Should Labeling Play In The Addictions Assessment Process?/

Views and Models About Addiction: Differences Between Treatments for Alcohol-Dependent People

and for Illicit Drug Consumers in Italy

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ALLAMAN ALLAMANI

Centro Alcologico, Gruppo Prevenzione e Ricerca, Florence Health Agency, Florence, Italy

Treatment of people who are alcohol-dependent and treatment of users of illicit drugs differ remarkably in Italy, in keeping with the perception of the general public that drinking alcoholic beverages is a time-honored behavior, while consumption of illicit drugs is a deviant behavior. From a clinical perspective, the treatment for alcoholism essentially stands on the principle of free choice, motivation to change, and a family approach, while the treatment of people who are illicit drug users is characterized by control, pharmacotherapy, and individual therapy approaches. From a socio-political viewpoint both were established in the 1970s, the former being a “bottom-up” movement that started as “spontaneous” responses that mutual help groups and a few clinicians and institutions gave to alcoholics and their families; while the latter was provided “top- down” as a political response of the Government confronting the increase of illegal drug consumption among youngsters.

Keywords addiction; alcohol addiction programs; illegal drug addiction units; cultural viewpoints; mutual help groups

“A te convien tenere altro viaggio” Rispose poi che lagrimar mi vide Se vuoi campar d’esto luogo selvaggio. . . . Ond’io per lo tuo me’ penso e discerno Che tu mi segui, ed io sarò tua guida E trarrotti di qui per loco eterno Ove udirai le disperate strida. . . ” (Dante Divina Commedia, Inferno, I, 91–93;112–115)

“Thee it behoves to take another road,” Responded he, when he beheld me weeping, “If from this savage place thou wouldst escape.

Thanks to editors, Alexandra Laudet and Shlomo Einstein for their patience and competence in reading the manuscript and suggesting many appropriate changes. This article is therefore luckily affected by a challenging dialogue with the editors, while its weakness is entirely due to the author. Also, thanks to Donald Bathgate for his support in the English translation, and to Ivana Pili for her help in plotting the figures.

Address correspondence to Dr. Allaman Allamani, Centro Alcologico, Gruppo Prevenzione e Ricerca, Agenzia Sanitaria Locale, Villa Basilewsky, Firenze, Italy. E-mail: allamana@gmail.com

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Views and Models About Addiction 1705

..Therefore I think and judge it for thy best Thou follow me, and I will be thy guide, And lead thee hence through the eternal place, Where thou shalt hear the desperate lamentations”

Viewpoints on Addiction

The aim of this paper is to describe the striking differences between the treatment of people who are alcohol-dependent and the treatment of illicit drug users in Italy. In the last analysis such differences, we posit, draw on the different meanings that alcoholic beverage consumption and illegal drug use have among the general public and, more specifically, on the values that alcoholic beverages—namely wine—traditionally maintain among the Italian population and among politicians and health professionals as well. Also, in Southern Europe, alcohol beverages are mainly drunk daily or nearly daily at meals by the majority of population, and are generally endowed with the aspects of taste, pleasure, and conviviality. Intoxication, or loosening of tensions, as it is typical in Northern Europe or in United States, is not generally sought by Italian drinkers. On the other hand consumption of illicit drugs is clearly considered to be a deviant behavior, as it is the case all over the western world.

This paper discusses the different viewpoints existing in Italy regarding addictions and their treatment, how Italians and particularly clients and caregivers perceive the problems related to alcohol beverage, and drug consumption, and how programs have been created to respond to them and their various needs.

This section introduces the idea that there is no single perspective with which one can adequately understand the addiction phenomena; one needs to consider several relevant viewpoints including the clinical, the psycho-social, the moral, the socio-political, and the spiritual.

Indeed our conceptualization or view of reality, and of problems of behavior, in partic- ular, can be broadened by resorting to models of interpretation that may reflect the different aspects of human beings. These views are based on values with different cultures—specific to countries, communities, sectors, and professions, over time—attribute to activities or objects and, in the case of substances used, to the substances themselves and the behaviors by means of which people interact with them.

The Moral Viewpoint

There are certain circumstances in which these views are obviously “graded”—a substance which is acceptable in certain quantities becomes unacceptable in higher quantities, such as food, alcoholic beverages, and medicinal products. In other circumstances, by contrast, usage is not acceptable in any quantity, shape, or form such as, for example, illicit drugs. There are also considerations such as frequency of use, context of use, meanings attributed to the substance as well as its use and users or nonuse and nonusers (i.e., being a temperate person). With some minor variations, substance use in the western world can be variously perceived as being socially acceptable and good, or indicating problematic acts, behavior and even lifestyles, with medical, psychological and deviancy implications, or immoral ones.

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The Social Viewpoint

Considering the social aspects (one of the exogenous facets) of substance use and misuse with regard to the population as a whole it behooves us to ask: Why should the social side concern us when one considers the need for intervention (treatment, prevention, control, policies, research, etc.)? It can be, and is, perceived, for example, as being an improvement on the more traditional individual endogenously driven, clinical-oriented approach. Indeed the one-on-one clinical approach is still prevalent in the western world especially in the professional treatment1 of substance addiction, despite its obvious limitations in dealing with substance use and abuse2 on the one hand and on the other its rigidity and repetitiveness and consequent incapacity to produce or incorporate innovation, hemmed in as it is between the conception of biological medicine and psychological causality.3

As a point of fact, in 1970s research in the systemic, family-oriented approach in the United States, successfully diffused in Italy in the 1980s, paved the way for change of the typical clinical one-on-one approach (see Kaufman and Kaufmann 1979; Steinglass, 1987). This perspective translated the alcoholism of the individual into the “alcoholic family,” changing the individual-oriented perception of the medicalized “alcoholism” problem into a family and social issue. Indeed, the Al-Anon, or family members of alcoholics’ groups, developed in 1952 in the United States, were the first means for drawing attention to the problems and symptoms of family members being involved in and with the problems of the “tagged” alcoholic individual.

In general, contextualizing addiction behavior implies considering the parts and roles which family, environment, and society can and do play in the actual phenomenon of addiction. For example, how each of these separately and in combination are able to exert some informal control on those modes of behavior and the critical conditions which are necessary for such behaviors to operate or not to operate. The “tagged” substance, per se, is unable to define the problem, e.g., detoxifying an individual from heroin does not guarantee that relapsing into dependence on alcohol, or medications—used for nonmedical reasons and purposes—will not occur.4 A reasonable explanation for this is that whereas a detoxification process “cleans” systems of the living organisms, abstinence—however defined—harm reduction, and quality-of-life based treatment goals and models are behavioral and life- style processes and outcomes.

1Treatment can be briefly and usefully defined as a planned, goal-directed change process, of adequate quality and appropriateness, which is bounded (culture, place, time, etc.) and can be categorized into professional-based, tradition-based, mutual-help-based (AA, NA, etc.), and self-help (natural recovery) models. There are no unique models or techniques used with substance users—of whatever types—and non-substance users. In the West, with the relatively new ideology of “harm reduction” and even the newer quality of life (QOL) treatment-driven model, there are now a new set of goals in addition to those derived from/associated with the older tradition of abstinence-driven models. Editor’s note.

2The journal’s style utilizes the category substance abuse as a diagnostic category. Substances are used or misused; living organisms are and can be abused. Editor’s note.

3Sir Bradford Hill published the following nine criteria in 1965 to help assist researchers and clinicians determine whether risk factors were causes of a particular disease or were outcomes or merely associated. The nine criteria include: strength of association, consistency between studies, temporality, biological gradient, biological plausibility, coherence, specificity, experimental evidence, and analogy. and are defined below (Hill, 1965). Editor’s note.

4One or few trials learning, in humans, is quite rare complex, dynamic, multidimensional, phase/level-structured, nonlinear processes/phenomenon—which are also bounded (culture, time, place, etc.). Thus a “lapse” or “relapse” may be a necessary dimension for initiating, sustaining, and integrating a change process. Editor’s note.

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According to the system approach, a family is a system of relationships which is based upon how interaction is organized among its members. In such a process, it continuously determines and implements its own characteristics, dynamics, and values. Family pathology kicks in when family interactions become and/or show up to be rigid. This means that even when some values are discovered to be inadequate in certain phases of family development, they are perceived as, and all too often are experienced as being, the only possible reality with no other viable alternatives being deemed possible.

The main conflict of an “alcoholic family” occurs in the marital arena with the actual pharmacological as well as the anticipated effects5 of alcohol consumption allowing emo- tions to be expressed. Family members often are affected by “co-dependency,” a relatively recent “diagnosis”6 which has been characterized by a pathologized addiction—like over involvement with and a continuous “caring” about and a concern for their alcoholic family member who is a patient. In a paradoxical sense the concerned family system needs the person to continue being the family alcoholic, and s/he remains in the family by playing out this role; the system remains stable with clear role and behavior definition. How- ever, if the identified and “tagged” family member, but also a so-called “healthy” mem- ber, accepts help, e.g., by attending a therapeutic group or program, a positive behavioral change can be initiated. In this case, one or more family members can be transformed into needed therapeutic resources both for the individual “alcoholic” as well as for the “sick” system.

Thus, the behavior of the identified alcoholic person and his/her family members man- ifests itself either as being dependency-driven or as a reaction to dependency.

In dependency, the individual complies with and depends on others. In reaction to dependency, the individual claims to be “dominant” or “independent.”

Dependency is experienced as a weakness to reproach and is likely to be connected to the feeling of shame. Dominance, both by the individual and of his/her family member, is experienced as strength, which, however, is also to be reproached since it is linked to the feeling of guilt. Shame (concept, process, and outcome), which in the United States is often used interchangeably as guilt, is a powerful experience that has been considered to contribute to the development of as well as to the maintenance of addiction-related problems; according to a cyclical pattern humiliation and shame, because of loss of control, are “sedated” by the use of a substance, and the addiction to the substance triggers increasing shame with consequent use of the substance (Wiechelt, 2007), Such behavior is rooted in the fact that Western culture has developed a tendency to hide shame, or to be ashamed of feeling shame (Wiechelt, 2007). The psychology of shame and its theoretical development is connected with the issues of one’s struggle for identity, that is one of the recurring problems of our age (Kaufman, 1985). The case of Italy is peculiar since while in the Italian culture the feeling of guilt appears particularly underdeveloped, the shame seems a much more diffused feeling,

5The effects of psychoactive substances in humans have been categorized as being due to the “drugs” chemical action (which has to do with a chemically active substance entering an organism, getting to a receptor, being metabolized, and then being excreted) and what has been coded a “drug experience”, which is the outcome of the interactions between the human and his expectations, the active chemical, and where this complex process is taking place. Humans do and have described “drug experiences” from nonpharmacological “drugs”. Editor’s note.

6Any diagnosis is a data gathering process designed to help make needed decisions and is based, medically, upon at least three bits of information: etiology, process, and prognosis of that which is being diagnosed. Whereas a “diagnosis” is part of a nosological system all nosologies are not diagnostic. The relatively recent diagnosis “substance use disorder” can easily be understood by “labeling theories” given its limitations of evidence-based etiology, process, and prognosis. Editor’s note.

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linked as it is to the condition of not to being perceived as being part of the social group (Battacchi and Codispoti, 1992).

It was the family-based perspective that, together with epidemiological studies in- dicating a link between the various forms of substance abuse,2 especially the use of il- legal drugs, alcohol, and food (see, e.g., Krahn, 1991; Schuckitt et al., 1996), laid the theoretical foundation for developing the concept of transmission down through the gen- erations, especially the intergenerational theory of substance use (Framo, 1992). Obvi- ously, this thesis also has to consider recent investigations about genetic alterations in- ducing addiction and their capability of being transmitted (see, e.g., Begleiter and Kissan, 1995).

If we take one step back from the more traditional medical–pharmacological approach with its classical concepts and derived processes of diagnosis and therapy, we can better appreciate and understand how medications and physicians have, in fact, been used and co-opted as a means of keeping a tight rein on behaviors related to pleasure-seeking and on posited illness outcomes chronic in nature—which have been and continue to be deemed as unchangeable over time.7 In such a “substance use disorder” illness, relapses are considered to be predictable manifestations of the underlying illness which emerge from time to time. We may reflect on how the different therapeutic communities in Italy became a means for a total, purifying re-education against the problematic behaviors of “homogenized” and all too often stigmatized individuals who are atoning for society’s problems (Picchi and Caffarelli, 1991).

From a more traditional perspective substance addiction/dependency/habituation have become a “consensualized” scapegoat of our modern family and/or globalized society and are linked to the guilt or shame feelings which are generated within our culture (Steinglass, 1979).

The Socio-Political Viewpoint

Politics and general awareness of social problems turn our attention to the task of safeguard- ing the disadvantaged. The social-political approach may therefore be used to view and give a macro-perspective to the world of addiction with its “narcoscapes,” social networks of users, and a range of stakeholders and gatekeepers.

However, the socio-political arena may not be “an appropriate domain for understanding the substances” (Kleinig and Einstein, 2006). It is much more a site of “political power and dominance” where “more or less restrictive ideologies” are enshrined in legal format and the fear of the substance consumers “leads to their disempowering, marginalization, and stereo- typing” (Kleinig and Einstein, 2006). Reflecting on the meanings that politics and society attribute to substance use, misuse, and addiction—when they place it among the objectives which they intend tackling—we can again refer to S. Einstein who, summarizing his views on the characteristics of “substance use disorder” treatment, posits that “drug treatment” and “alcohol treatment” are unethical given that (1) there are no unique and/or specific treatment models for substance users and non-substance users; (2) there are many vested interests opposed to needed change; (3) scientific veracity has been turned into slogans; (4) new and generalizable findings are generally not introduced into viable intervention efforts; and (5) substance users, representing a heterogeneous group of people and patterns

7Readers interested in either of these processes are referred to Brandt, A. M. and Rozin, P. (1997) Morality and Health Routledge NYC, particularly to their concept of secular morality as well as to the recent literature about “disease mongering” which is easily found on Google. Editor’s note.

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of use, continue to be treated in “specialized” programs which are distanced from the main- stream of the treatment of non users—“normed treatment of normed diseases”—all too often manifesting imparity in availability and delivery of needed services (Einstein, 2006).

The Recovery

The recovery may be defined as a “complex interaction of mental, physical, and spiritual actions that leads to living a conscious and sane life” (Schaub and Schaub, 1997). Such con- cept is influenced by the view of Alcoholic Anonymous (AA) and implies a process or a path that may be well described by the verses from Dante’s Divine Comedy that opens this paper, which define how to face your problems is not to escape fear—as Dante appeared to do at the moment he found himself in the deep forest—but to face it and get in touch with it, with the help of a guide, that is the Latin poet Virgil. Actually the whole Divine Comedy is a metaphor of the recovery process, as it is shown by a recent book by Schaub and Schaub (2003).

The term recovery (recupero) is not common among Italian Public Health Care Ad- diction professionals who prefer the more neutral word treatment (trattamento). This is in keeping with the usual expectation in Italy that patients—the diagnosed, chronic substance use disorder—are to be treated for the rest of their lives by health workers by means, e.g., of long-term methadone maintenance, the treatment being essentially to control clients; or that, notwithstanding the posited chronicity of their disease, they will quit “illicit drug use” completely by following the therapeutic community-based life style. . . having sufficiently matured. However, “recupero” is a usual term among Italian AA members. The issues of “natural recovery” (see Einstein, 2006) and of spontaneous remissions (see Klingemann et al., 2001) point to an as yet unresolved dilemma which continues to exist. The broad “re- covery” literature has not adequately considered and integrated the documented processes and outcomes of substance use cessation by a broad range of types of users and patterns of “drug” consumption without the use and help of tradition-based, professional-based, and/or mutual-help based treatment and support. How did they “exit” from a posited, di- agnosed, chronic disease and remain “recovered” in a field which does not use the concept “in remission?”

The “Risk”

Another aspect of “recovery” meriting consideration is the perception of “risk” and its mea- surable expression within and by society-at-large, and its health workers. Worries about risks seem to occur cyclically across years or even centuries, independently from current scientific information. For example, the report on the disasters wreaked by alcohol con- sumption in Italy that Guido Garofolini wrote about in 1887 (Garofolini, 1887) may be identical to today’s pronouncements by the Ministry of Public Health in Rome (see Italian Ministry of Health, 2005). Or, going further back, the exhortation of the Rule of St. Benedict of the sixth century A.D. which provided that monks in good health should not drink more than a hemina (quarter litre) of wine, predates the preventative recommendations of the WHO by 1300 years.

. . . bearing in mind the condition of the weakest, we believe that a quarter litre of wine a day is sufficient. (Rule of Saint Benedict, 1985)

. . . Epidemiological data suggest that the risk of alcohol-related problems grows significantly when consumption is greater than 20 grams of pure alcohol a day (World Health Organisation, 2000)

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The Spiritual Viewpoint

The spiritual aspect of substance use perceives the so-called illness of addiction as being actually a spiritual illness. In more specific terms, it is a disturbance of the relationship between body and spirit in which the individual lacks the capacity to interpret or integrate. In alcoholism, for example, this means that the individual seeks the spirit of the grape or the grain forgetting the Higher Spirit. The program of spiritual-based therapy stems from acknowledging the limits or fallacies of professional-based models of therapy. This program was established on the advice that the psychiatrist C. G. Jung gave to an alcoholic patient of his at the end of a psychotherapy process which was crowned with failure.

In Bill’s words, Jung stated that “The healing process could not be activated by further medical and psychiatric treatment, but there could be a hope only on condition that the alcoholic could become the subject of a spiritual or religious experience—in short a genuine conversion”. (Alcoholics Anonymous, 1984, p. 382)

And according to a letter that Jung wrote as a reply to Bill, “The only right and legitimate way to such an experience is that it happens to you in reality, and it can only happen to you when you walk on a path which leads you to higher understanding. You might be led to that goal by an act of grace or through a personal and honest contact with friends, or through a higher education of the mind beyond the confines of mere rationalism”. (Alcoholic Anonymous, 1984, p. 384)

Perception of Alcoholic Beverages and of Related Problems in the Italian Society

Italy, like some other Latin populations, has a certain sociological specificity compared to the other European countries, especially north European ones, in terms of family ties and family dependency, which are a major accepted fact of Italian society (see the chapter on the “Mediterranean Mother” in Bernhard, 1969). Autonomy of the individual on the other hand is not such an eagerly sought-after asset as in other cultures. This is likely to have effects in a range of “addiction” behavior manifestations, albeit in an increasingly globalized culture that tends toward uniformity with the other cultures of the western world.

The models for understanding substance addiction-dependency generally and alcohol misuse in its various categories in particular, have been developed over time, beginning with the perception, established at the end of the 1800s, that alcohol misuse had become a social issue which on the one hand was linked to the rise of the urban proletariat and on the other hand with the development of the temperance movement from its north European and north American counterparts, which in Italy was becoming fairly well known for some time (Cottino and Morgan, 1985). The onset and evolution of Fascism in the 1920s and 1930s stressed a moralistic model, that of the Italian male, strong and virtuous, and those years saw the earliest legislation sanctioning drunkenness.

In the 1970s, a well-defined, health-related perception of alcohol “abuse” emerged deriving mainly from the birth of specialization in hepatology and gastroenterology and the almost contemporary shut-down of the psychiatric hospitals by the 1978 law tabled by Franco Basaglia, to which alcoholics had been traditionally confined up to the previous decade (Cottino and Morgan, 1985). Whereas hospitalization in psychiatric wards gave a

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connotation of deviancy to the behavior of “the alcoholic,” hospitalization in a medical hospital first “normalized” the alcoholic who, here, shared equal rights with other patients. However, experience over time has adequately documented that treating liver cirrhosis did not mean treating “alcoholism” but only a few selected effects of it. The need to diversify treatment in order to tackle the issue of addiction and its medical manifestations leads to the present situation where hospital Toxicology Units, middle- or long-term hospital pro- grams, Emergency Departments have supervened with their in-patient treatment programs. Nevertheless, hospitalization in Italy is now less frequent, out-patient community services and community mutual help and volunteer resources being a more frequent option for individuals affected by alcohol addiction dependency.

AA drew Italy’s attention to the fact that alcoholism can be and is conceptualized as being an existential sickness which can be intervened with separately from the health system by group mutual help treatment support which is characterized by spiritual rebirth. The first public conference of AA in Italy was held in Palazzo Capponi, in Florence, in July 1974 when addiction to illicit drugs and their use was beginning to take root, and the television film “Silvia è sola [Sylvia is on her own]” was broadcasted some years later telling the story of alcoholism of a woman who went on to join AA. This drew Italy’s attention to the fact that alcoholism is an existential sickness and can be tackled by group treatment. In a time when Italian culture was immersed in the values of post-Fascism, post-Idealism, and Marxism, the self-generation and the spirituality-based model typical of AA took time to gain ground. However, AA has a higher profile now than it did 30 years ago, while the 12-step program brought about a turnaround in the approach to addiction treatment in Italy, too, as it became applicable to almost every posited “addiction”: food, drugs, gambling, etc.

In short, alcoholism had been perceived for years as being the problem of an unfortunate, fairly easily identifiable few in a country or neighborhood. The idea of becoming “one of them” struck one with fear or shame, a moralistic-based perception which continues to exist, but less so over time. The fact that more women as compared to those in the past are attending alcohol addiction treatment services and groups like AA is a sign that they, their husbands, fathers, and sons, and our society as a whole, are less branded by shame and are seeking ways forward rather than sticking to the traditional behavior of denial—covering up and not seeing. Today, there are even fewer program administrators and politicians getting waylaid on this issue. Alcoholism is not perceived as being “the problem” of a few, but rather is now considered to somehow be an issue of social relevance for the Italian community as a whole.

Accessible resources are now available in contemporary Italy to treat persons mani- festing problems related to their consumption of alcohol beverages as well as for those who are involved with such persons and who seek help and support. Some cities have developed needed services including alcohol addiction treatment facilities as well as mutual help and volunteer groups.

Today’s inadequacies are also visible. The media often confuses alcoholism with the misuse of alcohol by young people or members of the immigrant community, associating such use with causing road accidents or acts of violence, as well as with illegal drug use. These are surely significant problems, but information of this kind contributes to lowering concern about alcohol addiction, its consequences to and implications for individuals and systems by associating alcohol addiction and misuse to a certain age-group or culture; perceiving it as being something “separate from us” in the same way as we talk about “drugs.”

Epidemiological research, instead, tells us that alcoholism is not infrequent. Even if reliable information about the number of individuals who are affected by alcoholism in Italy does not exist, according to the observatory on smoking, alcohol, and drugs of the Italian High Institute on Health, they are estimated to be approximately 2% of the general

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Table 1 Program sources to treat substance consumers and misusers in Italy.

Professional 12-Step Voluntary Religious

Community Alcoholics Clubs for Therapeutic programs Anonymous Alcoholics in Communities Hospital beds Al-Anon Treatment University beds Narcotics

Anonymous Overeaters Anonymous

population of Italians (approaching 60,000,000), namely approximately 1 million (Scafato, 2005). Some other experts claim that they are 0.5%, and others up to 5% of the total population (cf. Voller, 2007). In two national surveys carried out on the general population by the Osservatorio Giovani e Alcool in 2000 and 2005, attempts were made to measure the dimension of alcohol dependence through the CAGE questionnaire, and the results may be considered as being consistent with the above-mentioned rates. The results of the 2005 survey revealed that the number of people who gave three or more positive answers to the four CAGE questions—that is those posited to be at potential risk8 of alcohol addiction or alcohol-consumption-related problems—increased from 0.8% (2000) to 1.9% (2005) out of all the consumers (Osservatorio Permanente Giovani e Alcool, 2000, 2007). In terms of problems involving not just alcoholic individuals, but family members as well, such figures have to be doubled, trebled, or even quadrupled.

On the other hand Italian drinkers-at-risk— individuals who are not alcohol dependent but consume more than 20 g/day of pure alcohol for females and 40 g/day for males—are estimated to represent 10–20% of the general population, that is between 5,000,000 and 12,000,000, according to international and national studies (Anderson and Baumberg, 2005; Innocenti, 2000; Voller, 2007).

Development of Italian Programs to Treat Illicit Drug Users and Alcoholic Addicts

Program sources to treat substance consumers and misusers in Italy can be divided into professional-based, 12-step mutual help based, voluntary-based, and religions-based pro- grams (see Table 1).

By and large, treatment of users of illicit drugs and of people who are alcohol-dependent differ remarkably in Italy. Both treatment resources were established in the 1970s, the former being a political “top-down” response provided by a government confronting a

8This concept is often noted in the literature, without in any way helping the reader to adequately understand its dimensions (linear, nonlinear), its “demands,” the critical necessary conditions which are necessary for it to operate (begin, continue, become anchored and integrate, change as de facto realities change, cease, etc.) or not to and whether its underpinnings are theory-driven, empirically based, individual and/or systemic stake holder-bound, based upon “principles of faith” or what. What is necessary—endogenously as well as exogenously—for the posited process to happen? This is necessary to clarify if the term is not to remain as yet another shibboleth in a field of many stereotypes. Editor’s note.

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sudden increase in illegal drug consumption among youngsters, while the latter was a “bottom-up” movement that started as “spontaneous” responses from mutual help groups and a few clinicians and institutions that begun to give help to alcoholics and their families.

Programs to Treat Illicit Drug Users

The spread of heroin consumption among young people in Italy had dramatically followed the student and young adult protest activities that pervaded Italy during the late 1960s. Consumption of heroin in Italy’s large cities began in the 1970s and subsequently spread to include smaller towns. A few politicians on the one hand, and some family doctors on the other, had provided the first attempts to treat individuals who began to present physical harm and problem behavior, and administration of morphine at the doctor’s office was then the first available program. However, formal specialized professional out-patient community services for treating illegal drug addiction, recently named as SerT (Servizi per le Tossicodipendenze) were approved by the Italian Parliament with Law N. 685, December 22, 1975. These services developed very quickly to meet such a new and for Italians a shocking phenomenon, which was experienced as being a real national emergency. These interventions and services were especially supported by left-wing governments, which footed the cost of funding the services with no contribution being asked from clients, as is traditionally the situation in Italy for Public Health Care institutions.

In general, in Italy left-wing parties have developed an approach to illegal drug user treatment that is different from the approach of right-wing parties as well as from the Catholic Church. A fourth perspective is one of the small but very active Radical Party, that for the last 20 years has been proposing the depenalization and liberalization of illicit drug use. Left-wing parties are communist and post-communist: their efforts have been to oppose the too-individualistic approach of drug consumer treatment and eventually to at- tempt a harm reduction approach which focused on methadone maintenance programs and to the reintegration of the treated drug users into the societal network. The Catholic Church also responded to the “drug problem” during the 1970s with the creation of Italian Ther- apeutic Communities (TCs). The meta-goal and ideological underpinning was to cure the addicted persons and to restore the “new man” inside. The church initiated and maintained TC movement spread in many regions in the country especially during the 1980s–1990s. More recently, they were followed by a few public or “private-public” Therapeutic Com- munities. Right-wing parties, that are represented by post-WWII fascists and a number of new political parties created during the early 1990s and have generally been sympathetic to the “law and order” approach became, somehow, closer to the ideology of Therapeutic Communities. They wanted youngsters to avoid deviant behaviors, forcing them to adapt to an “appropriate” lifestyle.

Consequences of the quick creation of the illegal drug addiction treatment services which merit concern include:

(1) the comparatively low levels of professional skill and experience of the workers in- volved;

(2) program staff who lacked the appropriate university specialization (since for years Universities did not include any aspect of “addictions” among their subjects in their faculties); and

(3) a scarcity of locally produced research.

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A social awareness and a political interest in the disadvantaged or/and the marginalized- outcasts was what was deemed to be necessary for working in this area.

This may initially have bound the professionals to the agendas and specific interests and goals of political parties and secondly contributed to fewer innovations in the created services. It may also have produced more professional turnover in the “addiction” treatment services when compared with other disciplines in the Italian health and delivery of care system.

All too often politicians and political parties tend to fund services which are mandated to tackle problems which societies’ stakeholders and gatekeepers have the greatest fear of for a variety of reasons and, in turn, the visibility of these services keeps the interest of politicians focused on them.9 The nexus between moral crusades, moral entrepreneurs, and politics is one such example. Substance use intervention remains a highly politicalized arena. The “War on Drugs,” which is a “war” on selected groups of people is a contemporary example of this.

Programs to Treat Alcoholic Addicts

By and large, alcohol-consumption-related problems have been deemed as being of lesser importance in Italy even though their associated health impact and mortality rates are higher than those relating to “drug addiction.” For example, in 2005, 603 drug addicts died from acute causes, while overall alcohol-consumption-related mortality, including from chronic consequences, were estimated to be between 17,000 and 42,000 (Italian Ministry of Health, 2005; Italian Ministry of Social Solidarity, 2006). This is additional evidence of the power that the culture of people has which enables one to fly in the face of hard numbers and data, and instead to form and to disseminate myths and misinformation. A culture in which opinions equal facts.

A reaction to alcohol misuse in Italy began a bit earlier than the treatment for drug ad- diction, especially in the Gastroenterology departments that were created in Italy during the early 1970s and which began to treat cirrhoses of the liver and their link to “alcohol abuse.” At the end of the 1970s, there were four national health system units in Italy independently experimenting with specific treatment programs for chronic alcoholics in three hospitals (the Geriatric Unit in Udine in Italy’s north-eastern Friuli-Venezia Giulia region; the Gastroen- terology Units in Florence and Arezzo, Tuscany) and the out-patient drug-addict service in Dolo in the Veneto region, cooperating with the Gastroenterology Unit in Padua (Allamani, Barbera, Calviani, and Tanini, 1994). In Florence, the out-patient Alcohol Unit of Gastroen- terology treated approximately 1,000 alcoholic patients between 1987 and 1990, who were mostly referred to the Unit by the Gastroenterology in-patient staff. AA groups and Al-Anon groups were mainly involved. The first year after the program was started in Undine (1979), 198 diagnosed “alcoholics” were treated. In addition, the voluntary groups “Club of Alco- holic in Treatment” were called in to support the patient and his/her family (Buttolo et al., 1982).

The development of programs, services, and centers for treating alcoholics in Italy during the 20-year span from the mid ’1970s to the mid ’1990s is an interesting example of

9The interested reader is referred to the large “moral panic” and “moral entrepreneur” literature as well as to books such as Bullen, R. J. et al. (eds.), Ideas into Politics (London: Croom Helm, 1984) and Brandt A. M. and Rozin, P. (1997) Morality and Health Routledge NYC; MacCoun, R. J. and Reuter, P. Drug War Heresies: Learning from Other Vices, Times and Places. (2001) London, Cambridge University Press. Editor’s note.

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how a system of treatment arose first of all from below through a creative synergy between the efforts of organized groups of alcoholics and their families, and the contemporary interest of medicine to open up to society, all within a process of transformation of values of the rural, urban, and industrial, up to post-industrial societies in the general population. In this process, the role of legislation was to subsequently institutionalize an existing pathway that was started years before.

It must, however, be acknowledged that since the beginning of the 2000s services and units for treating alcoholics in Italy have remained unevenly distributed and in some cases have even regressed. Alcohol addiction treatment programs are now more visible, but only in the context of illicit drug user programs created as a result of a concern about the use of drugs and alcohol beverages among the young. Treatment centers and services for alcoholics dedicated exclusively to alcohol-consumption-related problems may be at-risk of closure because of their quest for maintaining their own autonomy from and even being ahead of the SerTs. Lastly, the planned creation of more needed structures for the treatment of alcoholics in contemporary Italy has not taken place, probably because of financial restrictions.

By and large, the development of substance use and its intervention in Italy, from a historical perspective, may appear to be a déjà vu or a delayed replication of what happened with mental illness. The latter had been particularly stigmatized up to the 1970s as if it was related to as being an expression of a social obscenity and societal stigma. By closing asylums and fostering acts at the community level, Franco Basaglia10 and others fought vigorously to free “lunatics” from the condition of being protected/controlled/segregated in order to make the real meaning of madness known to the society which, in Basaglia’s opinion, had generated it (Basaglia, 1968). For Basaglia madness socially represents obscenity or indecency, “markers” of those deviant parts of society that society does not accept to be parts of itself. A fellow like Basaglia nowadays would draw the attention of policymakers, specialists, and the population at large to the stigmatizing, “homogenizing” labeling of “difference”—a THEM that is assigned to the addict, as we keep him/her at a distance from US and our “normed” sites of treatment. If recovery is to be a viable process and outcome—as it is and can be—one needs to be aware of and consider their ongoing levels and qualities of treatment disparity and how human diversity can be accepted in the same manner as it was in the history of responses to psychiatric illness and its treatment.

Laws

It is a truism that society is continually on the move and legislation tends to follow suit, setting the present in order and enshrining it rather than creating it. In a certain sense, therefore, the laws passed about “addictions” and their associated behaviors and planned interventions can be viewed and considered as being reliable indicators of the way in which a society, during a given period and place, perceives the phenomenon of addiction. This includes among other considerations, selected substances, their sources, their “users” of various types and categories, patterns of use, manner of use, sites of use, abstinence, etc.

The first law about illegal drugs in Italy was approved in 1923. It listed a number of substances that were considered to be illegal at that time. Additional laws followed during the 1930s, and in 1954 laws were passed which were related to the issues of health and

10Franco Basaglia (1924–1980) was an italian psychiatrist and an innovator of an important italian mental health system (reform Law N.180, in 1978) which established the abolition of the mental health facilities.

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punishment. The first comprehensive law which governed illegal drug consumption was issued on December 22, 1975, Law N. 685: “Regulation of narcotics and psychotropic substances. Prevention, treatment, and rehabilitation of drug addiction.” According to this law, consumption of moderate quantity of illegal drugs, and the possession of the amount needed by the consumer for 3–4 days, was the matter of free choice, while the user was also considered as being affected by a disease and therefore could be treated within the National Public Health System.

This law provided the driving force for developing the regional health units for treat- ing patients affected by drug addiction by means of maintenance programs based on ad- ministration of prescribed medicaments. In 1990, according to the “Jervolino–Vassalli” Law N. 162, June 26, 1990, which is known for its harsher “treatment or punishment,” the average daily amount of drug allowed to be in the user’s possession was reduced in comparison with the previous law. After a national abrogative referendum on April 1993, larger personal amounts of drugs were allowed again. Nevertheless, in 2005–2006, and in all likelihood swayed by the United States “War on Drugs”, the government in- troduced harsher measures (Fini-Giovanardi law, 49/2006). Penalties were increased as part of Italy’s “war on drug addiction.” For example, possessing substances was now pun- ished with jail sentences ranging from 1 to 6 years, and even up to 20 years in cases of serious offences. Cannabis use was made equivalent to the consumption of heroin or co- caine. Police intervention was intended to be especially relevant. At the same time, the drug user treatment programs began to be used more as a function of the penal or ad- ministrative sanctions (Italian Ministry of Social Solidarity, 2006). Such law, whose main outcome appears to be an increase of cases of imprisonment of drug users, was strongly supported by right-wing parties under the emotional popular wave of “less crime and more safety” and by religions-based Therapeutic Communities, while many arguments against it have been put forward mainly by addiction professionals and members of the left-wing parties.

A series of government measures earmarking funds for the SerTs were approved be- tween 1975 and 2005. They have mainly been used for rehabilitation and treatment initiatives while substance use prevention was essentially addressed to high school students.

A few laws about alcohol consumption and related problems have been approved, especially during the last 20 years in Italy. Indeed, already in 1889, under Zanardelli, the National Minister of Justice who was involved in the temperance movement, the first penal code resolution was passed against public drunkenness which was considered to be “offensive or dangerous to the public.” This law also punished those who caused such a state of intoxication in somebody else (Cottino and Morgan, 1985). The 1931 Penal Code, known as the Rocco Code which is still enforced, punishes public drunkenness: the punishment for crimes committed under the influence of alcohol was harsher than for the same crime committed when sober. The 1931 Penal Code also established age 16 as the minimum legal age for purchasing any kind of alcoholic beverages in both on- and off-premises (Cottino and Morgan, 1985). However, until recently this principle was rarely applied since the traditional “informal” control of consumption of alcohol beverages, as well as of caffeine a nicotine product, was under the responsibility of the families or of neighborhood. There was a long time lapse until 1988. Ten years earlier, in 1978, alcoholism had been recognized as being a medical disorder by the National Health System and could be officially treated both in hospital and in medical offices, like any other illness, without any charge of money. In 1988, a Ministerial Decree established the blood alcohol concentration (BAC) of 0.8 g/l in a driver as the threshold above which a driving license was withdrawn. In 1990 the “Jervolino– Vassalli” Law N. 162 introduced the concept of making it possible for adjudicated alcohol

Views and Models About Addiction 1717

(and drug) addicts having been sentenced for a maximum of 4 years’ imprisonment to choose between prison and rehabilitation.

In August 1993, a Ministry of Health decree recommended some guidelines to the Italian Regions for the prevention and treatment of alcohol addiction (Decree of the Italian Ministry of Health, 1993). It recommended an interdisciplinary approach at the local level and the increase of dedicated hospital beds for alcoholics, highlighting the medical aspect of the system and indicating mutual help groups as being the rehabilitation side of treatment.

Eventually, in 2001, the Italian Parliament approved a Frame Law on alcohol and alcohol-consumption-related problems, N. 125, March 30, 2001 (Allamani, Cipriani, Voller, Rossi, and Anav, 2007). This law especially focused on re-organizing community addiction treatment services and hospital centers specializing in the treatment of alcohol-consumption- related problems and on stimulating preventive actions. It also established a maximum BAC, when driving, of 0.5 g/l; it regulated advertising of alcoholic beverages; it prohibited the supply and consumption of alcoholic beverages in work places where the effects of consumption constitute a risk for health and safety.

In conclusion, the two aims of the above-mentioned law were both to foster the de- velopment of hospital-based treatment services and to delineate and “translate” prevention principles from a control–restriction perspective.11 However, the former position is a med- icalized perspective and is probably superseded by the fact that today the problems related to alcohol consumption in Italy are essentially being responded to by public community services and mutual-help groups. The latter do not seem to adequately take into account the characteristics of drinking in Italian culture, namely a culturally anchored activity which generally occurs during the week at mealtimes and in the company of others—family, friends, colleagues, etc. Such position appears to be strongly influenced by the position ex- pressed in current Scandinavian, British, and American medical and sociological literature which primarily focuses on the toxic and inebriating outcomes that alcohol consumption has in those cultures and in which prevention takes the form of prohibition and control.

There are very few Italian studies about alcoholism and of alcohol consumption in Italy (for the latter, see Allamani, and Prina, 2007). It is to be hoped that there will be an increase in research in Italy as well as in southern Europe that focuses attention on the specific meaning(s) that alcoholic beverages and their consumption have at these latitudes and cultures and in particular about the programs and policies of prevention and their effectiveness over time.

Patients and Professionals

It is useful to raise a series of questions in order to better understand substance-use inter- vention in Italy and its implications for recovery.

What is the extent of addiction, and how many individuals using or misusing substances actually seek treatment as well as become patients, in Italy?

11Drug supply and demand reduction continues to be the underpinning for drug control efforts in many parts of the world and is exemplified by the U.S. “War on Drugs” and the ideology for United Nations intervention, among others. It is noteworthy to consider that notwithstanding increases in illegal drug seizures there also continues to be an increase in drug users of various types and ages and decreases in the prices of “street drugs.” It is useful to consider that the “supply and demand reduction” model is linear in its dimensions albeit its use to effectively intervene with processes which are dynamic, complex, nonlinear, multidimensional, and bounded (time, place, culture, etc.). Editor’s note.

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Figure 1. Types of NHS alcohol addiction services in Italy (2004). Source: Italian Ministry of Health, 2005

Who are the professionals in Italy in the area or field of alcohol, drugs, and other psychoactive substances intervention?

How are they organized? What was/is their training (types, foci, treatment ideology)? And what is the link between them and mutual-help groups?

We shall seek to answer these questions, as well as how the resources earmarked for Italian substance user therapeutic programs have been organized.

Epidemiology provides us, at best, with estimates about “addiction” in Italy, which is not an adequate description and explanation of substance use and misuse as being a dynamic, complex, nonlinear, multidimensional phenomena which is bounded (time, place, culture, etc.)12

As previously noted, reasonably accurate, generalizable knowledge about the number of individuals who are affected by alcohol dependence in Italy does not exist; estimates range between 300,000 and 2,500,000.

Given these estimates it is important to note that only a relatively small proportion of those Italians who are “diagnosed” as being alcohol-dependent are currently participating in any National Health System professional treatment program. An additional small proportion attends private health or mutual-help organization programs.

According to official Italian data, people in public treatment programs rose by more than double over 8 years: there were 21,509 in 1996 and 53,914 in 2004. Services for treating alcohol dependence rose by 64% from 280 in 1996 to 441 in 2004. More than an increase in centers and services for alcoholics dedicated to programs for alcoholics this may have been an increase in alcoholic-oriented activities within the SerT and in any case a result of the rise in territory-based out-patient activities at the cost of hospital-based in- and out-patient ones. In 2004, the national health system services for treating alcoholic patients were mainly community services (93.2%) and not hospital-based (as was the case in the 1970s); in fact in 2004 hospital units were just 4.1% and university-based clinics 2.3% (Figure 1). In 2004, there were a total of 808 educators, physicians, psychologists, nurses, and social workers who were employed full time in the treatment of alcoholic patients; they were 22% of all 3,680 professionals, including those working part-time (probably on

12In a manner similar to what the General Semanticists posited that the map is not territory; incidence and prevalence (of substance use–misuse-dependency-addiction) is not “the PROBLEM”. Editor’s note.

Views and Models About Addiction 1719

Table 2 Number of NHS services, professionals employed, and clients treated according to Alcohol

and Illegal Drug Addiction treatment programs in Italy

NHS services (N ) Professionals (N ) Clients (N )

Illegal drug (2005) 535 6,692 180,000 Alcohol (2004) 404 1,344∗ 53,914

∗This figure is adjusted by adding 808 full time professionals to 736 (total of 3,680 ) part-time professionals hypothetically working in the alcohol addiction treatment program one day per week.

Sources: Ministries of Health (2005) and Ministry of Social Solidarity (2006).

an average 1 day/week) in the care of alcoholic patients (Italian Ministry of Health, 2005) (Table 2). The ratio between professionals and alcoholic clients was 1:34.9 (Figure 2).

Dealing with the issue at community level rather than in hospital departments may have contributed to lowering the hospital admission threshold especially for women. This may be so because women are more reluctant than men to take days off for the hospital, in order to remain at home. Indeed, in the 1980s, for example, the female/male (f/m) ratio of treatment was shown to be 1:4 (Allamani, Voller, Kubicka, and Bloomfield, 2000) while during the period 1996 through 2004 a ratio of 1:3.5 is reported (Italian Ministry of Health, 2005). The treatment approach for alcohol dependence in Italy is more oriented toward interaction- oriented programs than toward medication. According to a nationwide survey conducted by the Italian Health Ministry in 2004, it included individual or family counseling (for 25.6% of clients), social worker interventions (11.8%), group therapy (10.2%), and individual or family psychotherapy (11.5%) (Italian Ministry of Health, 2005). Pharmacotherapy, as a

Figure 2. Clients/professional ratio in Italy: alcohol misuser (2004) & illegal drug user (2005) treat- ment programs Sources: Ministries of Health (2005) and of Social Solidarity (2006).

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Figure 3. Alcohol misuser and illegal drug user treatment programs in Italy (2004): pharmacotherapy versus interactional approach Sources: Ministries of Health (2005) and of Social Solidarity (2006).

treatment modality was used less often by professional workers than one would expect, being carried out only with 28.9% of the identified alcoholics (Italian Ministry of Health, 2005) (Figure 3). While alcohol-consumption-related pathologies are best treated with appropriate medications, as it is usual for most medical conditions or problems, professional constraint in administering appropriate medications in order to detoxify a person affected by alcoholism may be due to the fact that pharmacotherapy can turn out to be less effective than an interactive treatment approach.

One explanation is to be found in the fact that the addiction paradigm does not fit well with the traditional medical paradigm that links symptom and medication within a causal relationship13; it rather fits the dimension of meaning. The latter perspective changes the main potential question of the individual from the “causal” questions: “Why I use a drug?” and “What I shall have to do in order to overcome such problem?” to the questions that search for meaning: “For what purposes am I using a drug?” and “What is the meaning of my life, now?” Also, the prescribed medications may not cause the cure or relief of symptoms since they are administered in a supposed and needed (by the professional) traditional medical context of a therapeutic alliance between the therapist and his/her client, where the client essentially is expected to maintain her/his autonomy; while autonomy is exactly the problem within the therapeutic relationship between an addict individual and the health professional.

Moreover, many medications can in turn induce a problem of dependence and therefore become a potential object of further treatment. This appears to be common for substance consumers and misusers treated with pharmacotherapy. It also may be an unwanted outcome for long-term treatment of originally nonaddicted patients, e.g., treatment of different kinds of pain.

13The reader is referred to Hills’s criteria for causation which were developed in order to help assist researchers and clinicians determine whether risk factors were causes of a particular disease or were outcomes or merely associated (Hill, 1965). Editor’s note.

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National epidemiological data for 2004 portray a model of treatment for alcohol addic- tion which makes relatively little use of the therapeutic communities and hospitals. Indeed, referrals by the community health services to therapeutic communities were only 2.3%, while hospitalization decreased from 10.6% in 1996 to 7.5% in 2004 (Italian Ministry of Health, 2005).

Most cooperation in the alcohol addiction treatment programs involves groups of vol- unteers and mutual-help. In 2004, 53.1% of health services referred their clients to the Clubs for Treating Alcoholics (see later) and 34.0% to AA (Italian Ministry of Health, 2005).

Obviously, the treatment that the national health system organizes for alcohol- dependent individuals has a cost—except for the 12-step mutual-help groups which tra- ditionally do not receive any economic support at all. The estimated overall social and health cost of alcohol drinking in Italy was 5,600,000 Euros in 2003 (Scafato, Allamani, Codenotti et al., 2006).

Although diversification characterizes contemporary Italian substance user treatment, a specific profile of alcohol addiction treatment can be drawn, which tends to be different from that of other drug user treatment.

The specificity of alcohol intervention draws upon the following:

� poly-professionalism and group cooperation; � minimal threshold acceptance; � minimization of delay time (waiting lists) before the first clinical visit; � a communication and motivational approach; � family involvement; � being able to give more than one therapeutic option, or a “menu” (freedom of choice); � being able to link up with local resources and mutual-help groups.

Moving to those individuals who consume illegal drugs, the prevalence in 2005 in Italy of opioid “problem user” was about 7 per 1,000 residents, while the prevalence of cocaine “problem users “ was 4 per 1,000 residents, and has been increasing every year. The estimates about the number of 15- to 54-year-old Italians who could be eligible for treatment for their psychoactive substance dependency in 2005 is posited to be 10 people per 1,000—about 300,000 individuals. About 180,000 individuals—i.e. 60%—were being treated in SerTs in 2005 (Italian Ministry of Social Solidarity, 2006). Among them, infectious diseases were quite diffused, even if at a lower rate than in 2001: Hepatitis C (61.4%), Hepatitis B (41.7%), and HIV (13.8%). Also, about 30% of SerT clients were attributed to a psychiatric diagnosis.

There were 535 SerTs during 2005. Also, there were 1,212 socio-rehabilitation centers in Italy: 766 residential, 217 semiresidential, and 229 out-patient, most of these centers being governed and supported financially through religious organizations (Italian Ministry of Social Solidarity, 2006). The majority (60%) of those centers cooperate with the SerTs.

In the last year, the SerT staff number remained the same or somehow decreased. In 2005 there were 6,692 health workers representing medical-health disciplines, and between 27% and 52% psychosocial health professionals (Table 2). The ratio of professional to patient varies between 1:20 and 1:slightly over 30. There were 6,200 caregivers in the private social arena, with a caregiver/client ratio of between 1:1 and a maximum of 1:6 (see Figure 2).

The SerT treatment system is based on prescribed medicaments and on psychosocial intervention. The former is more diffused: between 2003 and 2005, 29–40% of SerT clients were treated only with prescribed drugs—mainly methadone, naltrexone, clonidine, and buprenorphine being prescribed in fewer cases—while 23–36% with only psychosocial interventions (mainly social worker interventions, less often with psychological support or psychotherapy), the remaining drug users were treated in both types of programs. Italy’s

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harm-reduction programs are still underdeveloped (Italian Ministry of Social Solidarity, 2006) (Figure 3).

Prison has now become one common outcome of illegal drug use. In 2005, 25,541 addicts were imprisoned, 25% more than the previous year, while 2,539, mostly Italians, were able to be part of a court mandated treatment program (Italian Ministry of Social Solidarity, 2006).

SerTs usually cooperate with rehabilitation centers (therapeutic communities), while they have little collaboration with hospitals. Moreover, the interaction of SerTs and Narcotics Anonymous is almost nonexisting; the latter, in Italy, consisting of a few groups and a small number of fellows (in 2006, about 50 groups and less than 1,000 people).

Communication Skills and Training Programs

Contrary to all the other medical disciplines, including psychiatry, the area of substance user treatment of people manifesting problems related to alcohol and other drug use, misuse, and dependence is characterized by minimal diagnostic procedures and therapeutic tools, and by a “poor” technology. Indeed, diagnosis often relies on the fact that a person appears at the health service eventually alleging that she/he has a problem with alcohol or with an illicit drug. No other assessment tool is administered. There are few routine medications given; psychological tests and psychological interviews are sometimes required.

However, in order to identify a “problem drinker” and his/her alcohol-consumption- related problems, to motivate him/her and his/her family to change their behavior and at least to begin treatment, alcohol or illegal substance misuse treatment professionals should be appropriately trained in communication skills, education, rehabilitation, and prevention. This is the reason why a certain number of training programs have been created during the last two decades.

One of such training programs is the Therapeutic Communication developed by Vera Maillart in the Tuscany region. It differentiates between eight communication techniques, such as “paying attention” and “reformulating.” It can be taught and learnt through feedback in a context of peer confrontation and preferably in a multidisciplinary setting. It can be learnt by and taught to any Primary Health care professional (Maillart Allamani, Marchi, and Milo, 1992).

The type of training which introduced a great innovation all over the country that stemming from the motivational theory. It has enjoyed a substantial development in Italy over the last 15 years (Spiller and Guelfi, 2000, 2007). The motivational approach is im- plemented during medical consultation, nurse counseling, and educational interventions with individuals and groups. Professionals assess the level of problem awareness of a client and/or family members, prefer the process of increasing the client awareness, and promote the client’s decision. The motivational approach has been more successful in the field of alcohol addiction treatment than in drug user treatment programs.

The ultimate aim of this approach is the voluntary change of people’s behavior. Stages and tasks of change, from precontemplation to contemplation, preparation, action, and maintenance have often been described and are well known. Readers are referred to the studies of Prochascka and DiClemente (among others, see Prochaska and DiClemente, 1992).

Another type of training program for the treatment of alcohol misusers is organized by the Clubs of Alcoholics undergoing Treatment called Territorial Alcoholism Training, which aims at developing skills especially at a volunteer level, in cooperation with professionals

Views and Models About Addiction 1723

and public organizations and institutions (Salerno, 2004). These programs have been partic- ularly beneficial in developing territorial programs for treating alcoholism throughout Italy.

Cooperation Between Mutual-Help Groups and Professionals in the Treatment of Alcoholism and Drug Dependence (or not?): A Growing Model of Cooperation

The model of cooperation between the health system with Non-Governmental Organizations (NGOs), namely mutual-help and volunteer groups in Italy, is an excellent example of modern cooperation between professionals and substance user associations. It has been an indispensable part of the treatment for many years. The groups are AA and Al-Anon (relatives or friends of alcoholics) on the one hand and the Clubs for Alcoholics undergoing Treatment (CAT) on the other.

In 2005, approximately 40,000 people, at least 0.07% of the Italian population, were estimated to be involved in either a 12-step or a CAT program.

AA in Italy, was first established in Rome in 1972, when an Italian alcoholic joined a local English-speaking group. The foundation of another group in Florence in 1974 was accompanied by the first-ever public conference held by AA in Italy (Allamani and Petrikin, 1996). It was not until the 1980s that AA started to grow. There were approximately 500 Italian groups by 2005 with at least 10,000 participants of which approximately 3,000 were women (f/m ratio 1:3). They were present in metropolitan areas and small towns, and more in the northwest of the country than in the south (Servizi Generali Alcolisti Anonimi Italia, 2004).

The other major NGO for alcohol dependency treatment is the Italian Clubs for Al- coholics undergoing Treatment (CAT), which stems from a multifamily group program established in Croatia during the 1960s by Vladimir Hudolin (Hudolin, 1991; Patussi, Tu- mino, and Poldrugo, 1996). In 1979, CAT was imported into Italy through experiences in Trieste and Udine. The clubs consist of groups of between 5 and 15 persons, wherein alco- holics and family members meet together once a week, guided by a social worker or health professional or by a “recovering alcoholic” or his/her family member. This method spread rapidly throughout many regions in Italy, especially in the late 1980s. In 2005, approxi- mately 3,000 clubs were reported with approximately 20,000 members, who generally were referred from hospitals or social services. Usually CAT actively cooperates with the public treatment systems for alcoholics and with the health authorities at the local and regional levels in supporting public-funded treatment and prevention programs.

CAT differs from AA in that meetings are led by a helper called “servant,” who is a leader certified by means of brief Territorial Alcoholism Training (Salerno, 2004). This group leader may be a health or social worker professional, or an alcoholic or family member.

In its initial stages, AA in Italy, as it had in the United States, distanced itself from health care professionals and institutions and cooperation was quite limited for a long time. On the contrary, the beginning of the movement of the Clubs for Alcoholics undergoing Treatment was quickly successful because their initially nonspiritual approach was more acceptable to the medical paradigm.

It is the usual practice that very soon after (or simultaneously with) a period of out- or in-patient clinic treatment, patients are referred to AA or to Clubs for Alcoholics undergoing Treatment (CAT).

A relevant study conducted with 480 new patients admitted to six Italian alcohol addic- tion treatment services in 1995 examined the interaction of mutual-help groups and health care system in Italy; 297 (62%) of them were also referred to AA. After 12 months, many

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(70%) of those referred to AA were still in touch both with the group and the health service, and were still abstinent. Entry into the mutual-help group does not and did not deter people from returning to their doctor (Jean et al., 2004).

Conclusion

The implication of the attitudes about drugs and alcohol and about treatment of Italy’s population at large and stakeholders, including politicians, administrators, and helping professionals, is wide.

Two general attitudes pervade contemporary Italian society i.e., the issues of: (1) eco- nomics and (2) security. In the case of alcohol beverages and of illegal drugs these attitudes translate into a sort of shrinkage of both economic and human resources being allocated to the addiction services and more of a police-law enforcement approach to substance user. At the same time there is the beginning of a perception among the general population of new risks coming from alcohol beverages consumption, especially those which are actually or are posited to be consumed by youngsters and immigrants. This change is mixed with a lessened worry about illegal drugs, namely cannabis, especially among the younger generations.

On the other hand, active resources and enthusiastic stakeholders fostering the recovery for users and misusers of psychotropic substances are found in the community and they are successfully cooperating with the Public Health services. Among them there are a few examples of GPs involved in the education of their clients who drink hazardously (Scafato, Allamani, Codenotti, et al., 2006), and of community-driven prevention interventions (Alla- mani et al., 2007). Twelve-step groups and CATs appear to be critical in promoting attention to the treatment programs. Narcotics Anonymous is just beginning to be known by SerT professionals.

Harm reduction programs could be further developed by health and social workers. In any case, training programs to help health and social work professionals to commu-

nicate with their client and the local population at large appear to be needed. Professionals’ interaction with their clients should go beyond the traditionally authoritative and permissive attitudes, being more focused on the individual and group needs, and on attempts to solve them.

RÉSUMÉ

Vues et modèles sur la dépendance chimique: Différences entre les traitements pour les personnes alcooliques et pour les consommateurs de drogues illicites en Italie

Le traitement des personnes qui sont alcool-dépendantes et le traitement des utilisateurs de la drogue illicite diffèrent remarquablement en Italie, en accord avec la perception du grand public selon laquelle boire des boissons alcooliques est un comportement honoré par temps, alors que la consommation des drogues illicites est un comportement déviant. D’une perspective clinique, le traitement pour l’alcoolisme se tient essentiellement selon le principe du choix libre, de la motivation pour changer, et de l’approche familiale, alors que le traitement des utilisateurs de drogue illicites est caractérisé par les approches de contrôle, la pharmacothérapie et de thérapie individuelle. D’un point de vue sociopolitique, les deux modèles ont été établis dans les années 70: l’alcoolisme étant un mouvement “de bas en haut” qui a commencé en tant que réponses “spontanées” que les groupes d’aide mutuelle et quelques cliniciens et établissements ont données aux

Views and Models About Addiction 1725

RESUMEN

Opiniones y modelos sobre la dependencia quı́mica: Diferencias entre los tratamientos para las personas alcohólicas y para los consumidores de drogas ilı́citos

en Italia

El tratamiento de las personas que es alcohol-dependiente y el tratamiento de los usuar- ios de la droga ilı́cita difieren extraordinariamente en Italia, de acuerdo con la percepción de la opinión pública según la cual beber bebidas alcohólicas es un comportamiento hon- rado por tiempo, mientras que el consumo de las drogas ilı́citas es un comportamiento que desvı́a. De una perspectiva clı́nica, el tratamiento para el alcoholismo se tiene esencial- mente según el principio de la elección libre, de la motivación para cambiar, y del enfoque familiar, mientras que el tratamiento de los usuarios de droga ilı́citos es caracterizado por los enfoques de control, del pharmacothérapie y de terapia individual. Desde un punto de vista sociopolı́tico, los dos modelos se establecieron en los años 70: el alcoholismo que es un movimiento “hacia arriba” que comenzó como respuestas “espontáneas” que los grupos de ayuda mutua y algunos médicos y establecimientos dieron al alcohólicos y a sus familias; mientras que el último se proporcionaba “de arriba abajo” como respuesta polı́tica del Gobierno que enfrentaba el crecimiento del consumo de droga ilegal entre jóvenes.

THE AUTHORS

Allaman Allamani, M.D. (Italy) Psychiatrist, Family Therapist, Researcher, since 1993 Coordinator of Cen- tro Alcologico, Florence Health Agency. Author or co- author of 140 articles, editor or co-editor of 13 books. He is a member of the Editorial Board of Substance Use and Misuse and a faculty member of the Middle East- ern Summer Institute on Drug Use. From 1973 to 1993 he worked as a gastroenterologist clinician in the Gas- troenterology Unit of Careggi Hospital in Florence. In the 1970s, he co-founded the Tuscany section of the Ital- ian Psychosomatic Society and the Centre of Interactional and Family Therapy in Prato, Italy; in the 1980s, he also co-founded the Tuscan section of the Italian Society of

Alcohology. In the same decade he contributed to a Regione Toscana project on Ther- apeutic Communication for helping professions together with Vera Maillart and others. Later on, he started a comprehensive Alcohol Problem Treatment and Prevention program in Florence, also focused on eating problems, based on low access threshold, family and motivational approach, and cooperation with mutual-help groups. He developed the first community action alcohol use intervention projects in Italy in the Florence area. Well known to the Italian 12-step movements, he was the first nonalcoholic trustee of Italian Alcoholics Anonymous from 1997 to 2003. He is trustee of the Psychosomatics Training Institute, Florence.

1726 Allamani

Glossary

Alcoholic beverage addiction: Consumption that corresponds to DSM IV criteria for alcohol dependence.

Alcoholic beverage use: Moderate daily consumption especially of wine at meals. Co-dependency: Relatively recent “diagnosis” with over involvement of a family member

with another family member who is the “identified” or “tagged” alcoholic patient or drug user.

Illicit drug use: A substance consumption pattern that is socially connoted as being deviant as well as illegal.

Models: Organised views by means of which different people or professions interpret the phenomenon of addiction and its treatment.

Non-Governmental Organizations (NGO): Twelve-step groups like Alcoholic Anonymous, Al-Anon, Narcotic Anonymous on the one hand, and the voluntary multifamily Clubs for Alcoholics in Treatment on the other hand.

Servizio Tossicodipendenze, Drug Addict Health Service (SerT): NHS treatment for illicit drug users.

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