THAILAND, MAY – JUNE 2006 Report by: Anna M. Cannon, Medical Herbalist, M.A., MNIMH
Consultant at Caversham Herbs Clinic, Reading
Through my acquaintance with Mike Sarson, East-West Detox founder-director, I had known about the Thamkrabok Monastery detoxification centre for drug users for several years before I went there myself in May 2006 to observe its unique treatment programme in action and to try to assess its clinical outcomes.
In my capacity of qualified consultant medical herbalist (member of the National Institute of Medical Herbalists) I accompanied a group of five drug users in various stages of planned withdrawal from substance misuse. I was able to observe and record their reactions to the treatment extended to them at Thamkrabok and to attempt a preliminary evaluation of the clinical effects of the detoxification regimes involved.
It is worth noting that I was the first Western medical herbalist ever permitted to come as an observer to Thamkrabok on the personal invitation of the Abbot of the monastic community, Luang Por Charoen Parnchand.
My observation of the treatment regimes and patient reactions at Thamkrabok (TKB) leads me to postulate that the substance misuse detox programme followed there offers no predictable health risks to those users who are accepted for treatment under the stringent standards and precautions adopted under both TKB and East-West Detox (EWD) regulations. It also suggests strongly that patients can become free of most physical and many psychological symptoms of substance dependence/withdrawal in remarkably short time as compared with standard Western detox regimes.
On the basis of my own findings as well as available data and information on the Thamkrabok treatment programme, I would not hesitate to recommend it to any suitable prospective patient who is sufficiently motivated to undergo the regime while focused on the ultimate goal of becoming rid of his or her addiction and beginning a personal healing process of body, mind and soul.
ACCOUNT OF OBSERVATIONS MADE AT THAMKRABOK
I travelled from the UK to Thailand on 19th May 2006, to spend a fortnight there as member of a group accompanying Patients A., B., C., D., and E. (drug users booked into the TKB programme). Patient A came with her partner, F. – a former user who had successfully completed the TKB treatment in 2005 – and their 11-week-old baby.
Three of the patients went to TKB as EWD’s formal clients and had thus received preparatory instruction from Mike Sarson and his co-workers. Patient A. had already witnessed her partner F.’s successful recovery from drug dependency and had a good understanding of what the TKB programme involved. The last patient, E., was travelling in association with the group, but was funded from another source and had not undergone EWD’s standard preparation and stabilisation phase prior to entering treatment. At the time of writing, he is the only one of the group to have relapsed into substance dependency.
Four patients were habitual heavy users of heroin and/or crack cocaine. Up to and during our travel to Thailand they were all taking prescription medications methadone or subutex. One patient had had a long history of extensive cannabis use and dependency.
None of the users had been my regular patients prior to the trip. I accompanied them to Thamkrabok in my capacity of medical herbalist as a qualified independent observer.
Patient treatment programme at TKB began the morning after our arrival, with formal registration of the new arrivals at the centre and an induction talk given to the group in English by a resident senior monk .
Then followed the first important step in the programme: the taking of the sacred pledge or vow (sajja) to renounce – for life – all taking of, and dependence on, addictive drugs. This is an essential aspect of treatment: patients may not start the programme without first taking the sajja. As part of the detox treatment, the solemn, and highly ritualised, pledge of the sajja is taken very seriously indeed by the monks and the community at Thamkrabok. It has been called “a solemn declaration about a truth that one will put into reality by one’s action” and “a sacred act that (…) will connect you with your willpower and with ‘something beyond’ that Luang Por Charoen has called ‘the whisper of God’”.
It is important to emphasise that it is open to believers of every religion or belief system and non-believers alike. The TKB centre accepts for treatment adherents of any, or none, religious denomination equally and without prejudice or preference. No attempts whatever are made to proselytise, convert or try to influence patients to accept the Buddhist precepts practised by the monks in the monastery. The text of the sajja is varied for the participants depending on their system of belief or a lack thereof. Believers can call on Jesus Christ, or Allah, etc, and non-believers are asked to make their vow to the earth, the sky, and to those present as witnesses to this solemn pledge.
We then proceeded with our group to the enclosed patient compound for the next step in the programme, which was to be repeated for the next five days: the taking of the special herbal detoxification medicine – first formulated to a unique secret prescription at the monastery some 50 years ago – designed to cleanse the system and rid it if residual toxins through the process of carefully controlled vomiting. Again, it was a highly ritualised occasion. It took place in the open air in a large concreted yard at the centre of the compound. Patients lined up on their knees in front of a long trough in the concrete floor, a bucket filled with water and a largish plastic bowl next to each person. Across the trough, another group of “stage-two patients” – those who had already completed their five days of taking the medicine – stood facing the “vomiting line”, preparing to cheer and encourage their fresh-intake colleagues.
A small solemn procession then entered the compound: the chief medicine monk, dressed in special robes with a distinctive sash that appears to be a ceremonial mark of office, accompanied by a couple of assistant monks. The medicine monk carried a slim-necked bottle filled with thick-looking brown liquid, which he proceeded to dispense to each patient (in what I estimated to be roughly single 50 ml doses, undiluted from the bottle).
At the same time, the group of “stage-two” addicts began loud rhythmic drumming, chanting and hand-clapping as the patients in the vomiting line were instructed to swallow bowlful after bowlful of water from the buckets until the volume of fluid in their stomachs, combined with the effect of the medication, began to induce nausea, retching and emesis. Unsurprisingly, considering the large amounts of water ingested, the vomiting was in most cases voluminous and often projectile. This, however, varied from patient to patient. Some had to struggle initially to bring themselves to vomit, while others clearly gave in to it easily and copiously. This would have been influenced by their physical condition at the time, any existing comorbidities and, possibly more significantly, by psychological and emotional issues surrounding the experience of vomiting itself.
Assistant monks on duty at the patient compound and two Western volunteer helpers, N. and K. (both ex-users who had successfully completed the programme some years ago and are now resident at Thamkrabok) were at hand at all times, at the ratio of roughly one helper per 1-2 patients. They observed patients’ progress closely and carefully, and gave constant support and encouragement. At that stage, assessment of a patient’s progress seems to be based to a large extent on the colour of the liquid leaving the stomach: dark-coloured contents mean that the detoxification process is continuing while clear fluid indicates that that particular detox session has been satisfactorily completed.
In most cases, the whole process seemed to take no longer than 20-30 minutes. Patients who appeared to be struggling or in distress were allowed to rest or stop before completing their session (I understand in such cases they have their five-day vomiting regime adjusted, but the required five days are still completed). Additional medication to help patients was administered in some cases, in the form of herbal pills and, on one occasion, a herbal infusion to which an aromatic plant oil was added.
The medicine is taken on an empty stomach as patients are not allowed to take any food for five hours previously. This serves to minimise the physical distress of emesis, as no undigested stomach contents are forced out by reverse peristalsis. The copious amounts of water swallowed help to dilute the hydrochloric acid or bile in the gastric system, thus minimising potential oesophageal and pharyngeal irritation.
The vomiting medicine ritual began at 1630 every afternoon. I later discussed the timing with the medicine monk who confirmed that this was carefully planned to allow the body to rest for the remainder of the day, when no strenuous physical activities were envisaged, and also to allow sufficient time for any delayed purging effect of the medicine (further emesis, increased micturition or bowel evacuation).
Regular patient interviews conducted for our group every morning at the detox compound provided the bulk of the data from which I could draw conclusions about the physiological, mental and emotional effects of ingesting the medicine over the five-day period. Patients were asked to reply to a number of questions from a set EWD monitoring form, which required them to evaluate – on a scale of 1 to 5 – their experience of physical symptoms such as: tiredness, nausea, stomach cramps, breathing difficulties, chest pains, joint/bone or muscle pains, numbness and tremors. In addition, the quantity and quality of sleep was assessed, as well as appetite levels and enjoyment of food, and food and fluid intake. The questionnaire also asked patients to evaluate their mental and emotional status. This involved questions about levels of depression or happiness, anxiety or calmness, fear or confidence, anger or equanimity, pessimism or optimism, ability to enjoy the experience, and ability to interact socially. Other factors were taken into account, such as physical treatments and activities undertaken from day to day, levels of craving for addictive substances, any particular thoughts, feelings, anxieties, or perceptions that could shed light on the patient’s condition.
I was also able to carry out regular daily observation and examination of patients’ clinical signs and symptoms, such as pulse rate, skin and tongue appearance, fever, sweating, headaches, change in bowel habit, and so on. At no time in the five-day regime, or the remaining time of the fortnight, did I observe or record any significant aggravation of patients’ signs and symptoms that might merit medical intervention. I found most of them generally improving at a steady and relatively rapid rate from one day to the next.
Given the relatively short time span of this phase of treatment, I had been prepared to find highly individual reactions and varied rate of progress, depending to some extent on patients’ own physical and emotional status, subjective interpretation of their symptoms, degree of adaptation to the conditions found at the compound, personality traits and other such unmeasurable factors which are simply impossible to quantify in this type of clinical investigation. However, I soon noticed that an overall pattern began to emerge, in which patients’ evaluation of their symptoms and emotional status, as well as my clinical findings, began to improve noticeably in sustained progress from Day 1 to Day 5. The detailed questionnaire forms which support these findings are kept at EWD archives for record purposes and can be analysed in more detail as needed.
In addition to the administration of the “vomiting medicine”, the treatment programme includes herbal pills, herbal steam baths, herbal teas, Thai massage, balanced nutritious diet (mostly Thai cuisine, but some Western-style food can be served on request), work therapy, practice of mindfulness, spiritual instruction sessions and introduction to meditation techniques including mindful and insight meditation. All are integral parts of the programme, complementing one another and in their totality crucial to the eventual outcome of the treatment.
Before taking a steam bath, and also at intervals during the day, patients are given additional remedial herbal tea to drink. In the public part of the TKB site, the tea is served from urns situated at the saunas and is freely available to all. It has a distinctive, powerfully bitter flavour reminiscent of extremely strong overbrewed black coffee – not at all unpleasant to my taste although, admittedly, it took a couple of cupfuls before I was quite happy to drink it. Some patients tolerated it well while to others it was unacceptable, even to the point of inducing nausea and retching. In my case it had no emetic effect at all. As with the vomiting medicine, the composition of the tea is a secret formula and will not be released to outsiders.
As is to be expected at a monastery specialising in herbal treatments, other resident TKB monks are also apparently skilled, to differing degrees, in herbal medicine, although the principal “officiating” medicine monk appears to hold the highest authority as regards preparation and administration of herbal medicine and any additional supervision and treatment of patients in the programme. I have not yet been able to establish much about the duration, scope or format of the training which qualifies a TKB monk to become a herbal practitioner but I am hoping that further visits and correspondence will throw light on the subject.
Herbal steam baths were taken by patients once a day at one or the other of the saunas operating on TKB premises. The sauna facilities are basic but adequate for the purpose. There are separate steam rooms for men and women. The men undergo treatment stripped to the waist, while the women wear the full pyjama outfit. Sessions are supervised at all times by the monk in charge of the sauna. Bundles of freshly-gathered herbs are used in the steam baths for cleansing and detoxification purposes. The herbs added to the steam bath are said to be exceptionally good for the lungs, the eyesight and for the skin (it is claimed that even long-standing scarring from injecting needles can be resolved). They are also said to aid sleep.
Although the composition of both the vomiting medicine and the herbal tea is a closely guarded TKB secret, fortunately I was permitted to take notes and photographs of the herbs used in the steam baths. I am planning to conduct further research on these, as they are a classic element of physical purification in the Thai system of herbal medicine and therefore not covered by the secrecy stipulation concerning the vomiting medicine and the herbal tea.
Incidentally, although we do not know the detailed composition of the chief detoxifying “vomiting medicine” used at TKB, such type of therapy is in itself well known in Western herbal tradition. For example, patient detoxification through carefully prescribed, controlled and monitored vomiting is one of a range of purging and cleansing processes which have had well documented use through much of the nineteenth century and onward, especially in the North American physiomedicalist school of herbal medicine. Even today, the use of an emetic to rid the system of toxic poisoning is standard and acknowledged medical practice. I noted with interest that a plant closely related to one which constitutes a major ingredient of the American version of the “vomiting medicine” grows in Thailand and is recognised as a medicinal plant by research academics at Bangkok’s Mahidol University Department of Pharmaceutical Botany.
Thai massage is available to patients on a daily basis. As I understand from literature on the subject, Thai massage is not considered mechanical bodywork, but rather is seen primarily as a therapy of energy, to relieve symptoms and stimulate healing. At present, I have no clinical data on specific effects of the massage on our patients’ wellbeing other than they generally reported the treatment relaxing and bringing some considerable relief for their physical withdrawal symptoms. I will be interested in gathering more information on this during future visits.
As with the massage, I have at present no reliable information on the diet. Patients took their meals in the detox compound. Allowing for drug withdrawal symptoms (including loss of the sense of taste and smell and suppressed appetite), culinary unfamiliarity and individual tastes to be considered, it would be difficult if not impossible to make any evaluation of the effect of just a fortnight of the new diet on patients’ wellbeing. Nevertheless, I noted a couple of our patients remarking on a gradual return of their sense of smell and taste and increased appetite.
As treatment progresses, patients are expected and gradually encouraged to find ways and strategies of coping for themselves with mundane repetitive routines of each day and so to learn to rely on their own inner resources rather than leaning on other people or reaching for the familiar prop and crutch of drugs. They are expected (but never forced) to take part in work therapy offered at TKB. This consists of taking part in sweeping the compound on a daily basis and has been called “sweeping meditation”. In the words of the TKB introductory pamphlet, it “trains concentration and endurance, keeps the energy flowing, builds up resistance and prevents boredom”. Patients can also take part in regular meditation practice every day in the late afternoon.
As recent Western neurobiological studies indicate, meditation can be a very valuable tool for relapse prevention when practised on a regular basis. To quote Dr Vanessa Crawford, Consultant Psychiatrist and Clinical Director , East London & the City Addiction Services, who also accompanied the group as an observer, research findings “support the hypothesis that meditation enhances awareness and cultivation of alternatives to mindless, compulsive behaviour. Mindfulness meditation may alleviate craving by allowing heightened awareness and acceptance of the initial craving response, without judging, analysing 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”.
Patients are encouraged to attend regular (nondenominational) spiritual instruction sessions led by a senior monk. They can also take part in the monks’ daily chanting sessions which take place every evening at the communal hall/shrine at the centre of the site, and to which everyone is welcome. As in work and mindfulness meditation, chanting can be seen as a neurobiological tool which can concentrate the mind and encourage and reinforce the desired positive treatment outcomes.
The TKB programme balances the elements of herbal and dietary regimes, Thai massage, work therapy, meditation, mental discipline and spiritual healing as a harmonious whole. Importantly, it also incorporates symbolism and the use of drama and ritual into its healing techniques. Such integrated treatment approach depends for its success on the interplay of all its elements. It is important to understand that all these elements should be seen as crucial to the overall outcome. Although each of them can be appraised and evaluated in its own right, very little would be gained by insisting that the whole package be split into individual components, to be dissected by an orthodox reductionist scientific analysis which would then be used as a basis for judging the whole treatment by its isolated findings.
On the contrary, considered analysis of the nature of the TKB programme, seen as a whole, reveals how carefully and even brilliantly every element and every minute detail of its various regimes have been designed to maximise the treatment’s therapeutic potential. The more I reflect on it, the more impressed I am with the understanding, the knowledge and the insights shown by the monks who have developed and perfected the programme. All essential facets and techniques of the integrated therapeutic approach are there: the physical, the emotional, the psychological, the spiritual; the ceremony, the drama, the ritual, the symbolism. Even the features of the natural environment are of value in reinforcing the recovery process for the patients. Sharp rocky outcrops surround the monastery compound and cradle it in their embrace providing, as it were, a stage on which the drama of patients renouncing their past life and claiming a new personal freedom is played out. There are mysterious womb-like caves in the hillsides surrounding the compound, where patients can meditate in peace and semidarkness, and then emerge into the brilliant sunlight as if in a symbolic rebirth to a new life. The rich greenery of the tropical vegetation, the scents and the brilliant colours of the blossoming plants add an important sensory dimension to the therapeutic recovery experience.
All in all, I would not hesitate to say that the programme represents to me a classic example of the whole being greater than the sum of its parts.
Since the inception of Thamkrabok’s unique detoxification programme, more than 100,000 addicts have been treated at the monastery. The majority have been Thai, but there has also been a steady stream of Westerners. No fatalities related to TKB treatment were ever recorded at the centre. Over the past nine years, the East-West Detox charity has sent or accompanied almost 170 patients to Thamkrabok, with the impressive programme completion rate of one hundred percent. On follow-up, it is claimed that about 70 percent of those remained abstinent for 12 months.
As discussed above, the overall success of TKB treatment programme is to be only partially attributed to the herbal detoxification regime itself. Clearly, no accurate estimations can be made about the proportional value of its contribution, although the Abbot himself has stated that the herbs account for some five percent of the programme’s effectiveness, the remaining 95 percent or so depending on the patient’s mind and his or her continuing and sustained commitment to keeping the solemn pledge given and witnessed in the ritual sajja ceremony at the monastery.
It is not unusual for patients to apply to the Abbot for permission to stay on at the monastery for a while after completing the programme, taking temporary vows as Buddhist monks or nuns. This can be of great help to them in strengthening their resolve to stay off drugs by increasing their personal discipline, stability and maturity through work, meditation and development of spiritual life. On this occasion, three members of our group decided to take that option. F. stayed on for three months after his partner, Patient A., finished the programme and returned to the UK with their baby; Patient C. is still at Thamkrabok at the time of writing, serving as a temporary monk following the completion of his initial treatment. Patient B. stayed on as a temporary monk for a few weeks and is now back in the UK. On follow-up, A. has been free of drugs or methadone for more than six months now and is competently taking care of her children, while Patient D. has finished a post-treatment aftercare programme at a retreat and meditation centre in the UK and has enrolled on a college course to gain skilled occupational qualifications.
Moreover, my observation of the treatment methods and practices used at Thamkrabok leads me to conclude that not only are they remarkably successful but also that they guarantee maximum patient safety. There are stringent admission criteria depending on the patients’ health status and any existing comorbidities or excluding conditions (for example, no patients suffering from insulin-dependent diabetes are allowed to go into the programme, nor do alcoholics who have not been dry for a specified period of time; the treatment is not recommended during pregnancy or after recent surgery). Patients are carefully monitored and supported every step of the way. The principal medicine monk is on call day and night to minister to emergencies and a number of monks trained in patient care are on 24-hour duty in the treatment compound. A resident trained nurse is also on call and a medical doctor visits the monastery every week. There is a modern fully equipped general hospital about five minutes’ drive from the monastery.
As a medical herbalist following in my practice the philosophy of concerted approach to the mending of body, mind and soul as an indivisible unity, I believe that – for the suitable and well-prepared patient – it is the ideal treatment programme to ensure not only that they remain abstinent for a given period, but also that they continue on a journey of personal growth and development which is their only hope of achieving lasting freedom from drug dependency.
It is important to recognise that the Thamkrabok detox programme may not be suitable for every Western user. To succeed in it requires a very high degree of determination to break the habit and a readiness to accept an unfamiliar environment, a different culture and a certain measure of personal discomfort. The latter includes the initial vomiting regime. It should be stressed here that – when viewed within the context of the whole programme – this is certainly not as grimly “drastic” or “brutal” as some sensationalist Western reports have occasionally made it out to be. Indeed, the purging action of the vomiting regime is actually a meaningful symbolic representation of “exorcising the demon of addiction”. Furthermore, to succeed in the programme requires the courage to recognise and accept one’s own weakness – and then be willing and determined to work hard to overcome it. It requires a willingness to accept that there is a spiritual dimension to our life which can help us to become free and whole again. It requires a readiness to make a unique, personal and very challenging “journey of the hero”.
It is my opinion that East-West Detox plays an invaluable role in preparing patients for embarking on such a journey and then accompanying them every step of the way.
The fact that one hundred percent of all the patients sent or accompanied to Thamkrabok through EWD have successfully completed the initial TKB treatment attests to the feasibility of the above stipulations.
Over the years, East-West Detox has had long experience in identifying users who would be best suited to respond well to TKB treatment. Its success in this area must be largely credited to Mike Sarson’s extensive and intimate understanding of all issues involved, his long experience in the field, his empathy with candidates and his passionate commitment to the charity and its mission.
As mentioned in the introductory remarks, I was the first Western medical herbalist ever permitted to witness the Thamkrabok detoxification treatment programme and observe its effects. As well as feeling honoured and privileged to be so invited, I was aware that this was an introductory “ice-breaking” visit and that I needed to tread softly and be careful to establish my credentials both with the Abbot- leader of the community and its highest spiritual and temporal authority – and with the monks on the ground before I could feel free to fly about the monastery asking the many questions I want and need to ask for my research and evaluation processes.
The fact that I then had no Thai and that the chief medicine monk, from whom the most herbal information would be obtained, has little English, was initially somewhat of a hindrance. However, with the help of interpreters and dictionaries, a lot of improvised sign language and plenty of pictures being drawn in notepads, significant headway was made in establishing good communication and initiating a two-way professional co-operation. Fortunately, no such drawbacks were present in gaining valuable information from the monk in charge of the herbal steam baths, who is a native American speaker. I am currently learning Thai in preparation for further visits and correspondence.
Given the above, during my visit to Thamkrabok I restricted my research primarily to clinical examination and observation of the progress of the five patients in our group, backed to some extent by my own experience (as a non-addict) of taking the medicine and the herbal tea, and also taking advantage of the herbal steam baths and Thai massage. I also talked to a number of former users either resident or visiting the monastery at the time, sat in as an observer at a spiritual instruction session for patients, and attended the evening chanting several times during my stay.
As research samples go, the above is not statistically representative, but there already exists a body of information on the TKB treatment outcomes which can serve as a useful springboard for further research which I hope to conduct in the future.
Thanks to Mike Sarson’s contacts in Thailand and in the international academic community, I have already had an introductory meeting with several members of the Department of Pharmaceutical Botany, Faculty of Pharmacy at the Mahidol University in Bangkok. I was able to gain from them much valuable information on the practice of herbal medicine and the organisation of the medical herbalist profession in Thailand, and I am looking forward to future correspondence and further personal contacts with the Faculty when I next visit Thailand.
I believe that in the future we can both fully honour and respect Thamkrabok’s right to keep their formulae secret and still gain better understanding and clinical confirmation of their effectiveness through systematic and methodical observation and examination of the empirical evidence of patients’ response to treatment. This will call for longer-term and more extensive studies on statistically representative samples of patients. I hope to conduct such research over the next few years and am currently planning to work towards a doctorate in comparative herbal studies concentrating on Eastern and Western approaches to herbal drug detox treatments.