Alcohology Network in Heraklion, Crete.

Iannis A. Mouzas, Associated Professor

Interdisciplinary Alcohology Center, Medical School, University of Crete

Alcohology Outpatient Clinic, University Hospital, Heraklion, Greece

Introduction

During the last ten years an Alcohology network has evolved in Crete, based in Heraklion, the biggest city of a
650.000 inhabitants’ island.

Persons with alcohol-related problems and their families are offered support and help for personal change by a
structure of collaborating parts, both institutional and voluntary. The system of intervention is mainly based on a
systemic and ecologic approach.

The institutions consist of:

The Alcohology Outpatient Clinic of the University Hospital in Heraklion, which supports persons with
alcohol-related problems and their families through psychiatric help and psychological counseling from
the psychiatrist and social worker of the Alcohology Team.

The Interdisciplinary Alcohology Center of the Medical School of the University of Crete, which is
focused on research and education in the field of Alcohology.

Regional hospitals in major cities of Crete, rural Health Centers, municipalities, with professionals (social
workers, psychologists, physicians active in local institutions) collaborating with the Alcohology
Outpatient Clinic of the University Hospital.

The volunteer organizations consist of:

EPISTROFI, a volunteer association based in Heraklion, dedicated in supporting persons and families
with alcohol-related problems, and

Clubs of Alcoholic Families (Clubs of Alcoholics in Treatment), multifamily communities structured

according to Hudolin approach.

Volunteers from clubs and other initiatives participate in the multidisciplinary team of the Alcohology Outpatient
Clinic.

Local conditions include both difficulties and opportunities. According to our personal experience from the
development of this Alcohology Network in Heraklion, collaboration of health professionals and volunteers in the
field of Alcohology is both feasible and rewarding, with better and sustainable final results. The practical
advantages of this collaboration are valid for both parts, professionals and volunteers.

In this report we present and discuss a system of collaborating bodies, both professional/institutional and
voluntary/charitable/communal as they evolved during the last decade in Heraklion, Crete, taking eventually the
form of an Alcohology network.

1. Some important data. Geography and alcohol use.

Crete is the biggest Greek island with a population of 650.000 inhabitants. Main activities of the local economy
are agriculture (olive products, citrus fruits, vineyards with table grapes and wine grapes, early season
vegetables and limited breeding of goats and sheep) and tourism.

Crete became one of the major tourist destination in Europe in the last 20-25 years. This fact has had a profound
influence in the way of life of the inhabitants, mainly in adopting Northern European styles of food and spirits
consumption. In Crete, among other Mediterranean regions, has been studied the so-called “Mediterranean or
Cretan diet” consisting in meals rich in vegetables, olive oil, bread, fruit and poor in meat and dairy products with
a low daily consumption of alcohol in the form of wine during the meals. This diet has been associated with a
lower life incidence of heart disorders and cancer.

There is evidence that the change in diet and especially alcohol consumption in Crete that has been observed in
the last decades is connected with massive tourism and globalization. Dietary and lifestyle habits have shifted to
frequent meat and fat consumption. Some important changes in the patterns of alcohol use were also observed.
The use of beer and distilled spirits raised, taking place more frequently out of domestic boundaries and no more
related to meals, as it used to be. Binge drinking from being a rarity became more frequent, especially in young
people.

Problematic alcohol use is becoming a major public health problem in Crete, not yet receiving proper social or
governmental/legislative attention. It seems that heavy alcohol consumption has been integrated to modern
lifestyle and, generally, is not considered to be an antisocial activity.

In rural areas, daily consumption of alcohol in places of social interaction (cafés, tavernas, bars) is more than
common, as well as intermittent heavy use at social events (religious celebrations, local feasts, marriages and
baptisms). In urban areas, daily consumption is neither that prominent nor extended. Nevertheless, binge
drinking has started to emerge where it was unknown before and the number of youth and adolescents that are
being exposed to binge drinking is raising.

1.2 Prevention policies related to alcohol use in Greece

The main prevention policies that regard alcohol use applied in Greece are referred to three sections: control
over production of alcoholic beverages, restriction of sales of alcohol to young people and rules on driving after
alcohol consumption. In details:

Production of alcoholic beverages requires state permission, which is handed mainly in order to ensure taxation.

It is forbidden to serve alcohol to minors less than 17 years of age. Yet, this measure is not reliably applied and
there is no restriction of selling alcohol over the counter.

It is forbidden to drive when alcohol blood concentration is above 25 mg/dl (0.025%). In order to enforce this
measure, random breath tests take place. In case of a car accident with a subsequent injury, implicated drivers
are submitted to blood tests. Intoxicated drivers may be arrested and prosecuted.

Drawbacks consist in poor implementation of alcohol selling and pricing policies, of restrictions over advertising,
not clear restrictions over alcohol consumption at workplace, inexistent consumer warnings on bottles of
alcoholic beverages.

2. The alcohology net in Heraklion, Crete. Institutions and professionals.

In what concerns the institutional support, the Alcohology Outpatient Clinic of the University Hospital in Heraklion
offers support to problematic alcohol users, family members and other persons close to them in the form of
psychological and counseling support from the psychiatrist and social worker of the Alcohology Team. Besides,
the Interdisciplinary Alcohology Center of the Medical School of the University of Crete is focused on research
and education in the field of Alcohology. Finally, regional hospitals (in other cities of Crete), rural Health Centers
and professionals like social workers and psychologists active in local-governmental institutions collaborate
mainly with the Alcohology Outpatient Clinic of the University Hospital. Therefore, the Alcohology Outpatient
Clinic constitutes a key point in the flow of clients and their families and the support that is offered to problematic
alcohol users and their families.

2.2 Alcohology Outpatient Clinic of the Heraklion University Hospital

As mentioned above, the target groups of this Outpatient Clinic are persons with alcohol related problems,
members of their families, their friends and colleagues.

The Alcohology Outpatient Clinic is working with families, applying a systemic approach. All family members are
encouraged to participate at the sessions. The interdisciplinary team consists of two gastroenterologists, one
psychiatrist, two social workers (one contributing as volunteer), a nurse (volunteer) and two volunteers, members
of CAT (group facilitator or “servant-teacher”). The social worker provides professional counseling and social
support, while the team conducts the family therapy sessions. Furthermore, there are offered cognitive
behavioral approach, and an integrated medical support through connection with inpatients clinics
(Gastroenterology and Psychiatry Departments).

In table 1 the demographic data of persons who asked for help due to alcohol related problems and came for the
first time to the Alcohology Outpatient Clinic, in two consecutive years, 2006 and 2007 are presented. Women
are represented at a scale that corresponds to data from other countries, that is between 10-20% of the total.
There is a slight predominance of people coming from rural than urban areas, which corresponds well to the
distribution of population in the regions of Crete. In immigrants, a population subgroup with high levels of stress,
alcohol related problems are a major cause of concern. In this subgroup, problematic alcohol use is related to
the capacity of alcohol as an easy to find sedative and anxiolytic drug. This fact is reflected in this table.

2006 2007
Persons (first appeared) 65 105
Women 11 14
Immigrants 9 9
Rural/town 38/27 61/44
Age 19-69 15-67
Median age 38 45
Presented with family 40 45
members
Other family members 6 8
presented (non alcoholic)
Social class I (Graffard) 8 10
medium-high
Social Class II (medium) 16 19
Social Class III (medium- 31 29
low)
Social Class IV (low) 7 15
Professional situation: regular 37 44
job
Professional situation: 13 9
irregular job
Professional situation: 10 6
unemployed
Professional situation: retired 3 14

Table 1. Demographic data of persons first appeared at the Alcohology Outpatient Clinic, 2006-7.

Median age of people coming for help due to alcohol related problems corresponds to the 4th and 5th decades of
life (30-50 years of age), the most productive years in one’s life span. Indeed, concerning their professional
situation 60-70% of people coming for help had a regular or irregular job that kept despite the alcohol related
problems. As expected, all social class are represented corresponding to the their allocation in the region.
Hence, alcohol related problems make no predilections related to social class. In half or more cases at the initial
interview participated as well other members of the families with alcohol related problems. In some situations,
with a prevalence around 10%, the persons that came initially to the first interview were direct relatives of the
ones with problematic alcohol use. These data underline the participation of the whole family in the problem and
justify the use of the term «alcoholic family» and, furthermore, widely support the systemic/ecologic approach in
dealing with these problems.

In table 2 some other data are presented which concern alcohol related problems in persons who asked for help
and came for the first time to the Alcohology Outpatient Clinic in the two consecutive years 2006 and 2007. From
these data it is clear that only a small proportion (10-15%) of patients came to the Outpatient Clinic after their
hospitalization (mainly from Gastroenterology and Internal Medicine in-patient Clinics), the vast majority of them
coming as ambulant patients-clients in order to get help to their alcohol related problems. Furthermore, some
patients, a percentage of 5-8%, need inpatient care after their first consultation at the Alcohology Outpatient
Clinic. About one third of our patients have had a psychiatric consultation at the Alcohology Outpatient Clinic,
thus underlining the fact that psychiatric comorbidity in persons with alcohol related problems is a common
condition.

2006 2007
Persons (first appeared) 65 105
Hospitalized before 6 16
consultation
Hospitalized after first 5 5
consultation
Psychiatric consultation at 22 28
Alcohology Outpatient Clinic
Pattern of consumption: daily 54 85
Pattern of consumption: in 3 7
weekends
Pattern of consumption: 6 5
episodic -binge
Use of drugs in the past: 2 3
heroin
Use of drugs in the past: 3 1
cocaine
Use of drugs in the past: 6 2
cannabis
Frequented meetings of CAT 26 30
Any antidepressants taken 30 18
Any naltrexon taken 10 9
Any benzodiazepine taken 25 30

Table 2. Clinical data of persons first appeared at the Alcohology Outpatient Clinic, 2006-7.

The main pattern of alcohol use is the daily use, the episodic-binge pattern being not rare. The prevalence of use
of illegal drugs in our patients is 7-12%, while the use of prescribed antidepressants is decisively higher (20-
50%) reflecting the already mentioned psychiatric comorbidity. The use of naltrexon as relapse prevention
medicine had a prevalence of 10-15%. More than 30% of the patients or families that had their first consultation
at the Alcohology Outpatient Clinic followed for at least 3 sessions the Clubs of Alcoholics in Treatment. We
believe that in achieving this successful connection of a professional institution with a multifamily community the
role of volunteers participating at the Alcohology Outpatient Clinic was of paramount importance.

3. The alcohology net in Heraklion, Crete. Volunteer organizations

Concerning volunteer organizations, help and support is offered by EPISTROFI (a Greek word meaning “coming
back” or “turnaround”), a volunteer association based in Heraklion, dedicated in supporting persons their families
with alcohol-related problems, and the Clubs of Alcoholic Families in Treatment. Clubs of Alcoholics in
Treatment (CAT) are multifamily communities structured according to the ecological-social approach (Hudolin
method) that meet once a week in the premises of two major Heraklion church parishes and in EPISTROFI’s
headquarters. During the meetings of CATs, all members of families with alcohol related problems are invited to
participate. Special importance is paid in changing attitudes and problematic relation in the family sub-system,
according to a systemic approach.

Volunteers from both the CATs and other initiatives (volunteer Red Cross nurses, volunteers from health
professions) participate in the multidisciplinary team of the Alcohology Outpatient Clinic. The approach as
already mentioned is mainly systemically centered.

3.1. Volunteer Association EPISTROFI

The two main aims of this association are

Support and help to persons with alcohol related problems as well as to their relatives, friends and colleagues,
and

Primary and secondary alcohol prevention. The financial support of EPISTROFI comes mainly from membership
fees, donations and members’ contributions, as well as from contracting and realizing European programs.

Epistrofi is an association of citizens of Heraklion that supports any initiative aiming at helping families with
alcohol-related problems. It works like an umbrella organization for self help groups and for organizing evens of
alcohol primary prevention (interventions in educational institutions and local community). In the premises of
EPISTROFI there are activated in this supporting initiatives a social worker and two self-help groups (one
influenced by the 12-steps approach). Until now (2009) EPISTROFI has been the main organizing partner of the
five “Heraklion Alcohol Prevention Weeks”. Heraklion Alcohol Prevention Week is an event that lasts 5-7 days
and takes place in the city of Heraklion once a year during the month of April. It brings together several private
and institutional bodies (sport, leisure, and cultural citizens’ associations as well as the University, Municipal and
Regional institutions, the Church, primary and secondary educational institutions) that contribute to the
organization, support and sponsorship of events that are either directly or indirectly related to primary alcohol
prevention and healthy way of life. Such events may include among others: sport events (marathon in the city
where all citizens are invited, bicycle tour of the city, walking tour of the city walls etc), open air music concerts
during which non-alcoholic drinks are offered (aimed mainly to attract young people), movies’ nights with related
topics, advice to drivers at important traffic points by volunteers (with the participation of school children and their
teachers), open air festivities at central places where several volunteer organizations may participate, scientific
symposiums and seminars on alcohol prevention.

3.2. Clubs of Alcoholics in Treatment (CAT)

They are based in the social ecological approach, profoundly influenced by systemic thinking. The approach
together with its practical aspects constitutes the Hudolin method, mainly expanded in Italy, where more than
2000 CATs exist. A servant teacher (may be a health professional or not) caring about the regular flow of the
meeting according the CAT principles takes part at the meetings. Servant teachers are trained initially by means
of a 50-hours course and receive further continuing education.

In the following the main regulations and traditions of the Clubs of Alcoholic Families in Treatment (CAT) are
presented:

Each CAT is structured in a simple way: between 2 and 12 families gather once a week in a multi-family
community, based on the family approach.

The CATs follow these fundamental rules:

Meetings are fixed in time and place. Punctuality is very important;
Smoking is not allowed during the Club meetings;
When the Club reaches 13 families, it should be divided. It is advisable that this happen once a year, in
order to encourage more families to join the Club.
The discussions within the Club are confidential.

The servant-teacher should provide simple and clear information to the new families joining the Club, at
the Local School on Alcohol Related Problems. The 1st level of this School consists in 10 meetings for
new families, while the teacher should be the same servant-teacher in all meetings

Families entering the Club should have a first interview with the servant-teacher. This first interview
cannot be substituted by previous interviews by any other.

Training and updating of servant-teachers are organised as follows:

Basic training: a Course of Sensibilization on alcohol related and mixed problems;

Updating courses on alcohol related and mixed problems (alcohol and drugs, alcohol and psychiatry,
etc.)

Intermediate Courses of two/three days (relapse, family approach, etc.)

The CAT methodology includes the possibility to introduce in the club families with alcohol related problems
and mixed problems at a maximum 20% of the total number of families. Mixed problems are the
 combination of an alcohol-related problem and either the use of psychoactive substances, psychiatric
disorders, or homelessness. The servant-teacher must be specifically trained and updated on mixed
problems. The servant-teacher must also cooperate with the professionals (for example psychiatrists)
who are actually treating patients with mixed problems.
The Club works well in the handling of relapse. Relapse is not seen as a tragedy but as a common evolution
in the history of families with alcohol related problems. Usually relapse is considered in terms of drinking
alcohol again. Yet, a more frequent form of relapse is a withdrawal to old behaviours and lifestyle.
Relapse is an acceptable situation in the Club, it should not be emphasized, but everything should be
done to eliminate it. Besides, one should not forget that Clubs are there for people who drink and
consequently also for people who relapse.
The CAT methodology is based on the family and its spiritual and material bonds. If a member has no family
it is necessary to find a substitute family, which has the same responsibilities as the other families.

The principles the Club’s methodology fit very well into the health promotion principles included in many
documents of the World Health Organization (WHO).

4. Conclusions

Alcohol is a very old psychotropic substance incorporated in the way of life and culture of our modern societies.
Today a diversity of alcohol related problems is manifest. This fact demands strategically planned interventions
in both individual and community level. Collaboration of specialists and volunteers in a community setting is
instrumental in effectively treating families with alcohol related problems as well as in realizing interventions in
primary and secondary prevention.

In this paper we presented an account of the realization of a local Alcohology Network in Heraklion, Crete. We
referred mainly to the present situation as this has been developed by now (2009), beginning in the year 2000.
One should keep in mind that the evolution of this network was and still is closely related to local conditions,
including difficulties and opportunities. There are two main points that we would like to emphasize from our nine-
years experience in the development of this Alcohology Network:

There is an important advantage in working interdisciplinary in Alcohology, both for health professionals
(continuous education, clinical decision making, follow up, getting involved in teamwork) and patients (holistic
approach, better treatment due to the availability of different health professionals in the same team, better
understanding of a complicated health problem)

Collaboration of health professionals and volunteers in the field of Alcohology is both feasible and rewarding.
Working in a community setting according to the principles of mutual respect and clearly defined roles makes no
difficulties for both professionals and volunteers. On the contrary, the end result is improved and the occupation
satisfaction is greater.
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