With addiction, or Substance Use Disorder as it is now known, expected to rise dramatically in India,The Cabin, a leading rehab in Thailand with modern practices, is in New Delhi for a roadshow that will take them to Mumbai as well. The main site of The Cabin is spread over nearly three acres. They charge $12,000 a month for a well-furnished teakwood room. One room to a person. In this in-depth interview, the top two of The Cabin - Programme Director Alastair Mordey and Clinical Consultant Prem Kumar Shanmugam explain how they have modernised addiction treatment, and what the future holds for India in terms of addiction.
Q: The Cabin is a new rehab. Current treatment methods of Substance Use Disorder [addiction] are of great interest. What have you zeroed in on? What are your treatment methods?
A:We start with an abstinence model, which is based on the 12 Steps. The idea that one must abstain. You have to abstain from the substances and behaviour [that cause addiction]. The problem is that a lot of behaviour issues show up. You could have compulsive substance use and compulsive behaviour.
So there is both - substance and behaviour. We have evolved a process that moves beyond the 12 Steps. We call it The 3 Circles.
Q: How does it work?
A:In the early days, the first few days, would be the workshop model. Two group therapies in the morning with a big exercise session in between. You come in in the morning and there's general psychotherapy.
Check your feelings. How are you feeling today; offloading. Then there is the meaty therapy work, which is traditionally 12 Step work in most of the rehabs. We do 3 Circles.
Q: What are the 3 Circles?
A:It has Cognitive Behavioural Therapy [CBT], a highly personalised approach customised to the needs of an individual, and a secular and rational version of the 12 steps to suit modern requirements. Simply put, the 3 Circles are: Inner Circle, Middle Circle and Outer Circle.
The Inner Circle is what you must not do. The Bottom Line. You must not do substances. When you thus abstain, you have a sobriety date. The Middle Circle is what you must be aware of as risk factors that could trigger relapse.
Adverse environment, unbalanced emotions and a negative belief system. For instance, you may not be drinking but you could go to a bar. This creates an adverse environment that could trigger a host of tricky emotions and responses.
The Outer Circle is where you dispute the addictive belief systems and build a lifestyle that encourages recovery. You think and act positively to encourage recovery.
Q: How does The Cabin teach the 3 Circles?
A:In the first few days, the clients learn about addiction; about brain circuitry. It's very simple. Certain people have a predisposition to this illness. It's basically that dopamine - the reward chemical in the brain - is not produced enough in people who have the disease.
We go through our life until adolescence feeling ill as we don't have enough of our reward chemical. And then we find a drug or behaviour that is a dopamine reinforcer. Like heroin or gambling. As soon as we take it or do it, the lights go on. We go wow. We are topped up to abnormal levels of dopamine.
Then, the memory system of the brain gets involved and says: Never ever forget to do it; this is your medicine. Then the memory system goes to the impulse control system and turns it off, to enable you to do all sorts of stupid things you need to do to get your dopamine. It's basically as simple as that.
It's a lot more complex than that but this is how I explain it. You have a circuit in the brain that is screwed up from the start more than likely. This is how it is genetically. And anyway, even if you don't have genetic issues, the environment - neglect and trauma - will cause it when you are young and that will be it.
This is a disease you are born with or caused in your brain by your environment and what's happened is that you end up with poorly functioning dopamine. Not low levels but a bit more complex than that. The tone of one's dopamine is not sufficiently good or the receptors of dopamine are not receiving well or one thing or another that has to do with the dopamine system, which is the reward and pleasure system.
I won't get a nice buzz with a cup of coffee because of poor feelings of reward and pleasure. My brother didn't inherit it and he will get a nice buzz with coffee. He reads a book or enjoys a game when he's 10 years old and he'll have fun. I won't.
By the time I'm in my adolescence I am therefore looking for things to boost my reward system; external things that are dopamine reinforcers, usually alcohol and drugs.
Q: You have explained the brain's pleasure circuit very well. Recently, medicine has found that the stress circuit operates similarly and can cause addiction. Even one drink at the end of a hard day's work to relax can cause lifelong problems. This is something I try to explain to people. There is a pleasure circuit and a stress circuit and both ways, you're risking it.
A:Yes. And that's the third way you can develop addiction. You stop an average person on the street and ask, how do you get addicted? They say by drinking lots. But actually it's rare that people get addicted by drinking lots. You can get physically dependent by drinking lots. But I can get them off that and they will be fine if they don't have the disease.
Some people degenerate their brain by using so much that they develop this disease. But actually it's born with or caused by environment. The third is that dopamine levels will crash down so much and your brain will be permanently hardwired through drug use itself.
A lot of people have all three. They are born with a predisposition, they have a terrible environment, and they will use drugs so much that it will degenerate their reward system. And they wind up with a permanent need to medicate themselves.
Once they've got it, they have it. This is a chronic disease. It is not going to go away. This is another thing the 12 Steps got right from the beginning. They did understand that it is not something you can cure. You can only treat this disease, not cure it.
It will come back and it has noticeable symptoms. And actually, if you stop drinking, this is what happens. The symptoms come back. The symptoms of this disease are not alcohol or drug use. The symptoms are: mind-crushing boredom, a lack of meaning in life, and things that you have before you probably even touch alcohol.
And compulsive drug use is self-medication to get rid of the symptoms of the disease. You stop drinking and still have the symptoms. The fellowships have a word for it - dry drunk. You stop drinking and you get ill.
Q: You can get seriously angry or perfectionist, for instance.
A:There is a reason why a trait like perfectionism in particular is a symptom. Because of the lack of reward and pleasure in the brain, deriving pleasure becomes a compulsion. So we develop traits like perfectionism.
That's how we fix it. It is self-medication. I will get the reward if I am the best. What you need to do, to be the best, is be perfectionist.
Everybody stops drinking thinking that if they stop drinking, they will be well. The opposite will happen. You stop drinking and you will only be well like you were before you started drinking. The trick is to find out how to treat it without drugs.
Drugs create homeostasis, a balance. If you look at it medically, it's like I'm hot and I sweat and get cool. If I'm too cold, I shiver and get warm. If you've got no reward chemicals in your brain, you're going to have to do something compulsive and exciting to feel normal.
So how do we feel excitement and reward without big dopamine-striking events like drug use? Service work, getting on well in our careers, exercise to release endorphins and natural opiates, social cohesion by being accepted by groups like AA, making amends, and seeing the look in the eyes of your families when they love you again now that you've created peace with them.
These are the things that will slowly release those chemicals that we need. That is our treatment programme.
Q: That is the 1st Circle. What is the 2nd?
A:The 1st Circle, the Inner Zone, is the danger zone actually. That is the things one must not do. In AA and NA they call it Step 1. What can I not do? And when I do it, it is repeatedly destructive. It is compulsive behaviour that I cannot engage in. It's the danger zone. This is how you get your clean time.
The Inner Circle has to be defined first. Like Step 1 has to be done first. You have to find the chemicals and the processes that you cannot control. You try repeatedly to control and then you can't. And they are destructive in your life.
Once you can acknowledge what they are, and you can go a variety of ways doing that, you almost build an abstinence contract. From that day are your sober birthday and your clean time. That is all the Inner Circle is. The must not dos, cannot dos.
The 2nd Circle, the Middle Circle, is things you can do. But they are really dodgy. So by going into a bar in early days [of recovery] you haven't lost your clean time. If you stay in the bar the whole day and the next day, you're probably not going to be sober much longer.
It is the wrong environment. The reason this is important is that a food addict or a sex addict cannot abstain. They have to choose where they will be and what they do and don't do. This, obesity, is going to kick in in India in the next 20 years.
Overeaters Anonymous asks its members to abstain from white flour products and sugar. It's scientific. They know the food stuffs that pump the reward system and therefore become uncontrollable. There are people who use food as medication.
White flour products and sugar go in the 1st Circle. But salads, meat and some of the good stuff do not. They probably go in the Outer Circle, the 3rd Circle. In the Middle Circle go fast food restaurants or listening in to conversations about food, turning on channels with food programmes.
The Middle Circle, the 2nd, is the environment and behaviours that will lead you back to the Inner Circle.
The Outer Circle is all the helpful recovery activities - AA meetings, religious affiliations, secular programmes, rational thinking clubs, service work, charity, exercise regime and so on. It is ever so simple a tool.
Q: How long does the 3 Circles treatment take?
A:That is another reason I developed it. Private rehabs across the world are going down and down in terms of the time they take. Or should I say that people and economic pressures are cutting rehab time into less and less.
28 days is just about enough time to do something. You need two or three months. It takes time for the fibre systems in the right parts of the brain to thicken and become strong. But people want to go home because of economic pressures.
What can I do? I can have two months of aftercare. I have a month of care to start with. If I use the Steps, the guy leaves after Step 3 or Step 4. He is totally emotional. Step 1 can take a long time. Twelve years ago, I didn't leave but 98 percent of people with me did. And only two percent came into recovery.
I am not going to start the Steps when they have to leave halfway. So I said let's not use start the Steps in the traditional model. Let's use another 12 Step tool, which is sound. Bring in the food addict and the sex addict.
In AA and NA, they say come for 90 meetings. But if I have 28 days, what can I do? I can have a recovery plan that will tell what they cannot do, what they should not do, and what they should do.
Q: Let's say I was to come to The Cabin. How long would I have to stay?
A:That will be dependent on what you and we agree on. I'm going to be trying to get you to stay longer than 28 days. We are going to assess you for residential in-patient treatment at The Cabin. If you are severe and you are physically addicted to alcohol or heroin, let's say, we know there's going to be a detox process at the front.
Take that away. You are going to be detoxing and you're not going to benefit from counselling. We're looking at a minimum 4-5 days if it is alcohol to up to two weeks for heroin users before they make sense.
I will add 4 weeks to the detox period and say we will review after that. If we find we are still worried about you, if we find your reasoning capacity still impaired, we will recommend to you and your funders that you stay another two weeks. You might stay a week, so somewhere between 6 and 8 weeks would be about the average stay at The Cabin.
Q: Even 8 weeks would be among the shorter stays in an Indian rehab. The first month is usually gone in defiance because the Indian mind seems to think differently from, say, the American or the British mind. All that happens in 4 weeks is that physical hunger returns. A person begins to eat. Progress, if any, is between the second and fourth month. It often takes six months in India.
A:Don't forget the milieu that they're in. The rehabs are probably not educating or stimulating them very well. From the word go, you are hit with messages.
Image: Vijay Simha (L) in conversation with Prem Kumar Shanmugam, clinical consultant (R) and Alastair Mordey, programme director. Photo credit - Parul Abrol
[Next: Part II of the interview]
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Vijay Simha is an independent journalist and sobriety campaigner based out of New Delhi. His most recent journalism assignment was as executive editor with The Financial World, New Delhi, and tehelka.com.
He was a guest on Season 1 of the popular Indian TV show Satyamev Jayate, hosted by Aamir Khan.
Vijay blogs here and may be contacted at firstname.lastname@example.org.