Webinar — Rehab at Home: How & Why? By David Stanton
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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.
The webinar was hosted by Mr Vikram Kumar – Managing Director of RehabPath, India. In the webinar, Mr Stanton shared his views on EDAS and rehabilitation at home.
In this blog, you can read the summary of the webinar or watch it online.
Vikram: Please tell us about you and your work.
David: My name is David, and I am a psychotherapist and mental health consultant. I also do clinical supervision for other healthcare workers and train mental health professionals. My journey with addiction started when I was five years old. I was a difficult baby who cried a lot. Somehow, I found a medicine cabinet in the nursery where I used to sleep. I managed to reach the cupboard and open the door to find a bottle of codeine cough syrup.
We all know that codeine is an opioid, of which I drank multiple bottles until my parents realised what was going on. The cough syrup made me sleep a lot and feel great. It was only the beginning of my addiction journey. I was profoundly dyslexic and a skinny kid, so I was left behind in academics and sports at school.
To get the feeling of belonging, I got in some bad company and started smoking cigarettes at the age of 12 years. I started smoking hashish and weed when I was 13 years old. By the age of 15 years, I had already started taking amphetamine, cocaine by 17 years, and heroin in my early 20s. This is my history of addiction. I then had a 14-year heroin addiction coupled with crack cocaine. I had become a functioning addict. By the time I was 30 years old, I had lost my family, home, business, and had tried to commit suicide.
After all this, I ended up going to a rehab facility. For me, it was death or recovery. When I walked into rehab, I only had a pack of clothes and no friends or family. After spending two years in a rehab facility, I thought I would stick to smoking hash as I enjoyed it, but my counsellor made me understand that I may relapse. I spent five months in primary, seven months in secondary care, and a year in tertiary care. For another four years, therapist visits were consistent.
By the age of 24, I became a drug counsellor in a college where during the day, I used to counsel people for drugs while at night, I lit a joint. Although I did not have any qualifications, I was still a counsellor. I then graduated in Intuitive Counselling with a specialisation in substance use, abuse, and addiction treatment. I had support from people because I was dyslexic. I was also determined to help other people, especially after my rehab experience. When I got a job in Bristol, UK, I started working my way up with this. I am in my early 60s now.
I managed a residential and daycare service for recovering addicts. I then decided to do something more for the less advantaged or entitled people. I went to South Africa to setup rehabs and community-based mental health services with a specific emphasis on substance use and addiction while working around HIV and AIDS, where I spent five years. I did the same things in Thailand for six years, where I met my business partner Kripi, who was also working in the same rehab in Thailand.
Although we have a substantial age gap, we have similar philosophies on mental health. While people are doing amazing work in this field, we both felt it had become a medical model. People were going to psychiatrists, getting diagnosed, and being given prescribed medication. While it was great, we knew nobody was looking at the disease’s reasons, say depression. They were only medicating people to mitigate their problems, and it often did not help because the problems manifested in various other ways.
To have a different approach, we decided to move to Goa five years ago and started Tatva — a mental health awareness and emotional wellness organisation. We offer various services and specialise in substance use/abuse and harm reduction.
Vikram: You were travelling more and dealing with patients across the world before the pandemic. How is the current situation around the world with COVID-19 and mental health?
David: I think it is tragic. Unfortunately, we all have brought it on ourselves. The consequences of COVID-19 are horrendous in the UK and worldwide, especially for mental health considering lockdown and other factors. I often tell people that addiction is an isolating illness as there is stigma and shame attached. COVID and lockdown have only increased this isolation, so things like anxiety, depression, domestic violence, substance use/abuse, alcoholism have increased massively. Having been an addict myself, two obvious things are a lack of supply of illegal drugs and the abuse of prescribed medications. People are facing severe withdrawals, and it is all spiraling out of control. It is not just COVID but all the mental health problems associated with it.
Vikram: As far as India is concerned, there has been a consistent dip in the COVID cases over the last few weeks. Can you please help us understand what EDAS is and what rehab at home is like?
David: EDAS was born in 2007. As I mentioned earlier, I was involved in managing and setting up rehabs in Africa, Europe, and Asia. One of the things I noticed when people went home after completing their rehab time, they often relapsed. Families spent a substantial amount of money sending their loved ones to rehab. Even if it was not an expensive facility, the patients would go home to all the triggers that enabled self-medication in the first place.
The other thing about substance abuse or addiction is that it is a family illness. It is not just about the person with dependency problems but all friends, family, and colleagues. Addiction ripples out and affects 40 people per addict on an average, which is a huge number. Old school thinking was to send the addict to a rehab facility or get them out from the places where they consumed substances or alcohol so that the family would rest while ensuring the safety of the addict. While I agree that sometimes people do need this change, the lack of care afterwards is obvious. The treatment, in my view, was flawed. When the addict goes back after recovering at the rehab, they usually relapse quickly for the same reason.
Therefore, I thought of taking de-addiction treatment to people’s homes and educating the family or giving them family therapy sessions as the experiences are traumatising for them as well. We can identify all the triggers. We assess all the cons in their environment, their social, work, and spiritual lives and look at every aspect contributing to self-medication.
EDAS is a comprehensive and hands-on service. Since we are a home-based service, you get a personal therapist who stays no more than 15 minutes away from your home. We do not live with you because it would be unethical and an invasion of privacy. If you ring us at 4 am and tell us that you are going out for a drink or consuming any substance, we reach your home in 10 minutes to talk you out of it and learn about your feelings at the moment. My team and I are passionate about this labour intensive work. Many evidence shows that recovery is more successful when carried out at home than going away.
Vikram: How is your team structured for EDAS?
David: I have built a team over the years since the launch of EDAS in 2007. There is a core team of nine people, where a core member resides in each continent. We do not work in North America because of its policies, procedures, and licensing; however, we work in Canada, Central and South America. Apart from this, we also work in Africa, Asia, and Australia. We have team members from South Africa, the Philippines, Britain, France, Spain, and various other parts of the world. We are similar to a global organisation. Clients can ring us from any country after which we usually fly out one of our team’s core members once they have agreed to take our service. We also have a set of database professionals in almost every country with whom we collaborate and work.
For instance, somebody rings us from Tanzania. One of our core members in South Africa will connect with the client and start their treatment. We work with them for a minimum of two weeks to a maximum of three months.
The process starts with a detailed assessment moving onto detox, which is done either at home or a local hospital as per suitability. We sit with them most of the time while they go through medical detoxification for a minimum of two weeks which is the minimum time for a detox. We persuade them to extend the treatment to work on the reasons that led to addiction in the first place.
I do not believe that addiction treatment has moved with time. The 12-step programme and various others are good for getting better as I have experienced them first hand. In the 80-90s, other programmes were also started like CBT that seem only as add-ons. My problem with addiction treatment (residential and outpatients) is that they focus too much on stopping the drug or alcohol use while ignoring the core reasons. This is where we differ.
We do in-depth and intense psychotherapy. A Canadian addiction expert says that most people with dependency problems have got some trauma in their past. We focus on healing this trauma. It is not just about getting people abstinent because some people can control their drinking while others can’t. First of all, the longer they pursue treatment, the better. Secondly, the desire to self-medicate ends once the trauma is healed. It is almost like you can grow out of addiction. I know many people from Alcoholics Anonymous who were abstinent for 20-30 years. They do not want to ruin their recovery by partaking in drug or alcohol consumption. I think it is rigid.
One of the things we do at EDAS is to give responsibility back to the client. We do not tell them what to do; we say this is your life and you have a choice at the end of the day. We can talk for six months, but you have to choose between picking the glass or not. I am only trying to inform you and help you make better choices. I am trying to heal the damage or baggage for you not to feel the need to self-medicate.
Therapeutic relationships are important to us. We come in on a level playing field where we meet at an adult level and not a professional-client level. Working with no more than six clients at a time makes us a bespoke service. We also indulge in many creative therapies like art, music, drama, and nature, and offer multiple healing approaches.
The process is more intimate and not like residential rehabs where you go and enjoy, have ‘one programme fits all’ form, the counselling team going through all emotions and knocking the client. Although it does help people with the dependency problem, ours is a more personal and hands-on approach in overcoming such problems.
Vikram: What are the key differences between traditional residential programmes and EDAS?
David: I enjoy working with groups and love facilitating group therapy — which I believe is hugely beneficial in addiction treatment. It is where residential treatment helps. If you have people sitting around who have been through similar experiences, you can relate to recovering better. When I was in rehab, I used to think that I am the only person who feels that nobody understands me. It was only in my early 30s, when I felt heard and seen. I have also been physically and sexually abused, and my fiance was killed in a car accident. I am not trying to justify my addiction problems, but I went through major trauma that required healing.
Therefore, I think peer support is invaluable. When I started listening to others in groups, I thought they felt the same as me. I was ashamed of what I had turned into that I was driving around the UK in disguise. Good therapy is significant, and you may not get it in a home-based service. But in a micro-cosmic way, we offer group sessions while working with the client’s friends, family, and even work colleagues.
We try to integrate the clients and their families because they also face the same trauma. If you have a bad relationship with your family, they can become enablers or triggers for the addiction. Therefore, home-based therapy may not be the right fit. I think this is one of the huge differences.
People find change difficult. Quite often, we sabotage things because familiarity is easier than success. The patient’s family having issues with our visits is a significant challenge. Sometimes, they are not cooperative because they think it is not their problem.
Confidentiality and consent are our cornerstone. We do not push therapy on anyone, as some people do not want to go down that road. So, we start with education — didactic lectures, talks, befriend the family. By all this, we get an idea of how far the clients or their family wants to get involved. Since the family is the main support network, they need education.
Although residential rehabs offer aftercare, it is sketchy. There is a lot of research that says addicts feel isolated, so through our process, the idea is to enable cohesion and build that love or connection again because no matter how annoyed we are with our sisters or brothers or parents or partners, we still love them. Interestingly in India, you have a good family culture. Our ways of working differ in India and Asia than in the West because of the same reasons.
Vikram: How is home-based therapy perceived in India?
David: We have been operating since 2007 and work with not more than six clients at a single time. It also depends upon the work routines of core members where we have to sort out logistics. The interest from India has been favourable.
There is a disparity between India’s quality of services and a substantial gap between the wealthy and the poor. One of the things we want to do is to make our services available to everyone from Bollywood to the village people. We use the money we get from certain clients to subsidise the treatment for people who do not have enough money. We have to be quite decisive and choosy because sometimes we may not have that amount of money in hand.
Apart from this, we do offer online therapy sessions. We have services where we refer people to residential rehabs if they do not want to continue home-based programmes with our special arrangement with 17 rehab facilities in Europe, Africa, Asia, and Australia. These are some of the best evidence-based rehabs where the patient can get treatment.
The younger generation in India is more leaned towards home-based programmes than going to a rehab centre. A major advantage is that you do not have to stop working. It can be helpful because we are not with them 24*7; however, we are available for that period, essentially meaning they have a private therapy team in hand. They can ring the therapist anytime, and within 10 minutes, the team will be at their stop. We collaborate on the issues to work out the timetable for work and family commitments.
Vikram: With a personal team at hand, it may sound a little expensive to many. India’s population is largely middle class or lower middle class, but the problem is prominent across all classes. How do you see home-based models being adapted from the expense point?
David: EDAS is a sister-company of Tatva where we do educational work. It is not only addiction treatment, we also go to workshops to reduce the stigma around it all over India. EDAS is about bespoke personal treatment, but I understand the huge disparity between people with and without money. I hope you will also appreciate that we are a business and must make money. As we are not for profit, our money goes back into the services we offer. We set up support groups and visit villages to educate people about addiction. We have a sliding scale of the price through our various treatment methods. Our basic price is 250 Euros for 24 hours, which is cheaper than most residential treatments.
There are treatment centres in India cheaper than this price, some of which I have visited. I was shocked to see patients handcuffed at a few rehabs where no recreation or counselling had been conducted for almost three months. I understand that money is a problem for middle-class people as for everybody else. We assess the situation and consider their means. 250 Euros is our basic price, but if I have to fly to Mozambique for your treatment, I am afraid you are paying for it. So, we try to build the relationship from the first point of contact. We ask them how much money they have spent on their addiction or how determined are they to get better.
We are passionate about our work of helping people rather than making loads of money.
Vikram: How does licensing work for you? Also, are there any special cases based on EDAS that you would like to mention here?
David: I came back to the UK in August last year, since then I have been trying to get back to India. Licensing varies for different countries. In the UK, we have a governing body where I have to join a Quality Care Commission. EDAS has to be COVID-friendly as we have to abide by the government rules and regulations, including health policy and procedures. As I mentioned earlier, we collaborate with local people.
One of the reasons we case-manage people through rehab is because some of them are not accountable or transparent. We are very hot on transparency and accountability, and I make sure the client gets what they are paying for.
In India, we work with many psychiatrists and other local people, making us aware of the licensing requirements of different states. To be honest, it is a logistical nightmare for us. Our insurance is huge; otherwise we would get sued probably every week (not literally). We have to be ethical. When we see outside people claiming to be such professionals without any qualification, they are doing more harm than good.
There have been many case studies. There was a guy who was incredibly wealthy and good at hiding his addiction problem for many years. He knew it would probably hit the fan, so we worked with him on his private yacht. He is clean and sober now. It was an interesting case for us. We have worked with famous people and celebrities.
I remember a guy in Rajasthan who lived with his sister and an elderly mother. He was drunk 24*7, and the poor ladies were doing everything, where he would only sit outside his farmhouse and be a complete nightmare. He was not a wealthy guy, but we worked with him, and he is sober now.
There is a whole gamut of people and it is why I love my job because we do not know who we will meet next.
Vikram (Question from participant): Do high functioning addicts tend to use more drugs and in larger amounts?
David: I can answer this from my personal experience and working in this field for almost 50 years. Addiction is a progressive illness. Since tolerance goes up, people tend to use more drugs to feel better. For example, if you are a long-time addict, the drugs stop working the same way; therefore, you tend to use more to get the same effect. Alcohol is the worst drug of all. There are more alcoholics in the world than anything else. It is one of the worst addictions to have as it rots your body. If there were classes of drugs today, it would be Class-A.
However, it is a socially acceptable drug.
Vikram (Question from participant): How does several years of addiction affect a person?
David: I have used drugs for a long time, and I am 27 years in recovery. I am fit and healthy now, but this is only an exception. Most people with a long history of addiction or similar to mine are almost dead. They say in Narcotics Anonymous that addiction can lead to jail, institution/rehab, or death.
Many people smoke weed these days, but we don’t know that it messes up with memory. Weed or hash is like a short-term memory loss drug, which often does not come back. It can also lead to schizophrenia.
Vikram (Question from participant): Are there any unique challenges dealing with addicts in India?
David: The stigma is more in India, Asia, or any other third world country. Less education and awareness is available for people throughout the mental health spectrum. Counselling is new in India.
I remember in the UK, when I started working with psychiatrists and psychologists, they would prescribe medications and we would handle counselling. Collaboration is a great way of working. In India, the younger generation is now turning towards us more than going to a psychiatrist to take prescribed medication. I also think the family culture is difficult in India as everything is kept within. As I said before, the root cause of the problem is often family that may not be intentional.
I have come across people who told me that their mothers object to them seeing a therapist and not talking to her about the issues. The addict or person may not be able to talk to their mother because they can also drive the patient towards insanity or addiction.
The family culture is different in the West, where young people want to get out of their families as soon as possible. So, we have to adapt as per the assessment.
Vikram: What would you advise the family of the patient who has bipolar disorder caused due to marijuana consumption?
David: My biggest passion is education. I think people must be educated about substances from an early age. Marijuana is a depressant. If a person is bipolar or manic, they are enhancing their depression by consuming marijuana. The person might think that they are chilling or calming down, not realising it is a central nervous system depressant. It is not doing any good, just like alcohol. People say, “well, I will have a drink as it relaxes me.” You might feel jolly after a couple of drinks but it is a spiral downhill afterwards.
I work with bipolar people from my private practice who do not use any substance. I think that there is always a reason behind it. It is not like someone just had bipolar, so it needs treatment; rather it is more about why that person got it in the first place.
Vikram (Question from participant): Do you see stigma and shaming around addiction within families? How do you manage it?
David: This problem is not just in India but across the globe. The stigma is all fear-based because the families do not know how to deal with it. When someone starts behaving weirdly, they are in a dilemma about what can be done with all these problems. Also, you do not want to visit your friends or family and share your problems. One of the things an addict faces is shame and guilt, especially the shame that eats them away from the inside. It is why this becomes a family problem and not just an individual one.
My parents did not speak to me for two years. My mother was a judge, and the shame I brought on my family was huge. Luckily, we sorted out everything before they passed away, which makes me understand other people’s problems. It is why we need to educate others that it is not about willpower but an illness. It is a dis-ease with oneself. It is about the individual’s feelings and many other things like the lack of a sense of belongingness or increased disappointments.
Vikram (Question from participant): Will the patient become dependent if they pursue therapeutic relationships for long? How is this problem countered?
David: The regulatory body in India is a concern because people get into helping others for the wrong reasons. They want to “Save the world” and quite often, the people who help others are themselves twisted. They think if they help someone, it will sort them out. I am particularly strict about my team that they have to be qualified and must have boundaries. They also have to be in personal and professional development while working with others in therapy because clients tend to push buttons. Many of the members can also be in recovery. So, you do not allow that relationship to manifest because if you are good at your job and have professional boundaries, dependency does not arise.
While I have fancied some clients and a few have also fallen for me to become dependent, you must put it on the table. It is the way to deal with such situations. I have firm professional boundaries and ethics. I will not allow my feelings to intrude to take advantage of the vulnerable.
People who do such things, break trust of the patients and must not work in this field.
Vikram (Question from participant): Please share your message with us.
David: There are two messages from my side. First is not to isolate, be it a mental health problem or addiction or anything. Do not try to sort it out on your own because you won’t succeed. Seek the available help.
The second is to ask for help. Do not be ashamed. I am living proof of it as I am 27 years in recovery and have an amazing life. I am glad that my suicide attempt 7-8 years ago was a failure. Despite COVID or all other things going on worldwide, remember that we only get one life.
It is what you choose and make it. These are my lessons.
If you have any substance abuse problem, take 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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