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A Little Italian Story – Service Development

Fiorani, C., Poggioli, M., 2009. A Little Italian Story – Service Development. Reformulation, Summer, pp.13-14.

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“Let your hook always be cast.
In the pool when you least expect it will be a fish.”
Ovid said this. This is what we did.

We kept on going, we kept the fishing rod (The CAT Competencies) in the water of a service that was slowly evolving and being restructured, dealing with severe anorectic girls. We improved our fishing techniques and were always ready (attending conferences in Italy when we knew about them, continuing with supervision and clinical discussions, translating CAT articles and discussing them.) Finally we were noticed and we caught the fish: I have a tiny funding and some recognition by an Italian State Run Health Service, the equivalent of the UK NHS (AUSL = Azienda Unita Sanitaria Locale)

The AUSL Service in which I work

The health Service in Piacenza decided to finance an in house programme for Eating Disorders (DCA –Disturbi Comportamento Alimentare= Eating Disorders) because they are a serious and widespread problem amongst adolescent girls and young women.

In Italy out of 100 girls in the at risk age (12 to 25 years) on average 8-10% suffer from some form of eating disorder, and out of these 1- 2% manifest the more severe and dangerous forms. (Anorexia or Bulimia nervosa)

The Piacenza AUSL therefore expects each year to see in the target population some 1500 adolescents and young women with some form of eating disorder, of which some 200 manifest the most serious and potentially life threatening forms. The service run by the “Reparto Neuropsichiatria Infantile e della Adolescenza” (The Child and Adolescent Neuro Psychiatric Department) which would normally only include a population up to the age of 18, has been extended up to the age of 25 for Anorectics and Bulimics.

The AUSL has decided to implement an integrative service in order to be more effective and reduce costs. This new service is aiming at collaboration between different professional figures that communicate and decide together the best care plan on both the medical and psychological levels.

This has been implemented to prevent the “merry-go-round” of visits which used to take place between GP, psychiatrists, psychologists, paediatricians and dieticians without much success. In this project all the professionals involved communicate with each other. They have been guided and educated on the parameters for making a quick referral and diagnosis, rather than waiting until there are more serious problems and the girls are excessively thin.

This programme is unusual in Emilia Romagna, since Piacenza is the only district to have this approach. The hospital nutritionists, dieticians, paediatricians, psychiatrists and all other professionals involved liaise with the GP and a psychologist. The patient is case manage, has a care plan and there are regular meetings. This is very different from what used to happen.

I am a Psychotherapeutic Psychologist employed by the Piacenza AUSL. It is a medical department, as psychology departments do not exist in Italy. I have been working in this service since 1990, and have seen it gradually develop. I began to see my patients using CAT with the supervision of Marisa Poggioli, a Chartered Counselling Psychologist and CAT practitioner. We started in a small way and kept going over a 10 year period. Initially we also had the precious help and supervision of Anthony Ryle in 3 or 4 cases. I am now being supervised by Claire Tanner, which is another evolution.

The head of the service over time noticed through audit that I treated more cases than other colleagues; this came about because using CAT my intervention was briefer and I got results quicker than other professionals using analytical methods. More girls gained weight sooner and in a few cases there was symptom remission. The department’s interest in CAT was born out of this Clinical Audit. CAT was unknown in the department; it was a totally new form of therapy. The department’s interest increased when I also pointed out that CAT was indicated in the NICE Guidelines as a suitable for intervention for patients with eating disorders.

These patients and their families can be very difficult to manage, and the professionals involved often reciprocate without being aware of what is happening. This caused a lot of splitting, especially between the doctors and the psychologists involved. On one such occasion, with my fledgling CAT knowledge, I attempted a Contextual SDR. It was a simple diagram with some procedural sequences which I jotted down at the case meeting. It was a turning point in my relationship with one particular doctor.

The aspect of CAT which I greatly appreciate is the normal everyday language that is used. It is easily understood by other professionals and lay people. I began to share the SDR with other professionals, explaining the procedures and reciprocal roles that one was likely to be invited to respond to by any particular client. The concepts of collusion or reciprocation were also explained. The other professionals involved responded, and we began to be more united. The feedback I have received has been positive; the shared SDR’S have had a predictive value. This has prepared the other non-psychologist members of the team for the likely reactions by patients and family. There is now a shared concept as to what their behaviour means and how it might be reacted to.

It has made working with difficult, complex cases easier and has provided a means for common understanding. It has created a climate of cooperation rather than one of feeling attacked and having to justify oneself.

From 2001 when the DCA programme was started on average approx 150-200 girls a year have been seen with serious eating disorders (from 2003 the data is very precise) with the following criteria for inclusion:

• Only psychiatric cases, not disordered eating, or auxiliary pathologies that are not eating disorders, or obesity
• BMI under 17
• Serious health risks
• Psychiatric co-morbidity

On average I have personally followed approximately 10-15 cases a year using a CAT informed approach with the supervision of Marisa Poggioli. All the girls were given the Psychotherapy File and the PSQ; we have letters and diagrams for them all, although maybe some of them are far from perfect.

And I have, when possible participated and attended any CAT event in Italy: Rome, Milan, Ferrara, and Bologna).

But then what happened?

“istud quod tu summum putas gradus est” Marco Aurelio
(What had seemed to us like the mountain peak, turned out to be just the first step)

We were thrilled and excited The department has recognised the value of CAT !! But they are now asking that I become qualified as a practitioner and that Marisa Poggioli becomes qualified as a supervisor in order to be able to continue our work.

In Italy bureaucracy is of the utmost importance, so now we have to prove we know what we know with the right documents!

Dott.ssa Cristina Fiorani
Psicoteraputa, Psicologo Dirigente, AUSL, Piacenza, Italy

Marisa Poggioli
Chartered Counselling Psychologist,
CAT Practitioner (and translator)

Full Reference

Fiorani, C., Poggioli, M., 2009. A Little Italian Story – Service Development. Reformulation, Summer, pp.13-14.

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