A few months ago I interviewed a drug rehabilitation counselor on his experience with various facilities, including the traditional therapeutic community rehabs and those based on the 12 steps. (Link) This current interview with Rechi Christobal of the Family Wellness Center describes his work training counselors for the Department of Health and other organizations. It includes his thoughts on the drug war and a slide show of the latest official statistics. Thanks to Rechi for the photo and the PowerPoint.
I do some work for the Department of Health as a resource person, specifically for training in addiction counseling and screening and assessment. In connection with my foundation, I help train DOH or government health workers. Because of the war on drugs and a great many addicts who have surrendered, called “surrenderees,” the various facilities have had to hire new staff. That’s where I come in.
What kinds of rehabs are there here?
There are therapeutic community programs, which nowadays are slowly modifying their approach from the traditional and very confrontational TC. Then 12-step-based programs, which are not really 12-step programs, with most considered eclectic. Then there are combinations of TC and cognitive behavioral therapy or combinations of CBT and the 12-step program. Nowadays what the government calls faith-based programs are becoming popular. They are basically church-based organizations that have put up their own rehabs. And then eclectic programs.
Okay, why don’t you describe what could happen to a patient entering each one.
Ideally, regardless of the modality they are working on, all of these professionals would learn how to do assessment screening first in order to determine the severity of each patient’s drug problem, whether it’s low, moderate, substantial or severe. We use an assessment tool. From that diagnosis a professional would be able to determine what kind of program to refer an individual to. If you are assessed as having a low or moderate problem, you can go to an out-patient,community-based program at the level of the barangay [local government unit] If it’s moderate to substantial you go to the out-patient program. If it’s substantial to severe—there is a thin line there—you’re referred to a residential or in-patient program.
How long is the treatment in each one of these?
With the community-based programs, nowadays that depends on the local government’s policy. Some programs are for six months, some 18 weeks, some 90 days. For the out-patient program there’s a follow-up. In the residential program it’s a minimum of six months to a maximum of one to two years, depending on the organization. For government facilities the law is a minimum of six months to one year.
But a lot of these people have to come back again, right?
Some do. People who were in the facility for six months or a year come in for after-care, as mandated by the government. Government programs have to follow the law. In the private sector it’s a bit flexible, and you might have a choice of whether to come in or not.
You mentioned that the therapeutic communities are modifying their approach, so you don’t have as much shaming or yelling orders as before.
I heard that there are still some that are very confrontational, but not as much as many years ago. I know that in some private facilities the staff still shout at patients. I don’t know if you’d call it shaming—it’s sort of shaming. They get patients to stand facing the wall for a whole day or sometimes three days. I really don’t understand the logic there. They say that if a patient faces the wall he will be forced to reflect on what he’s done.
In the US this is a typical punishment for little kids to have to sit in the corner.
Yes, it’s basically the same thing. They have to stand facing the wall for a day or two. If they’re told to sit it’s for a very long time. These are still remnants of the old TC.
And what is it being replaced with?
Most of the facilities are still TC, but a bit more non-confrontational, non-shaming.
When you said it’s still TC, you mean it’s still very uncomfortable to be there?
Sometimes I see it as effective for some patients. Making them very uncomfortable is like teaching them a lesson: if you take drugs again you’ll be put back here. I guess the level of discomfort makes some people decide against using drugs for fear of being sent back. It’s basically a matter of instilling fear.
It might make some people angry, too.
Oh, yes, a lot. It depends on how the individual was able to process being there.
A lot of the TC patients are court-ordered, right?
In the government facilities, yes. In the private ones, it’s a different story. It’s mostly a matter of social class.
How is it decided whether a person goes into a private program or a government program?
It depends on the family. Obviously, a rich family wouldn’t put their loved ones in a government rehab because of the accommodations. The government rehabs have to make sure they are accepting the indigent, the poor. Most moneyed families put their loved ones in a private facility.
Can you describe what the facilities look like?
There’s a big difference in the quality of accommodations. Some private rehabs have air-con. They still have bunk beds but they have bedding. The rooms are cleaner. They have a nice bathroom and shower area. In government facilities, the patients live in a dorm. There might be a hundred guys in one big building. They have their own bathroom, but it’s very Spartan, not very clean or very nice. The food is different, of course, since the government facilities have a tight food budget.
With regard to treatment, the private rehabs are more intensive, I guess because there are fewer patients. One particular government facility I think has 1800 patients, while a private one might have 60.
What’s the ratio of staff to patients?
I’ll get back to you on that, but I think in private rehabs it’s maybe one staff member to five or ten patients.
The training you give the staff, what does that consist of?
Primarily the modules are in individual counseling, group counseling, family counseling, relapse prevention and relapse prevention therapy. I also teach how to conduct cognitive behavior therapy and motivational interviewing. Sometimes I’m asked to lecture on screening and assessment. It’s usually about intervention inside the facility.
When you are teaching people how to do the counseling, do you have model sessions set up and you have role-playing and that kind of thing?
Because this training is skill-based, after the lecture we do role play. I group participants into threes and give them the roles of counselor, patient and observer. Then after five minutes or more they change roles, so at the end of the session, each person has played each role. Then I ask for comments about how they felt during the role play.
So how long is the training for the staff?
It depends. Some facilities ask for a three-day training program, some one week. The DOH has a policy I really agree with. Starting I think in 2009 the DOH required all rehab workers to undergo rehabilitation training. Many years ago people were setting up facilities without any proper formal training. Now the DOH has set up accreditation training—two weeks, Monday to Friday. It starts with what is addiction, then screening, then epidemiology of addiction to after-care, including the legal aspects, counseling, HIV-AIDS and how to handle HIV-AIDS patients. It’s definitely time for an accreditation program.
So what you were just talking about, that’s the training for which program?
Most of my work is for the DOH. But lately some local government units are also asking my foundation to work directly with them. Then I also do training for the United Nations Office of Drugs and Crime. In February they’re sending me to Davao. I think it is to train some community-based health workers in the Mindanao area. That’s basically what I do.
You don’t do anything with the faith-based community?
Most of their programs are really about bible study. I think they would really rather do counseling their own way. I’ve observed that a lot of individual participants in the community-based organizations are church people, like pastors, but the facilities themselves have their own way of doing things.
It’s a little hard to see what bible study has to do with addiction.
That’s something we tried to tell them. There are some faith-based facilities now that are slowly starting to participate. I think they realize that the bible study is very effective only when they are able to motivate patients into the program.
So if the patients are already motivated then bible study can work?
I think they realize that bible study works better if combined with addiction counseling. Exactly as you just said, some addicts will be asking, “Why am I doing bible study? What I need to know is how to stop using.”
How do the 12 steps fit in here?
I’m glad that a lot of facilities have started to consider including the 12-step principles. The out-patient and after-care programs are especially interested because they are starting to see how effective the 12-step support groups can be after treatment. Patients won’t stay in the rehab forever, and when they leave they have no support system.
If the circumstances of their lives haven’t changed, it’s probably easy enough to slip back into addiction.
When they go home to their communities, they may struggle with their addiction and they have nowhere to find help. Meetings give them a place to talk about their situation with people who understand. Sharing augments recovery. So now the DOH is slowly including the 12-step philosophy in their programs, and so are the private places.
Because of the war on drugs, over a million addicts have surrendered. How many have come into the programs, and what’s the success rate?
We haven’t really gotten accurate numbers on the success rate, but let’s say out of 1.8 million surrenderees2% go into an in-patient program and 98% go to out-patient or community-based programs. The community- based programs are in the barangay level or in the municipality level, sponsored and funded by the local government units.
Are they any good?
Effective, yes they are, although not all are being observed and assessed properly. I think this is why people may get the idea that the programs aren’t working. If addicts aren’t being assessed properly and then referred to the wrong program—meaning some should perhaps have been referred to an in-patient program—it can make the treatment appear ineffective. People with severe addiction need in-patient treatment because otherwise they can’t stop using.
I always say that we need to make sure the staff sees why they need to do a proper and effective screening and assessment. No program will work if we are referring the wrong patients to it. But yeah, I’ve seen some community-based programs that are really effective, whether they’re faith-based or medical model or health programs.
Can you give an estimate of the number of people who have problems with drugs who have surrendered?
I can send you the latest official statistics.
When someone surrenders just to avoid getting shot, what happens then?
You go to the police and get profiled, which means you have a record. The only way to clear your name is to enroll in a community-based program and finish it. Then you get a certificate saying you completed a program which includes drug tests and counseling.
Say that you go to the police, you surrender, but you decide not to go to the program, then what happens?
Then they come knocking at your door, especially if you’re on the tokhang list. They will take you to the police station or to a barangay, and eventually convince you to go to a program. Or else, they might tell you that you might end up in jail. The number of people who surrendered in the Philippines is the largest in the world.
What does tokhang mean?
It’s a really nice term formed from two Visayan words: katok means “to knock”, and hangyo “to ask a favor.” So it was supposed to be very compassionate. But the way it was used—not to mention the rhetoric—plus how they planned it, especially with the one initially in charge, they made it very, very aggressive. The whole thing became notorious. It was all about fear. They frightened everyone. So a lot of people surrendered. The problem with fear is that after a while it disappears.
People get comfortable.
Yes, that’s why most of all those who surrendered are back to using drugs again.
When did the war on drugs start?
Right after Pres. Duterte was elected. You have to remember that was his main campaign promise, and in fairness he really did what he said he would.
Since the beginning of the war on drugs, how much has the drug rehab business grown?
For a while there was no change in the private sector, very few admissions. I think what happened was the families with money became afraid of the tokhang, so they didn’t want their kids to be put in rehabs. But in the government sector the poor went into rehabs because they were afraid not to. So you can see the effect of the tokhang on the different social classes. The rich ones hid their kids, while the poor asked their kids to surrender. We all know who got killed in the tokhang. It was mostly the poor. Nobody was killed in the wealthy gated communities in Metro Manila.
Occasionally my friends abroad say they’re worried about my safety, and I say it’s not dangerous in the middle-class place where I live. I heard that the mayor of Tagaytay said there would not be any killings in his city.
No, they wouldn’t come after you unless you are really notorious, and probably not even then.
Personally, I am really for the war on drugs because it was way past time for somebody to address the problem. But I don’t agree with how it was handled. It wasn’t studied very carefully. They just got an idea and implemented it. In one sweep, more than one million Filipinos surrendered. The communities weren’t ready. They didn’t even know what to do with these people. That’s why, in the first few months of this tokhang, barangays were coming up with aerobic exercises as treatment.
They didn’t think aerobic exercise would do it?
No, they just had to come up with something. Personally, I think drastic measures were needed, but not aggressive like they were.
Now, I’ve heard several people say that the drug war was necessary, but I don’t think they meant shooting people was necessary.
I was told that the narco-list, the list of people who are in the narcotics trade, first appeared during the time of Pres. Ramos. Many years ago it was said to be about this thick [fingers about an inch apart], and when Duterte came to power it was this thick [about four inches]. That means more and more people are becoming involved in narcotics. I was told that many years ago the list just held the names of the pushers, the drug lords. Now, as you’ve heard, we have governors, a lot of barangay captains and mayors protecting drug lords or involved with drugs. Without the war on drugs we would become a narco-state. Shabu, methamphetamine hydrochloride, is in all of the barangays. Ten years ago, it was only in a few. So some sort of a drug war should really be imposed. I just don’t agree with the way they implemented it—the aggressiveness which I think was due to a lack of planning.
The police thought they were getting a green light because of Durterte’s rhetoric. I know that some of the people who were shot were really notorious, but unfortunately, there were also innocent victims.
It’s really a numbers game, actually. I was just talking to a police captain the other night, and he said doing a lot of shootings is regarded as achievement.
What’s the numbers now, about 25,000 people killed?
I can email you all the recently updated figures.
What people don’t know is that a lot of policemen were killed during this drug war, shot either by the police during the operations or by the syndicates.
A free-for-all broke out like with cowboys in the Old West, like an open playing field. People in the narcotics trade were killing each other, and the policemen were cleaning up their acts. Suppose, for example, the two of us are dirty cops who are taking money from a drug pusher in exchange for protection. One day we get an intelligence report that our pusher will be apprehended by a group of anti-narcotics police. What do we do? Kill her. Otherwise, after she’s captured she’ll talk about us. Anyway, she’s just a poor squatter, a low-level pusher, so we just eliminate her. In a lot of cases, that’s exactly what happened. There was always the accusation that the police were the ones doing the killing. It’s true. What people don’t know is that there were cops involved in the drug business as well. Not to mention that the syndicates themselves were also killing each other. You can see why there were so many deaths.
Well, there were also innocent bystanders, little kids…
There will always be collateral damage. It’s a dirty business, and I don’t see any alternatives. Maybe that’s why no preceding Filipino president actually declared war on drugs. It’s very dirty. Even Duterte admitted last year that he was shocked at how bad the drug problem was. That’s how deep it is, how dirty it is.
What do you see in terms of improvements?
Treatment. I always say that, and that is why the DOH is now pushing for continuous improvement of the treatment programs, both government and private. That’s really all we can do. On the prevention side, we really need to focus on maybe a more effective educational program starting with grade schools and high schools. People have to be made aware of what addiction is. We have to work on support for families.
Supply reduction is for the police. They really have to get their act together.
Shabu is made here, right?
No, that’s the funny thing. It was many years ago, but—as we discussed at a conference I just came from—now it originates in China. That’s well known. So now it makes a detour to Malaysia. From there it’s being brought to the Philippines cooked and ready to use. I’ve heard a general say that the syndicates will always be one step ahead.