Sam Nugraha runs a rehab center in Indonesia, and to understand his approach to addiction, he says it's important to know something about his country.
Sometimes, Nugraha says, Indonesians smile when they aren't really smiling. They're smiling, but underneath the smile, they aren't.
"Because the culture tells us we have to be polite," he says, "when we don't know the answer, then we have to smile. When we feel threatened, we have to smile. In our culture we are not supposed to expose our shortcomings to other people."
There's an Indonesian word that captures this — malu. There are a lot of ways to translate malu, but one way is to define malu as a mask. Everyone knows what's underneath, but you still keep the mask on, hiding the stuff that doesn't look good.
In the 1990s, a lot of heroin came into Indonesia from other parts of Southeast Asia. Nugraha became addicted in college. He spent time in mental hospitals and in jail. Finally he landed at a rehab program based on the famous addiction treatment program Alcoholics Anonymous, or AA. The program also offered meetings of NA, Narcotics Anonymous.
AA wasn't common in Indonesia, and it was all new to Nugraha. Especially the AA approach of sharing in meetings, where group members tell stories of addiction and their path to recovery and abstinence — AA is an abstinence-based program. Nugraha still remembers his first NA meeting.
"They always introduce themselves by telling, 'Hi, my name is X, and I'm an addict.' And the group immediately respond, 'Hi X!' " Nugraha laughs. He remembers thinking, "What's going on?"
Malu culture had taught Nugraha to conceal his feelings. Now he was talking to a group about deeply personal things, like his relationship with his father. "I was scared to be honest. It's twisting everything you believe."
"It's very American — people saying out loud their feelings to strangers and all that."
Even though this approach was foreign, Nugraha ultimately embraced it — in three years he made it through the 12 steps. Then he did a six-month training program and became a peer counselor. Nugraha embraced the talking-about-your-feelings approach and AA's emphasis on abstinence.
John Kelly, a professor of psychiatry and addiction medicine at Harvard Medical School, has done a lot of research on Alcoholics Anonymous. "As an entity broadly speaking, [AA]'s most well suited for abstinence," Kelly says. The 12 steps, he says, are designed for people who want to quit — who want to completely stop drinking or using drugs.
And in AA, sobriety often comes with congratulations. You can receive plastic tokens as milestones for your weeks, months or years of sobriety — in some meetings you can even receive birthday cake celebrations for your "sobriety birthday" to mark another year of abstinence.
As a counselor, Nugraha subscribed to this idea of abstinence only until something happened with a client he really liked. The client ultimately stayed sober and graduated from the program. Less than six months later, Nugraha learned that his former client had overdosed and died.
"And that actually got me thinking, 'What was wrong?' I mean, what can prevent him from dying?"
Nugraha started to wonder, what if AA and its focus on sobriety weren't right for everyone?
In 2010 he decided to start his own addiction treatment program called Rumah Singgah PEKA — Indonesian for Stop-by House. The official motto is "When the whole world rejects you, stop by at Rumah Singgah."
The center is in Bogor, a city about an hour south of the capital, Jakarta, with views of the nearby mountains. It's located in a big peach-colored house with a tile walkway to the door that's lined with several small dogs. Nugraha says the dogs are "addicts too" — apparently they're addicted to humans.
The rehab center has a staff of around 20, including three addiction and mental health specialists. There's also a doctor on call who specializes in working with people who use drugs. Rumah Singgah is currently funded entirely by the Indonesian government.
The place has many of the things you'll find at a lot of rehab centers, like cognitive behavioral therapy, a type of talk therapy with a counselor, and job-training programs.
But there's something that's a departure from the abstinence-based AA model. Rumah Singgah clients are not required to be completely sober.
The patients can't use on the premises, but Nugraha will not kick out patients who do drugs or drink alcohol while still in the program, as long as they tell their counselors. It's the first rehab program of its kind in Indonesia, but it's part of a movement around the world that's sometimes called "harm reduction."
"Harm reduction is an agreement that you start with the person where they're at," says Daniel Ciccarone. He's a professor of family and community medicine at the University of California San Francisco and the lead investigator on the Heroin in Transition project funded by the National Institutes of Health. He has been working in harm reduction for two decades. "The underlying philosophy is that we don't immediately think, a priori, you're going to change your person," he says. In other words, you're starting with the person as they are.
"It came out of ... a stance that we're not taking care of people with HIV, we're not taking care of people who use drugs," Ciccarone says. "We're not taking care of a number of people in society with highly stigmatized illnesses."
Harm reduction in addiction treatment grew during the AIDS crisis in the 1980s as clinicians promoted clean syringe exchanges, acknowledging that patients might keep using drugs but still trying to reduce the spread of HIV and hepatitis and decrease overdoses.
Today harm reduction can also refer to prenatal clinics designed for pregnant women addicted to drugs — clinics keep that in mind in treatment. Or even, in other places, supplying the patient with small amounts of the drugs the patient is addicted to.
Ciccarone sees harm reduction as a reaction to a doctor-knows-best approach to medicine. He says that in the past, patients would listen to doctors "as if they were your pastor. You listened to them and you obeyed them, right?"
He sees harm reduction as a more collaborative approach to addiction, with the patient and the doctor engaging in "a negotiated contract to make [the patient] better."
Nugraha's Rumah Singgah treatment program is based on partnerships with patients. "We do not decide what's best for our clients," Nugraha says. "The clients have to decide what's best for them."
And that might include drinking alcohol once a week. Nugraha does not measure success based on whether people get sober but on their quality of life. Are they holding down a job? Are they healthy? How are their relationships going? The overriding question is how well the patients are achieving the goals they set for themselves with their counselors.
Harm reduction programs often provoke strong reactions. When Nugraha's clinic opened, his neighbors attacked him for his approach — especially his methadone program. Methadone is a medication that helps with the cravings associated with heroin addiction, much like a nicotine patch would for those trying to quit smoking. With patients coming into the neighborhood for methadone medicines, the neighbors told Nugraha, "[You're] a new drug dealer in town. You're just helping people to keep using drugs."
The way Nugraha sees it is that addiction is a disease like diabetes or any other. You can't expect everyone to get sober. And Anna Lembke, medical director of addiction medicine at Stanford University's School of Medicine, says that the medical community across the U.S. is broadening its understanding of the role of sobriety in addiction treatment.
"There's a rethinking in the field of addiction medicine whether abstinence is the only definition of recovery," she says. "As we're encountering more and more behavioral addictions like addictions to food and sex — we can't expect people to abstain from food and sex — therefore we have to think about what healthy consumption looks like."
Nugraha does recommend abstinence-based AA programs to clients who he thinks will benefit from the support group element. And Kelly notes, AA and NA accept that relapse is a part of a process, and those who relapse and come back to the program are accepted and encouraged. There's even a line in the NA booklet that reads, "The newcomer is the most important person at any meeting."
But Nugraha thinks that in Indonesia, the AA approach can sometimes stir up feelings of malu and fears of being shamed — especially when relapse is involved. AA is a volunteer organization made up of thousands of groups around the world. Nugraha notes that in Indonesia some groups are less accepting of members who relapse and those who lie and are found out.
"Many people feel ashamed when they slip, [when] they use again," he says. "And they don't want to admit, because it gives that feeling of being a failure."
Nugraha is trying to create an environment in his center where people don't feel ashamed for having an addiction or for relapsing. And he doesn't want to shame them for lying.
"Lying is part of the business," Nugraha says. "Humans are fragile."
Nugraha's approach is growing in Indonesia. Now he's consulting with the Indonesian government and doing trainings across the Asia-Pacific region. People around the world need help reaching the hardest cases, and as Nugraha has found, sometimes the first step is getting past shame.
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