitations of the clinical approach of intervention to
substance use treatment. It then examines the emerging ecological perspective to
guide interventions. The section concludes on the paradigm shift in intervention
with substance use and its implications,
Clinical Approach ofIntervention with Substance Use
This section on the 'Clinical Approach of Intervention with Substance Usc' first
looks at the changing trends in substance use in India, and then looks at the
emerging responses, mainly the clinical one, to contain the problem. Finally, it
focuses on the funitations of the clinical approach and the·need for developing a
rational and balanced drug policy in order to guide appropriate interventions in the
country.
Changing Trends in Substance Use in India
The Historical Context: The use of mind-altering substances is certainly not a
contemporary phenomenon within the Indian context. Traditional drugs of use,
such as opium, cannabis, and home brewed alcohol have had a long history of use
since the pre-Vedic times, and then with the coming of the Aryans, the Mughal era
and later, during the British period. (Chopra and Chopra, 1965; Dube, 1972;
Dwarkanath, 1965; Kohli, 1966; Khan and Krishna, 1982; Shanna, 1996). Most
ancient literature is replete with the therapeutic value of opium and cannabis in the
Ayurvedic and Unani Tibbi medical systems for over tcn centuries (Dwarkanath,
1965). Compulsive dependence was, however, relatively unknown, as society at
1
large disapproved of the regular use of these substances barring certain SOCIO
economic classes and ethnic groups (Dube, 1972). In this conte>.."!, Singh (1993) has
aptly commented, that addiction did not have such a disruptive impact on social
health, as the social control mechanisms prevalent in the Indian society including
the 'traditional moorings, social taboos, the emphasis on self-restraint, and the
influence of the joint family system' led to functional use of substances in specific
population groups. Substance use was closely connected with social rituals,
religious beliefs and socio-economic conditions (Mohan, 1980), and what Charles
and Britto (1994) referred to as the 'functional association between mind ~Itering
substances and the attainment of higher realms of existence - both mundane and
transcendental'. Sharma (1996) opined that caste, religion, local customs and
traditions - all played an important role in detennining the pattern of .consumption
and choice of drugs in semi-urban and rural populations.
India, in the post-independent period, witnessed a number of changes in her social
and economic policies, much of which had an indirect effect on the rise of
substance use problems in both rural and urban settings. Firstly, the new
Constitution of India under Article 47 in 1950 stated, "that the State shall
endeavour to bring about the prohibition of the consumption except for the
medicinal purposes of all intoxicating drinks and drugs which are injurious to
health" (as cited in Sharma, 1981). This led t·o the registration of all opium
smokers in all the States under medi-cal grounds. By 1953 opium smoking was
totally abolished, and by 31 st March 1959, the non-medical and quasi-medical use
of opium was totally prohibited, except in the case of those who had registered as
medically sick on or before the stipulated date (31 st March, 1959) '.
The policy with respect to cannabis followed a similar trend as that of opiurn,due
to increasing international opinion against the use -of hemp and the general
negative attitude towards it within t he country itself. India ratified the Single
Convention on Narcotics Drugs 1961 and later the Convention on Psychotropic
Substances 1971, and' thus committed herself to the total prohibition .of 'I1on-
I The total number of registered opiwn addicts in 1975 was 80, 809 (India: Ministry ofHeahh and Family Welfare).
2
Table 4.8: Distribution of Cases According to Age at Recovery 161 and Length of Recovery
Table 5.1: Characteristics of the User System and Support 194 System During the Preaddiction Phase
Table 7.1: Characteristics of the User System and Support 313 System During the Addiction Phase
Table 7.2: Characteristics of the User System and Support 315 System During the Recovery Phase
Table 8.1: Stages of Change and Social Work Interventions 356
medical use of opium and cannabis. India still remained as the major exporter of
opium to meet seventy percent of the world's requirements of the drug for medical
and scientific purposes (Bhatnagar, 1981). Dorabjee and Samson (2000) point out
that until the early eighties, opium and cannabis were available to registered users
from government-authorised shops.
Post-independent India saw rise in the production of synthetic alcoholic beverages,
and its consumption as major developments in the socio-economic matrix of the
country. Development in the agricultural sector, industrialisation. urbanisation and
modernisation of education resulted in the gradual weakening of the attitude "Of
self-restraint, giving way to a more socially tolerant attitude towards alcohol and
other drugs. Besides, the Government of India had placed itself in an ambivalent
position by linking its drug control policy for production and distribution of
alcohol with the revenue raised from its sales (India: Ministry of Health and
Family Welfare, 1977).
The hippie cult in the late sixties essentially ushered in a -new era where non
traditional drugs such as heroin, charas, methaqualone, psychedelics,
amphetamines and other psychotropic substances assumed a considerable degree of
popularity amongst the elite youth population in urban metropolitan areas (Chitnis
and Fazalboy, 1974; Dube, Kumar, Kumar and Gupta, 1977; Marfutia and Patkar,
1972; Mohan, Thomas, Sethi and Prabhu, 1979; Singh and Singh, 1979; Varma
and Dang, 1978;). In rural areas, the rise in alcohol related problems was noted 'by
different researchers (Deb and Jindal, 1974; La! and Singh, 1978; Mohan, Sharma,
Sundaram and Mohan Das, 1981; Mohan, Sundaram, Advani, Shanna and Bajaj,
1984; Sethi and Trivedi, 1981; Vanna.. Singh, Singh and Malhotra. 1981;). Much
of the focus, however, remained on urban areas in comparison to examining the
prevalence and incidence rates in rural areas (Khan and Krishna, 1982).
The Heroin Epidemic of the Eighties: With the government's stringent policy on
the sale of psychotropic substances in the late seventies, a majority of the
dependent users of morphine, barbiturates and other psychotropic substances,
switched over to alcohol, raw opium or cannabis derivates{Kapoor, 1991). It was
3
problems amongst the injecting users in the North Eastern States of India, Sarkar,
Das, Panda, Naik. Sarkar, Singh, Ralte, Aier and Tripathy (.1993), noted that
pethideine and morphine were the preferred drug of choice m Manipur and
Nagaland m 1983, and heroin gained popularity only m mid--eighties.
Seroprevalence amongst intravenous drug users in Manipur had increased from 0
percent in September 1989 to 54 percent in March 1990, and 73 percent in 1993
(20 % of those who had tested positive in the country were from Manipur.) By the
early nineties, the practice of injecting drugs had percolated to the smaller towns
and cities and users began to combine buprenorphine with pheniramine,
promthasine and diazepam to prolong the effect of the drug (Dorabjee and Samson,
1997). In a recent report, Kumar, Mudaliar, Thyagarajan, Kumar, Selvanayagam
and Daniels2 (2000) note that in the north-eastern states where injecting drug use
contributes significantly to mv infection the seropositivity rate amongst injecting
drug users was estimated to be in the region was almost 147.12 per 1000 in
Manipur, 50.18 per 1000 in Nagaland and 18.08 per 1000 in Tamil Nadu.
At the same time, a considerable level of internationalconcem was evoked as India
emerged as a major transit country for piping out illegal heroin to countries in the
west, and buprenorphine to the neighbouring countries, that is, Nepal and
Bangladesh. In addition, the rise in the incidence of injecting substance use ted to a
near panic situation, both at the national and international level, as the spread of
mv in this section of the user population has increased beyond proportions
(UNDCP, 1996). While noting that the spread of injecting use amongst substance
users, especially in the context of devetopingcountries, is a complex phenomenon,
Stimson and others (1996) concluded that the practice of injecting offers
advantages to the user in terms of drug effects, costs and concealment. The rise in
incidence of injecting use in Southeast Asia, according to them was a result of
'production related consumption'. In other words, earlier patterns of opium
smoking were replaced by heroin smoking and then injecting as a result ·of the
establishment of heroin production and distribution network in these plant-
2 By May 1999, the HIY seropositivity rate for India was 24.61 per 1000 persons tested [total cumulative individuals detected with HIY was 85, 166 out of3, 480. 658 persons screened] (Kumar and others, 2000).
5
producing countries. Manipur was strategically located in the major drug
distribution route from neighbouring Myanmar through to other parts of India and
Nepal (Stimson and others, 1996).
Responses from the Governmental Sector: The Government of India in
November 1985 introduced the Narcotic Drugs and Psychotropic Substance Act
(N.D.P.S.), as the predecessors to this Act were extremely lenient having several
inherent loopholes, namely, the OpituTI Acts of 1878 and 1957, and the Dangerous
Drugs Act ef 1930. Mandatory minimum punishment was not laid down in aU
these previous Acts. On the other hand, the N.D.P.S. Act clearly categorized all
drug related offences as non-bailable and cognisable (Singh, 1993). Besides
prescribing penalties and other legal aspects, the Act also contemplated schemes
for the treatment and rehabilitation of substance users (Mathur, 2000).
The Act was further amended in 1988, which spelt out a definite scheme for the
apprehension, treatment and rehabilitation of addicts. It provided for a reformative
condition under Section 39, whereby the court could release an addict offender
who has been convicted to an institution maintained and recognized by the
Government for undergoing treatment. Section 64A, as incorpQrated in 1988, has a
provision for immunity for the first time to an addict who voluntarily seeks to be
treated in an institution or a hospital maintained or recognized by the Government
or the local authority. Lastly, Section 71 empowered -the Government to establish
centres for identification, treatment, education, aftercare, rehabilitation and social
reintegration of addicts. In other words, under the present law addicts are subject to
compulsory treatment.
In the Seventh Five Year PIan, the Ministry of Welfure identified the need for
developing more community based treatment and rehabilitation -of substance
abusers. Singh (1993), in his report has highlighted the following objectives in the
Eight Five Year Plan which has been promoted by the Scheme for Prohibition and
Drug Abuse Prevention: 1) evolving culture specific models fur the prevention-of
drug abuse and the treatment and rehabilitation of addicts, 2) providing a whole
range of community based services for the identification, motivation, counselling,
6
during this period, that is 1980-81, that the new drug, brown sugar, (a crude fonn
of heroin) was introduced into the illicit drug market, and it was so well timed, that
a majority of the dependent users turned to this cheap form of heroin, without
really being aware of its highly addicti.ve properties or i.ts long term <:onsequences.
It is within this historical context that the emerging drug problem of the eighties
must be examined.
The heroin epidemic of the early eighties generated widespread community
concern as the Indian sukontinent was ill-equipped to deal with this sudden crisis
situation in terms of policies, legal framework and the mobilisation of resources to
contain the problem. The new drug, brown sugar, an adulterated form of heroin,
had drastically altered the traditional patterns of substance use in this country. It
was no longer restricted to a particular social class or a specific geographical area.
The problem had percolated through all the socio-economic groups, moving from
urban metropolitan areas to remote rural belts {India: Ministry of Welfare, 1992;
Mohan, Adityanjee, Saxena and La!. 1985; Muttagi, 1985; Sengupta and Desai,
1988; Singh, 1993; SPARC, 1988;}. With the subsequent implementation of the
NDPS Act in 1985 with its restrictive policy on control of licit and illicit
substances, many of the traditional users of opiwn and cannabis resorted to these
synthetic drugs (Dorabjee and Samson, 2000).
The mid-eighties saw the rise in heroin injecting in the north-eastem states {Naik,
Sarkar, Singh, Bhunia, Singh, Singh and Pal, i 991; Sarkar, Mookherjee, Roy,
Naik, Singh, Shanna, Ibotombi, Singh, Tripathy, and Pal, 1991;) which was
followed by an epidemic of pharmaceutical injecting in Delhi, Calcutta and
Chennai (Basu, Varma and Malhotra, 1990; Chowdhury and Chowdhury, 1990;
Kumar, 1997; Panda and Chatterjee, 1997). Dorabjee and Samson (1997)
commented on the rise in the incidence of injectable buprenorphine as an
alternative amongst heroin users, especially in these metropolitan cities (If the
country. The high frequency of sharing needles, unsterile equipment and the
general poor health status of the users gave rise to vulnerability of injecting related
harms, such as the increase in the incidence of mv, HBC and HCV amongst this
section of the user popUlation. Reflecting on the rapid increase of IllV related
de-addiction, after-care and rehabilitation of addicts, 3) promoting collective
initiatives and self-help endeavours among individuals and groups vulnerable to
addiction or at risk, 4) establishing appropriate linkages between State level
interventions and voluntary efforts in the field of prohibition and drug abuse
prevention, 5) increasing public participation and public co-operation in demand
reduction activities and finally, 6) strengthening preventive educational
programmes at the individual, the family and the community level.
The Ministry of Social Justice and Empowennent (formerly known as Ministry of
Welfare), in a recent review has highlighted the significance community-based
approaches, especially community de-addiction camps, counselling and awareness
centres, treatment cum rehabilitation centres including prisons, work facilities
prevention, night shelters for street addicts, community outreach programmes and
is encouraging indigenous systems of treatments such as acupuncture, naturopathy,
yoga and hydrotherapy for the management of painful withdrawals (National
Institute of Social Defence: 2000). There is a need, however, for greater conceptual
clarity in the policy documents with respect to rationale, objectives, methodologies
and expected outcomes of these de-addiction units, 'whole person recovery' and
rehabilitation programmes.
While the Ministry Health and Family Welfare recogruzes the significance of
community based approaches, and.has been promoting ,this since the Seventh and
Eight Five Year Plans, it continues to focus on the development of Drug De
addiction or detoxification centres at the Centre and at the State level medical
colleges and district hospitals, Even in the Ninth Five Y~ Plan. the government's
focus, according to Mathur (2000) has been on developing health education
strategies, innovative treatment approaches, and is seriously considering the
adoption of harm reduction and maintenance programmes in north-eastern states
with the rise in the incidence of injection drug use and the -high prevalence of
HIV I AIDS in the user population.
Today, while there is a move towards promoting more community based
approaches in interventions with substance users (Pars had, 1995; Singh, 1993), and
7
the adoption of harm reduction strategies and maintenance or drug substitution
programmes, (Dorabjee and Samson, 1997; Ray and Pal, 2000;) in lieu of
abstinence models, prevention of relapse following treatment and the lack of
effective social reintegration initiatives is a serious issue confronting professionals
at the level of practice. One major problem contributing to this situation is the
absence of a comprehensive national drug policy, which can influence
interventions at the grassroots level.
Hence, while professionals and policy makers have been advocating community
based programmes to contain the high incidence and relapse rates, the core
components of these programmes still seem to be primarily rooted in clinical
approaches, which ignore the social context of the user. This includes, sudden or
gradual detoxification programmes, drug-substitution or maintenance programmes
and long-term residential treatment facilities, which are essentially medical models
of intervention.
Responses from the Non-Governmental Sector: A majority of the prevention
and therapeutic programmes in the country evolved, between 1981 to 1989. While
some programmes developed from existing social welfare, health and development
based projects, others emerged independently as a response to the rising trend in
substance use in different parts of the country. In the initial years, a wide range of
therapeutic services such as detoxification units, residential rehabilitation
programmes, day-care centres, and counselling units emerged. Preventive efforts
were restricted to public awareness campaigns and information related to the
harmful consequences of drug use.
In the intervening years, with the increase ID professional knowledge and
experience, the focus of programmes gradually shifted. For instance, there was
lesser reliance on medical interventions; more openness to innovative approaches
from other parts of the region; change from drug-informational approaches to skill
based educational programmes, peer involvement in prevention, health
promotional activities and provision of alternatives to vulnerable groups (lesser
focus on the substance of use and more emphasis on the person); acceptance of the
8
harm-reduction approach, especially in areas where injecting drug use and
seroprevalence rate is high or in the context of homeless street children and youth;
focus on rehabilitation before/without detoxification and the encouragement of
voluntaristic community strategies of rehabilitating alcoholics and substance users
through the 'camp approach'; higher priority given to developing integrated
community based projects where the focus was on collective action, utilization of
local resources and empowering the people to tackle the substance use problem in
their neighbourhoods; and finally, recognizing the limitations of centralized
treatment units or specialized after-care centres which were cost intensive, and
catered to a very small percentage of dependent users, and were inaccessible to a
vast majority of users from marginalized and economically deprived groups
(Kapoor, 1994),
Kapoor reviewed the existing programmes in the country and broadly categorised,
community level responses against the problem of substance use into the following
five groups: those, which were part of community mental health centres or primary
health, care units, mostly in rural areas where the problem of alcohol dependence
was high for instance in Bangalore, Chandigarh, Vellore and Madras (Srinivasa
Murthy, 1991); those which developed as need based projects from existing
welfare and locality development community projects for marginalized
populations, in urban slum areas or villages; those, which evolved from grassroots
structures, as in the case of anti-alcohol movement mainly organized by women's
groups and activists in many tribal and rural areas, for instance, in Maharashtra,
Haryana, Andhra Pradesh, and Chhatisgarh; those that were based on the roncept
of creating drug free zones through the 'camp approach' or the open community
approach to drug abuse contro~ which covers the area of rehabilitation,
detoxification and primary prevention, Jodhpur in Rajasthan where opium users are
detoxified in camp settings and the rural camps for alcoholics organized by TTK
Hospital in Madras are the two successful corrummity approaches tried out in the
country (Kaplan, Shiota, Sell and Bieleman and others, 1992; Ranganathan, 1996;
Sell, 1990; United Nations: 1995); those that involved recovering alcoholics, drug
users and their families in substance use prevention and treatment within the
community as in the case of Social Awareness Service Organization (SASO) a
9
group of recovering addicts in Manipur or the Narcotic and Alcoholic Anonymous
progran1ll1es in Bombay, Delhi, Madras, Goa, and Calcutta or the Nagaland
Mothers' Association (Kapoor, 1994).
Conclusion: In sum, it may be said that a wide variety of treatment modalities
exist in the country today. The diversity in the pattern and prevalence of substance
use, in different parts of the country call for different types of innovative responses
at the community level. There is a need therefore, to focus on both hann reduction
strategies and total abstinence oriented programmes keeping in view the local
context and the needs of the client system. The clinical model still remains the
predominant model of intervention in most parts of the country, and even within
commWlity based approaches. The interrelationship and interdependence between
the user, the substance and his or her environment is not adequately recognised at
the level of practice.
India, still lags behind in the development of a comprehensive and rational drug
policy which is appropriate to her diverse social context and sensitive to her
cultural patterns of use in different segments of the population. For developing
such a policy, she has to stop looking at clinical models of interventions designed
in the west, and search for responses from within ·her rich and socially relevant
historical repertoire of experiences in the management of substance use problems,
while incorporating the core ingredients of successful interventions developed in
other parts of the world. For instance, community based interventions, social
movements against alcohol and other illicit substances, and the '<:amp approach'
are not only cost-effective but are also, culturally relevant approaches, in sharp
contrast to the <:oncept of therapeutic communities or long-term residential
treatment programmes which were developed in <:ountries where there was a
visible absence of family ·and other social support systems. Community and family
ties still remain strong in this country and we need to explore ·the possibility of
developing programmes, which simultaneously aim at empowering users and
communities/families in the process of mutual problem solving with respect to the
area of substance use. To comprehend the significance of this suggestion, it is
important that we review in depth the limitations of the predominant clinical or
10
medical paradigm that has remained the most tenacious model to date while
evidence of its ineffectiveness has already been documented in the west.
Clinical Approach and its Limitations
The influence of the Cartesian paradigm on medical thought, according to Capra
(1982) led to the emergence of the biomedical model, which forms the basis of
modern scientific medicine. Capra goes on to add that, "By concentrating on
smaller and smaller fragments of the body, modem medicine often loses sight of
the patient as a human being, and by reducing health to mechanical functioning, it
is no longer able to deal with the phenomenon of healing. This is perhaps the most
serious shortcoming of the bio-medical approach" (Capra, 1982: 118-119). The
philosophy of reductionism that emerged from the biomedical approach, according
to Peele (1981) assumed that human behaviour could successfully be resolved into
its biological components, which in turn could be described as chemical and
electrical events. Furthermore, the eventual goal from the reductionist perspective
was 'to find neurological correlates for individual actions, perceptions, feelings,
thoughts, and memories-as well as for entire behaviour syndromes such as
addiction and schizophrenia' (Peele, 1981).
The field of addiction has been a casualty of such an ideological hegemony for the
most part of the last centw-y. Medical practitioners and pharmacists have
dominated the field, and the hold of the deterministic perspective has not wavered,
although from time to tilpe people have shown their disenchantment with coercive
methods in treatment including compulsory closed-ward treatment fur substance
users, and the still dominant status of the criminal law in the social response to
substance use (Bayer, 1993). The growing buoyancy amongst many biologists,
neurologists, psychiatrists and psychologists in the addiction field emerges from
recent advances in several areas of research and speculation in the neurosciences:
the discovery of neurotransmitters and the potential relationship between these
substances and schizophrenia, depression, addiction, and pain; and the genetic
predisposition to of these maladies as a consequence of imbalance of these
chemicals in the body (Peele, 1981).
11
E.M. Jellinek systematically introduced the idea that addiction is a physiological
construct3 in 1960, which set the stage for the medicalisation of the substance use
problem with its subtle emphasis on pharmacological duress. The preponderance of
the loss of control driven 'disease' model, dominated popular and pharmacological
thinking in the west and has continued to influence policy and practice in different
countries to date. From this perspective, addiction has been viewed not only as a
. disease', but that its course is progressive and irreversible, and that abstinence is
the only viable treatment goal (Peele, 1983). As Peele and DeGrandpre (1998:235)
have explained further, "Around the turn of the twentieth 'Century, medical
authorities appropriated addiction as a property of narcotics. The behavioural and
psychological markers of addiction were codified as pathologic withdrawal and
craving in a deterministic model that replicated the alcoholism-as-disease notion of
drug-induced loss of control". Ironically, the same clinical paradigm was
transplanted to other parts of the world where the heroin -or cocaine epidemics
emerged at a much later date.
The positive aspect of the 'disease-illness concept' was that it removed
stigmatisation and value-laden moralistic judgements about the 'alcoholic' or the
, addict', and effectively mobilised financial resources for treatment, research and
education as alternatives to punitive incarceration (Bayers, 1993;). Acknowledging
some of the advantages of the medicalisation of problematic substance use, Polak
(1995) asserted that to an extent the medicalisation of the dependency problem
offered some compensation for the damage to health and society resulting from
repressive policies. Medicalisation in one sense meant improved medical care for
users especially with the rise in the incidence of injecting substance users (who
were/are at risk of contracting illV / AIDS and HeV), and the graduale"pansion of
the idea of providing medical prescription for psychoactive drugs (as seen in the
methadone maintenance and buprenorphine substitution programmes fur opiate
users). Still, as he argued, that medicalisation can 'never compensate fully for the
senseless damages and injustices caused by the systematic prohibition of drugs'. In
J In his book, . The Disease of Alcohol', JeJlinek (1960) wrote that' a disease is what the medical profession recognises as su.:h'. Robinson's (1979) comment to this has been, " .... Then from the layman'S point of view it is perfectly reasonable to define as disease, 'anything which the medical profession is seen to be willing to deal with in some way".
12
a compromising tone, he summed up his opmJOn, " ... In a repressive system it
nonet he1ess represents a step forward, like medical care near a battIe field" (Polak,
[995: [)
On the whole, however, the 'illness-disease' concept of addiction posed (he
greatest stumbling block to effective interventions by potential change agents
within the social system of the user, namely, his or her family, spouse, children,
employer or the helping professionals. Labelling an individual as . sick' hinders
more than it helps, as Unfortunately, the disease conception of addiction continues
to be predominant model held by helping professionals and the general public,
although in the sixties and the early seventies it carne under challenge from a
number of quarters. Thomas Szasz the revolutionary psychiatrist reiterated in his
evocative paper, 'Bad habits are not Diseases', " ... what matters is that as
physicians and teachers we resist politically motivated and mandated redefinitions
of (bad) habits as diseases; that we condemn and eschew involuntary medical and
psychiatric interventions; and that, instead of joining and supporting the 'holy war'
on alcoholism and drug abuse, we actively repudiate this contemporary version of
'popular delusion and crowd madness" (1979:78). In a similar vein, Fingarette
(1988) vehemently rejected the disease model of alcoholism on the grounds that it
only strengthened the denial system of the user, as it extricated him or her from
taking complete responsibility of his or her excesses. Drinking or (drug taking),
from his point of view, ought to be seen in the context of the person's way of life,
and what role or roles it played for that person in coping with his or her Life.
Stanton Peele one of the more challenging writers and addiction experts in recent
years has confronted the prevailing concept of addiction as disease. He introduced
an anthropological perspective to theories of addiction with the objective of
bringing attention to the host of nonpharmocologica1 factors including cultural and
historical variables, that influenced not only one's reactions to drugs but also their
susceptibility to addiction (Peele, 1998) . In addition, the model has also
encouraged the simultaneous labelling of substance users as . sick' and 'bad',
which often is the by-product of the process when we make diseases out of moral
or (social) issues. Hence, while on one hand, many physicians espouse the -disease
13
concept of addiction, they often view addicts as weak and responsible for their own
'misfortune' (Conrad and Schneider, 1980).
Elaborating on the 'sick role' theory propounded by Talcott Parsons in the fifties,
Beyerstein (1995) noted that the 'sick role' involves a set of nonns and
resporuibilities conferred upon those who are diagnosed as ill. Once the medical
community sanctions this status to those defined as 'sick', they are entitled to
sympathy as well as temporary abdication from family, social, occupational and
financial obligations. Besides, they can rightly expect, not punitive measures, but
access to effective, non-judgemental treatment for their condition. In the context of
substance users, however, it has been observed that this 'sick role'
conceptualisation has consistently failed to endorse the same rights and obligations
conferred to those who are diagnosed as ·sick'. This was one of the paradoxes of
the current clinical approach in treating substance users as exemption from blame
and various social obligation was dependent on the user's acceptance of himself or
herself as 'sick' and their willingness to cooperate in whatever measures advocated
by medical gatekeepers to restore him or her to health.
Clearly, the American experience in the seventies highlights the disgruntlement
with the conservative-medical oriented policy in the context of substance use, and
a move towards adopting a more liberal drug policy (Bayer, 1993). Individualistic
socia-cultural approaches were given more recognition by anti-traditionalists in the
field of addiction, who looked outside the United States, especially within
indigenous cultures and more tolerant approaches in Europe, for answers to
address their substance use problems. Thomas Szasz (1972), for instance, became
critical of the prohibitioillst policies in America and suggested a radically
individualistic perspective of addiction within a free market economy, which in a
covert way supported' the move towards Jegalisation of illicit <lrugs, and
decriminalisation of users. Szasz hypothesised that substance use and addiction
were the result of personal decision-making, and he linked the freedom to use
drugs with the right to exchange ideas freely.
14
While the concept of de-medicalisation of addiction, decriminalisation and
legalisation of less harmful substances was gaining momentum across ,the globe,
traditionalists in America opposed these recorrunendations as the politicians were
not ready to adopt a tolerant system like the British, the Dutch or the Swiss
systcm(s) (Reinarman, 2000). At the turn of the century, India and most of the
countries in South-east Asia are still influenced by drug policies and programmes
developed in the United States of America. The current legislations and policies of
the Government of India still remains embedded in the medical-disease driven
model of addiction, while the incidence and prevalence rates of synthetic substance
use continues to escalate not just in urban areas, but in small towns and rural areas
as well.
While there has been substantial gains in therapeutic options for substance users,
ranging from medical to psychosocial and behavioural strategies, attempts at
preventing or reducing relapse rates amongst 'treated' clients has been the greatest
stumbling block for practitioners. Sell (1992) in this context reiterated that with
the recognition of drug dependence as a disease and a medical condition led to the
emergence of a number of treatment modalities and 'culminated in the strategy that
a number of treatment options should be available to ·each individual patients t{)
optimise chances for cure'. Most of these treatment options such as,
'psychotherapy, drug-substitution or maintenance, long-term antidepressants,
rehabilitation in its various orientations of acquiring marketable skills or skills of
drug-free living', according to Sell, were based on medical and psychiatric
principles and techniques, which had shown their effectiveness' in speciJic diseases.
However, their simple transfer to the 'disease' of addiction has had limited
success. Pleasure-seeking' behaviour or the strong desire to do what others
disapprove of can hardly be regarded as a medical paradigm, according to Sell,
although it forms the core'component of the dependence syndrome.
While the role of environment and social factors has been acknowledged within the
clinical model, they are usually relegated to a secondary status. Not surprisingly,
there has been little consensus amongst practitioners regarding the nature 'of
addiction, its course and its eventual resolution as a condition. Today, the field of
IS
addiction treatment is increasingly being invaded by professionals from different
disciplines, such as, medicine, psychiatry, psychology, sociology, social work and
so on, each addressing the issue from their particular standpoints and thus,
overlooking the need for developing an integrated response to the problem and its
solution. What seems clear, however, is that addiction is not caused by a single
factor in the individual's life and thus, any intervention that fuils to take into
consideration the range of factors that may influence the individual's decision to
resort to a drugs, will be unable to adeq uately address the issue of substance use in
a holistic way. This implies that there is a need to move away from clinical -
reductionist approaches to embracing more comprehensive approaches, which take
into account the social realities of the user's life. One such approach suggested is
the ecological framework in our understanding of addiction and the process of
recovery.
Ecological Approach of Intervention with Substance Use._
This section on the 'Ecological Approach of Intervention with Substance Use',
first briefly examines the multifactorial causation of substance use and then goes
on to describe the emerging ecological approach to substance use intervention. It
then reviews self-help programmes and organised religious groups, which are the
traditional ecological approaches used to sustain the recovery of long-term
substance users.
Multi-Factorial Causation of Substance Use
A peculiar characteristics of the field of addiction thus fur has been that a great
variety of current and historical theoretical constructs exist, besides the 'disease
model' to explain the causal factors, appropriate agents and mechanisms for
change and implied interventions (Hester and Sheeby, 1990). This abundance of
theory, according to Emrich (1992), does not reflect the immaturity of the science
of substance use. Since, each substance user or a potential user is the 'nexus of an
enormous number of potentially relevant variables', Emrich reiterated that each of
these theories have been useful in explaining the individual differences amongst
different groups or types of users. The interplay between a range of factors such as
pharmacologica~ genetic, neurological, psychological and more recently, socio-
16
cultural in the development and sustenance of substance use dependency have been
explored in depth through these theories.
As the prevalence and incidence rates of substance use showed little signs of
changing in most parts of the world, one response by policy makers and
researchers was to redefine and restructure previous perspectives and policies on
substance use through international forums. In 1987, the Comprehensive and
Multidisciplinary Outline proposed by the International Conference on Drug Abuse
an Illicit Trafficking (ICDAlT) highlighted socio-economic factors, migration,
urbanisation, change~ in attitudes and values, as the primary factors leading to
substance use (United Nations: 1988). Today, more and more research seems to
allude to macro-system factors, prevalent in the social environment of the
individual, which predisposes him or her to developing substance use problems.
Some of the social factors identified thus far, include rapid urbanisation,
modernisation, migration, unemployment, absence of familiar support systems,
new found wealth, (Abarro, 1988; Emrich, t992; India: Ministry of Health and
Family Welfare, 1977; Kapoor, 1989; Singh, 1993; Sbahandeh, 1985;) and more
recently, the impact of structural adjustment programmes and the ensuing
liberalisation of developing economies has been implicated (United Nations:
1994).
All these developments gradually led to the emergence of the ecological
perspective in substance use control (Shahandeh, 1985), wherein the reciprocal
relationship between the individual and his or her social ~nvironment and
substance use was recognised. Expounding on this thesis, Emrich (1992) noted that
finding a niche within one's environment which was consistent with one's ascribed
role becomes more difficult for individuals in times of rapid changes in the socio
cultural environment when "a large proportion of one's resources to conduct such
an adaptive search' is rendered irrelevant. Substance use, and other forms of social
pathologies, then may be viewed as responses of pathological adaptations as
individuals are forced to seek alternative behaviours and/or expectations in the
absence of viable and socially approved niches (Emrich, \992).
17
Ecological Approach and Its Implications
In recent years, there is has been mounting evidence that health and disease are
detcmlincd by complex interactions among biological, psychological and
sociological factors which has led researchers to propose an alternative to the
biomedical model. Kumpher and others (1990) moved beyond the traditional
clinical paradigm and proposed the biopsychosocial model or the ecological model
of vulnerability to substance use. Within the interdisciplinary field of addiction, no
clear 'paradigm shift' had occurred, according to them, as they emphasised that the
field of substance use was in a pre-paradigm phase, It has been suggested that the
biopsychosociaI model or the ecological model is a reasonable way to
accommodate the complementary, and ofien-competing causative theories of
addiction within one single conceptual framework. Owing t{) the multi-causal
nature of addition, the traditional clinical model, which was primarily a
mechanistic, linear model, was unable to address the complex eJ..'periences of users
and their social context. The general systems theory, aCCOl'ding to deRosnay
(1979), provided a metatheoretical framework for the development of specific
biopsychosociaI Or ecological models in the area of addiction, and for further
organizing aetiological factors for substance use.
Unlike the reductionist model, the ecological model does not simply bind old
theories t{)gether, each of which, prioritises problems differently; has its own
distinct relationships between terms and concepts; and essentially locks
practitioners of different theories into separate worlds isolated from one another.
On the other hand, it provides a common platfonn for addiction professionals from
diverse disciplines to come together to work under the umbrella of common
terminology and concepts. The ecological approach characterizes the population of
substance users as heterogeneous and recognizes the importance of comprehensive
individual assessment in order to adequately determine the needs of client gmups.
Besides it allows for the delivery of hann reduction services that minimize hann to
substance users who continue to engage in high-risk behaviour. Since the approach
considers substance use as embracing a variety of substance use disabilities, it
actively promotes the concept of a hierarchy of harm reduction outcome goals
including abstinence related goals.
The role of social and spiritual mctors in the development of and recovery from
substance use is acknowledged and it aUows for future analysis of these elements.
In short, the approach unifies prior biological, psychological, and social theories of
addiction. The net result is the synthesis of a unique conceptual franlework
comprised ofa unique set of hypotheses.
Over the years, there have been futile attempts to prevent and reduce relapse rates
by focusing solely on 'individual centred' approaches, which have neglected the
larger social context within which the client lives, Thus, the process of 'social
reintegration' has received fur less priority than 'rehabilitation' of clients, which is
mostly occurs, within treatment settings. Appropriate 'social reintegration' would
involve involvement of more and more community based natural and organised
support systems, (Caplan, 1974) which are readily accessible to the recovering
client in his or her social environment. For treatment professionals, knowledge of
the variety of supportive mechanisms that can be mobilised for the recovering user
outside the formal treatment setting can enable them to develop more meaningful
programmes, which respond appropriately to the needs of the target population.
The limitations of centralised and highly specialised treatment units for substance
users is increasingly being recognised as they are cost-intensive and not accessible
to a large segment of the clients from the low income groups. Today, 'there is a
definite move towards evolving more community based and holistic interventions,
which rely heavily on locally available resources and participation of community
members, to facilitate the client's re-entry into society. Thus, the role of a
professional social worker within such a context is not just restricted tQ
establishing one-to-one relationship with the client, but enCQrnpasses a range of
other roles, the major one being that of a community organiser so as to mobilise
local resources to support himlher during his or her prolonged addictive career
marked by several relapse episodes and spontaneous remissions.
It is within this context that the concept ·of social support in relationship to relapse
and recovery becomes significant, although research in this area is still vcry
sketchy and fragmentary. Experiential accounts and testimonies of former
19
substance users have, however, provided ample substance in favour of self-help
groups and other natural systems of support such as, religious and spiritual groups
and cults. The next section will explore tbese two areas in greater depth.
Self-Help Support Groupsjor Substance Use Recovery
In recent years there has been a rapid and considerable growth of mutual aid
groups, often referred to as self-help groups, which now represents a significant
aspect of modem life. There has been substantial disgruntlement, and rightfulJy so,
with the current health care system which undermines the powers of individuals to
care for themselves or shape their environment and the alleged failure of traditional
institutions in most societies (Robinson, 1980). Within a broad framework, Katz
and Bender (1976) have defined self-help groups as "voluntary small group
structures formed by peers who have come together for mutual assistance in
satisfying a common need, overcoming a common handicap or life-style disrupting
problem and bring about desired social andlor personal change" {as cited in
Ashery, 1979:135). The fact of sharing a central problem according to Katz and
Bender (1976) defines the membership status despite many individual differences.
The self-help approach is increasingly being viewed as one of the most effective of
all approaches in the area of substance use with the launching of the Alcoholics
Anonymous (AA) in 1935. The AA movement spawned the self-help therapeutic
communities such as Synanon, for substance users for several decades (lshiyama,
1979).
The AA programme, is perhaps largest and the most popular of all self-help
groups. Narcotics Anonymous (NA), one of the earliest attempts to transplant the
AA programmes, was developed for users of the different types of drugs,
excluding alcohol. Although there have been limited research studies on these
groups, their effectiveness in the treatment of substance users is widely
acknowledged by professionals. Today, self-help and professional help are not
viewed as mutually exclusive, but in most cases they complement each other
(Blum and Blum, 1976). The primary goal of AAfNA is to assist individuals in
attaining and maintaining abstinence, and the only qualification for membership is
the desire to stop drinking. Beigel and Ghertner (1977:216) noted that these groups
20
have " .... no formal authority structure, with the only authority being derived from
the prestige of maintaining sobriety and the ability to help others resolve their
problems through diminishing anxiety and enhancing self-esteem".
While trying to examine the principles underlying the AA approach, Robinson
(1980) noted that at the personal level, AA aims to transfonn isolated and
dependent individuals into attaining a level of independence, integrity and sobriety.
At the group level, AA has tried to remain self-reliant and self-sufficient. While the
primary goal of both AA and NA is to live a drug free life, yet . slips' are not
viewed as fuilures. In fact, relapse may be instrumental to recovery by provoking
greater efforts towards personal refonnation. Relapse is viewed as a starting point
and the addicts may make progress despite the relapse: they may have eliminated
personality and behavioural characteristics associated with their addiction so that
they are much closer to being able to sustain a drug free lifestyle (Peyrot, 1985).
The programme focuses on 'emotional sobriety' rather than mere physical
abstinence.
AAlNA members regard testimonials and step studies as 'Twelve Stepping', which
involves 'carrying the message' to other addicts and alcoholics. This activity is
considered to be self-therapeutic, because the individual sees himseWherself in the
other person befure finding the programme. Antze (1976 as cited in Peyrot, 1985)
noted that this 'sharing of lessons' serves the function of 'self - indoctrination'.
Participation reinforces their self-identification as addicts and their new role as a
non-user. The identification between the speaker and the audience is crucial if
'testimonials' and 'step studies' are to become effective. Although the speaker
shares hislher individual life problems, yet by virtue of the fact that they share a
common problem and identity, the audience applies the whole experience to their
lives as well through the process of identification. In other words, the theme of the
addict's narrative is potentially applicable to all others in the audience,
Tfie dominant rote of AA in current therapeutic programmes has, however, not , i
tieen without it critics. Tournier (1979) for instance, argued that the pervasiVe
iM1~ence of AA inhibits innovation, alienates early problem drinkers, and limits
21
treatment strategies (as cited in Ogbome and Glaser, 1985). Others have
speculated that AA's insistence on the 'disease model' and that any drinking by a
recovering by a user will inevitably lead to loss of control can become the basis of
a self-fulfilling prophecy (peele, ! 990-91). Peele further noted that the few studies
that have used random assignment and appropriate control groups suggest that AA
works no better, and perhaps worse, than no treatment at all. The value of AA,
according to him, like any other fellowship is dependent on the perceptions of
those who choose to participate in it.
Early research has indicated that AA members were not representative of all
alcoholics who receive treatment. Emrick (1988) noted that alcoholics who had
more severe alcohol dependence problems and those who used other drugs were
more like to attend meetings than those with less severity and who were not dually
addicted. Those who used more external supports to stop drinking were more likely
to be AA a.£fiIiates. In addition, individuals who were more s9ciable, guilty about
their past behaviour, middle class, physically healthier did well in AA. In short,
AA effects may not have been positive for all categories of users. For instance,
those alcoholics who sought to reduce drinking to an asymptomatic level and many
have dropped out rapidly who could not adhere to the abstinence goal (Emrick,
1988).
In sharp contrast to the abstinence model proposed by the AAlNA model, in recent
years with the rise in the incidence of HIV/AIDS amongst injecting substance
users, new models of self-help groups have emerged in some of the countries in the
west, where harm reduction or risk minimisation is the preferred goal. Rampant
negative social attitudes towards injecting users were one primary factor
responsible for mobilising users through peer support programmes. As Wodak
(1993:4) observed, "Before the discovery of AIDS, the concept of an organisation
of injecting drug users (IDUs) in Australia would have been considered both
unnecessary and impractical ... lndeed, the perception of IDUs as incorrigible
demons was one of the earliest casualties of the process of developing a network of
IDU organisations". In fact the success of male homosexual lobby groups in
22
different parts of the world provided a model for such groups at risk of contracting
HlV/AIDS.
Autonomous drug self-help organisations began to emerge in the Netherlands in
the early seventies and reached their peak in the eighties. The explosion of HIV
epidemics amongst IDUs created the first group called 'junkie bond' in Rotterdam,
which began to expand amongst groups of IDUs, and health workers who were
concerned about HlV. The success of this group created optimism aoout the
possibility of developing such peer support programmes in other countries as well
(Trautmann and Barendregt, 1994).
Most of these user group organisations take the lead in providing information to
drug injectors, distribution of risk-reduction supplies and involvement in the
syringe exchange services. They pr-ovide advice and useful critique to drug
treatment agencies. There are reports of users organising demonstrations fur
changes in treatment policies. Others have networked with law enfurcement
agencies with the view of promoting harm reduction strategies and have acted as
pressure groups to prevent marginalisation of users. In addition, as Friedman
(2000) pointed out" They also serve to legitimate -the humanity of users to users
themselves and thus to help users deal with the attacks and stigmatisation they
undergo".
Trautmann (2000) noted that the initiation of these support groups was felt as
AIDS prevention by regular drug services had not met with an overall success.
Drug users had access to little or no information regarding illY/AIDS, HBV and
Hev as drug services could not reach them, and most importantly, user groups
distrusted them. This feeling of distrust was one of the primary factors in the
growth of peer support groups as traditional drug treatment services and health
care outreach workers were not readily accepted by users on the streets. Issues
such as personal drug use and the paraphernalia attached to it as well as sexual
behaviour could be more readily discussed with peers who had know1edge from
personal experience and who users could trust.
23
As Trautmann (2000) emphasised, "Experience furthermore underlies that social
influence on drug user's attitude towards safer behaviour and a growing self
efficacy through role modelling are the most important features of peer
education/peer support. This implies that providing social information is more
important than offering mere facts. The fact that peers are familiar with group
norms and they are easier to trust for drug users also helps to get reliable
information about risk behaviour". This emphasis on shared experience and
equality of status is the focal point of developing drug user self-organisations Who
are working for current" users and not recovering users or ex-users as seen in the
AA and NA model.
These self-organisations mainly promote the interest of users and in recent years
they have incorporated a political agenda and human rights issues as well. Hence,
besides voicing their concerns for adequate and accessible drug services, these
groups have been playing an advocacy role against decriminalisation and
repressive polices as defined by the crirrllnallaw (Fried~ 2000). Wodak (\993)
reiterated that most Australian IDU organisations were consulted in the design
stages of state and commonwealth education campaigns and other activities. For
instance, they advised governments about methods of improving the practice of
disposing used injection equipments after the establishment of needle and syringe
exchange programmes or developing more user-friendly drug substitution
programmes. Recently some peer support programmes have developed and ·remain
embedded in an already existing professional drug programme. Ther-e are
dilemmas, which still confront these groups; whether they should be paid for their
work or receive other motivational incentives or whether to include only active
drug users or those on drug substitution or ex-users.
For a developing country like India, cost-efficient programmes such as the AA and
NA fellowship has been a blessing for most recovering users, and needs to Jbe
encouraged at all levels. However, there is also a growing need to incorporate peer
support groups within existing programmes, which have the potential of reaching
the hidden population of users who fail to show up in traditional therapeutic
settings. Drug users' organisations provide a socially supportiveenvirorunent
24
including relevant information sharing for current user groups especially in the
area of prevention of HIV infections and pathways to recovery. Moreover, they
provide an opportunity to learn new skills and perform sociaUy valuable services
for the community. In return communities will gradually learn to respond in a more
compassionate manner to the needs of this stigmatised popUlation and fucilitate
their eventual reintegration into the conventional social order.
Traditional Religious Groups as Support Systems
In this section an attempt has been made to put together information collected from
a variety of sources to understand the relationship between substance recovery and
the role of various religious groups. It needs to be added here, that research studies
in this area of interest is virtuaUy non-existent and whatever scant material is
available is fur from being methodologically sound.
Scanning through the available literature, it was observed that revival of several
religious movements, especially in the West in the late sixties, was direct.oo
towards users of psychedelic drugs and opiates. These movements emerged from
different religious denominations, such as the pentacostals, evangelicals, baptist
churches, and the International Society for Krishna Consciousness, ,(ISKCON) to
name a few (Blakebrough, 1990; Satsvarupa, 1993; Stephan, 1990). On the other
hand, several therapeutic communities, such as the Daytop, the Minnesota and the
Hazeldon models have borrowed extensively from the philosophy of AA, which is
a spiritual programme in the most basic sense (0' Brien, 1988; Cook, 1988;).
Reminiscing the tenacious mission of Bhaktivedanta Swami in spreading Krishna
Consciousness amongst the hippies during the late sixties in America's poverty
centres Satsvarupa (1993:191) noted that hundreds of substance users quit drugs,
by embracing the Vedic religion and discovering constructive spiritual alternatives,
through the process of chanting (japa and sankirlana or congregational chanting),
and devotional service. The Vedic scriptures suggest that humans often adopt
different means to deal with the continuous influx .of problems they confront in
their daily lives. However, more often than not, the means they adopt to mitigate
2S
their problem is worse than the original malady itself. This was the experience of
substance users who approached the Swami in the late sixties.
Baad (1997) commented on the role of the traditional Indian system of
Saffvavajayi cikitsa and Mantra cikifsa, (which involves change in the spiritual
consciousness of the addicted person), which was utilised by Bhaktivedanta Swami
to elevate substance users of the West from the state tamo guna (mode of
ignorance) and raja guna (mode of passion) to the purified state of sattva guna
(mode of goodness) and gradually to the achievement ofthe state of suddha sattva.
Through her effective street corner organising skills and the gift of 'healing' heroin
addicts in the crime infested Walled City (Hong Kong), Pullinger (1980) received
international accolade with the publication of her book, 'Chasing the Dragon'.
Several heroin users were baptised in the 'Holy Spirit', and thus accepted the
Gospel of Jesus Christ.
More recently, experiences of people worldng directly with addicts in different
parts of the world have suggested how therapeutic programmes are increasingly
collaborating with traditional religious groups to strengthen the individual
spiritually. For instance, Azayem (1988) and Shahandeh (1985) described the
involvement of the Abu El Azayem Mosque in Cairo, as a pioneering experiment
to study the influence of religion in the treatment of addiction through training of
the mullahs (priests) and changing public attitudes towards substance users. Samad
(1992), reviewing the multidisciplinary approach adopted by two Malaysian
Institutional Programmes for addicts, commented on the religious practices of
Islam which eventually change the belief systems of the clients by strengthening
their faith and encouraging them to pursue these practices.
Mahakun (1988) and Shahandeh (198.5) discussed the role of a Buddhist temple,
Tam Kraborg Temple in Thailand, in treating heroin addicts. The clients,
according to the authors, pledge a life of abstinence before Buddha. Some ex
addicts are trained in priesthood and later ordained as Buddhist monks in
collaboration with the National Council on Social Welfare of Thailand. Similarly,
Kodagoda (1993) and Samarasinghe (1989), from Sri Lanka, using the camp
26
approach to detoxification of heroin addicts, found the usefulness of Buddhist
monks in enabling clients to remain drug-free. Blakebrough (1990) conducted
special church services for almost 300 clients who attended the methadone clinic,
situated within the premises of the John Baptist Church at Kingston.
Stephan (1990) noted that with the rise of the drug problem in the seventies,
evangelicals in Singapore were mobilised to reach out to the addicts, through
therapeutic communities and through individuals as Volunteer Aftercare Officers
(VAO's). According to him, the therapeutic process operated within the framework
of spiritual transformation through the promotion of a devotional life-style. In the
late seventies, these projects collaborated with another drug ministry of the
Church, called the Teen Challenge, which was initiated by Rev. David Wilkerson
in the U.S. In the nineties, Teen Challenge, according to Stephan (1990), has
extended beyond its traditional role in narcotics and substance use rehabilitation, in
a vision to reach out to people of the 'Fourth World', which in Wilkerson's words
refers to the subculture of addicts, runaways, ~elinquents, alcoholics, sex-workers,
street people, criminals, prisoners, con-artists, homosexuals, pimps and other such
socially deprived groups.
Conclusion on the Paradigm Shift
In conclusion, it may be said that ill recent years, there is a move towards
attempting to reconceptualise the problem of substance use from the 'disease
model' to one that takes into account biopsychosocial as well spiritual factors,
However, the 'disease model', remains tenaciously predominant in the field ·of
addiction. The persistence of this according to Peele (1998) is the consequence of
prejudices, research deficiencies, and the legal and illegal issues surrounding
substance use. Moreover, drug policies, which have developed from moral
perspectives resulting in prohibition and abstinence strategies, have not proven
effective, 'fhis is further compounded by the lack of organized data collection
systems and valid analyses concerning not only treatment evaluation, but also the
unchecked, exorbitant costs of enforcing prohibitionist policies through supply
reduction tactics. Viewing the problem of substance as solely a medical issue or a
27
law enforcement problem. inadvertently precludes concerned societies from
addressing the social, cultural, and environmental problems contributing to drug
use, or building on prevailing psychological frameworks that could be incorporated
into interventional paradigms.
Besides, the medicalisation of problematic intoxicant use with its inherent bias
contained in the 'disease model' further limits our approach to developing a
rational and pragmatic drug policy, which in turn determines the types of
interventions that are adopted at the level of practice. There is also an indication
that in the field of addiction, theory and practice are not synergistically linked, as
practitioners seem to be oblivious of the emerging evidence against the prevailing
reliance on the single-factor disease driven model of addiction. In the ultimate
analysis, this 'sickness model' has made addiction treatment a commodity, which
has promoted a market for pharmaceutical companies, health insurance industries,
and the phenomenal expansion of the health care sector, especially within the
context of the developed countries.
The American drug policy continues to influence drug policies in other ·countries
where the heroin epidemic emerged since the early eighties. In almost all these
countries, including India, prohibition and the draconian narcotics and
psychotropic substances act has systematically led to the marginalisation of
substance users, especially for those who belong to disadvantaged groups. Supply
reduction efforts in most of these countries has not significantly deterred drug use
or drug trafficking. With increase in the incidence of injecting drug use, the ·health,
and social dangers, especially mv I AIDS, associated with substance lise have
increased. In the interim period, the harm caused by licit substances such as
nicotine and alcohol has been a ruefully neglected area.
Within the Indian context, a radical change in drug policies is needed. It is hoped
that more innovative community based hann reduction and minimization
approaches will be implemented and that the legal status of certain psychoactive
drugs will be re-examined. The spread of the problem of substance use has
exposed regional variations, and in general a more varied situation has emerged in
which one model of service provision no longer holds sway. In a period of cost
28
constraints, accountability and cost-benefit analysis of interventions must be the
top most priority of policy makers and service providers. Today, there exist a
greater variety of substances and substance users, which bas led to the
development of a greater variety of interventional modalities. No single paradigm
can exclusively address the changing drug scenario, which diffurs from region to
region in a pluralistic and culturally diverse country like India. Perhaps a mix of
different elements of each paradigm, reviewed in this section may be useful in
developing an eclectic model, which will respond to the local situation
appropriately.
The ecological perspective can be regarded as the emerging paradigm for
understanding the concept of addiction and the process of recovery where the
complex interplay amongst the physical, psychological, social and environmental
aspects of the user's world is adequately recognised. In short, the ecological
approach focuses on the evolutionary and adaptive view of substance users, and
integrates intervention strategies for users and their environment. It aims at
facilitating the adaptive capacity of the user while at the same time improving the
supportive qualities of his or her environment to foster mutual interdependence,
and thereby understand the nature of this transformation from addiction ·to
recovery.
The ecological perspective of addiCtion postulates that substance use .is the net
result of a complex interaction between the combinations of biological,
psychological, social and spiritual dimensions. The ecological theory is a
conceptual framework that aUows attention to be focused on all problems related to
substance use. This enables programme planners and policy makers to address the
broad range of problems, which converge on user populations. This continuwn of
substance use generates a continuwnof services. Furthermore, early intervention
services for those clients with less severe substance use problems are considered to
be as important as services for people with more severe problems.
Research was needed to examine the extent to which factors other than the clinical
treatment may either facilitate or impede the process of recovery from mind-
29
altering substances. In more specific terms, the role of support systems in the
maintenance of continued abstinence and the overall improvement in the quality of
life of former users has not been examined in a systematic way. A study, which
tried to explore and examine these support systems which influence the substance
user's use and recovery status, was thus, an exigency of our current struggle to
address the need for a paradigm shift in prevention, control and recovery from
substance use.
REVIEW OF RELEVANT RESEARCH
The first part of this section reviews the state of addiction research in India
including epidemiological surveys and the current rapid situational assessments,
which highlight the changing prevalence and patterns of substance use in specific
populations. It then looks at family-based research and other non-medical
interventions in the area substance use. From here it moves on to examining
research studies on the role of support systems in substance use recovery, not done
in India but relevant to this study. Some of the major follow up studies that have
been carried out in other parts of the world, and which throw light on the systems
contributing to sustained recovery in substance users is examined thereafter,
followed by a conclusion on the section.
Addiction Research in India
It has been pointed out elsewhere in literature that prior to the seventies the field of
substance use was the least explored area at the national and local levels (Sharma
and Mohan; 1991). One of the earliest studies within the Indian ()ontext was
carried out by Chopra and Chopra (1965) on a sample of 300 drug users in 1958
where the researchers tried to study the aetiology and pschosociological aspects 'of
substance use. Almost five decades ago, when there were no treatment Or
rehabilitation facilities for substance users, the researchers had acknowledged the
significance of medical, psychological, sociological and economic factors in the
development of substance use problems. Interestingly, the researchers were not in
favour of the medical profession's attitude towards substances users, that is, 'once
a drug addict, always a drug addict".
30
Epidemiological Studies
Majority of the studies in the country have been conducted during the late sixties
and the seventies. The bulk of studies carries out during this period, however, were
epidemiological surveys conducted in either the general population (Deb and
Jindal, 1974; Dube and Handa, 1969; Mohan, Sharma, Sundaram and Mohan Das,
1981; Mohan, Sundaram, Advani, Sharma and Bajaj, 1984; Mohan, Sundaram,
Bhadra, Dutta and Shanna, 1984; Sethi and Trivedi, 1981; Singh and Lal, 1979 ;
and Varma, Singh and Malhotra, 1981); or the student population (Dube, Kumar,
Gupta, 1977; Mohan, Thomas, Sethi, and Prabhu, 1979; Mohan, Rustagi,
Sundaram and Prabhu, 1981; Sethi and Manchanda, 1977; Singh and Singh, 1979;
and Varma and Dang, 1978).
The first national level multi-centred study conducted amongst the student
population, (N=4415) between 1976-78 in seven centres (Bombay, Madras, Delhi,
Jaipur, Hyderabad, Varanasi and Saugar) of the country revealed that the drugs that
were of special concern to the international community, such as, the psychotropics,
opiates, cannabis and psychedelics were reported by a very small percentage of
respondents in all the centres (Mohan, 1981). This study however, 'suffered from a
number of methodological flaws as it failed to comment on the rising trend of
substance use in the non-student population, especially users of illicit and synthetic
drugs. The second multi-centre study conducted in 1986 once again failed to
reflect the actual profile of substance users in the country even though the country
was in the midst of a major heroin epidemic, as it showed a 'statusquo in drug use,
except the emergence of heroin between 0.1 to 0.3 percent (Sharma and Mohan,
1991:272).
Studies conducted in different metropolitan cities since 1984 had highlighted that
the problem of heroin addiction was no longer restricted to the youth from the
upper classes and that for the first time in the history of the country the middle
class and the lower socio-economic groups had ·been seriously affected by it
(Muttagi, 1984; Mohan and others, 1'98S~ SPARe, 1987; Sengupta and others,
1988.) Senguptaarui others tried to provide possible reasons for the steady rise of
addicts in slums communities and lower socio-economic groups identifying factors
31
such as SIZe, density and heterogeneity of the population, problems of
unemployment and under employment, existence of an illegal peddling network in
these areas, and lack of alternatives. The authors concluded "drug peddling had
become an entry point into addiction for the unemployed poor".
However, a more recent multi-centre study conducted in the early nineties in 33
drug prone cities and areas, commissioned by the Ministry of Welfare,
Government of India, confumed the phenomenal increase in substance use, in the
age group 16 to 35 years and most of the drug users were male and literate. The
study also that highlighted that drug abuse was prevalent in varying degrees among
all religious and caste groups, and that it had percolated to the lower income
groups in the country. Difference in marital status or living alone did not seem to
contribute to drug abuse. While there were regional variations in the prevalence
and pattern of substance use, the major drugs of abuse were alcohol and heroin in
urban areas, raw opium and cannabis was popular in the rural settings. Besides,
there was rise in the number of intravenous heroin users in the north-eastern states
of the country. Moreover, the study showed that in many areas the knowledge
about the services available through welfare agencies for the treatment of addiction
was still scant, although a large number of addicts bad utilised treatment services,
and most individuals and fiunilies were aware .of the ill effects of drug abuse.
(India: Ministry of Welfare, 1992).
Rapid Situational Assessments
In 1998, a series of five rapid situational assessment (RSA) of injecting drug use
was undertaken covering the major metropolitan cities of Mumbai, Chennai,
Calcutta, Delhi and lmphal to determine the extent and patterns of injecting drug
use (IDU), the available responses, current and planned interventions, and drugs
users' perceptions of injecting and sexual-related risk behaviour (Dorabjee and
Samson, 2000; Kumar and others, 2000). The RSA was necessary as there was
paucity of comprehensive data on the extent of IDU in India, although reports ·of
increasing seropositivity and increase in the incidence of hepatitis B and C has
been acknowledged in literature since the early nineties (Kumar and others, 1997;
Panda and Chatterjee, 1997). According to Dorabjee and Samson (2000), one key
32
outcome of the assessment was the endorsement of the IDU across India by the
National AIDS Control Programme in their Policy Document for 1999. Moreover,
it was well received by practitioners in the field of addiction who were interested
in innovative approaches in the management of mv related infections amongst
drug injectors and their sexual partners. The researchers also note that with the
implementation of the RSA, there has been a shift in the focus of future research in
the country. The value of street level research carried out by those working on the
streets, in terms of the identification of new trends in area of substance use is fur
more useful than assessment by highly skilled professionals. Finally, by linking
research to intervention and recognising the role of practitioners in the research
process is by far the most phenomenal achievement of the RSA as compared to the
previous large scale epidemiological surveys conducted in the general.population.
In 1999, the Ministry of Social Justice and Empowerment, Government of India
and the United Nations International Drug Control Programme, Regional Office
for South Asia (UNDep-ROSA) decided to Undertake a \arge-scale national
survey to obtain information on the extent, pattern and magnitude of drug abuse in
the country. The major components of the study included the National Household
Survey, Drug Abuse Monitoring Systems and the Rapid Assessment Survey
(RAS). In addition, focussed studies on specific populations like women, rural
subjects, people living in border towns and prison population has been carried out.
The findings from the women's' study and the RAS have been released (Kapoor,
2002; Kumar, 2002;). The study on women substance users was -carried out in
major sites, that is, Mumbai, Aizawl and Delhi and the problems and issues
confronting working women, women in treatment and women involved in sex
work were identified to help in the development of gender sensitive interventions
(Kapoor, 2002).
The RAS was carried out on 14 cities of the ·country including the four
metropolitan cities. The findings showed the drug users were young and
predominantly male. While one-fourth were homeless, half were unmarried, one
fifth were illiterates and one-third were unemployed. Majority of them carne from
improvised environments. Heroin was popular amongst 36 percent of the users,
33
followed by buprenorphine, propoxyphene and opium (29%) and cannabis (22%).
Almost 71% of the heroin users came from Delhi, lmpha~ Kolkata, Chennai and
MlUllbai, and this was followed by buprenorphine injectors (N=l ,817). In the other
sites, (N=2,831) cannabis was the primary drug of choice, followed by opiates and
heroin. The study indicated a serious pmblem for the country as 43 percent of the
sample was injecting users and the mean age of starting injecting ranged between
15 to 28 years. Sharing of syringes and unhygienic injection practices, as well as
unsafe sex was observed, which has serious implications in the wake of the
HlV/AIDS epidemic in the country. Treatment services in these fourteen sites were
inadequate and most of the users were not in touch with any agency.
Family-Based Research
Although the role of the family has been recognised as significant in influencing
the course of different types of illnesses, especially within a fumily centred eulture
like that of India, limited research data is available which examines the role of the .-
family as a support system in the maintenance of the recovery status of substance
users. Under the auspices of the Ministry of Social Justice and Empowennent,
Government oflodia and the UNDCP-ROSA, a study was conducted to understand
the impact of substance use on the family, especially the women who were the
primary burden carers (Ray and Mondol, 2002). Only highlights of this study have
been released and the detailed report will be available at a later date. The highlights
clearly show that services for affected :fiunily members are non-existent and most
of the female members of the household suffered physically, emotionally and
mentally due to the presence of an addicted member in their midst.
SlUllan and Nagalaksbmi (1995) examined the nature of family interaction patterns
in alcoholic families (n=40) and compared it a sample of non-alcoholic families
(0=10) drawn from the general population. Alcoholic families were characterised
by poor communication, lack of mutual warmth and support, spouse abuse and
poor role functioning. The spouses of the alcoholics expressed greater
dissatisfaction in aU the areas of family functioning in comparison to the
alcoholics. On the other hand, non-alcoholic families were characterised by free
and open communication, mutual warmth and satisfaction and sharing of
34
responsibilities. The study recommended the need for marital and/or fanlily
therapy for alcoholic fumily systems to enhance the effectiveness of treatment.
The coping behaviours of wives of alcoholics have been examined in two studies
(Chakravarthy and Ranganathan, 1983; and Sathyanarayana Rao and Kuruvilla,
1992). Both these studies hypothesised that certain coping styles used by family
members would facilitate the process of recovery, while others would be
ineffective.
While both these studies indicated that alcoholism had serious consequences on the
families, Chakravarthy and Ranganathan (n= 46 males) noted t·hat discord, fearful
withdrawal and avoidance seemed to be the most consistently used coping styles
used by wives of alcoholics. Sathyanarayana Rao and Kuruvilla's study (n=30
wives of alcoholics), on the other hand, showed that there was no basis for the
assumption that the wife's psychopathology was responsible for the husband's
alcoholism. The wife's coping style was dependent on various factors such as
cultural upbringing and personal assets of the wife being the major ones. In other
words, it was the personality of the husband which resulted in his alcoholism and
which in turn caused the coping behaviour of the wife. Both these studies have
failed to adequately show how certain coping 'styles having positive effect on the
recovery process and how others may be ineffective, as has been shown by other
studies in the West (Holmia and Natera, 1987; Orford, Oppenheimer, Egert,
Hensman and Guthrie, 1976; Velleman, Bennet, Miller, Orford, Rigby and Tod,
1993).
In another study carried out by Andrade, Sarmah and Channabasavanna (1989) the
psychological well being and morbidity in parents of 21 narcotic dependent males
were compared with an equal number of matched controls using the Subjective
Well Being Inventory. The study showed that the 'narcotic parents' experienced
more clinically significant psychological distress than did the controls, and that this
impairment was greater in the 'narcotic mothers' than their husbands. The parents
in general experienced less well being, fulfilment of aspirations, confidence in
coping, spiritual satisfaction, social support, and social contact. In addition, the
35
•
mothers experienced a lesser ability to cope with life phenomena that potentially
disrupted mental equilibrium, and had a higher perception of personal ill health
than had their husbands. Interestingly, the 'narcotic parents' and controls did not
differ on measure of satisfuction with family relationships, family support and
cohesiveness, and perception of physical ill health. The researchers recommended
the need for improving parental coping skills, increasing their social network,
promoting better utilisation of intra-and extra family social support systems, and
providing general supportive psychotherapy to prevent relapse episodes and
therefore for a better prognosis for the user.
In a related study of 368 alcoholic patients who had attended the programme at the
TTK hospital in Madras, Deskikan and Chakravarthy {no date) found that only 30
percent of the patients reported having supportive ties in their immediate network.
Hence, the programme felt the need to develop a social support programme for
users, although the researchers acknowledged the fuct that the impact of this
programme could only be assessed after a period of two to three years follow-up.
Non-medical Interventions
Other studies have focused on the efficacy of holistic approaches such as Yoga
(Willoughby and Petryszak, 1996), spiritual bibliotherapy (Kripa, 1996) and
Vipassana Meditation as a stress coping strategy for drug users (Chokhani, 1988).
A three year follow - up of drug users who attended a ten day course of Vip ass ana
Meditation in the final phase of their rehabilitation programme at Igatpuri,
according to Chokhani, was very encouraging in reducing the incidence of
subsequent relapses. Chandiramani (1991) noted that the use of Vipassana
produced a good response in rehabilitating alcohol and drug ·dependents as it
tackled 'craving' or 'tanha' which is the root cause of addiction. The following
mechanisms in Vipassana, that is, shift in cognitive mode, blanking out, sensory
deprivation, directed self-attention, neutralisation, feedback, and promotion of
reality orientation, according to Chandiramani, helps individuals to deal with
different types of pathophysiological syndromes of both psychosomatic and non
psychosomatic origins.
36
In his study of addicts in Calcutta, who were exposed to Yoga, Chandra (1990)
noted that the experinlental group showed reduced anxiety state, increased span of
attention and enhanced sense of well being, in comparison to the control group.
Golechha, Despande, Sethi and Singh (1987) and Golechha, Sethi, Despande and
Rani (1991) have reported the positive effects of 'agnihotra' ( a Vedic ritual of
lighting fire in a copper pyranlid pot with the use of Mantras) in the tr.eatment of a
heroin user and a group of 18 male alcoholics in Delhi. According to the
researchers with the practice of 'agnihotra', at the end of an eight-week period, 55
percent had remained abstinent. While spirituality has been recognised by several
progranmles in aiding recovery, (Chakradhar, 1993; Kapoor, 1996; Lobo, 1986;
Pavamani, 1994; Peer and Rayappan, 1996; Thampu, 1994), the process of change
experienced by an individual when he or she becomes a member of a religious
group needs to be explored in greater depth.
Conclusion
Since the use of synthetic substances is a fairly recent phenomenon to the country,
it is not difficult to understand why process based -research in understanding
systems contributing to use and recovery is virtually non-existent. Neither has
treatment evaluation research been given adequate priority by policy makers and
professionals in thetield, although the trend is changing with the involvement of
international funding agencies.
Many of the studies reviewed have focused on traditional methods of healing
which have been used by substance users, but have not examined tbe process of
recovery usmg these methodologies. Moreover, evaluation of medical
interventions has received far more priority than community based interventions,
psychosocial or ecological approaches to relapse prevention and sustaining
recoveries. This is a serious lacuna within the Indian conte>..1.
The success of rapid situation assessments as an alternative low cost methodology
to previous large-scale surveys of general and special population is promising.
From the public health perspective it can serve as an effective tool for advocacy
and the enhancement of current services for substance users. It has the potential of
37
providing a realistic picture of the drug-using scenario amongst specific vulnerable
groups in the community. The focus on addressing the target individual and his or
her social environment, and integrating interventions into the social and political
structures of local conunWlities is a definite shift from traditional clinical
approaches in research to adoption of the ecological perspective in the conduct of
current research in the country. Although this is just the beginning, promising as it
may seem, much can be learnt from the studies conducted in other parts of the
world, wherein the role of social systems in substance use recovery has been
examined.
Foreign Research on the Role of Social Systems in Substance Use Recovery
This section reviews studies including intervention based research carried out in
the west, which have examined the role of natural and organised social systems in
aiding the recovery process of substance users through the provision of social
support. It concludes with the need for examining the processes through which
substance users access these SQcial support resources frQffi w:ithin thtir soci.a\
systems.
Studies showing a relationship between social support and recovery from
substance use disorders are limited. A majority of the studies 'have been carried out
in the area of menta! health, especially depression. Within the area 'ofthe substance
use, they have focused mostly on smokers and alcoholics. How fur the results 'Of
these studies can be applied effectively to users of other illicit drugs, such as heroin
or cocaine has not been investigated. The role of social systems in the recovery
from mind-altering substances has not been adequately researched within the
Indian context, which has been mentioned earlier in this chapter. However, what
has been documented is the mobilisation of entire communities in both urban and
rural areas to prevent and reduce the problem of substance use through 'Conununity
based treatment camps/interventions (Datta, Prasantham and Kuruvilla, 1991;
Kaplan, Shiota, Sell and Bieleman, 199-2; Kapoor, 1989; Manickam, 1997; Sells,
1992; Srinivasa Murthy, 1991; Ranganathan, 1996; U.N.: 1995).
38
The Role of Natural Systems in Substance Use Recovery
The 'Community Reinforcement Approach' (eRA), a microsystem intervention for
alcoholics which was developed by Nathan Azrin and his coUeagues in the
seventies was aimed at reducing relapse rates by rearranging vocational, fumily
and social reinforcers of alcohol users in such a way that drinking would result in
withdrawal of potential reinforcers (Hunt and Azrin, 1973). The drinker's
micro system was totaUy restructured to accommodate social support variables.
Environmental enrichments of various kinds formed an important component of
CRA, which was contingent on the sobriety status of the user. The eRA offered
not only medical aid in the form of 'antaabuse', but also 'reciprocity marnage
counselling', a job club for unemployed clients, l'esocialisation training,
recreational activities and an early wanting system for prevention of relapse. In
the absence of natural families, synthetic fumilies were created to provide support
to the recovering alcoholic.
The results of eRA seemed to be quite reassuring compared to matched controls.
SUbjects reduced their quantity of intake. worked more, spent more -time with their
families, and the results were stable over a two year period, thus suggesting that
the procedure was effective in relapse prevention (Azrin, 1976). According to
Peele (1989) the CRA in essence addresses the natural processes that Valliant
found were the keys to remission in alcoholism. Yet this approach has been utilised
only for research studies and its applicability in treatment programmes in the
United States or elsewhere has largely been ignored.
Utilising the conceptualisation of social network analysis, Hawkins and Fraser
(1983) studied the social networks, drug use patterns and other variables of 106
street heroin users, before treatment and during the foUow-up periods in four
residential treatment centres. The study showed that during the pre-treatment stage
the network members of users' used hard drugs two or more times a week,
especiaUy in the case of opiate users and had positive attitudes towards drug use.
Further, opiate users' networks contained fewer members from conventional
settings such as work, schoo~ and organisations, and significantly more illegal
business contacts than did network members of other users. The interactional data
39
suggested that a subculture did exist ill which users were embedded. These
relationships were typically characterised by high level of commitment, intensity,
reciprocity, frequency and duration of contact. In short, the users' interactions with
network members appeared to be stable, hierarchical, enjoyable, friendly, and
reciprocal, with exchanges focusing on a range of activities including, but not
limited to, drug use.
Following treatment most of the respondents who returned to the community tried
to constitute new social networks that did not favour drug use, even though their
pre-treatment networks were relatively stable and dense. Those who did not use
opiates three months after discharge from treatment reported significantly fewer
regular users of hard drugs in their networks than those who returned to opiate use.
Surprisingly, by three months after treatment, the networks of the opiate users were
reported to include a greater proportion of conventional members than ·they did at
I-month follow-up. The authors concluded that while major changes in 'Social
network composition seemed to follow residential treatment, ~d while returning
clients seemed to establish more pro social networks of interaction during their first
months back in the community, opiate use appeared more likely when returning
clients did not establish networks that provided consistent affective support and
when their networks did not include role models whom they deem worthy of
imitation.
The findings from this study carried out by Hawkins and Fraser has been 'Supported
by other studies as well. Studies conducted by Goehl, Nunes, Quitkin and Hilton
(1993), Gordon and Zrull (1991), Havassy, Hall and Wasserman (1991) have
shown that the number of current opiate users gradually reduced in the social
networks of recovering substance users, while there was an increase in the size of
non-using conventional others.
Based on their research with smoking cessation, Cohen, Lichtension, Mennelstein,
Kinsolvers, Baer and Kamarck (I988) hypothesised that social support facilitated
change in addictive behaviour via rour macro processes, a) by buffering stress, b)
by influencing motivation to initiate or maintain behaviour change, c) by
40
influencing the availability of smoking cues in the environment, and d) by applying
social influence to abstain. In the context of drug users, it has repeatedly been
found that use of mind-altering drugs helps in dealing with negative affect. Hence,
the significance of the . stress buffering effects' 0 f social support needs to be
recognised as it may trigger alternative stress coping strategies or result in
potentially stressful events being appraised as relatively mild, and thus enable the
drug user to stay off drugs. Social support thus influenced motivation to change by
providing appropriate reinforcement, and it had an indirect effect on motivation by
enhancing feelings of self:esteem through the awareness that others 'Cllre about the
user and want him or her to succeed.
Beattie, Longabaugh, Elliot, Stout, Fava and Noel (1993) noted that while general
social support for alcoholics was hypothesised to affect the level of subjective well
being, alcohol-relevant social support affects the degree of alcohol involvement.
Findings from a study conducted by them on a sample of 148 alcoholic clients
entering treatment showed that alwhol involvement is explained by alcohol
relevant affiliative and instrumental support {albeit weakly), and subjective well
being is explained by general affiliative and instrumental social support. They
suggested that treatment programmes should involve significant others from the
user's social networks, first to provide general social support and later a1cohol
relevant support.
In an attempt to study the effect of social support on outcome of alcoholism
treatment, Booth, Russe~ Soucek and Laughlin (1992) enlisted sixty-one
alcoholics in an inpatient alcoholism treatment program at a rural mid-western
medical centre in the United States, who completed an assessment .of six forms of
social support (guidance, reliable alliance, reassurance of worth, ·opportunity for
nurturance, attachment, and social integration) in tenns of support obtained from
friends and family and the treatment environment. One year following discharge,
the findings showed that reassurance of worth from family and friends, and the
numbers of previous hospitalisations were independent, and significant predictors
of time to readmission. Higher levels of reassurance .of worth or esteem support
41
significantly lengthened time to readmission, with reverse relationship found for
number of previous hospitalisations.
The National Institute of Drug Abuse in a study on a sample of 170 women and
202 men entering heroin treatment programmes in Miami, Detroit and Los Angeles
in 1975-1976, examined the utility of applying the social support-stress-coping
paradigm to the study of substance use, and on refinements needed in the
conceptualisatioll of the coping aspect of the model (Tucker, 19&2). An earlier
review of a sulJ"sarnpJe of the data had indicated that heroin addicted women had
significantly less social support on a number of dimensions and felt lonelier than
socio-economically similar non-addicted women {Tucker, 1979 as Cited in Tucker,
1982). Tucker noted that the social support-stress-coping paradigm appeared to be
an especially useful approach to the study 0 f female substance users. According to
her, addicted women were under greater strain and had more reason to use
substances and therefore, would need .greater social resources than either ·non
addicted women or addicted men.
The analysis of results was concerned with the extent to which avaiJable social
relationships were tapped by drug-using women and men when confronted with the
aversive emotional states of anger and depression. Clearly, among both males and
females; perceived social relations were used when individuals were distressed.
The research also explored the extent to which the absence of support would be
associated with the use of non-social potentially dysfunctional coping strategies.
The findings demonstrated the exlstence of such an effect for women. Among
men, the pattern was clear only for drinking, and that in itself was dependent on the
quality of the interaction with the mate. In other words, the results of the study
showed that persons without support tended to engage in activities that either did
not add to problem resolution or may have created other stresses (for instance, drug
taking, drinking or taking out feelings on children). It is possible that people with
non-social dysfunctional coping behaviours discouraged the establishment of
social ties. Finally, the study indicated that women were more driven by social
considerations, and that men used more negative strategies in the absence of
support (Tucker, 1982).
42
In sum, it may be said that based on these findings, addiction researchers and
practitioners have hypothesised that by increasing the social support from the
potential user's spouse, friends and co-workers, the individual user may be able to
quit and stay off drugs of all kinds. Moreover, the studies reviewed thus far have
restricted the concept of social support to fumilies, partners, and friends or
artifkially created primary networks. Support s)'1>tems obviously go beyond this
level. It is important to understand the functioning of other systems of help in the
community, which exerts a great deal of influence on the individual's value and
belief systems. Religious organisations and mutual aid groups are important to
take into consideration in this context. Although there is paucity in systematic
research data in this area., some studies have been identified.
Role of Organised Systems in Substance Use Recovery
While reviewing some of the studies on the religious aspects of substance use,
Gorsuch (1995:65), pointed out that most studies have suggested that religiousness
is associated with lower substallce use, as religiously inclined people are socia:lised
to accept anta abuse DOrms, are involved in anta abuse peers and "have a
mecharrism for satisfYing needs for social contact and meaning in life". According
to him, although religiousness has seldom been a variable in the treatment of
substance use, the available data suggest, that treatment which shifts clients from
restrictive, negativistic, and ritualistic religiosity, towards a nurturing, empowering
and supportive religiousness, is more effuctive than others. Thus, for 'Such persons
who experience punishing and restrictive religiosity, change in ·their type of
religiousness will change substance abuse patterns as well. Joining a religiouscuIt
may be seen as religious change of this type.
In another study on the relationship between self-reported religiosity and drug use,
carried out by Turner,and Wills (1989), a sample of 379 students in the U.S.
participated voluntarily. A significant relationship between religiosity and current
use of alcohol and marijuana was found. Subjects wllo described themselves as
more religious tended to be infrequent users in comparison to those who tended to
define themselves as less religious. This relationship between self-reported
religiosity and drug use is further clarified in the reasons frequent and infrequent
43
users gave for abstaining from drugs. Parental influence was significantly related
to religious students abstinence from marijuana, barbiturates, amphetamines, and
the hallucinogens. Parental influence was inversely related to reasons for
abstaining among non-religious peers. Of course, one interesting finding of this
study was that some of the frequent drug users reported deepening of religious
feeling. The researchers have tried to interpret this finding by suggesting that drug
use may serve as an alternative way of religious experience.
The role of Alcoholics Anonymous (AA) as a support group for substance users
has been widely recognised in literature, but research studies in this area has been
limited as the AA tradition discourages any form of fonnal research. Some studies
have tried to examine the characteristics associated with Alcoholics Anonymous
(AA) affiliation. Mindlin (1964, as cited in O~bome and Glasser \985) has argued
that the social nature of AA would appeal most to people who function in ·groups.
He noted that regular attendance at AA helped many members to feel less isolated,
l~mely or socially ill at ease. Other studies have suggested that AA would appeal
more to socially stable problem drinkers than the skid row -inebriate, as the
necessary social and economic support which the second group would require falls
outside the scope of AA (Ogbome and Glasser, 1985). -Beigel and Ghertner (1977)
noted that the AA progranune had failed to attract alcoholics from the affiuent
classes due to their inability to relate to other levels of society. In addition, they
may not be able to accept the goal of total abstinence and are disinclined ·to .expose
themselves in public, although the researchers note that other studies have
indicated that a large number of successful businessmen and professionals were
members of AA
Humphreys and Noke (1997) in a one year longitudinal study (n=2, 337) found that
12-step involvement after treatment predicted better general friendship
characteristics (for instance, number of close friends) and substance use-specific
friendship characteristics (e.g., proportion of friends who abstain from drugs and
alcohol) at follow-up. George and Tucker (1996) in a study of45 alcoholics who
were either in treatment or attending Alcoholic Anonymous (AA) found that those
who sought help reported less network encouragement to drink, more network
44
arrangement to seek help and greater alcohol-related psychosocial problems
compared to untreated problem drinkers. Zapka, Stoddard and McCusker (1993)
noted that improved drug use behaviour was associated with decreased number of
friends who inject drugs (social network), increased nwnber of people to talk to
when upset (social support), and increased argument skills about safe drug use
(social i.nfluence).
With respect to cocaine users (n=67) and alcoholics (n=48), McKay, Mclellan,
Altennan, Cacciola, Rutherford and O'Brien (1998) found that more years of
cocaine use, greater current legal problems and a lack of current alcohol
dependence predicted greater self-help participation. !n a fairly recent I'eVleW,
Green, Fullilove and Fullilove (1998) have examined the process of spiritual
awakenings experienced by some persons in recovery. The data suggests that
persons in recovery often undergo life-altering transformations as a result of
embracing a power higher than one's self, that is, a Higher Power. Emrick and
Hansen (1983) observed through their review of studies, that individuals who were
more active spiritually were more likely to affiliate to AA
Conclusion
In conclusion, it may be said that while some approaches such as the
'Collaborative Consultation' and the 'Community Reinforcement Approach' have
attempted to add the component of social support in their programmes for
substance users and have found it useful in influencing and changing substance use
patterns in their clients, Barber (1995) noted that often artificially created support
networks have not yielded much evidence to show that they can positively
influence recovery and prevent relapse.
While this area still remains shrouded in controversy, the role of 'Social support in
recovery from substance use is increasingly being recognised by professionals, as
they are begirullng to accept the limitations of fonnal treatment interventions. For
one, the latter are truly limited in scope due to the institutional rules and policies,
which often thwart the flexibility of the programme and, therefore cannot meet the
needs of their client group as and when they emerge. Besides, they lack the
45
spontaneity to provide the support and assistance on a continued basis. In the
context of substance use disorders, such supports for the individual and the family,
has to be continuous and long term, throughout the long periods of relapses and
remissions.
It needs to be highlighted here that there are limitations to the pro-social quality of
both support systems and social networks. Dalal (1995) noted that although social
support literature tends to emphasise the benefits that may accrue from human
relationships, a growing number of clinical and life crisis studies suggest that in
many cases, support efforts do not lead to the intended outcomes. Gottlieb (1983)
pointed out that much of clinical practice is fundamentally directed towards
undoing the harm caused by destructive relationships, teaching human relation
skills and assisting people to recover from social rejection or losses. Very often,
people's existing social networks are not able to support the individual who is
confronted with a crisis situation.
This point must be kept in mind when we are looking at a chronic and relapsing
. disorder such as substance use which has an added component of social
stigmatisation, for addiction is also viewed as a manifestation of 'adaptive failure'
due to the lack of support, and opportunities emerging from either the family or the
other interlinked social systems in which the user is embedded. Some of the major
follow up studies conducted in the west, suggest that in the .post-treatment phase,
the course of recovery is often influenced by tbe natural forces and structures
operating within the environment of the client, such as the family, the community,
the religious/spiritual groups, self - help programmes, and other such traditional
support systems (Valliant, 1988). However, much mOre information is required to
understand the interaction of these contextual factors and the impact it has on the
outcome of treatment, and the process of spontaneous remissions in the addictive
careers of substance users. The next section will specifically look at recovery
indicators outside the treatmcnt setting, which have ·contributed to sustained
abstinence in chromc substance users.
46
Follow-Up Studies on Substance Use Recovery
This section examines the major follow-up studies of treated and untreated samples
of alcoholics and opium users, which have been carried out in the west. It aims at
identifYing factors outside the treatment setting, which contribute to sustained
recovery, and factors, which dispose, relapse episodes in former substance users.
Some of the major follow-up studies on the pattern of relapse and abstinence have
been carried out in the U.S. and in Europe since the early sixties. Some studies
have focused on the long-term addictive careers of substance users while others
have tried to make a comparative study of groups of treated and untreated alcohol
and heroin users. Valliant and Waldorf pioneered research on spontaneous
remissions or natural recoveries to understand systems, which aid recovery outside
the treatment setting. Several other researchers followed suit subsequently.
Treated Sample
In a twelve-year follow up study of narcotics addicts (n= I 00 treated heroin addicts
and n=IOO treated alcoholics) in New York, Valliant (1966) correlated a number of
factors with eventual abstinence. Establishment of stable non-parental relationship,
substitute addiction, and compulsory supervision, all helped to facilitate abstinence
from heroin. The ex-addicts after having left treatment had created families had
achieved independence from home and had held down jobs. The study also
suggested that the ability of the addict to be gainfully employed, prior to admission
in a treatment centre, intact home until the age of six, and a late onset of addiction
were factors, which differentiated the ex-addict from a chronic addict. The study,
conclusively documented that the cycle of relapse and detoxification is eventually
interrupted, although the recovery process was a slow one. In 'Other words, the
process of detoxification did not prevent the occurrence of frequent .relapse
episodes and that external interventions that restructure the 'patient's life in the
community, namely, parole, methadone maintenance and Alcoholic Anonymous,
were often associated with sustained abstinence.
Another major follow-up study of treated heroin addicts (n=128) who had initially
been prescribed heroin and other psychoactive drugs by clinics in London was
47
carried out Stimson and Oppenheimer (1982), between 1969 - 1979. Only III or
86.7% of the addicts could be contacted during the follow up phase. In 1979, 49
persons were still attending the clinic, 60 were not and 19 had died. Over the ten
year period, 38% had stopped using heroin or other opiates. The general trend was
that those who had stopped using had made major changes for the better in nearly
all areas of living. One way the addicts learnt to achieve this was to reorganise
their livcs without drugs. Some people had tried to organise their lives in a new
way whilst they were still addicted, whereas others were suddenly precipitated into
abstinence, by imprisonment or other events, which took them by surprise, and
subsequently, had to react more quickly in reorganising their lives. These changes
were more prominent in the area of work, friendships, living conditions, and crime
and general health. Other specific reasons addicts gave for coming off drugs were,
disappointment with drug effects and the addict lifestyle, seeing themselves as
being too old for the addict life style, bad drug experiences and health fears,
problems related to arrest and imprisonment, and interference with other things
they wanted to do or with leading a normal life.
A major contribution has been made by the Drug Abuse Reporting Pwgram
(DARP) in the United States to understand the factors that influence the course and
length of addictive careers (Simpson, 19&4). Data collected from a 12-year follow
up of addicts (n=490) who were interviewed six years following entrance into
treatment, indicated that there were multiple pathways and metors involved in the
initiation, maintenance and cessation of substance use. Subjects reported that the
metors likely to influence initiation were, euphoria, anxiety reduction, and
availability of heroin, to a lesser extent, interpersonal pressure. The most common
reasons given for cessation of drug use were being ''tired of the hustle", "hitting
rock bottom, "fear of jail, fumily responsibilities, and other personal events" . The
study also found that some of the reas-oTIS for initiation into substanoe use were
correlated with the addicts' motivation throughout their careers, that is, -the same
reason was consistent for his continuation, relapse, and cessation of heroin use.
Moos, Finney and Chan (l98 I) conducted a comparative study of married
recovered (n=55) and relapsed alcoholics (n=58) with matched community
48
controls (n=113). Both group of alcoholics were fonowed-up two years after
treatment. The results showed that the proportion of current drinkers was about the
same among the community controls and the relapsed alcoholics, but was much
lower among the recovered alcoholics. The relapsed alcoholics complained of
more depression, anxiety and physical symptoms and were more likely to have
been hospitalised during the past year than the recovered alcoholics. The three
groups were similar in their participation in religious and organised social
activities. The community controls reported more informal social contacts than
either the two groups of alcoholics, but there was no difference between recovered
and relapsed alcoholics. Relapsed alcoholics were much less likely to be working,
much more likely to have changed jobs and have lower incomes than members of
either of the other two groups.
Recovered alcoholics and the community controls had higher level of social
competence and better 'U-concept than the relapsed groups. Relapsed alcoholics ;),c>
described themselves as less ambitious, confident, energetic and out-going.
Besides, they had experienced fewer positive life events than the recovered group,
and more negative life events than either the recovered or the control group. The
recovered alcoholics reported a more extensive network of social support than did
the community controls. The relapsed alcoholics showed less. cohesion and less.
active-recreational orientation in their fumilies than the recovered patients; they
also showed less. expressiveness and organisation and more conflict. The
recovered alcoholics did not differ from the community controls in their perception
of the work envirorunents, but relapsed alcoholics perceived more work pressure
and less physical comfort in their job settings than did recovered alcoholics.
Untreated Sample
Waldorf (1970) tried to examine the social adjustment of heroin addicts (n=422) in
New York who had maintained long-term periods of voluntary abstention outside
jails. and treatment programmes. The study showed that the use of heroin by most
addicts was not a steady, uninterrupted process, but was a periodic or ,episodic one.
Use was interrupted by periodic detoxifications,involuntary or voluntary periods
of abstention in and out of jails and treatment facilities.
49
Social adjustment of the ex-addict was strongly associated with education, family
compatibility and criminality prior to heroin use, a finding that has been echoed by
other studies as well. The better the social adjustment of the ex-addict the longer
was hislher period of voluntary abstention. The individual's ability to have
meaningful interpersonal relationships within the family and the society helped
himfher to adjust and cope better after he/she was off heroin. In short, adjustment,
according to Waldorf, was aided by positive response from others.
In yet another naturalistic study of alcohol users, Valliant (1983) used a sample of
men who were not patients. He selected a group of school boys (n=400) who were
followed from the age of 14 to 47 years, and at some point in time 110 developed
alcohol dependence. Within a year or so, 49 became abstinent, and <only in 30% of
the cases was abstinence associated with clinic attendance or hospitalisation. The
study identified factors that contributed to recovery of substance users, some of
which like compulsory supervision and inspirational group membership such as
attending AA groups were similar to the findings of his previous studies. The
other factors he identified were, experiencing a {;()nslstent aversivee"-perience
related to drinking, finding a substitute dependency to compete with alcohol use,
such as meditation, compulsive gambling, overeating and so on, and lastly,
obtaining a new social support, for instance a marriage or a earingemployer. One
or more of these factors were present during the first year of abstinence in a
majority of the cases. The study, in its recommendations for future action thus
placed greater value to community based interventions such as parole, self-help
groups, work and so on, than conventional clinical interventions. These
interventions interfered with the drug seeking behaviour of the addict by imposing
a structure on hls or her life.
In another series of studies conducted by Waldorf and Biernacki in 1-981 and 1983,
the recovery process amongst untreated addicts was examined, using a snowball
sampling procedure and focused interviews. The researchers collected
retrospective data on a sample of ex-addicts (n=200), half of who .had drug
treatment histories and had not received treatment. The findings suggested that
untreated addicts had shorter addiction careers (6.2 years) compared to the treated
50
sample (9.9 years). Otherwise, the two sub-samples were found not to differ on
such variables as religion, education, employment, and drug use. In a later
communication, Waldorf and Biernacki (1981) noted that patterns of recovery
from drug use seemed to be related to the conditions and consequences of the
addict lifestyle as well as environmental influences. Such patterns included,
maturation, religious, spiritual, or ideological conversion, behavioural change
brought about by environment, cessation of drug use while otherwise maintaining
the addict lifestyle, alcohol substitution or mental illness, and drifting into societal
mainstream. Self-reported rationales for stopping drug use, ranged from, "hitting
rock bottom", which characterised as despair and existential crisis, to street hassles,
police involvement, and other such aspects of a dysfunctional lifestyle.
Relocation of residence was found to have a positive impact on the abstinence
status of opiate users (Maddux and Desmond, 19.82 as cited in Platt, 1986). In a 20-
year study, opiate users addicts (n=248) were found to be voluntarily abstinent, ~---- ---
54% of the time during relocation, and 12% of the time doring residence in their
hometown, San Antonio, Texas. When abstinent addicts returned to San Antonio,
some 81 % resumed opiate use within one month. The moving away from their old
drug sub-culture and developing positive peer modelling lead the authors to
suggest the encouragement of relocation.
In the United States, Tuchfeld (1981) studied the life histories of men (0=35) and
women (n=16) who resolved their chronic problems without professional or formal
treatment, to determine whether and by what means spontaneous remiSsion from
alcohol occurs. Interventions by friends, family or untrained ministers, and
diagnostic medical warning by a physician were not considered to be formal
treatment. The general findings of this study indicated, that theresalution of
alcohol problems occurred without the aid of formal treatment or professionals and
trained therapists, and that this resolution was effective for some people. The study
also showed that the processes and associated factors were amenable to empirical
investigation and had theoretical implications. Most respondents were disinclined
to enter formal treatment centres due to the negative labelling attached to the tenn
'alcoholic', which encouraged unnecessary stigma. Quitting alcohol enhanced
TISS LIBRARY
III 11111111111111111 098890
Z E ". 51 ::;;
self-esteem in the respondents, and some attributed their strength to significant
others or to religion.
However, commitment to resolution was associated with the following mctors such
as personal illness or accident, education about alcoholism, religious conversion or
experience, direct intervention by inunediate family or by friends, financial
problems, alcohol-related death or illness of another person, legal problems, and
finally, extraordinary events including personal humiliation, exposure to negative
role models, events during pregnancy, attempted suicide and personal identity
crisis. Post resolution behaviour was followed by supportive social conditions such
as the availability of non-alcohol-related leisure activities, reinforcements from
family and friends, and the existence of relatively stable social and economic
support systems. Moreover, initial commitments were accompanied by
commitment mechanisms often external to the individual.
Peele (1989) studied saIIljJles of untreated addicts (sample size not given) and
described a variety of psychological strategies that they used to reinterpret their
cravings in a negative light so that these urges lost their power. Some individuals,
according to Peele became very health conscious, concerned about their physical
well being, and reorganised their lives around new friends and non-drug related
things. In other words, untreated addicts select idiosyncratic techniques of negative
contexting that bas special relevance and meaning to their lives.
Klingemann (1994) in a Swiss study, made a -comparative examination of
auto remission in alcohol and heroin user groups. He recruited 60 subjects, (30
alcohol users and 30 heroin users) who had demonstrated "significant
improvement" in their alcohol or heroin consumption, without any considerable
intervention of professional or self-help groups and whose remission had lasted at
least one year before the interview. According to him, of the 60 subjects who he
referred to as "practically treatment-free remitters", 28 of the heroin users and 17
of the alcohol users had stopped their consumption of drugs totally. The
motivational factors leading to autoremission were, "hitting rock bottom, wanting
to drop out before reaching the absolute rock bottom point, which he labelled as
52
'cross-road cases', those for whom social pressures played a role and the "maturing
out" process. His study highlighted that abstinence was the usual solution for
heroin users, and controlled or 'functional abstinence' was more frequently
observed amongst the alcohol users. Moreover, 86% of the heroin users had come
off drugs before the age of 30, which once again confums the "maturing out"
hypothesis.
Examining the social relationship between current and abstinent heroin user and
their female mates (6 couples) in the U.S., Lex (r990) found that the abstinent men
had begun drug use later, had a family history of affective disorders, and had
initiated their conjugal relationship with a non-user after cessation of heroin.
Female mates of the abstinent users had positive ratings of their mates'
perfonnance of social roles, and were striving to obtain formal training to improve
their employment skills. Interactional analysis of dynamics in relationships of men
currently abstinent, revealed that participation in mates' family life served to
reshape tbeir behaviours into more stable acceptable roles.
In another follow-up study carried out by Humphreys, Moos and Cohen (1997), a
sample of previously untreated alcoholics (n=628) were recruited at detoxification
units, alcohol information and referral services. Of these 395(68.2%) were
followed at 3 and 8 years later. Most were white (n=329) and men (n=198).
Regular attendance at AA meetings in the first 3-years predicted remission, 10wer
depression, and higher quality of relationship with friends and spouse/partner at 8
years follow-up after treatment. Extended family quality at baseline also predicted
remission and higher quality of friendships and family relationships at 8 years.
Charles Winick propounded the concept of'maturing out' which is often examined
in recovery studies in the early sixties in the U.S. WInick (1964) carried out a
statistical survey amongst a sample of narcotic addicts (n=7, 234) who had been
registered with the Federal Bureau of Narcotics since 1953 but were inactive
(inactivity defined by the researcher as not being reported as a drug user for 5
years) during the time of data collection. The study concluded that between the
ages of 35 to 40, a large number of heroin users had stopped using drugs, maybe
53
due to the fact that the problems for which the user originally began taking drugs,
the challenges and problems of early adulthood, became less salient and less
urgent. This process of emotional homeostasis, which the addict achieves in the
course of his or her addictive career, was referred to as the ·maturing out
hypothesis'. The results of the study suggested that maturing out of addiction
accounted for approximately two-thirds of the sample. The researcher concluded
that perhaps addiction may be a self limiting process for two thirds of the addicts:
it may be a function of the age at which the addict begins taking drugs or perhaps
the function of the cycle of the disease of addiction itself; or a combination of the
two processes. The study also pointed out that geographic and other e»'ternal
factors might affect the eX1:ent to which a particular group of addicts either matures
out of or reverts to narcotic use.
Robins, Helzer, Hesselbrook, and Wisll (1977, as cited in Platt, 1986) noted that
12% of the returning veterans who had been addicted to high quality and
inexpensive heroin in Vietnam to have been addicted in the first three years after
return. The follow-up data for those who had been re-addicted in the three years
after return showed tbat at least 70% had quit heroin in the next two years. Glasser
(1976) commented that heroin use in Vietnam helped the veterans to cope with the
extremely stressful condition, but on return they were able to resume a -normal life
they had no overpowering desire to continue the use of this illegal drug. In a mOl'e
recent review, Robins (1994) noted that the veterans used heroin in Vietnam
because it was inexpensive, unadulterated, and easily available, alternatives were
few, and their war service was not of their real lives. When the situation changed,
especially due the change in setting on return to America, the veterans had no
difficulty in giving up heroin.
Conclusion
While these studies have thrown some light on the non-pharmacological fuctors,
which aid in recovery, our knowledge of recovery is still far from adequate. While
relapse is observable ahnost immediately, recovery is a complex, long-term
: phenomenon. In short, recovery needs to be viewed as a process, and according to ••
54
Leukefeld and Tims (1989), the process of recovery is emphasised rather tban
achieving the state of recovery.
Some of the major recovery factors that have been identified by these studies
which may have some relevance to the Indian contex1: are: inspirational gmup
memberships, gainful employment, establishment of non-parental relationships
following marriage, obtaining new and stable social and econOmlC support
systems, change in residence, living conditions, friendship networks, reduced
involvement in crime, meaningful interpersonal relationships within family and the
society, pursuing an educational career, religious and spiritual conversion or
experIence, availability of non-substance use related leisure activities, and
enhanced self-esteem, feelings ofself-competencelbetter self-concept.
However, most research so far has concentrated on opiate users and alcoholics and
has neglected those who use other drugs or are dependent on them. Ghodse (1989)
noted that this yawning gap in our koowledge is usualli papered over by
unjustifiable extrapolations from studies of opiate addicts. Thus, this can be
regarded as a major limitation of the studies described above. In recent years, with
the adoption of harm reduction as a viable goal for user groups, the issue of
abstinence seems misplaced. For instance, recovery goals could include,
elimination or reduction of criminal activity, cessation of illicit drug use,
establishment of socially acceptable behaviour such as obtaining employment,
maintaining a basic standard of living by legitimate means and maintaining stable
relationships with family and friends (Ghodse, 1989).
Conclusion ontbe Review of Relevant Research
The review of research indicates the relative lack of studies, especially within the
Indian context, showing the relationship between social support and substance use
recovery. The situation in other countries has been no different, although the need
for conducting such systematic studies is being felt. For instance, Waldorf and
Biernacki, (1981) noted that since the 1960s the emphasis of research has been on
identifYing how people be<:ome addicted, the incidence of addiction, and how
55
addicts must be treated, thus largely ignoring the need for developing a fuUer
understanding of the natural course of addiction.
Within the Indian contex1, hardly any study has been conducted to study natural
recoveries or autoremission. Studies carried out by Valliant, Waldorf and others
clearly show that there are other events, experiences and actors in the addict's tife
who influence his/her non-using status. Hence, it would be important to remember,
according to Ghodse (1989:236), ..... that professional intervention is only one
factor in a complex and ever changing situation and it is arrogant to assume that it
lies at the root of the subsequent change".
These studies do not provide an analysis of the process through which users
mediate and utilise these social systems and support networks. MOfeover,
continued abstinence from mind-altering substances involves changes in ·certain
core values, attitudes, perception and beliefs, which were integral part of the
substance user's world. How this change came about, either through the positive
influence of social support mechanisms or other factors has not been adequately
explained either by self-help groups or the religious groups working with substance
users.
The conspicuous absence of studies, which examine the role of social systems in
the recovery of substance users within the Indian context, is truly a limitation for
the field of addiction research in India, which is still at its infancy. So far, research
interest on the coping behaviours of wives of alcoholics and parents of narcotics
addicts, has been studied more extensively, than the role of the family as,a support
system in the addictive careers of substance users. As the concept of 'co--- ---~,.-. ----- .. dependency' gains popularity with researchers and addiction professionals, it seems
likely that for a long time, the family will be perceived as a source ,of negative
support or non-reciprocity, rather than as a source of optimism and positive
support. This is a serious concern as the concept of social support is not new to the
Indian cultural ethos.
56
There is a growing need to explore the possibility of examining extra-treatment
factors. especially social systems, outside the family system. so that professionals
may be in a position to offer a variety of options and alternatives to their clients
during the process of rehabilitation and reintegration. For too long, the family is
the only system which professionals are comfortable working \\lth, not laking into
consideration whether the fumily wants to remain involved in therapy or not. A
search for other viable support systems in the natural environment 'Of the user and
the process through which help seeking and receiving behaviours are mediated,
will thus contribute meaningfully towards interventions aimed at preventing
relapses and strengthening recoveries of former substance users.
57