British Journal of Addiction (1992) 87, 1631-1636
PRACTICAL BUSINESS OF TREATMENT—24
The opening of a high care hostel for problem drinkers HARRIET BRETHERTON Rugby House Project, 8/9 Long Yard, London WCIN 3LU, UK
Abstract This paper gives a personal and practice based account by one of the Team Leaders of the opening of a highcare hostel for problem drinkers in North London. The hostel, Rugby House, was set up to provide detoxification and assessment facilities for thirteen residents. It was part of the Rugby House Project, an alcohol agency in the voluntary sector. The paper explores the processes involved in setting up a new project; how the new paid employees turn a committee's vision into practice; how a group of individuals become a team; the importance of clarity about boundaries and underlying values and assumptions; the need for openness about negative as well as positive feelings; and the recognition that some of the experiences of staff will resonate with those of the residents for whom giving up drinking is a major life change.
Introduction Being involved in starting up a new project is like starting out on the exploration of unknown territory. Like so many of the best journeys, best in retrospect at least, you set out with only the haziest picture of what will be involved and the places you will visit. The new project was a highcare hostel for problem-drinkers, Rugby House, which opened its doors in January 1991. In describing my par^n the journey I hope not only to give a picture of the landscape and environment through which I have travelled but also to examine the impact the voyage has had on me. In the summer of 1990, my eye was caught by an advertisement in the Inner London Probation Service Circular for a 3-year secondment to the Rugby House Project as one of two Team Leaders to set up and run a "highcare hostel for problem drinkers in the Holborn area". I had been a Probation Officer in
Correspondence to: Harriet Bretherton, 128 Bamsbury Road, London Nl OER, UK.
London, on and off, part-time and full-time for 20 years. I now wanted a change of scene. This seemed to offer the prospect of doing something quite different but at the same time using the social work skills I had acquired over many years. I hoped to get some experience of management, more specialised knowledge of a particular client group, the opportunity to work in the voluntary sector and most important of all, the chance to have a hand in creating a project from scratch. The package seemed attractive, just what I needed to blow the cobwebs away. I applied for the job and got it.
The Rugby House Project The Rugby House Project (RHP) had been set up by a consortium of statutory and voluntary agencies in North London in order to meet gaps in the provision of services in the alcohol field in that area. Two main deficiencies had been identified. First, there had been no agency providing a consultancy
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and training service on alcohol issues to professionals whose primary task was not in the alcohol field, such as Probation Officers and Social Workers. When I joined the Project, this work had already been started by the Mobile Alcohol Service, part of the RHP, which employed three workers. Second, there were an inadequate number of beds for detoxification in the capital. This was the need the hostel was set up to redress by providing thirteen beds for men and women. From 1986, the Coordinator and Management Committee of the RHP worked together to raise the capital and running costs for a detoxification and assessment centre. A building in Holborn was renovated and converted for this express purpose. The building work was completed in December 1990 3 months after I joined the Project. Both the building work itself and the furnishing were to a high standard. However, space was limited which has constrained management and programme options, for example by making it difficult to provide for any physical activities in the hostel. In September 1990, with the other hostel Team Leader, I embarked on a crash course (an induction programme) to familiarize myself with the other agencies in the alcohol field who would be referring to the hostel and to whom we would refer. I discovered a rich and varied ecology, a wide variety of colourful and large fish swimming in what seemed to me then a surprisingly small pool. It was all very exciting. At the same time I was getting to know my new colleagues and trying to understand in detail the intentions of the Management Committee as expressed in the comprehensive Operational Handbook and Policy and Procedures Handbook. These provided the framework on which we were to elaborate the procedures and practice of the hostel. Looking back on that period, I can see that I was working hard to make someone else's vision my own, a process which involved dovetailing my beliefs, attitudes and skills to other people's experience and purpose. This is a process which has to occur in every new project when the paid employees arrive to give reality to the committee's vision. It is a process that cannot be rushed and which needs a willingness to work openly and with as much clarity as possible on both sides. One of the main premises of the RHP was that for most people detoxification need not be primarily a medical procedure. A safe and supportive environment was argued to be the key ingredient unless there were exceptional medical or psychiatric factors. Being new to this field, I had to take this largely
on trust, as with the exception of St Dismas in Southampton, at that time all detoxification centres in England employed some medically trained staff. None of the 12 staff at the hostel are employed as nurses though we work closely with a local GP practice. Every new resident is medically examined by a GP who usually prescribes a standard reducing regime of chlodiazepoxide.
Staff induction At the end of October, six Project Workers joined the staff. The full complement was to be 10 by the time the hostel opened in January 1991. The background of the staff was varied, some coming from residental work, some from nursing, others from counselling, one worker was a seconded Probation Service Assistant. The first month was spent on an induction programme which was designed to establish a common basis for practice. Staff learnt how their work at Rugby House fitted into the existing network of alcohol agencies in North London. They began to share their differing attitudes to problem drinking and ways of supporting future residents in stopping drinking. A team was created from a group of disparate individuals in the process of interpreting the Management Committee's policies and procedures and turning them into day to day rules and practices for the hostel. For example, we had to decide whether residents should be back at a certain time in the evening, what time that should be and whether it should be the same weekends as weekdays. We had to learn how to fill in claims for Income Support on behalf of residents. We discussed how to manage detoxification. The induction programme was drawn up and run by myself and the other Team Leader for the hostel. We were to manage the hostel together as equals reporting to the Coordinator who was based at the Project Headquarters and not in the hostel. We both worked to the same job description. In my experience, undifferentiated co-responsibility is an unusual management model, presumably because of the dangers implicit in a situation where there is no built-in mechanism for resolving confiict and allocating responsibility. We were both aware of the possible pitfalls from the start and realised that to avoid these and use the strengths of the model we needed to be as open as possible with each other and tackle difficult issues between us as they came up. I have valued the personal support that co-working has provided. Under pressure this has allowed us to
TTie opening of a high care hostel be less defensive than we might have been as individuals and often the quality of analysis and decision-making has benefited from two heads rather than one. As we have worked together we have divided up responsibility for certain tasks between us but have remained clear that overall responsibility for the hostel remains with us both. Co-working between the team leaders has been a model for co-working between all staff in the hostel. A minimum of two staff, normally a man and a woman, are on duty 24 hours a day working three shifts. As the maximum stay at the hostel is only 28 days and staff work on a 24-hour rota, we decided from the start not to have a keyworker system. This has meant that all staff are jointly responsible for all residents. Good communication between staff is therefore essential to allow for consistency and effective decision-making. We have developed an elaborate communication system, which depends on half hour handovers between shifts, contact sheets, weekly case reviews and fortnightly staff meetings. It takes time to pass on information, thrash out differences, share perspectives and decide on policies. But it is time that can make the difference between chaos and coherence and between confusion and clarity.
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Maps and underlying assumptions By the end of the 4-week induction programme, we had developed a shared view of what we were intending to do at Rugby House and the means of doing it. It was very roughly summarized in Table I, a crude map for the journey we were about to undertake together. In essence the 'map' shows the four stages residents move through just before and during their stay at the hostel, referral, detoxification, assessment and onward referral. It shows that at the different stages staff offer different kinds of support to the residents and that residents are expected to engage in different activities. It also shows that we expected a stay at Rugby House to be a dynamic experience for the residents in that we hoped their relationship with us would affect them and leave them changed (preferably for the better). Finally we acknowledged that when a resident arrived s/he would start in a dependant (child) position in relation to the staff but that the effectiveness of our work could be measured by their shift to a self-determining (adult) position. More generally we used the time we worked together as a staff team prior to opening to clarify the assumptions underpinning our work. These have provided a point of reference when we have got lost
Table I. High care hostel for men and women in crisis who want to stop drinking' Processes Physical state
Drinking
Withdrawing
Not drinking
Methods of intervention
Tel referral
Detox Medication Physical care Emotional support Admission interview Medical check
Assessment: Groups One to one interviews Physical care Alcohol education Informal support Liaison with agencies Referral onwards
Tasks
Decision making (Is this an appropriate referral?)
Information —purpose —rules
Problem exploration Re-evaluation Action —drinking history contact —why do I drink? group support other —do I want to stop! decision to agencies —can I stop? seek referral —what help can I get? on choices made
Information giving
Dynamic process
Admission —DSS —Info from client —monitoring Provision of medical can! —type and level
Information giving Maintenance of Safety (for referral) —rules/sanctions Improvemem in physical health
Child Provision of a safe physical and emotional environment so that growth can take place Need for containment and boundaries Acceptance of > ADULT/ADULT responsibility for CHILD/PARENT own life
Objectives: (1) ensuring the physical well-being of the residents; (2) maintaining an environment in which residents can begin to understand their drinking and consider future options; (3) help with onward referral.
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or needed to assess our progress. We have three clear and focused objectives, first to provide a safe place for residents to withdraw from alcohol, second to give residents the opportunity to begin to understand the nature of their drinking and third to support them in moving on to an appropriate programme after they leave Rugby House. For myself the notion of 'containment' is important. I saw Rugby House as offering a safe place, not only 'to withdraw from alcohol', but more importantly for needs and feelings to be expressed, 'reality' explored and new behaviour tried out. The notion of 'containment' is difficult to test out and demonstrate but in my view underlies our whole programme and indeed is of greater importance than any individual element in the programme such as whether groups are structured or unstructured. Closely allied to 'containment' is another abstract but equally powerful notion, that of boundaries. Central to the brief given to us by the Management Committee was the no drink/no drugs rule (apan from prescribed medication). We felt that because residents had only just stopped drinking when they were with us, we could not operate a relapse management programme as the messages implied would be contradictory. So if we knew that a resident had used alcohol or a nonprescribed drug we would ask them to leave. This is a policy we have always adhered to. The other clear boundaries are those of time. We expect residents to be in the hostel by 11.00 p.m. and to be punctual at all the groups we run. We will ask a resident to leave if they arrive back after 11.00 p.m. or if they are twice late for a group. The significance of the time boundaries lies not in the times themselves but in a strict adherence to action following any breach. Finally, the induction programme and the subsequent planning for the opening of the hostel demonstrated the need for staff to be involved at all levels in decision making. Together we had to turn policy into practice. This meant first debating and making the policy our own and then devising the systems for implementing it. We had to be clear about who we would admit, how we would take referrals, how we would care for residents while they were withdrawing from alcohol, how we implemented the Project's equal opportunities policy, in what circumstances we would ask a resident to leave, what records we needed to keep for what purposes, what we meant in practice by confidentiality, what statistics should be kept.
From nothing we created a culture that allowed us to operate satisfactorily as soon as we opened our doors and which has developed organically as we have become more skilled and experienced. Every member of staff could pick out certain 'cultural' features that he or she contributed, but equally many other features are the product of joint debate and experiment. Imposition of ideas and methods from the top could not have produced the enthusiasm, the creativity, the hard work and the commitment that have emerged in a staff team trusted with the responsibility for developing and running a project.
Anxiety With the excitement of creation went the anxiety. This was an emotion that coloured much of the period prior to the opening of the hostel. I learnt just how powerful it was for me on the day HRH Prince Andrew formally opened Rugby House. I had arranged for a member of staff to use my camera to photograph the occasion, the Prince going round the hostel, cutting the cake, the speeches. Imagine my horror when it was all over and I discovered that I had failed to load the film correctly. We had no photographic record of the occasion. I realised that because of the high level of my anxiety I had not checked the film properly. I also realised that it was quite appropriate for us all to be anxious. Were we going to be able to do the things we said we would do? Would we make utter fools of ourselves? Were we allowed to make mistakes? We began at this point to take tentative steps to being more open with each other about uncomfortable feelings. We needed to be able to listen to our own and each others fears, frustration and disappointment, if we were to be available to residents experiencing the same feelings. And I needed to find a better way of recognising stress than by leaving the film out of the camera! The hostel opened on the 2nd January 1991. Two residents were admitted that day and the hostel was full within 2 weeks. It was a relief to be doing the job after so many months of planning. We all knew that planning can only take you so far. Inevitably many major and minor adjustments have to be made as soon you get going. There are a hundred and one unforeseen and unforeseeable circumstances. And the team has to learn to work together through the fierce and compelling pressures of day-to-day work with residents. The first 3 months were a time of immensely hard
The opening of a high care hostel work and improvisation. We had to devise more and more forms for our own records, to cope with the Department of Social Security and to collect the statistics we needed. In the first month the cook resigned. For 2 weeks we struggled with ordering food and arranging for residents to do all the cooking which they resented. Most difficult of all, we became aware that we disagreed about methods of working and particular decisions. One shift would be critical of the decisions taken earlier on another shift. Our resources for resolving differences were painfully inadequate. It was easy to become defensive and blame others, in this respect often mirroring similar processes in the resident group. Is it possible to avoid this uncomfortable stage at the beginning of a project? I doubt it. Working effectively together means learning where your colleagues differ from you and why, and above all how to use these differences creatively. We were much exercised at this time with our decisionmaking process. What decisions could be taken by two people on a shift? by four at a handover? by the staff at the weekly case review? by the whole staff team? by management? Early on we decided to have fortnightly instead of monthly staff meetings which gave us badly needed time to discuss many of these issues. We also decided to use a facilitator for the staff group on a monthly basis. This facilitator acted as consultant to the two team leaders. The increased staff meeting time and the facititator gave us the opportunity to begin to understand what was happening and some tools for coping with the stresses.
Learning from experience In April we held an All Day Review to learn from our experiences in the first 4 months and to use the lessons to modify our practice. The pressures of daily interaction with the residents and with each other seemed to be prising us apart rather than bringing us together. The All Day Review gave us the opportunity to check out our underlying assumptions and beliefs. We were relieved to discover that we shared these to a much greater extent than we had anticipated. The three assumptions that we articulated were, first, that if someone needed to come to Rugby House it was because they had a serious drink problem, second, that a stay at the hostel was only a small part in a much longer process of change that a resident would need to undergo if they wished to overcome their drink problem and, third, that we expected all residents to
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be active in using their time with us. On the face of it, these assumptions may seem basic and obvious, but this was far from the case. Our Policy and Procedures Handbook stated "we made no assumptions about a resident's eventual drinking goal". We had interpreted this as an instruction to make no assumptions about a resident's drinking, either in terms of its severity or the need for a programme to effect change. Our Review Day allowed us to say, "Our residents have a very serious drink problem which they can only effectively tackle by seeking professional help." This was now our position so far as the short and medium term were concerned. We left the 'eventual' to look after itself and not obscure our view of the present. A clear articulation of our underlying beliefs had a significant impact on our practice. We revised our groupwork programme to make it more focussed and relevant to residents who were struggling with recent abstinence and with the need to take pressing decisions about their future. We introduced a first assessment for all residents on their third or fourth day with us, followed by weekly assessments thereafter. The purpose of the assessments was to give residents regular 'preserved' time with a member of staff to look at the nature of their drinking problem and the treatment options open to them. It also gave us the opportunity to monitor whether a resident was using his or her time with us. During the first 4 months of operation, we had become very concerned about residents who we saw as holidaying at Rugby House. We now negotiated specific tasks with residents at the end of each assessment to be completed during the next week. If these were not done, we would discuss what had got in the way at the next assessment. We had a basis for considering asking a resident to leave if the evidence was that he or she 'was just sitting on their backside'. After we changed our practice, which included having a more rigorous expectations of the residents, our statistics showed that a greater proportion left the hostel on a planned basis, that is they left when they said they would go, normally to further treatment. The proportion went up from 40% 'planned leavers' in the first 3 months to 60% in the last 3 months of the year.
The end of the beginning By the Autumn of 1991, Rugby House was no longer a new project. The initial phase of creation was over. The staff shared a common sense of purpose, there was a greater feeling of mutual respect, and we knew
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that we competently performed our tasks, both individually and as a staff group. But with the end of that first phase came a sense of disillusionment which we sometimes experienced as anger and betrayal. Creation involves vision and vision always has elements of idealization and fantasy. Despite the fact that we were experienced adults working in the real world, at a conscious and unconscious level, we entertained the illusion that we were creating a perfect high care hostel and a perfect place to work. The end of the beginning is perhaps the recognition that the work has limitations, that colleagues let one down and worse of all that one's own contribution is flawed. What son of a place was Rugby House after the first 9 months? What mini-culture now existed were none had been before? Before we opened we had been clear that an important part of a resident's experience at Rugby House would be due to a shift from the dependant, child position during physical withdrawal to an adult position of responsibility in the post detoxification phase. At its most basic, the resident had to be responsible for not drinking, for living in a community and for taking decisions about involvement in a further programme. The first 9 months of practice confirmed that our initial theoretical position had been correct. Above all Rugby House offered a safe physical and emotional environment in which residents could begin to understand their own needs better and experiment with changed behaviour. A painful lesson for me of those first few months was that it is one thing to talk in theoretical terms of 'a safe physical and emotional environment' and quite another to live and work in it. Such an environment is one where staff and residents relate to
each other as human beings with as much openness and honesty as each can muster at the time. Feelings are often strong and raw. The anger, despair and vulnerability of the residents finds echos in similar feelings in the staff group. The 'safe environment' can feel far from safe. Paradoxically, the capacity to feel vulnerable and anxious is the spur to understanding and experimentation with changed behaviour. This is as true of the resident, the staff team and team leader. 'Safety' in an institution such as Rugby House lies in a commitment to listen and to search for the meaning behind overt statements and behaviour. There are no doubt as many arguments, frustrations and disappointments at Rugby House as at any other similar project, but during the first months of the project we began to appreciate the importance of understanding what lay behind them and to use this understanding in our work as a team on behalf of the residents. I started this anicle by likening the creation of a project to a journey. I should have said to many simultaneous journeys. There was amongst the staff a richer and more profound understanding of what helps people to change and what makes change difficult. There was my professional development from fieldworker into manager. There was the transformation of a group of individuals into a functioning team capable of helping a distressed and vulnerable client group. Finally, there was the journey each and every resident made while he or she was at Rugby House. In a number of ways my experience of being part of a new project has paralleled the experience of the residents at Rugby House. There has been the same desire to start afresh, to rediscover and use past strengths, to learn new skills, to gain knowledge.
PRACTICAL BUSINESS OF TREATMENT—24
The opening of a high care hostel for problem drinkers HARRIET BRETHERTON Rugby House Project, 8/9 Long Yard, London WCIN 3LU, UK
Abstract This paper gives a personal and practice based account by one of the Team Leaders of the opening of a highcare hostel for problem drinkers in North London. The hostel, Rugby House, was set up to provide detoxification and assessment facilities for thirteen residents. It was part of the Rugby House Project, an alcohol agency in the voluntary sector. The paper explores the processes involved in setting up a new project; how the new paid employees turn a committee's vision into practice; how a group of individuals become a team; the importance of clarity about boundaries and underlying values and assumptions; the need for openness about negative as well as positive feelings; and the recognition that some of the experiences of staff will resonate with those of the residents for whom giving up drinking is a major life change.
Introduction Being involved in starting up a new project is like starting out on the exploration of unknown territory. Like so many of the best journeys, best in retrospect at least, you set out with only the haziest picture of what will be involved and the places you will visit. The new project was a highcare hostel for problem-drinkers, Rugby House, which opened its doors in January 1991. In describing my par^n the journey I hope not only to give a picture of the landscape and environment through which I have travelled but also to examine the impact the voyage has had on me. In the summer of 1990, my eye was caught by an advertisement in the Inner London Probation Service Circular for a 3-year secondment to the Rugby House Project as one of two Team Leaders to set up and run a "highcare hostel for problem drinkers in the Holborn area". I had been a Probation Officer in
Correspondence to: Harriet Bretherton, 128 Bamsbury Road, London Nl OER, UK.
London, on and off, part-time and full-time for 20 years. I now wanted a change of scene. This seemed to offer the prospect of doing something quite different but at the same time using the social work skills I had acquired over many years. I hoped to get some experience of management, more specialised knowledge of a particular client group, the opportunity to work in the voluntary sector and most important of all, the chance to have a hand in creating a project from scratch. The package seemed attractive, just what I needed to blow the cobwebs away. I applied for the job and got it.
The Rugby House Project The Rugby House Project (RHP) had been set up by a consortium of statutory and voluntary agencies in North London in order to meet gaps in the provision of services in the alcohol field in that area. Two main deficiencies had been identified. First, there had been no agency providing a consultancy
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Harriet Brethenon
and training service on alcohol issues to professionals whose primary task was not in the alcohol field, such as Probation Officers and Social Workers. When I joined the Project, this work had already been started by the Mobile Alcohol Service, part of the RHP, which employed three workers. Second, there were an inadequate number of beds for detoxification in the capital. This was the need the hostel was set up to redress by providing thirteen beds for men and women. From 1986, the Coordinator and Management Committee of the RHP worked together to raise the capital and running costs for a detoxification and assessment centre. A building in Holborn was renovated and converted for this express purpose. The building work was completed in December 1990 3 months after I joined the Project. Both the building work itself and the furnishing were to a high standard. However, space was limited which has constrained management and programme options, for example by making it difficult to provide for any physical activities in the hostel. In September 1990, with the other hostel Team Leader, I embarked on a crash course (an induction programme) to familiarize myself with the other agencies in the alcohol field who would be referring to the hostel and to whom we would refer. I discovered a rich and varied ecology, a wide variety of colourful and large fish swimming in what seemed to me then a surprisingly small pool. It was all very exciting. At the same time I was getting to know my new colleagues and trying to understand in detail the intentions of the Management Committee as expressed in the comprehensive Operational Handbook and Policy and Procedures Handbook. These provided the framework on which we were to elaborate the procedures and practice of the hostel. Looking back on that period, I can see that I was working hard to make someone else's vision my own, a process which involved dovetailing my beliefs, attitudes and skills to other people's experience and purpose. This is a process which has to occur in every new project when the paid employees arrive to give reality to the committee's vision. It is a process that cannot be rushed and which needs a willingness to work openly and with as much clarity as possible on both sides. One of the main premises of the RHP was that for most people detoxification need not be primarily a medical procedure. A safe and supportive environment was argued to be the key ingredient unless there were exceptional medical or psychiatric factors. Being new to this field, I had to take this largely
on trust, as with the exception of St Dismas in Southampton, at that time all detoxification centres in England employed some medically trained staff. None of the 12 staff at the hostel are employed as nurses though we work closely with a local GP practice. Every new resident is medically examined by a GP who usually prescribes a standard reducing regime of chlodiazepoxide.
Staff induction At the end of October, six Project Workers joined the staff. The full complement was to be 10 by the time the hostel opened in January 1991. The background of the staff was varied, some coming from residental work, some from nursing, others from counselling, one worker was a seconded Probation Service Assistant. The first month was spent on an induction programme which was designed to establish a common basis for practice. Staff learnt how their work at Rugby House fitted into the existing network of alcohol agencies in North London. They began to share their differing attitudes to problem drinking and ways of supporting future residents in stopping drinking. A team was created from a group of disparate individuals in the process of interpreting the Management Committee's policies and procedures and turning them into day to day rules and practices for the hostel. For example, we had to decide whether residents should be back at a certain time in the evening, what time that should be and whether it should be the same weekends as weekdays. We had to learn how to fill in claims for Income Support on behalf of residents. We discussed how to manage detoxification. The induction programme was drawn up and run by myself and the other Team Leader for the hostel. We were to manage the hostel together as equals reporting to the Coordinator who was based at the Project Headquarters and not in the hostel. We both worked to the same job description. In my experience, undifferentiated co-responsibility is an unusual management model, presumably because of the dangers implicit in a situation where there is no built-in mechanism for resolving confiict and allocating responsibility. We were both aware of the possible pitfalls from the start and realised that to avoid these and use the strengths of the model we needed to be as open as possible with each other and tackle difficult issues between us as they came up. I have valued the personal support that co-working has provided. Under pressure this has allowed us to
TTie opening of a high care hostel be less defensive than we might have been as individuals and often the quality of analysis and decision-making has benefited from two heads rather than one. As we have worked together we have divided up responsibility for certain tasks between us but have remained clear that overall responsibility for the hostel remains with us both. Co-working between the team leaders has been a model for co-working between all staff in the hostel. A minimum of two staff, normally a man and a woman, are on duty 24 hours a day working three shifts. As the maximum stay at the hostel is only 28 days and staff work on a 24-hour rota, we decided from the start not to have a keyworker system. This has meant that all staff are jointly responsible for all residents. Good communication between staff is therefore essential to allow for consistency and effective decision-making. We have developed an elaborate communication system, which depends on half hour handovers between shifts, contact sheets, weekly case reviews and fortnightly staff meetings. It takes time to pass on information, thrash out differences, share perspectives and decide on policies. But it is time that can make the difference between chaos and coherence and between confusion and clarity.
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Maps and underlying assumptions By the end of the 4-week induction programme, we had developed a shared view of what we were intending to do at Rugby House and the means of doing it. It was very roughly summarized in Table I, a crude map for the journey we were about to undertake together. In essence the 'map' shows the four stages residents move through just before and during their stay at the hostel, referral, detoxification, assessment and onward referral. It shows that at the different stages staff offer different kinds of support to the residents and that residents are expected to engage in different activities. It also shows that we expected a stay at Rugby House to be a dynamic experience for the residents in that we hoped their relationship with us would affect them and leave them changed (preferably for the better). Finally we acknowledged that when a resident arrived s/he would start in a dependant (child) position in relation to the staff but that the effectiveness of our work could be measured by their shift to a self-determining (adult) position. More generally we used the time we worked together as a staff team prior to opening to clarify the assumptions underpinning our work. These have provided a point of reference when we have got lost
Table I. High care hostel for men and women in crisis who want to stop drinking' Processes Physical state
Drinking
Withdrawing
Not drinking
Methods of intervention
Tel referral
Detox Medication Physical care Emotional support Admission interview Medical check
Assessment: Groups One to one interviews Physical care Alcohol education Informal support Liaison with agencies Referral onwards
Tasks
Decision making (Is this an appropriate referral?)
Information —purpose —rules
Problem exploration Re-evaluation Action —drinking history contact —why do I drink? group support other —do I want to stop! decision to agencies —can I stop? seek referral —what help can I get? on choices made
Information giving
Dynamic process
Admission —DSS —Info from client —monitoring Provision of medical can! —type and level
Information giving Maintenance of Safety (for referral) —rules/sanctions Improvemem in physical health
Child Provision of a safe physical and emotional environment so that growth can take place Need for containment and boundaries Acceptance of > ADULT/ADULT responsibility for CHILD/PARENT own life
Objectives: (1) ensuring the physical well-being of the residents; (2) maintaining an environment in which residents can begin to understand their drinking and consider future options; (3) help with onward referral.
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or needed to assess our progress. We have three clear and focused objectives, first to provide a safe place for residents to withdraw from alcohol, second to give residents the opportunity to begin to understand the nature of their drinking and third to support them in moving on to an appropriate programme after they leave Rugby House. For myself the notion of 'containment' is important. I saw Rugby House as offering a safe place, not only 'to withdraw from alcohol', but more importantly for needs and feelings to be expressed, 'reality' explored and new behaviour tried out. The notion of 'containment' is difficult to test out and demonstrate but in my view underlies our whole programme and indeed is of greater importance than any individual element in the programme such as whether groups are structured or unstructured. Closely allied to 'containment' is another abstract but equally powerful notion, that of boundaries. Central to the brief given to us by the Management Committee was the no drink/no drugs rule (apan from prescribed medication). We felt that because residents had only just stopped drinking when they were with us, we could not operate a relapse management programme as the messages implied would be contradictory. So if we knew that a resident had used alcohol or a nonprescribed drug we would ask them to leave. This is a policy we have always adhered to. The other clear boundaries are those of time. We expect residents to be in the hostel by 11.00 p.m. and to be punctual at all the groups we run. We will ask a resident to leave if they arrive back after 11.00 p.m. or if they are twice late for a group. The significance of the time boundaries lies not in the times themselves but in a strict adherence to action following any breach. Finally, the induction programme and the subsequent planning for the opening of the hostel demonstrated the need for staff to be involved at all levels in decision making. Together we had to turn policy into practice. This meant first debating and making the policy our own and then devising the systems for implementing it. We had to be clear about who we would admit, how we would take referrals, how we would care for residents while they were withdrawing from alcohol, how we implemented the Project's equal opportunities policy, in what circumstances we would ask a resident to leave, what records we needed to keep for what purposes, what we meant in practice by confidentiality, what statistics should be kept.
From nothing we created a culture that allowed us to operate satisfactorily as soon as we opened our doors and which has developed organically as we have become more skilled and experienced. Every member of staff could pick out certain 'cultural' features that he or she contributed, but equally many other features are the product of joint debate and experiment. Imposition of ideas and methods from the top could not have produced the enthusiasm, the creativity, the hard work and the commitment that have emerged in a staff team trusted with the responsibility for developing and running a project.
Anxiety With the excitement of creation went the anxiety. This was an emotion that coloured much of the period prior to the opening of the hostel. I learnt just how powerful it was for me on the day HRH Prince Andrew formally opened Rugby House. I had arranged for a member of staff to use my camera to photograph the occasion, the Prince going round the hostel, cutting the cake, the speeches. Imagine my horror when it was all over and I discovered that I had failed to load the film correctly. We had no photographic record of the occasion. I realised that because of the high level of my anxiety I had not checked the film properly. I also realised that it was quite appropriate for us all to be anxious. Were we going to be able to do the things we said we would do? Would we make utter fools of ourselves? Were we allowed to make mistakes? We began at this point to take tentative steps to being more open with each other about uncomfortable feelings. We needed to be able to listen to our own and each others fears, frustration and disappointment, if we were to be available to residents experiencing the same feelings. And I needed to find a better way of recognising stress than by leaving the film out of the camera! The hostel opened on the 2nd January 1991. Two residents were admitted that day and the hostel was full within 2 weeks. It was a relief to be doing the job after so many months of planning. We all knew that planning can only take you so far. Inevitably many major and minor adjustments have to be made as soon you get going. There are a hundred and one unforeseen and unforeseeable circumstances. And the team has to learn to work together through the fierce and compelling pressures of day-to-day work with residents. The first 3 months were a time of immensely hard
The opening of a high care hostel work and improvisation. We had to devise more and more forms for our own records, to cope with the Department of Social Security and to collect the statistics we needed. In the first month the cook resigned. For 2 weeks we struggled with ordering food and arranging for residents to do all the cooking which they resented. Most difficult of all, we became aware that we disagreed about methods of working and particular decisions. One shift would be critical of the decisions taken earlier on another shift. Our resources for resolving differences were painfully inadequate. It was easy to become defensive and blame others, in this respect often mirroring similar processes in the resident group. Is it possible to avoid this uncomfortable stage at the beginning of a project? I doubt it. Working effectively together means learning where your colleagues differ from you and why, and above all how to use these differences creatively. We were much exercised at this time with our decisionmaking process. What decisions could be taken by two people on a shift? by four at a handover? by the staff at the weekly case review? by the whole staff team? by management? Early on we decided to have fortnightly instead of monthly staff meetings which gave us badly needed time to discuss many of these issues. We also decided to use a facilitator for the staff group on a monthly basis. This facilitator acted as consultant to the two team leaders. The increased staff meeting time and the facititator gave us the opportunity to begin to understand what was happening and some tools for coping with the stresses.
Learning from experience In April we held an All Day Review to learn from our experiences in the first 4 months and to use the lessons to modify our practice. The pressures of daily interaction with the residents and with each other seemed to be prising us apart rather than bringing us together. The All Day Review gave us the opportunity to check out our underlying assumptions and beliefs. We were relieved to discover that we shared these to a much greater extent than we had anticipated. The three assumptions that we articulated were, first, that if someone needed to come to Rugby House it was because they had a serious drink problem, second, that a stay at the hostel was only a small part in a much longer process of change that a resident would need to undergo if they wished to overcome their drink problem and, third, that we expected all residents to
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be active in using their time with us. On the face of it, these assumptions may seem basic and obvious, but this was far from the case. Our Policy and Procedures Handbook stated "we made no assumptions about a resident's eventual drinking goal". We had interpreted this as an instruction to make no assumptions about a resident's drinking, either in terms of its severity or the need for a programme to effect change. Our Review Day allowed us to say, "Our residents have a very serious drink problem which they can only effectively tackle by seeking professional help." This was now our position so far as the short and medium term were concerned. We left the 'eventual' to look after itself and not obscure our view of the present. A clear articulation of our underlying beliefs had a significant impact on our practice. We revised our groupwork programme to make it more focussed and relevant to residents who were struggling with recent abstinence and with the need to take pressing decisions about their future. We introduced a first assessment for all residents on their third or fourth day with us, followed by weekly assessments thereafter. The purpose of the assessments was to give residents regular 'preserved' time with a member of staff to look at the nature of their drinking problem and the treatment options open to them. It also gave us the opportunity to monitor whether a resident was using his or her time with us. During the first 4 months of operation, we had become very concerned about residents who we saw as holidaying at Rugby House. We now negotiated specific tasks with residents at the end of each assessment to be completed during the next week. If these were not done, we would discuss what had got in the way at the next assessment. We had a basis for considering asking a resident to leave if the evidence was that he or she 'was just sitting on their backside'. After we changed our practice, which included having a more rigorous expectations of the residents, our statistics showed that a greater proportion left the hostel on a planned basis, that is they left when they said they would go, normally to further treatment. The proportion went up from 40% 'planned leavers' in the first 3 months to 60% in the last 3 months of the year.
The end of the beginning By the Autumn of 1991, Rugby House was no longer a new project. The initial phase of creation was over. The staff shared a common sense of purpose, there was a greater feeling of mutual respect, and we knew
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that we competently performed our tasks, both individually and as a staff group. But with the end of that first phase came a sense of disillusionment which we sometimes experienced as anger and betrayal. Creation involves vision and vision always has elements of idealization and fantasy. Despite the fact that we were experienced adults working in the real world, at a conscious and unconscious level, we entertained the illusion that we were creating a perfect high care hostel and a perfect place to work. The end of the beginning is perhaps the recognition that the work has limitations, that colleagues let one down and worse of all that one's own contribution is flawed. What son of a place was Rugby House after the first 9 months? What mini-culture now existed were none had been before? Before we opened we had been clear that an important part of a resident's experience at Rugby House would be due to a shift from the dependant, child position during physical withdrawal to an adult position of responsibility in the post detoxification phase. At its most basic, the resident had to be responsible for not drinking, for living in a community and for taking decisions about involvement in a further programme. The first 9 months of practice confirmed that our initial theoretical position had been correct. Above all Rugby House offered a safe physical and emotional environment in which residents could begin to understand their own needs better and experiment with changed behaviour. A painful lesson for me of those first few months was that it is one thing to talk in theoretical terms of 'a safe physical and emotional environment' and quite another to live and work in it. Such an environment is one where staff and residents relate to
each other as human beings with as much openness and honesty as each can muster at the time. Feelings are often strong and raw. The anger, despair and vulnerability of the residents finds echos in similar feelings in the staff group. The 'safe environment' can feel far from safe. Paradoxically, the capacity to feel vulnerable and anxious is the spur to understanding and experimentation with changed behaviour. This is as true of the resident, the staff team and team leader. 'Safety' in an institution such as Rugby House lies in a commitment to listen and to search for the meaning behind overt statements and behaviour. There are no doubt as many arguments, frustrations and disappointments at Rugby House as at any other similar project, but during the first months of the project we began to appreciate the importance of understanding what lay behind them and to use this understanding in our work as a team on behalf of the residents. I started this anicle by likening the creation of a project to a journey. I should have said to many simultaneous journeys. There was amongst the staff a richer and more profound understanding of what helps people to change and what makes change difficult. There was my professional development from fieldworker into manager. There was the transformation of a group of individuals into a functioning team capable of helping a distressed and vulnerable client group. Finally, there was the journey each and every resident made while he or she was at Rugby House. In a number of ways my experience of being part of a new project has paralleled the experience of the residents at Rugby House. There has been the same desire to start afresh, to rediscover and use past strengths, to learn new skills, to gain knowledge.
