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An Italian success story By Ennio Palmesino

History

The foundation of the Clubs of Alcoholics in Treatment is connected with the revolutionary movement which took place in psychiatry in the 1950's. At that time some advanced countries started to develop the “open door policy” in psychiatry, which meant unlocking the doors of psychiatric institutions, releasing psychiatric patients from various coercive measures, introducing therapeutic communities, group work, and new drugs into psychiatric treatment.

Professor Vladimir Hudolin spent the years 1952/53 in Great Britain and Sweden on a WHO scholarship, and thus directly participated in this new approach. He worked in Maxwell Jones’ Therapeutic community at the Belmont Hospital in small psychotherapy groups with Joshua Bierer, and in large psychiatric hospitals (in London, Leeds, Inverness, Edinburgh, Aberdeen). When he returned to Zagreb, he was appointed deputy head of the Neuropsychiatric Department at the Dr M. Stojanovic Hospital, and there he introduced, in turn, the “open door policy” in the psychiatric system, with a therapeutic community, work in small groups, and a family approach. Many psychiatric institutions in Croatia and elsewhere did the same, but much later, and some have yet to follow suit.

During this work, Professor Hudolin noted that a large percentage of admittances, especially urgent cases, were alcoholics, and it is still so in many psychiatric institutions. Alcoholics were admitted, they recovered, stopped drinking, were discharged, and after a short time, had to be re-admitted for another treatment. The discharge papers regularly had the remark "improved". Moreover, as it is often the case in psychiatry, after every discharge, the situation appeared to have improved, but in the long run it had in fact deteriorated.

These negative results encountered whilst working with alcoholics, along with long-term experience with therapeutic community in psychiatry, and his own reflections, persuaded Professor Hudolin to remove alcoholics from the psychiatric department and to start working with them in separated therapeutic communities, or in smaller groups (or clubs) in the presence of their families and a therapist, outside the hospital structure. This is how the Clubs of Alcoholics in Treatment were born, on April 1st, 1964. Ironically, the address of the Hospital was in Vineyard Street.

Clubs of Alcoholics in Treatment were opened in several Zagreb municipalities and soon spread to other parts of Croatia and Republics of former Yugoslavia. Before the Patriotic War began, there were about 300 Clubs of Alcoholics in Treatment in Zagreb, about 1,000 in Croatia and about 2,000 in Yugoslavia. They became involved from the beginning in the development of a territorial network of support for alcohol related problems.

The importance of organising and promoting education, training, and continuous updating of the Clubs’ members, as an integral part of Clubs’ work, also emerged. In the first place, it was decided to train the professional personnel in alcoholism, and specific courses were organised, providing basic information and guidelines for the practical work almost from the first day. Firstly, the School for Social Psychiatry, Alcoholism and other Addictions (The Zagreb Alcoholism School) was founded, then a one-week long course (50 hours) was organised on the medical-social approach to alcohol related problems (as it was called at the time). There followed a six-month school of specialisation in alcoholism and a two year post-graduate course at the University of Zagreb.

Gradually, also the Club members, and other volunteers from the local communities, were invited to attend the 50 hours course, thus providing more and more volunteers, to carry on the enormous task of caring for all the alcoholics in the Clubs, as there were not enough professionals to do all this work.

Evolution

At the end of 1979 Professor Hudolin and his associates were invited to hold the first 50-hour course in the Udine Hospital in Italy. Shortly after that, the first Club of Alcoholics in Treatment was founded in Italy, initially at Mr and Mrs Pitacco's house in Trieste. Professor Hudolin and his associates were the first servant-teachers in that Club, and this is how the project began in Italy. Today there are more than 2,200 Clubs in all Italian regions, and in other twenty-eight countries throughout the world.

One of the most important stages in Clubs of Alcoholics in Treatment development was the Congress of Clubs of Yugoslavia and Italy held in 1985 in Opatija. On that occasion, Professor Hudolin stated in his introductory paper that, in his opinion, alcoholism was not a disease but a disorder in behaviour and lifestyle. Resistance appeared immediately after the lecture, mainly from the alcoholics themselves. They much preferred to be ill, they wanted to be ill, to be protected, without personal responsibility for their behaviour and lifestyle. Experts in various fields also showed resistance, and some still do today. Medicalisation and psychiatrisation, when working with alcoholics, appear quite often, and can be considered a form of relapse of behaviour. The Clubs gradually accepted the stand that alcoholism is a behavioural and lifestyle disorder.

Club operation

The Clubs of Alcoholics in Treatment have gone through a number of stages, contemporary developments, scientific ideas, and personal reflections, but the basic concept changed only slightly. Their goal was to help families in trouble through a systematic family approach, to reach sobriety, and to achieve a change in behaviour and life style. Club members are contributors and consumers at the same time. They are part of the problem, but are also part of the solution.

In the first stage, one-year long abstinence was considered an optimum. Later, experience showed that abstinence had to last much longer, even a lifetime. Today, Club membership is considered permanent or, as Professor Hudolin often said, “till the flowers”.

On the territory covered by a Club, members can receive and give most in the primary, secondary and tertiary prevention of alcohol related problems. Research carried out during the last six years shows that in areas where more than one per cent of the population is included in the programme, the whole community goes through a gradual change of behaviour and lifestyle.

The Clubs of Alcoholics in Treatment is a multi-family community consisting of a minimum of two and a maximum of twelve families, along with a servant-teacher, included in its territorial community. It is self-governed, self-reliant, and independent of any official or private organisation. When the Clubs of Alcoholics in Treatment were founded in Croatia, they were registered as groups of citizens.

Achieving the sobriety of the whole family holds an important place in the work, but this is the easiest part of it. It is much more important and difficult to bring about changes in behaviour and life style, which is a long-term process.

There are no strict rules in the work of Clubs of Alcoholics in Treatment, the few basics would in any case be part of any socially acceptable behaviour. They are: regular weekly attendance at Clubs' meetings, punctuality, no smoking at the meetings; a Club is not a selected group and must accept anyone who feels the need to join; no one can be rejected; when the thirteenth family joins, the Club has to split in two, because a big Club cannot provide good mutual contacts and interaction for all family members; members shall not report information of a personal character learnt in the Club. Anyone with a problem has to be able to report and discuss it in the Club, but in the Club no advice is given, members share their own experiences, which are in fact messages to other Club members, from whom feedback is expected. Even the servant-teacher should not give any advice.

The process of splitting-up (multiplication) is a self-reproduction process, making it possible for new families to join a Club. The work of the Club is a continuous, long-lasting process in which only members and Club servants can participate. No admission is possible for guests, observers, probationers, or trainees. Servant-teachers from the same area should meet once a month, to discuss their experiences, problems, and difficulties, which serves as a kind of self-supervision.

The Clubs of Alcoholics in Treatment has its own structure. It is important for every member to have a role and particular duty. All the duties in the Clubs of Alcoholics in Treatment are elective and last for a fixed term of office, so that in time all the members get a chance at performing all the duties. The Club has elective offices of president, one or two vice-presidents, secretary, and treasurer. The term of office is from six to twelve months.

A Club meeting lasts about one and a half hours. It is chaired by a chairman chosen at the previous meeting. The chairman is a Club member, never the servant-teacher. A report is drawn-up by a reporting person chosen at the previous meeting.

The servant-teacher is a Club member whose role is to provide a catalyst for the process in the Club and thus significantly contribute to the main goal, which is to change the members' behaviour and life style. In addition to not giving advice, the servant-teacher should not manage the Club or the meetings. In order to become a servant-teacher, a person has to attend a Course of Sensibilization (that is: raising awareness), and then attend, from time to time, the various updating courses. Today, almost 70 per cent of the servant-teachers are volunteers, without a professional background, the remaining 30 per cent have some sort of background connected with health.

Results

Professor Hudolin used to suggest that we should put in writing what we do, if we want to give scientific dignity to our work. After a few attempts made on a regional basis, AICAT, who has the responsibility to represent the Club world at public level, both in Italy and abroad, decided to start nationwide research at the beginning of the 2000s. We needed a tool that could summarise the efforts that are being made by over 20,000 families and nearly 3,000 volunteers acting as servant teachers in the Italian Clubs. What we got is the National Data Base, which in its latest edition, incorporates data from as many as 19,000 persons who attend the Clubs’ meetings regularly. It is the picture of a huge organization.

It is important to point out that the research is not done by someone else on the Clubs. On the contrary, the families themselves do it. The Club members are, at the same time, the subject and object of the research. The results must be used by the families themselves, in the first place, because they must know the level of effectiveness and quality achieved by the work that they themselves carry out in the Clubs. Only at a later stage can the results be used by AICAT to raise awareness, in both Italy and abroad, on the existence of this methodology and its results.

The database of the results of the work done in the Clubs, and the self-evaluation that the families provide about the way they have changed their lifestyle, are the backbone of the research. As can be seen from the charts, it is evidenced that about 85 per cent of Club members do abstain from alcohol consumption, and a number of them also abstain form illegal drugs, from tobacco, and self prescribed drugs. It also appears that the large majority of the families are satisfied about their own change in life style.