The Cabin, a modern rehab in Thailand, is in India to tell Indians what Substance Use Disorder [addiction] can do - and to train Indians in counselling skills. Spread over three acres, The Cabin charges $12,000 a month for a well-furnished teakwood room - one room to a person. In Part II of an in-depth interview, The Cabin Programme Director Alastair Mordey and Clinical Consultant Prem Kumar Shanmugam look at the reform needed in addiction therapies, especially the 12 Steps.
Q: There are huge issues with rehabs in India. For instance the physical space and costs, which are important aspects of treatment. The Cabin is spread over three acres and charges $12,000 a month. In India, several rehabs have a hall in which people sleep on the floor or on folding cots; there is one washroom, an activity room and a kitchen. There are better rehabs that charge about $1825 a month but they don't have high quality counselling or great rooms. Another issue is that people don't pay for treatment. The Cabin charges more for a month than many high end Indian rehabs do for six months. I know counsellors with 20 years of recovery and more than a decade of work who are paid $365 a month. All this creates chaos and affects the quality of treatment in Indian rehabs.
A: I think the thing here Vijay is to stress to people that they get what they pay for. The way for people in India is to look at the treatment period, not the number of months of stay. One month in The Cabin would be worth at least three in India.
If it costs $12,000 for six months in India and it doesn't work, and it costs $12,000 for a month with me and it will work, I'd choose The Cabin. I'll do in one month what they'll do in six in India. And then they will be back in India after a month with me and earning for the next five months.
Q: We would associate $12,000 for The Cabin with excellent counselling, resort-like atmosphere and facilities, superb treatment, great food and the emergence of a wholesome personality after treatment. In India, they would not associate any of these with $12,000 even for six months. And then, let's not forget the wages and quality of staff.
A: Well, the quality of work is an important factor. If they are not going to develop themselves, they are not going to motivate themselves. We probably have 120 on our staff when you include the consultants and the marketing. We have feedback questionnaires for the clients, asking them what pissed them off, what went wrong when you were there.
We have 500 years of combined experience among our people. We pay them top rates. We pay them in Thailand what they would earn in Britain. Can you believe that? Living in Thailand costs 25 percent of what it would in Britain. These guys are rich. We pay them what they would be paid in The Priory [Britain's costliest rehab].
Q: The Priory costs between 1.5 crore [$275,189] and 2 crore [$364,860] for six months.
A: And it is not satisfactory. You go in, you're a number. When you come out a month later, you might have met your counsellor a couple of times; probably not. The sofas have cigarette holes. Their overheads are crippling. It is a big country house if you look at it from the outside.
But from the inside, the paint is peeling off. Your counsellor doesn't get to you for two weeks. He'd be too busy. There are 70 other guys in there in the paying programme. We've got 55 beds at The Cabin and they are all in different programmes.
We have a Sober Living programme in town. We've down our job in two months and we put them in step down therapy. He's going shopping but we still test his urine. We have gradations of therapy.
Q: The relapse rates are very high in India. How is it with The Cabin?
A: Not very high. Let's remember that it is a chronic relapse condition. In 1927, it was the old world. It was not this new world. Carl Jung was talking to Bill W [co-founder of Alcoholics Anonymous] about the rates of recovery from alcoholism.
Bill W said I can't stop them from dying and Jung said you are right, you're absolutely screwed. The death rates of this disease then were 100 percent. Occasionally, he said, there are strange people who recover through religious experiences. They were talking about a few people from millennia.
It was a terminal illness. You didn't not die from this disease. Now, with treatment methods, 98 percent people die from this illness. If you go to a rehab you can bring this down to 60 percent. In our programme, we are looking at 40 percent to 50 percent people being sober at the end of 12 months.
We have long-term recovery rates, at the end of two years, of around 37 percent to 38 percent. It's about seven or eight times the normal rates in rehabs. In the average rehab you are looking at five percent recovery.
The important thing to tell the Indian people is to go and watch the HBO series on addiction called Addiction. In one of the episodes they talk of what to look for in a treatment centre. They say that on an average a person has four spells in a rehab, especially if they are young.
You need to tell parents that it's not going to be sweet and cheap. The odds are against a 20-year-old recovering the first time in rehab. Eventually he will but not straightaway. That is the horrible reality of this expensive and difficult condition.
Q: I went into real rehab once. Before that I spent one day and night in a halfway home and year ago, a few days in an asylum partly converted into a rehab. But I went into a serious rehab stint only when I was dying. Before that I tried several times – cold turkey each time.
A: Every piece of treatment counts. For me [Alastair] it was two serious interventions. Every bit of information gets lodged in your reasoning system. Even the rubbish rehabs have done something. Even a failure is at worst only part failure.
Q: A recent report in the US has questioned the efficacy of rehabs. What does The Cabin think of the future of rehabs?
A: In 2011, all the doctors got together and collected all the research on the condition. These doctors were largely pro-12 Steps and pro-rehabs. They issued a public policy document that said it was a brain disease.
Large bodies of psychiatrists from across the world, including Australia, who are pro-harm minimisation, are against addicts helping addicts. They want the white coats in. They are in bed with the insurers and the pharmaceutical companies.
They are saying, how stupid of you. You've given us a document that proves this is an illness. We'll take over. Thank you very much. The problem is that it is a medical illness that needs to be treated with behaviour therapy. That is what they don't understand.
Lifting weights would be better for addiction than taking a medicine because behaviour changes the structure of the brain. If I sit here and teach you five computer games, how to become sharper in your reflexes, your ADD will get better. Everything we do changes the structure of our brain.
When I'm lifting weights it is not just lifting the fibres in my biceps and making them bigger, it is changing the neural network inside my brain. They thought we were so stupid we didn't know that. But we do.
Your brain changes dramatically when you do counseling, when you go to rehab, when you are in AA. In fact, it changes a lot more than giving it a medicine. Our brains are intelligent. It knows how to help itself. We teach you how to help yourself. Pills don't teach your brain. Habits do. So I tell you to do new and better things.
To be fair, big insurance companies in the US are being crippled by rehab costs. They are trying to buy back and do something about it.
Q: I have found the AA and NA fellowships uncomfortable in India, which is a reason why I'm not AA or NA. I did a few meetings in 2003 and 2004 and that was it. I have not stepped into a meeting again. To me the 12 Steps are like the alphabets. Everybody who is born uses the alphabets. Nobody owns them. Similarly the 12 Steps are a lifestyle fix, which anybody can use for any situation in life. I separate the Steps from the fellowships and the rehabs.
A: If you don't get what you are looking for, you will not go to fellowship meetings. If we explain to the Indian population what addiction is, we can use various methods to treat it. We know it is a mid-brain illness. We know it is a primary, chronic disease. It is not a symbolic disease like how AA talks about it.
It is a neurological disease and all addictions are the same. Any addiction will fold in on top of the last addiction. If you get rid of the heroin addiction, you start overeating. Smoking is exactly the same, so is computer games.
For anyone who has this chronic illness, they will fold in any compulsive behaviour into the brain's reward circuit. Anything will medicate them. When you explain that to people, they go, Aha! That makes sense.
It does not matter that they have had no exposure to good AA meetings. They are educated. They will understand that. Once people get that, they see why they need to abstain. AA is right in that you need to abstain.
Q: In a diverse country like India, the nature and quality of fellowships changes from state to state. Do you think fellowships have done their bit? Or do they have something to give still if they improve? Punjab and Delhi, for instance, is the hub of addiction currently but the fellowships there are the worst. There are trust issues. There are people you can't evolve with. There are people who move from substance to behaviour addictions. It is about power play. It is not liberating, although it is better in Mumbai.
A: It is a complicated question. They still are essential. Fellowships are full of unwell individuals. I think you said it best. The basic text, traditions and principles of the fellowships are essential. They cannot be done away with even if they were to be metamorphosis. In my view, something new needs to happen.
The terminology of the 12 Steps is becoming increasingly difficult for young people from other cultures that aren't Christian-based, to understand. We need to grapple with that. At some point there needs to be some revision.
The revisionists are always hated. I am a revisionist. They want to hear you say what you have to say as much as they want to chisel their own toenails off. They really don't want to hear that stuff but that has always been the case for revisionists.
It might be damaged or eventually die if we don't revise it. Revision is the order of the day. Wisdom can't be obsolete but they must change the language because language changes. In 500 years, we may not be speaking English. It may be some other thing that does not sound like English.
So why have the 12 Steps in a language that will become gobbledygook. No one in the world understands. Some of the words are so archaic, so challenging to modern people. They don't like words like 'powerless'.
We know what Bill W meant when he said powerless. We know what the 1930s Christian people meant when they said powerless. They mean something very good and psychologically healthy when they said it. They didn't mean become weak.
People misunderstand all these things because of the words. We need to change the words. We need a working lexicon to standardise the terms. Terms like powerless don't work for Indians. Indians are with the Americans and the British there. They have egos. Who in the world wants to be powerless in these cultures?
Q: I sort of simplified the Steps. I don't use some of the original words. There are Steps that most people don't understand now. Step 3 is one of them. What do you mean 'made a decision to turn our will and our lives over to god'? It is so cultish.
A: Yes. It is.
Q: It doesn't get across to many in India.
A: It doesn't in the West either. Many of the Westerners are rabid individualists.
Q: The Big Book makes sense in many places although not in totality. For instance, Chapter 8, To Wives, probably won't pass muster today. It could guarantee the alienation of women instead.
A: Yes, that's right. Here's when we have to explain to youngsters that this man [Bill W, who wrote the Big Book] was talking in the 1930s in the midwest of America and he was coming from a heavily Protestant background. Even Catholics like me would have been slightly disturbed by his terminology.
He was culturally in one setting. As long you understand where he was coming from, there is no problem. But for me as a professional, I don't have the excuse to tell a young person that he just has to get it. I have to explain to him. That's my job.
A lot of rehabs in the US don't do that. They say, you know what, you don't get it, there's the door. Well, I am a private clinic. Your mum sent you here because you are going to die. So I really need to explain to this guy so he can get it.
That is why I have put work into it. It is not acceptable for young people to struggle with 1930s terminology. Or go back and die.
Q: You might find resistance in India because in India even the 1930s [AA] stuff is not yet understood. It is not likely that the fellowships will understand 2013 interpretations in 2013. It could take 50 years for them to understand what you are doing today. I have been often frustrated by this lack of understanding. I therefore work on alternatives.
A: I think that if we jump straight to 2013 interpretations, they will probably get it. India is an extremely modern, forward-thinking nation with the middle classes. So, why not hit them with the times we are in.
Q: I have written the Secular 12 Steps, which is an attempt to reach out to the largest possible section of people.
A: In Finland, I think, they had their version of Secular Steps. I think there was a Secular Big Book as well, which didn't do well because it had lost some of the magic of the original. The thing is to write secular interpretations with the magic of the earlier versions. So, would it be right to say that many of the rehabs in India are 12 Step-based?
Q: There are, perhaps, only 12 Step-based rehabs in India. And most of them have no idea of the 12 Steps. Most of the rehabs in India are run by AA and NA members and even the fellowships don't fully understand the Steps. I have found that they recite the Steps without internalising them. Recovery is about what you do with the Steps. You would've got the same wisdom from grandparents and religious texts too. But it made no sense because we didn't internalise it. How do you deal with uncomprehending fellowships?
A: I always tell the guys in the room, the fellowships, that I'm not interested in a translation of the Steps. They calm down when I tell them it is an interpretation. You've got the very controversial Step 3 on 'made a decision to turn our will and our lives to the care of god as we understand him'.
Some people don't believe in god in terms of their religious beliefs. They don't have a god. They have a guru, a man. So, we know that they then translate it and interpret it as their Higher Power. Why not make it easy to say we committed to following a process greater than ourselves.
I interpret the Steps and then I can explain to a young person, to a Buddhist, what these Steps are actually trying to do.
[Next: Part III of the interview]
Also by the author:
Sober talk: 'Food addiction will abound in India in the next 20 years'
Karnataka, a way ahead
Ten ways India can make China respect it
New India, new police
Rajiv Gandhi and the muddlemen of Indian defence
Silly Vijender, sillier state
Parliament resolutions: What you need to know
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.