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

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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

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'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