Webinar – The Journey of an Addict in a Rehab Centre

In our weekly webinars, we talk about various industry scenarios and challenges of rehabs across the country along with the de-addiction and mental health challenges faced by the mental health community and people in general.

In the fifth webinar of the series, we invited Dr BR Madhukar – Managing Director & Senior Consultant Psychiatrist at Cadabams Hospitals, along with Dr Anitha Bharathan – Consultant Psychologist & Lead Psycho-oncologist at Cadabams Hospitals. The webinar was hosted by Mr Vikram Kumar – Managing Director of RehabPath, India. In the webinar, Dr Madhukar & Dr Anitha share their views on the journey of an addict in a rehab centre.

In this blog, you can read the summary of the webinar, or you can watch it online here.

Vikram: Please tell us about your background and throw some light on the history of Cadabams and its journey in India.

Dr BR Madhukar: I’ve been in the psychiatric profession for around three decades. I did my post-graduation from NIMHANS, subsequently worked in the UK, and returned to India in 2003. I’ve been part of Cadabams since 2009. Having worked in subspecialties of psychiatry like deaddiction & old-age medicine; it has been a great experience working with Cadabams. Cadabams has been in the field of mental health for more than 28 years now, started by Mr Ramesh Cadabams – Chairperson, and Mrs Sudha Cadabams in memory of the former’s sister.

Having started in the area of mental retardation and intellectual disability, we subsequently moved on to deaddiction and other specialities. We also have a centre in Bengaluru, catering to acute mental health problems. Cadabams offers tri-star facilities to all & separate facilities for women who come under low socioeconomic status. Our facility Anunitha has world-class infrastructure. We have had visitors from all over India and across the world. Some of my friends – who practice psychiatry – have also visited Anunitha and were marvelled at the facilities.

Anunitha is home away from home where we offer facilities to make patients comfortable, including sports. Concerning the deaddiction centre, we do come across people with addiction problems relating to alcohol, cannabis, drugs, gadgets, and gambling. Mr Cadabams and the team have created a place that offers world-class facilities with the help of Ms Saraswati – Vice-Chairperson. We have professionals of various categories like physicians, counsellors, clinical psychology and so on to ensure that patients get comprehensive care. I would ask Dr Anitha to add more to my answer.

Dr Anitha: I am a consultant clinical psychologist, working with Cadabams for the last six years. I have done my PhD in psycho-oncology specialising in paediatrics. I’ve been practising psychology for over a decade now. Now taking forward Dr Madhukar’s thoughts, it is imperative to address addiction as an important issue pertaining to the current generation. There are almost 60% of adolescents who are going through this problem and require professional care. They need support from their families and their environment.

V: Talking about the journey of an addict in a rehab centre, there is always a day one. When they come to your doorstep, how do things work? What are the next immediate steps?

Dr Madhukar: I’ll take a step back before starting on this. The question is simple – do I have an addiction problem? Many people, when they begin doing any drug, they start for recreation. Over a period, it doesn’t remain the same. Their family and friends try to get them to rehab during such times. Before this, they go through a consultation with a psychiatrist – who tries to understand root cause of their addiction. Once you visit, busy people like to be treated as outpatients. If they are non-successful, then they visit rehab centres. Nobody likes to visit a rehab centre as a first step.

Staying with the strangers in a rehab centre, away from family, is already scary for most people. That’s why we encourage them to visit, talk to professionals, and see how well patients are being treated as it can make a huge impact on their mindset. They can see for themselves if patients are sitting at one place sedated or are going through some therapeutic programs.

If a person is using mild substances or has not gone through severe withdrawals, they can go through counselling sessions. A counsellor is more like your friend who makes you comfortable and encourages you to interact with others and takes care of all the needs.

First few days, the focus is on investigating the problem and going through physical check-ups, and that you start understanding therapeutic sessions. You get comfortable with the place when you go to gym or individual sessions.

Everyone must understand here that once a person starts having withdrawals, they stop interacting with friends and family. Since they are taken off the substance here, they have to rework on their interactive skills or building relations. There can be a bit of anxiety or hesitation at the start. It is where the counsellor comes into the picture. A lot of group activities happen to adjust to the environment and the food here, making their first week easier. In the initial phase, massive support is given by all the professionals.

We also take family sessions to address anxieties about their child.

Dr Anitha: In the first stage, they would have some apprehension as rehab centres have a controlled environment. Based on their withdrawals, they are also put under detoxification processes where medical management tries to understand and control their physical symptoms by starting the entire road to recovery.

Their day starts with scheduling, by trying to understand the routine, and build connections with comfort.

Then we move on to psychosocial interventions.

Vikram: Let’s say I sign up for your alcohol program. What does the first day look like? Do the addicts feel like they have entered a new world?

Dr Madhukarss: Having been dropped by the family, clearly you go through a range of emotions. Have you done the right things? Is it necessary? How do I cope? Who will be my new friends? Can I trust all these people here?

There can be an unsettled phase for a day or two. It is where nurses and counsellors give extra care. On the same day, the person meets the Registrar, who is also a psychiatrist. Maybe you have to spend extra time with the patient to understand the gravity of their situation and probably introduce them to more therapeutic activities. Residents (addiction patients) are observers on their first day than an active participant. Some of them may need medication to take care of their withdrawals. You will be overlooked by nurses. If they share room with another person who’s been here for a couple of days or more, it can be more comforting as they can help to relax.

If someone has already been to such a facility before, they might be aware of many things. If they haven’t been to one, it can take time for them to adjust. The anxiety in such cases has to be taken care of as it can last for a couple of days. I have seen here many individuals who get relaxed on their first day with the help of our professionals.

We also advise family members not to call them frequently as it works as a reminder for them to go home soon. It helps them concentrate better on recovery. So, we act as a link between the family and the patient.

Dr Anitha: It requires a lot of effort from our team. A person is overwhelmed when they enter rehab for the first time. They may be disoriented and have emotional turmoil. At a varied interval for this, professionals meet the resident and try to calm them down by making them understand the importance of these processes. It is not a punishment they undergo; it is for their well-being for which the decision has been taken by their family or themselves. It is the message that needs to go through. Along with continuous observations from resident doctors, nurses, or other professionals, it helps them calm down.

Vikram: You are dealing with a situation where the role of family is critical. What is your policy for allowing the residents to meet their families or talk on phone or smoke during initial days? Do you allow food from families?

Dr Madhukar: Staying away from phone has already become difficult for everyone these days. However, we have policies in place for such things. In our centre, we don’t allow residents to have mobile phones. As far as family is concerned, counsellor and the treating team mediate to make them understand the situation. However, there can be situations where it can be relaxed. We explain them in advance about the rules and regulations; also, we keep them updated. We get in touch with them in case of a psychiatric emergency.

We do not encourage families to bring food as there are other residents as well. We ask them not to make phone calls to the patient frequently. During the therapeutic activities, we also arrange outdoor activities for recreation with the counsellor like going out for a movie or having lunch at a restaurant and come back. Family visits are planned so that they meet the medical team along with the resident. There are also joint sessions scheduled with the family.

Dr Anitha: Members of the treatment team are always in touch with the family of the patient as counsellors and conduct intense discussions to identify the issue and its triggering factors. Initially, the family is taken into confidence by making them go through a psychological analysis session, where they are explained about the current condition of the resident and possible treatment options. Once the resident starts the journey, we conduct a psychological assessment to understand personality issues or any other difficulty they are facing. If there are concerns in the family, a series of sessions are taken by involving them in every process. Generally, the family wants to know about their role. These questions are answered to make them emotionally stronger. Also, when the resident steps outside, their family is fit to understand or handle them emotionally.

Vikram: Not all rehab centres have a good recovery success rate. It’s difficult to understand all the complications and factors, relating to alcoholics starting from relationships or career. Once a patient comes out of a critical situation, how does the remaining period go? How do you engage them to keep them motivated?

Dr Madhukar: Just to say, nobody feels bored there. They have a timetable for a diverse set of activities like counselling sessions, yoga sessions, games, sports, and so on.

Something we have to always keep in mind is how it all started. There is a lot of guilt involved – be it from family or the resident. Many times, half-hearted people are also there. You must understand the gravity of their situation. The problem doesn’t come in a single day, which also goes for corrective measures. We talk about personality tests that are taken here by a team of professionals, including Dr Anitha, that helps them understand their areas of weakness and the level of motivation.

We help them stay abstinent. Such things take an enormous amount of time, and don’t happen overnight. The sessions are planned for maintaining continuity between sessions and identifying obstacles, including the methods to overcome.

Continuous introspection also happens in all stages. We have many outdoor sports activities, like basketball and cricket. People who haven’t played games in a long time get involved as it is therapeutic. It brings back their self-worth.

For families, we also have a series of activities and sessions where they participate enthusiastically.  

It’s all well-thought and well-executed so that motivation stays intact. We also work with families to bring back a sense of hope.

Our rehabilitation centre has also won cricket tournaments 4 times in Bangalore. Residents also look forward to such sports events.

Dr Anitha:  Somebody going into addiction also goes into a nutshell. They avoid social contact & meeting people, making their entire functionality come down. So, it becomes important to balance physical and psychological activities. Initially, we give importance to physical well-being with the help of yoga or any other physical activities. They start becoming physically strong with psychological effects. It helps them prepare for psychosocial intervention. We also have mindfulness club where they can relax. They can also join music, reading, and many other clubs. Apart from this, they have sessions with the counsellor. They start their day with physical activities and end with cognitively enhancing activities.

Vikram: Social activity is a massive part of connectivity & pulling someone out of addiction. How does a festive celebration look like in Cadabams?

Dr Madhukar: Not only festivals but birthdays of all residents are also celebrated. All the festivals with the day’s speciality are celebrated in our centre. Entire staff and residents indulge in the celebration.

Vikram: You have already covered addiction programs at Cadabams. Is there anything else you’d like to add?

Dr M: I’d like to talk about other problems as well, comorbidity – the presence of psychiatric illness with addiction problems. When we recognise that there are other mental health issues, it becomes necessary to treat them. Many people may have an underlying personality disorder, which may have been troublesome to their families or society. It involves sitting with the resident and their families. It could be someone with extremely emotional characteristics like anger or crying. It may be demanding, but gives long-term gains. The family environment is also an essential aspect to study here – if they have any addiction history or need to change lifestyle a bit for the resident to return to a safer environment. It is not about finding faults but creating a happy and understanding environment for them to return. We also have to understand the mental health needs of the family too.

Vikram: How does the discharge happen? Who decides whether a resident is fit to go home or not? How do they feel about leaving the facility?

Dr Madhukar: After having interacted with many residents, I can say that they’d miss leaving the premises of Cadabam’s Anunitha. They’d have made many friends, gotten used to a routine, interacted with people, and when they come back for a routine check-up, they meet their friends and share stories of discharge or recovery. It is a positive influence on them while leaving the facility. They continue meeting friends whenever they come for a routine check-up at Anunitha or any of the hospitals.

Now, discharge is decided by the resident, treating team, and the family collectively. The foremost factor is the progress a resident has made in 1, 2 or 3 months. Do they feel confident about the resident getting discharged? Do they feel that they are still craving? When a resident goes to the outside world, can they say no to the substance? All such questions are kept in mind. Past relapses are also included. Finally, the views of family and residents are collected.

The decision is based on recovery, the confidence of handling the situation, staying abstinent, building in early warning signs and recovery.

Dr Anitha: Discharge is not a single event; it is a process consisting of multi-disciplinary professionals, family & the resident. A resident may have many triggering factors that need to be addressed. It is all based on their motivation, readiness to change, acceptance, putting efforts after rehab, and their confidence.

Once we see all these things in a resident, we slowly start exposing them to the outside world, where they go out for a day. It gradually increases to a couple of days, where they learn to handle themselves. Considering everything, discharge is initiated.

Vikram: How is a reluctant patient handled? Would they be kept sedated?

Dr Madhukar: If you look at it, the reluctance could be assessed based on certain parameters. It could be an underlying mental health problem. If a person is disturbed, say from substance abuse, they require a lot of help in the crucial stage. With our trained staff, we talk to them and make them understand the importance of treatment. However, if there’s too much psychological disturbance like anxiety or depression, medication is essential to calm them down. During withdrawal, a person can become suspicious, like hearing voices, where they can also be violent – medicine is necessary not to let them harm anyone. Sedation is required only to control them from emotional imbalance, for a short period, not throughout the course.

After a couple of days, they are better and ready to coordinate. Everything is closely monitored by our psychiatrists in such situations. Else, all other treatments are conducted in their conscious or alerted state.

Vikram: It is equally essential for a family to understand what their child is going through. How should it be done to make their child’s journey easy? Should they be involved in every stage or none at all?

Dr Madhukar: I’m a firm believer in the involvement of family from day one. They have to be updated for every step, encouraged to take part in sessions with the psychologists or therapists, and make them understand their child’s guilt and other problems. We also conduct many sessions dedicated only to the families.

Vikram: After quarantine, we can see many mobile phone addicts. How do rehab programs help them?

Dr Anitha: Unfortunately, because of the lockdown, we are seeing an increase in the screen time and usage of social media or technology in general. If it affects their daily patterns, they develop addiction problems. In rehab, they can go under an enormous amount of anxiety initially. There are specific dedicated programs or therapies, which are exclusively for behavioural addiction. There are various models – behavioural modification or cognitively trying to relieve them from negative thoughts. They are kept away from technology. It slowly starts to calm them down. We call it a sort of desensitising the entire process.

Vikram: If a person has a borderline personality disorder (BPD) and develops an addiction later, what is treated first? Or are the treatments simultaneous?

Dr Madhukar: The treatments are simultaneous. If a person has been diagnosed with BPD before, the psychological treatments are started first followed by de-addiction programs. Anything to do with personality problems, we begin with therapy, but it is a continuous process. Post-discharge, residents and their family have to continue with the therapy be it BPD or any other.

Vikram: What precautions are being taken during this COVID-19 pandemic at Anunitha?

Dr Madhukar: We are using thermal scanning. Sanitisers are standard now. We run through COVID-19 questionnaire too for travel history to identify patterns. We have taken care of social distancing. We are strictly adhering to the standards suggested by the Government of India.

Vikram: If a person behaves aggressively because of cravings, what steps do you take to control such behaviour?

Dr Madhukar: When you look at withdrawal symptoms or a state of severe craving, a person can be restless, agitated, not sleeping or aggressive. For instance, in nicotine addiction, you do have the patches or Nicorette – which we try to use, decreasing the restlessness. At the same time, if there’s underlying anxiety or other mental health issues, we have to use medication. Giving personal attention helps them be comfortable. However, if they need medicine to calm in severe cases, we’d not hesitate to use it. Sedating them is not the goal, making them comfortable is. After a couple of days, their cravings come down with lesser withdrawals. We use medicines for temporary or immediate relief. When we talk about cravings, we are also looking at a psychological program or intervention. Initially, medications may be required, but once they are cooperative, the psychological intervention takes place.

Vikram: Please share a message to all our viewers or readers.

Dr Madhukar: The stay or rehabilitation is only the beginning. Much of the work is going to happen once they are back in their natural environment. We put a significant amount of focus on the patient post-discharge. With counsellors, therapists, or other professionals, we reach out to the patients for follow ups. If they live outside Bangalore, we connect via video calls to know about their challenges, if any. We also have post-care discharge plans, where they are enrolled every month to visit the centre and meet their counsellor for evaluation of psychological, mental health and coping mechanisms. It continues for 3-months, followed by a self-follow-up process. If they are living in Bangalore, we arrange home meetings where our professionals visit their house to address their psychological needs.

It is a continuous process. If there is a relapse, we encourage early intervention.

Let’s wake up to the fact that there are problems in our country, like other nations. At the same time, some qualified professionals or centres are also available to help. A person should not delay their access to mental health. Do not think of it as somebody’s problem. Get help fast and now. We are here to look into your psychological needs.

Our website contains more information on such topics with helpline numbers.

I must thank Mr Sandesh Cadabams. We have professionals and world-class facilities. We encourage everyone to visit our centres before taking further steps. You can come to meet and talk to us anytime.

Dr Anitha: We have our helplines where you can reach out to us. You can follow us on social media platforms. The quickest way to reach us is by telephone and then through social media.

Vikram: I’ve had the privilege of talking to Mr Cadabams. He is truly knowledgeable. Thank you for a fantastic session.

If you have any other substance abuse problem, get help as fast as you can. Go to your nearest psychiatrist or a rehab centre and get the help you need. All the rehabilitation centres are open. 

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