Sam Nugraha, who was himself a heroin addict, now runs a rehab core in Indonesia with a opposite kind of truth than abstinence-based programs.
Julia Simon for NPR
Julia Simon for NPR
Julia Simon for NPR
Sam Nugraha runs a rehab core in Indonesia, and to know his proceed to addiction, he says it’s critical to know something about his country.
Sometimes, Nugraha says, Indonesians grin when they aren’t unequivocally smiling. They’re smiling, yet underneath a smile, they aren’t.
“Because a enlightenment tells us we have to be polite,” he says, “When we don’t know a answer, afterwards we have to smile. When we feel threatened, we have to smile. In a enlightenment we are not ostensible to display a shortcomings to other people.”
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There’s an Indonesian word that captures this — malu. There are a lot of ways to interpret malu but one proceed is to conclude malu as a mask. Everyone knows what’s underneath, yet we still keep a facade on, stealing a things that doesn’t demeanour good.
In a 1990s a lot of heroin came into Indonesia from other tools of Southeast Asia. Nugraha became dependant in college. He spent time in mental hospitals, in jail. Finally he landed during a rehab module formed on a famous obsession diagnosis module Alcoholics Anonymous or AA. The module also offering meetings of NA, Narcotics Anonymous.
AA wasn’t common in Indonesia, and it was all new to Nugraha. Especially a AA proceed of pity in meetings, where organisation members tell stories of obsession and their trail to liberation and avoidance — AA is an abstinence-based program. Nugraha still remembers his initial NA meeting.
How To Speak Addiction
“They always deliver themselves by telling, ‘Hi, my name is X, and I’m an addict.’ And a organisation immediately respond, ‘Hi X!’ ” Nugraha laughs. He remembers thinking, “What’s going on?”
Malu culture had taught Nugraha to disguise his feelings. Now he was articulate to a organisation about deeply personal things like his attribute with his father. “I was frightened to be honest. It’s rambling all we believe.”
“It’s unequivocally American — people observant out shrill their feelings to strangers and all that.”
Even yet this proceed was foreign, Nugraha eventually embraced it — in 3 years he finished it by a 12 steps. Then he did a six-month training module and became a counterpart counselor. Nugraha embraced a “talking about your feelings” approach, and AA’s importance on abstinence.
John Kelly is highbrow of psychoanalysis and obsession medicine during Harvard Medical School and he’s finished a lot of investigate on Alcoholics Anonymous. “As an entity broadly speaking, [AA]’s many befitting for abstinence,” Kelly says. The 12 steps, he says, are designed for people who wish to quit, who wish to totally stop celebration or regulating drugs.
And in AA, seriousness mostly comes with congratulations. You can accept cosmetic tokens as milestones for your weeks or months or years of seriousness — in some meetings we can even accept birthday cake celebrations for your “sobriety birthday,” for another year of abstinence.
Nugraha subscribed to this thought of “abstinence only” as a counselor, until something happened with this customer he unequivocally liked. The customer eventually stayed solemn and graduated from a program. Less than 6 months after Nugraha schooled his former studious had overdosed and died.
“And that indeed got me thinking, what was wrong? we mean, what can forestall him from dying?”
Nugraha started to wonder: What if AA and a concentration on seriousness wasn’t right for everyone?
In 2010 he motionless to start his possess obsession diagnosis module called “Rumah Singgah PEKA” — Indonesian for “Stop-by House.” The central sign is: “When a whole universe rejects you, stop by during Rumah Singgah.”
The core is in Bogor, a city about an hour south of a collateral Jakarta, with views of a circuitously mountains. It’s located in a large peach-colored house, with a tile corridor to a doorway that’s lined with several tiny dogs. Nugraha says a dogs are “addicts too” — apparently they’re dependant to humans.
The rehab core has a staff of around 20, including 3 obsession and mental health specialists. There’s also a alloy on call, who specializes in operative with people who use drugs. Rumah Singgah is now saved wholly by a Indonesian government.
The place has a lot of a things you’ll find during a lot of rehab centers, like cognitive behavioral therapy, a form of speak therapy with a counselor, and job-training programs.
But there’s something that’s a depart from a abstinence-based AA model. Rumah Singgah clients are not compulsory to be totally sober.
The patients can’t use on a premises, yet Nugraha will not flog out patients who do drugs or splash ethanol while still in a module as prolonged as they tell their counselors. It’s a initial rehab module like this in Indonesia, yet it’s partial of a transformation around a universe that’s infrequently called “harm reduction.”
“Harm rebate is an agreement that we start with a chairman ‘where they’re at’,” says Daniel Ciccarone. He’s a highbrow of family and village medicine during a University of California San Francisco and a lead questioner on a Heroin in Transition plan saved by a National Institutes of Health. He’s been operative in mistreat rebate for dual decades. “The underlying truth 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 a chairman as they are.
“It came out of… a position that we’re not holding caring of people with HIV, we’re not holding caring of people who use drugs,” Ciccarone says, “We’re not holding caring of a series of people in multitude with rarely stigmatized illnesses.”
Harm rebate in obsession diagnosis grew during a AIDS predicament in a 1980s as clinicians promoted purify syringe exchanges, acknowledging that patients competence keep regulating drugs yet still perplexing to revoke a widespread of HIV and hepatitis and revoke overdoses.
Today mistreat rebate can also impute to prenatal clinics designed for profound women dependant to drugs — clinics keep that in mind in treatment. Or even, in other places, provision a studious with tiny amounts of a drugs a studious is dependant to.
Ciccarone sees mistreat rebate as a greeting to a doctor knows best proceed to medicine. He says in a past, patients would listen to doctors “as if they were your pastor. You listened to them and we obeyed them, right?”
He sees mistreat rebate as a some-more collaborative proceed to addiction, with a studious and a alloy enchanting in “a negotiated agreement to make [the patient] better.”
Nugraha’s diagnosis module during Rumah Singgah in Indonesia is formed on partnerships with patients. “We do not confirm what’s best for a clients,” Nugraha says, “The clients have to confirm what’s best for them.”
And that competence embody celebration ethanol once a week. Nugraha does not magnitude success formed on either people get solemn yet on their peculiarity of life: Are they holding down a job, are they healthy, how are their relations going? The major doubt is how good a patients are achieving a goals they set for themselves with their counselors.
Harm rebate programs mostly incite clever reactions. When Nugraha’s hospital non-stop his neighbors pounded him for his proceed — generally his methadone program. Methadone is a remedy that helps with a cravings compared with heroin obsession — many like a nicotine patch would for those perplexing to quit smoking. With patients entrance into a area for methadone medicines, a neighbors told Nugraha, “”[You’re] a new drug play in town. You’re usually assisting people to keep regulating drugs.”
The proceed Nugraha sees it is that obsession is a illness like diabetes or any other. You can’t design everybody to get sober. And Anna Lembke, medical executive of Addiction Medicine during a Stanford University School of Medicine, says that a medical village opposite a U.S. is broadening a bargain of a purpose of seriousness in obsession treatment.
“There’s a rethinking in a margin of obsession medicine either avoidance is a usually clarification of recovery,” she says. “As we’re encountering some-more and some-more behavioral addictions like addictions to food and sex — we can’t design people to refrain from food and sex — therefore we have to consider about what healthy expenditure looks like.”
Nugraha does suggest abstinence-based AA programs to clients whom he thinks will advantage from a support organisation element. And Kelly notes, both AA and NA accept that relapse is a partial of a process, that those who relapse and come behind to a module are supposed and encouraged. There’s even a line in a NA pamphlet that reads, “The visitor is a many critical chairman during any meeting.”
But Nugraha thinks that in Indonesia a AA proceed can infrequently stir adult feelings of malu and fears of being abashed — generally when relapse is involved. AA is a proffer organization, finished adult of thousands of groups around a world. Nugraha records that in Indonesia some groups are reduction usurpation of members who relapse and of those who distortion and are found out.
“Many people feel ashamed when they slip, [when] they use again,” he says, “And they don’t wish to acknowledge since it gives that feeling of being a failure.”
Nugraha is perplexing to emanate an sourroundings in his core where people don’t feel ashamed for carrying an obsession or for relapsing. And he doesn’t wish to contrition them for lying.
“Lying is partial of a business,” Nugraha says. “Humans are fragile.”
Nugraha’s proceed is flourishing in Indonesia. Now he’s consulting with a Indonesian supervision and doing trainings opposite a Asia Pacific region. People around a universe need assistance reaching a hardest cases, and as Nugraha has found, infrequently a initial step is removing past shame.
Julia Simon is a unchanging writer to NPR’s Planet Money. You can also hear her on a NPR business table and NPR podcasts Code Switch and Rough Translation.