1. Education and Change) 35th Annual Alcohol Epidemiology Symposium of the Kettil Bruun Society (KBS 2009) Copenhagen, Denmark, June 1-5, 2009 www.kbs2009.dk A training oriented approach for a customised alcohol treatment program ( Education and Change) www.kbs2009.dk Allaman Allamani* Alberto Centurioni* Canio Lomuto* Carmen Lenci+ * ACA Training Group, Florence Italy + CE.R.AS.AL Research Center, Senigallia Italy

2. The terms Addiction and Alcoholism involve moral, social and medical values- a sin, a disease, a social deviance - as well as spontaneous remissions, the mutual help treatment (e.g. A,A.) and the formal types of treatment. Addiction represents many interests by individuals as well as by systems. The individual consumer is a subject of needs and part of a system – family, society and culture.

3. The treatment process of people manifesting a substance use disorder (SUD) can be differentiated according to 3 phases: (1) Detoxification (2) Rehabilitation: including short-term residential programs (30-90 days), therapeutic communities (3-12 months), outpatient programs (a few mths- years) (3) Continuing care, generally in an aftercare setting, typically in association with mutual help groups activities. (Mc Lellan 2006)

4. Features specific of SUD treatment programs are: - avoiding the one/to one therapeutic relationship - promoting e.g. “rotation of therapists” and the “Therapeutic Milieu”. Such an approach requires a reconceptualization and a re-organization of the therapeutic setting, and a training that addresses the new needs. An ethical focus is also necessary when training professionals in the addiction area. (Krampe et al, 2004,Yalisove 2006, Chemtob and Levy,2009)

5. The prevailing view in treatment is using evidence-based (EB) approaches However, persuading clinicians to change their practices requires more than reading a book /attending a workshop. Moreover “top-down” applications of EB pre-existing programs may ossify practices into stereotyped procedures. On the other hand, a training process that involves a “down-top” approach for professionals, who are capable of tailoring existing SUD programs to their own needs and to those of the clients, appears relevant..

6. The Senigallia Project June 2008 - April 2009

7. This project was implemented within an in- patient medium-size hospital unit at Senigallia (near Ancona, Central Italy), well known for treating acute alcoholics, who are referred there from several Italian regions. This project aimed at inducing changes within the hospital, the hospital manager being interested to make the therapeutic system more efficient.

8. The project team (one coordinator, two teachers, the hospital social worker - who functioned as a local facilitator) agreed on 5 project phases.

9. PROJECT PHASES Phase 1 - meeting of project team & stakeholders to tailor a preexisting questionnaire to assess the personnel needs (June 2008). Phase 2 - pretest & administrate questionnaires, collecting opinions and analysis of needs (July- August 2008). Phase 3 - feedback of results to co-plan the Training Course (Sept. 2009). Phase 4 - Training Course (Oct. 2008– Jan. 2009) Phase 5 - Training outcome & evaluation: defining a new organisation model (March 2009}. Education & Change

10. ANALYSIS OF NEEDS- a synthesis 1 The needs reported by the personnel were:  better acknowledgment of own working role  need of co-operation with other professions  support for their interaction with patients.

11. Education & Change ANALYSIS OF NEEDS- a synthesis 2 79% deemed that their own opinion was not considered when client problems were faced; 90% thought this was also the case when staff problems were met. 58% believed that the information given by colleagues was not enough for their own work. The majority thought patients were not listened to or sufficiently cared after.

12. Education & Change TRAINING OBJECTIVES ACTIVE EDUCATION SHARED PLANNING ORGANISATIONAL CHANGES

13. Education & Change Education & Change TRAINING MODULES Learning module Worksite module CONTENT Therapeutic Communication System Approach Projecting and Experimenting

14. TRAINING OUTCOME 25 people (1/2 of the clinic staff) attended. One outcome of the training was co-planning and implementing daily morning meeting a “daily morning meeting ” involving the entire staff. This meant changing a hierarchical/vertical organisation into an horizontal one - also making a better circulation of the information possible.

15. Training Evaluation 1 At the end of the training the hospital personnel was asked to write down their opinions and impressions about the training. Following is a synthesis of the reports of some professional groups

16. Training Evaluation 2. The training course has been an opportunity to know each other, outside of our working roles, and also to know the activity of every professionals better then before, openly expressing our problems… (kitchen & cleaning personnel) It has allowed us to develop the ability to introduce ourselves to the patient implementing a positive communication, which takes in consideration the particular needs and feelings of the ill person and permit to enter in tune listening and accepting, and not judging him/her…(nurses)

17. Training Evaluation 3... The daily morning meeting appears to be a constructive co-operation among professions, to favour a better motivation to work, and to give professionals greater cohesion and consistency of participation… (psychologists and social worker) One of the more interesting aspects of the course has been that a good part of the staff who operate in the Hospital Unit to have been involved…Thus, having decided about he daily morning meeting with all the professions attending, in spite of initial difficulties and “resistances”, we were able, as a group, to..make a decision..that until just months ago seemed quite difficult to imagine… (medical doctors)

18. COMMENT 1 At the end of this Training the improvement of communication both among professionals and among professional groups was a most positive change as perceived by participants.

19. COMMENT 2 Participants were able to appreciate the chance of self-observing when applying the communication skills both with their clients and their colleagues at the laboratory level and in the working context as well.

20. COMMENT 3 Any organizational system has an “inertia” that operates as an institutional barrier against the forces for needed change. The success of the training in introducing an organisational change (dmm) is attributable to the combination of the personnel motivation and to the management’s clear determination to pursue the on going changes.