Giampaolo Carcangiu
Vladimir Hudolin – History of a scientific revolution
Dedicated to my wife Loredana, and to our children Sara, Francesco and Niccolò
Graphics by Sara Carcangiu – front cover “The path of Vladimir”
Free translation in English courtesy by Ennio Palmesino, in collaboration with Andrea Manfredi and Caterina Anna Melis
Preface and introduction: page 1-2
Chapter 1: Vladimir Hudolin
Chapter 2: Psychiatry and alcohol problems
Chapter 3: Vladimir Hudolin
Chapter 4: The scientific development of Hudolin Methodology
Chapter 5: Vladimir Hudolin
Biography of names mentioned
References
Note from the translator:
I have gladly accepted to translate in English this booklet, as I feel it is important for all the Clubs of Alcoholics in Treatment in the rest of the world to learn something about the history of what the author calls “A scientific revolution” by Vladimir Hudolin. Particularly for all those who have not had the chance to meet him personally, this booklet goes a long way in explaining the evolution of his thinking, and how he reached his conclusions. A revolution that he summarized in the following sentence “Clubs require that treatment is de-medicalized and de-psychiatrized, this is the modern approach to alcohol related problems …. The Clubs try to take away the alcoholic from the traditional medical treatment, which usually estranges him from the community and does not offer satisfactory results”. I am sure this booklet will make an interesting reading for all of you.
Ennio Palmesino – Chairman WACAT (World Association of Clubs of Alcoholics in Treatment), Genova 2014
Preface by the author
The decision to write this booklet has been taken on the ground of the intense and passionate participation of several Clubs’ servant-teachers who have attended the updating course in Cagliari (Sardinia), on 20thApril 2013, denominated “Hudolin methodology: the development of a scientific revolution”. As a matter of fact, I had already prepared a smaller booklet soon after the course, containing all the presentations made during the course, plus a biography of Prof. Hudolin. Such booklet was published in October 2013 and has been rapidly sold out.
In order to proceed with a second edition I have decided to introduce some additions and alterations, with the aim to make it more comprehensive.
A deep sentiment of gratefulness towards Prof. Hudolin has accompanied my work.
I hope this booklet will be seen as a tribute to Prof. Hudolin’s memory while we are approaching the 50thanniversary of the establishment of the first Club of Alcoholics in Treatment (Zagreb 1964).
I wish to thank for their invaluable contribution, friends and colleagues such as Giovanni Ballicu, Caterina Carta, Andrea Manfredi, Caterina Anna Melis, Massimina Serra. I also wish to thank all the families and servant-teachers of the Clubs of Alcoholics in Treatment in Sardinia, who have always supported and encouraged me. I also wish to remember my close friend and collaborator Giuseppe Russo, who recently passed away.
Giampaolo Carcangiu
Introduction
“It happened to me to play the role of Devil: my scope has been to dig out the stones from the quarry, to the best of my capacity, and I was happy if I managed to lay them, by hook or by crook, in such a way that they could seem like a building. My duty was to carry out this hard work, the hard way, now it’s up to you. You can lay back, in peaceful meditation, and draw the project of an harmonious building, something that I never had the chance to do”. (Sigmund Freud 1910).
Since the second half of last century, the interest connected with alcohol related problems has considerably increased. Scientific research (medical, psychological, social) has produced a number of studies worth to read. Specific interventions have been put in place, while laws and regulations have been implemented in fields such as road safety, workplace safety, in the control of alcohol beverages consumption and its consequences. More attention has been devoted by the institutions to the prevention of alcohol harm and to the health protection and promotion. Such attention has produced new strategies in the field of physical, social and psychological alcohol-related complications, a great scientific work aiming at the improvement of quality of life.
The WHO has stated that “there is no safe, recommended quantity of alcohol consumption that is totally free of risk” and this represents the basis to try and change the general culture, which imprudently promotes the drinking behaviour, as if it was acceptable or even desirable.
Training and updating of all operators working in the alcohol field (medical doctors, psychologists, social workers, nurses, volunteers) are regrettably underscored and neglected, and this is despite the study of alcohol problems, which is a recently born discipline, has received various acknowledgements and consensus by the scientific community, for example in all the documents issued by the WHO since 1951 till today.
Among the various theoretical models, one that has been created and has widely spread over the last 50 years is the “social ecological approach to alcohol related and mixed problems” also known as “Hudolin Method” after the name of its inventor, Prof. Vladimir Hudolin (1922-1996). Such approach can offer an original interpretation of the alcohol related problems and a solution which is based on the Club of Alcoholics in Treatment (CAT).
Such Clubs were originally conceived (1964) to treat alcohol problems on the basis of the Therapeutic Community, in other words as a group therapy, according to several experiences that were conducted during those years in some psychiatric hospitals in Europe and in the United States. The weekly meetings were intended to recruit family members within the therapeutic process, to rebuild ties within the family, those ties that had been malfunctioning when the alcoholic was drinking, and to put together all the therapeutic resources in order to maintain abstinence from alcohol over the time. With the multiplication of the experiences, the Club has progressively represented a development of the original model of the Therapeutic Community, towards the idea of a Multifamily Community, being integral part of the local community, and engaged in the process of health protection and promotion.
In this booklet, in addition to some biographic notations of Prof. Hudolin, I have tried to review the historical milestones that he has laid down, that have earmarked the organization and the development of his methodology, which has impressed many observes because of its simplicity and the capability to be set up and replicated very easily.
I hope that this modest contribution will help to consolidate the great scientific value of Prof. Hudolin’s work (and his wife Visnja too) so that our day-to-day work maintains a close tie with the origins. In the movie “Sarah’s key” (by G. Poquet Brenner, France 2010) you can find the following sentence “ When you tell a story, it cannot be forgotten. It becomes something else, the memory of what we were and the hope of what we can become”.
I cannot conclude this brief introduction without mentioning, once again, that I feel a deep gratefulness towards Prof. Hudolin and his wife, two persons that have marked my personal and professional life, and whose teaching has influenced many passages in my life.
Chapter 1
Vladimir Hudolin – biographical notes (1)
“When a man likes a place, he tries to return often to that place; that’s why I wish to visit again Ogulin and walk again along the Klek” (Ljudevit Vukotinovic 1813-1893)
Vladimir Hudolin was born in Ogulin (Croatia) on 2nd May 1922. Ogulin is located in the center of Croatia, between Zagreb, the capital, and Rijeka, in a large valley where two picturesque rivers slowly flow (Dobra and Zagorska Mreznica). The father was dressmaker and the mother housewife. He had one brother, who died at age 8, probably for pneumonia, and a younger sister, Lyubica, who died very recently. Vladimir’s father passed away rather young, before he was 40, for complications connected to alcoholism. This sad story has no doubt influenced Vladimir, at the time an adolescent, to get involved, once grown up, in the study of alcohol problems.
The background was that, in those years, alcoholism was not considered a behavioural disturbance, worth being cured, but rather a vice, to be criticized and to be repressed. Alcoholism was considered a diversion, alcoholics were marginalized and were considered morally defective. The “cure” was generally the hospitalization in psychiatric hospitals. If and when they were discharged, they could not rely on any rehabilitation programme, the general opinion was that it was a problem that could not be resolved, according to the motto “Alcoholics once, alcoholics forever”. Today, as we can find out later on in this book, alcohol related problems can be handled and resolved, in most cases, destroying the notion that they cannot be resolved. At the time, regrettably, alcoholics were passing away rather young, leaving behind a burden of suffering for the family members, a sense of shame, the frustration caused by the incapacity to do anything, so that their sorrow was irreparable.
Only in November 1935 people started to have access to a new kind of support created outside the institutions, that was the Society of Alcoholics Anonymous (A.A.) which had been established in Akron (Ohio, USA). The creation of A.A. can be indirectly connected to the famous psychoanalyst Carl Gustav Jung (1875-1961). Ellenberger (1976) reported that a certain Roland H. approached Jung in 1931 for alcohol problems, and started a psychotherapeutic process with him, that lasted about one year. After a relapse, he called up Jung again, who suggested him to find a solution through a religious or spiritual experience. Roland H. then joined the evangelical movement “Oxford Group” and succeeded in getting rid of alcoholism. The Oxford groups made sober also Ebby T. who in turn, in 1934, reported his story to Bill W. After a while, Bill had a religious experience and started to dream about a society of alcoholics, who were exchanging their own experiences among themselves. Then in 1935 Bill and Bob actually met, in Akron, and on 10th June 1935 Bob drunk his last glass. Thereafter the two decided to establish the A.A., whose development is now well known.
The tormented adolescence of Vladimir Hudolin, originated from the sad experience with his father, did not prevent him from being very successful in his studies. He was one of the best students at the Grammar School in Sudak, then he became member of the youth catholic association “Domagoj”. Once completed the high school in 1940, following his humanistic and scientific aspiration, he moved to Zagreb where he attended the Medicine and Surgery Faculty. Despite the difficult historical period, he got a brilliant degree in 1948.
The second world war
“From suffering emerged the strongest souls, but even the strongest personalities had plenty of scars”(Kahlil Gibran 1923)
During the second world war, the Nazis occupied Zagreb in April 1941, and consequently, with the support also by the Italian Fascist Party, the Croatian nationalist party “Ustasha” proclaimed the independent republic of Croatia, that included also Bosnia and Herzegovina. Chief of the Croatian Republic was the dictator Ante Pavelic (1889-1959), well known for his repression of Serbians, Jewish, Gypsies. With all the traditional jails being crowded, the Ustasha Government built 8 lagers, similar to those used in Germany, including the infamous Janosevac compound, the third largest lager in the world, where hundreds of thousands of people were killed, perhaps 400,000, but all evidence was destroyed before the liberation. During this difficult period, the young Hudolin was arrested and sentenced for political reasons, as he was indeed opposing the Ustasha regime (as revealed to me by Dr. G. Corlito).
At the end of the war, in 1945, no less than 300,000 Croatians had died, and despite the destruction and desperation, people started to hope for a period of long lasting peace.
In May 1945, Croatia became member of the Federal Socialist Republic of Yugoslavia, president Josip Broz Tito (1892-1980). Hudolin continued his political involvement, and became member of the Parliament, even though for just one term. His duty was how to reorganize the Health Services in the country (as confirmed to me by Dr. G. Corlito).
In 1985, Hudolin wrote about the terrible war period “The war has stimulated the movements that, later on, have developed the social work, the idea of therapeutic community and group psychotherapy. The social development needs the elimination of all repressive policies, as they are also eliminated by the society. Psychiatric treatments in those years were very similar to Nazis camps, they were containing those ideas against which humanity had been fighting during the war. People suffering by mental illness were the first victims of Nazis regime”.
Professional training
“If I will manage to grant even only one alcoholic to see with sober eyes the beauty of the world surrounding him, I believe I will have accomplished my duty” (Hudolin 1987)
After his degree, Vladimir Hudolin got his specialization in 1951 in neuropsychiatry, and started to operate as assistant medical doctor in the Mladen Stojanovic hospital (the name was in memory of a Serbian doctor who was killed in 1942 by the Ustasha). In that hospital he met the colleague Dr. Visnja, whom he married in 1952. They had one child (Ivica) who unfortunately did not survive. The unfortunate event however gave them to chance to stay closer together and strengthen their ties. In fact, Visnja will stay behind him for his whole professional life, supporting him and promoting the development of the social ecological approach to alcohol related and mixed problems.
Hudolin had his professional training in the 1950s according to the psychoanalytical model; this represented at that time the most scientifically significant psychotherapeutic model. He spent some time in Great Britain and Sweden, where in 1953 he specialized in electroencephalography under a WHO scholarship. In the same period he visited Scotland, where he studied the effectiveness of insulin shock in the treatment of alcoholism, and Rome, where he learned the electroconvulsive therapy technique. Especially in the United Kingdom he managed to have access to the best training levels of that time. He worked with Melanie Klein (1882-1960), psychoanalyst at the Tavistock Clinic in London; Klein was a student of Sandor Ferenczi (1873-1933), who was the first psychiatrist in the world to teach psychoanalysis, at the Budapest University in 1918, which helped that new scientific discipline to be officially recognized. Hudolin also worked with Joshua Bierer (1901-1984), psychiatrist at the Marlborough Day Hospital in London, who created the “social clubs” for psychiatric outpatients and relatives, inspired by his experience within the Israeli kibbutzim; Maxwell Jones (1907-1990), psychiatrist and psychoanalyst at the London Belmont Hospital, who first developed the concept of the therapeutic community (or healing community); Franco Basaglia (1924-1980), Italian anthropo-phenomenological psychiatrist, director at the Gorizia and Trieste psychiatric hospitals and inspirer of the Italian psychiatric reform law. Basaglia evokes the atmosphere of British psychiatry in the early 1960s with these words: “a reality that was totally different from European asylums. Within the National Health Service the mental patient had become an “informal patient”, similar to any other. The inpatients number was beginning to decrease; market was in need of new labour force; asylum “deinstitutionalization” techniques were arising, among them the therapeutic community; for the first time the social side of psychiatry came clearly to light”.
Hudolin spent some time at the Belmont Hospital as a trainee and as Maxwell Jones’ pupil. He participated in group work with Melanie Klein at the Tavistock Clinic. He worked in the outpatients and relatives socio-therapic groups with Joshua Bierer. He worked then in several other specialized facilities in London, Leeds, Aberdeen, etc. he also cooperated with the forenamed Franco Basaglia and with Jules Masserman, psychiatrist and psychoanalyst from Chicago, president of the American Psychiatric Association and the American Society for Group Therapy. The collaboration with Prof. William Gray from Boston, author of the well-known “General systems theory and psychiatry”, proved particularly fruitful.
It was actually about the 1960s that Hudolin, like many other famous psychiatrists of his age, started to apply the principles of the General Systems Theory by the Austrian biologist Ludwig von Bertalanffy (1901-1972) to psychiatry and alcohol study. In that way he developed, mainly in the alcohol field, a new and original integrated medical and psychosocial approach. Prof. Hudolin directed his efforts towards both interdisciplinarity and a careful analysis of the effect of family and social interactions in generating, developing, maintaining and resolving alcohol-related disorders.
Chapter 2
Psychiatry and alcohol problems – historical notes
“ Medicina non ingenii humani partus est, sed temporis filia”.
(Medicine is not produced by human genius, but is a product of its time)
Giorgio Baglivi, De praxi medica (1696)
“Those who cannot remember the past are condemned to repeat it”; Hudolin often quoted this sentence by George Santayana (1863-1952) to remark, as he wrote in his numerous books (“Psychiatry and Psychology”, 1963; “Mental Health and Psychiatry”, 1967; “Psihijatrija”, 1981; “Socijalina psihijatrija i psihopatologija”, 1982 etc.) the importance of the contribution by many eminent physicians, especially since the Second World War, in the determinant, albeit slow and cautious process of demolition of the custodial asylum model, unbearably too similar to the systems of isolation and repression of the Nazi concentration camps, “So that such a horror will never happen again“.
The long and sad story of the bond between men and alcohol was represented over time and characterized by a depreciatory labeling, prejudice, hostility and discrimination against those who suffer, whether they were “crazy” or “alcoholics”, without any distinction . The social stigma that associated (and still associates) them has contributed to their segregation, internment and exclusion, often subjecting them to extreme forms of repression.
The creation of the first asylums in Europe, as places of custody and care, rather than mere imprisonment, would date back to the period between the late 1700s and early 1800s and coincides with the broader reform of care facilities and hospitals and with the birth of psychiatry. “Drunk” and “abusers of alcoholic liquors” appear among the lunatics admitted between 1772 and 1787 into the infamous Bethlehem asylum in London, and in Parisian Charenton in 1804.
In the same period, in 1785 the american Dr. Benjamin Rush (1746-1813) in his work ” An Inquiry Into the Effects of Ardent Spirits Upon the Human Body and Mind: With an Account of the Means of Preventing, and of the Remedies for Curing Them “, and in 1804 the English physician Thomas Trotter in his “Essay on drunkenness” claimed alcoholism to be considered a disease. Thanks to medicine, then, “madmen”, including “alcoholics”, began to be distinguished from other social rejects; they started to be considered real patients and not elements of social disorder anymore.
It was the French psychiatrist Philippe Pinel (1745-1826) in 1793 who managed to free the “madmen” in chains in the asylum of Bicêtre, which is located in the suburbs of Paris, and which was well known for introducing in 1870 the straitjacket as a method of physical restraint. Pinel was considered the founder of the new psychiatry; he introduced at Bicêtre, and later at Salpetrière hospital, the concept of curability that was based on two main therapeutic strategies: isolation of patient from the outside world and moral treatment, that is an attempt to normalize the lunatic through recovery of his lost reason, a myth that dates back to Ariosto. Mental disease becomes thus a partial and reversible alteration. Among the most faithful supporters of Pinel, Dr. Jean Etienne Dominique Esquirol (1772-1840) continued the his master’s work until the adoption of the national law of 1838, which promoted the institution in France of “maisons” of hospitalization for all the people suffering from mental disorders, including alcohol-related. In Italy, the first asylum based on the Pinel model, the hospital of St. Boniface, was built in Florence in 1789 by Dr. Vincenzo Chiarugi (1759-1820). Chiarugi is considered the father of Italian psychiatry, because he established for internees a new medical treatment, more human and civilized than that in use in other psychiatric hospitals.
In this same period several definitions related to “alcoholism” were also proposed, such as the “Periodic dipsomania” described in 1819 by German physician Carl von Bruhl Cramer, and the “Alcoholismus Chronicus” in 1851 by the Swedish physician Magnus Huss (1807-1890). In America, Dr. Samuel B. Woodward (1787-1850) argued, as for mental illnesses, that alcoholism was a physical disease; for its treatment he founded the first hospital for intemperance, the “New York State Inebriate Asylum “.
In the second half of 1800, the asylum model went into a crisis. Psychiatric institutions were redefined “factories of incurable patients” and, as a reaction, they protected themselves within their own walls, further exacerbating the isolation and social exclusion of their inmates. At that time the conceptualisation of the medical model was strengthened, in order to restore some professional dignity to the “young” psychiatry; this one did not possess specific therapeutic tools, but relied on supposed scientific insights to justify equally improbable therapies: bloodlettings, evacuations, purges, enemas, hydrotherapy or ice baths, thebaic, camphor, potassium bromide, and more. Chronicity, irreversibility and inheritance of mental disorders represent the three pillars on which psychiatry will develop through the 1800s and 1900s until after World War II.
Between late 18th and early 19th century the industrial revolution started to develop, initially in the United Kingdom. This led to deep productive, technological, economic and environmental transformations. New social classes arouse: the exploited and poorly paid proletarians as opposed to the ambitious and wealthy bourgeoisie. The mass of workers crowded in suburban areas, where living conditions were very poor and unhealthy. In these areas prostitution, crime, mental suffering, and alcoholism spread. It was noted that the latter had a negative impact on the productive capacity of the workers. Then repressive and punitive laws were enacted, driven by the dominant false bourgeois morality rather than a healthy need for social justice. The first anti-alcohol organizations were established and spread across both the Old and the New World. Their aim was to limit this phenomenon and to fight against the growing industrial production of alcoholic beverages. Among many organizations we can remember in America the Woman’s Christian Temperance (WCTU) in 1872, the Anti Saloon League, organized by Methodists, and the American Temperance Society, in Europe the International Organization of Good Templars (IOGT), and in Italy the Temperance League in Lucca (1892), the Anti-Alcohol League in Milan (1907), the Teetotal Trainmen Society, and so on. Until the end of the nineteenth century, a moralistic approach to alcohol-related problems gained increasing ground. This kind of approach maintained that the alcoholic is a vicious, sinful and depraved for which it is necessary to intervene with punitive means and moral condemnation. Cesare Lombroso (1835-1909), an eminent Italian physician and anthropologist, father of modern criminology, devoted an emblematic chapter of his book “The Criminal Man” to alcoholics. Here, alcoholism is considered a vice, the cause of which in most cases is to be found in a hypothetical hereditary defect: “habitual drunkards are immoral and bear children that are criminal, insane, or with early lustfulness“.
In 1908 Clifford Whittingham Beers (1876-1943), the founder of Mental Hygiene movement, published “A mind that found itself. An autobiography”. In this work he described the mistreatment and abuse he underwent during three years after admission to a U.S. psychiatric facility. Profoundly marked by this experience, when he was discharged, he decided to publicly denounce the terrible conditions of the inmates of mental hospitals and fight for the reform of the methods of treatment of mental disorders.
Hudolin devoted much space in his many treatises on psychiatry and alcohology to the description of unbearable conditions of the patients in mental hospitals and so-called “therapies”, very similar to forms of physical and psychological coercion rather than careful clinical interventions.
The following passage from the book “The Life and Work of Semmelweiss” by the French writer and physician Louis-Ferdinand Céline (1894-1961) is an exhaustive description of the European asylum panorama: “…Moreover, wich victory can expect, death, in the most degraded place in the world? Is there anyone who contends these human larvae, these sly foreigners, these grim smiles wandering through the void, into the path of the Asylum? Prison for instincts, insane asylum, let those who want to take these screaming, whining, eager freaks! Where the lunatic begins, there the man ends, the animal is higher, and the last of the snakes at least flickers like its parent…”. Ignaz Semmelweis (1818-1865) was a Hungarian physician who was credited for the “simple” but effective intuition of handwashing as a medical practice for the prevention of contagion of puerperal fever. Because of this discovery, which was considered insane, he was forced in a mental hospital where he died soon thereafter. The above description shows the standard of care for a poor madman. Let’s say poor because the fate of lunatics was often decided based on income, indeed, if they were rich, they were hospitalized in private nursing homes, if poor in an asylum.
As said, the industrial revolution brought about, with the introduction of new production methods, a large availability of alcoholic beverages and their easy accessibility. This contributed to the increase in the proportion of consumption and alcohol-related problems. For these reasons, for example, in the United States of America from 1919 to 1933 a law came into force that totally prohibited both production and consumption of alcohol. This law was later abolished because it proved useless, ineffective for achieving its objectives, and dangerous because it increased smuggling and the interests of organized crime.
In the early 1900s, in Vienna, Dr. Sigmund Freud (1856-1939) developed his psychoanalytic theory. From this one a wide innovative current will develop over time, involving a large number of psychiatrists and helping in many ways to change the cultural attitude towards mental suffering and its treatment. On the basis of Freudian theory the conception of psychiatry as a branch of medicine, that had to take care of mental disorders, according to the conceptual model of classical physics, became shaky.
Based on the systematic study of unconscious processes of the human mind, psychoanalysis was the first to argue that mental distress can be understood as an element of life experience and a process of personal growth, rather than a foreign entity to the individual and his relationships. In this way the so-called mental illness was seen as the result of a balance, a “compromise” (albeit unsatisfactory) between different urges, or instances, internal and external to the individual. According to the psychoanalytic conception, the difference between a mentally “sound” and “ill” person can only be quantitative and not qualitative. These statements sounded revolutionary as compared to traditional “organicist” psychiatry. The latter saw the origins of mental disorders only in a defect of one or another mental function, according to a linear causality logic, and reserved to psychiatrists the only role of making a “diagnosis” depending on the type of symptoms presented, not unlike what happens in other fields of medicine.
Psychoanalysis also stated, which was equally revolutionary for that time, that the study and treatment of psychic phenomena differ radically from all other fields of science. In this case, in fact, the observer-therapist is not neutral nor independent from the investigated phenomenon, because he will utilize, as a tool of investigation and treatment, a psychic apparatus subject to the same limitations and distortions of that of his patient.
In the first half of the 20th century a new class of drugs was also introduced into psychiatry: barbiturates (Veronal 1903 – Luminal, 1912). They were used for their sedative hypnotic and anticonvulsant properties in the treatment of mental disorders (narcotherapy or sleep therapy) and psychoanalysis (narco-analysis). These substances are considered to be the precursors of psychotropic drugs that, after the Second World War, will represent a crucial discovery for the development of a new psychiatry. At the beginning of the century studies on the alcohol pathophysiology were enhanced and methods for the detection of blood alcohol content (BAC) and other biological fluids were developed (Widmark, 1933).
In this same period various other forms of “therapy” began to be experienced: malariotherapy, introduced in 1917 by the Austrian physician Julius Wagner Juaregg, who won the Nobel Prize for Medicine in 1928; psychosurgical techniques (prefrontal lobotomy and leucotomy) in 1936 by the Portuguese neurosurgeon Antonio Egas Moniz, who won the Nobel Prize for medicine in 1949; aversive conditioning with apomorphine or emetine, based on the study of conditioned reflexes by the Russian physiologist Ivan Petrovich Pavlov (1849-1936); electroconvulsive therapy in 1938 by the Italian physicians Umberto Cerletti and Lucio Bini; therapy based on LSD (lysergic acid diethylamide, extracted from ergot, a rye-parasite fungus), one of the most powerful psychedelics, which was synthesized in 1938. Today, most of these treatments have been thankfully abandoned.
In Akron in 1935, as already mentioned, Alcoholics Anonymous (AA) was founded. That movement will spread all over the world and still represents one of the best approaches to the treatment of alcoholism interpreted as a disease.
The Nazi wave in Europe and especially in Germany marked one of the saddest pages in the history of mankind. German psychiatry assumed the mentally ill, including alcoholics, in the category of non-belonging to the Aryan Project, condemning them first to mass sterilization and then to indiscriminate extermination. With the enactment of the fuhrer Law for the Prevention of Genetically Diseased Offspring of January 1, 1934, more than 5,000 alcoholics were sterilized in two years. That was the prelude to more extensive and planned psychiatric holocaust, or rather ethnic cleansing applied to the insane (up to October 1941 approximately 60,000 mentally ill patients, including alcoholics, were suppressed).
Between the two world wars, at Yale University (New Haven, CT), the Center for Alcohol Studies was founded. It was directed by the renowned Professor Elvin Morton Jellinek (1890-1960), one of the founders of modern alcohology. He developed the concept of alcoholism as a disease (“The disease concept of alcoholism”, 1963), supporting the validity of the medical approach to alcoholism. Jellinek is credited with identifying some clinical features and stages of development of alcoholism (Alpha, Beta, Gamma, Delta, Epsilon), but most of all with defining very broadly drinking as an ecological community risk factor. He stated that ” the use of any alcoholic beverages that causes any damage to the individual, society, or both” has to be considered as alcoholism. In 1977, following the example of Jellinek, Hudolin identified a category of alcoholics which he called “Zeta”, that react abnormally to even the slightest amount of alcohol and manifest aggressive behavior. Nowadays this typological partition is no longer taken into account, as it is widely accepted that in reality there are as many alcoholisms as the individuals and families who suffer from it.
Immediately after the second world war, neuro-psycho-pharmacology research started to develop and the first psychotropic drugs became available: Chlorpromazine (1952), the earliest example of antipsychotic drugs; Isoniazid (1957), of antidepressants; Chlordiazepoxide (1960), of sedatives and hypnotics. In 1948 the alcohol-aversive action of Disulfiram (Antabuse ®, Etiltox ®, Tetidis ®, Astinil ®, Cronetal ®) was discovered by chance by Danish researchers Erik Jacobsen and Jens Hald. At the time this substance was being studied as an anti-parasitic remedy. It happened that the two investigators that were testing the drug on themselves reported severe symptoms after the consumption of alcohol. Medical literature promptly reported the usefulness of the new aversive drug in the treatment of alcohol-related problems; in that way Disulfiram was enthusiastically, and I should add unwisely, referred to as the ultimate remedy against alcoholism.
In 1951, the group of World Health Organization experts on alcoholism, including the aforementioned Professor Jellinek, expressed the first definition of alcoholism: “alcoholics are those excessive drinkers whose dependence upon alcohol has attained such a degree that it shows a noticeable mental disturbance or an interference with their bodily and mental health, their inter-personal relations, and their smooth social and economic functioning; or those who show the prodromal signs of such developments. They therefore require treatment”. This definition, however incomplete and in some respects unclear, definitely exerted an important influence for the development of alcohol study as an autonomous discipline. The World Health Organization also had the great merit of perceiving the danger of increasing alcohol consumption in the world and organizing the first prevention programs in the alcohol field. In 1948 alcoholism appeared as a psychiatric disorder in the sixth edition of the International Classification of Diseases, by the World Health Organization itself. In 1952, diagnostic criteria for alcoholism as a mental disorder were included in the first version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-I), developed by the American Psychiatric Association (APA) (later in DSM-II, 1968 DSM-III, 1980 DSM-IV, 1994 DSM-V, 2013).
During the same period in some European countries the movement “Open door policy in psychiatry” had started. It proposed the removal of barriers to mental hospitals, the release of psychiatric patients from various coercive measures, the introduction of the community therapy, group therapy, and the adoption of new psychotropic drugs in the treatment of patients. The forefront country of this movement was Britain, where, after the Second World War, the Labour governments launched important social security measures, including the establishment of the National Health Service. For the first time in the history of psychiatry, people suffering from mental illness were included in community rehabilitation programs, beyond the mental hospital walls.
It was in those years that the concept of therapeutic community started to develop. It was intended by its creator, British psychiatrist Maxwell Jones, as “…a group of people who gather with a common purpose and who have a strong motivation to bring about some change. The purpose of the therapeutic community is growth, understood as an individual and social process. Its task is to help an individual to achieve his potential”. The first therapeutic community was created in 1947 by Jones at the Henderson Hospital in London, where World War II veterans suffering from “war neurosis” were hospitalized, with the aim of involving the patients and making them aware of their responsibilities on the management of psychiatric institution in which they were housed. His idea was transforming a strictly hierarchical institution, based on “vertical” relationships, into a “horizontal” organization with an equal relationship between residents and health professionals. Following several sociological studies, that brought to light the destructive effects of institutionalization on the life and health of psychiatric patients, therapeutic community was meant to overthrow the traditional setting of “dual” treatment, limited to the physician-patient relationship. It rather focused on exploiting for its therapeutic purposes all the resources of the institution itself, considered as a non-hierarchical organized set of patients, physicians and support staff.
A study of that period, which analyzed the work of the therapeutic community of Henderson Hospital therapeutic community, conducted in 1960 by the renowned sociologist Robert Rapoport, put in light four fundamental qualities: 1. Democratization: the opinions of all the residents and the staff were equally taken into consideration; 2. Acceptance: community members showed a high degree of tolerance for the behaviors of more disturbed patients; 3. Communalism: the feeling of belonging and sharing that is expressed in the idea of “living together”; 4. Reality confrontation, to which all the therapeutic community members were continually being reported.
A vivid description of life in a therapeutic community is included in David Clark’s “Social Therapy in Psychiatry” (as quoted by Giovanni Jervis, “Manuale critico di psichiatria”, 1975, free translation): “The place is pretty shabby and does not seem to have been swept recently. There are people around, but there is no way of knowing who or what they are, since they all wear ordinary civilian clothes, and everyone is on first-name terms (…) If the visitor stays for a few hours, or a day or two, he is soon captured by the life of the community and involved into the crises of the moment. In addition to many formal sessions, and instant ‘crisis’ sessions, he will be a participant at community meetings, which have a rather formal structure, with a president, reports and minutes (…) He will gradually get to know the people, to identify which among them are doctors, social workers, nurses, patients: he will realize that the role divisions are minimal, and he will get the impression that leadership can shift to any member of the group at any time. (…) There may be workshops and ateliers, but the main commitment of all is in speaking and interacting. Soon it becomes clear that many of the residents are seriously disturbed people, with many suicide attempts, hospitalizations and serious breakdowns behind. So, stormy emotions often arise in an explosive way within the community“.
The ultimate goal of this practice was to allow each of the members who joined the program to leave therapeutic community in order to test themselves in the real world. This goal led British pioneers to structure life in the community in such a way that it resembled as much as possible to daily life. This model of a democratic therapeutic community is not be confused, of course, with facilities for drug addicts, also called “therapeutic communities”, but in reality with a strong hierarchy, that were being experienced in the same period in the United States and who are still widespread and sometimes proposed for alcohol-related problems treatment.
It is noteworthy to remember the decisive support by Dr. Jacob Moreno (1889-1974) to the movement “open door policy in psychiatry”, and his significant contribution to the development of the concept of therapeutic community. After being a student of Sigmund Freud in Vienna, he emigrated to the USA in 1926; Moreno introduced the expression and the model of “group psychotherapy” and eventually founded the psycho-dramatic movement. A further development of group therapy was carried out in Britain by the German psychoanalyst Siegfried Heinrich Foulkes (1898-1976), founder of group analysis and a student of Melanie Klein, and by the famous English psychoanalyst Wilfred Bion (1897-1979). Both moreover worked at Northfield Military Hospital in Birmingham, according to models similar to those used in the same period by Jones.
Also the theories of Professor Harry Sullivan (1882-1974) played a definite role in the formation of Hudolin’s thinking and in the structuring of his method. Sullivan was founder of the Chicago School of interpersonal psychiatry, or social relations psychiatry. Among his major contributions to the development of the new psychiatry, his consideration for the centrality of interpersonal interaction in the construction and maintenance of mental disorders has to be remembered.
In those years the systemic approach, inspired by the general theory of systems of Austrian biologist Ludwig Von Bertalanffy (1901-1972), broke into psychiatry. This approach leads to consider the origin or the consequence of mental disorders and/or alcohol related problems in familiar relational difficulties, thus expanding the field of observation to socio-environmental background. Each individual is part of different systems, the simplest of which is family, understood as a bio-psychosocial nucleus based on significant emotional relationships. Even when there are problems, conflicts that trigger anger and aggressiveness, these relationships remain significant. Systemic theory is also important for having understood and planned family involvement, in whole or in part (dyad, triad, etc..), in psychotherapeutic treatment and rehabilitation. The introduction of the systemic model has therefore resulted in a veritable revolution in the world of mental health.
In September 1958 in Palo Alto, California, the Mental Research Institute (MRI) was founded by psychiatrist Donald deAvila Jackson (1920-1968). At MRI the work of several outstanding personalities offered a decisive contribution to the understanding of the pathogenesis of schizophrenia and founded the principles of brief psychotherapy and systemic family therapy. Jackson’s great merit was also to recruit a number of brilliant researchers including John Weakland, Jay Haley, Virginia Satir, Antonio Ferreira, Richard Fisch, Janet Bavelas-Bevin, Art Bodin, Lynn Hoffman and Lynn Segal and many other professionals from all over the world, who came to Palo Alto to study and learn the model of brief therapy developed by the Institute. Paul Watzlawick (1921-2007) and Gregory Bateson (1904-1980) were among the most illustrious representatives of MRI.
More specifically Bateson, a former pupil of the famous Polish anthropologist Bronislaw Malinowski (1884-1942), in his essay “The Cybernetics of ‘Self’: A Theory of Alcoholism” (1972) stated that this phenomenon was nothing more than a symptom of an epistemological error. Alcohol intoxication is here interpreted as an extreme attempt to change the way of being sober; in other words, it enables the alcoholic to experience complementarity in the relationships which surround him. Furthermore, the prescription of self-control in drinking or return to a moderate drinking is ineffective and absurd, because it simply does not work. These considerations will be taken up later by Dr. Peter Steinglass, director of the Ackermann Family Therapy Institute in New York. He argued that the family system is organized around the alcoholic drink, contemplating the stages of “dry”, “wet” and “transition” (from drinking to not drinking, and vice versa); a stable phase of controlled or “moderate” drinking represents a rare and not statistically significant event. Hudolin came to the same conclusions: in his opinion, alcohol-related problems could be addressed only through the achievement of complete abstention from consumption of alcoholic beverages, understood as a free personal choice. He was also the first to question the model of moderate, social or adequate drinking as a healthy lifestyle, pointing out its continuity with problematic drinking and alcoholism: “Alcohol dependence and alcohol-related problems are closely linked to the consumption of alcohol, which is a recognized and often accepted form of social behaviour. Although it is not their only cause, it is obvious that alcohol-related disorders would not exist without alcohol”.
In the same period, in Italy, the above mentioned Italian psychiatrist Franco Basaglia (1924-1980) was experimenting therapeutic community, initially in the Gorizia psychiatric hospital and then in Trieste. He found himself at work in a particularly obsolete and inadequate situation, like it was at the time in the Italian psychiatric hospitals. Consequently Basaglia went beyond the concept of the therapeutic community within the hospital, and pointed decisively to the abolition of the asylums as such. Hudolin and Basaglia were great friends; they had met in London at the “court” of Maxwell Jones in the early ’50s and they transferred, each in its own territory, their experience with the same enthusiasm and passion in the alcohol studies field (the former) and in the psychiatric one (the latter). Professor Visnja Hudolin stated in this regard, in a passage from “La magnolia è fiorita” by Laura Musso (The Magnolia has Blossomed, 2006): “Reading again passages from the writings of Hudolin and those of Basaglia you are struck by the extraordinary similarity of their concepts, it would be enough to replace the word “mentally ill” with the word “alcoholic” to read the same concepts”.
The basic concept, innovative at the time, was the categorical rejection of institutionalization as the only means of treatment and recovery of mental suffering, because the person is not sick but just a human being with all his/her needs (affection, relationships, money, family, etc..). If treated as a human being, the “crazy” is no longer a patient but a man who is going through an emotional, relational, social, existential “crisis”, which cannot be crystallized in a “simple” diagnosis or, even worse, restricted in a “simple” restraining fence, let alone the indefinite period of time. The closure of the asylums was, in Basaglia’s intention, only a first step towards a socio-cultural change, that is social acceptance of insanity. The experiment started in 1962 by Basaglia brought, about 15 years later, to the Italian law 180/78 (also known as Basaglia Law), which provided for the transformation of so-called “asylums” in treatment, and no longer confinement places. In fact, only after 1994 the legal provision of definitively closing mental hospitals was fully achieved in Italy.
To conclude this brief historical medical, psychological, alcohol-related and social excursus, I would like to quote a Professor Hudolin’s statement from his Handbook of alcohol, 1991: “… But also the medical approach to alcohol-related problems has over time revealed its limits; it is not able to clarify the etiology, to ensure a diagnosis, and to put in place effective primary, secondary and tertiary prevention programs. Nowadays, alcoholism is treated as a phenomenon pertaining to health and social facilities, and alcoholics have the same rights to health care as people suffering from other disorders; it is therefore possible to better study the medical approach and identify its shortcomings. This was not possible when the most important issue was to try and ensure such rights to alcoholics. Observations that call into question the medical and psychiatric models of approach to alcoholism are becoming more and more frequent, and the conclusion that alcoholism is not a mental illness seems to be accepted by now”, and, more precisely, “… I consider alcoholism as a particular pattern of behavior, as a lifestyle that can result in a disease when organic, psychological and social complications occur … At the end of the ‘50s the introduction of the systemic approach took us to see in alcohol-related disorders the result, or the origin, of family difficulties … If in the ‘60s we started to talk about a family alcoholic disease, today this term should rather be corrected in family alcoholic life style, as well as , social and working environment alcoholic life style”.
Chapter 3
Vladimir Hudolin – biography (2)
“We were a heterogeneous bunch of people, kept together by training. Some were coming and going, vagabond people staying on the sidelines, without really making big efforts, or newcomers joining us for one single meeting and disappearing, or visitors taking with them a burden of emotions and mental blocks, strong theories and beliefs, so that it was impossible for them to find room for something new. They were in disagreement and would soon disappear. But for the whole time we had a solid group of followers that never missed one single meeting” (Kennet Walker 1976)
After his fruitful period spent in England, Hudolin got back to Zagreb and thanks to his rich professional experience was appointed vice director, and in 1959 (at age 37), director of neuropsychiatric dept. at Mladen Stojanovic hospital. Despite some strong resistance in the beginning, he introduced there the so called ”open door policy in psychiatry”, in order to change the rigid hospital organization into something more flexible, where the alcoholics should be kept separated from the psychiatric departments, should be involved and made responsible for the organization of the hospital set up and work.
This ambitious project was opposed by the traditional psychiatry, even though the new ideas were spreading all over the world and were contaminating a number of professionals, but it was not easy to break the impassable wall of the psychiatric institutions. When Hudolin started to experience the new psychiatric theories, together with his wife Visnja, the assistant doctors Nebojsa Lazic and Vasco Muacevic, the social workers Liuba Ulemek and Slaviza Jauk, he was watched suspiciously, and his ideas were considered dangerous, potentially capable of disturbing the existing order and social security, which were guaranteed by the traditional method of shutting the alcoholics in the psychiatric hospitals.
But Hudolin had noticed that the alcoholics, admitted by the hospital for 3-4 weeks, would stop drinking, then were discharged, but after a month or two, were coming back again. Therefore he decided to change the organization of his clinic, separating the alcohol problems from psychiatric problems, and implemented the principles of the therapeutic community, starting small groups which he called “Klub liyecenih alkoholicara” or in English “Clubs of Alcoholics in Treatment”, groups that were gathering outside the clinic, and were attended also by the family members and by one therapist. This idea came in consideration of the fact that there was no service offered to people being discharged by the hospital.
On the 1st April 1964 Hudolin established the Centre for the study and control of alcohol related problems and other dependencies c/o Neurology and Psychiatry Clinic, part of the University Hospital Mladen Stojanovic. In order to offer the most flexible and effective solutions to families, Hudolin started to diversify the services, creating an Information Centre, the Day Hospital, and subsequently also the Week-end Hospital.
Initially Hudolin was thinking that alcoholism was a special kind of disease, which needed a specific care, different from those utilized for the other patients in his service. He was eager to find a compromise between the various theories regarding alcoholism, a compromise that should be scientifically rigorous but at the same time also practical and effective. He was determined to find a valid solution, and therefore, by making different attempts, making corrections, examining experiences and results, he promoted a model of operation that became famous all over the world. He was invited by a number of congresses and conferences to present his results, raising huge interest from the Public Health Organizations. He was appointed as expert in alcoholism and other dependencies by the WHO, a role that he will maintain for a long period, from 1965 till 1992.
Hudolin, together with Joshua Bierer and Jules Masserman, had the merit to start the social psychiatry movement, that would include also the pioneers, such as Maxwell Jones and Harry Sullivan. He established the Mediterranean School of Social Psychiatry, which was also publishing a journal. Social psychiatry had the ambition to organize the psychiatric treatments at community level, to adopt the family approach and to build a “competent community”, that means a community able to recognize its problems and to find the resources to solve them. Not surprisingly Hudolin stated “Modern community psychiatry can recognize the causes and developments of alcohol related problems within the social inter-relations, and tries to fight them, acting within the same community where men live and work, activating primary, secondary and tertiary prevention programmes”. He also stated “This is not a branch of psychiatry, this is the only possible psychiatry”.
The new trend in psychiatry was collecting great success, despite some strong opposition. Therapeutic community became, in Hudolin’s way or working, a great social laboratory where one could “live and learn” (living-learning experience) “….a community of people who freely discuss, trying to better understand some topics, learning from the others, gaining from others’ experience. If the setting can offer a good reception, there are possibility to change one’s behaviour” (Hudolin 1984).
Social psychiatry meant, and still means today, family approach. Alcohol related problems in this vision, should not be considered anymore as an individual behaviour, but a family behaviour, all the family members should no longer delegate the doctor or some other professionals to find them a solution, but become the actors of the change. Today we can talk about promoting the “reputational commitment” of the families of the Club to the choice to think and act for the common good[1].
In addition, medical interventions or health care facilities had to be reduced to the strictly necessary because the problem was no longer just a health problem.
The General System Theory offered Hudolin a precious scientific tool to analyze and organize specific interventions in his country. Hudolin afforded the development of this theory specifically to alcohol related problems to his collaborator Dr. Nebojsa Lazic, who set up the famous seminars held in Zagreb by Prof. William Gray in 1975. Hudolin realized that it was necessary to consider the family system and the community system as target for a cultural change, in order to properly understand alcohol related problems. This means deploying the project in the community. A community, like Hudolin said many times, “is not an administrative or political definition, but rather the complex relations that exist among the people who live and work in the same territory. For the individual, the events that are happening in the world have no meaning, what has a meaning is what happens in his house, with his neighbours, at his workplace, in his community. Promoting the quality of life in his community is the best guarantee for his health”.
Hudolin also realized, after a short practical experience, that for a family with alcohol related problems, it was best to join immediately a Club, while pending other decisions regarding the clinical interventions. This is what happens still today in most countries.
As we have seen, when Hudolin in 1964 started the Centre for the study and control of alcohol related problems and other dependencies, he also started the first Club of Alcoholics in treatment, outside the clinic. The Club’s life in the beginning proved to be quite difficult. Official medicine would not accept such a revolutionary approach, or better, it would not accept a programme meant for the alcohol related problems outside the hospital or other health institutions. The majority of the health operators were skeptical and were against an approach which they considered rather raw and simplistic. Only a few showed enthusiasm for a method that could represent a new therapeutic resource. Other criticism was brought by the family members, because they were also required to join the Club meetings, but they were convinced that only the alcoholic (“the patient”) should have been cured, not anyone else.
Initially Hudolin used to describe alcoholism as an “alcoholic disease” or “alcohol dependence” even though he realized that the majority of the consequences were not of medical nature. Prof. Hudolin in addition designed a complex educational system, in order to train many professionals (doctors, nurses, social workers, volunteers) and thereafter involve them in both the hospital and the Club activities. In 1975 he established the Zagreb School of Social Psychiatry for Alcoholism and other dependencies, otherwise also called the 600 hours School, which was a post-degree Master in Alcoholism, which was directed from 1975 till 1984 personally by Prof. Visnja.
Hudolin used to follow personally the supervision activity of alcohol programmes in Croatia, and since 1979, also those developing in Italy. Thereafter he created the Course of Sensibilization (or Sensitizing Course) based on the medical-psycho-social approach to alcohol related problems, an intensive course lasting 50 hours, meant to recruit and train the volunteers in order to become operators in the Clubs. Even with some slight modifications, this course remains, still today, the backbone of the training activity of the Club movement and the basic requirement to become servant-teacher in the Clubs of Alcoholics in Treatment.
Another ambitious target for Hudolin, since the very beginning, was to develop scientific researches to evaluate the results reached with the treatment. Already in 1965 he created the Register of Hospitalized Alcoholics in Croatia, which still today represents a valuable source of information and suggestions to evaluate the quality of health services, both at clinical and territorial level. Only through research and evaluation Hudolin was able to modify his methodology and adapt it to the results of the research and the ever changing social and cultural setting.
1985 has been a turning point for his vision. At that time Prof. Hudolin was still Director of the Neurology and Psychiatry Clinic, and professor in the same Faculty at the University of Zagreb. He was also still collaborating with the WHO and was chairing the Mediterranean School of Social Psychiatry. He was also deeply involved in the development of the alcohol programmes in Italy. During the Italian-Yugoslavian Congress of the Clubs of Alcoholics in Treatment, in Opatija (Istria), he introduced the concept of life style. Such renewed approach included at the time (and still includes today) the following reference-points:
- Alcoholism is an unwanted, side-effect of drinking
- Alcoholism is a specific tie between the man and alcohol. The solution of the clinical complications arising from alcoholism belongs to the medicine
- Alcohol related problems, including alcoholism, are disturbances of the behaviour, with high prevalence and incidence, so that a huge part of the population is affected
- Psychoanalysis, family therapy or group therapy can only be applied to a small number of people and not to such huge numbers
- Every human being belongs to a social group, first of all to a family, which is a wider system compared to the individual, while the family is a sub-system of the community system, and so on until we define the whole society as systems and sub-systems
- Alcoholism is therefore a systemic disturbance, it has to do with the whole system where the individual has some relations
- Alcohol related problems, including alcoholism, are the expression of the family life style, a concrete, day-to-day complex of relations
- Changing the life style within a family cannot be defined as “cure”
- Differentiating between use and abuse does not make any sense
- The Club of Alcoholics in Treatment (CAT) is the backbone of the territorial alcohol programmes, is a rather simple project and has proved to be effective wherever it has been replicated
- CAT is based on the principles of the Therapeutic Community, but is something different, in so far as it is integral part of the local community
- CAT is a human laboratory where it is possible to change one’s life style without compelling him to migrate from his own social setting
- In a CAT the interactions and cross-relations empower the people to “cure” the problems and prevent further problems offering a reference point for a real change
- Within a CAT the family can develop a new culture based on sharing, and gradually can become part of the local community
Chapter 4
The scientific development of Hudolin Methodology
“Increasing human knowledge is just one of the aims of science, but the ultimate aim is improving human condition” (Joseph Rotblat, Nobel Prize for Peace 1995)
A scientific method is a set of criteria (both theoretical and operational) whereby a theoretical or experimental result can be considered as scientific. Basic point is that, given the same materials and methods, the experiment can be replicated anywhere, so that it can be studied by other scientists. Scientific development is a path where new elements are being added at each step, and the progress thus achieved should not be considered as ”linear” development, but rather as a circular movement, or even as spiral movement. Moving forward involves adaptation, re-elaboration, updating with always new results.
A scientific observation must be made following its basic criteria, if the expected result takes place, then the theory can be considered (temporary) confirmed.
Hudolin established a rational model of the alcohol related problems, and found that the experimental solution dubbed “Club of Alcoholics in Treatment” could be the solution for a great number of people suffering for that situation. Solving the problem for a number of people would reduce the incidence of the problem in the general population.
Since 1964 in Zagreb, through the Opatija Congress in 1985, until these days, the spreading and dissemination of the Club of Alcoholics in Treatment, the accumulation of their experience, have confirmed the effectiveness of the Hudolin’s model and it capacity to be easily replicated. The concept of Social ecology is still very much up to date, with its theoretical links (General System Theory, Psychoanalysis, Therapeutic Community, Socio-therapeutic Clubs, Alcoholics Anonymous, Social psychiatry etc.) and it has proved to be a milestone in the modern scientific evolution.
The provocation represented by the statement “alcoholism is not a disease” was justified, according to Hudolin, by the fact that the traditional methodology in curing alcoholics was obviously not effective. In fact, what Hudolin meant was “alcoholism is not only a medical issue”. This change of perspective, or “paradigm shift” (as described by American philosopher Thomas Kuhn – 1922-1996) has granted the opportunity to switch from the traditional view of alcohol related problems to a multi-disciplinary, humanitarian and cultural view. The switch from one paradigm to another cannot take place slowly, it must happen just at once. This is what happened in Opatija in 1985.
The reaction to this switch was not enthusiastic. Hudolin defined alcoholism as an unwanted side effect of drinking alcohol beverages, a systemic disorder, a multi-dimensional suffering, drinking as a life style, a risky behaviour, a risk for health, certainly not “a state of complete physical, mental and social well-being” (W.H.O. 1948). Hudolin on the other hand did not want to underestimate the importance of the official medicine, and of the contribution that all the health professionals could offer to the scientific development of his model, what he was pursuing was a closer collaboration among the various actors, the doctors, the psychologists, social and cultural workers, health operators and volunteers, the model was in fact trying to put together, in an original way, a true example of inter-dependence and multi-discipline.
The provocative statement “alcoholism is not a disease” therefore should not be read literally, otherwise there is a risk to make the concept a mere commonplace, to undermine the innovation contained in the “systemic disorder” concept. Alcoholism and alcohol related problems, provoked by the consumption of alcohol beverages, do not belong to the medical level only, on the contrary, they belong to various levels, political, economical, psychological, social, behavioral, cultural, religious, spiritual, because they are all involved, being all inter-dependent, and therefore the solution of such problem relies on the community as a whole.
Hudolin used to quote the French scientist Henry Ernest Sigerist (1891-1957) who had stated “The aim of medicine is so large that it includes far more than the activity of the doctor”. To confirm this, Hudolin wrote “Whether or not alcoholism is defined as a disease (in its classical meaning), is not important. What is important is to intervene so that alcoholics modify their life style in time, before they get sick and die for an alcohol related disease”.
The bottom line was that the whole health system was invited to be more flexible, in response to the social and ecological changes that were taking place in society, acknowledging the (at the time) current development in ecological psychiatry and the study of alcohol problems. “Health system should be rewarded for the health it is offering, rather than the disease it is curing”. Even more directly, Hudolin stated “The duty to start new Clubs and to train the operators should belong to the doctors … unfortunately, the doctors are seldom aware of the possibilities offered by the Clubs and other alternative treatments….. Clubs require that treatment is de-medicalized and de-psychiatrized, this is the modern approach to alcohol related problems …. The Clubs try to take away the alcoholic from the traditional medical treatment, which usually estranges him from the community and does not offer satisfactory results”.
Hudolin therefore ignited a crisis which involved medicine, psychiatry, alcoholics and their families. As a matter of fact, alcoholics used to feel protected by the definition of alcoholism as a “classic disease”, this was allowing them to get access to hospital care the same way as other ill persons, and in addition they felt released from any responsibility for their behaviours. Doctors and psychiatrists would no longer be able to view the alcohol related suffering as pathology and symptoms, diagnosis and therapy, but they should bring into the picture the human being, with his social and familiar problems, and the opportunities to prevent them or overcome them.
Hudolin was facing a complex task: changing the Club philosophy, persuading a majority of operators that his decision was right under many aspects, moral, political, scientific, and even more complicated, this project needed to involve entire sectors of the community, if it wanted to be implemented on a large scale. Experience will show that this has proved successful only where an organized cooperation has taken place within the territorial network, involving various roles, institutional and non-institutional, professionals and volunteers, who managed to modify the old response system to an old problem like alcoholism.
Hudolin introduced as well the concept of ”ecological”, explained by the other concept of inter-dependence or “all are responsible for all” (John Paul II). In this way alcoholism finds its place among the disorders of the ecological balance of a community, and the cure can only be offered by a “community who cure”, a system which is based on significant human inter-relations, oriented to health protection, and capable of becoming a “competent community” that can recognize the problems, face them and solve them, including the alcohol related problems.
Nelson Mandela (1918-2013) stated “Education is the strongest weapon to change the world”. Similarly Hudolin insisted on the importance of organizing a training system, rooted in the community, the only way to reach out the community members and modify their life style. “When we change the health and general culture of our communities, we reach a better quality of life”.
The practical result of this revolutionary approach was that the Clubs ceased to be therapeutic groups, the therapist would disappear and would be replaced by an “operator” and then, in 1994, by a ”servant-teacher”. No therapy would be delivered any more to Club members, but the Club’s servant would ensure that the atmosphere within the Club allows the change and the servant would then be described as a catalyzer of the process.
Hudolin was certainly inspired in his thinking by Pope John Paul II, he would quote very often the Enciclica “Sollicitudo Rei Socialis” dated 1987, and the Charter for Health Operators dated 1994.
In addition to the Course of Sensibilization, Prof. Hudolin introduced in due course in the educational system the Local Alcohol Schools, deployed in three different modules, the first two dedicated to the families attending the Clubs and the third one dedicated to the local community. Aim of such schools is a better understanding of health protection and promotion. Then in 1986 Hudolin established in Trieste the European School of Alcohology and Ecological Psychiatry, in order to ensure the training of all the operators coming from various countries of Europe. In 1988, on the occasion of the 4th Italian-Yugoslavian Congress of the Clubs of Alcoholics in Treatment he promoted the project of the so called “Territorial Functional Alcohol Center” which was a light and effective way to put together the various public and private agencies already working in the alcohol field and get them to cooperate.
At the beginning of the ‘90s he was proposed as candidate for the Nobel Prize for Peace, in consideration of his contribution as a benefactor of humanity. Up until 1988 he was in charge as professor of Neurology and Psychiatry at the University of Zagreb. During his long career at the University, he wrote about 60 papers and produced about 500 written reports or researches, some of them were published by the most prestigious journals and magazines, and one can say that he was de facto proposing himself as the father of the modern ecological approach to alcohol related problems.
Even though he was not interested in collecting academic or public acknowledgements, because he was concentrating all his efforts in improving the quality of life of all the families having alcohol related problems, he has been recognized as being the creator, at least in Italy, of the “largest social experiment in mental health on large scale, considering that it has involved about 30,000 families that were mobilized for the self-promotion and self-protection of their own health. This experiment perhaps is only second in dimension to the reform of psychiatric assistance” (Corlito 1997).
Chapter 5
Vladimir Hudolin – biography (3)
“Because wars sparkle in the mind of men, it is in the mind of men that the defense of peace must be built up” (UNESCO Constitution 1945).
In 1991 a new war was ignited between Croatia and Serbia (1991-1995), with the aggression by Serbian army to Croatia. The background was the death of Josip Broz Tito in 1980 and the subsequent explosion of Serbian nationalism. When in 1990 the elections in Croatia brought to the power the Democratic Union Party (Hrvatska Demokratska Zajednica – HDZ) lead by Franjo Tudman (1922-1999), one of the first change was to establish the “Croatian National Guard” and one year later Tudman declared the independence of Croatia from the Yugoslavian Socialist Federation. Taking such position was obviously in contrast with the federal policy conducted by Belgrade and by the Serbian ethnical minority. This brought to surface again the ancient tensions between Croatian and Serbian population, that had been kept at bay by the 50-year obligated cohabitation under Tito leadership. The spreading of nationalism is the main reason for the dissolution of Yugoslavia. Within the federal army the Serbian component was prevailing, and they put in place a ferocious repression of the Croatian independence, starting in July 1991. Several Croatian cities, including Sisak, Sibenik, Zadar and Vukovar were sacked and thousands of people were tortured and killed, even among civil population, in complete disregard of international war conventions. Even the capital Zagreb was bombed, at a time when Prof. Hudolin and his wife were in Turin conducting a Course of Sensibilization. Violence went on fire everywhere, Croatians against Serbians, Catholics against Orthodox against Muslims, hundreds of thousands of unarmed citizens involved in one of the most complex, confused and bloody wars that we have ever seen in Europe.
On 21st November 1995 the Peace Agreement was eventually signed in Dayton (Ohio) and the borders were drawn among the ex-federal republics. Croatia became officially Republic of Croatia, and it recently became the 28th member of the European Union. Nothing was left of the previous founding principles of the Yugoslavian Federation, brotherhood, unity and cohesion among the various ethnical groups. The project was just too ambitious. Still today there a tensions among some of the populations inhabiting the Balkans, so that appeasement and reconciliation are still a long way to go.
At the end of the war at least 20,000 people were calculated to have been killed, 52,000 were disabled, a great number were homeless, refugees, abandoned. In addition, some 30,000 were diagnosed as victims of “war neurosis”, what we call today “Post-traumatic stress disorder”. Psychiatry was obliged to take care of such people, being an absolute emergency. Consequently, the study of alcohol related problems lost the attention it had drawn from the institutions before the war. As Prof. Visnja stated later on “In Zagreb before the war we had in operation almost 300 Clubs, and about one thousands in the whole of Croatia, today they are much less”.
In 1992 Prof. Hudolin was reflecting about this new war, which was tearing apart his country, and wrote “Thinking about my experience, throughout my life, I have tried to study the surfacing of aggressiveness, and the explosion of war. I was born soon after the end of First World War, whose consequences have lasted almost until the beginning of Second World War. The period between the two Wars has been underlined by several small and medium wars. In those years I could observe, on the walls of churches and monuments, list of people who were killed in wars getting longer and longer. Interestingly, but sadly, the majority of these wars has been described as a liberation war, and therefore a fair and holy war. In Croatia we have been liberated many times: in 1918, in 1941, in 1945, and they claim also today. If all this was true, I would have so much freedom that I could share it with all of you. But I won’t do it, because in my experience every liberation has come together with a war. We were hoping that after the injuries of the Second World War, a better social organization would prevent it from happening again, but this new war in Croatia, caused by an aggression, a never declared war, worse and more cruel than anything before, has caught us and is rolling us into the deep. Only now it seems clear to me, in the past I did not realize it. And the same is happening to many other people in my social setting, we got used to aggressions, so that we are not even perceiving them, we are almost used to accept them, even accepting a war, as a normal expression of life.
Working in psychiatry, over the years, I have come to know human suffering better, and slowly I have learnt that such suffering can only be alleviated through the protection of the societal fundamental rights, human rights, by changing the prevailing health and general culture, through the establishment of harmonious interactions in the communities, through the deployment of the conditions necessary for a peaceful cohabitation”.
During the tragedy of war, Hudolin was extensively travelling in Italy, and he was taking the opportunity of the various meetings to elaborate about the concept of peace, while his thinking was stretching more and more to a spiritual dimension. It was in this way that he organized in May 1993 the first Congress on Anthropological Spirituality in Assisi (Italy) with the invaluable collaboration of Father Danilo Salezze. This Congress has taken place once a year since. In Assisi he introduced the new orientation of the methodology “It makes no point to quit alcohol if in the meantime a real change does not start in the individual, in the family and in the community. This change requires more solidarity, friendship and love, the possibility to improve cohabitation, the fight for human fundamental rights, social equality, and eventually, the most important thing: peace”.
To explain the introduction of the concept of anthropological spirituality, Hudolin reminded us that “There is a share inside the man, that we cannot see, we cannot touch, but that we know it is existing, a share that cannot be defined in material terms, but which makes the man different from all other living creatures. I refer to emotions, to love, to friendship, to a certain number of rules of behaviour that are born with us, or are inherited, I refer to religiosity, to faith, to politics, in other words to the human behavioural characteristics, to existing human culture”.
Of course Hudolin did not refer to religiosity when he was mentioning spirituality, even though religion does take an important role in human history, but rather to an aspect that keeps together believers and non-believers, different nationalities, different ethnical origins, various political visions, something that is common to all of us and makes us to be all similar. The fact that all men are similar, he said, will allow us to recognize the needs of our neighbour, to understand each other and therefore to help each other.
Prof. Hudolin consequently believed that all territorial alcohol programmes for health protection and promotion, had to be based upon solidarity, friendship, love, upon the search for peace, and centered on changing the health and general culture, which means also changing the prevailing spirituality of our communites. He also felt the need to change that particular culture whereby “it is scientific only what can be measured, weighed, observed through a microscope, diagnosed with precise methodologies” . Hudolin did not want to neglect the importance of measuring, but underlined that what is measurable is only a part of human life. If we emphasize only the measurable, there is a risk that we consider not scientific the study of all the main characteristics which set the man apart from other living beings on our planet.
Spirituality therefore represents the conceptual bridge between the substance(s) and the importance of man, of human relations, of human values. In this way the day-to-day work takes a more general perspective, becomes an effort to change life style and to improve the quality of life of human communities.
Hudolin defined “spiritual trouble” that particular situation whereby an individual does not accept himself, his behaviour, his role in the community, does not accept the prevailing social culture and social equality. The individual in that situation feels the frustration for being unable to understand his trouble, not to mention changing it. As a consequence, the Club (and the operator inside it) had to undergo a crisis, a switch from the “simple” difficulty to change the drinking behaviour to the need to accommodate and understand the spiritual trouble, and leave enough space inside the Club, so that such trouble could be freely expressed and elaborated.
In 1994, again in Assisi, Prof. Hudolin proposed to abandon the term “operator” and switch to “servant”. “You have to be at the service of families, therefore it is more appropriate to talk about servants”. In 1996, Hudolin added that each servant should also be a teacher, thus creating the expression ”servant-teacher” which embodies his latest vision, a role that has various meanings, including responsibility, inter-dependence, love, service to life, and peace.
His latest vision was actually presented during his last attendance at an Italian National Congress, the one held in Grado in 1996, a couple of months before passing away. ”Current spirituality, or social culture, is coming short of what is needed: we can see the increase in the consumption of psychoactive substances, in the alcohol related problems, in terrorism, the spreading of wars, the lack of social equality, and many more problems. We, members of Clubs, should get involved in more initiatives to improve the quality of life of our families and our communities. Within the Clubs, we have to talk about friendship, solidarity, love, sharing, cohabitation, peace, social equality, in other words, about anthropological spirituality. This means working at community level and spreading the concept of social ecology, which means not only the protection of environment, but also that of human society. Working not only at individual level, but also at family and community level. Health cannot be protected if there is no Peace, and therefore we have to work for Peace, Peace in the interior of man, Peace in the deep of the heart of man, which then could be transmitted at family level, at community level, at national level, at planetary level. To take part in this process for peace, today and in the third millennium, we should always include a discussion about peace in every meeting or Congress. We all are not working simply for abstinence, but for families, for sobriety, for a better life, for growth and maturation, and eventually for Peace. Peace cannot be conquered if, first of all, we cannot have it inside ourselves, a peace inside our own heart ….” (Hudolin, Grado 1996).
Hudolin in this way summarized his intense and productive life, and managed to switch his suffering for the war in his homeland, and for his illness, into seeds of hope and civil engagement for all. “So that such a horror will never happen again” Hudolin, after having used this expression after the Second World Ward, had to repeat it again. He was also suffering because he was perceiving that “his psychiatry” was trying to switch back towards an organic approach, as if the complexity of human species could be reduced to the study of neurons.
After he passed away on 26th December 1996, his wife Prof. Visnja continued to take an active part in the dissemination of the alcohol related programmes, in Italy and abroad, until she also passed away, on 13thApril 2008. Today, the Clubs are represented in 32 countries and in 4 continents.
No doubt Prof. Hudolin has represented, in the scientific and humanistic panorama of last century, one of the most original presence. He can be considered an “extraordinary man” according to the definition given by the Armenian philosopher Georges Ivanovic Gurdjieff (1872-1949): “From my point of view, a man can be called extraordinary if he can be set apart from his contemporaries because of the resources of his spirit, his capacity to contain the manifestation of his own nature, and at the same time showing appropriate and indulgent understanding towards the weakness of the others”.
Similarly to other extraordinary men of his age (Gandhi, Martin Luther King, Nelson Mandela, Mother Teresa of Calcutta, Karol Wojtila and others), Hudolin had the merit to translate great theories into practical and accessible paths, towards the improvement of quality of life, of health, peace, and supporting his ideas with courage, determination and an outstanding sense of social equality.
In conclusion, I wish to quote a sentence by Giovanni Allevi, a genius of modern music, that I feel is mentally very close to the extraordinary persons that I mentioned in the story I just told you: “An idea, to be able to be implemented, must respond to a condition: even before its practical deployment, it must be crystal clear, even if apparently crazy….. then the idea will leak into the world, will flood everywhere, it will have supporters and boycotters, will provide riches and delusions, and, mind you, luck does not exist, what exists is the luck to have a strong idea, and to believe in such idea…. The first move belongs to us, to conceive an idea supported by emotion”.
Finally, Hudolin last words to the world of Clubs: “I beg you to continue working in the Clubs and in the communities, I wish you all the best, I wish you Peace, and I beg you to take the same greetings to your families and your communities”. Vl. Hudolin, Grado Congress, October 1996.
Vladimir Hudolin was born in Ogulin on the 2nd May 1922, his father was dressmaker and the mother housewife. He had one brother, who died at age 8, probably for pneumonia, and a younger sister, Lyubica, who died very recently. Vladimir’s father passed away rather young, before he was 40, for complications connected to alcoholism. This sad story has no doubt influenced Vladimir, at the time an adolescent, to get involved, once grown up, in the study of alcohol problems. The background was that, in those years, alcoholism was not considered worth being cured. Alcoholics were generally hospitalized in psychiatric hospitals, and if and when they were discharged, they could not rely on any rehabilitation programme. Therefore many alcoholics would die still relatively young.
Only in November 1935 people the Society of Alcoholics Anonymous (A.A.) was established in Akron (Ohio, USA). The creation of A.A. can be indirectly connected to Carl Gustav Jung. Roland H. approached Jung in 1931 for alcohol problems, and started a psychotherapeutic process with him, that lasted about one year. After a relapse, he called up Jung again, who suggested him to find a solution through a religious or spiritual experience. Roland H. then joined the evangelical movement “Oxford Group” and succeeded in getting rid of alcoholism. Then Ebby T. involved Bill W. who in turn had a religious experience and started to dream about a society of alcoholics, who were exchanging their own experiences among themselves. That’s how the A.A. were established, whose subsequent development is well known. (H.F. Ellenberger, 1976, Boringhieri)
Since he was an adolscent, Vladimir Hudolin was highly dedicatyed He was one of the best students at the Grammar School in Sudak, then he became member of the youth catholic association “Domagoj”. Once completed the high school in 1940, following his humanistic and scientific aspiration, he moved to Zagreb where he attended the Medicine and Surgery Faculty. Despite the difficult historical period, he got a brilliant degree in 1948.
IN 1941, during the second world war, with the support by the Italian Fascist Government and of the German Nazis Government, Croatia self-proclaimed the independent republic of Croatia, that included also Bosnia and a small part of Serbia. Chief of the Croatian Republic was the dictator Ante Pavelic (1889-1959), well known for his repression of Serbians, Jewish, Gypsies.
During this difficult period, Hudolin was arrested and sentenced for political reasons, as he was indeed opposing the Ustasha regime (as revealed to me by Dr. G. Corlito). At the end of the war, in 1945, Croatia became member of the Federal Socialist Republic of Yugoslavia, with Zagreb as capital. After his degree, Vladimir Hudolin got his specialization in 1951 in neuropsychiatry, and started to operate as assistant medical doctor in the Mladen Stojanovic hospital. In that hospital he met the colleague Dr. Visnja, whom he married in 1952. They had one child (Ivica) who unfortunately did not survive. Visnja will stay behind him for his whole professional life, supporting him and promoting the development of the social ecological approach to alcohol related and mixed problems.
The war has stimulated the movements that, later on, have developed the social work, the idea of therapeutic community and group psychotherapy. The social development needs the elimination of all repressive policies, as they are also eliminated by the society. Psychiatric treatments in those years were very similar to Nazis camps, they were containing those ideas against which humanity had been fighting during the war. People suffering by mental illness were the first victims of Nazis regime. (Hudolin 1985).
Hudolin had his professional training in the 1950s according to the psychoanalytical model in Great Britain and Sweden, where in 1953 he specialized in electroencephalography under a WHO scholarship.
Especially in the United Kingdom he managed to have access to the best training levels of that time. He worked with:
Melanie Klein (1882-1960), psychoanalyst at the Tavistock Clinic in London, student of Prof. Sandor Ferenczi
Joshua Bierer (1901-1984), psychiatrist at the Marlborough Day Hospital in London, who created the “social clubs” for psychiatric outpatients and relatives
Maxwell Jones (1907-1990), psychiatrist and psychoanalyst at the London Belmont Hospital, who first developed the concept of the therapeutic community (or healing community)
Franco Basaglia (1924-1980), anthropo-phenomenological psychiatrist, director at the Gorizia psychiatric hospital and inspirer of the Italian psychiatric reform law.
Hudolin spent some time at the Belmont Hospital as a trainee and as Maxwell Jones’ pupil. He participated in group work with Melanie Klein at the Tavistock Clinic. He worked in the outpatients and relatives socio-therapic groups with Joshua Bierer. He worked then in several other specialized facilities in London, Leeds, Aberdeen, etc.
He also cooperated with Franco Basaglia, with Jules Masserman, psychiatrist and psychoanalyst from Chicago, president of the American Psychiatric Association and the American Society for Group Therapy, with Prof. William Gray from Boston, author of the well-known “General systems theory and psychiatry”, etc.
A great contribution in the development of a new Psychiatry was given by Clifford Beers (1876-1943), the founder of Mental Hygiene movement, who published his book “A mind that found itself. An autobiography” in 1908
Immediately after the second world war the movement “Open door policy in psychiatry” started in some European countries. It proposed the removal of barriers to mental hospitals, the release of psychiatric patients from various coercive measures, the introduction of the community therapy, group therapy, and the adoption of new psychotropic drugs in the treatment of patients.
Therapeutic community
“…a group of people who gather with a common purpose and who have a strong motivation to bring about some change. The purpose of the therapeutic community is growth, understood as an individual and social process. Its task is to help an individual to achieve his potential” (Maxwell Jones)
The first therapeutic community was created in 1947 by the psychiatrist Maxwell Jones at the Henderson Hospital in London, with the aim of involving the patients and making them aware of their responsibilities on the management of psychiatric institution in which they were housed. His idea was transforming a strictly hierarchical institution, based on “vertical” relationships, into a “horizontal” organization with an equal relationship between residents and health professionals.
Shortly thereafter the psychiatrist Don Jackson founded in Palo Alto, California, the Mental Research Institute (MRI). At MRI the work of several outstanding personalities offered a decisive contribution to the understanding of the pathogenesis of schizophrenia and founded the principles of brief psychotherapy and systemic family therapy.
Paul Watzlawick (1921-2007) and Gregory Bateson (1904-1980) were among the most illustrious representatives of MRI. They proposed a revolutionary approach to mental disorders with new psychotherapeutic instruments, alternative to psychoanalysis.
Jacob Moreno (1889-1974), a student of Sigmund Freud in Vienna, emigrated to the USA in 1926; he introduced the expression and the model of “group psychotherapy” and eventually founded the psycho-dramatic movement. Harry Sullivan (1882-1974) founded the Chicago School of interpersonal psychiatry, or social relations psychiatry.
In those years the systemic approach grew up, inspired by the general theory of systems by Austrian biologist Ludwig Von Bertalanffy (1901-1972). This approach considers the possibility of overcoming complex problems (mental disorders, alcohol-related problems) by expanding the field of observation to socio-environmental background. Each individual is part of different systems, the simplest of which is family, understood as a nucleus of people tied by significant emotional relationships. Even when there are problems, conflicts that trigger anger and aggressiveness, these relationships remain significant.
In the same period, in Italy, Franco Basaglia (1924-1980) was experimenting therapeutic community in the Gorizia psychiatric hospital. The basic concept, innovative at the time, was the categorical rejection of institutionalization as the only means of treatment and recovery of mental suffering. The closure of the asylums was, in Basaglia’s intention, only a first step towards a socio-cultural change, that is social acceptance of insanity. The experiment, started in 1962 by Basaglia, brought, about 15 years later, to the Italian law 180/78 (also known as Basaglia Law), which provided for the transformation of so-called “asylums” in treatment, and no longer confinement places. In fact, only after 1994 the legal provision of definitively closing mental hospitals was fully achieved in Italy.
“Reading again passages from the writings of Hudolin and those of Basaglia you are struck by the extraordinary similarity of their concepts, it would be enough to replace the word “mentally ill” with the word “alcoholic” to read the same concepts” (Visnja Hudolin, 2006).
After his fruitful period spent in England, Hudolin got back to Zagreb and thanks to his rich professional experience was appointed vice director of neuropsychiatric dept. at Mladen Stojanovic hospital. Despite some strong resistance in the beginning, he introduced there the so called ”open door policy in psychiatry”, in order to change the rigid hospital organization into something more flexible, where the alcoholics should be kept separated from the psychiatric departments, should be involved and made responsible for the organization of the hospital set up and work. This ambitious project was opposed by the traditional psychiatry, even though the new ideas were spreading all over the world and were contaminating a number of professionals.
“In any psychiatric hospitals the alcoholics were many, almost 50% of people being hospitalized. At one stage the director of Neuropsychiatry decided to afford my husband, who was 37 at the time, the direction of the Psychiatry Dept. so that he found himself relatively free to make his choices. I remember the day when he decided to open the doors of the department, which was part of a huge hospital structured on 4 stories and many other departments. The other directors and doctors were all very concerned “It is not possible to make this, we will be all killed !!” In fact, none was ever killed”. (Visnja Hudolin, La Magnolia è fiorita, 2006)
“When my husband introduced this new approach, he had to face many difficulties. Every new step is regarded suspiciously, people believe the old way is safe and is more positive. In the psychiatric dept. the alcoholics were admitted for 3-4 weeks, they would stop drinking, then were discharged, but after a month or two, were coming back again. Therefore he decided to change the organization of his clinic, implementing the principles of the therapeutic community, and starting small groups which he called Clubs, because there was no service offered to people being discharged by the hospital”.
(Visnja Hudolin, La Magnolia è fiorita, 2006)
Hudolin was thinking that alcoholism was a special kind of disease, which needed a specific care, different from those utilized for the other patients in his service. In the meantime, he, together with Joshua Bierer and Jules Masserman, started the social psychiatry movement. Social psychiatry had the ambition to bring the whole family, as part of the society, inside the psychiatric system, which means extending the psychiatric treatment to the community. The methodology was: shutting the psychiatric hospitals, organize the treatment in the community, by setting up small groups, that would include family members, utilizing the systemic approach. Social psychiatry means, first of all, family approach.
Alcohol related problems in this vision, should not be considered anymore as an individual behaviour, but a family behaviour, all the family members should no longer delegate the doctor or some other professionals to find them a solution, but become the actors of the change. In addition, because the problem is not only a health problem, there was no need for medical treatment. Hudolin realized that for a family with alcohol related problems, it was best to join immediately a Club. This is what happens still today in most countries.
When the Department for Alcohol Problems was started in 1964, also the first Club was started. The servant-teacher (at the time dubbed “therapist”) was and still is today a social worker called Stefiza, which means “Little Stephanie”.
(Visnja Hudolin, La Magnolia è fiorita, 2006)
The Club’s life in the beginning proved to be quite difficult. Official medicine would not accept such a revolutionary approach, or better, it would not accept a programme meant for the alcohol related problems outside the hospital or other health institutions.
Soon a new Club started in the centre of Zagreb, and then in other areas of the city, and then in other cities, in Slovenia, Voivodina, Macedonia, Montenegro and so on. The family approach is not easy to introduce in many branches of science. Family members think they are all right, only the sick person needs a treatment, therefore at the beginning they do not realize which is their role in the treatment. But we believe in psychiatry the family approach is even more important than in alcohol problems.
Clubs of Alcoholics in Treatment work according a systemic approach. This means identifying alcohol related problems and their consequences within the same bio-social system where the man lives and works…. In this way it is easy to understand why the Club addresses first of all the family. Changing behavior, or life style, is not possible, outside such system. Sometimes we find resistance, both by the alcoholics and by the family members, this is why the whole family must be initially trained, and then updated from time to time. Clubs cannot operate if the whole family does not attend the treatment, when part of the family is missing, we start having difficulties.
(VL. Hudolin 1993).
Initially Hudolin used to describe alcoholism as an “alcoholic disease” or “alcohol dependence” even though he realized that the majority of the consequences were not of medical nature. For this reason, Prof. Hudolin involved many professionals (doctors, nurses, social workers, volunteers), trained personally by himself, in both the hospital and the Club activities.
Another ambitious target for Hudolin, since the very beginning, was to develop scientific researches to evaluate the results reached with the treatment, and make it more effective. In fact, over the years, Hudolin adjusted the methodology according to scientific research and not only to the changing characteristics of alcohol problems.
1985 has been a turning point for his vision. At that time Prof. Hudolin was still Director of the Neurology and Psychiatry Clinic, and professor in the same Faculty at the University of Zagreb. He was also still collaborating with the WHO for mental health and since 1979 was also involved in the development of the alcohol programmes in Italy, where he was collaborating with several institutions.
During the Italian-Yugoslavian Congress of the Clubs of Alcoholics in Treatment, in Opatija (Istria), he introduced the concept of life style. Such renewed approach included at the time (and still includes today) the following reference-points:
- Alcoholism is an unwanted, side-effect of drinking
- Alcoholism is a specific tie between the man and alcohol. The solution of the clinical complications arising from alcoholism belongs to the medicine
- Alcohol related problems, including alcoholism, are disturbances of the behaviour, with high prevalence and incidence, so that a huge part of the population is affected
- Psychoanalysis, family therapy or group therapy can only be applied to a small number of people and not to such huge numbers
- Every human being belongs to a social group, first of all to a family, which is a wider system compared to the individual, while the family is a sub-system of the community system, and so on until we define the whole society as systems and sub-systems
- Alcoholism is therefore a systemic disturbance, it has to do with the whole system where the individual has some relations
- Alcohol related problems, including alcoholism, are the expression of the family life style, a concrete, day-to-day complex of relations
- Changing the life style within a family cannot be defined as “cure”
- Differentiating between use and abuse does not make any sense
- The Club of Alcoholics in Treatment (CAT) is the backbone of the territorial alcohol programmes, is a rather simple project and has proved to be effective wherever it has been replicated
- CAT is based on the principles of the Therapeutic Community, but is something different, in so far as it is integral part of the local community
- CAT is a human laboratory where it is possible to change one’s life style without compelling him to migrate from his own social setting
- In a CAT the interactions and cross-relations empower the people to “cure” the problems and prevent further problems offering a reference point for a real change
- Within a CAT the family can develop a new culture based on sharing, and gradually can become part of the local community
The scientific development of Hudolin Methodology
A scientific method is a set of criteria (both theoretical and operational) whereby a theoretical or experimental outcome can be considered as scientific. Basic point is that, given the same materials and methods, the experiment can be replicated anywhere, so that it can be studied by other scientists. Scientific development is a path where new elements are being added at each step.
“Understanding is the essence of what is obtained from intentionally learned information and personally lived experiences. On the contrary, knowledge is the mere automatic memory of a sum of words learned in a certain order” (George Ivanovic Gurdjieff, 1872-1949)
Since 1964 in Zagreb, through the Opatija Congress in 1985, until these days, the spreading and dissemination of the Club of Alcoholics in Treatment, the accumulation of their experience, have confirmed the effectiveness of the Hudolin’s model and its capacity to be easily replicated. The concept of Social ecology is still very much up to date, with its theoretical links (General System Theory, Psychoanalysis, Therapeutic Community, Socio-therapeutic Clubs, Alcoholics Anonymous, Social psychiatry etc.) and it has proved to be a milestone in the modern scientific evolution.
The meaning of Hudolin’s scientific revolution
Science is a fragmented process where new elements are continuously added to the picture, new theories are advanced, which stimulate new researches.
The statement “alcoholism is not a disease” was justified, according to Hudolin, by the fact that the traditional methodology in curing alcoholics was obviously not effective. This change of perspective, or “paradigm shift” (Thomas Kuhn – 1922-1996) has granted the opportunity to switch from the traditional view and redefine alcohol related problems. The switch from one paradigm to another cannot take place slowly, it must happen just at once.
This is what happened in Opatija in 1985.
In 1991 a new war was ignited between Croatia and Serbia (1991-1995), with the aggression by Serbian army to Croatia. The background was the death of Josip Broz Tito (1892-1980) and the subsequent explosion of Serbian nationalism. At the end of the war at least 20,000 people were calculated to have been killed, 52,000 were disabled, a great number were homeless, refugees, abandoned.
“In Zagreb before the war we had in operation almost 300 Clubs, and about one thousands in the whole of Croatia, today they are much less”. (Visnja Hudolin, 2006)
“Thinking about my experience, throughout my life, I have tried to study the surfacing of aggressiveness, and the explosion of war. I was born soon after the end of First World War, whose consequences have lasted almost until the beginning of Second World War. The period between the two Wars has been underlined by several small and medium wars. In those years I could observe, on the walls of churches and monuments, list of people who were killed in wars getting longer and longer. Interestingly, but sadly, the majority of these wars has been described as a liberation war, and therefore a fair and holy war. In Croatia we have been liberated many times: in 1918, in 1941, in 1945, and they claim also today. If all this was true, I would have so much freedom that I could share it with all of you. But I won’t do it, because in my experience every liberation has come together with a war. We were hoping that after the injuries of the Second World War, a better social organization would prevent it from happening again, but this new war in Croatia, caused by an aggression, a never declared war, worse and more cruel than anything before, has caught us and is rolling us into the deep.
Only now it seems clear to me, in the past I did not realize it. And the same is happening to many other people in my social setting, we got used to aggressions, so that we are not even perceiving them, we are almost used to accept them, even accepting a war, as a normal expression of life.
Working in psychiatry, over the years, I have come to know human suffering better, and slowly I have learnt that such suffering can only be alleviated through the protection of the societal fundamental rights, human rights, by changing the prevailing health and general culture, through the establishment of harmonious interactions in the communities, through the deployment of the conditions necessary for a peaceful cohabitation”. (Vl. Hudolin. Umago 1992)
During the tragedy of war, Hudolin was more and more elaborating the concept of peace, while his thinking was stretching more and more to a spiritual dimension.
“It makes no point to quit alcohol if in the meantime a real change does not start in the individual, in the family and in the community. This change requires more solidarity, friendship and love, the possibility to improve cohabitation, the fight for human fundamental rights, social equality, and eventually, the most important thing: peace”.
(Vl. Hudolin Assisi 1993)
Finally:
“I beg you to continue working in the Clubs and in the communities, I wish you all the best, I wish you Peace, and I beg you to take the same greetings to your families and your communities”.
Vl. Hudolin, 1996.
After Prof. Hudolin passed away (26th December 1996) as well as his wife Visnja (13th April 2008), the alcohol community programmes have been carried on, Clubs are active in 28 countries in the world and in 4 continents.
“An idea, to be able to be implemented, must respond to a condition: even before its practical deployment, it must be crystal clear, even if apparently crazy….. then the idea will leak into the world, will flood everywhere, it will have supporters and boycotters, will provide riches and delusions, and, mind you, luck does not exist, what exists is the luck to have a strong idea, and to believe in such idea…. The first move belongs to us, to conceive an idea supported by emotion”.
(Giovanni Allevi, La musica in testa, 2008)
The field that Vladimir and Visnja have planted with trees many years ago, is still growing.
“…often I am being critic because in our system we usually get to know only some slides of the Hudolin production. It is something like the red booklet by Mao, we wave like a flag only some bits and pieces of a great heritage that we should study in its entirety. It is an invaluable heritage, and a lot of questions could be answered, if we knew well the whole process. We had the venture of being small dwarfs laying on a giant’s shoulders, this is our great advantage”
(G. Corlito, Cagliari 2011)
Appendix
Biographical notes about the persons mentioned in the book
Ludovico Ariosto (1474-1533). The great Italian renaissance poet included in his “Orlando Furioso” (1516-1532) the story of the knight Astolfo, who is sent to the moon to retrieve the lost sense of his friend Orlando, by inhaling it from a special bulb, which is the symbol of the transience of human reason.
Franco Basaglia (1924-1980). Italian psychiatrist and neurologist, reformer of psychiatric discipline in Italy and inspirer of the Law 180. Trained according to the existential-phenomenological model, he was particularly interested in the critique of “total institutions” by authors such as Foucault and Goffman. In 1961 he was appointed director of the psychiatric hospital of Gorizia. There he decided to reform the hospital, by experiencing a therapeutic community modeled on the one created by Maxwell Jones in Britain. In particular, all forms of physical restraint and electroconvulsivant therapy were eliminated, and the gates of the departments were opened. This experiment marked the beginning, for the Italian psychiatry, of calling the traditional models into question. Basaglia later worked in Parma and especially in Trieste. Based on these experiences, he developed progressively the belief that it was not sufficient to improve the conditions of the patients within the psychiatric hospital, but it was necessary to get to the total closure of asylums and their replacement with a network of external services, integrated into the community. According to his conception, psychiatry had in fact to cease playing a role in the exclusion of the “mentally ill”, that was commissioned by an ideological system convinced it can deny and cancel its own contradictions by putting them away from itself and marginalizing them. In 1973 he founded the movement “Democratic Psychiatry”. Thanks to his work, the Italian psychiatric reform law (Law 180/78) was approved in 1978, which marked the passing of the psychiatric hospital and the implementation of mental health community services.
“Madness is a human condition. Madness is inside us as much as reason. The point is that a so called civil society should accept madness as much as reason, instead it instructs a science, psychiatry, to translate the madness into a disease in order to eliminate it. The asylum has here its own raison d’être, which is exactly to make the irrational rational. In fact, when someone enters a mental hospital, he ceases to be crazy to become ill, and so he becomes rational because of being ill”. From Che cos’è la Psichiatria (What is Psychiatry), 1967
“It may happen that the asylums will revert to be closed and more closed than before, I do not know”. From Lezioni brasiliane, (Brazilian Lectures), 1979.
References:
– L’istituzione negata (The Denied Institution), Einaudi,1968.
– La maggioranza deviante (The Deviant Majority, Einaudi, 1971 (with Franca Ongaro).
– Scritti (Works) (voll. I and II), Einaudi, 1981-82 (Franca Ongaro ed.).
Gregory Bateson (1904-1980). British scientist and philosopher . His activity went through and unified fields of study traditionally considered separated, such as biology, anthropology, ethology, cybernetics, psychology, communication theory. He was son of the important geneticist William Bateson, and a pupil of the anthropologist Bronislaw Malinowski. His wife was the well-known anthropologist Margaret Mead. In 1939 because of the war he moved to the United States. There he took part in the studies which gave rise to the so-called Palo Alto Group and to the “double-bind” theory in the genesis of schizophrenia. He is considered the father of systemic family therapy. The basic principle of Bateson’s conception is that it is not possible to distinguish in a clear way the organism from the environment in which it lives. For this reason, human beings are not external observers of the biosphere, but a component of the biological universe, inexorably linked to all the others. His book Steps to an Ecology of Mind includes, inter alia, an interesting systemic reinterpretation of the Alcoholics Anonymous methodology.
“The beautiful and the ugly, the literal and the metaphoric, the sanity and madness, comical and serious… all these and even love and hate are matters that science presently avoids. But in a few years, when the split between problems of mind and problems of matter ceases to be a central determinant of what is impossible to think about, they will become accessible to formal thought”. From Angels Fear: Towards an Epistemology of the Sacred, 1987.
References:
– Steps to an Ecology of Mind: Collected Essays in Anthropology, Psychiatry, Evolution, and Epistemology, University of Chicago Press, 1972.
– Mind and Nature: A Necessary Unity, Hampton Press, 1979.
Clifford Whittingham Beers (1876-1943). Founder of the American mental hygiene movement. In the course of his life, Beers was hospitalized for long periods of time in various psychiatric institutions, where he was a witness and victim of serious ill-treatment by staff. In 1908 he published his experiences in the book A Mind That Found Itself, which soon became a best seller and raised a national protest movement. From then on, Beers devoted himself, with the support of a part of the medical profession, to the reform of psychiatric care in his country and in 1913 he founded the first outpatient psychiatric facility. He was the founder of the American Society of Mental Health.
Ludwig von Bertalanffy (1901-1972). Austrian scientist, known for having codified the General System Theory. After studying biology, he joined the famous group of scientists and philosophers known as the “Vienna Circle”. After the Second World War he moved to Canada. The General System Theory, as opposed to the mechanical model (which traces back the properties of a whole to its individual parts), deals with the formation and properties of a system as such, that is different from the simple sum of its components. As such it is applicable, and it has been applied, to various fields of natural and social sciences, such as cybernetics, history, psychology, psychiatry, sociology, etc.. Its introduction into psychiatry dates back to 1965 (William Gray); introduction into alcohol studies is due to Vladimir Hudolin.
Reference:
– General System Theory, George Braziller, 1968.
Joshua Bierer (1901-1984) psychiatrist born in Austria, he moved to England after the Nazis took the power. He has collaborated with the great psychoanalyst Alfred Adler and is considered a pioneer of social psychiatry. In fact, he launched in 1940 the work in small groups for psychiatric patients, called “Social clubs”, both for patients inside the hospital, and those already discharged by the hospital. The Clubs were organized as autonomous groups, they were electing the members on duty, and were publishing a journal. The hospital staff could only attend the meetings upon invitation by the Club. Bierer used to experiment in the group work also the therapeutic community technique and that of team work. In 1946 he established in Hampstead (North London) the first psychiatric Day Hospital in the world. He had drawn some of his ideas from his experience in the kibbutz (Israel). His contribution to the development of social psychiatry, although relatively less known than others, has been fundamental.
Bill & Bob. William G. Wilson (1895-1971), financial promoter from New York, ruined by the big 1929 crisis, and Bob Smith (1879-1950), surgeon from Ohio, have established the Alcoholics Anonymous organization, in Akron (Ohio) on 10th June 1935. The wives, Lois Wilson and Anne Smith, in turn established Al-Anon, addressing the family members of alcoholics.
Wilfred Bion (1897-1979). British physician and psychoanalyst. He made his first professional experiences during the Second World War at the Northfield military hospital, where he began to develop his theories on therapeutic groups. Group treatments experimentation originated, at the time, from the need to effectively and efficiently manage the clinical needs of a large number of traumatized soldiers, against the availability of few therapists. He then undertook a psychoanalysis with Melanie Klein in 1945 and quickly became a leading figure in the British Psychoanalytical Society. Although after the 50s Bion did not work anymore with therapeutic groups, his perception of the individual as firmly rooted in the group permeates all his subsequent work as a psychoanalyst.
Reference:
– Experiences in Groups, Tavistock, 1961.
Louis-Ferdinand Céline (1894-1961). Medical doctor and writer, has been one of the most important French authors in the 20th century. His graduation thesis, written in 1924, was also his first literary study, where he tells the story of Dr. Ignaz Philipp Semmelweis.
Vincenzo Chiarugi (1759-1820). Doctor born in Florence (Tuscany) he was charged in 1789, by the Grand Duke of Tuscany, of the direction of Bonifazio Hospital, dedicated to people suffering from dementia. He introduced innovative methods, in parallel with the activity of Dr. Pinel in France. In 1794 he wrote the treatise “About madness, kinds and species” inspired by humanity and rationality. He was among the first to define mad people as unhappy and unlucky, not as sinner or deviated.
Jean-Étienne Dominique Esquirol (1772-1840). French psychiatrist, educated by Philippe Pinel, in 1801 he started the first maison de santé (healthy house), a private recovery centre. He was the first teacher in psychiatry in French language. Between 1801 and 1817, Esquirol decided to visit all the psychiatric structures in France, bearing his own costs, and wrote a report to the Minister of the Interior, where he described the terrible conditions affecting the people suffering from mental health. Such report became the basis of a whole reform of mental health in France, which lead in 1838 to the launching of the Psychiatric Assistance Act, a law that would remain in force in the country until 1990. It would implement the medicalization of mental health, which would prevent the patients from being abused by the Police as before.
Sandor Ferenczi (1873-1933). Hungarian psychiatrist and psychoanalyst, he was a pioneer of psychoanalysis in his country and one of its most outstanding exponents worldwide. The key point of his work was the reflection on the origin of the traumatic neurosis, and on child abuse, which had a great influence on further psychoanalytic developments. Analyst and teacher of Melanie Klein, he was the inspirer of the so-called “group of the Hungarians” (which included, besides Klein herself, outstanding psychoanalysts such as Michael Balint and Franz Alexander). This group was considered the most creative and innovative wing of the psychoanalytic movement, because it aimed to extend the findings of psychoanalysis to group therapy and social psychiatry. Ferenczi was the founder of the prestigious “International Journal of Psychoanalysis”.
Reference:
– The Clinical Diary of Sandor Ferenczi, Harvard University Press, 1995.
Siegfried Heinrich Foulkes (1898–1976). German doctor and psychoanalist, he moved to England as a refugee in 1933. In 1942 he was working at the Northfield Military Hospital, where, together with Wilfred Bion, he implemented innovative methods, in parallel with the experiences carried on by Maxwell Jones. He experimented group psychotherapy, and therapeutic community. In 1952 he established in London the Society of Group Analysis. He would consider the basic social groups (family, culture, society) as the fundamental factors which would model the personal identity of each individual.
Sigmund Freud (1856-1939 ). Austrian neurologist and psychoanalyst, founder of psychoanalysis. Born in a Jewish family, Freud lived and worked in Vienna along almost the entire course of its existence. After his first professional experiences as a neuropathologist, since 1895 he became mainly interested in the scientific study of the unconscious psychic phenomena. For this purpose he used at first hypnosis, and later the analysis of phenomena such as dreams, slips of the tongue, neurotic symptoms and “free associations”. Based on his findings, Freud developed the method of treatment of mental disorders which he called psychoanalysis (see above). Despite strong opposition and distrust of traditional academia, psychoanalysis rapidly acquired a great reputation, especially in Britain and the United States, that welcomed a large number of psychoanalysts fleeing Nazi persecution. For the same reason in 1938 Freud emigrated to London, where he died the following year. Despite the large number of different theories, currents and schools developed over the years, Freud still remains the key figure of psychoanalysis.
References:
– A General Introduction to Psychoanalysis, Liveright, 1920 (Or. Ed. 1916-17).
– Civilization and Its Discontents, Penguin, 2002 (Or. Ed. 1930).
Mohandas Karamchand Gandhi, dubbed the Mahatma (1869-1948). Indian politician and philosopher, he is the father of modern India. Educated in England, in his youth he was the head of Indians’ civil rights movement in South Africa. He successfully experimented the non-violent practices denominated satyagraha (“true force”). Back in India in 1915, he could see and share the miserable living conditions of his compatriots, and he became the leader of the anti-colonial movement. The target was the total independence (political, financial and spiritual) of his country from Great Britain. The fight for independence lasted 30 years during which he frequently used to go on a hunger strike (fasting), was practicing the boycott of English goods and institutions, or civil disobedience, which meant refusing to obey to laws and regulations that he considered unjust, and take the relevant punishment without resistance. Gandhi in addition strongly opposed the existing division of his country by religion or classes, and was fighting constantly ignorance, poverty and alcoholism. Being a deeply religious spirit, he maintained throughout his life a personal life style inspired by simplicity and frugality. Once India became independent (1947) Ghandi was recognized as the founding father of the new state and a spiritual authority in the whole world. He was killed the subsequent year by a Hindu fanatic. The importance of Gandhi heritage goes much beyond his successes as a politician, he has been an inspiration for all non-violent movements, and for the defense of civil rights. He has been considered one of the highest expression of human spirituality, because of his deep philosophical conception and the capacity to remain coherent between the ethics he preached and his own personal behavior.
“I am prepared to die, but there is no cause for which I am prepared to kill”
Reference:
– The Essential Gandhi: An Anthology of His Writings on His Life, Work and Ideas. Vintage Books, 2002 (Louis Fischer Ed.).
William Gray. Psychiatrist from Boston, he was the first one to introduce in psychiatry, in 1965, the study and implementation of the general system theory. Since 1975 he collaborated with Hudolin, taking part to various seminars in Zagreb illustrating the application of System Theory to alcoholism study.
Reference:
– General System Theory and Psychiatry, Little, Brown,1969 (Gray W., Duhl F.J. and Rizzo N.D. Eds.).
Georges Ivanovich Gurdjieff (1872-1949). Armenian philosopher, writer and mystic. His teaching combines Sufism and other religious traditions in a set of psychophysical techniques designed to facilitate the overcoming of automatic psychological and existential automatisms that affect the human being. The fundamental teaching of Gurdjieff is that human life is flowing in a state of apparent waking very similar to dream. To transcend the sleep (or dream) state, he elaborated a specific “work on oneself” in order to obtain a higher level of vitality and self-awareness. After recruiting a large number of students and disciples among whom were people of some significance, he founded a school for spiritual development, called the Institute for the Harmonious Development of Man.
Reference:
– Meetings with Remarkable Men, Dutton, 1963.
Visnja Hudolin (1923-2008). Neuropsychiatrist from Croatia. After getting a degree in Medicine in 1949, she worked at the “Mladen Stojanović” hospital in Zagreb, neuropsychiatric department. There she met Vladimir Hudolin, and the two got married in 1952. She has been active as clinician and researcher in the field of neuropsychiatric diseases, in 1960 she became head of the neuropsychiatric department at the University (faculty of Neurology, Psychiatry and Dependences), role that she maintained until retirement (1982). She specialized over the years in social psychiatry, study of addictions, alcohol related problems. Collaborating with Vladimir Hudolin, she offered a strong contribution to the development of the social-ecological approach, often taking a role of stimulus, orientation and supervision of the alcohol programmes in various countries, a role that she carried on also after Hudolin passing away (1996) representing for the world of the Clubs a continued reference for growth and success.
Magnus Huss (1807-1890). Swedish doctor, professor at Karolinska Institutet in Stockholm. Well known for having introduced the term “alcoholism”, defined as a disease of the nervous system, typically relapsing, with psychic and physical symptoms. In reality, Huss attributed such syndrome to people that used to drink only spirits, a misconception that is still affecting many doctors in the 20th century.
Donald deAvila Jackson, better known as Don Jackson (1920-1968). American psychiatrist, one of the pioneers in the field of family therapy. Educated with Sullivan, he collaborated with Bateson, Weakland, Haley and Fry, in the study of the system theory and of the brief intervention in psychotherapy with systemic approach, as an alternative to traditional psychoanalysis. One of the results of such studies was the so called “double link” theory, in the genesis of schizophrenia. In 1958 he established (and directed) the Mental Health Institute, which became the heart of the Palo Alto School, point of reference for the whole world for the systemic therapy.
“A phenomenon remains unexplainable as long as the range of observation is not wide enough to include the context in which the phenomenon occurs”. From Pragmatics of Human Communication.
Reference:
– Pragmatics of Human Communication. W. W. Norton, 1967 (with P. Watzlawick and P. Beavin).
Elvin Morton Jellinek (1890-1963). American physiologist and bio- statistic, educated in the best european universities, he made many researches in Africa and Central America, then worked for long time in Geneva as collaborator of the W.H.O. for alcoholism. From 1941 till 1952 he worked at Yale University in the first center entirely dedicated to the research on alcoholism ever created (well known today as Rutgers Center). The center was the first to offer a sort of Day-Hospital for alcoholism. He conducted some of his research together with the organization of A.A. His book “The disease concept of alcoholism” represents still today a milestone in the medical concept of alcoholism.
Maxwell Jones (1907-1990). British psychiatrist born in South Africa, he has been active in the U.K and in the States. He is recognized as the father of therapeutic community. Similarly to Hudolin, he lost his father for alcoholism when he was very young. Educated in Scotland between the two wars, he worked in the British Army during the Second World War, mainly at the Mill Hill Hospital and subsequently taking care of the ex-prisoners at Dartford Hospital. In this activity he had to face an enormous amount of mental disorders caused by the war, with a lack of competent therapists, which pushed him towards the research on group treatment and community treatment. He was convinced that psychiatric hospitals should be entirely re-organized, to become less hierarchic and more interactive, In 1947 Jones was charged by the British Government to manage the “industrial neurosis Unit” at the Belmont Hospital (subsequently renamed Henderson Hospital), a structure dedicated to patients chronically unemployed and with problematic social inclusion. In this setting Jones could fully deploy the therapeutic community model, which he had partially tested before. He was then consultant for the W.H.O. in the field of rehabilitation, then from 1962 till 1969 he directed the Dingleton Hospital in Scotland, then he spent the rest of his life in North America.
Reference:
– The Process of Change, Routledge & Kegan Paul, 1982.
Carl Gustav Jung (1875-1961). Swiss psychiatrist, psychoanalyst and anthropologist. His technique and theory, originated from psychoanalysis, is called “Analytical Psychology” or “Depth Psychology”. Initially close to Freud’s views, he left them since1913, expanding the analytical research field from the history of the individual to the history of the human community, and postulating the existence of a collective unconscious as well as the individual one.
References:
– Two Essays on Analytical Psychology, Psychology Press, 1966 (Or. Ed.. 1928)
Martin Luther King (1929-1968). Protestant clergyman, politician and activist in the United States, leader of the movement for afro-americans civil rights. Born in Atlanta, since 1955 he had a role in fighting racial segregation, at the time still practiced in the southern states.
Some of the provisions of such segregation were the schools, public buildings, and even toilets and fountains separated for black and white, the prohibition of mixed marriages.
The fight for civil rights culminated with the “March for freedom and work” held in Washington in 1963, in front of President John Kennedy (1917-1963). During the March. King made the famous speech “I have a dream”. Inspired by Gandhi, King promoted the use of non-violent demonstrations (boycott, sit in, civil disobedience etc.) and was against the Vietnam war. Like Gandhi, he was killed by a fanatic, in Memphis in 1968. But by then, his fight had been successful and the segregationist laws had been abrogated.
Melanie Klein (1882-1960). Austrian psychoanalyst, she lived a long time in Hungary, where she was patient and student of Sandor Ferenczi. In 1926 she settled in London. In comparison with Freud’s ideas, Melanie Klein stressed the importance of the earliest stages of human life. Her importance is related to her studies in the field of child psychoanalysis, in which she developed the technique of the game, and to the development of object relations theory, according to which the child’s inner world is populated by fantasies and unconscious representations of external “objects”, such as the mother’s breast. The psychic life and the unconscious impulses of the child eventually develop around these representations. Despite the controversies aroused by her theories, Klein was one of the most influential personalities of the psychoanalytic movement, of which she became in the ’40s and ’50s the most important exponent in Britain.
References:
– Envy and Gratitude, Hogarth Press, 1957.
– Narrative of a Child Analysis, Hogarth Press, 1961
Thomas Kuhn (1922-1996). American philosopher, in his outstanding literary work “Structure of scientific revolutions” (1962), claimed that scientific progress is not made by a progressive accumulation of knowledge, tending towards truth, but is an alternate process between “normal science” and “scientific revolutions”, where the latter in turn determine, over time, changes to the basic criteria. A paradigm consists of theories, laws and tools which define the traditional way in which the research is being done. New theories, if they fall within such paradigm, are easily accepted by the believers in the paradigm. But a scientific revolution happens when new observations cause an outbreak of a crisis of the previous paradigm, if such paradigm is unable to explain the new observations. This change of perspective, or “paradigm shift” will set up a new paradigm which will replace the old one and will be initially accepted by a sufficient number of scientists and then gain universal support.
Cesare Lombroso (1835-1909). Italian medical doctor, anthropologist, criminologist and jurist. Exponent of scientific positivism, he is considered a pioneer of modern criminology, even if his views were later surpassed. His works are based on the concept of the criminal by birth: the origin of criminal behavior is inherent in the anatomical characteristics of the criminal, a person physically different from normal man because of hereditary anomalies and “defects”.
Mother Teresa of Calcutta (Anjëzë Gonxhe Bojaxhiu, 1910-1997). A catholic sister, born in Albania. Since 1929 she lived and worked in India, as teacher in a catholic college. When she realized the miserable condition where people were living in the Calcutta Slums, she obtained permission to leave the college and start working in favour of “the poorest of the poor”. In the beginning she was working on her own from a poor hut, but then she created a network of volunteers and in 1950 she founded the Congregation of Charity Mission, offering assistance in the first place to ill people that were rejected by the hospitals, including the leprous. Mother Teresa life style was inspired by San Francis and was particularly severe, austere, in line with the poverty she was trying to assist. Her reputation soon went beyond the boundary of India and she became a world celebrity. She was awarded in 1979 the Nobel Prize for Peace. In 2003 she has been declared Saint by Pope John Paul II.
“To be rejected is the worst disease that can happen to a human being”
Nelson Mandela (1918-2013). South African politician. Leader of the movement against apartheid, the segregation and discrimination regime ruling in South Africa for many years. He organized acts of sabotage against the regime and therefore he was jailed in 1962 and released only in 1990, upon strong pressure from public opinion both in South Africa and abroad. His liberation brought to the opening of a democratic and multi-racial regime.
He was awarded in 1993 the Nobel Prize for Peace, then in 1994 he was elected President of Republic of South Africa. He promoted the transition to democracy through the establishment of the Committee for Truth and Reconciliation. The scope of the Committee was not to find and punish the offenders who had committed crimes during the apartheid, but just to find out which crimes were committed and make the population aware. Mandela thought that bearing the blame for the crimes, and subsequently forgiving the crimes, was the only way to heal the injuries suffered by the nation. Many white men, sentenced guilty, were forgiven, having admitted their crimes. Passage to democracy could then take place without any other bloodshed.
Jules H. Masserman (1905-1994). American psychiatrist and psychoanalyst of Polish origin. In the 70’s was president of American Psychiatric Association and subsequently honorary president of World Association of Social Psychiatry.
Jacob Levi Moreno (1889-1974). Born in Romania, he lived in Vienna since 1905 and in the United States since 1926. He was a Freud’s pupil in Vienna, but he soon abandoned the orthodox psycho-analytic school and elaborated between the 20’s and 30’s the psychodrama technique, aiming at group treatment. Moreno was convinced that a group represents the functional nucleus of all social dynamics, and when a group gets mixed with other groups it can create more complex structures.
Ivan Petrovich Pavlov (1849-1936). Russian physiologist, medical doctor and ethologist, Nobel Prize for medicine in 1904. His name is linked to the discovery of the conditioned reflex, which he announced in 1903: Pavlov understood as some visual and auditory stimuli in animals, not directly related to food, can generate salivary secretions commonly known as “mouth watering”; thus he could demonstrate that the brain controls not only social behaviors but also physiological ones. Later, the theory of conditioned reflex was used to give credit to the North American Psychological current of behaviourism, which studies the psyche through the simple analysis of the behaviour.
Philippe Pinel (1745-1826). French psychiatrist. He is considered a founder of modern psychiatry for his new conception of mental illness, that separated it from other forms of social exclusion, which it was commonly associated with. He was the first to practice the physiological analysis of mental illness, making it emerge from the climate of mystery and superstition by which it was until then enveloped. Under the stimulus of the ideals of the Enlightenment period, the insane were recognized as ill people to treat by means of the internment, which was established by law by a medical certificate.
Karl Popper (1902-1994). Austrian-born British philosopher of science. Like Bertrand Russell (qv), he was among the critics of the inductive scientific method and maintained that the deductive method, based on hypothesis and experimentation, is more correct. According to Popper, human knowledge is conjectural and hypothetical in nature, and derives from the attitude of man to solve the problems he encounters; he intends by “problem” any contradiction between what is predicted by theory and the observed facts. He also suggested a new line of demarcation between science and non-science: any theory, to be controllable, and therefore scientific, must be not only verifiable, but also “falsifiable”. That means that, in logic terms, there must be at least one experiment, being based on its premises, that can prove the theory fully false when put to the test. This according to the logical process of the modus tollens (which means if we can deduce B from A, and B is false, then A is also false).
Bertrand Russell (1872-1970). British philosopher, mathematician and logician, primarily known for his contributions to the philosophy of language and knowledge (epistemology). Russell raised an important question about what was traditionally considered the way to work in science: the method of induction. According to this methodology, science would start from a collection of observations about a certain phenomenon, from which it is possible to draw a general law that allows to predict a future event. But in reality this is unwarranted on a logical level. What Russell observed, with classic British humor, is that even the American turkey as well, which the farmer feeds regularly every day, can come to predict that tomorrow it will be fed… but “tomorrow” is Thanksgiving day and the only one to eat will be the breeder (at the expense of the turkey). According to the deductive method, in contrast, it is not empirical observation to stimulate scientific research, but the formulation of theoretical hypotheses that are evaluated in practice by experimentation. Convinced pacifist, Bertrand Russell was co-author in 1955 of the “Russell-Einstein Manifesto”, considered the most important document of protest about the threat of nuclear weapons for humanity.
George Santayana (1863-1952). Spanish-born American philosopher and writer. One of the main themes expressed in his works is the ambivalent relationship between nature and reason, which he indicated as that between “mechanical forces” and order of life, or rather between existence and essence. The sentence quoted in the text comes from The Life of Reason: or the Phases of Human Progress, 1905-1906.
Harry Stack Sullivan (1892-1949). American psychiatrist and psychoanalyst. He studied with psycho-analyst Alfred Adler, he created the inter-personal psychiatry school, collaborating with other psychiatrists and psychoanalysts, such as Karen Horney, Erich Fromm, Erik Erikson e Frieda Fromm-Reichmann. Sullivan used to study the psychology of the individual on the basis of his network of relations. He was paying much attention to the socio-cultural factors in the genesis of mental disease. He was trying to extend psychoanalytic treatment also to schizophrenia, and was supporting the idea that it is possible to manage psychiatric hospitals through inter-relation processes and not only through authority.
Reference:
– The Interpersonal Theory of Psychiatry, Norton,1953
Paul Watzlawick (1921-2007). American psychologist and philosopher born in Austria. He was an outstanding member of the Palo Alto School. Initially he had an education after the Jung psychoanalysis, then since 1961 he worked at the Mental Health Institute with Jackson. There he became one of the best known supporters of the systemic approach, in particular in the field of pragmatics of human communication, theories of change and radical constructivism. He was a supporter of the relativistic conception of so-called philosophical constructivism, which considers our representation of reality, and therefore the world in which we live, not as an immutable fact, but as the result of the permanent constructing action of our cognitive structures.
References:
– Pragmatics of Human Communication, Norton, 1967 (with D. Jackson and P. Beavin).
– The Language of Change, Norton, 1977.
Karol Józef Wojtyła (1920-2005), Pope of the Catholic Church with the new name of John Paul II. Born in Poland, he became priest in 1946 and in 1963 archbishop of Krakow. As such he could attend the Council Vatican II. In those years he was opposing the communist regime in Poland. He was elected Pope in 1978, the first non-italian pope after more than 400 years. He strongly contributed to the fall of the communist regime and of the soviet system as a whole. Wojtyla was however equally critic towards the excesses of capitalism, supporting instead the priority of dignity and social equality.
In the moral field, he confirmed the traditional Catholic approach to sexuality, to bachelorhood of priests and non-female priesthood. He also contributed strongly to peace, for instance he was against the war in Iraq in 2003, and was in favour of inter-religious dialogue. He has been promoted Saint in 2014, only 9 years after his death.
Samuel Woodward (1787-1850). American physician, he was from 1833 superintendent of Worcester State Hospital in Massachusetts and first president of what later became the American Psychiatric Association. Rejecting the supernatural explanation of mental illness, in vogue until then, Woodward proposed for its care the so-called “moral treatment” consisting in a compassionate and individualized approach, which aimed to respect the patient as a human being.
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