Innovative Interventions with Alcohol Problems in Rural Areas: An Indian Experience and its Relevance to Rural America

Conventional interventions used to address the complex problems of substance abuse call for multifaceted approaches reflecting the diverse backgrounds of affected populations. In this paper the rural context is highlighted as an asset in contributing to sustainable recovery from alcohol problems. Against the background of comparing two international rural contexts and recognizing shared identities, a case is made for transfer of knowledge east to west. The success elements of a unique approach to intervention with problems associated with excessive drinking in rural areas of South India, based on the experiences of Community-Based Rehabilitation camps is described. Spanning two decades of systematic implementation, the camps utilize existing community resources for planning, execution, and follow-up of treatment while simultaneously creating greater awareness about alcohol abuse through community education. After a critical examination of prevailing treatment options for problem drinking in rural America, inter-country analysis reveals contextual similarities between rural America and rural South India based on community-orientation, cost-containment, and social capital formation with implications for rural social work intervention with alcohol problems in the United States.

Interventions to address the complex problem of substance abuse (including alcohol) have necessitated ‘multifaceted’ context-sensitive approaches reflecting the intricate diversity in client backgrounds (Ell and Vourlekis 2005; Gundy 2006). Community oriented interventions to work with alcohol problems date back to the 1970s, with a renewed focus in the past two decades. The key themes driving this approach have been first, the strengths accrued through community involvement and participation and second, prevention. Achieving efficient outcomes and sustainability through local availability amidst limited resources has been yet another motivating factor (Midford et al. 2006; Ormond et al. 2000; Saxe et al. 2006). For the purpose of this paper, the focus is the rural context and addressing intervention for alcohol problems tailored to the assets and limitations of rural populations.

The rural population of the United States shares the disadvantages ubiquitous to rural communities elsewhere, namely deficits in ‘financial, physical and human capital’ (Belanger 2005, 75). It also shares strengths characterized as typically rural: face-to-face contacts, community cooperation and willingness to know and intervene in crises involving others in the community (Harley et al. 2005). The latter characteristic is increasingly recognized as an asset to be capitalized, ‘social capital’ based on the qualitative relationships and interactions and the wealth inherent in social connections and informal networks within the community (Belanger 2005, 77; Gundy 2006). There is also an inherent rural diversity in keeping with the primary source of economic base with implications for policy and practice (Davenport and Davenport, 1995). Today, three distinct ‘rural Americas’ have been identified: amenity-rich, declining resource-dependent and chronically poor communities (Rural America in…., 2007). In the welfare sphere, prevailing health care disparities are constant concerns with challenges that include limited public funding, paucity of personnel, wider geographic area coverage leading to access problems, smaller hospitals with restricted budgets and scattered distribution of limited resources (Berkowitz 2004; Galambos 2005).

Karen Van Gundy’s (2006) report on ‘Substance Abuse in Rural and Small Town America’ surmises that though use of illicit drugs is less in rural areas than urban, alcohol abuse is a serious problem especially among rural youth and young adults. Alcohol-related problems are also more marked in individuals with less education and those who are unemployed or unmarried. This report was based on a critical review of The 2003 National Survey on Drug Use and Health (NSDUH) report. Her report urges the need for alcohol abuse treatment services, especially community interventions developed with and for rural communities through use of local resources. Stressing the limitations encountered in existing infrastructure, the report advocates tailoring treatment programs to the uniqueness and inherent strengths of rural communities.

The purpose of this analytical paper is (1) to review the current situation in rural America with regard to the treatment infrastructure for alcohol problems, (2) to present evidence of a time-tested treatment model that has proved successful in rural South India and the philosophy backing the model, and (3) to critically examine the suitability of adapting this experience from the East to address treatment for alcohol problems in rural America.

What follows is a literature-backed critical examination of the treatment situation for problem drinking in rural America and the advocacy for rural community development and community-based practice. The paper then examines the rural South Indian experience in combating problem drinking using Community-Based Rehabilitation camps. This unique approach to alcohol intervention has had about twenty years of successful implementation in rural India. The final part of the paper presents a cross-cultural analysis of the parallels that can be drawn between contexts (South India and United States) for rural social work practice in intervention with alcohol problems.

Generally described as an abstinent culture, prescribed by both the Hindu and Muslim religions, a review of historical reality presents a more ambivalent image of the drinking culture in India (Benegal 2005). Though the post-independence Prohibition movement catalyzed by the center, the federal government, proved a major preventive force for a major part of the twentieth century, effective enforcement of abstinence has been elusive (Chakradhar 1992). With the ushering in of a free market economy, socioeconomic flux and growing disposable incomes, there is not only increased alcohol production but also attitudes favoring alcohol use and a corresponding escalation in consumption (Benegal 2005).

Scientific recognition at the governmental level for intervention for alcohol problems originated only in the 1980s. Treatment for alcohol/drug problems across the country is offered mostly in public mental health institutions, psychiatric departments of government hospitals, private psychiatric clinics and substance abuse treatment centers. The treatment itself ranges from individual/group psychotherapy with family involvement to behavioral methods in both inpatient and outpatient settings. Remedial interventions that include dietary regimens, religious indoctrination and those offered by alternative medicine and indigenous healers also add to the gamut (Chakradhar 1997). Of the substance abuse treatment-seeking population 45-50 percent is for alcohol dependence (Satyanarayana as cited in Ranganathan, 2001; Benegal 2005).

A stark realization in this evolution of formal services for alcohol problems was the need to focus on rural areas. Nearly three-quarters of India’s population of more than one billion live in villages (Pasupuleti et al. 2004) with a larger share of drinking problems than in urban areas (Ranganathan 2001; The Extent….2004). India’s health care system was envisioned and implemented as a tiered de-centralized system, a logical viable alternative to reach the people locally rather than having them travel to urban hospitals. The dismal reality, however, is that the rural health centers are plagued by a shortage of doctors and drugs, absenteeism, inadequate referral services and rampant spread of communicable diseases amidst rural poverty (40% of the population) and illiteracy (Pasupuleti et al.2004). Thus people from rural areas often have to travel to urban locations, with the accompanying disruptions to work and family life (Benegal 2005).

Against this background, in the year 1989, emerged the initiative for rural camps to combat alcohol problems. This is a 15-day in-patient program conducted in villages within locally available infrastructure such as schools, community centers or wedding halls, with each camp serving 20-30 clients. The initiative was taken by the TTK Hospital, Chennai in South India (see Chakradhar, 1993; Society for the Study of Addiction, 2005 for details of their treatment program). The discussion of the program below is based on both published and unpublished reports by the hospital and interviews and correspondence with Dr. Shanti Ranganathan, the founder of the hospital.

The unique features that went into initiating the rural camps were the adaptation of the concept of ‘Community- Based rehabilitation’ involving intervention in the community, using available community resources. This initiative included a cost effective intervention within rural communities with attention to the appropriateness and acceptability of the model to the community. This also involved conducting the intervention at no cost to clients, making it accessible to the clients. In addition, therapeutic sessions that are offered are tailored to the community context, e.g., the use of narrative stories and the language and its nuances that are familiar to the community. The responsibility of intervention is shared between the professionals and the members of the community, with the community providing the physical infrastructure and aftercare help. Education provided to the community by treatment personnel, including orientation to the recovery process, empowers the community and creates a sense of ownership. Apart from knowledge acquisition and attitudinal change, community support for recovering alcoholics and continuity of care is ensured.

Recognition and repeated acknowledgement of the benefits of the community approach both internationally and nationally, not only with alcohol and other drug problems but also with other health and environmental issues, was an added impetus to this initiative. Treatment camps have been a viable alternative to supplement healthcare in rural settings in India from preventive screenings and immunization to secondary and tertiary preventive interventions since the ‘70s. For substance abuse in particular, opium treatment camps were pioneered in the ‘80s and have been in operation sporadically, sponsored by psychiatric departments of public teaching hospitals. Such community based initiatives had also been reported from other countries in South East Asia and Canada (Ranganathan 2001; Lok Raj et al. 2005). The camp approach model presented here, however, has been the most long-standing one of its kind in India.

A distant parallel to the South Indian camp experience can be found in the publicly funded, nonprofit social model programs in California that began five decades ago. Though not examined in the rural context, this model offers valuable lessons. Supported by the understanding that alcoholism is a multifaceted disease, these programs constitute a continuum of care from social setting detoxification (nonmedical) to residential recovery homes, non-residential neighborhood recovery centers and sober living houses. They are staffed exclusively by recovering alcoholics, follow AA guidelines, encourage participant involvement and experiential learning and have minimal hierarchy. The staff also acts as advocates for participants in providing liaisons to appropriate sources in the social network. Cost effectiveness data reveal that they almost halve the cost of other residential approaches achieving similar outcomes. Oxford Houses (Polcin 2006) and the Ohlhoff Skip Byron Primary program (Polcin et al. 2002) are examples of this success story. Despite initial opposition towards its meeting accreditation standards, this model received sustained recognition through an alternate review system, the California Association of Alcoholic Recovery Homes (CAARH). This model, however, faced rough times in the move towards medicalization and professionalization of what? through federal and state actions. The absence of these very elements gave this program its uniqueness and enabled cost savings (Borkman et al. 1998). Recent reviews of this model highlight an urgent need to systematically evaluate and establish its efficacy despite noticeable “erosion” since it has held its ground in not only being successful, but also getting increasing referrals from the criminal justice system. The reason for the erosion or decreasing adherence to social model principles has been attributed to the dominance by managed care and mandated treatment referrals from court systems (Kaskutas et al. 1999, 607; Polcin 2001; Kaskutas et al. 2003-2004).

Recapitulating the rural intervention experience in South India and its supportive features will be a worthwhile exercise to draw comparisons with the rural context here in the United States in order to estimate the possibility of transferring various aspects of the experience across nations.

Community-based initiative and community participation: The rationale proposed earlier in this paper through the available literature has established favorable ground that such an initiative is possible. Rural America is a well recognized existing asset including its rich rural networks (formal & informal). Messinger’s (2004) account of a comprehensive community initiative in rural North Carolina addressing issues like health, housing and education is a case in point. Ushering the inclusion of ‘indigenous nonprofessionals’/‘community guides’ as an important element of postmodern social work practice, Ungar et al’s ( 2004) study of indigenous non- professional helpers underscores the need to combine formal and informal resources in a community. Their research surmises that indigenous community helpers (non professional) “can be a catalyst for change and a bridge to inclusion, but only when operating from a position of immersion” (p.560). The successes in involving community leaders and use of natural community networks have been reinforced by other researchers as well (Harley et al. 2005).

Ryan et al (2005) make a convincing case for the potential that voluntary participation has in rural community improvement projects. They cite literature through the 20th century in which the passion for volunteering is presented as unique to American society and even a precursor to its stability. Backing their theoretical analyses is both their citation of the systemic model of community attachment of Kasarda and Janowitz and a survey by the authors of 9000 citizens across 99 small (500-10,000) Iowa communities. They argue that the combined influence of interest and sentiment nurtures social capital and the likelihood of residents working together for common purposes. These key observations closer to home provide fertile ground for tapping this resource to forge initiatives in alcohol intervention.

The national asset of voluntary participation (Ryan et al. 2005) can be exploited to enlist the support of health professionals within the community to volunteer their time and expertise towards such a camp initiative. Merwin et al’s (2006) report of an experience from rural Southwestern Virginia offering free health services using volunteers in a Remote Area Medical (RAM) clinic through health fairs offers immense potential for innovative implementation. The replication of the California experience despite ‘medicalization’ and managed care challenges is a worthy possibility that needs consideration (Borkman et al. 1998; Kaskutas et al. 2003-2004). Funding possibilities for such low-cost initiatives have been cited, as well (Zimmerman et al. 2004).

Murthy (2005) offers alternatives for a revival of rural social work through a list of community-based initiatives. Advocating for decentralization of services, she recommends that service providers begin with a community needs assessment. Social workers in such regional programs (targeting various issues) could be assigned the valuable task of studying the community and its resources to better plan intervention efforts. Introducing the idea of ‘travelling specialists,’ rural one-stop multiservice centers hosted by the community in which workers from diverse programs visit and implement services, is another possible innovation. Funding concerns and directions have also been included.

Cultural Relevance: Though in the Indian context a high degree of trust in the treatment agency and collective decision-making (family/community members) serve as advantages in steering the individual towards treatment commitment (Nimmagadda and Cowger 1999; Ranganathan 2001; Society for the Study of Addiction 2005), the context in the United States is one of encouraging individual choice and self-determination at every phase of intervention (Bischoff et al. 2003). Though both these dynamics are culturally driven, the latter may pose some barriers depending on the individual’s stage of readiness for change.

The de-emphasis of professional markers like credentials, documentation and absence of managed care pressures in India is seen by this author as a precursor to diffusing barriers and enhancing relationships between professionals and the community (including clients and families). One would seldom find framed display of professional credentials in social workers’ offices in India. This is a viable possibility in rural contexts here in the United States since “rural people tend to evaluate social workers based on help delivered or problems solved rather than on their degrees, years of education or areas of specialization” (Davenport and Davenport, 1995, 2081) and are suspicious “of professional jargon” (Gumbert and Black 2004, 158).

While in the Indian context the absence of or limited anonymity in the rural milieu was identified as an asset in diffusing denial of alcohol problems (Ranganathan 1994; Ranganathan 2001), limited anonymity features here as both an asset (Harley et al. 2005) and a stigma (Lo and Stephen 2002) especially when considering problem drinking and alcoholism. Stronger ties within the community could be a cause for stigmatization, discouraging employed and older residents from seeking treatment for fear of a threat to social status (Lo & Stephen 2002). Fortney et al’s (2006) study of at-risk drinkers (n=733) confirms this perceived stigma as a pervasive phenomenon. They recommend educational programs directed both at affected individuals, their networks and the community since the stigma poses a major barrier to seeking treatment.

Whereas the Indian cultural context does not expect or demand confidentiality, in the American context confidentiality is a treatment/profession-driven ethic with legal stipulations and implications (Code of Ethic 2006). However, the tricky nature of adherence to it in rural practice is also being increasingly acknowledged, along with a need for a culturally sensitive approach to suit the rural environment (Gumpert and Black 2005; Strom-Gottfried 2005). Croxton et al (2002), reporting on their empirical study of urban and rural practitioners in Michigan, find that the value of confidentiality is held high in both contexts though the problem of dual relationships is inevitable in rural areas. They add that “absolute positions are unrealistic and unnecessarily restrictive” (121) and that “therapist(s) need to exercise judgment and not always follow the rules” (122). In the rural context, the positive aspect of observing clients in non-clinical contexts needs to be seen as an asset, according to these authors. This need for ‘elasticity’ with due regard to the uniqueness of practice situations is further affirmed by social workers in rural Australia (Green et al. 2006).

Respect for institutions, which is part of the rural fabric, places religion as a significant entity that can play a key role in the treatment and recovery process (Brown et al. 2004; Hodge et al. 2001). Rural Americans are more likely than their urban counterparts to attend church and identify as “born-again Christians,” though there are regional differences and denominational preferences (Dillon and Savage 2006). Churches are key community assets. Some intervention programs especially with older populations could be planned, such as church retreats that may counter the role of stigma.

Finally, delivery of educative inputs through use of narratives and storytelling to promote understanding of drinking condition, which had high value in the rural camps in South India, has been reported to have favorable potential especially for rural clients in this country too. In one such report, storytelling was used within a social skills group to help members in addiction treatment deal with negative thinking. It is seen to generate enthusiasm in the group and provide an avenue for group members to examine their personal issues related to their addiction (Leukefeld et al. 2002).

Simplification of intervention strategy: In the Indian rural camp experience, as cited by Ranganathan 2001, medical barriers were overcome through home detoxification, de-dramatizing withdrawal, de-mystification of the need for drug support and empowerment of natural support systems in enabling recovery. Bischoff et al (2003) highly recommend a similar approach, i.e., social setting detoxification, especially for the noninsured and people with limited financial resources. Sharing their positive experiences at a community mental health center they present a balanced account of the strengths of treating clients in their own environments, using the resources available in the community including AA and other agencies. While in rural South India, the camps were a necessary precursor to forming AA groups, this process may be less difficult with the already existing AA network in rural America.

Building social capital through homogeneity: The homogeneity of the treatment group (a specific village/ rural area) in South India was seen as favorable, enabling bonding through the sharing of common experiences and events within the community (Ranganathan 1994; 2001). Rural communities in the United States, though diverse, depending on their geographic distribution and changing demographic characteristics, in and of themselves are seen to have distinct common features (Murthy 2005). Homogeneity in treatment groups could also be created through common demographic characteristics like gender, age, race, criminal justice referral and the like.

In conclusion, amidst the backdrop of a growing recognition of the disparity of health services delivery between urban and rural populations, we see the evolution of a strengths perspective that can auger new and fruitful directions. Mental health services, including help for substance abuse problems, face additional challenges in rural contexts due to their obvious effect on the psyche, prolonged duration of treatment/recovery and associated stigmae. This paper, in recognizing the growing push for community-oriented, cost-containing, social-capital-focused alternatives to current substance abuse interventions, draws attention to one such successful movement in rural India for intervention with alcohol problems. In analyzing its applicability to rural populations in the United States, we see a substantial possibility for its appropriate replication in rural America. Reports of valuable experiments in relation to community oriented initiatives (Julia and Kondrat 2005; Leukefeld et al. 1999; Messinger 2004; Veysey et al. 2004), along with the analysis presented in this paper, help to begin our exploration of further implementations of Community-Based Rehabilitation in rural America.

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Author´s Address:
Dr Kala Chakradhar
Murray State University
101S Applied Science Bldg.
USA-Murray, KY., 42071
United States
Email: kala.chakradhar@murraystate.edu