Independent medical adviser to East-West Detox
THAMKRABOK MONASTERY THAILAND
A valid alternative for detoxification and rehabilitation
A SUMMARY PAPER FOR FUNDING BODIES
Dr Vanessa Crawford
Consultant Psychiatrist / Clinical Director
East London & the City Addiction Services
July 2006
FOREWORD
Complex problems require flexible solutions. There is no one method alone that suits or works for all drug users. Many drug users who desire to be drug-free do not achieve abstinence during their first admission for residential treatment. There need to be a range of options for a heterogeneous group of service users. Outcome is not straightforward and not well documented. Long-term follow up of drug users after residential treatment is time consuming and costly and has not been rigorously documented except in a small number of studies.
Thamkrabok monastery in Thailand is as valid as any of the current available options. There is unlikely to be a huge demand as it is in an unfamiliar environment that many drug users will not opt for. This report is prepared for submission to Drug Action Teams and other potential funding bodies, to give an insight into the opportunities provided by Thamkrabok.
I have had the privilege of visiting the monastery on 2 formal visits (See Appendix D for visit 1). The most recent visit was a 2-week observational study of the process. On that visit I travelled with East-West detox (EWD), the UK based charity that has been supporting service users to travel to Thailand since 1997 and a group of UK based service users going for treatment.
Dr Vanessa Crawford
Consultant Psychiatrist / Clinical Director
East London & the City Drug Services
July 2006
Thamkrabok – a valid alternative for residential drug treatment
Why would we want to send some people abroad when there are good facilities in the UK? I will outline some of the research evidence around UK residential treatment. As an addendum I attach a report based on my first visit to Thamkrabok in 2004. My view about the positive value of the treatment for some individuals remains.
Two excellent UK studies looking at the impact of residential treatment show clear advantages and improvement over time. The first is the study from City Roads Crisis Intervention Service www.cityroads.co.uk and entitled ‘On the rocks: a follow-up study of crack users in London. The study was of a cohort of 100, followed up 6-times over 18 months. There was an average age of 31 years, 40% being female and 47% from BME groups. 50% of the women were sex working. BME respondents were drinking more alcohol but injecting less than their non-BME counterparts. The average daily spend on crack was £100, 72% were using daily. The average weekly spend on drugs fell from £800 prior to 1st interview to £80 at 18-month follow up. The average weekly spend fell to £145 at one month follow up – all drug use decreased except for cannabis. Those who returned to crack were more likely to have used heroin in the 1-month before 1st interview. Women were more likely to return to crack use than men (43% cf 27%) 55 interviewed at 1-month follow up had used crack or heroin in the preceding 30-days, 61% did so within 3-days of leaving City Roads. Of 34 who used heroin, 33 did so within 14 days. 25 completed a residential rehab during the course of the study, more being from the BME community. Methods for choosing residential rehab were described as being at best random and at worst dependent upon funding availability. Those who were able to access their 1st choice of rehab were more likely still to be in touch with that service at 1st follow-up interview compared to those who could not (83% vs 62%). (www.sbu.ac.uk/cpru).
The biggest UK study is the NTORS study, the national treatment outcome research study. The study looked at 1075 adults, 90% of whom were opiate dependent. They carried out a prospective, longitudinal, cohort study with the group, 74% male, 91% white UK. The group in residential residential treatment had more serious problems. At 5 year follow up 38% residential group were abstinent from a range of 6 drugs. Initially 19% were abstinent from opiates and this increased to 47% after 5 yrs. Non-prescribed benzodiazepines dropped from 44% to 13% over 5 years. Crack use was noted in 20% at the start if the study in 1995, 6% at 1 yr, and 13% at 4-5 yrs. Injecting halved and sharing of equipment dropped from 36 to 12%. There is no doubt therefore that residential treatment is successful in reducing drug use, but there is still a long way to go in improving reduction in drug use at 5 years, if that is the aim of treatment for an individual.
The evidence for the long-term outcome of residential treatment is limited to a small number of studies, due to the huge amount of time and money it would take to follow people up assertively. What we do know is that many people relapse after detoxification and rehabilitation and we have certainly not come up with a one size fits all solution. Therefore if there is an economic alternative, should we not be open to a range of options to treat the heterogeneous group of drug users we work with?
During the past 9 years 161 people who made contact with EWD went through treatment at Thamkrabok. A total of 73 were accompanied by EWD workers and the rest made their own way. Some individuals remain in touch with the charity. Due to the small size and limited funding for the charity, long-term follow up studies although desirable, have not been feasible.
Preparation for the treatment programme
Patients can go to Thamkrabok independently, but it is likely to be more beneficial to prepare well for the experience and have the benefit of the links with aftercare through East-West Detox. If patients are going to travel independently they should make contact with the monastery first if possible, by letter, e-mail or phone. The e-mail and phone are not always fully functional.
There are patients who have previously accessed treatment who would be happy to advise future patients. Please contact East-West Detox to be put in touch with previous patients of Thamkrabok.
Exclusion Criteria
No medication is allowed except for that administered by the monks, nuns or visiting doctor. Therefore the patient’s GP must confirm their current prescribed medication via the attached standard letter (Appendix A). People with significant alcohol dependence should not go to Thamkrabok because they will not be treated with benzodiazepines to prevent withdrawal seizures or thiamine to prevent Werneke Korsakoff’s psychosis. Pregnant patients or those who have had recent surgery are not suitable for admission.
A medical doctor from Bangkok currently visits Thamkrabok every week. There are hospitals in Saraburi, Lopburi and Phraphuttabat. The nearest hospital is 5 minutes away.
Cost of treatment
Drug charities are not well subscribed to and the numbers going out for treatment from the UK are currently small. Therefore the cost for each individual includes overheads for the running of the charity which is on a very small scale. The ideal would be to support four individuals to go out every 3 weeks, allowing for a 1-week overlap to allow for peer support. The charity is not looking to push a high volume of people through the programme, but to concentrate on maximising the benefits for a small number of individuals.
The benefits of the environment
The monastic life
Part of monastic life is to accept the routine, to embrace the sameness of things, day in day out. Part of the issues around addiction is the difficulty in doing just that and returning to the use of substances to break that viewed ‘boredom’. Therefore, living the monastic life gives an opportunity to overcome that impulsivity. (Claassen, x)
Meditation
The neurobiological findings support the hypothesis that meditation enhances awareness and cultivation of alternatives to mindless, compulsive behaviour. (Marlatt, 2002). Mindfulness meditation may alleviate craving by allowing heightened awareness and acceptance of the initial craving response, without judging, analyzing or reacting. It is said that mindfulness may actually serve as an alternative addiction, a gratifying replacement behaviour. Mindfulness may reduce susceptibility to use and decrease the inclination to impulsive behaviour (Witkiewitz, Marlatt and Walker, 2005)
The medication
The monastery has a ‘medicine monk’ who is an expert in the use of plants for health purposes. There is a standard preparation for the 5 days of detoxification and additional preparations are given for other ailments. The exact nature of the detoxification preparation will not be disclosed by the monastery, but has not been seen to be harmful over many years of use and 9 years of taking service users from the UK for treatment. There seems to be evidence that the period of withdrawal is shorter than experienced by the service users in previous detoxification programmes. This may be due to the medication, but the value of the remote spiritual environment cannot be underestimated – nor can it be measured.
Aftercare Options
Individuals will be guided and supported to look at their own aftercare needs. An excellent option is to stay on at the monastery to undertake a period as a monk, thus strengthening the work done during the four week stay and learning a greater level of discipline and management of quiet time. However, the crucial point is to have a robust plan in place that helps to prevent relapse on leaving the monastery.
One option used by East West is Winford Manor Retreat. It is approximately seven miles South of Bristol and takes housing benefit. It is not a specific drug rehabilitation centre.
References
Witkiewitz, K., Marlatt G.A., & Walker, D. (2005). Mindfulness-Based Relapse Prevention for Alcohol and Substance Use Disorders. Journal of Cognitive Psychotherapy: An International Quarterly, 19(3), 211-228
William Claassen Alone in Community – Journeys into the monastic life around the world ISBN 0-9395 16-52-7 Forest of Peace Publishing.
Appendix 1
PATIENT FEEDBACK
The question posed was ‘What guidance would you give to future patients?’
This is the response from one of the UK service users I travelled with, written towards the end of his second week at the monastery:
“You’re going to try to keep it together. You’re going to feel and see some things that you won’t understand. It will be hard to smile for what seems like an eternity – but hold tight just a few days and you’ll see why it makes it all worth while. You’ll be so happy that you’re achieving what you have probably dreamed about for years…. to be free from the misery that comes with whatever your poison.
You will have to face some demons that have been plaguing you, and you have to be ready when you hit rock bottom, but the key to the strength and character building, with plenty of time to think about where you are with your life right now and where you want to be in the future.
If you think you know everything, you DON’T, so do your homework and be ready ‘cos it’s a rollercoaster ride of emotion and when you come out the other end, with a lot more faith in your heart and a real smile on your face, better than ever equipped to deal with the struggles of the Western world, you’ll learn to appreciate the tiny things in life, respect yourself and take nothing for granted. And believe you can do good for you and others, ride with the strong positive forces at work, I still can’t get my head round. You’ll understand what I’m saying once you open up your heart and soul. That’s the most important, otherwise you’ll miss your chance to advance. You’ll learn to function with just you and your thoughts, living proof I don’t need Class A drugs to come to terms with who / what you are. Don’t let your ego get in the way. Nevertheless the confusion clears and you’ll find yourself still standing…ENJOY your new found freedom.
P.S. You’ll feel the power when you land at TKB
Paul
May 2006
Appendix 2
THAMKRABOK 2004
Dr Vanessa Crawford, Consultant Psychiatrist / Clinical Director
My first knowledge of Thamkrabok was in 2003, when a patient had asked his keyworker about being funded to go there and I had spent some time looking into this. At this time I had my first contact with Mike Sarson at East-West. I had also seen the BBC documentary during my search for more information. I have kept myself updated via the internet and newspaper articles relating to Thamkrabok and decided to go and take a look for myself when I realised that my restless legs would not allow me to spend the whole of my 2 weeks annual leave in London. I had attempted e-mail contact with the monastery, but had not realised a response, so chose a relaxing break in Bangkok, with the idea of paying a visit to Thamkrabok. I went with a driver and interpreter on an opportunistic visit and was greeted warmly and introduced to two of the volunteers from East-West who, fortuitously for me, were there with 4 UK service users. One of the monks showed me the area for the preparation of the medication and invited me to try just a dab on my tongue – it has a distinctive bitter taste and is said to be made of a combination of over 100 different natural plant components. I arranged to spend a 24-hour period at the monastery 2 days later, so that it could be officially cleared with the Abbot. On my official visit I had the opportunity to meet and talk with the 4 UK service users accompanied by East-West. They were into their third week of a 4-week stay and shared their experiences and future plans with me. I then had the privilege of sitting and talking with Phra Hans, a Swiss monk, who has a particular role in guiding the overseas visitors. He is a calm, wise, source of inspiration and guidance; he encourages people to take responsibility for themselves again and keeps them mindful of the vows that they have made. I also met people from the UK who had chosen to stay on as monks and Natalie who has a pivotal role in supporting the English speaking visitors in their treatment. In the evening I listened to the chanting and then was able to meet with the Abbot to ask questions about Thamkrabok. I was then given the opportunity to take my own vow (sajja), something that is said to be far more important than the medication. The taking of the vow instils a sense of strength and it was clear from talking to Phra Hans and one of the service users that it is very important in the recovery process. It has been extremely helpful to me as something to reflect on when the pressure appears to be building up at work. To take the medicine one has to have taken a sajja. I had gone with a desire that I should take the medicine, although I did not want it to be done for the wrong reasons, given that it has almost become a gimmick for the media to focus their attention on. I also had some apprehension about the act of vomiting, not having been sick for perhaps 20 years and always having had perhaps a fear of being sick. I was accompanied by a wonderful, calm East-West volunteer, who had himself been in recovery for some years and had taken the medicine on several occasions during this his first visit to Thamkrabok. We joined Phra Hans and some of his colleagues, to take the medicine. The monks take the medicine on an intermittent basis; I am not certain if the strength is the same as that given to those in treatment, but it was not noticeably different to the volunteer accompanying me. The medicine is drunk from a small glass, in one swallow and washed down with a small amount of water. We then sat and talked in the warm evening for about one hour. I have a view that the medication of itself is not an emetic, although for some the taste does provoke an emetic response. After one hour my volunteer colleague suggested that we then went to drink the water and induce vomiting. We sat on chairs by a concrete trough with a large bucket of water and bowls to drink looking up at the beautiful sky. Drinking large volumes of water is rather counter-intuitive to me, but the aim is to fill the stomach to a level of discomfort, nausea and then induce vomiting. The process needs to be repeated several times but I was told that it was not essential to feel that one had vomited all the medication and clearly as it is a liquid there would be some absorption in the waiting time. The subjective experience varies for everyone but certainly at one stage I could feel my head and shoulders sensing themselves being lifted upwards.
Those in treatment induce vomiting almost immediately. This may be part based on the nausea they may already be experiencing in withdrawal, the taste of the medication and the fact that this is something that takes place in front of peers over a short period of time and is not designed to be laboured over for long periods. The medicine is taken for 5 days. In terms of side-effects, one was that of such a large fluid intake and involved nocturia, every half hour for about 2-3 hours and a headache. I feel that the headache may have been as a result of a restless night’s sleep getting up to go to the toilet, sharing a room with a stranger and being in a hot climate. It is not possible to know the importance of the medication in the detoxification. I think not having the knowledge of the content of the medication adds to its’ magic and to break the code would add little to understanding the way Thamkrabok can help people and may even be detrimental to the treatment programme currently used. The overall experience of Thamkrabok was very uplifting for me; it does not rely on a specific religious belief. I have a great respect for the treatment offered there; there is nothing sinister about it, no enforced religion, rather a collective wisdom to guide people.
It is clearly not for everyone – those who find physical symptoms of withdrawal particularly difficult may struggle with this programme. Those who need to be on regular medication cannot be treated. There is good medical support, with visiting doctors and a nearby hospital. It is very clear that Phra Hans knows when the limits of Thamkrabok, in terms of medical and psychiatric problem management, have been reached. The peer and volunteer support is excellent, there are activities, but equally individuals have a lot of time to fill and this really is important for them to learn to manage periods of unscheduled time. The magic of a foreign country, the calmness of the surroundings, the positive wisdom of Buddhism and the importance of being entrusted with a vow all add to the chances of success. As with any detoxification a solid aftercare plan is essential to follow up after the 4-week period of detoxification.
Appendix 3
THE ABBOT’S PERSONAL MESSAGE (1991)
On the East-West Detox website. His philosophy remains the same in 2006.
“You are invited to stay at Thamkrabok. There aren’t many rules, and everyone is welcome here. You are invited to join in whatever activities you are capable of, or feel would be of benefit to you. We are available 24 hours a day to help educate people. Thamkrabok is like a university, or marketplace of education.
Whatever you want to know, you can ask, what you suspect, you can confirm, and what you know, you can share.
At Thamkrabok you are in the illumination of Buddha. We do things the same way the Buddha did, everyone here strives for this level of consciousness to help teach themselves, love themselves, and use their abilities to help themselves, instead of taking advantage of, or depending on others.
The feelings of peace and tranquillity produced by the medicine are the results of your actions – what you’ve done while you are here. Which is to say, you have the intention to quit using addictive drugs and follow the way of the vows you have taken.
These feelings will happen to everyone, but they cannot experience, or come into contact with them unless they are serious about the vow. It is like carrying a bag of heavy stones with you at all times, once you have set them down you feel lighter, you feel freedom.
What you have done for yourself while here gives the result of the feelings that you are experiencing.
For addicts who come here, we cannot really do anything to help them very much; we can only provide the environment that allows them to help themselves. When they follow through on their intentions, they help themselves, and move away from the bondage of addictive drugs.”
When you first start moving away from your vices it may feel extremely uncomfortable because you have depended on them for so long to help you through times of need. But if you are honest with yourself the so-called help has never done anything except add more weight to the stones you are carrying, and dragging you down.
Addictive drugs are poison. Addicts take them in the hope that they will somehow help them to feel less pain, experience happiness or make their lives better in some way. But in reality all they do is cripple and destroy every part of the addict’s life – piece by piece, until your very nature as a human being is lost: -
Your basic goodness and humanity suffers
People and friends around you no longer have any importance to you
It is nearly impossible to go to school or hold a job
And perhaps most importantly, your parents and family suffer tremendously.
You become like a tree that has been hit by lightning…there is nothing left for re-growth.
Here at Thamkrabok we use the benefits derived from the vow to help humanity. The basic tenets of the vow are to stay away from addictive drugs, not to steal or cause harm to others, and to make an effort at self-improvement to move your life forward through education, business, or whatever means that apply to you in your situation. Basically, to become the best person that you are capable of being.
The way of the vow is the most direct way to resolve many problems. There are many different ways to detox from addictive drugs, but as everyone knows, nearly none of these ways has positive results in the long-term.
If you believe in the vow, have patience and persevere, you will win the battle over addictive drugs and regain the life you deserve to be living.
Ultimately the vows are something that help keep your mind and heart in tune – in focus, so that you are capable of helping yourself. If you cannot help yourself then there is no way you can ever help others.
At Thamkrabok we focus on the powers of the heart more than anything else. This brings the rest of the body into harmony with the environment. If you have faith in the vow it empowers your heart and mind to live within a state of truth and hold onto that even when faced with the difficulties of everyday life.
You have the absolute opportunity to stay away from addictive drugs for the rest of your life and do good for yourself and others.
We do not have modern facilities or materials; the strongest medicine we provide here is giving the vows, which allow the healing of the heart. The vows have tremendous strength; strength which will go with you out into the rest of your life if you hold them close to your heart.
If it is damaged or crippled, a doctor or hospital cannot heal your soul. At Thamkrabok we can help you to heal at every level.
Thamkrabok is the window of the heart.”
