Journal of Ethnicity in Substance Abuse

ISSN: 1533-2640 (Print) 1533-2659 (Online) Journal homepage: https://www.tandfonline.com/loi/wesa20

The role of the admission phase in the Italian

treatment setting: A research on individuating
shared practices in psychotropic substance users’
communities

Antonio Iudici, Davide Fenini, Daniela Baciga & Giulia Volponi

To cite this article: Antonio Iudici, Davide Fenini, Daniela Baciga & Giulia Volponi (2020): The
role of the admission phase in the Italian treatment setting: A research on individuating shared
practices in psychotropic substance users’ communities, Journal of Ethnicity in Substance Abuse,
DOI: 10.1080/15332640.2020.1713955

To link to this article: https://doi.org/10.1080/15332640.2020.1713955

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JOURNAL OF ETHNICITY IN SUBSTANCE ABUSE
https://doi.org/10.1080/15332640.2020.1713955

The role of the admission phase in the Italian

treatment setting: A research on individuating shared
practices in psychotropic substance users’ communities
Antonio Iudicia , Davide Feninia,b, Daniela Bacigaa,c, and Giulia Volponia
a
Department of Philosophy, Sociology, Education and Applied Psychology, University of Padova,
Padova, Italy; bCEAL (Lombardia Coordination Accredited and Authorized Bodies), Milano, Italy;
c
Interactionist School, Padova, Italy

ABSTRACT KEYWORDS
There are various and diversified ways of admission of a sub- Admission process; health
stance user into a therapeutic community. When these ways care; substance user;
result from actions that are inconsistent with the general therapeutic communities;
user drug service
objective of the service, they may lead to adverse outcomes
that substantially impact both therapeutic interventions effi-
cacy and services efficiency. Consequences are multiple, con-
cerning the substance user, other users of the service,
professionals working at the service, and the center’s relation-
ships with the service network to which the center belongs.
This study aims to define and share major interactive and
organizational problems concerning the admission process at
CEAL accredited structures and to define and standardize a
protocol of procedures aimed at managing and supervising
the admission process, through specific and commonly agreed
indicators. The research was carried out according to the focus
group methodology and involved sixty directors of various
health communities offering residential services for substance
use treatment. The research was guided by a focus group
moderator. The research has made it possible to identify the
biases and errors in the admission process and selected those
practices shared by the therapeutic communities and condu-
cive to generating positive outcomes. The findings in the def-
inition of a procedure, complete with precise indicators that
are applicable across the therapeutic communities and to the
shared activities that constitute and are conducive to the suc-
cess of the admission process.

Introduction
The admission process is defined as the whole set of actions the center
takes in order to assess and manage the intervention request, right up to
the moment of admission into the structure of the services

CONTACT Antonio Iudici antonio.iudici@unipd.it Department of Philosophy, Sociology, Education and

Applied Psychology, University of Padova, Via Venezia 14, Padova, Italy.
Supplemental data for this article can be accessed at https://doi.org/10.1080/15332640.2020.1713955
ß 2020 Taylor & Francis Group, LLC
2 A. IUDICI ET AL.

The admission of a psychotropic substance user in a therapeutic commu-

nity is one of the elective strategies used by institutions in the treatment of
substance abuse. Learning from their experience, these residential commun-
ities have moved from an informal welcome toward welcome as part of the
treatment—to be conducted in the presence of qualified specialists and pro-
fessionals (Palumbo, Dondi, & Torrigiani, 2012). Although residential treat-
ment has several facets (i.e., biological, physiological, psychological, and
sociocultural), each community tends to prefer interventions specific to one
or some of these aspects (Jason et al., 2018). According to this, scientific
research deals with further specific aspects such as the type of the users’
disorder (Becker, Midoun, Zeithaml, Clark, & Spirito, 2016; Prendergast,
Podus, Finney, Greenwell, & Roll, 2006; Zvolensky, Bernstein, & Vujanovic,
2011), the group activities and strategies pursued by the users (Brown &
Abrantes, 2006; Donaldson, 2007), abstinence or substance use cessation
(McLellan, Luborsky, Woody, & O’Brien, 1980; Nutt & Lingford-Hughes,
2009), job training (Layard, 2006) and social reintegration (Bishop, Benz, &
Palm Reed, 2017; Buchanan, 2004; Sumnall & Brotherhood, 2012).
However, each rehabilitation service differs from others in its specialization,
approach and treatment.
Since an intending user of the center’s services does not have a prior
knowledge of such differences between one service and another, the selec-
tion of the community which would meet the intending user’s needs may
be hard. For instance, substance users may end up relying on personal
opinions of other users, based on unsubstantiated beliefs about some cen-
ters as being better than others, although users’ characterization of a center
and its offered services rarely matches users’ expectations. This may lead to
such issues as users asking to be moved to another center without complet-
ing the treatment on the plea that the current center does not meet their
needs. Indeed, users very often expect an aid-based intervention and not an
educative approach and seek individual treatment because they underesti-
mate the importance of the group dimension; others may be willing to par-
ticipate in some group activities and not in others; finally, some can enter
a community just to merely solve their biochemical addiction without the
least interest in dealing with the reasons underlying it. As a result, there is
disparity between the user’s expectations and the treatment that professio-
nals plan for them, which partially explains the high rate of dropouts from
the treatment, also because of poor compliance or low trust (Janeiro,
Ribeiro, Faısca, & Lopez Miguel, 2018). The admission process differs from
community to community depending on their distinct organizational pro-
cedures, the extent, the type, and the number of services managed by the
organization to which they belong (Angelini et al., 2017; De Giovanni &
Dal Canton, 2013). Moreover, the type of service considered to be provided
 JOURNAL OF ETHNICITY IN SUBSTANCE ABUSE 3

to the user requires a complex and defined management of the admission

process based on the underlying objectives of the contemplated service.
Therefore, the entry into the substance users’ community is a very deli-
cate step and it can facilitate the adherence to a therapeutic program with
positive outcomes.
However, there are many different ways in which substance users can be
admitted into therapeutic communities. Some of these ways are informal,
often because the admission phase is considered external to the treatment
(Barone & Bruschetta, 2014; Vigorelli, 2014).
While the admission process is unrelated to the objectives of the service
or host community, some effects can be obtained that have substantial
negative impact on the therapeutic alliance (Diamond et al., 2006; Janeiro
et al., 2018; Meier, Barrowclough, & Donmall, 2005), on the efficacy of
therapeutic interventions and, consequently, on the drug users of the center
services, on the professionals who work in the center, and on the center’s
relationship with the service network to which the center belongs (Ferruta,
Foresti, Pedriali, & Vigorelli,1998; Paget, Thorne, & Arun, 2015; Pearce &
Pickard, 2013).
Nevertheless, many authors state that this initial step may influence the
therapeutic program (Bezzi & Morandi, 2007; Marsden, Ogborne, Farrell, &
Rush, 2000; Torrigiani, 2014a) and determine the users’ relationship with
psychologists, educators and therapeutic directors, as well as the develop-
ment of user-specific intervention strategies and the efficacy of the treat-
ment (Marsden et al., 2000).
Although much research involves individual cases, wide systems, compli-
ance and efficacy (Serpelloni, Macchia, & Mariani, 2006), little attention
has been drawn to the process of admission by researchers. The present
work aims to fill this lacuna by a) analyzing the process of admission the
users into the substance users’ communities; b) individuating admission
procedures in order to lay the necessary clinical foundation for effective
intervention to follow.

Policy and substance users’ community in Italy

Communities for drug addicts became a part of Italian services during the
1970s, mainly due to the social emergency of heroin use. At that time, the
policies adopted were repressive, characterized by criminal sanctions and
prohibitions, and consequently, the drug abuser was considered a criminal
to be punished and isolated (Campedelli, 1994). Subsequently, there was a
decriminalization of the drug abuser, although penalties were maintained
for activities related to consumption such as the production of drugs, and
4 A. IUDICI ET AL.

the sale, transfer or possession of quantities of substances that are not

related to personal consumption.
Regarding drug users, the regulatory framework is defined in terms of
protection: To build a ‘drug-free’ environment in which drugs cannot be
found easily (Palumbo et al., 2012). The concept of the consumer as a per-
son needing protection has led to preventive laws aimed at reducing the
risk of the users harming themselves and others. For instance, there are
restrictions on granting driving license to the drug users (Regoliosi &
Scaratti, 1994). During the early 70’s, the substance user was commonly
viewed as a deviant, disturbed and weak individual and, therefore, margi-
nalized. This drug users’ communities were formed in order to contrast
marginalization and deviation and to prevent users from producing and
trading in drugs. These centers were often founded by religious institutions,
and, therefore, treatments were founded on moral principles: their aim was
to ‘redeem’ the users (Fazzi & Scaglia, 2001). These centers were the first
Italian experience of aid-based interventions.
In 1975, the National Sanitary System began dealing with the phenom-
enon of drug-abuse by establishing health centers that provided expert
services. Subsequently, CTST (Committee for Coordination of the
Protection and Health of Drugs Addicted1) was founded, and only in 1990,
Law No. 3092 established to design specifically dedicated services for sub-
stance users.
All these experiences, which have been introduced by national regula-
tions, have constituted outpatient services that foresee individual interven-
tion projects. The different types of offers are therefore, part of an
articulated system which also composes of harm reduction, risk reduction,
and prevention in order to offer different services for each user
However, even after that date communities were considered the only spe-
cific intervention for substance users; therefore, they were decreed to pro-
vide specific treatment for curing and rehabilitating substance users. Back
then, health services were traditionally founded on the assumption that a
strong turn in the drug user’s life was necessary to cause a cure.
Particularly, there was the belief that living for a certain period in a
‘protected’ environment (a drug free environment) and working and shar-
ing experiences with other substance users could definitely lead to quitting
drugs (Nestler, 2004; Salvini, Testoni, & Zamperini, 2002). The predomin-
ant idea of those who founded the drugs communities was that the drug
user was neither a mentally disturbed person nor a criminal, but only a
‘socially disturbed’ person, therefore the person was in need of socially-ori-
ented intervention. Back then, many differences among the communities
such as those that relied on moral principles or others that relied on mod-
ern medical treatment and others. Each service operated according to what
 JOURNAL OF ETHNICITY IN SUBSTANCE ABUSE 5

its operators considered as ‘fair’ and ‘right’ by their criteria (Palumbo et al.,
2012). In Italy, to date, there are two-thirds of the total therapeutic pro-
grams in Europe and this is a specificity of the Italian context, due to a
delegation of public service to private services (Vanderplasschen,
Vandevelde, & Broekaert, 2014; Vanderplasschen & Vandevelde, 2018).
Unlike other countries, the Italian system has been characterized by consid-
ering drug addiction as a symptom of an underlying social malaise that
involves different areas (Zanusso & Giannantonio, 2000). Moreover,
recently Italian communities are evolving to respond to specific needs,
related to those who are in the community for alternative measures to
prison or those who have a child with them (women with addictive prob-
lems) and individuals suffering from psychiatric disorders in addition to
their drug problems. Another specificity concerns the frequent involvement
of families (Goethals, Soyez, Melnick, De Leon, & Broekaert, 2011).
This system has distinguished itself over time from the Anglo-Saxon
model, based on individual growth, and the American model, based on
self-help therapy.
Access to social and health service by substance users is not direct.
Primarily, the user must contact the outpatient services that decide the
necessary treatment: in case residential treatment is considered necessary,
service is delivered to the user at home. At this stage starts what is com-
monly known as the ‘admission process’, which ends with takeover/accept-
ance of the user into the residential service.
As we have seen, residential interventions for psychotropic substances
users have developed since the early 70’s up to now. Interventions evolved
from an improvised volunteer movement to an institutionally acknowl-
edged system which is integrated with public services. This brought about
significant systematisation and formalization of the intervention methods.
The formalization of methods has brought to light the differences in the
operations of the communities at various services (Kaneklin & Orsenigo,
1992), and it was possible to identify three types of communities (Table 1).
Even if the three types of services operated simultaneously, a historical
evolution can be observed from a prevalence of ‘A’ type services to a preva-
lence of ‘C’ type services.

The CEAL association (Lombardia coordination accredited and

authorized organization)
CEAL is an organization of social promotion which to which 66% of
accredited and authorized communities in the field of prevention, cure,
and reintegration of drug users are affiliated. The receiving capacity of resi-
dential services registered with CEAL totals to 1468 drug users.
6 A. IUDICI ET AL.

Table 1. Types of communities.

Type A
The communities oriented toward
the transmission/imposition of
adequate behavioral models
Consider the user as dependent on
and a subject to the institution
The core of the intervention lies in
meeting ‘good subjects’ and
dealing with hierarchy, control,
and participation in the
therapeutic groups
The task of this community is to
save, heal, correct, and contain
The therapeutic process ends
within the community
Operators are mainly ex-drug users
and the direction of the
community is in the hands of a
charismatic leader
Type B
The Communities oriented to
move/nurture users
Consider the user though the light
of his positive resources
The core of the intervention lies to
provide the person with the
necessary means for maturation
such as job, study, community
life organized in a familiar way,
and periodic ‘assessment and
planning meeting’
The task of the community is to
‘give, transmit, and provide the
user with notions, emotions,
and experiences
The community represents a step
in the therapeutic process, the
final objective is the
reintegration of the subject
into society.
Staff is composed of educators
Type C
Communities oriented to
understanding behavior
Consider the user not aware of
their actions and
personal history
The core of the intervention lies to
facilitate the growth of the
individual through group
therapy and community life
(meetings, work, study)
The task of the community is to
‘sustain and support substance
users even in the more
regressive moves. Hypothetical
problems of dependence are
considered as a part of the
growing process, therefore,
temporary and reversible
The community is just a step in
the therapeutic process
Staff is composed by specifically
trained operators

CEAL is made up of private organizations that have been authorized to

operate in the sector by the Italian Health Service (SSN) and that manage
services accredited to the SSN according to criteria defined by specific rules
that do not offer any specification regarding the admission process of drug
users. Within the Italian Healthcare System, these services are equated to
Public Services even if they are managed by private organizations. Among
the services, we find all types of services for addictions: residential and
semi-residential pedagogical and therapeutic-rehabilitation services, special-
ized residential services (double diagnosis, alcohol addictions, families),
prompt reception services, low-level services care intensity, outpatient
addiction services, harm and risk reduction projects, prevention projects,
projects for adolescents and families, projects for gambling addiction.
The main aims, shared with all the bodies adhering to the CEAL, are
the following:

 activate synergies to enhance and innovate the offer of services, with a

view to early engagement in a constantly changing context;
 delegate to CEAL the representation by all the adhering bodies, so that
it can become a recognized interlocutor by the regional, provincial and
local institutions;
 JOURNAL OF ETHNICITY IN SUBSTANCE ABUSE 7

 support and represent, in a unified way, the needs and aspirations of

the associated bodies, protecting their rights;
 offer the Region of Lombardy a clinical and planning contribution in
the organization of the network of addiction services, by participating
in regional, mixed public and private worktables;
 promote the culture of solidarity and protect users’ rights.

CEAL purposes have allowed the realization of this study which aims to
develop knowledge that allows the innovation of the service system.

Research
Participants
The study involved sixty directors of residential or semi-residential com-
munities and drug service accredited by the National Healthcare System of
Lombardia Region in the field of prevention, cure, and reintegration of
substance users are affiliated. The work of CEAL began in October 2015
and ended in March 2017 and has been conducting the meetings to discuss
the procedures and problems to bring uniformity among the former and
solve the latter. During that period, the managers participated in fifteen
study-days (at monthly intervals) to analyze the set of problems involving
major organizational processes linked to the provision of the services: the
quality assessment aimed to build standardized procedures for each process.
Moreover, the working group shared the indicators used in the supervision
and management of these difficulties.

Objectives
This study pursued the admission process with the following objectives:

1. Define and share major interactive and organizational problems con-

cerning the welcoming process at CEAL accredited structures;
2. Define and standardize a protocol of procedures aimed at managing
and supervising the admission process, through specific and commonly
agreed indicators.

The final step of the research aims to make this procedure generalizable
to the whole regional health-care system and to other health-care systems
with a similar structure, with regards to the provision of substance
user services.
8 A. IUDICI ET AL.

Methods: the focus group

Focus group is a research technique suited to gather ideas, comments,
judgements, and opinions from a team of professionals on a specific topic
(Bertin, 2009; Migliorini & Rania, 2001). Zammuner (2003) defines the
focus group as a qualitative technique to detect data. This may be used as
an instrument either in marketing or in academic field. Its authorship is
attributed to Robert K. Merton who, in 1941, ideated the focus group inter-
view, aiming to evaluate the efficacy of some radio programs sponsored by
the government (Bloor, Frankland, Thomas, & Robson, 2002). Generally,
focus groups are activated to investigate the effects of a product or a pro-
ject, to formulate hypothesis, to test an instrument, to analyze results, to
corroborate a working hypothesis or to gather information through ques-
tions addressed to a select group. The focus group offers access to mean-
ings, processes, and rules within a group. The representations of the
inquiry object derive from collective constructions woven into normative
orientations (more or less explicit). According to Barbour and Kitzinger
(1999), focus groups are recommended when the aims of the research are:

 Explore how different perspectives and points of views are constructed

and expressed
 Study the people’s attitudes and experiences about specific topic
 Analyze how knowledge, ideas and communication processes are
socially built

In the present research, focus group was composed of managers of resi-

dential and semi-residential services registered with CEAL. The researchers,
playing the role of the moderators, selected the questions that could allow
the participants to offer texts relevant to research objectives. Text analysis,
firstly, facilitated the identification of the organizational processes followed
in all the services. Secondly, it helped in defining the problematic aspects
and management indicators of the said processes.

Data collection and analysis

The answers collected (See Supplementary Data 1) were offered by the
teams of sixty services with different types of offer/user: male/female, resi-
dential and semi-residential, pedagogical and therapeutic-rehabilitation
services, specialized residential services (double diagnosis, alcohol addic-
tions, families), prompt reception services
During meetings, we asked to each of the participants to fill a form that
indicated the major problems linked with the process of admission. This
step was aimed at identifying horizontally the services’ problems with the
 JOURNAL OF ETHNICITY IN SUBSTANCE ABUSE 9

Table 2. Problematic aspects and management indicators.

Problematic Management indicator
1. Thorough collection of information, Presence/absence of documents useful to the project
documents and diagnosis construction and to user’s management.
Compilation of highlighting Form
2. Waiting lists management Presence of explicit criteria for waiting
a. Time management lists management
Declaration of frequency of updating of waiting lists
b. Visibility of places availability Difference between estimated and effective
c. Definition of shared criteria within intervention times
the service for the setting of priorities Declaration/supervision of time admission of a
d. Management of requests from new user
diversion/probation Coherence between personal need and community
characteristics
3. Request relevance Type of certification
a. Type of service Therapeutic offer: coherence between request and
offer objectives
b. 3.2 Task sharing Presence of explicit objective collection (by SerT/SMI
and user)

process of admission. The form asked the following question: ‘What are the
problems that characterize the admission process in your service?’
Problems reported by the services were transcribed in a table omitting
the names of the authors in order to present the result as a product of the
joint effort of the group. This approach avoided attribution of responses to
any specific service or managing director, and to avoid requests for per-
sonal reasoning or explications. These responses were used as material for
the workgroup in the meetings that followed. The workgroup was divided
in subgroups of 4/5 service managers to activate focus groups with the
following tasks:

1. Analyze answers reported in the form, sorting out the statements linked
to problems and the statements linked to other topics.
All responses that did not refer to issues and indicated anything else
have been eliminated or rephrased in a relevant way. The focus groups
classified the responses ‘not relevant’ when they did not indicate any
specific problematic of the welcoming phase.
2. Clustering the answers and classifying them under various commonly
faced difficulties
Each of the responses that indicated a problem was placed in a cluster.

Afterwards, products of the subgroups’ efforts were discussed at the plen-

ary level, explicating analysis and the defined sets of problems, and as iden-
tifying the problems concerning the admission process that were relevant
to the whole group. For saturation, each response was placed in specific
categories representing the data (See Supplementary Data 1 and Table 2).
On the basis of problematic aspects defined at the first stage of work, man-
aging indicators were formulated to help the services to monitor the
10 A. IUDICI ET AL.

management of the process. The analysis of the admission process at the

services required four plenary meetings and four meetings of
each subgroup
Second stage of the work consisted of activating the focus group to facili-
tate everyone to participate. The work concluded with a meeting of the
plenary group for revising and validating the defined indicators. The pro-
cess ensured that the product and the relevance of the indicators to the
defined problems were visible to the whole group. The plenary work con-
sisted of the presentation of subgroups’ products and work strategies and
eliciting explicit question within the group to promote verification and val-
idation of the relevance of the indicators to the defined problems.

Findings
Identification of sets of problems: data and general comments
The initial question was posed to twenty-two residential substance users’
services teams—resulting in 82 different answers. The number of answers
and the wide differences among them attested to distinctly different
approaches to the process of admission, as highlighted by literature ana-
lysis. The highlighted aspects were: differing focuses on interest and habits,
a great variety of problems perceived by each director, a set of problematic
outcomes generated by non-formalised management of the admission pro-
cess, and, consequently, reduced possibilities to identify the manner of
intervention aimed at improvement.
Following are some example of answers to illustrate the situation.
‘Information about the possible need for psychiatric assessment or pharmacological
support are generally scarce. If the user came already compensated, the integration
would probably be faster and less risky’ (See Supplementary Data 1, Answer 3)

‘The number of personnel on our staff dedicated entirely to knowledge interviews and
evaluation for entrance into the community is inadequate. If we had more such
persons, it would result in reduction of working time during the day and reduction of
the knowledge interviews to be conducted by each person to the minimum’
(Answer 29)

‘The incidence of pluri-diagnosed persons has increased. It is difficult to respond to

them with the programmes that we have’. (See Supplementary Data 1, Answer 73)

These examples clearly illustrate, the confusion between outcomes and

processes, which poses risk of a strong impact on management strategies,
efficacy of services, motivation of the operators, and users’ satisfaction.
Answers generated by the focus groups were re-elaborated and discussed
by participant under the supervision of the focus group moderator. Nine
elements out of 82 were identified as related specifically to the process of
 JOURNAL OF ETHNICITY IN SUBSTANCE ABUSE 11

admission. This step reduced the number to a manageable level and

enabled the services to re-configure the admission process as the first inter-
vention opportunity with the user.

Crucial/decisive (or problematic) aspects in the admission process

The following aspects have been identified by the focus group as crucial in
the process.

Thoroughness in the collection of information, documents and diagnosis

Many of the answers collected through the forms were related to the prob-
lems stemming from the absence or the lack of information about the
users. As stated earlier, it is fact that no advance interventions are possible,
except for the late ones, who come after the problem has already been
identified (See Supplementary Data 1, answers 1, 3, 5, 13, 22, 39, 77). The
lack of information may have serious consequences on the intervention,
and, therefore, on the user as well. For example, incomplete or fragmentary
information about users’ health or about their legal status can undermine
the success of treatment from both the healthcare and judicial points
of view.

Waiting list management

The management of the waiting lists represents a crucial aspect of the gen-
eral management; the focus group identified three main issues:
a. Prompt provision of intervention
Providing prompt intervention is essential to address the reasons for the
intervention request. Before the focus group’s work, services met difficulties
and problems in the management of waiting lists and thought these were
intractable. They just accepted the lack of management as a fact. As a
result, there were periods when the waiting list had very few entries and
other periods when the waiting lists were very long. With the waiting lists
were long the services could not respond promptly to every request, prob-
ably leading to worsening of some cases due to prolonged wait (See
Supplementary Data 1, answers 4, 14, 17, 31, 35, 36). Repercussions were
even wider because the delivering services would begin to consider a center
as temporarily unavailable, resulting in its remaining inactive afterwards.
Therefore, fewer users were likely to access the services than the actual cap-
acity for the territory.
b. Visible availability of services
As stated above, an active management of waiting lists may anticipate or
avoid the intermittent periods of high and low activity of the services.
12 A. IUDICI ET AL.

Before the focus group’s work, the presence of periods with high request
and no availability alternated with periods with no request and service
availability were accepted as an inherent peculiarity of this service (See
Answer 4). The focus group’s work delved into the levels of complexity
implied in providing this type of service. This helped to create the aware-
ness that these levels exceeded the simplistic assessment that the user that
delivered and residential services are both continuously sharing information
about opportunities on both sides (the availability of residential services
and requests arrived for delivered services). Though, this work may appear
secondary or irrelevant from therapeutic point of view, it has actual impact
on the system capability to respond to territory necessities.
c. Definition of service shared criteria for prioritization
The absence of service shared criteria for waiting lists management gen-
erated conflicts within the organization that reduced the efficiency and effi-
cacy of the service itself. Therefore, the focus group let each structure
identify its priority criteria in waiting lists management. Even the definition
of shared criteria for the identification of priorities requires a complex ana-
lysis, which does not only consider the availability of places in the structure
but even anticipates on the user-community group’s interaction, and the
relation between the type of request and the type of the supplied service;
on the situation’s urgency and the possibility of further development, and
on the objectives defined by the delivering service (See Answer 66).

Request relevance assessment

The denominated ‘Request relevance assessment’ is a crucial aspect; it has
been structured in two specific dimensions.
a. Relevance of the request to the type of service
The match between type of service and user’s necessities represents a
crucial aspect, which if ignored, may lead to admission of users whose situ-
ation would not benefit from the intervention offered by the service. On
the other hand, it may lead to inaccuracies that might strongly impact the
user, the community group and the staff (See Supplementary Data 1,
answers 4, 29, 41, 47, 81).
b. Task sharing
Eventually, the task shared by the community with the user and the
delivering services needs to be managed so as to avoid problems or mis-
takes in the admission process. Deficiency in task sharing leads to interven-
tions which pursue objectives that are unrelated to the request for
delivering services or to users’ necessities, thus impacting negatively on
clinical treatment, which may be considered inadequate to the above neces-
sities (See Answers 33, 47, 74, 75).
 JOURNAL OF ETHNICITY IN SUBSTANCE ABUSE 13

Management indicators of crucial aspects of admission process

After the definition and sharing of problematic aspects concerning the
admission process, criteria for the management assessment were defined.
This enabled each service to identify and define specific strategies for
enhancement of the admission process. We report defined indicators for
each problem.

Collection of information through documents, and diagnosis

The management of this problem was examined through two indicators:
a. Presence/absence of documents useful to the construction of treatment
strategy and to user’s management.
The first management indicator detects the presence of documents to be
collected during the admission process: Territorial services entrance report;
Identity documents; Health insurance card; Residence certificate; Residency
permit (for non-European citizens); Pharmaceutical prescriptions;
Addiction certification—with treatment instruction to the specific service;
Healthcare exemption.
b. Compilation of the Reporting Form
The second indicator detected was the compilation of the Reporting
Form which specifically asks the delivering service to indicate: Anamnesis,
Healthcare/psychiatry relevant information (and related documents: diagno-
sis, therapy, clinical exams), Legal-judicial position, The history of con-
sumption of psychotropic substances consume history, Prior clinical
treatments, Social condition: working, housing, level of education, Services
related to the different necessities, Identification of the contact person in
the delivering service, Objectives of the required intervention,
Psychological assessment.

Waiting lists management

The following indicators relates to the problems of waiting
lists management:
a. Presence of explicit criteria for waiting lists management
This indicator allows to share within the service the, criteria for waiting
lists management.
b. Declaration of the updating frequency of waiting lists
It is useful that services update their waiting lists periodically, otherwise
its management will be problematic. The frequency of updating has to be
defined by each service/body with reference to its management necessities.
This update is necessary as well as the declaration of its frequency.
c. Difference between estimated and effective intervention times.
14 A. IUDICI ET AL.

Waiting lists’ management requires the estimation of time needed for conclud-
ing other interventions; this allows for anticipating the availability of services
other users. The estimated times and the actual time taken are likely to be differ-
ent: the smaller this difference is, the better is the waiting list management.
d. Declaration/supervision of time admission of a new user
Given the length of some waiting lists, a declaration of the estimated
waiting time (and its supervision) will help in monitoring the above differ-
ence between the estimated and the actual times.
e. Coherence between personal need and community characteristics
This indicator facilitates making of decision about whether it is possible
to admit a new user (offering an adequate service), regardless of the avail-
ability of places on the service.

Request relevance
This problem has been structured as follows.

Type of service. The relevance of request to the type of service is monitored

through the following indicators.
a. Type of certification
The type of certification (document that reports the formal treatment
requested by delivering services) facilitates the evaluation of the type of
intervention requested and the type of service supplied.
b. Therapeutic offer: coherence between request and offer objectives
This second indicator monitors the request characteristics, left undefined
by the normative framework. For instance, the normative does not contem-
plate reintegration services (services characterized by strongly integrating
interventions in order to promote new opportunities for users at the con-
clusion of the intervention). Among the accredited services, some pursue
this particular aim. Requested for services have to be evaluated on the rele-
vance it has with the structure offer.

Task sharing. The task sharing is of core importance to the evaluation of the
request. Therefore, it has to be monitored through the following indicator.
a. Presence of explicit objective collection (by SerT3/SMI and user)
This indicator measures the cohesion between objectives declared by the
delivering services and by the potential users. These will be managed dur-
ing the intervention, in order to respond to the necessities.

Discussion
The focus group’s work enabled the participants to define, in a shared way,
information collecting strategies and the instruments for data checking. As a
 JOURNAL OF ETHNICITY IN SUBSTANCE ABUSE 15

result, the group drafted an Information Collecting Form (See

Supplementary Data 2), which facilitates the information needed for deliv-
ering the services. By highlighting the missing information, the integration
of the latest entrants may be made easier. This was a significant work,
because of the positive influence of the collected information on the effi-
cacy and efficiency of the service. In the past, the absence of the informa-
tion collecting form was a significant hindrance because it increased the
expense on professional fees, time, and material resources in the effort of
gathering information and delayed the process. Thus, gathering the infor-
mation in anticipation of its need certainly should have a positive influence
on this aspect. The use of a single and shared tool for gathering the infor-
mation necessary for the evaluation of the request and the start of the
intervention for 65% of the residential and semi-residential services in the
Lombardy region has impacted the operating methods of the entire
regional system of services for dependencies by starting a process of shar-
ing information useful and necessary for the intervention. Today the send-
ing services know what the relevant information is for all residential and
semi-residential services and can put themselves in a position to collect this
information by facilitating the reception processes.
With reference to the identification of crucial/decisive (or problematic)
aspects in the admission process, the explanation of the need to manage
the time and criteria of the waiting list so that it is useful for the interven-
tion and the definition of specific monitoring indicators has allowed each
service to identify management strategies, priority and evaluation criteria of
the request that are consistent with the objectives of the intervention. In
the absence of this assessment, the criterion used refers exclusively to the
timing of submission of the admission request.
The definition of the problematic relating to the offer of visible availabil-
ity services allowed the CEAL to discuss with the Regional Health System
Authority to obtain a change in the legislation such that, today, all the serv-
ices of the system are required to publish on its website the number of pla-
ces available and the number of people on the waiting list.
The detection of the problem relating to the relevance of the demand in
relation to the type of service questioned the managers on the possibility of
illustrating the services to all the stakeholders. They organized meetings on
the sending services to illustrate the specific characteristics of each service
and they shared improvement actions to respond more effectively and effi-
ciently to requests for intervention in a system vision. They have identified
more precise and usable ways of presenting services to users on websites
and service cards.
The need to share the purpose of the intervention with the user and the
sending services brought the attention of service managers to the specific
16 A. IUDICI ET AL.

objectives of each individualized intervention. Following this analysis,

CEAL modified the user’s report form by introducing the request to indi-
cate the objective defined by the sending service.
The above results involve the movement of the focus from a concept of
the process of intervention as ‘what happens between the professional and
the user’ to a wider concept: the intervention starts before the drug user
has actually become a user of the community and continues after he has
left it, for example, reintegration into the Labor market and its mainten-
ance (Maarefvand, Babaeian, Rezazadeh, & Khubchandani, 2017; Magura &
Staines, 2004). In fact, what happens in the therapeutic treatment cannot
be considered regardless of what happens at other levels of the organiza-
tion—sometimes it comes as an outcome of the latest (Pawson, 2013; Iudici
& Corsi, 2017).
During focus groups, participants became aware that various problems
were the result of practices aiming to respond to the normative framework,
rather than to an adequate and responsible reflection. The analysis of serv-
ices has led to different ways of picturing and dealing with procedures:
from impeding obstacles to resources and opportunities for professionals’
and services growth. In fact, once it was acknowledged that problems were
sustained by a certain way of operating, participants moved from an execu-
tive approach to a managemental one: they individuated horizontal practi-
ces to prevent the problematic situations which had generated in the study
itself (Iudici, Castelnuovo, & Faccio, 2015). Along with that, they individ-
uated indicators to supervise how these practices are applicated.
According to the participants, the path taken through the focus groups
has led to a more intense self-reflection about the way users of therapeutic
communities are managed.
This shows how important it is to implement training interventions that
help professionals to recognize their biases and errors in order to limit
their scope.
The management of the admission process as part of the intervention
leads to creating advantageous conditions for the substance user to find an
adequate response to his/her situation within appropriate service and at an
appropriate time, as well as supported by international research (Haigh &
Worrall, 2015; Paget et al., 2015; Pearce & Pickard, 2013).
In this sense, the results of this research indicate that the potential users
select the service based on elements that do not deal with therapeutic
objectives (for example, the presence of recreational activities, the permis-
sion to have a mobile phone or to move autonomously out of the struc-
ture); many ‘dropouts’ (interruptions in therapeutic treatment) are linked
to the fact that users do not find what they are looking for in the service
they have been admitted to. As a result, they migrate from one service to
 JOURNAL OF ETHNICITY IN SUBSTANCE ABUSE 17

another one on the basis of availability of the desired structure, sometimes

giving up to the idea that an intervention would be useful to them
(Palumbo et al., 2012). The theories behind these decisions substantially
undermine the potential of the system to trigger a responsibility in the
choice of treatment or to recommend a personalized and shared treatment.
In addition, the meetings between the various residential services on defin-
ing how to meet the demands of drug users have made it possible to identify
proposals that can be made to the legislator to promote the production of
legislation that is more in line with the needs and objectives of the services.
It is precisely for this reason that the research shows the need to pro-
mote a continuous synergy between service provision and residential care,
so that the provision of interventions reaches the territory and citizens
beyond the specific tasks (Torrigiani, 2014b). Therefore, the construction of
shared practices between the services therefore also becomes a way to inter-
fere at a cultural level with those beliefs that are not useful for the pursuit
of care objectives (Faccio et al., 2017; Turchi, 2007; Turchi & Della, 2007).

Conclusions
The present work highlights the close link between ways of managing the
organizational process of a service and its capability to respond to users’
necessities.
Furthermore, the meeting of all residential services has created advanta-
geous conditions not only for responding to normative requests but also
for structuring proposals to the legislator. This shift promotes legislation
linked to territorial and services necessities and objectives.
Moreover, taking over the governance of its own processes also allows
residential services to be recognized as an active part of the service network
and not just as the executive arm of a client (the sending services).
This study highlights the transformative power of involving a large num-
ber of services: the same outcomes could have not been reached if every
service had operated individually.
This data also responds to a problem reported in the literature: the
excessive fragmentation of the interventions of the remarkable communities
present in the reality of Italian services (Angelini et al., 2017;
Vanderplasschen et al., 2014; Vigorelli, 2014).
A coordinating body like CEAL becomes fundamental in order to
enhance co-working and related increase of services offering quality—not
only in the substance use field. This opens the access to a heritage of
instruments and practices for the following: detection of formative necessi-
ties of service staff; elaboration of proposals for legislators; identification of
shared practices and indicators to assess their application; and promotion
18 A. IUDICI ET AL.

of a territorial culture which allows the meeting of requests and offers—in

order to move toward the same goal, the cure.
There is no regulatory framework for this process, although it is an integral
part of the intervention. Indeed, we find no specifications of requisites in the
legislation. However, the management of this process is vital to the services
themselves, as also recommended by several international studies on stand-
ards (Marsden et al., 2000; Paget et al., 2015; Serpelloni et al., 2006).
It begins before the service takes on the responsibility of the user in the
residential center. The process of admission paves the way to the process of
acceptance, and therefore, is central to the intervention itself. In fact, the
admission process is an opportunity for both the services and their intend-
ing user to share their intervention objectives, thus tracing the relevant var-
iables, and the adequacy of the request, which are also the elements
necessary for the management of the waiting list. To sum up, it is a good
opportunity to gather the necessary information for further intervention. It
is evident that step is not taken into consideration by the legislation, is evi-
dent because, for this entire process, no remuneration is provided to the
volunteers. In fact, boarding costs for residential and daytime services are
paid only from the admission fees of the user to the service.
In order to organize the entire process, the law requires nothing more
than a waiting list. However, in some clinical scenarios and on certain con-
siderations the entire process cannot be reduced to such a simplistic strat-
egy. The admission process is a proper part of the intervention and it
substantially influences further development of the therapeutic work
(Bruschetta & Barone, 2015; Madeddu, Fiocchi, & Pianezzola, 2006).
Therefore, it is essential that the therapeutic significance of this process is
acknowledged by going beyond its ‘informative’ appearance, by not pictur-
ing it as a ‘pre’ stage but as a ‘part of’ the entire process of intervention.
This study made it possible to analyze the management of the admission
phase in addiction residential and semi-residential services. The impact of
the results of this study on the operational practices of the services can
stimulate the development of research also on other processes that charac-
terize the treatment and that Ceal’s Services have in common, such as the
evaluation of effectiveness, the personalized design of the intervention,
teamwork, and the conclusion and discharge of the intervention. We hope
that other researchers will be able to further develop studies across services
and generate more and more shared practices.

Notes
1. Researchers are well aware that the term “drug addicted” is to be considered obsolete
and inappropriate as it may elicit negative stereotypes and stigmatization. Nevertheless,
the Italian legislation, as well as the service provision system, still use this terminology.
 JOURNAL OF ETHNICITY IN SUBSTANCE ABUSE 19

2. Decree of the President of the Republic. No. 309 of October 9th 1990. Consolidation of
the laws governing drugs and psychotropic substances, the prevention, treatment and
rehabilitation of drug addicts.
3. Psychotropic substance users outpatient Service.

Disclosure statement
The authors declare that they have no conflict of interest.

ORCID
Antonio Iudici https://orcid.org/0000-0002-9630-5989

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