Evolving Practice Models for Substance Abuse Prevention and Rehabilitation

Below is the speech of NoBox’s founder and director, Ma. Inez Feria, at the 2nd Public Health Convention on Mental Health at Century Park Hotel, Manila on October 13-14, 2016. She spoke on the topic of Evolving Practice Models for Substance Abuse Prevention and Rehabilitation: Private Sector Response to Drug Abuse.

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What is NoBox? 

NoBox is a philosophy as it is a nonprofit organization. Our mission is to bring humanity back to the way we understand - and respond to the human experience of drugs.
 
As I sat to write for this presentation, and it being the –ber months, I settled on my favorite seat and clicked on a Christmas Album on my Spotify. And then it hit me. Christmas this year will be so devastatingly painful for so many of our kapwa Filipinos. And only because we have been and still are so totally misdirected in our obsessive pursuit of a drug-free Philippines. 
 
For the longest time, we have, as a society, focused on drugs as the The Evil we need to free ourselves from. And getting rid of this evil has meant, to this day, doing so at all costs, and regardless of human costs. 
 
In treatment, this has meant that many times, the obsession is solely about stopping use rather than the more important and crucial challenge of figuring out what’s truly helpful for the person. Responses have been accompanied by moralistic and punitive attitudes that are perpetuating stigmatization, vilification, and dehumanization of people who use drugs.
 
Treatment and rehab have become synonymous with something to be avoided or forced into. It turns into a game of “fake it till you make it.” That is, comply with rules while we’re here, and use once we’re out of treatment’s reach.
 
People are dragged and drugged, and forcibly brought into confinement -- or they end up in jail (and we know how that looks like). People escape rehabs. And then we see the same people back in rehabs over and over again, in what we refer to as the “revolving door phenomenon.”

These would always be explained as deficits of the person using, and any punishment or sanctions are justified, even deserved. Denial, sinungaling, manipulator, matigas ulo, adik kasi. 

And so it seems, we have missed our mark.
 

But, wait. What if ….

  • What if there were a way that makes people okay to come ask for help, and on their own?
  • What if we have people who stay on with “treatment” because they choose to? Because it's truly and genuinely a helpful and positive presence in their lives?
  • What if “treatment” meant people received the services they actually need to improve their quality of life, long after they leave “treatment” behind?
  • What if treatment can be made more appealing, more engaging, more relevant?

 In our current situation, we are obliged to respond to the 700,000 forced to waive their rights and present themselves, who are all now awaiting some kind of “treatment.” This is a wake up call. Not only are we unable to respond to what each of the 700,000 might need, simply from sheer volume, but the more crucial question has become, how can we respond, and respond effectively and ethically? What might that look like?
 
Many years ago, we had a stay-in residential center in Cubao where we practiced living the philosophy of harm reduction. Interacting and engaging and relating with our clients — people who use drugs — personally every day, day in and day out, has shown us there is so much more than a "good and evil" black and white binary. Allow me to share some things we have learned and continue to learn.

Connection is important. And respect. Mutual respect.
 
Treatment needs to be low-threshold. Lowering the threshold for entry into treatment means anyone can come and connect with treatment services at any time, i.e. with no pre-set conditions for them to access these services. A common obstacle is demanding abstinence prior to acceptance into a “program.”  But not only is it illogical to ask a person to cease what exactly he may be asking help for, but to discriminate against, and to deny a person help and treatment simply because that person is still using is simply unethical. We don’t do that for other health-related concerns! 

This also allows us to connect in however way the person may come to us. When a person came to us, for example, and said, drugs aren’t my problem, it’s my girlfriend, she’s the problem -- we worked with that, i.e. the relationship problem. And by reaching out to understand his perspective and taking his reality into consideration, we had allowed him to become an active part of his own treatment process. He eventually brought up his concerns about substance use, and because he was the one who brought it up, he owned his treatment process, leading to higher adherence to strategies and treatment goals.

 We also had a student who had called us, panicking because her parents found out she was using: they wanted to pull her out from one of the top universities in the country, fly her back to the province, and send her to rehab. But as we looked into the circumstances of the student, and likewise explained to her parents, it was clear she was functioning alright and, in fact, doing well in school. There was no need to take her out from school. The student asked to meet with us regularly until she finally resolved the issues in her life related to her use. She is now about to graduate. 

Small change is big change. Conventionally, when we speak of change, we expect (demand) to see some sort of observable behavior. More often than not, that “behavior” means “cessation of drug use.”

But change is very personal, and sometimes invisible.  Like: when a person, as earlier mentioned, is beginning to feel concerned about their use, or starting to worry, thinking about how they are affecting their children -- we may not see these behaviorally, but they’re there, and we need to support this person at this stage of change.

It’s great we are now -- and finally -- talking about community-based treatment. It is so important, because for the longest time, the prevailing choices were confinement, and confinement: if not rehab, then jail. So there has always been this huge segment of the population that had nowhere to go. They are the people already concerned about their drug use, wanting to do something about it. But they’re not ready to be abstinent. Or maybe they’re not willing. Or maybe they don’t even need to be. And we must be ready to support them and work from there to making positive changes in their lives. These are golden opportunities we cannot afford to waste.

Recognizing that change can come in many forms, both visible and invisible, means defining -- or redefining -- what we mean by success. For the longest time, success has only meant abstinence. But if we’re focusing solely on abstinence, then we miss out on all the other successes in these people’s lives!

A young man came to us feeling alienated from his family. His family complained about his using marijuana, and also complained how he withdraws and refuses to join his family during dinnertime.  Through the process, we were able to work through the issues together and identify what would work for both parties. At that stage where cessation of use was not an option, he and his family took steps towards his joining the family at dinnertime, to the joy of everyone, especially his mom.

When we step back and look at the bigger picture, we realise that cessation of use is not, and cannot be, the only criterion for success. What may have seemed to be “a little change,” is not: Small change is big change -- and these changes need to be appreciated and supported.

Seeing treatment as a partnership is another we found to be very effective. There’s a tendency for us, providers, to say, we are the experts so you need to listen to us and do - and not do - as we say. 

Harm Reduction invites the whole person into the process. It is a two-expert model: we may have the training, we may have our experiences (as providers), but the person in front of us has their own experiences, their own difficulties, their feelings of ambivalence, have a sense of what their challenges are, and they are the expert of their own lives. We have to invite all that into the process, respect their agency, and work together. 

This gives them a sense of ownership, a sense of achievement. That alone is huge: that sense of achievement in a society that has been telling them nonstop that they are a failure.
 
We also need to talk about relapse. It is part of the recovery process, and yet we punish it. Why?

Effective relapse management is hinged on creating that environment where the person seeking help actually feels safe, where they won’t feel judged or condemned.

We see this repeatedly: when we had the residential center, we had clients who had left, relapsed, and in the middle of the night called us -- they called us! -- asking if they could come back to the center. We said, of course!

We knew, having had used shabu, they probably hadn’t eaten or slept for several days, so when they came, we made sure they had a nice warm dinner at the table (with fruit salad, because that’s what we had at home that evening!). Afterwards, we told them to please go ahead and rest, and we can talk when you’re ready to talk. 

What I’m saying here is that people who use drugs are people, and need to be treated and engaged with as people, as human beings. We need to see that and understand that, kasi minsan, nakakalimutan.

And throughout the entire process, it is so important to work towards establishing a good therapeutic alliance. Journeying together in the discovery and understanding the circumstances of that person’s life. This has been mentioned repeatedly that a number of people with problematic use experiences have histories of trauma and have come from violent families. There are mental health concerns, legal concerns -- all of which affect how they use and how they cope with treatment and recovery, and require a collaborative approach from multiple people. It is crucial that these complex needs be understood, so they can be just as appropriately addressed in whichever way is most relevant.

There is one thing I’d like you to take home today.

Kindness. Please know that there is no such thing as being too kind. People respond to kindness, and in an environment where they feel respected not judged, welcomed not punished, they come. They really do come. And they connect, they stay, they engage. And to connect is so important, today more than ever. Connection. And respect.

This is Harm Reduction. In an environment that allows it, this is what happens.

These beautiful moments of engagement, which we all can do and which is so important today more than ever, they cannot flourish within a war! A war that ostracizes and isolates.

We had already made strides.  

Back in 2002 when our current drug law was passed, there was an attempt,  a recognition of drugs as a health issue. Jurisdiction over treatment and rehab was transferred from the NBI a to our Department of Health. But it was a half-baked attempt.  
 
The language of the law continues to speak war and remains punitive.  We still criminalize drug use, when we shouldn't. The law considers people who use drugs as criminals, when it shouldn't. The law speaking of treatment refers to people who use drugs as “offenders”, and now we even also call them “surrenderers.”  Rehabilitation requires a “court order.”  And, worse, you can land in jail for 12 years for something we have said is natural part of the recovery process:  relapse. Our law is confused and misguided.
 
A war disconnects when what we actually, truly, desperately need today is to connect.  Our next steps need to keep us moving forward instead of back to the middle ages. 

I said in the beginning that NoBox is bringing humanity back to the way we understand and respond to the human experience of drugs. But that was a headfake. What we truly need is to bring humanity back to the way we understand and respond... to people. 

It's not about drugs. It has never been about drugs; it has always been about people.
  
Thank you.