Helge Kolstad
Coordinator for International Collaboration among Hudolin Clubs
Effective cure is good prevention
Hudolin Memorial Session, Croatian Academy of Sciences, Zagreb 9 December 2014
It is an honour to represent the clubs of alcoholics in treatment in this scienticif assembly. Our focus
is on the families and the communities. We have little resorces and few qualifications to do research.
Therefore, our activity is mostly under the radar. However, the fact that Hudolin clubs now are active
in more than 30 countries, speaks strongly in support of giving Vladimir Hudolin, along with his wife
Visnja, a special place in the history of the work against alcohol-related problems.
My background is a lifetime of work with alcohol-related problems, in my home country Norway, as
well as internationally as leader of IOGT, later scientist of the World Health Organization. I have been
a politician in Norway, and am now coordinator for international work in the club movement.
Before I start to speak about different concepts of alcohol and drug problems, and relatethem to
Prof. Hudolin, a small visit to Immanuel Kant may be of interest. The point is that there may be
different perspectives on alcohol, much dependent of where we stand. From one angle it may even
look nice, only showing happy people socializing. Other aspects are ugly. All of them hang together.
This paper commets on development over four or five decennia, whith changing perspectives on the
phenomenon alcohol.
Vladimir Hudolin’s biography is a perfect parallell to the developments in the understandingof the
problem. It is significant that he came from Yugoslavia, a communist, autocratic society, which still
had a few doors open to the world outside. Vladimir got the opportunity to go abroad, and worked
a.o. together with Maxwell Jones in Britain, who coined the term therapeutic community.He took
some of these ideas back to Zagreb. He got heavily involved in the movement for social psychiatry,
was president and chairman of the World Assembly of Social Psychiatry, and hosted at least three
international congresses here in Croatia during his career. In 1970, he published a biography of the
founding figure, Dr. Joshua Bierer of Britain, who had developed some of the ideas that Hudolin
worked with. Here terms like «social therapy clubs» and «self management» were frequently used.
In the home page of the World Assembly of Social Psychiatry there is ashort summary of its history.
It recognizes the Hudolins as main figures. It is also mentiones something which triggered my
curiosity, namely the fact that Hudolin in the 1960s and 70s frequently visited Portugal and helped
setting up clubs and self-governed therapeutic communities, parallell to what he did in Yugoslavia. In
two countries with autocratic regimes, these radical doctors could do such work!
Perhaps they were not quite as radical as some other proponents. In Italy, a variant called
«democratic psychiatry» was significant, with dr. Franco Basaglia of Trieste as the leading figure. This
school of thought was very influential. In 1978, the Italian parliament decided on the Basaglia Law,
which in effect closed down psychiatric hospitals. I saw the remnants of the psychiatric asylum in
Trieste a few years later, full of slogans like «Let the lunetics free, it is springtime!».
I do not think that Vladimir approved of this. Never-the-less, this phenomenon brought him heavily
into Italian affaires. Closing of institutions and lack of local capacity, left a craving for help which
demanded immidiate action. In 1979, an Italian from Trieste, Giovanni Pitacco, who had been
treated in Zagreb, initiated the first club of treated alcoholics in Italy. It was modelled after the
Croatian clubs. Hudolinsupervised the establishment, and saw to it that it was connected to the
health service. This filled a void, and the number of clubs grew rapidly, far beyond the capacity of the
health workers who were involved. During the first few years, the number of clubs increased rapidly.
In some provinces there vere clubs in virtually every village.
Initially, every club should have a professional health or social worker as a mentor. Along the rapid
spreading of clubs in Italy, the role of the mentors, the trained operators, changed. In order to meet
the demand, new forms of training had to be established, into which any mature person with good
communication abilities could be accepted. In this way, the link with the health service became less
significant, even if there still are many health workers among the club operators. Clubs in Italy are
now organised independently, as is the case in many other countries.
It is typical for Hudolin that he gradually accepted this shift of concept. He definitely saw the club
work as a task for the health service. But it was more important to help people than to put labels. So
in the next version of the club manuals, the new reality was recognized. Today, any person who will
take the role of mentor to a club, must attend a 50 hours training, including observation in two clubs,
regardsless of her or his previous training. The clubs are funtioning just as well as before.
Paradigm Shift
Now a little more about differences of perspective. During the 1960s and 70s the disease concept of
alcoholism was predominant. Dr E. Morton Jellinek, who wrote an important book about it (1960),
became advisor to the WHO, and his ideas about the nature of the problem and its treatment
became commonplace. Today, it seems that the fundament was relatively weak. The material
behindthe theory was collected via a simple questionaire published with the member magazine of
the AA movement of America. Only a small fraction of the subscribers responded. The sample which
was used by Jellinek, was less than one hundred persons. Let us admit that the device he suggested
was effective, and worked well for many people. It is, however, worth noting that it is perfectly
possible to run relatively successful therapy programmes at the same time as the problems in
society are growing rapidly, as it happened in most societies during this time.
This was the major criticism against the disease concept, coming from epidemiologists and public
health experts from around the world. Let me just mention two of those experts briefly. One was
French, namely the psychiatrist Sully Ledermann, who established a strong link between the total
alcohol consumption in parts of France, and the incident of liver chirrhosis. Other studies in many
countries confirmed thelink between averge consumption levels, and the incidence of alcoholrelated problems. This very term was coined by another important reformer, the Finnish sociologist
Kettil Bruun, who together with an international group of researchers published an important book
in 1975: «Alcohol-related Problems in Public Health Perspective.» They simply showed that the
condition alcoholism is only a minor part of alcohol-related problems. Violence, neglect, accidents
and other problems connected with behaviour is the bigger part. It is not only about the harm to the
individual with a diagnosis, but harm to others must be considered as well. This book was a
watershed, which led to a significant change in the WHO policies on alcohol and drugs, dating from
the World Health Assembly in 1979.
Just this timing brings me back to Hudolin. It goes without saying that the public health approach was
close to the thinking of social psychiatry. I do not think that Vladimir Hudolin approved of the closing
down of hospitals. But in a way, this move gave way the introduction of the Hudolin Club
methodology in Italy. The closing of hospitals created a massive need for other measures. One club
led to more clubs, members qued up, and the first clubs had to be split and grew further. Over a few
years, the Italian club movement grew to more than 3000 clubs, with a particularly tight network in
the northern provinces. In Friuli, I am told that there is more than one club for each village. This
constitutes a large scale intervention which may have effects beyond the families which are
immediately involved.
Treatment of Many Is Good Preventon
This leads me to my main point about the Hudolin legacy. His work with tertiary prevention,
i.e. treatment of patients, had also significant effect in primary prevention, i.e. in reducing
overall incidence of alcohol-related damage in the whole society.
I would have liked to have good quality figures to show you. But this piece of research is still
to be done. However, some solid community statistics give more than a hint of this effect.
You may remember the millennium goals of the World Health Organisation, introduced in
1985. No 17 was to reduce the over-all alcohol consumption of alcohol by at least 25 % by
the year 2000. Of the many countries of the European Region, only one succeeded, namely
Italy. Was it because of high prices or reduced availability? No, nothing of the kind happened.
But what is striking, is that in provinces with high prevalence of local clubs, overall
consumption dropped like a stone. This is a confirmation of the findings of those who have
worked with links between consumption and harm. Heavy drinkers influence others to drink
more heavily. They seek situations were drink is available, and may themselves initiate such
situations. When heavy drinkers are fewer, through the clubs, drinking occasions will be
fewer in the whole community, and people will tend to drink less each time. For most
people this is insignificant. But the effect on public health is very favourable.
I have urged my Italian friends to document this in more detail. Now, I wonder whether a
similar effect can be observed i Croatia. The figures from the time when clubs were spreading
rapidly in every community will be most important. My challenge to you is to make a study
of available community data to set a memorial of Hudolin’s effort to do more than herapy
for a few patients, but even make an impact on the community as a whole.
Clubs have spread to many countries. In some there are only a few clubs in competition with
numerous other therapeutic methods. But in others they spread rapidly, particularly where
alcohol and drug problems cause great concern, and where the professional services are far
to weak to meet them adequately. One such country is Thailand. Dr Francesco Piani, Olcott
Gunasekeraand myself were there recently, and saw how the simple club concept fits
perfectly into their firm desire to prevent that alcohol problem at a western scale develops.
We can help them by publishing the findings of Croatia and Italy. We can take another
example from Vladimir Hudolin. Problems as well as solutions are without borders. Do your
good work locally, but do not fail to tell the world.
Spirit and Motivation
There is one more aspect of Hudolin’s work which s worth mentioning. It may be contained in
the term «ecological psychiatry», which was his invention.Ecology was very fashionable in
the 80s and 90s. In my mind it i still a very fruitful approach to the huge challenges we face in
nature and society. It also fits well into the concepts of social psychiatry, as it is focusing on
complex systems in ever changing situations. Used as a tool to understand alcohol-and drugrelated problems in families and communities, it opens up new perspectives.
Havng said this, I must confess that I was somewhat sceptical to yet another use of the term
ecology in every field of science. But I have gradually been convinced. The message here is
that every human being must be understood in his social context. Health and illness is not
only a personal condition, butalso strongly influenced by physical and social environments.
The focusing on family and other social relations in treatment and after-care for alcoholrelated problems is necessary. This stands in clear contrast to medication and treatment of
individual symptoms only. Once upon a time I believed that this was self-evident. But science
can be very narrow-minded. If your approach is genetics, you may be blind to other factors.
Unfortunately it also works the other way around……
Back to Hudolin: his teaching is that all sides of the problem should be considered, in the
framework of an ecological equilibrium.
We are deep into philosophy now. We may as well ask some difficult questions which do not
have a scientific answer. One such question is «what moves us?», beyond the identifiable
need, or the infuence of society. Hudolin spoke of «antropological spirituality» as a name for
the forces in man which motivate painful change, personal growth,love and compassion.
Religious people love this. You may be aware that the Alcoholics Anonymous has a religious
aspect to them. But Hudolin stressed that spirituality could also be of this world. Coming
from secular Norway, this was another term with which I had some difficulty. In translating
Club manuals, I used the word «meaning»instead of spirituality, which went down well in
Scandinavians. But it was only when we heard the Sri Lankan interpretation of spirituality
that we really could appreciate what it could mean in real life. It took a buddhist scolar, my
good friend Olcott Gunasekera, who practise yoga andspeak of mindfulness to show how
much here and now spirituaity is. He simply took the rules of the club and interpreted them
in this light. Simple and obvious qualities of the Club community and it practises have
spiritual value. It is nice if we recognize it, but it may be helpful even if we do not.
I do not know how deep Hudolin was in this thinking. Important is that he came upon
something here which might help moving people in a healthy direction, and which can be
applied in different cultures around the globe. Some time in the future we may even be able
to understand it scientifically. A start could be to find and search in his personal archives and
library. His widow, prof. Visnja Hudolin set up a foundation which should take care of this,
which unfortunately has not been set in function. It is high time to do it now.
References
Hudolin, Vladimir: Joshua Bierer – man and personality. Zagreb 1970
Ferreira, AG: The Life of the WASP from 1964 to 1992. Home page of the World Assembly of Social
Psychiatry
Bassaglia Law. Wikipedia
Jellinek, E. Morton: The Disease Concept of Alcoholism, Hillhouse Press, New Haven 1960
Bourgeois-Pichat: Sully Ledermann, Population, vol. 22, 1967
Bruun, Kettil et al: Alcohol- Control Policies in Public Health Perspective, New Brunswick, N.J. :
distributors, Rutgers University Center of Alcohol Studies, 1975
Gunasekera, Olcott: Mindfulness in club work, Speech at the IOGT World Congress, Cha-Am, Thailand
2014