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Summary Report to Coolmine House in respectof an operations management and therapeuticaudit of services

Rowdy YatesSenior Research Fellow, Scottish Addiction Studies, University of Stirling

Salvatore RaimoCo-ordinator, Shared Office for International Relations - Ce.I.S. & I.F.T.C.

A PreciousInheritence:

The evaluation ofCoolmine House

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ACKNOWLEDGEMENTS 5

INTRODUCTION 7

BACKGROUND 9Drug Trends in the Republic of Ireland 9Changes in National Policy Positions 10Coolmine and the Therapeutic Community Movement 11

ORGANISATION 13Board of Directiors 13Chief Executive Officer 14Service Planning and Evaluation 14Marketing and Promotion 15Conclusions & Recommendations 16

STAFFING 17Staffing Structure 17Decision–making & Management 18Communication 19Conclusions & Recommendations 20

RESIDENTS 23Integration of Programmes 23Programme Structure 24Communication 25Conclusions & Recommendations 25

ENVIRONMENT 27General Environment 27Programme Content 28Groupwork 28Language and Symbols 29Conclusions & Recommendations 31

REFERENCES 33

APPENDICES 37Appendix A: The Audit Proposal 39

Contents

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Appendix B: The Impact of Therapeutic Communities 48Appendix C: Contracting & Business Planning 59Appendix D: Authors’ Curricula Vitae 76

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We would wish to place on record our gratitude and admiration for the openness,warmth and candour with which we were welcomed by management, staff and residentsof the Coolmine community during the course of this audit.

We were impressed by the engagement with - and loyalty to – the organisation, whichwas evident in all those whom we met and spoke with. As Salvatore recorded in hiscontemporaneous notes:

“ …in every moment of this visit, I have felt welcomed and people showed agreat willingness to question themselves and to increase their skills.”

The decision to commission an audit of this kind during a period of some turbulence wasundoubtedly a courageous one, which spoke of a strength of belief and purpose. By theend of the fieldwork element of our work, both authors felt convinced that this faith waswell placed. Whilst some of our evaluation is certainly critical, our overall impressionwas of a well-functioning organisation, managed and staffed by individuals who werecommitted to maintaining and building upon therapeutic community principles in a newand changing environment.

We noted too, the affection with which the organisation was viewed: by both current andformer residents with whom we spoke. Again, Salvatore’s notes summed up thefeelings of both authors:

“I met people who, basically liked to be in the place they were.”

On a more personal note, we were thankful for the welcome we were given, whereverwe went. We were never made to feel like intruders and everything that could be doneto make our stay both comfortable and productive was done – long before we hadthought to ask for it!

Rowdy YatesSalvatore Raimo

November 2002

Acknowledgements

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A full copy of the original proposal (excluding the curricula vitae of the two authorswhich are provided in Appendix D: Authors’ Curricula Vitae – pp. 76) for the study isprovided as an appendix to this report for information; although elements of thatproposal are reiterated within the body of this report as appropriate (see Appendix A:The Audit Proposal – pp. 39).

In September 2002, the authors of this report were commissioned by Coolmine House toundertake an operations management and therapeutic audit of that organisation in orderto:

• provide a thorough literature review of the salient issues pertaining tothe provision of abstinence-based services.

• undertake a comparative review of these issues in Europe andinternationally where applicable.

• examine all facets of the community’s day-to-day operations andconsider the efficacy of these processes against both operationsmanagement and therapeutic considerations.

• describe what new initiatives have been attempted in the community(since the previously commissioned report) and establish whichinitiatives were effective and which were ineffective.

• examine the options for a repositioning and/or further integration of thecommunity within the existing national policy framework where suchintegration appears beneficial and practicable.

• recommend changes in working practice and to provide detailed advicewith regard to the practical implementation of such advice.

The audit was conducted both as field and desk research, with the interview andobservational aspects of the study being undertaken on site whilst the report-writing andreview work was undertaken largely from the University of Stirling.

Introduction

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Fieldwork was conducted during the period 2nd September 2002 to 5th September 2002.The researchers - either together or separately – visited all the workplaces operated bythe organisation and undertook interviews and observations as follows:

Interviews

• Senior staff members• Board members• Maingrade staff members• Residents and/or other clients

Observations

• Senior staff meeting• Staff meeting• House operations• Groupwork interventions

Interviews were conducted using a semi-structured interview schedule agreedindividually, in advance between the two authors. However, the authors were aware ofthe role of research and audit in influencing the dynamic (see: Eley, Yates & Wilson,2001 on the “research encounter”) and as far as possible, interviews and conversationswere allowed to “follow their own path”. In keeping with this commitment, manyinterviews were undertaken in social settings, during meal breaks, even in cars travellingto other interviews.

It was recognised at the outset, that the proposal adopted an extremely tight timetablegiven the financial constraints within which the commissioning organisation wasoperating. In the event, whilst all the proposed staff and resident interviews (formal andinformal) were completed, only one member of the Board was available for interview. Inaddition, the questionnaire survey of a sample of residents (which the authors hadintended to manage through the organisation’s Suggestion Box system – see below: pp.25) proved undeliverable and interviews with external stakeholders could not bearranged within the available time.

However, despite these clear limitations to the audit, both authors feel confident that,ultimately, these constraints have in practice detracted only marginally from the eventualoutput and that what was recorded was the authentic ‘voice’ of the management, staffand residents of the community. It should also be noted that whilst the two authors tooklead responsibility for organisational structure/functioning and therapeutic content (asenvisaged in the original proposal), what is presented here, is very much a consensusreport summarising the views of both authors.

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No organisation exists in a vacuum. Any drug or alcohol treatment service will beinfluenced by current drug using trends; current policy on drug misuse; and servicescurrently offered by other providers. Also, since existing systems and beliefs are notentirely replaced by new ideas and concepts, the environment in which organisationsexist will be further influenced by past events and practices. This is particularly true ina field such as drug misuse, where the drug-using subculture operates a highly effective,but very often erroneous, samizdat news and information service, which can maintainmisinformation for many years. Therapeutic Communities for the treatment of drugusers are further influenced by the legacy of the therapeutic community movement. Inthis Background section, we have therefore sought to provide a thumbnail sketch of thebackcloth against which Coolmine House was examined by the authors.

DRUG TRENDS IN THE REPUBLIC OF IRELAND

Cannabis is the most commonly used drug in Ireland followed by ecstasy. However, interms of harm to the individual and the community, heroin has the greatest impact.

In a recent national study of 1,000 adults 12% admitted to ever having used cannabisand 30% reported that they personally knew someone who smoked cannabis (Bryan etal. 2000).

In 1997 and 1998 cannabis was the main drug of misuse for 10.6% of all thosereceiving treatment for drug use in Ireland (O'Brien et al., 2000). The ESPAD survey(1995) showed that cannabis was the most frequently used drug (37%) among the 15 -16 age group in Ireland (Hibell et al. 1997). The percentage of people receivingtreatment for drugs other than heroin was 30.1% in 1997 and 28.7% in 1998 (O'Brien etal., 2000).

Comiskey (1998) estimated that there were 13,460 opiate drug users in Dublin. Heroinuse in Ireland has remained a predominately Dublin phenomenon and the majority ofthose presenting for treatment are male, under 30 years of age, unemployed and earlyschool-leavers. The use of cocaine is increasing, particularly among young

Background

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professionals, although the numbers presenting for treatment are quite small. There is asignificant level of drug use occurring within Irish prisons. People who are homeless,the traveller community and those involved in prostitution are considered to be at highrisk of becoming involved in drug use.

Over half those presenting for treatment in Ireland inject their main drug while a thirdsmoke their main drug of use. There has been an increase in the number of peoplepresenting for methadone treatment nation-wide (from just over 500 in 1996 to over5,000 currently). There has also been a significant increase in the number ofindividuals on waiting lists for methadone treatment.

CHANGES IN NATIONAL POLICY POSITIONS

Until the 1990s the central objective of Irish drug policy was to maintain people in - orrestore people to - a drug-free lifestyle. As a result, the drug problem waspredominantly seen as a medical problem and the socio-economic and socio-culturalfactors relating to drug use were largely ignored by the government.

The governments’ abstinence-only treatment response was challenged in the late 1980sas a result of the emergence of HIV and AIDS. Subsequently, a harm reductionresponse was introduced and this is now the key feature of Irish drug policy.

Drug services now offer other options to total abstinence, which aim at attracting drugsusers into a range of different services. This approach is based on the premise that itwill help estimate the extent of drug use and also reduce the risk of harm to both usersand the non-using population.

The first policy document addressing drug use in the 1990s was the GovernmentStrategy for the Prevention of Drug Misuse (1991) which concentrated mainly on theopiate problem in the greater Dublin area. The Strategy promoted co-operation betweenvoluntary and statutory services, education, treatment services, local communities,prison services, customs and excise and international agencies.

In the mid-1990s a Committee was set up, chaired by Pat Rabbitte, the Minister of Stateto the Government, to review drug policy. The First Report of the Ministerial TaskForce on Measures to Reduce the Demand for Drugs (1996) contextualised the drugproblem, examined underlying causes and looked at the nature and extent of theproblem. The relationship between drug use and social exclusion was acknowledgedand as a result of the First Report, local Drugs Task Forces were set up in eleven areas(ten in Greater Dublin and one in Cork) where heroin use was considered the mostprevalent.

The Second Report of the Ministerial Task Force on Measures to Reduce the Demandfor Drugs (1997) looked at the use of non-opiates (in particular ecstasy and cannabis).

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Following the Second Report, the Minister of State at the Department of Tourism, Sportand Recreation was given special responsibility for Local Development and for theNational Drugs Strategy.

In May 2001, a Review of the National Drugs Strategy was published which endorsedthe existing approach already taken by the government. Changes made to the previousstrategy were to increase the number of treatment places to 6,500 by 2002; to enableimmediate access to counselling for addicts; to allow the prescription of methadone tounder 18 year olds and increase the number of drug seizures by 50% by 2008.

However, the strategy has been criticised for not having clear targets for reducing drugrelated harm and for not taking additional steps by putting in place safe injecting rooms(in view of high prevalence of hepatitis C) and for not clearly stating how ‘hard toreach’ drug users could be linked into services through the provision of more lowthreshold services and crisis counselling.

COOLMINE AND THE THERAPEUTIC COMMUNITY MOVEMENT

Therapeutic communities have been traced back by some authors (Glaser, 1977;Broekaert and van der Straten, 1997) as far as the religious communities of the Essenesin the Holy Land and some aspects of medieval monasteries (Broekaert et al., 1996).

In the twentieth century, some authors (Rawlings and Yates, 2001) have pointed todevelopments across Europe in the treatment of maladjusted children and thedevelopment of alternative approaches to schooling as possible precursors of the moderntherapeutic community movement. Amongst these early pioneers, the work of suchvisionaries as Homer Lane (Pines, 1999; Bridgeland, 1971), whose work at the LittleCommonwealth transformed approaches to the treatment of juvenile delinquency, bearsan uncanny resemblance to early descriptions of the work of Charles Dederich atSynanon (Kooyman, 2001, Yablonsky, 1965; Sugarman, 1974).

In more recent times, the development of the therapeutic community has been creditedto two independent movements. Firstly, the ‘democratic’ TC pioneered by MaxwellJones and others as part of the movement towards the dissolution of restrictive - andoften oppressive - Victorian psychiatric hospitals in the 1940s and ‘50s (Kennard, 1998).And secondly, the ‘concept-based’ TC modelled upon the work of Charles Dederich atSynanon in California with a group of long-term drug users (Kooyman, 1992). Both ofthese movements have had a huge impact upon the delivery of treatment to a broadrange of client groups including drug users. Both are characterised by their commitmentto harnessing the self-help potential of the very clients they seek to help.

In the early 1970s, the TC model initiated by Dederich but refined in treatment centreslike Phoenix House, Daytop Village, Eagleville and Odessy House was imported into

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Western Europe in a flurry of radical activity around the treatment and rehabilitation ofdrug users (Yates 2002). In 1971, Dr. Ian Christie established Europe’s first concept-based, or Synanon-style TC within the grounds of St. James’ Hospital, Portsmouth.Within a few years, a series of similar experiments had started across much of WesternEurope, including Ley Community and Phoenix House in England, Vallmotorp inSweden, Emiliehoeve in the Netherlands, de Sleutel and de Kiem in Belgium andCoolmine (initially titled Coolemine) in Ireland (Kooymann, 2001). A detailed historyof the establishment and the changing fortunes and influence of therapeutic communitiesis provided at Appendix B (pp. 48) in the form of an in-press paper by one of theauthors.

As with its sister communities in the UK, Coolmine enjoyed a period of significantinfluence and prestige during the first decade of its existence and this position of pre-eminence in the field, coupled with a strong sense of evangelism, saw TCs acrossEurope developing mutually supportive collaborations and exchanges; both betweenthemselves and with TCs in the USA. During the 1980s, however, the emergence ofHIV/AIDS; increasing concern over drug-related acquisitive crime; changes in thefunding mechanisms for drug treatment; and an emphasis on apparently more economicforms of intervention, led to the diminution of the influence of residential rehabilitationin general and TCs in particular.

This change in the fortunes of the TC movement was nowhere more dramatic than inIreland, where Coolmine House was the only facility of its type and where the relativelysmall size of the overall treatment community meant that any reduction in status andinfluence would, inevitably, be more visible and thus, more painful.

During the last decade, Coolmine House appears to have reacted to these changes bybecoming withdrawn, insecure and defensive. Whilst some senior management figuresmaintained limited contact with other TCs and with umbrella organisations such as theWorld Federation of Therapeutic Communities (WFTC) and the European Federation ofTherapeutic Communities (EFTC), the community as a whole became increasinglyisolated.

In recent years, however, there have been significant changes in the management andoperation of the organisation and a growing awareness of the need both to change inorder to maintain relevance to current trends in drug use and drug culture and to reclaimthose fundamental principles which underpinned the original model and which continueto provide a framework for a treatment modality unique in its approach and radical in itscommitment to self-help.

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This section of the report considers the overall organisation of Coolmine House andmakes a limited number of recommendations for further improvement in treatmentdelivery. The authors recognise that the organisation has recently emerged from adifficult period which saw the departure of a number of key senior management figures.Inevitably, this has been a painful and traumatic experience that seems to have left thesurvivors bruised but determined.

However, during the course of this study, it became clear that there remain within theworkforce some serious divisions and an unhealthy level of mistrust and uncertainty.There was evidence also, of a certain amount of overcompensation and over-identification with change as the solution. Much of the earlier work of the organisationwas disparaged by many of the ‘older hands’ as corrupt, wrongheaded and worthless,whilst many of the newer employees appeared to have little understanding of TCprinciples or appreciation of the legacy with which they had been entrusted.

BOARD OF DIRECTORS

Overall management control of the organisation lies with a non-executive Board ofDirectors. There have been significant changes to the composition of the Board withinrecent years; not least the appointment of a new Chief Executive Officer or Director.However, the Board remains quite small for an operation of this size and wouldundoubtedly benefit from the inclusion of new members drawn from the appropriateprofessional or experiential backgrounds.

In particular, the authors felt that both the Board and the organisation generally wouldbenefit from the appointment of a member with experience of the therapeuticcommunity movement elsewhere in Europe. It may be that an approach to the EuropeanFederation of Therapeutic Communities (EFTC) could pay dividends in securing theservices of an experienced practitioner/manager. We recognise that the financialimplications of such an appointment would not be insignificant, but feel that the benefitscould more than offset the cost. Moreover, we would wish to stress that ourrecommendation here is in relation to a short-term appointment of 18 months to 2 years.

We were concerned also that the process of devolution of power and decision-making,evident elsewhere in the organisation, appears not to have ‘taken root’ in any systematicway at this level (see the subsequent section on Chief Executive Officer). We thereforerecommend that the Board should seek to meet with the CEO and his senior staff team at

Organisation

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an early date to clarify the decision-making protocols and set out a clear agenda for theappropriate alignment of authority to responsibility.

CHIEF EXECUTIVE OFFICER

The recent appointment of a new Chief Executive Officer has clearly had a significantimpact upon the day-to-day functioning of the organisation and its vision. However, wewere concerned that much of the recent change – and the impetus for change - was over-identified with this new appointment and there was a sense of other senior staff feelingalmost paralysed within the decision-making process. We were told of – andoccasionally witnessed – incidents where senior staff deferred to the CEO in order toresolve issues which appeared to us, to fall within their own remits.

We were extremely concerned that the CEO appeared not to have been given a clearmandate to operate upon the Board’s behalf. In our view, the establishment of a clearprotocol – job description, standing financial orders etc. – for the post of ChiefExecutive Officer, is required as a matter of urgency.

SERVICE PLANNING AND EVALUATION

The bulk of the funding for the work of Coolmine House comes from three discreteareas of the public purse. Funding for overall operational running costs is provided bythe Health Board; through a Section 65 Grant. Per-capita funding for residents isprovided by the Probation and Welfare Department, whilst, in recent years, funding fornew initiatives and capital development costs has been provided by the South Inner CityTask Force.

However, there appear to be no formal contracts detailing the arrangements for theprovision and/or expenditure of these monies. Whilst a Cost Proposal had beensubmitted to the Health Board in respect of activities during the current financial year,there was no evidence of a formal acceptance of these proposals. In our view, the use oflarge sums of public monies should be adequately defined through a mutually agreedsystem of business plans and contracts.

We understand that there has been little enthusiasm on the part of the main funders toformalise arrangements in this way, but we are firmly of the view that this is not in theinterests of the organisation: particularly in an area of concern as politically volatile asdrug misuse. We therefore recommend that the organisation should take the initiative informalising financial arrangements with its major funders. As a starting point, we haveincluded in Appendix C (pp. 59) a sample contract and business plan. Whilst werecognise that these documents are written with a UK market in mind, we believe they

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should provide a basic template from which the organisation can produce proposaldocuments suitable for detailed negotiation with funding agencies.

There was no evidence of the organisation having been involved proactively in seekingfunding outside the national context. Nor was there any evidence of collaboration withother agencies in the TC movement to access – for example – European funding. Wefelt that activity of this kind would serve two important functions. Firstly, it would helpto ensure that the organisation became less insular and worked more closely with otheragencies. Secondly, it would give the organisation an opportunity to extend its currentfunding base.

We were impressed by the effort which had clearly gone into ensuring that individualclients were appropriately dealt with by the organisation; that individual treatment planscould be developed and implemented; and that client progress – both individually and bycohort could be evaluated. However, we found little systematic use of this system topromote the organisation as a modality which works and works well. This issue is dealtwith in more detail in a subsequent section (Marketing and Promotion).

Initial and ongoing assessment of need appeared thorough although we were surprisedthat the organisation had chosen to use its own assessment tool rather than one of themany validated diagnostic instruments already available (Maudsley Addiction Profile,European Addiction Severity Index etc.). Clearly, the use of a more universally appliedinstrument would give greater opportunity to compare activities with other treatmentservices both in the Republic of Ireland and elsewhere in Europe (see Fureman et al.,1990; Blanken et al., 1995; Gossop et al., 1998; Gossop et al., 1999). MARKETING AND PROMOTION

Marketing of the organisation appears never to have been undertaken in any systematicway. Whilst this is not by any means unusual in this field, it is nonetheless somewhatshort-sighted.

We were informed by one senior manager that marketing Coolmine House to thepotential client group was probably unnecessary since “most drug users out there knowabout us already”. However, in the preparatory research for this study, we found at leastone example of an apparently widespread story about a Coolmine resident being forcedto eat his own vomit. Needless to say, where informal marketing is of this nature, thereis a continuing need for a counter-balancing marketing thrust. We feel that CoolmineHouse would benefit from a strategic approach to promoting its facilities to the potentialclient group both through personal contact and promotional literature.

In addition, Coolmine needs to ensure that it is continually up-dating funders, otheraddiction services and relevant professions regarding its current services. At the time ofthe fieldwork visit, we noted that senior staff were in the process of writing an annual

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report for the previous financial year. However, we were concerned to hear that this wasthe first such report since the year 1996/97. We would recommend that the organisationprioritises the annual production of a short report which promotes the benefits of theservice to funders and potential customer organisations.

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CONCLUSIONS & RECOMMENDATIONS Whilst overall the authors felt that the organisation had recovered well from a period ofsome turbulence and that efforts had been made – and were continuing to be made – toensure that the organisation operated efficiently and to the benefit of its client group, wefelt that the following recommendations would go some way to ensuring furtherimprovement:

• The Board of Directors should seriously consider the need to increase itsexisting membership. We recommend that the Board give consideration tothe areas of professional competence it currently lacks and seeks to appointadditional members with this consideration in mind.

• The Board should consider the possibility of approaching the EFTC to securean experienced Board member as a time-limited appointment.

• There is an urgent need to clarify the role and responsibilities of the post ofChief Executive Officer.

• Similarly, there is a need to further clarify the management process in orderto empower the Senior Staff Team.

• The organisation should develop appropriate contract and business plandocuments for discussion with its major funding providers.

• The organisation should consult with colleagues in the EFTC regarding theopportunities for collaborative funding applications.

• The organisation should give some consideration to the possibility of usingmore generally utilised diagnostic and outcome measuring instruments.

• The organisation needs to give some thought to developing a strategicapproach to marketing its services to potential clients

• This will include the preparation of a simple promotional document (leaflet,poster etc.) for drug users and other services routinely in contact with suchindividuals.

• The organisation should prioritise the annual production of a report detailingrecent activity and promoting the services it offers.

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Within the last few years there have been significant changes both to the staffingcomplement and the line management structure. Most notably, the organisation hasmoved to a thematic management structure where managers adopt a pan-organisationalresponsibility for particular areas of the organisation’s activities regardless ofgeographical siting.

Whilst this system tends to be more flexible and allows the organisation to place greateremphasis upon particular elements of its operation, it is inevitably less comprehensiblethat a simple site management system where maingrade staff know that if they work in aparticular building or department, their line manager is the manager for that physicalentity. There was some evidence of confusion amongst the workforce regarding line-management responsibility and this will require clarification.

In addition, there appeared to have been a conscious ‘flattening’ of the staffingstructure; partly in reaction to a previous management style, now seen as autocratic andarguably, deliberately opaque. As with the above mentioned change, this appears tohave led to a degree of ‘role confusion’ which will require clarification and adjustment.

STAFFING STRUCTURE

During the fieldwork element of this study, the authors conducted interviews with thechief executive officer, all members of the senior management group, one team leaderand a sample of maingrade workers. In addition, the authors met with the seniormanagement team collectively and observed one staff meeting.

The move towards a more thematic or task-force oriented management structure is abold step. Handy (1992), argues that in a mature organisation, task-force structures canprovide more flexibility in a changing environment and a better overall ‘response rate’.

However, this style of management approach does inevitably mean that the linksbetween managers and their maingrade workers become more tenuous than with olderstyle site management. As a result, task-force management structures need to be veryclear to staff at all levels of the organisation. Staff within the task-force or theme needto be absolutely clear where they are located within the management chain and how thisrelates to other parts of the organisation (including the resident structure). This needs to

Staffing

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be reinforced by regular task group meetings, agenda setting, clarification of functionsand goals etc.

There was clear evidence that many maingrade staff where uncertain about the newmanagement structure and where they were located within it. Some maingrade staffappeared unsure who their line manager was within the new structure or, appeared tofeel that this chain of command was nominal.

We felt that there was a need to re-clarify staffing structure and further emphasise thisby ensuring that the appropriate systems are in place for regular line-managementsupervision and staff appraisal. We were aware that a new staff appraisal system wasnow in place and we felt that this would provide for a better delineation of roles andresponsibilities in the future. We noted however, that in-service training arrangementsappeared limited and would urge senior management to ensure that the new appraisalsystem is used to ensure a proactive approach to training needs analysis for all staff.

There had also been a deliberate ‘flattening’ of the decision-making structure, which wewere told was a relatively recent phenomenon. There appeared to be two reasons forthis development. Firstly, decision-making within the organisation had, in the past, beencentralised and, apparently, not very transparent. There was therefore, a conscious effortto open out the decision-making process. Secondly, the organisation was anxious toensure a devolution of decision-making powers; including a delegation of relativeautonomy to the residents.

As with the change in management style, the change in staffing structure and therelocation of ‘standing orders’ had led to a certain amount of confusion. Some membersof the staff team appeared unclear where along the command structure they were placed,what decisions could be taken and by whom. This appeared to have led to a slightfeeling of inertia, with many staff – including members of the senior management team– tending to check out certain decisions with the Chief Executive Officer beforeauthorising action.

Whilst this was not, in practice, particularly serious, both authors felt that they detectedin this a tendency towards the very centralisation of management control which therestructuring of the management process had been intended to address. A moretherapeutic analysis would suggest that the organisation is – probably unconsciously –attempting to replace what it would see as a bad parent with its new mirror image.

DECISION-MAKING AND MANAGEMENT

Whilst this restructuring of the management process and the devolution of decision-making is characteristic of a maturing organisation, the senior management team ingeneral and the Chief Executive Officer in particular, need to be aware of an

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unconscious drift in an altogether different direction. This is already evident in some ofthe activities and processes observed during the fieldwork visit.

During the observation of one group for re-entry residents, we noted that three membersof the senior management team were present. Perhaps not surprisingly, the two re-entrystaff - whose remit, presumably includes the facilitation of this group – remainedvirtually silent. We felt strongly that this was an inappropriate use of senior staffresources and one which actually disempowered maingrade staff.

At the outset of the fieldwork visit, we were informed that the Chief (the most seniorresident) would need to consider a request for the authors to visit both Coolmine Lodgeand Ashleigh House. This was offered as an illustration of the devolution of power andautonomy to the resident group because, “at the end of the day, it’s their house”. Wewere assured that, had the request been turned down, the visit could not have goneahead.

It clearly remains an open question as to whether a senior resident – albeit acting onbehalf of the resident community: at least nominally – could block access to the facilityby (for instance) inspection teams appointed by a funding agency or even members ofthe Board. We have used the term “inheritance” in the title of this report and we believethat the notion of legacy is instructive in this context. Clearly, the current residents donot ‘own’ the house in any legal sense and it is dishonest to imply that this is the case.They do, however, hold the house (and its principles) in trust. They therefore have aduty to previous residents, and an obligation to future residents, to honour thoseprinciples and maintain the physical fabric. In this sense they enjoy a temporaryownership and this notion should be encouraged.

A number of therapeutic communities allow ‘resident control’ of access to certain areasof the building(s) – a resident common room, some bedrooms etc. – but we are notaware of any community which extends this control to all parts of the ‘estate’ and wouldargue that such a notion is inappropriate. Whilst there is merit in encouraging residentsto assume certain responsibilities and exercise increasing control over their lives, theyalso have a right to be the ‘client’ or ‘patient’ too!

During one staff meeting, observed by the authors, a map of the staffing and programmestructure placed the Chief (a resident position) at the same level as a Team Leader (astaff position). But this structure would result in a resident holding a position senior tomany of the organisation’s maingrade paid staff!

We felt that the ceding of control to the resident group in this way was an abrogation ofmanagement power. A balance is required in any therapeutic community betweenallowing the resident community a democratic ‘voice’ and managing a valuable resourcewhich is in receipt of considerable public monies.

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COMMUNICATION

Many of the problems which we observed in the management of the organisation were,in part, the result of recent, significant changes in working practice. It was clear thatmany of these changes were still ‘bedding in’ and would require time to enter into thefabric of how life is organised in Coolmine House. However, we did feel that the seniormanagement team, whilst recognising the cultural and sub-cultural obstacles to change,might be underestimating the level of explanation and clarification required to achievechange of this kind.

In our view, the senior management team will need to devote a considerable portion oftheir resources to reinforcing the new arrangements. But communication should operatein both directions and the slight confusion observed in the command structure seemed tobe deterring maingrade staff from providing feedback on change or querying detail. CONCLUSIONS & RECOMMENDATIONS It should not be inferred from the criticism contained in this section that the organisationwas being poorly run. On the contrary, we found a staff group which was, at all levels,highly committed to the organisation. In addition, we observed much good work beingundertaken and the obvious rapport and respect between staff and the resident groupspoke of a great deal of hard work and energy.

We did however, feel that the changes which the organisation had undergone within thelast few years, would require time to ‘bed in’ and that more work would be required inreinforcing and explaining the new structure. Further major change is not required –indeed, it would be destructive – but some minor adjustment is required; particularly toclarify the relationship between the staff structure and the programme, or resident,structure. We therefore recommend that:

• The senior management team should consider ways of strengthening the newtask-force style management structure through regular communication, joint-working etc. In particular, the task, or tasks, of each section should beclarified.

• The new staff appraisal system is to be welcomed. The senior managementteam should see this as an opportunity to ensure that a pro-active trainingneeds analysis is in place in respect of all staff.

• As with the Board of Directors and the Chief Executive Officer, staff at alllevels will need to understand what decisions they are able to take and whatissues will require higher authorisation.

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• The senior management team should be aware of the need to empower otherstaff members by clarifying their remits and allowing them to take fullcontrol of them.

• The issue of ‘ownership’ needs to be resolved. Clearly the residents do not‘own’ any part of the organisation in any legal sense although a sense ofbelonging and responsibility is valuable.

• The interface between the staff structure and the programme structure needs tobe clarified: bearing in mind that residents have a right to be the ‘patient’ andthe use of residents as quasi-staff members needs clear parameters.

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As with the observation of staff function, the authors met with, talked to and observedresidents of the organisation at a time of change. Without exception, we found residentsto be cheerful and positive: both about themselves and in terms of their obviouscommitment to the programme.

INTEGRATION OF PROGRAMMES

Coolmine has, for some time operated as two single-sex communities although duringits first decade at least, the organisation provided a mixed gender community from theoriginal house, which remains operational today.

Over the past year, the organisation has begun a process of partial re-integration of thesetwo communities. In practice, this involves transporting the female population ofAshleigh House to Coolmine Lodge on a daily basis. The women arrive at the Lodgeshortly after breakfast and return in the evening. Whilst this arrangement has clearlybeen beneficial in that it allows a level of integration whilst still safeguarding someprivate space for the women in the evenings, a number of female residents highlightedthe disadvantages.

From their perspective, they are brought into the “men’s house… to do the cleaning andeverything”. Having cleaned the men’s house for them, they return to their own house(which they then have to clean) whilst the men “…can relax in the evening”. Clearly,this is not an entirely objective view of the process but it provides a salutary lesson inhow well-intentioned initiatives might be construed quite differently from their originalintent.

The re-integration of the two communities is a welcome development. However, currentarrangements, whilst imaginative and offering some benefits in terms of partialseparation, are time-consuming, costly and probably resented by some members of thetwo communities.

In our view, the organisation should consider a total re-integration of the twocommunities. This could be done relatively simply by moving re-entry residents intoAshleigh House and the women members of the community into the older part of theLodge. The current benefits of partial separation could be maintained since the old andnew parts of the Lodge are themselves physically separate. We recognised that there areplans for the redevelopment of Ashleigh House but are of the view that these would

Residents

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remain feasible with the proposed change of occupancy: indeed, there may be somepositive benefits.

PROGRAMME STRUCTURE

The programme structure within Coolmine is similar to that found in most therapeuticcommunities; with the resident community divided into four Departments. EachDepartment has its own management structure and overall co-ordination is theresponsibility of the Chief and her two assistants.

In Coolmine, residents are also allocated to a Clan. Clans within Coolmine have asimilar function to Houses in some schools. Their intention is to foster a sense ofbelonging and family. Clans are particularly predominant during those periods(evenings and weekends) when the community is not “on the floor”.

Sugarman (1974) notes that the central purpose of a therapeutic community is tomaintain a therapeutic (not necessarily supportive) environment. Interestingly, this wasa view espoused by Maxwell Jones also (Anderson, 2002). In this respect, the Clansystem can provide a generally supportive, though never unquestioning ‘safety-net’ forindividual residents in addition to encouraging identification with the community whichis relatively unaffected by the turmoil of the therapeutic environment fomented withinDepartments.

However, there appeared to be a certain amount of confusion regarding the relative rolesof these two structures. Recent discussions regarding the allocation of keyworkers toClans may further confuse the picture and will almost certainly undermine the status ofthe Department as one of the major building blocks upon which the TC system isfounded.

We have discussed elsewhere (Programme Content, pp. 28), the need for theorganisation to emphasise the role of the Department to promote and sustain atherapeutic environment, but we would wish to point out here that there is here, aconstant dichotomy in role-function. The organisation will need to be very clear as tothe relative functions and purposes of Clans and Department in order to ensure that theyare used to the optimum benefit of the resident group.

The involvement of the residents’ partners and families appeared to be somewhatlimited. We were surprised to note how poorly attended the regular Relatives Groupwas. Ensuring that the partners and relatives of a resident are involved in a meaningfulway in the treatment process should not be underestimated. In our view, theorganisation could do more to support the volunteers who currently sustain the ResidentsGroup and could involve this group more in the process itself. We would like to see theorganisation making more use of relative’s visiting, perhaps at the weekends, and ratherless use of home visits certainly during the early stages of residence.

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COMMUNICATION

Whilst there is a clear route for the Board and Staff to ensure that residents are aware ofcurrent arrangements, new developments etc., there was some evidence that theorganisation had a tendency to be over-reliant on the efficiency of this system. Onnumerous occasions during the fieldwork, the authors found confusion andmisinterpretation of messages. These issues were rarely of great importance inthemselves, but they were indicative of a communications system that could probably beimproved.

It was not possible to observe the House Council during the fieldwork, but we wouldurge that the organisation ensure that this important forum is reviewed to ensure that itachieves the purposes for which it is intended.

One very useful way of ensuring good communication from the resident group is to putin place an efficient and well-utilised suggestion-box system. We were shown asuggestion-box in the Reception Area of Coolmine Lodge but there were a number ofproblems with the system. It was not clear which member of staff (if any) wasresponsible for dealing with slips found in the box nor whether such suggestions wouldbe dealt with by the House Council or by some other mechanism. In addition, the boxwas not labelled, no pens or paper were available beside the box and there was no wayof telling when the box was last emptied.

We would suggest that the suggestion-box system be ‘relaunched’ with, at least, onemember of staff clearly identified as responsible for dealing with it. We would furthersuggest that the box is surmounted by a notice board which clearly indicated the lasttime the box was attended to, summarises the suggestions receives and indicates whataction is being taken over them. In our experience, a clearly responsive system of thistype very quickly becomes well used and is an effective communications tool. CONCLUSIONS & RECOMMENDATIONS In summary, the authors believe that the residents’ experience of the therapeutic processcould be enhanced by making a number of changes to the current structure. We thereforerecommend that:

• the organisation gives consideration to the possibility of fully integrating themale and female programmes on the main site: as detailed above.

• if this is felt to be inappropriate, the organisation will need to review thecurrent arrangements for semi-integration to ensure that neither section isdisadvantaged – or perceives themselves to be disadvantaged.

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• the organisation needs to establish clearly the respective role and function ofthe Clan and Department and ensure that programme developments areconsistent with this.

• more use could be made of the Relatives’ Group and more support could beoffered to the volunteers who currently run it.

• in particular, we felt that more use could be made of opening the main site toresidents at the weekends, with a consequent reduction in the numbers ofweekend passes.

• the organisation needs to ensure that the House Council has a clear remit andis functioning adequately.

• the current suggestion box system is inadequate and need to be overhauledand relaunched.

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Whilst, overall, both authors felt that the organisation was well-run and that there was astrong feeling of commitment to the organisation, we also felt that there was a dangerthat the fundamental principles of the therapeutic community would be lost within aprocess of very necessary change.

Certainly, the balance between individual work and groupwork with residents requirescareful and precise management. In addition, the organisation needs to remain awarethat the object is to create a therapeutic environment. We have earlier referred toSugarman’s (1974) contention that a therapeutic environment is not necessarily asupportive one. Nor is it necessarily a ‘real’ one and the notion that practices utilisedin a therapeutic community can be judged by whether or not similar practices exist inthe ‘real world', is fundamentally flawed. It is the real world which has nurtured theseproblems. Therapeutic communities work by creating an environment which isobservably different from the ‘real world’ and these differences should be celebrated.

GENERAL ENVIRONMENT

We were surprised that the buildings we observed were not kept in better order. Wenoted, on numerous occasions, rooms which were untidy, sometimes dirty and generallyunloved. We felt that there appeared to be two reasons for these observations. Firstly itseemed that there was a reluctance to enforce high standards since this level ofenforcement was associated with a previous regime which was now characterised asrigid and uncaring. Secondly, we noted on numerous occasions that the work of theDepartments was undermined by the obligations imposed by individual treatmentplanning. Clearly, residents’ counselling and other individual sessions were prioritisedabove working “on the floor”.

This resulted in an environment which, whilst welcoming and comfortable, wassomewhat down at heel. As Rowdy remarked in his notes:

“I felt very comfortable here. Too comfortable. In a TC which is workingwell, I think I should feel a little bit nervous about behaving appropriately. Ishould be worried about making any litter or saying the wrong thing – itshould be different from the outside.”

Environment

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This was perhaps best exemplified by the garden which has in the past been amagnificent resource providing much of the communities vegetable needs. We weretold that cultivating vegetables was no longer necessary since foodstuffs were providedfree of charge by the Health Board. This, in our view, misses the point. The vegetablegarden represented a valuable asset of which the community could be proud. Whilstthere would be little value in continuing to grow unnecessary foodstuffs, the asset couldhave been turned to other uses – growing flowers both for the organisation’s buildingsand for the wider community for example.

PROGRAMME CONTENT

These problems, in our view, go to the heart of our understanding of the therapeuticcommunity as a treatment modality. There appeared to be an unspoken view thatindividual counselling and groupwork were the therapeutic inputs, with working “on thefloor” merely occupying the spaces in between.

In our opinion, the central tenet of the TC is that it is the day-to-day environment whichconstitutes the therapeutic input. Formal interventions (groupwork, counselling sessionsetc.) merely allow release, understanding and goal-setting. Thus, creating a workingenvironment which is pressurised, rigorous and often stressful is the priority and needsto be recognised as the crucial element in the process.

The emphasis on individual treatment planning is helpful but needs to be set within theTC context. Therapeutic Communities work by harnessing the power and energy of thegroup (both staff and residents) and there is a danger that this process can be partiallyundermined by too great a reliance on individual work.

Confidences shared with a counsellor are, inevitably, confidences withheld from thegroup: and this will clearly have an influence on the power of the group to work uponthese issues. The organisation functions well at present but there needs to be morevigilance than we were able to observe, to ensure that group processes are prioritised,with individual work being used to resolve issues which are too sensitive to be exposedto that arena.

There is, of course, excellent evidence to show the effectiveness of approaches whicheither prioritise individual interventions or are exclusively oriented to them. However,these approaches are not characteristic of the therapeutic community.

GROUPWORK

During the fieldwork, the authors observed two conflict resolution (or encounter) groupsand one life-spheres group. Whilst we recognise that this is a small percentage of the

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groupwork content of the programme, we were reasonably content that the groups weobserved were generally indicative of the nature and quality of the groupwork activityon offer.

We have noted elsewhere that the life-spheres group was dominated by the presence of anumber of members of the Senior Staff Team (see above: Decision-making andManagement, pp. 18). We were surprised by the amount of swearing we noted in thisgroup. Whilst a high level of foul language might be expected (though certainly notcondoned) in an encounter or conflict resolution group, we felt it was inappropriate in adiscussion group of this nature. This was particularly so, since the majority of thosepresent were looking forward to an imminent return to life in the wider community.

The organisation has re-labelled its ‘encounter groups’ as ‘conflict resolution groups’.Whilst we can see why this change was made - and we accept that this was intended toreflect a real change in focus and content - we would wish to point out that the use of theterm ‘encounter’ is widely accepted elsewhere, whilst still recognising that such groupshave evolved considerably in the past decades (Toon & Lynch, 1994; Broekaert, 2001).

In both groups we felt there was a concentration on thoughts rather than feelings. Oneresident was told to, “…think about the work he had done in counselling on angermanagement”. This emphasis appears to indicate a rather low level of confidence andunderstanding amongst the group facilitators involved. The primary purpose of suchgroups is to explore the feelings of the protagonist and the group and not tointellectualise them.

In one group we observed a protagonist whose features were partially obscured by abaseball cap. We felt that this was inappropriate in an honest and open exchange ofemotions and we noted that the wearing of such headgear appeared to go unremarkedgenerally.

There is now a significant body of evidence (Farrell et al., 1998; Wilson & Yates, 2001;Ravndal, 1995) to suggest high levels of psychiatric co-morbidity amongst drugmisusing client groups; particularly those who present to residential treatment services.One recent study (Eley Morris, Yates & Wilson, 2002) found extremely high levels ofPTSD symptomatology with characteristic intrusive episodes. Clearly, where this is thecase, groupwork, with its concentration on feelings has more obvious value than morecognitively-based interventions. LANGUAGE AND SYMBOLS

On a number of occasions during the fieldwork, we were informed of changes tolanguage and names. More often than not, the rationale for these changes was given as,“ …well, no-one on the real world speaks like that”.

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We have remarked earlier in this report on the need for a therapeutic community tocreate a particular type of environment and we have pointed out that the fact that thistype of environment is not replicated in the wider community is, in many ways,precisely the point!

It is important to maintain a structure where relationships are more open and honest thanmight be expected in the wider community and where the ‘feel, of the human interactionis demonstrably different. The feeling that this is a ‘place set aside’ which differs in itsactions and language from the ‘real world’ is an important trigger for most residents torecognise the TC as a place where change is possible and where safety is assured.

Whilst many changes had been made to the language and structure of the programme,we felt that these changes had occasionally been motivated more from a desire to ridourselves of the old and discredited that out of a rational examination of the benefits.

The slip-box which has traditionally set the agenda for groupwork inputs had beeneliminated. Few of the residents appeared to be clear about the reasons for this change.One told us that it had been replaced by a suggestion box but that he was unsure wherethat was! In our view, one of the major lessons that a resident can learn ‘on the floor’relates to deferred gratification and the need to ‘act as if’. This process is symbolised bythe slip-box system and if this system is to be removed, then it will need to be replacedby some other equivalent system. We were not convinced that this change (and it is anextremely significant change) had had been fully thought through.

Examples of the concepts were found in most rooms and offices. However, we notedthat in many cases, these concepts appeared to be peculiar to the organisation and werenot – as far as we were aware – founded in the therapeutic community tradition. Indeed,we felt that some of these so-called concepts were rather trite and owed more to thetradition of joke office slogans (Don’t bother me with facts: my mind is made up etc.)than to therapeutic injunctions. This appeared to have led to a general devaluing of allthe concepts. Overall, we felt that the organisation needed to review the conceptscurrently posted and satisfy itself that they are helpful and credible.

We noted also that the title ‘Chief’ – signifying the most senior resident outside the re-entry group – was styled ‘Chiefie’ by both staff and residents. We felt that thisdiminutive was in some way dismissive and perhaps indicative of an underlyingresistance to the newly elevated status of this position.

We noted also that there was no visible system of honouring those who had successfullycompleted the programme. In most therapeutic communities, there is a ‘roll of honour’in a prominent part of the house and, whilst we recognise that this can prove a hostage tofortune (particularly where a former resident relapses) this disadvantage is undoubtedlyoutweighed by the positive impact it can have on the residents. We were told that issuesof confidentiality meant that such a display was no longer feasible but we noted that thisappeared not to apply to a display of mass cards for former residents who had since died.Again, we were informed by the staff, that this was intended simply to honour the

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memory of former residents. Residents, however, told us that the purpose was to warnthem, “ …what will happen if we split.”

Finally, we noted that Graduation Ceremonies no longer took place. We understand thatthese important events were discontinued as a result of a number of episodes of heavyand inappropriate drinking on the part of those who had just graduated. In our view, thisis insufficient reason to abandon a practice, which not only has huge significance for theresidents (and for the staff) but also offers an important marketing opportunity for theorganisation.

Many TCs use graduation ceremonies to promote their work to the wider community, tofunders and to potential funders: although there is a justifiable concern that themanagement of such opportunities needs also to respect the confidentially of theindividual graduates. We feel that the organisations need to re-establish itself as one ofthe foremost treatment services available alone would be an argument for areinstatement of these ceremonies. However, we feel that there are in addition manypositive therapeutic benefits to ceremonies of this type and that such problems as wererelated during the fieldwork could almost certainly be overcome. Once again, thiswould be an area where the experience of other TCs might well prove invaluable and itis perhaps a telling comment on the relative isolation of the organisation over the pastdecade that this option was, apparently, not considered.

CONCLUSIONS & RECOMMENDATIONS We felt overall that there was a need for the staff group as a whole to recognise the valueof what had been undertaken within the organisation in previous times. The therapeuticcommunity has a long and honourable tradition, which has evolved over decades toprovide a unique and radical treatment solution to the needs of a particularly difficultgroup. In general terms, Coolmine House is aware of and appreciative of this‘inheritance’ and changes have been thought through and implemented with greatsensitivity.

However, we did feel that there was a tendency to lose sight of some of the centralprinciples in the process of change and we noted that some more recent staff had littleunderstanding of the distinct nature of the TC modality. We therefore recommend thatthe organisation:

• looks to ensure that work ‘on the floor’ is given a higher priority and isundertaken to a significantly higher standard.

• remains aware of the need to maintain a balance between individual and groupinterventions.

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• encourages the use of groups to explore feelings rather than thoughts andprovides appropriate training – possibly through other TCs – wherenecessary.

• reviews those changes it has made – or is considering making – which involvechanges to language and/or designation. The fact that the language differsfrom the ‘real world is to be celebrated rather than castigated.

• review the abandonment of the slip-box system and ensure that appropriateand equally powerful symbols/structures have replaced it.

• review the current use of concepts and ensure that a smaller number areretained which genuinely give real sustenance to the residence and have clearprovenance within the TC tradition.

• review the use of the mass card display. If this is to be retained, we wouldrecommend that it is sited elsewhere – perhaps in a room reserved for quietcontemplation.

• review the decision to abandon the ‘roll of honour’. Whilst it is recognisedthat there may be legal reasons for this decision (though paradoxically not fordisplaying the names of former residents, now dead!), the symbolic valueshould be recognised.

• restart the tradition of graduation ceremonies. These ceremonies have apowerful impact upon staff and residents alike and are a very practical wayof collaborating with other TCs to enhance the feeling of ‘family’.

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Ana Liffey Project. 2001. Drug Services and Non-European Union National: A BriefSurvey (Dublin, North Inner City Drugs Task Force).

Anderson, D. (2002) Personal communication with one of the authors (Anderson wasSenior Social Worker at Dingleton Hospital during Jones’ incumbency).

Blanchard, K. & Johnson, S. (2001) The One-Minute Manager (New York, Morrow,William & Co.).

Blanken, P., Hendricks, V., Pozzi, G., Tempesta, E., Hartgers, C., Koeter, M., Fahrner,A., Gsellhoffer, B., Kufner, H., Kokkevi, A. & Uchtenhagen, A. (1995) EuropeanAddiction Severity Index: A Guide to Training and Administering EuropASI Interviews,(COST A6, Working Group).

Bridgeland M. (1971) Pioneer work with maladjusted children (London, Staples Press).

Broekaert, E. & van der Straten, G. (1997) Histoire, philosophie et dévelopement de lacommunauté thérapeutique en Europe. Psychotropes: Revue Internationale destoxicomanies 3, 1, pp.7-23.

Broekaert, E., Bracke, R., Calle, D., Cogo, A., van der Straten, G. & Bradt, H. (Eds.).(1996) De nieuwe therapeutische gemeenschap. (Leuven, Garant).

Broekaert, E., (2001) Therapeutic communities for drug users: Description and overview,in B. Rawlings & R. Yates (Eds.) Therapeutic Communities for the Treatment of DrugUsers (London, Jessica Kingsley).

Bryan, A., Moran, R., Farrell, E. and O'Brien, M. (2000) Drug-Related Knowledge,Attitudes and Beliefs in Ireland. Report of a Nation-Wide Survey (Dublin, The HealthResearch Board).

Comiskey, C.M. (1998) Estimating the Prevalence of Opiate Drug Use in Dublin:Ireland during 1996 (Dublin, The Health Research Board).

Department of Tourism, Sport & Recreation (2001) Building on Experience: NationalDrugs Strategy 2001 – 2008 (Dublin, Department of Tourism, Sport & Recreation).

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Eley Morris, S., Yates, R. & Wilson, J. (2002) Trauma histories of men and women inresidential drug treatment: the Scottish evidence, The Drug and Alcohol Professional, 2,1, 20-28

Farrell, M., Howes, S., Taylor, C., Lewis, G., Jenkins, R., Bebbington, P., Jarvis, M.,Brugha, T., Gill, B. & Meltzer H. (1998) Substance misuse and psychiatric comorbidity:An overview of the OPCS National Psychiatric Morbidity Survey, Journal of AddictiveBehaviour, 23, pp.909-918.

Fureman, B., Parikh, H., Bragg, A. & McLellan, A.T. (1990) Addiction Severity Index:A guide to training and supervising ASI interviews based on the past ten years(Pennsylvania, The University of Pennsylvania/Veterans Administration, Center forStudies of Addiction)

Glaser, F. (1977). The origins of the drug-free therapeutic community: A retrospectivehistory, in P. Vamos and D. Brown (eds) Proceedings of the 2nd World Conference ofTherapeutic Communities: The Addiction Therapist, Special Edition, 2, 3 & 4, pp3-15

Gossop, M., Marsden, J., & Stewart, D. (1998). NTORS at one year. The NationalTreatment Outcome Research Study: Changes in substance use, health and criminalbehaviours at one year after intake. (London, Department of Health).

Gossop, M., Marsden, J., & Stewart, D. & Rolfe, A. (1999). NTORS Two YearOutcomes. The National Treatment Outcome Research Study: Changes in substance use,health and crime. Fourth Bulletin. (London, Department of Health).

Handy, C. (1992) Understanding Organisations (London, Penguin).

Hibell, B., Andersson, B., Bjarnason, T., Kokkeve, A., Morgan, M. & Narusk, A. (1997)The 1995 ESPAD Report. Alcohol and Other Drug Use among Students in 26 EuropeanCountries. (Stockholm, The Swedish Council for Information on Alcohol and otherDrugs [CAN]).

Kennard, D. (1998) An Introduction to Therapeutic Communities (Second Edition)(London, Jessica Kingsley).

Kooyman, M. (1992) The therapeutic community for addicts: intimacy, parentinvolvement and treatment outcome (Lisse: Swets & Zeitlinger).

Kooyman, M. (2001) The History of Therapeutic Communities: A view from Europe, inRawlings, B. & Yates R. (Eds.) Therapeutic Communities for the Treatment of DrugUsers (London, Jessica Kingsley).

Korf, D., Riper, H., Freeman, M., Lewis, R., Grant, I., Jacob, E., Mougin, C. & Nilson,M. (1999) Outreach Work Among Drug Users in Europe: Concepts, practice andterminology, (Lisbon, EMCDDA Insight Series 2).

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Leitner, M., Shapland, J. & Wiles, P. (1993) Drug Usage and Drugs Prevention: Theviews and habits of the general public. (London, HMSO).

Morris, S., Yates, R. & Wilson, J. (2002) Researching Concept-based TherapeuticCommunities, in Lees, J., Manning, N., Menzies, D. & Morant, N. (Eds.), ResearchingTherapeutic Communities, (London, Jessica Kingsley) – in press.

O'Brien, M., Moran, R., Kelleher. T. and Cahill, P. (2000) National Drug TreatmentReporting System (Dublin, Health Research Board).

Pines, M. (1999) Forgotten pioneers: The unwritten history of the therapeutic communitymovement. http://www.pettarchiv.org.uk/atc-journal-pines.htm: Association ofTherapeutic Communities.

Ravndal, E., and Vaglum, P. (1995) The influence of personality disorders on treatmentcompletion in a hierarchical therapeutic community for drug abusers: A prospectivestudy, European Addiction Research 1, pp.178-186.

Rawlings, B. & Yates, R. (2001) Fallen Angel, in Rawlings, B. & Yates R. (Eds.)Therapeutic Communities for the Treatment of Drug Users (London, Jessica Kingsley).

Sugarman, B., (1974) Daytop Village: A therapeutic community (New York, Holt,Rinehart and Winston).

Toon, P. and Lynch, R. (1994) ‘Changes in therapeutic communities in the UK.’ In J.Strang and M. Gossop (eds) Heroin Addiction and Drug Policy: The British System(Oxford, Oxford University Press).

Wilson, J. & Yates, R. (2001) The Modified Therapeutic Community: Dual diagnosis andthe process of change, in Rawlings, B. & Yates R. (Eds.) Therapeutic Communities forthe Treatment of Drug Users (London, Jessica Kingsley).

Yablonsky, L., (1965) Synanon: The Tunnel Back. New York: Macmillan.

Yates, R. The impact of the Therapeutic Community on other Treatment Modalities, 4thInternational Symposium: Substance Abuse Treatment and Special Target Groups, April2002 EFTC, Venice, 2002 (submitted to International Journal of Social Welfare).

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Appendices

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APPENDIX A: THE AUDIT PROPOSAL

Coolemine House: an operations management and therapeutic audit of services

Co-applicants:

Rowdy YatesScottish Addiction Studies, University of Stirlinge-mail: p.r.yates@stir.ac.uk

Salvatore RaimoItalian Federation for Therapeutic Communitiese-mail: raimo.salvatore@libero.it

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Project Summary:

In this brief project proposal, the proposers set out suggestions for a short auditprogramme evaluating both the management structures within Coolemine House and thecommunity’s work with individual clients and residents. The proposal is costed at4,770.00 euros and would be completed in a six week period. A detailed written reportwould be made of all observations, findings and recommendations.

Drug Trends in the Republic of Ireland

Cannabis is the most commonly used drug in Ireland followed by ecstasy. However, interms of harm to the individual and the community, heroin has the greatest impact.

In a recent national study of 1,000 adults 12% admitted to ever having taken cannabisand 30% reported that they personally knew someone who smoked cannabis (Bryan etal. 2000).

In 1997 and 1998 cannabis was the main drug of misuse for 10.6% of all those receivingtreatment for drug use in Ireland (O'Brien et al. 2000). The ESPAD survey (1995)showed that cannabis was the most frequently used drug (37%) among the 15 - 16 agegroup in Ireland (Hibell et al. 1997). The percentage of people receiving treatment fordrugs other than heroin was 30.1% in 1997 and 28.7% in 1998 (O'Brien et al. 2000).

Comiskey (1998) estimated that there were 13,460 opiate drug users in Dublin. Heroinuse in Ireland has remained a predominately Dublin phenomenon and the majority ofthose presenting for treatment are male, under 30 years of age, unemployed and earlyschool-leavers. The use of cocaine is increasing, particularly among youngprofessionals, although the numbers presenting for treatment are quite small. There is asignificant level of drug use occurring within Irish prisons. People who are homeless,the traveller community and those involved in prostitution are considered to be at highrisk of becoming involved in drug use.

Over half those presenting for treatment in Ireland inject their main drug while a thirdsmoke their main drug of use. There has been an increase in the number of peoplepresenting for methadone treatment nation-wide (from just over 500 in 1996 to over5,000 currently). There has also been a significant increase in the number of individualson waiting lists for methadone treatment.

Changes in National Policy Positions

Until the 1990s the central objective of Irish drug policy was to maintain people in - orrestore people to - a drug-free lifestyle. As a result, the drug problem waspredominantly seen as a medical problem and the socio-economic and socio-culturalfactors relating to drug use were largely ignored by the government.

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The governments’ abstinence-only treatment response was challenged in the late 1980sas a result of the emergence of HIV and AIDS. Subsequently, a harm reductionresponse was introduced and this is now the key feature of Irish drug policy.

Drug services now offer other options to total abstinence, which aim at attracting drugsusers into a range of different services. This approach is based on the premise that it willhelp estimate the extent of drug use and also reduce the risk of harm to both users andthe non-using population.

The first policy document addressing drug use in the 1990s was the GovernmentStrategy for the Prevention of Drug Misuse (1991) which concentrated mainly on theopiate problem in the greater Dublin area. The Strategy promoted co-operation betweenvoluntary and statutory services, education, treatment services, local communities,prison services, customs and excise and international agencies.

In the mid-1990s a Committee was set up, chaired by Pat Rabbitte, the Minister of Stateto the Government, to review drug policy. The First Report of the Ministerial TaskForce on Measures to Reduce the Demand for Drugs (1996) contextualised the drugproblem, examined underlying causes and looked at the nature and extent of theproblem. The relationship between drug use and social exclusion was acknowledged andas a result of the First Report, local Drugs Task Forces were set up in eleven areas (tenin Greater Dublin and one in Cork) where heroin use was considered the most prevalent.

The Second Report of the Ministerial Task Force on Measures to Reduce the Demandfor Drugs (1997) looked at the use of non-opiates (in particular ecstasy and cannabis).Following the Second Report, the Minister of State at the Department of Tourism, Sportand Recreation was given special responsibility for Local Development and for theNational Drugs Strategy.

In May 2001, a review of the National Drugs Strategy was published which endorsedthe existing approach already taken by the government. Changes made to the previousstrategy were to increase the number of treatment places to 6,500 by 2002; to enableimmediate access to counselling for addicts; to allow the prescription of methadone tounder 18 year olds and increase the number of drug seizures by 50% by 2008.

However, the strategy has been criticised for not having clear targets for reducing drugrelated harm and for not taking additional steps by putting in place safe injecting rooms(in view of high prevalence of hepatitis C) and for not clearly stating how ‘hard toreach’ drug users could be linked into services through the provision of more lowthreshold services and crisis counselling.

Implications for the Study Project

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These developments have inevitably impacted upon Coolemine House as they haveupon abstinence oriented services across Europe where similar shifts at national andEuropean-level have taken place. Kooyman (2001) has recorded the impact onabstinence treastment in general and therapeutic communities in particular. In Irelandand a number of countries across Europe, a significant tightening of the public purse anda growing concern over the spread of infection (through needle sharing) and levels ofdrug-related crime has resulted in emphasis being place upon apparently cheaperintervention options such as substitute prescribing.

Moreover, the emphasis on evidence-based treatment which has been a common featureof treatment service commissioning across Europe in the past decade has increased thepressure on all services to monitor all aspects of intervention; to examine and re-examine long-standing practice; and to consider changes where monitoring systems orcontemporary research outcomes indicate that change might be required.

It is against this backcloth that the proposers submit the following suggestions for anoperations management and therapeutic audit of the services provided by CoolemineHouse.

Aims of the proposed research

• To provide a thorough literature review of the salient issues pertaining to theprovision of abstinence-based services.

• To undertake a comparative review of these issues in Europe and internationallywhere applicable.

• To examine all facets of the community’s day-to-day operations and consider theefficacy of these processes against both operations management and therapeuticconsiderations.

• To describe what new initiatives have been attempted in the community (since thepreviously commissioned report) and establish which initiatives were effective andwhich were ineffective.

• To examine the options for a repositioning and/or further integration of thecommunity within the existing national policy framework where such integrationappears beneficial and practicable.

• To recommend changes in working practice and to provide detailed advice withregard to the practical implementation of such advice.

Plan of investigation

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The audit will be conducted both as field and desk research, with the interview andobservational aspects of the study being undertaken on site whilst the report-writing andreview work will be undertaken largely from the University of Stirling. .

The research will be carried out in four phases, described further below.

Phase 1: Location of the relevant literature (1 day)Publications considering the efficacy of interventions - both abstinence-oriented andharm-reduction oriented - to combat drug issues, cover a wide variety of aims,theoretical approaches, methods, settings, populations and outcome measures. In orderto provide a valid and useful summary of the research, the proposers will use asystematic approach to the review. The team will generally follow the guidelines inUndertaking Systematic Reviews of Research on Effectiveness (NHS Centre forReviews and Dissemination, 1996).

In brief, the methodology will involve the searching of relevant electronic databases andjournal articles. Criteria for study quality will be established in consultation with thecommissioning agency.

This Phase will also include a detailed consideration of relevant internal and publicdocuments produced by the commissioning agency - eg. annual reports, employmentpolicy documents, complaints procedures etc.

Phase 2: Field Visit: Observation and Interviews (3 days)Phase 2 will comprise a field visit to the workplaces currently utilised by thecommissioning agency in pursuit of its existing objectives.

During this visit, the proposers will aim to observe some of the day-to-day practicalactivities of the community and conduct a series of semi-structured interviews asfollows:

• Senior staff members: 3 interviews• Board members: 2 interviews• Maingrade staff members: 3 interviews• Residents and/or other clients: 5 interviews• External stakeholders (funders, policy-makers etc.): 2 interviews.

In order to facilitate anonymised interviews with residents and/or other clients, theproposers will prepare a brief leaflet describing the aims of the study, descriptions of theproposers, an assurance of complete anonymity and a request for written views on theservice received. This leaflet will in addition ask respondents if they would be willingto be interviewed under the same conditions. It is assumed that the commissioningagency will undertake to distribute these leaflets, provide some form of ballot boxsystem for returned leaflets and allow access to clients agreeing to be interviewed.

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Phase 3: Initial Written Conclusions (1 day)The proposers will aim to draft a brief summary of their initial thoughts and conclusionsprior to departure at the end of the field visit. As a result, a further day has beenallowed on conclusion of the planned interviews and observational visits for reportwriting and for a briefing meeting with senior officers of the commissioning agencies.

The purpose of this meeting will be to clarify any outstanding issues, to check thatinformation received has been correct and factual and to give an early indication of thelikely content of the final report.

Phase 4: Report Writing (1 day)A final written report will be made available to the commissioning agency within 3weeks of the field visit. This first draft will be provided in electronic format forconsideration by the commissioning agency.

Any comments regarding factual errors or omissions, typographical mistakes etc. shouldbe lodged with the proposers within 1 week of receipt. A second and final draft willthen be provided to the commissioning agency within 2 weeks of receipt of allcomments and corrections. This final draft will be in publishable format and will besupplied in electronic and hardcopy (6 copies) format.

Timetable of work

No formal timetable is submitted. The proposers believe that the stated aims of theproposal can be achieved within a six-week period from formal award of thecommission. The proposers further suggest that the field visit should be undertakeneither in the latter half of August or the first weeks of September. However, thesearrangements would be entirely negotiable if the commission is awarded.

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Justification of requirements

SalariesBoth proposers have estimated their costs on the basis of a daily rate of 385 euros. Nocosts are included in this proposal for travel and accommodation during the field sitevisit since it is understood that these costs are to be met by the commissioning agency.It has been assumed that the field site visit will be conducted in a single block of 3 days,with a further on-site day allocated to initial writing up of findings andrecommendations. The formal writing of the report is expected to take a further day ofdesk research.

Consultancy of Salvatore Raimo6 days @ 385 euro per day 2,310.00

Consultancy of Rowdy Yates6 days @ 385 euro per day 2,310.00

Equipment and consumables

DASS Resource Room(stationery, floppy discs, photocopying) 75.00

Communication and Administration(international phone calls, e-mail/Internet usage) 75.00

Total 4,770.00

Total to be paid to IFTC 2,310.00Total to be paid to Scottish Addiction Studies 2,460.00

Travel & Accomodation

No financial allowance has been made within the budget for this proposal for travel andaccommodation costs incurred during the field visit stage of this study. It is assumed (ashas been stated above) that these costs will be met by the commissioning agency.However, the commissioners may wish to consider whether they would wish to organisethese arrangements themselves or would prefer that the proposers make their ownarrangements. If the latter is the case, an agreed system for reimbursement of expenseswill need to be established prior to the commencement of the study.

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Expertise of the research team

Rowdy Yates is a Senior Lecturer in Addiction Studies at the University of Stirling. Hehas worked in the drugs field for more than thirty years and prior to this appointment,was Director and co-founder of the Lifeline Project, one of the UK’s longest establisheddrug specialist services. He will focus particularly upon literature search and operationsmanagement systems during this study.

Salvatore Raimo is currently Co-ordinator of the Shared Office for InternationalRelations of the Ce.I.S. in Belluno, Venice, Treviso, Vicenza, Verona and of the ItalianFederation for Therapeutic Communities. Prior to this appointment he worked in andmanaged therapeutic communities in Italy and Switzerland. He will focus particularlyupon the therapeutic environment of the community during this study.

Full curricula vitae are provided as appendices to this proposal in respect of bothproposers.

Purpose and implementation of results

This project will provide the Coolemine House with a timely review of current activityand the efficacy of its current operational and therapeutic structures. The study will aimto highlight areas of good practice and set out detailed advice on changes which mightbe made either to improve therapeutic interaction and thus client outcomes and toincrease management efficiency within the organization as a whole.

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Key References

Ana Liffey Project. 2001. Drug Services and Non-European Union National: A BriefSurvey. Dublin: North Inner City Drugs Task Force.

Bryan, A., Moran, R., Farrell, E. and O'Brien, M. (2000) Drug-Related Knowledge,Attitudes and Beliefs in Ireland. Report of a Nation-Wide Survey. Dublin: The HealthResearch Board.

Comiskey, C.M. (1998) Estimating the Prevalence of Opiate Drug Use in Dublin,Ireland during 1996. Dublin: The Health Research Board.

Department of Tourism, Sport & Recreation (2001) Building on Experience: NationalDrugs Strategy 2001 - 2008. Dublin: Department of Tourism, Sport & Recreation.

Hibell, B., Andersson, B., Bjarnason, T., Kokkeve, A., Morgan, M. & Narusk, A. (1997)The 1995 ESPAD Report. Alcohol and Other Drug Use among Students in 26 EuropeanCountries. Stockholm: The Swedish Council for Information on Alcohol and otherDrugs (CAN).

Kooyman, M. (2001) 'The history of therapeutic communities: A view from Europe.' InB. Rawlings, and R. Yates (eds) Therapeutic Communities for the Treatment of DrugUsers. London: Jessica Kingsley Publishers.

NHS Centre for Reviews and Dissemination (1996). Undertaking Systematic Reviewsof Research on Effectiveness: CRD Report Number 4. NHS Centre for Reviews andDissemination, University of York.

O'Brien, M., Moran, R., Kelleher. T. and Cahill, P. (2000) National Drug TreatmentReporting System. Dublin: Health Research Board.

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APPENDIX B: THE IMPACT OF THERAPEUTIC COMMUNITIES

NOTE: This paper was originally presented to the 4th International Symposium:Substance Abuse Treatment and Special Target Groups, April 2002 EFTC, Venice,2002. The paper was subsequently submitted to International Journal of Social Welfareand may not be cited without due authorisation.

The impact of the Therapeutic Community on other Treatment Modalities

The introduction of concept-based therapeutic communities, based upon the modelpioneered by Charles Dederich with the Synanon community in California, was asignificant development in the evolution of drug treatment provision in the UK. For ashort period in the 1970s, these communities enjoyed unparalleled influence in thedevelopment and direction of treatment approaches across the whole spectrum ofservices.

This paper considers the developments in psychiatry and social care which prepared theground for this phenomenon. In addition, the paper considers the subsequent demise inthe importance of therapeutic communities to the direction of drug policy and theimplications that this might have for future development of residential treatmentservices.

Introduction

In order to understand the extraordinary impact concept-based therapeutic communitieshave had upon other United Kingdom drug treatment modalities, it is important tounderstand not only the general mood and nature of those other services at the time oftheir transposition, but also the changes which had been seen in the treatment of thementally ill and the socially dislocated over the previous decades.

Whilst this paper focuses upon the experience in the United Kingdom, during the firstdecades after the importation of the concept-based idea from the United States, there issome evidence (Kooyman, 1993 & 2001) that the rise and subsequent decline ininfluence of this type of treatment was mirrored, at least in part, throughout Europe.

A great deal of energy has been expended upon the scientific search for the predecessorsof the Synanon experiment (Bassin, 1978; Broekart et al, 1996; Kooyman, 1993).However, of more immediate interest to the sociologist, is the remarkable ease withwhich a quintessentially American approach to treatment and rehabilitation wasintegrated into the UK drug treatment system.

In part, of course, the answer lies in the British view of addiction and drug use at thattime. Since the focus of British drug policy (and, consequently the British drug

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treatment system) was firmly upon heroin and cocaine, to the almost total exclusion ofthe more universally popular amphetamines (Spear, 1994; Yates, 1999); and since thesedrugs, with their associations with jazz music and Hollywood films, were seen asproducts of a wayward USA, it was perhaps, unsurprising that post-war Britain vieweddrug addiction as an American disease which would, presumably, respond to Americantreatment regimes.

However, this reframing of the drugs experience as the ‘fault’ of the outsider, thestranger, the foreigner, is common to most cultures (Inglis, 1975) and goes only part ofthe way to explaining a phenomenon whose legacy within the UK drug field remainsclearly discernable over thirty years later.

A Fertile Environment

The groundbreaking work of Maxwell Jones, Tom Main and others, in the developmentof so-called ‘democratic’ therapeutic communities, first at Hollymoor Hospital,Northfield and later at the Henderson Hospital have often been described (Kennard,1983; Broekart et al, 1996; Kooyman, 2001). However, with one or two exceptions, atleast in the UK, these experiments were kept within the broad tradition of in-patientpsychiatric treatment and were largely unknown outside psychiatry.

Nevertheless, these developments were significant elements of broader changes withinpsychiatric treatment as a whole. For the previous century, psychiatry had been littlemore than a specialist branch of the criminal justice system, with psychiatrists providingincarceration and basic remedial treatment for the insane (Berridge, 1999). The impactof the work of Freud, Jung, Klein and others coupled with the availability of new andpowerful drugs had led to dramatic changes in post-war psychiatry. Whilst some ofthese changes were purely about the use of psychoactive drug treatments to facilitate amore humane management of mental illness, others focussed upon the ‘talkingtherapies’ pioneered by Freud et al, whilst still others, such as the experiments with LSDand psychodrama at Powick Hospital (Sandison, 1997) were a conscious attempt tomarry the two emergent traditions.

Foremost amongst this new radical group of doctors and therapists was the Scottishpsychiatrist, R. D. Laing. Laing had already been acclaimed for his experimental workin Scotland with the establishment of his ‘rumpus room’ in a Glasgow hospital, when inthe 1960s, he took the extraordinary step of moving his patients out of the psychiatrichospital altogether and establishing them in an anarchic therapeutic community -Kingsley Hall - in the east end of London (Laing, 1965; Cooper, 1967; Laing, 1994).Laing and other members of the Phildelphia Association he established, both influencedand, in turn, were influenced by patient-led movements such as People not Psychiatry(PNP) and the emergent Italian movement, Psychiatrica Democratica (Basaglia 1988;Wilkinson and Cox 1986); movements which brought together mental health patients,radical health workers and social and political activists in a common cause to promote‘community healing’ outside the established, hospital-based psychiatric traditions.

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Meanwhile, parallel experiments in the treatment of ‘maladjusted’ or ‘wayward’children and young people had been quietly proceeding for the past century or more.The movement towards the establishment of self-help communities for sociallydislocated young people began in Europe with the work of juvenile justice reformerssuch as August Aichorn (Mohr, 1966) and educationalists such as Steiner, Pestalozzi andMontesori. In the UK, the genesis of the movement is usually credited to an Americanformer woodwork teacher called Homer Lane.

Lane was a charismatic free-thinker who had led the self-governing Boys Republic inthe USA. Impressed by Lane's approach to working with the most aggressive anddelinquent children, George Montagu (later Lord Sandwich) invited him to the UKwhere he established the Little Commonwealth. The Little Commonwealth, onMontagu's 200 acre estate, accepted 'unmanageable' children both from the courts andfrom their parents. Lane's approach was a mixture of tough love (including somecorporal punishment), extensive self-government and hard manual labour. Residentswere divided into self-regulating 'families' and paid a wage for their work. This wagewas pooled and used to clothe and feed the family. Those who idled and thus reducedthe family's income were forcefully reprimanded by their peers in family meetings(Bridgeland 1971).

The experiment however, founded, as it was, largely upon the charismatic presence ofLane himself, was ultimately doomed. In 1917, the Home Office withdrew supportfollowing unsubstantiated allegations against him of sexual impropriety by two femaleresidents (Lane had become fascinated by the work of Freud and Jung and had embarkedon a programme of rather amateurish psychoanalytic sessions with some of the children)and Lane, accused on a technical charge of failing to register as an alien, agreed to gointo voluntary exile. Without Lane, the Little Commonwealth collapsed within a yearand, upon his death in Paris in 1925, W. H. Auden wrote:

"Lawrence was brought down by the slut houndsBlake went dotty as he sangHomer Lane was killed in actionBy the Twickenham Baptist gang."

(Auden 1937)

The legacy of Lane's Little Commonwealth was an impressive one, inspiring the work ofthe radical educationists, A. S. Neil and J. H. Simpson. Neil claims that such was Lane'sinfluence on him, that he felt himself incapable of independent thought until Lane'sdeath broke the spell (Bridgeland, op cit).

Of all the inheritors of the Little Commonwealth innovations, the most important wasperhaps the work of David Wills. Wills, a former Borstal housemaster, was employedby the Q Camps Committee (later to evolve into the Planned Environment TherapyTrust) to manage a new experiment with delinquent youths called the Hawkspur

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Experiment. Wills, who freely acknowledged his debt, drew heavily upon the work ofLane. The Hawkspur Camp was founded in 1936 with staff and residents living in tentsand building their own accommodation. Much of the ethos of the camp was draw fromthe open-air school movement but the tough love regime and the self-governingeconomy were pure Lane (Wills 1967).

The personal connections of those who carried forward this work are also intriguing.Norman Glaister, who was at the time working at the Tavistock alongside HaroldBridger (a former member of the Northfield team and a central figure in thedevelopment of therapeutic communities in Italy in the 1970s), was an influentialmember of the Q-Camp Committee. Both Bridger and Glaister were in contact withBertram Mandlebrote, another of Maxwell Jones’ TC collaborators who went on toestablish a Synanon-style TC in Oxford.

For historians of the Synanon-inspired therapeutic community movement, the story ofLane’s work and his subsequent legacy evoke eerie echoes of the Dederich story andBridgeland’s often moving account (1971) of life at the Little Commonwealth leaveslittle doubt that this was a social experiment arising out of the same humanistic tradition.

This is not to say that Dederich was in any way influenced by Lane’s work in thecreation of Synanon. Rather it is to emphasise that the new therapeutic communitieswhen they began to be established in the UK in the early 1970s were for many, bothwithin psychiatry and the juvenile justice system, reminiscent of earlier innovations; andthe more welcome for that connection.

In 1971, Dr. Ian Christie, returning from a visit to New York, converted a ward of St.James’ Hospital, Portsmouth into the UK and Europe’s first concept-based or Synanon-style therapeutic community. Within a few years, Professor Griffith Edwards of theMaudsley Hospital Addiction Unit had established the Featherstone Lodge Project (laterPhoenix House) in south London. Around this time also, Dr. Betram Mandlebrote (seeabove) created a concept-based TC in Littlemore Hospital, Oxford; later, like Christie,moving his creation out of the hospital and into the wider community. Later in thedecade, Dr. Walter Lyons, enthused by his experiences at Odyssey House, New York,began a community called Inward House in Lancaster in the north of England.

Significantly, all of these developments were, at least in part, the result of theenthusiasm of a group of progressive psychiatrist most of whom had been charged withthe running of a hospital based ‘drug dependency unit’ and inspired by their contact withAmerican TCs (notably, Phoenix House and Daytop Village) to do something quitedifferent.

Drug Dependency Units had been established throughout the UK as a result of the reportof the Interdepartmental Committee on Drug Dependence (normally called the ‘BrainCommittee’ after its Chairman, Lord Brain). This report noted that a significantblackmarket in heroin (and to a lesser extent, cocaine) had been caused by theinjudicious prescribing of a small number of London-based family doctors and proposed

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that the power to prescribe these drugs for the treatment of addiction be removed fromfamily doctors and vested in a small number of licensed medical practitioners; mainlypsychiatrists working in newly established specialised units (Micheson, 1994).

The idea was that the blackmarket could be stifled by ensuring that existing usersreceived a legal supply of drugs, sufficient to their needs but not enough to create asurplus with which to encourage the use of new drug recruits. But these developmentstook place during a period of great upheaval in psychiatry and few psychiatrists wereinterested in merely providing prescriptions for disaffected young people who couldhardly be classified as mentally ill in the true sense of the term. The search for asolution to the drug problem appeared to lie outside the walls of the psychiatric hospitaland many psychiatrists charged with the responsibility for the provision of a specialistdrug service established community-based facilities.

By the late 1970s, concept based therapeutic communities accounted for almost half ofthe 250 residential rehabilitation beds in the UK (Yates, 1981). Whilst this is animpressive ‘territorial’ claim, in terms of numbers of drug users presenting for treatment,TCs were a very small player. However, their influence was felt throughout thetreatment field.

By the mid 1970s, medical staff working in specialist centres were beginning toincorporate some of the techniques of the TCs into the clinical setting. The aim was toprovide a more therapeutic regime than the sterile interaction which had developed;largely dominated by staff-patient manipulation around the dosage and type of substituteprescription (Mitcheson 1994).

Non-residential treatment services, too were influenced by the TCs, with somedeveloping pre-entry ‘induction’ programmes (Strang and Yates, 1982; Yates, 1979)whilst others began to undertake group work modelled upon that found in TCs. In theNetherlands, a non-residential TC was established, and in a number of Europeancountries, existing non-residential services restyled themselves as providers of 'non-residential rehabilitation'.

Similarly, residential services were keen to adopt some of the TC practices, and anumber of Christian-based houses began to develop a more hard-edged, confrontativeapproach to the interactions between residents and staff (Wilson, 1978).

A Sphere of Influence far Greater than their Size

The concept-based therapeutic communities had an extraordinary impact upon treatmentpractices and beliefs in the UK and one which far outweighed their relative input interms of actual client contact. There appear to be a number of reasons for this.

Firstly, the majority of other services were working with what would now de classifiedby Prochaska and DiClimente (1998) as ‘pre-contemplative’ and there can be little doubt

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that this is a very unrewarding client group. Other services might work with a reluctantclient for many years only to see the credit for his ‘cure’ given to a therapeuticcommunity to which he had been referred by the very agency whose contribution he isnow apparently dismissing.

Secondly, the funding of residential treatment in the UK resulted in TC staff oftenworking in more attractive environments (an indeed, many TCs were established inattractive large houses in rural settings). By contrast, most street agencies and drugdependency units were in unnattractive areas and generally under-resourced materially.

Thirdly, whilst Freud et al had popularised the ‘talking therapies’ within psychiatry,radical and anti-psychiatry had placed the new tools into the hands of the lay practitionerand TC staff were at the forefront of this new movement.

Fourthly, TCs were essentially an evangelistic movement. Those within the movementsaw it as an intrinsic part of their role to ‘spread the word’.

Fifthly, like any emergent movement, they were also quite self-protective. Theydeveloped an exclusive fellowship of TCs of which the European Federation ofTherapeutic Communities (EFTC) was a logical outcome and where regular ‘jamborees’and ‘joint marathons’ were a natural expression of fraternity. As a result, the TCs werea strong united force within a field which was normally noted for its disunity.

Lastly, TCs not only appeared to work but they did so with aplomb. Not only did clientsappear to change for the better, but the change was often visibly and dramatic. Likesmall children watching a conjuror, the rest of the field was often transfixed; gaping inwonderment at the magic of it. For us, the circus had come to town and some of us justwanted to run away with it!

And then it was gone

The flowering of the UK concept-based therapeutic communities lasted for a little over adecade. The waning of their influence in the 1980s was reflected in similar changesacross Europe and for broadly similar reasons.

Firstly, TCs were slow to adapt to the changing demography. As the number of drugusers began to spiral at the end of the 1970s (Yates, 1992) the proportion of those whosecharacter-disordered behaviour required the sort of treatment TCs were designed toprovide, began to decline. With the escalation in drug users came an escalation in drugtreatment services and TCs struggled to make their voice heard in what was now asubstantial treatment field dominated by community-based services. When the BritishGovernment in 1983, embarked upon a major central government-funded pump priminginitiative to establish a national network of drug treatment services, residential

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rehabilitation services were unable to secure more than 10% of the new money, with thelion's share (56.2%) going to community services (MacGregor 1994).

Secondly, increasing alarm at the spread of HIV/AIDS ensured that after less than adecade in the wings, medicine had returned to centre stage. Almost overnight, thepriority client changed from the drug user who wanted to stop using to the one whodidn’t and who therefore presented the greatest risk for the spread of the virus.Effectively, the new political imperative was now infection control and TCs - the archproponents of individual and group therapy found themselves on the margins of thedebate without making any conscious movement.

Thirdly, in an increasingly finance-led culture, with a firm and increasingly ruthlesssqueeze on public expenditure, TCs were far too easy to cost. By comparison,community based treatments are financially dispersed with some direct costs attributableto specialist service provision but the majority spread across unemployment and housingbenefit; criminal justice services; child welfare; victim support etc. Residential servicesrapidly gained a reputation (not founded upon any scientific evidence) for high costprovision.

Fourthly, changes in the UK public funding of care resulted in a reallocation ofresources to local authorities. This left TCs - which in the UK had traditionally served ageographically diverse population - negotiating per-capita funding with a large numberof local authorities who were only too aware that the purse was limited and that other,more ‘worthy’ causes needed to be funded from within the same allocation. Thisproblem was further compounded by the growth of a private sector specialising inMinnesota Model style short treatment interventions.

As a result, most TCs in the UK found themselves under pressure to shorten programmelengths, abandon practices with which some funders were uncomfortable and ensure ahigher ration of ‘professional’ staff. Ironically, as the UK TC movement began toaccommodate changes for reasons of survival, they began to lose those distinctiveelements which made them a valued contributor to the treatment panoply.

Conclusion

Perhaps it is inevitable that a development which was initially so dramatic should, in thecourse of time settle back into mundanity, but cold logic of this type is hardly likely toprevent those of us who were there from mourning its passing.

Clearly, the future for the TC now lies in niche marketing of a kind already beginning tobe apparent in some areas. In order to ensure continued existence and integrity, TCswill in the future, need to target those areas where they can make the most impact andachieve the most good. This means designing specialised TCs for particular(vulnerable) populations such as the homeless and the dual diagnosed and establishing

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TCs in areas where they are likely to attract a higher proportion of their traditional clientgroup; TCs in prisons, detention centres etc.

Certainly, establishing TCs to work in collaboration with the criminal justice system iseffectively a return to earlier times since Synanon accepted court referrals from an earlystage in its existence (Rawlings and Yates, 2001). It would also have the advantage ofresponding to the current preoccupation of most European governments with the drugs-crime axis. For, in the past decade, the political imperative has shifted once again, awayfrom public health and towards crime prevention (Stimson, 1999).

Both Winick (1962) and Robins & Murphy (1967) have identified a natural maturing outof addiction in early middle age. It seems inevitable that the current policy of long-termprescribing will delay the onset of this phenomenon in many individuals. But it is surelyunlikely that it can undermine this natural process completely. The next decade,therefore, may be marked by an increase of those on long-term prescriptions seekingdetoxification and associated rehabilitative inputs. It is vital that those sectors of thetreatment field best able to provide such inputs be protected, nurtured and learned from.Whatever their faults, concept based therapeutic communities have shown over the pastfour decades that they are able to work effectively and compassionately with those whowish to change. They have proved their worth in a world which has often been hostile totheir ideals and aspirations and they have shown that they can survive and change whilstmaintaining the core values which underpinned those early days in a Santa Monicawaterfront hotel.

References

Auden W. H. and Macneice, L. (1937) Letters from Iceland. London, Faber & Faber.

Basaglia, F. (1988) 'Italian psychiatric reform as a reflection of society.' In, S. Rayonand M. Giannichedda, (eds) Psychiatry in Transition: The British and Italianexperiences. London: Pluto Press.

Bassin, A. (1978) The miracle of the T.C: From birth to postpartum insanity to fullrecovery: end World Conference of Therapeutic Communities. Montreal: McGillUniversity.

Berridge, V. (1999) Opium and the People: Opiate use and drug control policy innineteenth and early twentieth century England (London, Free Association Book)

Broekaert, E.., Bracke, R., Calle, D., Cogo, A., Van Der Straten, G. and Bradt, H. (eds)(1996) De nieuwe therapeutische gemeenschap. Leuven: Garant.

Cooper, D. (1967) Psychiatry and Anti-Psychiatry. London: Tavistock.

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Inglis, B. (1975) The Forbidden Game: A social history of drugs. London: Hodder &Stoughton.

Kennard, D. (1983) An Introduction to Therapeutic Communities (London, Routledge &Kegan Paul)

Kooyman, M. (1993) The therapeutic community for addicts: Intimacy, parentinvolvement and treatment outcome. Lisse: Swets & Zeitlinger.

Kooyman, M. (2001) 'The history of therapeutic communities: A view from Europe.' InB. Rawlings, and R. Yates (eds) Therapeutic Communities for the Treatment of DrugUsers. London: Jessica Kingsley Publishers.

Laing, A. (1994) R. D. Laing: A Life. London: Harper Collins.

Laing, R., Esterton, A. and Cooper, D. (1965) 'Results of family oriented therapy withhospitalised schizophrenics.' British Medical Journal II, 1462 - 1465

MacGregor, S. (1994) 'Promoting new services:The Central Funding Inititiative andother mechanisms.' In J. Strang, and M. Gossop (eds) Heroin Addiction and DrugPolicy: The British System. Oxford: Oxford University Press.

Mitcheson, M. (1994) 'Drug Clinics in the 1970s.' In J. Strang, and M. Gossop (eds)Heroin Addiction and Drug Policy: The British system. Oxford: Oxford UniversityPress.

Mohr G. (1966) 'August Aichhorn.' In F. Alexander, S. Einstein and M. Grotjahn (eds)Psychoanalytic Pioneers. New York: Basic Books.

Prochaska, J. & Diclemente, C. (1998) Changing for Good. New York: Avon.

Rawlings, B. & Yates, R. (2001) 'Introduction: The fallen angel.' In B. Rawlings, and R.Yates (eds) Therapeutic Communities for the Treatment of Drug Users. London: JessicaKingsley Publishers.

Robins, L. and Murphy, G. (1967) 'Drug use in a normal population of young negromen.' American Journal of Public Health 57, 1580 - 1586.

Sandison, R. (1997) ‘LSD Therapy: A retrospective.’ In: A. Melechi, (ed.) PsychedeliaBritannica: Hallucinogenic drugs in Britain (London, Turnaround)

Spear, B. (1994) 'The early years of the British System in practice.' In J. Strang, and M.Gossop (eds) Heroin Addiction and Drug Policy: The British System. Oxford: OxfordUniversity Press.

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Stimson, G. 'Blair declares war or the unhealthy state of British drugs policy.' InMethadone and Beyond: Expanding and exploring drug treatment options: MethadoneAlliance Conference London, March, 22, 2000, Methadone Alliance, forthcoming.

Strang, J. & Yates, R. (1982) Involuntary Treatment and Addiction. Strasbourg: Councilof Europe (Pompidou Group).

Wills, D. (1967) The Hawkspur Experiment. London: Allen & Unwin.

Wilkinson, K. & Cox, A. (1986) Principles into Practice: A developmental study of acommunity mental health service. Manchester: Youth Development Trust.

Wilson, F. W. (1978) 'Spiritual therapy in the therapeutic community.' In P. Vamos andD. Brown (eds) Proceedings of the 2nd World Conference of Therapeutic Communities:The Addiction Therapist, Special Edition, 2, 3 & 4, 204-205.

Winick, C. (1962) 'Maturing out of narcotic addiction.' United Nations Bulletin onNarcotics, 14.

Yates, R. (1979) 'An Experiment in Multi-facility Addiction.' Addiction Therapist(Special Edition), Winter, 3, 25 - 30.

Yates, R. (1981) Out From the Shadows. London: NACRO.

Yates, R. (1992) If it Weren't for the Alligators - A history of drugs, music & popularculture in Manchester. Manchester: Lifeline Project.

Yates, R. (1999) Only Available in Black: The limiting of addiction services in thetwentieth century, Uteseksjonen 30 Ar Pa Gata, November 1999, (Oslo, Uteseksjonen).

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62

APPENDIX C: CONTRACTING & BUSINESS PLANNING

NOTE: The following sample documents are provided for illustrative purposes only.The authors believe that they should provide a useful starting point to the developmentof similar documents tailored to the needs of Coolmine House. These documents wereoriginally published in:

Yates, R. (1997) A Guide to Developing Services for Alcohol and Drug Misusers(Edinburgh, The Scottish Office).

EXAMPLE CONTRACT

STREETLEGAL SERVICE AGREEMENT

This Agreement is made the .......................... day of ........................ 2000between theNowhere Local Authority, Gateway House, 10 Park Drive, Nowhere NW10TH(hereinafter called "the Authority") of the first part; and Streetlegal AddictionService, 3 Back Row, Nowhere NW2 1QT (hereinafter called "the Contractor") of thesecond part.

WHEREAS:

a The Authority in accordance with its powers under the Social Work (Scotland) Act1968 and under the National Health Service and Community Care Act 1990 isempowered to make financial contribution to the work of any relevant body.

b The Contractor is a body established for charitable purposes whose objectives (as setout in the Memorandum and Articles of Association of that body) have to do with therelief of suffering arising out of the misuse of drugs and alcohol.

c The Authority has agreed to provide financial assistance to the Contractor as detailedwithin the following Schedules in order to assist him to carry out the functions set outin Schedule Two (hereinafter called the functions´).

SCHEDULE ONE - TERMS OF THE AGREEMENT

1.1 The Project hereby agrees to provide financial assistance to the Contractor for aperiod of 36 months, as mutually agreed by both parties, in the pursuance of the saidfunctions.

1.2 The Authority acknowledges the dual role of the Contractor in both providingservices in respect of the relief of suffering arising out of the misuse of drugs and

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alcohol and campaigning for an improvement in the circumstances of those thusaffected and hereby agrees that no activity undertaken by the Contractor in pursuit ofthese objectives shall adversely affect the terms of this Agreement unless and until suchactivities are deemed to be in direct contravention of these terms.

1.3 The Authority reserves the right to use any information or materials supplied to itby the Contractor in any way that it shall deem to be appropriate; always providing thatdisclosure of such information in no way contravenes the letter or spirit of thisAgreement with respect to confidentiality as detailed in Items 1.11, 1.12 and 1.13 ofthis Schedule. Copyright will remain with the Contractor and due acknowledgementwill be given.

1.4 The Contractor shall indemnify the Authority against any expense, liability, loss,claim or proceedings, arising under any statute or at common law, in respect of damageto property, personal injury to, or the death of any person, arising out of or in the courseof, or caused by the carrying out of, the said functions; unless due to the neglect of theauthority or of any person for whom the Authority are responsible.

1.5 The Contractor shall ensure that the insurance in respect of personal injury or deathof any person arising under a contract of service with the Contractor and arising out ofan incident occurring during the course of such person employment, shall comply withthe Employer Liability (Compulsory Insurance) Act 1969 and the Road Traffic Act1972 and any statutory instruments made thereunder.

1.6 The Contractor is not and shall in no circumstances hold him/herself out as beingthe servant or agent of the Authority otherwise than in circumstances expresslypermitted by this Agreement.

1.7 The Contractor is not and shall in no circumstances hold him/herself out as beingauthorised to enter into any contract on behalf of the Authority or in any other way tobind the Authority to the performance, variation, release or discharge of any obligation.

1.8 The Contractor has not, and shall in no circumstances hold himself out as havingthe power to make varied discharge or waive any bye-law or regulation of any kind.

1.9 The employees of the contractor, are not, and shall not hold themselves out to be -and shall not be held out by the Contractor as being - servants or agents of theAuthority for any purposes whatsoever.

1.10 The Contractor shall at all times employ sufficient staff and voluntary workers ofappropriate quality, background and/or experience to ensure the provision of the saidfunctions to the reasonable satisfaction of the Authority. Such staff complements and/orqualifications, background and experience as deemed to be necessary, to be determinedby the Contractor in agreement with the Authority. The Contractor will be responsiblefor compliance with all statutory requirements of an employer (e.g. the employmentconditions, taxation, insurance etc.)

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1.11 The Contractor shall not during the term granted by this Agreement or at any timethereafter make use for his/her own purposes or disclosure to any person (except asmay be required by law) any information contained in any material provided to him/herby the Authority pursuant to the Agreement where such information has been indicatedto be confidential or might reasonably be deemed to be so.

1.12 The Authority shall not during the term granted by this Agreement or at any timethereafter, make use for its own purposes or disclosure to any person (except as may berequired by law) any information contained in any material provided to it by theContractor pursuant to the Agreement; where such information has been indicated to beconfidential or might reasonably be deemed to be so.

1.13 In accordance with Items 1.11 and 1.12 of this Schedule, the parties hereto agreeto respect the confidentiality of information concerning the employees and clients ofeither party which may, from time to time, become available to them and to abide bythe provisions of the Data Protection Act.

1.14 Any notice to the Authority or to the Contractor, as the case may be, shall bedeemed to be sufficiently served if addressed to and left at or sent by recorded deliverypost or by facsimile to the Chair, Streetlegal Addiction Service, 3 Back Row, NowhereNW2 1QT and to Nowhere Local Authority, at their registered office or last knownplace of business.

1.15 The terms of this Agreement may be amended only by written agreement betweenthe Authority and the Contractor. Where a proposed amendment is unacceptable to theother party, the party wishing to amend the Agreement shall instead have the right toserve written notice of at least three months of the expiry of the Agreement.

1.16 In the event of any breach or non-observance of any condition of this Agreementby one of the parties, which has not been remedied within a mutually agreed time, or ofany dispute arising from the Agreement as set out herein, which cannot be settled bynegotiation between the parties, the aggrieved party shall have the right to refer thedispute to a single Arbiter in accordance with, and subject to, the provisions of theArbitration Act 1950 or any statutory modifications or re-enactment there of for thetime being in force; or, by the service of three months notice in writing, terminate thisAgreement.

1.17 In the event of the Contractor ceasing to exist or entering into liquidation (eithercompulsorily or voluntarily) - for whatever reason - the Agreement will be terminated.

1.18 Notwithstanding anything set out in Items 1.14, 1.15 & 1.16 hereof, thisAgreement shall expire after......months (on the.......day of.........200....) unlessterminated by either party in advance of that date in accordance with any of theprovisions herein.

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1.19 Failure by the Authority at any time to enforce the provisions of the Agreement orto require performance by the Contractor of any of the provisions of the Agreement,shall not be construed as a waiver of any such provisions and shall not affect thevalidity of this Agreement or any part thereof or of the right of the Authority to enforceany provision in accordance with its terms.

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SCHEDULE TWO - SERVICES TO BE PROVIDED

2.1 In accordance with the provisions herein, the Contractor agrees to provide thefollowing services on behalf of the Authority and to their reasonable satisfaction.

A telephone advice and helpline

Drop-in service for drug misusers

A needle exchange and advice service

Support services for parents and relatives

2.2 The detail of services to be provided by the Contractor in respect of this Agreementshall be expressed in an annual business plan mutually agreed by both parties andwhich shall be submitted by the Contractor for the approval of the Authority on orbefore 30th November of each year. The Authority shall undertake to give formalapproval on or before1st January of each year. All the foregoing to be undertaken asdetailed at 4.3, 4.4, 4.5 and 4.6 of this Agreement.

2.3 The Authority shall not unreasonably withhold agreement in respect of anyprovision of service which is beyond the power of the Contractor to undertake orachieve, provided always that the Contractor has used his best endeavours so to do.

SCHEDULE THREE - EVALUATION OF SERVICES PROVIDED

Reporting Arrangements

3.1 The Contractor shall prepare and submit to the Authority by the 30th day ofNovember 2000 and upon the 30th day of November in each subsequent year up to andincluding the30th day of November 2003 annual reports of his progress inimplementing the services contracted for in the previous financial year.

3.2 In addition to the requirements of the Companies Act 1985 such an Annual Reportshould:

assess the performance of the Contractor in realising his aims and objectives;

identify any constraints limiting the achievement of the objectives;

record all monies sought and obtained;

report progress on implementing the agreed service provisions;

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include audited accounts in respect of all the Contractor activities during the previousfinancial year;

contain an adequate record of all client contact during the previous financial year

such records to include nature, source and duration of attendances.

Staffing

3.3 The Contractor shall provide, upon request of the Authority, details of any staffemployed during the previous financial year for the purposes of complying with any orall of the provisions set out herein.

3.4 The Contractor shall ensure that appropriate recruitment procedures are in place inorder to secure employees of adequate ability to undertake the said functions and thatsuch procedures which are in place do not contravene employment or common law nordiscriminate upon the grounds of race, religion, ethnic background, sex or sexualpreference, disability or health status, age, former drug use or other criminal conviction(except where such discrimination is deemed appropriate or necessary under the termsof employment law or in respect of the Rehabilitation of Offenders Act 1974).

3.5 The Contractor shall ensure that adequate arrangements are in place to supervise,support and appraise the work of staff/staff teams in order to achieve a high level ofcare and/or service for potential and current clients of the services provided and toidentify future training needs.

3.6 The Contractor shall ensure that adequate arrangements are in place to ensureappropriate access to in-service training for all staff; having in mind the necessaryconstraints of the budget.

3.7 The Contractor shall ensure that adequate procedures are in place for the resolutionof grievance or disciplinary issues and that such procedures as are available are knownto all the Contractor employees or that he has taken all reasonable steps to ensure thatthis is so.

3.8 The Contractor shall ensure that provisions similar to those outlined in Items 3.3,3.4, 3.5, 3.6 and 3.7 are also in place in respect of unpaid or voluntary staff recruited inpursuit of the said functions.

Consumer Evaluation

3.9 The Contractor shall ensure that adequate measures are in place to ensure that clientcontract, as described in Item 3.2.f is properly recorded and reported back to the

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Authority in the agreed form as set out therein.

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3.10 The Contractor shall ensure that adequate arrangements are in place for theevaluation of consumer response to the said functions; such arrangements to include theprovision of a clear and uncomplicated complaints procedure which is, where possible,made known to all consumers of the said functions and is operated without detriment tothe service provided to the complainant and/or his/her agency, family or othergrouping.

3.11 The Contractor shall use his best endeavours to ensure that the views of potentialand current clients of the said functions are both sought and, where possible, acted uponin such a way as to improve the quality of that service both for the respondent and forother potential and current users of that service.

Accessibility

3.12 The said functions shall be provided by the Contractor by mutual agreement withthe Authority at such times as deemed to be appropriate to the needs of the potentialand current client group. Such appropriateness to be subject to regular and thoroughreview in accordance with the terms and conditions set out herein.

3.13 The Contractor shall use his best endeavours to ensure that some service ordiversion to other services outside the agreed hours of operation is made availablewithin the constraints of the budget in order to ensure maximum possible access to thesaid functions.

3.14 The Contractor shall use his best endeavours to ensure that customers arewelcomed to the service provided - in whatever manner they choose to approach it (inperson, by telephone, letter etc) - with courtesy and discretion.

3.15 The Contractor shall ensure that the length of time between initial contact and theprovision of a service remains as short as possible and that waiting times in respect ofdrug and alcohol misusers, their friends and family members, are recorded whereappropriate and reported back to the Authority, as envisaged within Item 3.2 of thisSchedule.

3.16 The Contractor shall use his best endeavours to ensure that the services providedare so arranged as to ensure maximum potential access to the said functions regardlessof race, religion, ethnic background, sex or sexual preference, disability or health status,age, nature of drug use or criminal conviction.

3.18 The Contractor shall use his best endeavours to ensure that the said functions areadequately promoted and advertised in order to ensure maximum accessibility to thepotential client group.

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Other Evaluative Arrangements

3.19 In addition, the Contractor hereby agrees to allow full and free access to relevantpremises and/or personnel to any authorised officer or member of the Authority or anyother person or persons duly authorised to undertake evaluative work at its behest forthe purpose of evaluating progress in respect of the said functions. Such entry to besubject to written agreement served in the appropriate manner set out herein andprovided always that such access is not in contravention of the rights of the client andstaff of both parties to confidentiality and data protection as set out herein at 1.11, 1.12,1.13.

3.20 The Contractor shall not unreasonably withhold from the Authority anydocuments, information or other such materials necessary to the evaluation of the saidfunctions provided always that these are requested in the manner set out herein by anyauthorised officer or member of the Authority or any other person or persons dulyauthorised to undertake evaluative work at its behest.

SCHEDULE FOUR - ARRANGEMENTS FOR PAYMENT

Expenditure

4.1 Payment will be in the sum of ......... by ....... equal instalments paid 6 monthly inadvance/upon completion of the said functions/upon production of duly authorisedinvoices, receipts etc.

4.2 Payment date(s) will be as follows:

First payment - day/month 200 ..Second payment - day/month 200 ..Third payment - day/month 200 ..Fourth payment - day/month 200 ..Fifth payment - day/month 200 ..Sixth payment - day/month 200 ..Seventh payment - day/month 200 ..Eighth payment - day/month 200 ..Ninth payment - day/month 200 ..

4.3 The Contractor will submit to the Authority on or before the 30th Day ofNovember, a budget and business plan for the subsequent financial year commencingon 1st day of April thereafter.

4.4 The Authority and the Contractor, hereby agree to consult, in good faith, on thebudget and service specification submitted.

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4.5 The Authority shall, on or before the 1st day of January thereafter, notify theContractor in writing in the form set out herein, of its approval of the budget assubmitted by the Contractor.

4.6 Should the Authority choose to withhold approval of the budget as submitted by theContractor notice of that decision shall be served upon the Contractor on or beforethe1st day of January thereafter, in writing in the form set out herein.

4.7 The Authority shall not unreasonably withhold approval to the budget.

4.8 The Budget shall not depart unreasonably from the previous year budget.

4.9 The Authority will give consideration to requests for extraordinary payments orvariation of payment schedules where such payments or variations are renderednecessary through variations in costs unforeseen by either party in agreeing the budgetfor the year within which such costs are incurred.

4.10 Savings realised through efficiency, the utilisation of voluntary funds, staffingvacancies, sales of literature, materials or services or for any other reason will not bepenalised provided always that:

i savings realised have not been to the detriment of the said functions and that theContractor can show, to the reasonable satisfaction of the Authority that the statedobjectives have been achieved.

ii the Contractor can show, to the reasonable satisfaction of the Authority that thesavings achieved will be utilised within the subsequent financial year in the pursuanceof the aims and objectives as set out in his Memorandum and Articles of Association.

iii The Contractor can show, to the reasonable satisfaction of the Authority that suchsavings have been achieved by lawful act or measure and in accordance with his aimsand objectives as set out in his Memorandum and Articles of Association and with theterms and conditions as set out herein.

4.11 Payment of any such monies as may be decided in respect of the said functions asset out herein, shall not debar the Authority from other payment of any other monies tothe Contractor, in any form which shall be deemed appropriate pursuant to any otherfunctions which the Authority shall, from time to time, wish the Contractor toundertake on its behalf.

4.6 Should the Authority choose to withhold approval of the budget as submitted by theContractor notice of that decision shall be served upon the Contractor on or beforethe1st day of January thereafter, in writing in the form set out herein.

4.7 The Authority shall not unreasonably withhold approval to the budget.

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4.8 The Budget shall not depart unreasonably from the previous year budget.

4.9 The Authority will give consideration to requests for extraordinary payments orvariation of payment schedules where such payments or variations are renderednecessary through variations in costs unforeseen by either party in agreeing the budgetfor the year within which such costs are incurred. 4.10 Savings realised throughefficiency, the utilisation of voluntary funds, staffing vacancies, sales of literature,materials or services or for any other reason will not be penalised provided always that:

i savings realised have not been to the detriment of the said functions and that theContractor can show, to the reasonable satisfaction of the Authority that the statedobjectives have been achieved.

ii the Contractor can show, to the reasonable satisfaction of the Authority that thesavings achieved will be utilised within the subsequent financial year in the pursuanceof the aims and objectives as set out in his Memorandum and Articles of Association.

iii The Contractor can show, to the reasonable satisfaction of the Authority that suchsavings have been achieved by lawful act or measure and in accordance with his aimsand objectives as set out in his Memorandum and Articles of Association and with theterms and conditions as set out herein.

4.11 Payment of any such monies as may be decided in respect of the said functions asset out herein, shall not debar the Authority from other payment of any other monies tothe Contractor, in any form which shall be deemed appropriate pursuant to any otherfunctions which the Authority shall, from time to time, wish the Contractor toundertake on its behalf.

IN WITNESS thereof the Authority have hereunto affixed their common seal and thesaid Contractor has hereunto set his hand and seal the day and year first before written.

For and on behalf of Somewhere Local Authority

Signature .......................................................................... Seal

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Position .............................................................................

For and on behalf of Streetlegal Addiction Service

Signature ..............................................................................Seal

Position ................................................................................

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EXAMPLE BUSINESS PLAN

STREETLEGAL ADDICTION SERVICE BUSINESS PLAN

I. INTRODUCTION : AIMS & OBJECTIVES

We exist to improve the quality of life of the drug user and their family and friendsUltimately, the quality of the service we offer will be judged by the users of that serviceand the changes which occur in their lives as a result of their contact with us.(Streetlegal Addiction Service: Mission Statement).

In order to best serve these principles, we will:

provide a comprehensive "early intervention" advice and information service foryounger drug users.

provide a range of services appropriate to the needs of parents, friends and other carersof drug users.

provide a range of services appropriate to the needs of older drug injectors; includingservices aimed at preventing the spread of disease and infection.

2. THE CONTEXT

Streetlegal is a Scottish Charity established to provide services to "alleviate the distressand injury caused by the use of drugs of all kinds (including alcohol)"(StreetlegalAddiction Services: Constitution 1997)

The Agency operates within the local authority area of Nowhere, although, given themobility of the service user group, there has always been a small percentage of drugusers and their carers presenting to the service from outside the formal catchment area.

Traditionally the Agency has always targeted young adult injectors and their carers.

However, over the past few years, there has been a noticeable increase in the numbers ofteenagers presenting to the Agency for advice and assistance regarding their use of so-called "dance drugs". This newer group of service users is markedly different to ourtraditional "customer base" and has shown some reluctance to use services which theysee as being for "old junkies". Significantly, the majority of the contacts for this grouphave been by telephone.

A pilot study over three months of the previous year showed that the most demand from

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this group was at evenings and weekends. We therefore propose to offer an experimentaldrop-in session on Saturday afternoons, specifically for this new group.

We will also offer an experimental telephone advice and information line outside normaloffice hours.

The pilot study (see above) indicated that the average age of "dance drugs"enquirers was18 years (both sexes) and that many were in full-time employment or education.

Most were continuing to live at the parental home.

Targeting this younger group is therefore likely to increase the number of enquiries fromparents and other carers and we therefore propose to develop a small support group forcarers and special advice sessions and telephone services.

The Agency will meanwhile continue to offer a drop-in centre and counselling facilityduring the week for its existing service user group.

The Agency will also continue to offer needle exchange services for drug injectors.

3. AIM ONE : "DANCE DRUGS" SERVICES

To provide a comprehensive "early intervention" advice and information service foryounger drug users. Task 1: Weekend Drop-In ServiceThe Agency will provide a Saturday afternoon service for young people involved in the"rave scene". The service will aim to provide practical advice and information on thisarea of drug use and it will be manned by paid staff and a specially recruited cohort ofyoung volunteers.

Task 2: Recruitment of a Volunteer Advice TeamThe Agency will aim to recruit a cohort of 12 volunteers to assist with the provision of aSaturday service. Recruitment will be via posters in dance venues and local radio musicprogrammes. This will have the added advantage of advertising the existence of theservice.

Task 3: The "At Last It's Friday" LineThe Agency will offer an out-of-hours telephone advice service for users of dance drugson Friday and Saturday nights from 7.30 - 10.30pm. This service will be manned by paidstaff and a specially recruited cohort of young volunteers.

Task 4: Recruitment of a Volunteer Telephone Advice TeamThe Agency will aim to recruit a further 12 volunteers to assist with the provision of the"At Last It Friday" service. Recruitment will be as for Aim One: Task 2 and there will

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be some interchangeability of volunteers. Training will be provided by externalspecialist trainers.

4. AIM TWO : SERVICES FOR CARERS

To provide a range of services appropriate to the needs of parents, friends and othercarers of drug users.

Task 1: Weekly Support GroupThe Agency will provide a weekly support group for the friends, relatives, parents andother carers of drug users. This will be open to all carers but will be particularly targetedon parents of teenaged users.

Task 2: Special Weekly Advice SessionsThe Agency will offer weekly advice sessions on Wednesday afternoons. The Agencywill become appointment-only on that day. With the drop-in centre closed for that day, alower staff complement will be necessary and this will allow staff to be "redeployed" toSaturday afternoons (see AIM ONE: Task 1). The service would be widely advertisedthrough local newspapers, GPs surgeries etc.

Task 3: Carers Use of Telephone Service(see AIM ONE: Task 3) The Agency will offer a small number of its volunteer groupadditional training in responding to enquiries from carers. These volunteers and rotastaff will deal with all such enquiries to the "At Last It Friday" service. Calls will beseparately monitored with a view to determining the need for a special telephone servicefor parents. 5. AIM THREE : SERVICES FOR DRUG INJECTORS

To provide a range of services appropriate to the needs of older drug injectors;including services aimed at preventing the spread of disease and infection.

Task 1: Day-CentreThe Agency will continue to provide a drop-in centre, "low threshold" service on fourdays per week (Monday, Tuesday, Thursday & Friday) for drug users of all ages; butspecifically targeted at young adults injecting opioid (and similar) drugs. The drop-incentre will be open between 10.30am and 5.00pm

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Task 2: Counselling ServicesThe Agency will continue to offer weekly counselling appointments for drug injectorson Wednesday mornings. The Agency will be appointment-only on that day.Counselling appointments will be available on request during the rest of the week butsome attempt will be made to rationalise this service.

Task 3: Needle ExchangeThe Agency will continue to offer needle exchange services to those drug misusers whocontinue to use drugs by injection. This will be available during the week; Monday toFriday, between 10.30am and 5.00pm. The service will include provision of sterileequipment, safe disposal for used equipment and advice on safer drug use and injecting.

6. FINANCIAL & PERFORMANCE SUMMARY

AIM ONE : "DANCE DRUGS" SERVICES

Task 1: Weekend Drop-In ServicePerformance Indicators (Targets):Number of visits (750)Number of days open (40)Leaflets distributed (3000)

Practitioner Days:175

Costs:27,687.52

Task 2: Recruitment: Volunteer Advice Centre TeamPerformance Indicators (Targets):Number recruited(20)Number trained (12)

Practitioner Days:34

Costs:5,379.29

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Task 3: The "At Last It's Friday" LinePerformance Indicators (Targets):Number of calls (1000)Hours "on-line" (250)

Practitioner Days:175

Costs:27,687.52

Task 4: Recruitment: Volunteer Phone Advice TeamPerformance Indicators (Targets):Number recruited (20)Number trained (12)

Practitioner Days:34

Costs:5,379.29

AIM TWO : SERVICES FOR CARERS

Task 1: Weekly Support Group

Performance Indicators (Targets):Number of attendances (300)Number of groups (40)

Practitioner Days:30

Costs:4,746.43

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Task 2: Special Weekly Advice SessionsPerformance Indicators (Targets):Number of sessions (40)Number of visits (150)

Practitioner Days:50

Costs:7,910.72

Task 3: Carers Use of Telephone ServicePerformance Indicators (Targets):Survey completed (Nov 99)

Practitioner Days:12

Costs:1,898.57

AIM THREE : SERVICES FOR DRUG INJECTORS

3.1 Task 1: Day-CentrePerformance Indicators (Targets):Days open (250)Number of visitors (750)Number of visits (3,500)

Practitioner Days:470

Costs:74,360.77

Task 2: Counselling ServicesPerformance Indicators (Targets):Number of sessions (1,250)

Practitioner Days:170

Costs:

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26.896.45

Task 3: Needle ExchangePerformance Indicators (Targets):Number of visitors (350)Number of visits (1,750)Barrels given out (7,500)Barrels returned (8,000)

Practitioner Days:100

Costs:15,821.44

TOTAL 197,768.00

5. BREAKDOWN

Costs are based upon the following:-No. of Practitioners: 5No. of Practitioner days (@250 pa): 1250Cost per Practitioner day: £158.21

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APPENDIX D: SERVICE USER QUESTIONNAIRE

Salvatore Raimo born the 5th of January 1 9 5 7 , Italian citizen

Professionalbackground

1978 – 1980 International department of“Castelletti Trasporti” in Sassuolo (Italy)

1980–1982H. Rath G.m.b.H. import-export of fresh food West-Berlin

1981–1986 free lance as translator

InterContacts – Bologna: translation: German – Italian –English.

Logos – Modena: translation: German – Italian – English

CLEM Language School – Modena: German languageteaching

CITI – Modena: translation: German – Italian - English

1986 – 1991 Centro Italiano SolidarietàModena

Member of the staff of the Intake Unit

Head of the day care center

Head of the residential therapeutic community

Head of the Reentry

Head of the training department

Viadel

Taglio, 38

41100

Modena

Tel/Fax:

059-2377

24e-

mail:raimo.s@libero.i

t

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Head of the Office for international Relations

1991– 2000 Counseling and Supervisions1991 – 1995 Supervision of the therapeutic community Ruedli

e.V in Wimmis / Switzerland. Increasing the number ofresidents from 15 people to 60. Reorganization of theconcept, moving from one treatment facility up to fourdifferent treatment possibility for addicted people.

1992 – 2000 Head of the XENOS project (for addicted Italianimmigrants in Switzerland and Germany) together with theCeIS di Modena.

1992 – 2000 counselor for the Centro Familiare per Emigratiin Bern – Switzerland

1992 organization of the European Conference “euroTC ‘92”in Milan. It was attended by 450 people coming from 15countries

1994 – 2000 Head of the International Office of CeIS diModena

1995 – 1996 Head of the Family Counseling of the FOPRASFoundation in Basel - Switzerland

1996 – 2000 Opening and management of the CounselingUnit of the Missione Cattolica Italiana in Bienne -Switzerland

1999 - 2000 Supervision of the “Take-a-Way” project foryoungsters with behavioral disorders of the Drop – inAssociation in Bienne

Actual Jobs:

• Vice president of the European Federation ofTherapeutic Communities

• Coordinator of the Shared Office for InternationalRelations of the Ce.I.S. in Belluno, Venice, Treviso,Vicenza, Verona and of the Itaolian Federation fotherapeytic Communities

• Establishing of an Italian network in BadenWuerttemberg in connection with the Italian GeneralConsulate of Stuttgart

Training,TeachingsandSeminars

• Centro Don L. Milani: Mestre – I: “Alcoholabuse in Drug Treatment”

Ce.I.S. di Modena: Modena – I: “History and Methodology ofTherapeutic Community”

Proyecto Hombre: Madrid – E: “Family Involvement inTherapeutic Community”

Trempoline: Charleroi – B: “Methodology of TherapeuticCommunity”

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inars

Community”

ERASMUS: “Treatment and Research in the field of DrugAddiction” coordinated by the University of Gent – B

Self help group for the Families of the Missione CattolicaItaliana of La Chaud de Fond – CH

Arbeiterwohlfahrt: Stuttgart – D “Treatment of drug addictedItalians belonging to the 2° Generation”.

World Conference of Therapeutic Communities in KualaLumpur – Malaysia: presentation of XENOS in the plenary

World Conference of Social Psychiatry in Hamburg – D:speech in the plenary : “use of the self in the treatment ofaddiction”

European Conference “Europe against drug abuse” in Oslo –Norway: workshop: “Treatment of drug addicts belongingto ethnical minorities”

European Conference of Therapeutic Communities inMarbella – E: speech in the plenary: “Community Workwith abroad living, Italian Families””

University of Bologna: lecture: “The Therapeutic Community””

KETHEA in Thessaloniki – GR: “Relapse Prevention”

Fachhochschule fuer Sozialarbeit of Kanton Aargau – CH:“Community Work with Families belonging to ethnicalMinorities””

“Bethanienheim” Hospice for Handicapped People in Spiez –CH: “Communication about Communication”

Education

• Compulsory Education : “Carl v. LindeRealschule” Munich – D

• High school Diploma in CommunityManagement, vote: 60/60. c/o Istituto Tecnico F. Selmi– Modena

BA in Human Behavior: “La Jolla University” San Diego Cal.– European Campus di Lugano Work of Diploma:“Therapeutic Community “La Torre”: reasons for a change”Vote: A+

1986 Basic Course for staff members in TherapeuticCommunities c/o International School “Casa del Sole” -Castelgandolfo

1988 – 1990: Systemical Approach in the Treatment of DrugAddiction – Studio Campanini e Luppi

1989 “Family Therapy” with Prof. Paul Watzlawick

1996 Introduction in Systemical Approach in Family Therapyc/o “Accademia di Terapia Familiare” – Rome

1997 – 1998: Family and Migration – a Systemical Approach:Maurizio Andolfi c/o Centro Familiare di Bern

3rd year of “Supervision of Therapeutic Processes ”: Prof.Vittorio Soana

Contemporary History – University of Modena

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Anthropological Geography – University of Modena

Publications

Raimo/Dondi: “Das Beduerfnis nach Aenderung intherapeutischen Gemeinschaften fuer suechtigeMenschen” Ed.: Gerhard Rottger Verlag – Munich

“XENOS” therapy with abroad living, drug addictedItalians. Ed.: Proceedings World Conference oftherapeutic Communities – Malaysia 1992Dondi/Raimo: “Therapeutic Community and SocialNetwork” Ed.: Proceedings of the World Conference ofSocial Psychiatry – Hamburg“Il Trattamento Comunitario”: Trattato Generale sulTrattamento delle Dipendenze “ Ed.: (in printing) Piccin- Padova“Democratic and Concept – Based TherapeuticCommunities, and the Development of CommunityTherapy” Ed.: 2001 Kingsley Publisher – LondonFerrari/Raimo: “Tossicodipendenza e Prostituzione”(Rivista ADD, n° 1 year 2000)

Memberships:

EWODOR (European Working group on DrugsOriented Research)

European Federation of Therapeutic Communities

Experience in EU HORIZON (Spain, Germany, Belgium, Italy); INTEGRA (Italy,Greece);Projects: LEONARDO (Belgium, Spain, Netherlands, Italy, UK, Sweden)

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C U R R I C U L U M V I T A E

P. R. YATES MBE

May 2002

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1. DATE 23rd May 2002

2. RECORD

a) Name: P. Rowdy Yates

b) Current Post: Senior Lecturer (Addiction Studies)

c) Department: Applied Social Sciences

d) Date of Birth: 22nd October 1950

e) Post-school education: None

f) Career: 1967-67, Tailsman, David Clark, Claddach Sawmills Isle of Arran

1967-70, Woodcutter, Self-employed, Corrie, Isle of Arran

1970-70, Fisherman, D. Mackay & Sons, Kinlochbervie, Sutherland

1970-71, Vol. Craft Instructor, Community Centre, Kirkintilloch, Glasgow

1971-72, Vol. Drugs Worker, Lifeline Trust, Manchester

1972-76, Drugs Worker, Lifeline Trust, Manchester

1976-83, Manager, Lifeline Project, Manchester

1980-83, Manager, Lifeline Fieldwork, Gtr. Manchester

1983 - 93, Director, Lifeline Projects Ltd.Gtr. Manchester & Lancashire

1993 - 01, Director, Scottish Drugs Training Project, Department of Applied SocialScience, University of Stirling

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2001 - Senior Lecturer (Addiction Studies) Department of Applied Social Science,University of Stirling

g) Awards 1994 Made a Member of the Order of the British Empire (MBE) forservices to drugs prevention

3. DUTIES, RESPONSIBILITIES & ACHIEVEMENTS IN CURRENT POST

Teaching

Certificate in Drug and Alcohol Studies (on-line version)Drug, Alcohol and Nursing (on-line version)Understanding Drugs and Society (on-line version)

External Teaching

Member of teaching staff - Modena Institute (University of Gent)Member of teaching staff - Masters in Addiction Studies, Universidade do PortoMember of Development Team – European Studies in Substance Misuse

Research

Co-ordinator of the development of an educational exchange scheme under the EC's ALFAProgramme with other colleagues in European and Latin American universities

Senior member of research team evaluating two pilot Drug Treatment and Testing Orderschemes

Senior member of research team evaluating the pilot Drug Court in Glasgow

Senior member of research team evaluating the Scottish Prison Service Transitional Carearrangements

Executive President - EWODOR (the European Working Group on Drugs OrientedResearch). Responsible for the development of an on-line research service and theorganisation of annual symposia.

Co-ordinator of the Bridging the Gaps research seminar series

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4. PUBLICATIONS(In press and forthcoming publications not included)

Authored Books

YATES, R. (1988) If it Weren't for the Alligators - A history of drugs, music & popular culturein Manchester (Manchester, Lifeline Project)

YATES, R. (1997) A Guide to the Development of Services for Alcohol and Drug Misusers(Edinburgh, Scottish Office/HMSO)

Edited Books

RAWLINGS, B. & YATES, R. eds (2001) Therapeutic Communities for the Treatment of DrugUsers (London, Jessica Kingsley)

Short Works, Monographs, Pamphlets

YATES, R. (1979) Sniffing for Pleasure, (Manchester, Lifeline Project)

YATES, R. (1979) Recreation or Desperation, (Manchester, Lifeline Project)

YATES, R. (1981) Out From the Shadows (London, NACRO)

YATES, R. (1988) Drugs and the Law, (Manchester, Lifeline Project)

YATES, R. (1988) A.I.D.S.: The way forward, (Manchester, Lifeline Project)

YATES, R. & GILMAN, M. (1990) Seeing More Drug Users: Outreach work and beyond,(Manchester, Lifeline Project)

Conference Contributions, refereed

YATES, R., Comparisons between British and African Drug Prevention Systems, IFLD AfricaConference, September 1988, IFLD/Ministry of Health, Cameroun, 1990

YATES, R., Being straight - going straight, What Works Conference 1994 , January 1995,Salford

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YATES, R., Who are you looking at Pal?: Cocaine and the culture of violence, SimposioInternacional de Coca y Cocainna, October 1995, Santa Fe de Bogota, Universidad deLos Andes, 1996

YATES, R. et al, Improving Psychiatric Treatment in Residential Programmes for EmergingDependent Groups through Relapse Prevention: A brief description of a multi-centre trial& of an associated study of the prevalance & implications of histories of childhoodtrauma ,ERIT Conference , Bologna, 1998

YATES, R. On Trial for Association: An examination of the relationship between drugs andcrime, IV European Conference on Rehabilitation and Drug Policy, February 1999,PlanMarbella/EFTC, Marbella, 1998

ELEY, S., GALLOP, K., MCIVOR, G., MORGAN, K. & YATES, R. Drug Treatment andTesting Orders: An interim evaluation of the Scottish Pilots, 8th European Conference onRehabilitation and Drug Policy, September 2001, Polish National Bureau for DrugAddiction/EFTC, Warsaw, 2001

YATES, R. The Chemical Generation, 8th European Conference on Rehabilitation and DrugPolicy, September 2001, Polish National Bureau for Drug Addiction/EFTC, Warsaw,2001

Conference Contributions, other

YATES, R., An Abstract on Addiction C.U.R.R. Conference, November 1981, University ofGlasgow, Glasgow

YATES, R., Young People and Drugs, Scottish Drugs Forum Annual Conference, November1993, Glasgow

YATES, R., Prevalence Studies - The long arm of infection control, Grampian Health BoardNational Conference on Drug Research, March 1994, Aberdeen

YATES, R., Nursing Our Wounded Pride: The history of multi-disciplinary teams and the role ofthe nursing profession, Association of Nurses in Substance Abuse Annual Conference,May 1994, Glasgow

YATES, R. (1999) Shoot Out the Lights: The failure of objective reason to frame the response todrug realities, Uteseksjonen 30 Ar Pa Gata, November 1999, (Oslo, Uteseksjonen)

YATES, R. (1999) Only Available in Black: The limiting of addiction services in the twentiethcentury, Uteseksjonen 30 Ar Pa Gata, November 1999, (Oslo, Uteseksjonen)

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Edited Works: Contributions

YATES, R. (1984) Addiction: An everyday disease, in LISHMAN, J. & HOROBIN, G. (Eds),Research Highlights , 63 - 75, (London, University of Aberdeen /Kogan Page)

YATES, R. (1988) Treatment skills: Intervene for what? in HELLER, T., GOTT, M. &JEFFREY, C. (Eds), Drug Use and Misuse: A Course Handbook, (Keele, OpenUniversity/HEA)

WILSON, J. & YATES, R. (2001) The Modified Therapeutic Community: Dual diagnosis andthe process of change, in RAWLINGS, B. & YATES R. (Eds.) Therapeutic Communitiesfor the Treatment of Drug Users (London, Jessica Kingsley).

Editorships: Journals

Associate Editor (World Affairs), The Drug and Alcohol Professional

Academic Journal Papers

YATES R. (1983) Four commentaries on the report of the Advisory Council on the Misuse ofDrugs (1982): Treatment and Rehabilitation - view from a street agency: Money-shy.British Journal of Addiction, 78, 2, pp.122-124

ELEY MORRIS, S., YATES, R. & WILSON, J. (2002) Trauma histories of men and women inresidential drug treatment: the Scottish evidence, The Drug and Alcohol Professional, 2,1, 20-28

ELEY MORRIS, S. & YATES, R. (2002) Community energies under-evaluated: Drug initiativeson the margins, The Drug and Alcohol Professional, 2, 1, 36-410

YATES, R. (2002) A brief history of British drug policy, 1950 – 2001, Drugs: Education,Prevention and Policy, 9, 2, 113 - 124

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Professional Journal Papers

YATES, R. (1979) An Experiment in Multi-facility Addiction, Addiction Therapist (SpecialEdition), Winter, 3, pp 25 - 30

YATES, R. (1993) The Therapy Trap, Druglink, 8.1, pp 13

YATES, R. (1993) Escape from the Therapy Trap, Druglink, 8.2, pp 9

YATES, R. (1993) A Smack in the Eye, Druglink, 8.3, pp 13

YATES, R. (1993) Methadone and Slippers, Druglink, 8.4, pp 11

YATES, R. (1998) From Johnny B. to Ebeneezer: Goode times on the dancefloor, Druglink, 13.6pp15 - 18

Official Reports

STRANG, J. & YATES, R. (1982) Involuntary Treatment and Addiction, (Strasbourg, Councilof Europe [Pompidou Group])

YATES, R. et al (1987) Drug Services in Mid-Surrey: D.A.S. report, (London, NHS HealthAdvisory Service)

YATES, R. et al (1988) Drug Services in East Suffolk: D.A.S. report, (London, NHS HealthAdvisory Service)

YATES, R. et al (1989) Drug Services in Hertfordshire: D.A.S. report, (London, NHS HealthAdvisory Service)

YATES, R. et al (1990) Drug Services in Hull & East Yorkshire: D.A.S. report, (London, NHSHealth Advisory Service)

YATES, R. (1991) Drug Users in the Criminal Justice System: Evidence submitted to the WoolfInquiry into disturbances in the prison system, (London, HMSO)

YATES, R. (1993) Drug Use in Scotland: Evidence submitted to the Scottish Affairs SelectCommittee, (London, HMSO)

YATES, R. (1994) Knowledge-based interventions in Drug and Alcohol Misuse in Scotland:Evidence submitted to the Scottish Office Drugs Task Force, (Edinburgh, Scottish Office)

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Review Articles

YATES, R. (1994) Songs they Never Play on Radio, Druglink, 9.2, pp18

YATES, R. (1994) Getting to the Point, Druglink, 9.4, pp18

YATES, R. (1996) Coping with illicit drugs, Druglink, 11.1, pp19

YATES, R. (1997) Disco Biscuits, Druglink, 12.4, pp 20

YATES, R. (1998) Psychedelia Britannica, Druglink, 13.1, pp 26

Other Commissioned Work

YATES, R. (1993) Falkirk District Drugs Project: An Organisational Audit & Evaluation ofFuture Prospects. Audit report commissioned by Central Region Social WorkDepartment

YATES, R. (1994) Drugs and Alcohol in the Workplace: A Practical Guide for Managers.Drugs/Alcohol Workplace Policy commissioned by Royal Mail

YATES, R. (1995) Pictures of a Moving Train: An action study of the management of DundeeDrugs & AIDS Advisory Project. Audit report commissioned by Dundee YMCA

YATES, R. (1999) A Review of Counselling Service Provision. Audit report commissioned byStirling & District Association for Mental Health

YATES, R., MORRIS, S. & PRATT, R. (2000) Effective Responses to Alcohol and DrugConcerns in the Community: Evidence, dilemmas and solutions. Literature reviewprepared for Greater Glasgow Health Board, Health Promotion Department

YATES, R., ANDERSON, I., WILSON, J., WILSON, M. & FREEMAN, L. (2001) TroubleEvery Way I Turn: Homelessness and substance misuse in East Renfrewshire. Research reportprepared for East Renfrewshire Council, Housing Department