Special Articles / Shanthi Ranganathan / Social Work Profession in India: An Uncertain Future
Alcohol and other psycho-active drugs that can lead to addiction are collectively referred to as ‘substances’. Substances like alcohol are viewed in some countries or cultures as legal whereas drugs like cannabis and heroin are considered illegal. Medically used drugs such as pain killers and sleeping tablets can also lead to addiction when used without the doctor’s advice or in a larger quantity or frequency than prescribed.
Substances Used in India:
The National Household Survey on Drug Abuse in India by the United Nations Office on Drugs and Crime (UNODC) in 2004 reported that India at the time of the survey had 62.46 million alcohol users, about 8.7 million cannabis users and about 2 million opiate users. Buprenorphine, propoxyphene and heroin were commonly injected drugs . The survey notes several areas of concern – the practice of Intravenous Drug Use(IDU) , associated multiple high risk behaviour, drug abuse in rural settings, and a significant time lag between the onset of drug dependence and subsequent treatment seeking (Ray et al, 2004). Besides the effect of globalization, growth of service sectors (IT sector) changing working patterns (BPOs), high level of stress, and mass media influence on youth glamourizing alcohol and tobacco lead to use and abuse of alcohol and drugs leading to substance use disorders.
Substance Abuse and Dependence
Diagnostic and Statistical Manual of Mental Disorders (DSM –IV, 1994) prepared by the American Psychiatric Association, defines substance abuse as a “maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period”:
Substance dependence is defined as ‘a maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three or four of the following occurring at anytime in the same 12-month period’.
Substance Use Disorders and Social Work Practice
Social workers regularly encounter individuals, families and communities affected by substance use disorders (SUDs) and they can play vital roles in addressing their problems. A few may work in specialized centres for addiction treatment and many work in non-speciality settings in which SUDs are often integral to the clients’ presenting problems. These settings include primary health centres, mental health centres, general hospitals, child welfare organizations, correctional facilities, educational institutions, industries and corporate sectors, urban slums and rural communities.
In the 90s, Mary Richmond, the mother of social work, called inebriety as a ‘disease that could be treated’ and she encouraged early identification and treatment (DiNitto, et al, 2007). In 1970, National Institute of Alcohol Abuse and Alcoholism (NIAAA) , and National Institute of Drug Abuse (NIDA, now called SAMHSA) lent legitimacy to work on alcohol / drug problems. In 1995, an important step was taken by the formation of National Association of Social Workers (NASW) in the USA with a speciality practice section of alcohol, tobacco and other drugs. Thereafter, NASW developed a certification for social workers specializing in the field of addiction (DiNitto, et al, 2007). In the 21st century, social workers play a significant role. The social work profession’s unique, biopsycho-social perspective, its flexibility in adapting to new streams of thought and incorporating them into practice, and its ability to integrate dissimilar programmes into a systemic whole make it a profession extremely well suited to the ever changing field of addictions (Straussner, 2012).
In India, when brown sugar addiction was identified as a problem in 1986, the Ministry of Welfare, Government of India initiated a few de-addiction clinics through non-governmental agencies in several parts of the country. The majority of these centres were located in big cities and towns (Government of India, 1994). At present (2012), there are more than 400 integrated rehabilitation centres for addiction (IRCA) funded by the Ministry of Social Justice and Empowerment (MSJE). There are equal or more number of privately managed centres which are providing some kind of a treatment. The Federation of Indian NGOs for Drug Abuse Prevention (FINGODAP) was initiated at New Delhi in 1991 which organizes conferences once in two years. To improve the quality of the services, ‘Minimum Standards of Care in Addiction Treatment’ were developed by the TTK Hospital, Chennai (Addiction Treatment Centre) in the year 2001. These standards have been approved and adopted by MSJE to provide grants for non-governmental organizations (NGO) which are running treatment centres. In 2013, in collaboration with the Colombo Plan, a certification programme was introduced and for the first time in the history of Colombo Plan, TTK Hospital was given the status of Education Provider for the entire region of Asian countries.
Tasks Undertaken By Social Worker
Screening and Diagnosis
Some individuals may seek help to deal with alcohol and drug problems on their own initiative or due to the persuasion of their families and friends. But many fail to recognize the problem and do not seek help in the early stages of substance use. Professionals who are familiar with alcohol / drug use related issues can help identify addiction in the early stages and persuade individuals to seek help. It is important to remember that the earlier the intervention, the lesser the harm likely to be caused by substance abuse and better the chances of a favourable outcome of the intervention.
Given below is a list of hidden indicators. However these indicators alone cannot be taken as proof of substance use related problems, but can alert one to the possibility so that early intervention becomes effective (Thirumagal , 2012).
• Work Place Indicators
- Reduction in the quality and quantity of work output
- Increased involvement in accidents
- Frequent demand for loans
- Poor interpersonal relationships
- Poor grooming (unshaven, not being well dressed )
• Health Indicators
- Gastritis, neuritis and liver disorders (commonly
associated with hazardous levels of alcohol use)
- Abscesses or ulcers in injection sites common
among intravenous drug users.
- Sleep problems, irritability, violence and physical
deterioration with no known medical problems
- Poor compliance with medications and repeated
- Frequent falls or accidents
• Indicators Based on Spouse’s Behavior
- Socially withdrawn and depressed
- Poor care of self
- Bruises(due to domestic violence)
- Standard of living not in keeping with the income
- Attempts at suicide
• Indicators Based on Child’s Problems
The stressful dysfunctional family can affect the children and they may
- Appear dull and withdrawn
- Lack concentration
- Lack punctuality and have irregular attendance
- Have problems in getting along with others
- Display behaviour problems like hyperactivity,
rebelliousness and aggression
- Perform poorly in their studies in spite of adequate
- Be poorly groomed (cleanliness, neatness) and
display other signs of child neglect such as delayed
payment of fees
Social workers in nearly all practice areas need skills to screen for alcohol and drug related problems, and refer to treatment providers. Screening tools are generally short questionnaires administered by the social worker or completed by the client (self report). There are many screening tools. For example, the CAGE (Cut, Annoyed, Guilty and Eye-opener) is a four-item screening device for alcohol problems that social workers can administer. But helping requires more than asking clients questions about whether they have tried to reduce their drinking or have felt guilty about their drinking. Developing rapport, asking questions in a non-judgmental way, and ensuring confidentiality are also important (Lesieur & Blume, 1987).
The Alcohol Use Disorders Identification Test (AUDIT) is available in several languages and can be adjusted for drinking norms in different cultures (Babor, et al, 2001). Screening may suggest that an individual has a particular problem, but the social worker needs additional knowledge and skills to support or confirm a diagnosis. Patients who indicate little or no risky behaviour and have a low screening score may not need an intervention. Those who have moderate risky behaviour or reach a moderate threshold on the screening instrument may be referred for brief intervention. Brief intervention focuses on increasing a person’s insight into and awareness of substance use and behavioural changes. This intervention is provided through single or multiple sessions by general practitioners and other primary health workers including social workers. Screening takes 5 -10 minutes and can be repeated at various intervals as needed to determine changes in patients’ progress over time.
Referral: Patients who score high may need further diagnostic assessment and more intensive, long term speciality treatment. Social workers need to be familiar with the facilities available in the community and refer them to centres which offer professional services with the essential treatment components.
Providing information about the self help groups such as Alcoholics Anonymous (for alcohol dependants) and Narcotics Anonymous (for other drugs) helps. Explaining the philosophy and help available at these meetings, and details related to the time, frequency and places where the meetings are held in the area are important.
Treatment and Rehabilitation
Substance dependence is a treatable disease. Treatment has been defined by WHO as “the process that begins when psycho active substance abuser comes into contact with a health provider or community services and may continue through a succession of specific interventions until the highest attainable level of health and well being is reached”. Recovery is defined as a process of continuous growth and improved functioning over a person’s life time. Individuals work to improve their health and wellness, and live a meaningful life in a community while striving to achieve their full potential (WHO, 1998).
Key Principles (Volkow, 1999):
No single treatment is appropriate for all individuals and treatment needs to be readily available
Effective treatment attends to multiple needs; hence treatment needs to be flexible
Remaining in treatment for an adequate period of time is critical for treatment effectiveness
Individual and/or group counselling and other behavioural therapies are critical components of effective treatment for addiction
Medication is an important element of treatment for many patients
Drug-abusing individuals with coexisting mental disorders should have both disorders treated in an integrated way
Medical detoxification is only the first stage of addiction treatment
Treatment does not need to be voluntary to be effective
Possible drug use during treatment must be monitored continuously
Treatment programmes should provide assessment for HIV/AIDS, Hepatitis B and C, tuberculosis and other infectious diseases
Recovery from drug addiction can be a long-term process
These principles overlap with social work principles which are treatment to be based on the needs of individual client, addressing multiple problems, and maintaining confidentiality. Approaches which are more in tune with social work practice, such as ‘interpersonal skills of counsellors’ as, ‘a key factor in treatment effectiveness’ (Najavits & Weiss, 1994), motivational enhancement therapy, community reinforcement approach which alters the client’s environment, comprehensiveness of finding employment, community support are all in the same wave length of social work practice (Meyers & Miller, 2001).
Components of Addiction Treatment:
Twelve Core Functions of Professionals (SAMHSA, 2000):
Some of the tasks of social workers in IRCAs are assessment, counselling, conducting group therapy, re-educative sessions, family therapy, case management, referrals and home visits. Maintaining records and documentation of the services provided by social workers, conducting research projects and training are other obligations.
Evidence Based Therapies
Practices for which the evidence is strongest and most accepted and that are most likely to have significant impact on improving care are called evidence based therapies. There are a few evidence based therapies which are practised in many treatment and rehabilitation centres in India –Pharmacotherapy, Cognitive Behavioural Therapy (CBT), Motivational Enhancement Therapy, and Family Therapy. Social workers need to note that these therapies help in modifying attitudes and behaviour related to substance abuse.
Pharmacotherapy and Substitution Therapies
Pharmacotherapy is defined as the use of medically prescribed psychoactive substances to treat psychiatric and behavioural conditions. Medications are used to treat withdrawal symptoms and also the associated medical and psychiatric problems. For opiate addiction, substitution therapy in the form of buprenorphine and methadone are used in a few centres. While pharmacological opioid treatment allows patients to lead more normal lives, just providing such medications is not enough and they need a variety of additional psycho social services ( Friedman & Wilson, 2004). Disulfiram is a medication widely used in India for alcohol dependence. It produces extremely unpleasant side effects if the individual after taking it drinks alcohol. Disulfiram is given for a period of two years till recovery is stabilized. Naltrexone blocks opioid receptors that are involved in the rewarding effects of drinking and studies have documented that naltrexone with cognitive behaviour therapy decreases craving and reduces relapse risk (Srisurapanont & Jarusuraisin, 2005). Acamprosate acts on the neurotransmitter system and reduces withdrawal and craving to some extent.
Cognitive Behaviour Therapy (CBT)
According to CBT, thoughts and interpretations cause feelings and behaviours, and are not caused by external things. People can change the way they think (and feel and act), even if the situation does not change. CBT reduces self defeating behaviour by modifying cognitive distortions, maladaptive beliefs and teaches techniques of thought control. It is a collaborative, active and highly structured approach. Emotional and behavioural disorders are learned responses that can be replaced by healthy ones with appropriate training . Social workers through CBT prepare clients to acquire skills that help them recognize and learn strategies to reduce risks of relapse, solve problems, maintain abstinence and enhance self-efficacy. Home work is part of CBT approach, viz., reading assignments, keeping track of certain thoughts and behaviours, and practising new skills (Colombo Plan, 2011).
Motivational Enhancement Therapy
It is based on the stages of change model of Prochaska, et al (1992) and the clinical techniques of motivational interviewing (Miller & Rollnick , 1991). There are five stages: pre contemplation, contemplation, preparation, action and maintenance. The therapist helps the client weigh the advantages and disadvantages of changing (decisional balance) in order to resolve the client’s ambivalence about changing. Motivational approaches can help move clients along the stages of change, from pre-contemplation, where they may not recognize a problem (“I drink like everyone else,” “I can control my drug use”) or its cause (“I wouldn’t drink like this if my work weren’t so stressful”), to contemplation where they recognize the problem and consider changing, to preparation where they make plans to change, to action, where they make behavioural changes, and maintenance, where they continue to change and prevent relapses. The therapy emphasizes motivational techniques such as expressing empathy, developing discrepancies, avoiding arguments and rolling with resistance. Being client centered and nondirective, helps clients resolve ambivalence about treatment and stopping substance use and facilitates treatment entry. The ‘FRAMES approach’ is also utilized : F- giving feedback to the client on his problem behaviour; R-recognizing the individual’s personal responsibility to change; A-providing advice on how to alter the behaviour; M-offering a menu of choices about how to change; E-counselling in a warm and empathetic way emphasizing self efficacy (Miller & Sanchez, 1994).
Relapse Prevention and Recovery Management
The social worker should note that recovery from alcohol and drug related problems is a process of change through which an individual deals with relapses, achieves abstinence, and improves his health, wellness and quality of life.
Relapse prevention and sustaining recovery efforts include
Group Therapy and Individual Counselling
These are two effective methods practised in most of the treatment centres in India and can be part of social workers’ tasks. Individuals who share a common problem or concern are often placed in therapy groups where they can share their mutual struggle and feelings. Group therapy creates an environment in which clients help, support and confront one another. It also helps clients broaden understanding of the damage caused and barriers to recovery. Groups provide positive peer support and exert pressure to abstain from substances. It enables them to learn new coping skills, see how others deal with similar problems and witness the recovery of others. A client who feels isolated realizes that he is not alone in his problems and experiences a sense of relief. Group also provides opportunities for catharsis or a release of feelings through sharing followed by feelings of relief.
The optimal size of a group is between 8 and 15 , and therapy session lasts for one to one and half hours, facilitated by a trained social worker.
Individual counselling is a skilled dialogue through which the client is helped to resolve problems, avoid potential problems and make positive changes. Counselling enables him to take personal responsibility for his actions and consequences , pursue realistic goals and identify satisfying solutions to his problems. Some of the goals of individual counselling are to motivate client to continue in treatment with total involvement, offer support to handle medical and psychological problems, keep the focus on the problem of addiction and provide hope and confidence about recovery. Building rapport , assessing situations, ensuring client’s acceptance of addiction, exploring resources, developing individualized treatment plan, and maintaining follow-up with focus on further growth are some of the responsibilities of the social worker in consultation with the client. A few other tasks are scheduling sessions, recording, networking, advocacy and working as a team member.
Substance users are positive about social workers who develop a meaningful relationship with them based on empathy, can be trusted and treat them with respect and dignity, focus on their abilities and strengths, support them to make informed choices and decisions, help them get the services and benefits they are entitled to, are dependable and don’t give up on them where others have.
Addiction also affects the family members who develop a dysfunctional pattern of functioning . Hence they need help. Family therapy programme is conducted for spouses and parents of clients including children. The therapy includes re-educative sessions, group therapy, individual counselling with the family and couple counselling. Family therapy is a collection of therapeutic approaches that include family level assessment and interventions with an understanding that a change in any part of the system may bring about changes in other parts of the system. Family therapy in substance abuse treatment has two main purposes: to help the family (1) to see the inappropriate coping patterns adopted by them and make qualitative changes that enhance well being ; (2) to develop a positive frame of mind and support the patient in his recovery. Broad goals of family therapy are to provide information about addiction and its effects on the family system; to provide a safe and acceptable environment for the family to discuss their problems ; to provide optimism and a supportive environment; and to improve interactions among family members (Jayaraman & Thirumagal, 2010b).
Self help groups such as Alcoholics Anonymous (AA) , Narcotics Anonymous (NA) and Al-anon offer programmes of recovery on a voluntary basis, principally through a 12- step programme for personal change. AA and NA are for substance users and Al-anon are for families. The meetings are conducted in places affording privacy such as churches and school premises at times when the activities of the institution are suspended. Attending meetings help recovering users and their families share their experiences and support one another in a drug free lifestyle, and in turn provide long-term support.
Social work practice encompasses a supportive approach and is aligned with the core values of the social work profession. Listed below are some of the ethical principles to be followed by social workers.
Overcoming Challenges in SUD Care
To Sum Up
Social workers can play a vital role in delivering services which encompass early intervention, treatment and rehabilitation . By applying evidence based approaches that integrate established interventions and also by incorporating 12 core functions, social workers can markedly improve treatment services. This in turn requires that social workers be knowledgeable and acquire needed skills. Social work practice has certain core values or ethics which need to be followed to maintain high standards of personal conduct.
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