Starting Drug Treatment ‘Where People Are At’:
Acupuncture and Treatment Readiness
Auricular acupuncture, unlike a drug or pill, has a different reality for the drug user and the program. It helps treatment and the counselor to do something different with drug users. Acupuncture shows us that we don’t do something to the client or get them to do something. We cannot change the client, but we can provide a facilitating environment that supports the drug user in pulling together their own treatment at their own pace. Like acupuncture, this approach does not belong to a building or a particular treatment modality.
There is often a yawning gap between the streets or ‘natural settings’ associated with drug use or the outreach worker and the threshold of the drug treatment program where the drug user is expected to arrive committed, ready or interested in quitting drugs. During a brief but inspiring visit to Delhi, Suneel Vatsyayan, a community leader and social worker, showed me an empowerment project he and his wife initiated with young women. He then provided me the opportunity to visit several treatment and rehabilitation programs and to meet with staff and clients. While we drove through Delhi, Suneel Vatsyayan and I talked about the label of “addict,” the benefits and costs of a drug user understanding themselves in terms of addiction or disease, and the notion of abstinence as the only acceptable outcome. And we discussed the need to engage the drug user in the street in the ingredients and opportunities of treatment, particularly the experience of auricular acupuncture.
Why ask these questions? To start off with, drug treatment that is limited to abstinence and acceptance of the addict identity has excluded the majority of drug users who are not ready or interested in quitting drugs or taking on this identity or disease. It is important to keep in mind that a statement such as ‘I have a problem’ or ‘I think I should quit’ or ‘I have to do something about this’ is not the same as a resolution to change in the near future. Furthermore, an expressed commitment to change does not necessarily translate into to taking action, much less sustained action, i.e. quitting drugs. In fact, folks who ‘jump’ into or are pushed into action or even folks who complete an abstinence based program, for the most part, relapse. For these reasons, we understand that change is actually a process, where ambivalence or mixed feelings is common, and where relapse is part of the process of change rather than outside the process of change. Change is a process rather than a toggle switch between using drugs and being drug-free for life.
“Treatment readiness” is an approach that recognizes the possibility of engaging drug users in drug treatment even before they are committed to abstinence. With the use of auricular acupuncture, for example, a spectrum of drug users can be welcomed into the change process within drug treatment programs, primary care services, or in drop-in centers within the neighborhoods where drug users live. In New York City and in Central Asia, this approach has been termed treatment readiness or recovery readiness, but the name is less important than the aim: to have a greater impact on larger numbers of drug users, especially those who are not ready or interested in formal drug treatment by increasing the availability and access to a variety of possibilities and options for incremental and self directed change and growth.
A central principal of treatment readiness is to diminish the division between street and the treatment center. Approaches may include:
- Informal and unstructured drop-in activities on site, and in ‘natural settings’: auricular acupuncture, point of demand health assistance, managing family or legal problems, addressing the hierarchy of needs (Maslow), and individual and peer group counseling and training responding to needs expressed by drug users, such as overdose management, or contingencies of use, and harm reduction, vein rotation, injecting “vacations,” home detoxing.
- Formal and semi-structured activities on and off-site which allow drug users to build rapport and attachments to staff, peers, and particular service or activities that are relevant, meaningful, and provide a positive experience to them. This can include volunteer work. In India, the fact that social work is closely associated with community organizing, and that there is a strong tradition of collective empowerment, through helping rather than consuming services, is a cultural and social resource whose benefit cannot be underestimated.
- Structured activities organized to build self-efficacy and motivation appropriately matched to a client’s readiness for change, from modifying drug practices to reducing use or eliminating drug use or reducing the associated risks.
The role of ear point acupuncture
Acupuncture can be a useful complement in a wide variety of treatment readiness programs from those built around outreach or needle exchange to those organized to meet basic survival needs, including food, clothing, shelter, and a safe place to be for a few hours, a few days, or a few weeks. The acupuncture provides an immediate effect, a positive and calming experience that, while being a different reality from the drug experience, engages the strengths and capacities within the person. This is important because we know that lasting change, though socially mediated, is an ‘inside’ job. Acupuncture is usually non-threatening because it is non-verbal—the person does not have to explain or justify himself and it does not have to be associated with labeling or diagnosis, or an expectation that the person be interested in abstinence, much less drug or alcohol free at the time they are treated.
The flexibility of the auricular acupuncture protocol—1, 3 or 5 points-- is ideally suited to responding to a client’s comfort level in a variety of settings. The simplicity of the protocol permits it to be provided by trained outreach workers, social workers or counselors. While medically supervised, it is not a highly medical procedure and can be conducted, for example, in a drop-in center. Finally, it is not synonymous with detoxification and can be useful to people who are currently using drugs, are relapsing or who are in various stages of not using drugs. Acupuncture is useful because it doesn’t revolve around the drug.
The acupuncture allows greater flexibility in treatment approaches because the worker can step out of the expert role because the approach itself models a more horizontal relationship: ‘Did you swab your ears and are you ready for a treatment?’ ‘Can we do a breathing exercise together to make you more comfortable or relaxed?’ ‘Can I touch your ear for treatment purposes?’ ‘Can you brush your hair from your ear?’ ‘Can you rotate your head to the left?’ Through the way the counselor approaches and treats them, the individual, whoever he is, has an experience of being treated with dignity and respect, and this contributes to a positive association with the counselor and the treatment setting. It provides a reason to return, and that speaks to the issue of retention.
Drug users may report this as having ‘no effect’ or ‘nothing happened’. For a moment, the individual(s) have stepped out of the busy street and just sat with themselves, their thoughts, their feelings, which may already be a new experience or a momentary alternative to the drug high. The individual is allowed to feel empowered because the positive experience they have, the calm, is not in the needle or in the counselor or the setting but is something good inside them. We are not doing something to them, but instead with them. Lincoln Hospital’s Carlos Alvarez says to his trainees, “Through the breathing, we are saying, ‘we can do this together, one step, one point, at a time.’ If you want just one point today, let’s start there.” This is starting with people where they are at. At the same time acupuncture provides, if you will excuse my pun, the entry point and engagement into the treatment process, which can happen each time they show up, and even while they may be going through confusion, fluctuations in motivation, and ups and downs in their lives and relationships.
In treatment readiness, acupuncture does not confront the person. Dr. Michael Smith has noted that a verbal exchange is not required, nor is a readiness to talk with counselors or a willingness to complete an assessment or fill out a form. Acupuncture is a tool in which we can help people who are feeling stuck or conflicted or ambivalent about their drug use or about treatment. If the acupuncture is conducted in an informal or ‘sloppy’ circle, it provides a group setting that, because it is non-verbal, is non-threatening; yet it may break someone’s isolation, ease people into a group, encourage bonding, and foster communication with the peers and the staff, all of which are elements of the change process.
For the person who is still using drugs and alcohol: they are coming for the acupuncture as frequently—there is no such thing as an acupuncture overdose—and regularly as they like without having to face an external demand for action or commitment to abstinence. They can connect and form attachments with others, with staff, and other services and activities, at their own pace. While they are coming in for the acupuncture, they may do window shopping, looking around at what else is available in the setting and what others are doing.
Drop in centers
It has been observed that many drug users, particularly women, may do their detox at home with the support of family members or close friends and then volunteer with an outreach or treatment readiness where by coming in through a position of strength, as a helper, they can get the help they need. Drop-in centers as well as home visits are variants on the treatment readiness approach. In a program in Tajikistan, which has established an outreach/needle exchange and a treatment and rehabilitation program, they are experimenting with a drop-in center, a transitional station, that has a large front room for meetings, acupuncture treatment, and trainings for street youth, a small through-room for people to wash themselves and their clothing and to meet with counselors, and a back room for people to crash for a few hours or up to a week or ten days. The back room has a door to assure anonymity for the sex workers who see the shelter as a much needed nurturing home.
Counseling and treatment readiness
What is the role of the counselor or social worker in treatment readiness? First, to establish a helping or therapeutic alliance, the counselor needs to develop what is sometimes called “accurate empathy,’ which means, putting his or her own opinions or judgments aside in order to accept the person as they are (rather than who we think they should be), so that they don’t have to justify or defend themselves. Accurate empathy on the part of the counselor means being genuinely interested in understanding their perspective on their experiences or allowing them to provide the description of the situation as they see it. This is an alternative to our labeling or diagnosing them or their behavior. Secondly, to help someone change, the counselor must have hope for this particular person, no matter how hopeless they seem or feel about themselves. The counselor must see within the person possibilities, resiliencies, and capacities for change and even transformation. Thirdly, research on optimal treatment outcomes demonstrates that in addition to establishing respect and trust, the counselor needs to be attuned to the individual’s stage of readiness for change. Change can be incremental, and clients are viewed as amenable to change when abstinence is not the only option.
Building on strengths: the volunteer
A person may initially see change in terms of showing up and receiving acupuncture, hanging out in the friendly environment, or volunteering. Volunteering often allows people to come in as a helper and from a position of strength rather than as a patient or a problem. Creatively, we can see ourselves as in a helping relationship with the volunteers. And over time, at their own pace, they can create their own treatment, which may start with their just trying something, like acupuncture. It has often been the case, despite the rhetoric about stopping drugs, that others see the improved functionality of the drug user as a worthy goal—“my mother says I got my glow back; my wife sees me taking care of the kids; my boss said we had a good day at work-- as distinct from abstinence. Over time, as drug users are reconnected in their lives or engaged in new activities, they may come to understand that through these experiences that they are outgrowing their patterns of drug use or attitudes about drugs. They may use an activity within the program or their relationship within the group or their work or family as a kind of delaying mechanism, since it doesn’t fit to be “high” while they are engaged.
In fact, the notion of a day at a time, in Alcoholics Anonymous, is a delaying mechanism: ‘I won’t drink right now or today, I don’t know about tomorrow much less the rest of my life.’ This self-awareness is expressed in self-talk or self-coaching that may be spoken of in a counseling session or a peer group. Incrementally, a person may come to say ‘I won’t use drugs in this situation because I have seen what happens’, or ‘I will limit my use so that I am not out-of-control when I am there’. These incremental actions build self-efficacy for staying involved in the process of change and growth, which I alluded to earlier.