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CHAPTER FIVE: SERVICE PROVISION

"218 exists to reduce offending behaviour amongst women and to offer courts realistic alternatives to custody. We help women discover the strength to change by entering into open, honest and respectful relationships. We create an empowering and safe place in which most women can achieve their potential. We leave no stone unturned to offer a meaningful and engaging service which tackles the root causes of offending". (218 Mission Statement)

Programmes at 218

5.1 218 consists of both residential support and a day programme. The residential unit accommodates women who need more structured support, (which can include women who self-refer as well as agency referrals) or who would otherwise be taken into custody. The unit holds up to 14women at any one time. Residents normally participate in the SAFE programme (described below) though take part in this separately from women in the community-based programme ²⁹. The residential unit is also available to women taking part in later stages of 218's programmes, for example if they wish for support during 'detox' from methadone or Subutex.

5.2 Women in the residential unit have access ³⁰ to their own individual rooms and common areas in the residential unit but are otherwise escorted throughout the building as well as outside, for the safety of the residents ³¹. The building is not a secure facility, however, and staff cannot detain women who choose to leave. Women originally stayed in the residential unit for up to 12 weeks, depending on an ongoing assessment of need. Following long-term consideration of the women's progress, 4 - 6 weeks was found to be a more constructive length of time, and the general duration of the residential programme was reduced.

5.3 The day programme consists of 3 main parts. The programmes consist of a flexible package or menu of services and individual sessions which are intended to meet the needs of individual women. These are SAFE, CONNECTIONS, and LOSS. The SAFE programme is the introductory programme that centres on substance misuse, offending, and stabilising. This includes learning to work with a key worker, substitute prescribing, finding suitable accommodation, reducing offending, claiming benefits, and self-maintenance/care. The programme is delivered through 3 individual sessions each week over 12 weeks as well as a 'low key' group programme and additional support during "the many personal crises that emerge as she begins to let go of chaos". ³²

5.4 CONNECTIONS is the second stage of programming, offered to women assessed as mostly stable, who are offending less often, and who are ready for more sustained group work. The closed weekly group session is designed to help women work towards reducing or ending their use of substances and/or offending behaviour. In addition, 3 individual sessions each week over 16-18 weeks are designed to help develop relationship skills with friends, families, and authorities. An evening group programme is optional for women to "sample new experiences, new ways of handling reality and learn to look after others as well as themselves". ³² It aims to build women's networks of personal supports and prepare them for a life without substance abuse.

5.5 The final stage, LOSS, prepares women to "let go of their substitutes" ³² following a period of stability. This stage more actively helps women prepare for an independent life through training, education, or work as well as therapeutic work to address underlying issues that led to their substance misuse. The LOSS programme does not currently operate to a specific time-frame but responds to client needs as appropriate.

5.6 Programmes at 218 can be run repeatedly until a woman is ready to move on to the next stage. Programmes are never shorter than any court order imposed, though they may be longer. Women can finish a programme and return later to take part in a further stage. Group size will vary depending on demand, but groups are generally small in order to enable women to feel safe and for workers to be able to give all participants appropriate attention. Group lunches are an important feature of the daily activities at 218. These are aimed at encouraging women to develop an awareness of the importance of physical and emotional nourishment, and to gain experience and satisfaction from preparing meals and interacting as part of a group.

Services at 218

5.7 Support provided at 218 includes regular individual intervention from a key worker. Other services including group work and alternative and mainstream health interventions are provided in line with the woman's assessed needs. Services are "person centred and designed with the woman, her needs and capabilities in mind." Services can include:

• 'One-to-one' sessions and group work;
• Alternative therapies such as acupuncture, Indian Head Massage, and yoga;
• Detoxification;
• Psychological and psychiatric services;
• Reproductive health;
• Food programmes;
• Dental and physical health;
• Emotional support; and
• In-house 12-step attendance. ³³

5.8 Importantly for the clients, timing for services is flexible. The residential services are particularly client-led:

"… my first and second week it was hell, you know, I was going through hell because you are on methadone you do still rattle a bit, it doesn't take away your full rattle; because the staff give you acupuncture, and if you've got sore legs they rub your leg, they give you Indian head message, anything you want, any time four o'clock in the morning, amazing they are angels, honest to god." (Focus group 3)

5.9 Structured activities were also available in the evenings and at weekends for women on the day programme, should they feel they needed the extra support. These were suspended after the research period due to lack of uptake from the clients, though they may be considered again in future.

5.10 Most of the services are provided 'in house' by the NHS providers and by Turning Point staff and nursing staff. Daily prescribing support and treatment are given to women in need of drug or alcohol substitute prescribing. The substitute prescribing service is headed by the project's GPs who are contracted from the NHS Trust. Medical services are delivered by GPs and Team Nurses. 218 is rooted in primary care systems, and women can access additional care and support through referral systems to mainstream services.

5.11 The health care team based at 218: screen for mental illness and physical health; deliver on-going assessment; reduce harm caused by substance use; provide advice and support relating to sexual health; provide access to medical and nursing staff at a primary care level; offer psychological interventions; and prescribe where necessary as part of a reduction/stabilisation service.

5.12 Client progress is reviewed formally on an ongoing basis with the service team leader, key worker and service user, and workers from other agencies are invited to take part as appropriate. In addition, 218 aims to establish care pathways to existing mainstream and specialist social, health care and judiciary services, including Cornton Vale, generic liaison to the criminal justice system, educational, training/employment and social inclusion projects (see Chapters Six and Seven). These can be informal links to community-based resources as well as more formal ones such as outings to local parks, galleries, or health clubs:

"… it like gives you a bit of security for when you go outside as well, like yesterday we went along to Kelvin Park, like a few of the girls that were with me, they had drink problems before they came in here, and like there was crowds of youngsters in the park drinking, sitting with carry outs and that. And I think they were like 'oh no', but then you have got to get used to seeing things like that because you are going to see that a lot wherever you go. You have just got to learn to have willpower to stay back from all of these things." (Exit 26)

Remit

5.13 All members of staff were clear about their remit and about the role of 218. Residential staff expressed some concerns that their role had been relegated more to crisis management than to addressing root causes following the reduction of time clients spent there (see Chapter Three). Even so, staff seemed united in their belief that all professionals working at 218 shared a common goal and that, for the most part, they work effectively together as a team (recent problems in co-ordination with the health team were sometimes an exception to this; see Chapter Three). All believed 218 offered an alternative to custody for women. While all staff respondents believed the general criteria were appropriate, many also stressed the importance of a woman's willingness and readiness to engage in the service: a woman may choose to come to 218 rather than go into custody, but if she is then not willing to engage with workers in the support they offer her, many commented that her presence there wastes the effort of staff and interferes with the efforts of women who genuinely want to change. This is discussed more fully in Chapter Seven.

5.14 Also clear from the interviews was that staff saw 218 as offering something different to clients, primarily in terms of relationships (see below), but also in terms of philosophy. Part of this difference in philosophy was an understanding of addiction that meant that relapse was an acknowledged feature in the process of recovery. Clients who relapsed were not automatically excluded from the programme; on the contrary, they were encouraged to return as soon as possible. The issue of relapse in relation to perceived effectiveness of services at 218 is discussed more thoroughly in Chapter Seven.

5.15 Programmes were flexible enough to take into account the personal circumstances of clients and other agency providers recognised the broad remit of service provision at 218 and the importance of this:

"Well, the overall thing is to try and deal with root causes of women's offending and substance use. Whether that be mental health problems or housing, poverty or any relationship issues or whatever. It's to try and address and tackle the root causes is what the blurb says on the sheet." (Health professional)

5.16 Key stakeholders were clearly of the opinion that 218 provided a valuable service and were generally highly impressed with the way it operated.

Programme participation

Initial information

5.17 Most women who came to 218 knew little or nothing about the service before they attended. Staff informed clients of the rules and programme at 218 upon entry, and each client signed a contract of agreed behaviour, including protocols for searches, urinalysis, and breathalysing. Clients generally felt these rules were clear and fair, though one believed rules could be explained more clearly to family members who attended the service to visit or to hand things in. In contrast to the culture in women's prisons (see for example Loucks, 1998; Malloch, 2000), clients themselves were for the most part quick to enforce rules and did not define telling staff about drugs in the building as 'grassing':

"… in your one to ones you get asked all the time 'have you been offered drugs near the building or in the building'…. But the one time that has happened to me I went to the staff and told them, I don't think it's grassing I am keeping myself safe and anybody else around about me that's…would maybe be tempted…. But I don't agree with it anyway, you see if you are coming to a place like this, why bring in drugs, or why use drugs, because there is a big wide world out there, go out and use, do you know what I mean? There are people in here trying to get help." (Exit 27)

5.18 Some clients in the residential unit were surprised at the level of restriction in terms of exit from the unit (staff escort clients anywhere outside the unit, and the number of trips outside the building are restricted), though the extent of such restriction varied over the course of the research as staff tried to find the best approach. Most clients, however, seemed pleasantly surprised at the quality of service: "I didn't expect it to be as good…" (focus group 3). Of the 143 women who engaged in services at 218, 21% (n=30) took part only in the residential programme, while 39% (n=55) took part only in the day programme during the study period. One of the more common pathways was for women to take part in both the residential and the day programme (58 women, or 41%). Statistics recorded at 218 for the last 6 months of the study period (the statistics that were available during this time) showed that clients were admitted to the residential unit on 41 occasions, 54% of which (n=22) were referred from criminal justice sources. Over the same period, clients were admitted to the day service 21 times, 62% (n=13) of which came from criminal justice referrals. This figure is for new admissions, which does not include women who continued on to the day service following a period in the residential unit.

5.19 One of the best ways to distinguish between the programmes at 218 is to describe the outcomes expected at the end of each intervention, based on 218's own Service Outcome Check. Table 5.1 sets these out in detail:

Table 5.1 Expected programme outcomes

5.20 Table 5.1 shows that women referred to the SAFE programme are those just beginning their recovery who have come to 218 to stabilise from a chaotic lifestyle, dangerous both to themselves and to others. Those who move on to CONNECTIONS should be those who have achieved some level of stability, with the acknowledgment that they still have some way to go. CONNECTIONS is designed to help people move further away from criminality and substance misuse, as well as the many things that go along with these such as poor housing, financial instability, poor physical and mental health, and damaging relationships. LOSS, the final stage, is for women who have largely recovered from their addiction and are attempting to move on with their lives.

5.21 The main criticism the clients had about attendance at 218 was that they believed women should genuinely want to be there. In their view, women who were there subject to a court order often did not want to engage with the support on offer and that this could interfere with their own recovery and that of other women, for example if reluctant attendees brought drugs into the residential unit (see Chapter Four).

Client input

5.22 218 operates as a person-centred service, meaning it aims to empower clients to take responsibility for their own treatment and to participate fully in decision-making. This approach has proved particularly important in work with women (Bloom and Covington, 1998; Bloom et al, 2003). With a couple of minor exceptions involving personal conflicts with individual members of staff, clients universally believed they had a voice in what happened to them at 218. A care plan for the client is discussed at the outset, followed by regular reviews. Programmes at 218 are fairly structured in that individual sessions and group work are compulsory, especially for residential clients, but clients recognised a degree of flexibility in the regime: "Choice is a big thing in here" (Exit 12). Even where clients were unaccustomed to such autonomy, staff guided them through the various options: "They're always pushing me to ask … if you need anything just to ask…." (Exit 8).

5.23 The fact that the programme was voluntary was an important feature for the clients:

"I know the door's always open and I can leave whenever I want, so I've stayed. It's my choice."

(interviewer): "Did it help that you know you can leave whenever you want to? That you're not locked in."

"Aye. Aye. It helped." (Exit 33)

"… ultimately if … a woman decides that 'yeah, I want to go', obviously we talk through that with her, but it's ultimately her decision at the end of the day…." (Residential staff member)

5.24 Staff perceived client input as a means both of empowering women and of building relationships with them:

"… we are supposed to be taking a person centred approach and involved in negotiation and communication, it's not 'right come in, sit down, I'll do this up for you and here's what you're going to do'. It wouldn't help to build relationships if we came at it from that side, so yes, the woman should be involved all the way along in the process and have a say, have an opinion, and is entitled to all that." (Residential staff member)

5.25 Clients also recognised that expressing their views and listening to the views of others was necessary for maintaining relations in the residential unit. Importantly, empowering women throughout their participation in the programme was a means of preparing them for life after 218:

"When I came in here I was dead irresponsible, I put bills and everything in the bin and wouldn't answer the phone… When I came in here I was like 'no, I can't do that'…and she (staff member) said 'what do you mean you can't?' I went 'I don't know how to talk to them about things like that. No I don't like it.' She said 'just say what you think', and it was like 3 phone calls like to the council tax… and I did it all within 5 minutes. See the weight off my head that day, just, it was so simple, it was nothing…"Aye, they made me do it, do you know. They didn't make me, they just said 'try it'. " (Focus group 4)

'Typical' pathways

5.26 As part of our assessment of cost-effectiveness (see Chapter Seven), we attempted to identify 'typical' pathways of progress through the programmes at 218. We quickly found that no path was 'typical', specifically because the service is designed to be user-led based on the individual needs of the client. No 'package' of service was cast in stone, and clients could start and stop a programme as often as they needed to, depending on their own readiness to participate.

5.27 That said, 218 operated under a loose framework of service structured roughly as follows: a client begins with a placement in the residential unit (if deemed necessary) on the SAFE programme. Placement on the residential unit lasts an average of 4 weeks, with the option for extension where necessary, before the client leaves the residential unit and continues the remaining 8 weeks of the SAFE programme through the day facility.

5.28 Upon completion of the SAFE programme, a client will be linked into community resources, ideally with a prescription from a GP or addiction team based outside of 218, contact with other agencies, and with the knowledge that she can contact the staff at 218 or return to the service should she need to in that time. After this short period, the client then returns to 218 for assessment to continue her work at 218 for 18 weeks with the CONNECTIONS programme. Alternatively a client may wish to repeat the SAFE programme and can do so as many times as necessary until she is stable enough to continue with a further programme.

5.29 For the first several months of the research, the time frame for participation in programmes at 218 was much looser. Time in the residential unit was expected to last about 12 weeks, though in practice this varied considerably. Equally, women in the day programme could participate as long as they felt they needed it - with the result that many stayed on programme for months at a time while making little real progress. The staff at 218 recognised this and for the most part now agree that the time limit motivates women to work towards improvement and opens up spaces in the programme for others to take part ³⁴.

5.30 While they understood and agreed with the principle of time limits, staff in the residential unit in particular were concerned that 4 weeks restricts the residential unit to the role of crisis management and that difficulty in finding appropriate housing meant that women were more likely to be discharged to a hostel, where "they are almost guaranteed to fail" (residential staff member).

5.31 Many clients were also apprehensive about this, although they seemed to understand the necessity of the limit on their time with 218, as long as this had been explained to them:

"No I think that's alright. The last time I was in, there were lassies that had been in for a while, and I think you can start relying on the place too much, and it's no good because you have got to be able to do it out there…." (Follow-Up 9)

"...[I]t is for the best, because I was getting too dependent on the place, do you know what I mean?" (Exit 36)

Graduation

5.32 At the end of a client's programme at 218, the staff put in special effort for a graduation ceremony. This is set up as a small party for the clients who have completed a programme and includes handing out certificates and brief speeches by managers and whoever else wishes to speak:

"…it's a nice kind of party atmosphere…. But that's nice because it gives the girls a boost as well. They think they have achieved something, and they have achieved something. So it's nice, and I remember the last graduation this girl said 'I have never had a certificate for anything in my life'. I thought that's quite sad…. She had never had one ever. " (Day programme staff member)

The regime at 218

5.33 The hub of the work at 218 centres around the individual contact with project workers (one assigned worker for the day programme, or a rota of project workers in the residential programme, available 24 hours a day) and group work, described at the beginning of this chapter. Individual case counselling and group work are central to most drug treatment and support programmes and can be present in court-ordered disposals such as Probation and Drug Treatment and Testing Orders. We were therefore interested to know whether 218 was 'just another service' on a menu of services across Glasgow, or whether it differed somehow from the rest.

Differences between 218 and other services

5.34 Virtually all the women had been in contact with other agencies prior to time at 218. Most of this was extensive contact with a number of agencies over a number of years, such as moving in and out of detoxification and rehabilitation programmes, housing agencies, and prison. They believed that most of these agencies adopted a more restrictive, punitive approach rather than the therapeutic, supportive regime they said they found at 218. 218 had already developed a very positive reputation amongst women outside, but clients were still impressed with the positive, non-institutional atmosphere and the quality of support from staff. Their experience of getting a place on the project had been very straightforward, and they believed the process of assessment was appropriate. All women believed they had a voice in what happened to them at 218, for example in terms of their care plan and participation in the project.

5.35 A number of factors seemed to set 218 apart from other services in the area. For the most part this centred on the quality of the relationship between clients and staff. This is not to say that quality relationships do not develop elsewhere; rather, relationships made up the main focus of the service at 218:

"I think ultimately the main priority needs to be to try and build a relationship with the women, because you can't really work on anything unless you build that. I mean you can try and you can start to chip away at things, but you're going to get further if you have that consistent relationship, and one that's built on trust." (Residential staff member)

5.36 Relationships did not always go smoothly between staff and clients, ³⁵ though clients were quick to say that problems with staff were exceptional: "The staff are excellent; I have never been in a place where I could honestly say there is no staff that I don't like. That is quite amazing" (Exit 20).

5.37 The literature on programmes for women repeatedly highlights the importance of relationships to women and their recovery and indeed to their willingness and ability to persevere with a programme. Comparison of a number of studies has indicated that appropriate work with relationship factors, in particular 'family process', was very effective with women - indeed even more effective in reducing offending than cognitive skills training (Dowden and Andrews 1999). This was recognized by external agency workers and key stakeholders and was particularly evident when we asked clients specifically what made 218 different from, for example, contact with drug workers or Criminal Justice Social Work:

"I was quite self aware of the stuff that was going on with me, so … I could sit and actually … work out myself why I was feeling things, and as things came up, I could talk about them, and I got a lot of help off the staff, … to guide me." (Exit 44)

"[other services] have got 30-odd people in the addiction unit and only a few staff, do you know what I mean? So you are not getting the same attention." (Exit 42)

5.38 Also of importance was the work done informally with the women at 218. In the residential unit, project workers were available 24 hours a day, so women had someone to speak with whenever they needed. Support workers were also available, not for in-depth sessions, which were the remit of the project workers, but to have someone there to talk with over a cup of tea or to facilitate activities. Informal support was available 24 hours a day and meant a great deal to the clients.

5.39 Support staff, as described in Chapter Three, were a new innovation for 218. This 'informal' support to enable continuous social and emotional support and to ease the transition from 'institutional' life to independent living appeared to be a very valuable means of assisting the women in moving on from 218: "... I"ve been going to services for years. And this one has actually made a difference.... It's the only place that is really supporting me" (Exit 4).

A regime for women

5.40 The clearest difference between 218 and other services was its focus on women. Literature on female offenders continually emphasises the need for programmes designed specially for women rather than merely adapted for women from a male-centred treatment model or 'added on' to programmes for men (see for example Bloom, Owen, and Covington, 2003; Covington, 1998). The programme at 218 was designed with this in mind, building on work that had been started in the Turnaround project for women with addictions. The emphasis was both on delivering a programme designed specifically for women and, at least as importantly, creating a safe environment in which to deliver it. Responses from clients were slightly mixed on the need for an all-female environment. Criticisms referred to the 'bitchiness' of an all-female environment and the need for a male presence to temper this. In contrast, some women indicated that their time at 218 had provided the first opportunity to develop meaningful relationships with other women. Overall, both clients and staff were supportive of a women-only service (see also Rumgay, 2004):

"… a lot of the women are quite vulnerable when they are coming off drugs, and the guys know that, and they take advantage of that." (Exit 26)

"… apart from anything else, it gives the women time… to concentrate on themselves." (Residential staff member)

5.41 Relationships with the (few) men who worked at 218 were particularly important in this context:

"With it being a women only project, because I have got a lot of issues with men, which makes this place so much better, and so much safer, which I think a lot of people have to be honest with you. That's why I think it works so well, because it's all women…. They keep it to a minimum of men on the staff as you know, and even then the male staff they are fine, I don't know, they seem to hand pick them…. You get on really great with them, the men that come in.… Even down to the cleaners, it's certain people…they have not got an attitude problem, they have not got anything about them."(Exit 27)

Best and worst aspects

5.42 When asked what 218 was particularly good at, almost all of the external respondents referred to the ability of 218 staff to engage with the women. In many ways, the relationships which were developed between staff and service-users provided the basis for all further developments:

"I've had the opportunity to view health services out there and I don't know a lot about other addiction services you know, I can't say we're any better than anywhere else, but it's one of the best places I've worked in terms of that and in terms of the positive, non-judgemental positive regard for people, I would say it's by and large the best place I've ever worked." (Member of health team)

"I think that 218 gets to be known as a place of safety and a place of support and a place where they know there is no prejudice and no pre-conceived notions, so they are more likely... I think that's why they continue to engage, so the more services they have in it the less de-stigmatised these services can become." (Member of health team)

5.43 Staff too most commonly noted that the best thing about 218 was the quality of relationships they developed with the clients:

" I believe when women come here they get treated with respect, and they can feel like human beings, and I think that's probably one of the biggest positives we've got here is the respect that's shown and expected back and forward. Yes I think so, relationships." (Residential staff member)

5.44 This aspect of the service was emphasised by clients too. The group and one-to-one sessions in particular were highly valued by the women:

"It's made me realise I can actually talk about my problems without thinking there's no one there, no one cares, you know. And it's made me realise that I'm a confident and clever lassie. It's good." (Exit 47)

5.45 The welcoming physical environment was also mentioned as a positive feature: "I came up and it was like IKEA, that was the first thing I thought, IKEA…" (focus group 1). Some staff and clients mentioned the holistic approach as the most positive feature - "just everything" (Exit 3) - and that "a bit of time out" (Exit 46) helped them discover a life outside of addiction and offending.

5.46 A notable feature was that women appreciated having former/recovering substance users making up a proportion of the staff there. ³⁶ They believed this was an important and useful part of the service in that they felt staff genuinely understood what they were going through and served as role models to the clients:

"It's the fact that everybody here can relate to… I found before I started coming here people that I was dealing with were 'text book' people, and I found it difficult with that, although they are prescribing things for you and all the rest of it, I find that unless people have actually been where you've been, I don't really feel they can properly understand what it feels like, so that's what's great about this place, most of the women that are counselling you have been where you've been, and they understand totally, and everybody here is in the same boat.…" (Exit 11)

5.47 Responses regarding the most difficult thing about being at 218 varied. For the most part, clients believed nothing needed improvement: "I don't think you can change anything, honestly" (focus group 3). However this perception could vary with the stage of recovery of the client:

"At one point I would have said the breathalysing [policy should be changed], when I was drinking, but now I know they are only doing that for my own good, because drink and methadone just don't work. It's more dangerous than drink and drugs." (Exit 40)

5.48 Some women who had been in the residential unit mentioned difficulty living in a group situation in which everyone was feeling vulnerable and volatile, especially when clients are at different stages of recovery:

"…The only thing … is the bitching between the lassies but you're always going to get that. You can't change it. It's just putting so many needy people in the one place … It's just… lassies wanting attention … so you've just got to deal with it." (Exit 45)

5.49 In such situations even small problems can take on great significance; disagreements regarding levels and types of medication were one of these problems for some women. The physical setting could sometimes be difficult as well, namely because of the noise from the street (and previously from a night club directly across the street, now no longer there), and because of the restricted opportunity to spend time out of doors. Other suggestions for improvements to 218 included a bath for the residential unit; more activities around cooking, baking, and general nutrition; more support for clients with agoraphobia who may need more assistance to reach the project; and reconsideration of the financial allowance for clients in the residential unit, especially if they have children.

5.50 Gaps in the service were equally difficult to identify. A couple of staff members said they wanted to see more work done in terms of after-care and resettlement for the women, such as an outreach service. Some of the clients mentioned issues with moving on as well as a desire for placements rather than referrals and a more gradual process of 'winding down' from the service at 218. Both staff and clients also believed more could be done for the continued long-term recovery of clients who are doing well and have remained stable. A small number of both staff and clients said they wanted to ensure all women who needed such help were eligible to enter the project rather than restricting the service to those actively engaged in the criminal justice system. Some respondents believed that a parallel service should be made available for men.

5.51 Staff were more likely to comment about structural issues such as staffing levels, though some clients mentioned this as well:

"…it's annoying when there is not enough staff on, I would say that, that's really annoying. But they do their best, it's not their fault, it's all the cut backs and all that, so they can't be blamed." (Exit 42)

5.52 An early structural difficulty was the regime in the residential unit, which both staff and clients thought needed to be firmer. A client who had experienced both the original and the (later) more structured regime noted the improvement:

"When I first came in here I thought it was a bit lackadaisical, do you know what I mean? They kind of let you away with a lot more… But this time they have set a whole new structure, and they really insist that you do go to the groups and participate. They don't come down heavy, but they kind of drum it into your head, they would prefer you to be at the groups, not unless you have really got a valid reason for not being there…. So I think they are that wee bit tougher, and I think that's what is needed in a place like this…." (Exit 15)

5.53 Ongoing structural issues included communication between members of staff at 218, clarity of roles, particularly with regard to the health team, and improved transition to other services such as housing.

Child care

5.54 Of direct relevance to a regime for women is the question of child care:

"… it's very difficult for me. I am trying to build bridges with my family but…. You want to do things for the better of yourself, to better your wains but there is always this childcare issue that comes into…do you know what I mean? It comes into every situation…." (Exit 41)

5.55 The previous chapter on referrals showed that 67% of the clients had children, though substantially fewer were primary care-givers at the time they entered 218. Even so, a number were directly responsible for the care of young children (see also Scottish Executive, 2003; Scottish Executive, 2004a). While 218 can access facilities for children while women attend day-programmes, ³⁷ the residential unit had no provision for children. Clients were not always aware of the possibility of negotiated access to child care:

"… childcare… is going to be the main thing for me [in terms of continuing with the day programme]. …. Social work are looking at a private nursery, so we will wait and see what happens, but I don't know. But I do know I want to continue in the day program, but I need to wait until childcare is sorted." (Exit 41)

5.56 The literature is divided regarding assistance with child care for women in treatment. Bloom and McDiarmid (2000) note that engagement with families, particularly with children, can be highly effective in programmes for women. Chapple (2000: 34) states that "involving the children of a female offender in a residential program often helps to keep the woman in treatment", in which case the woman herself should retain primary responsibility for her children, and any residential facility must be designed to serve the children as well as the mother. Critics of this approach ( i.e. respondents interviewed in Fairweather, Loucks, and McIvor, 2003) expressed concern about the disruption for children. If a woman fails to complete a programme, for example, the child as well as the mother must leave, and the child may feel he or she has somehow failed.

5.57 Other authors, such as Jacobs (2000), argue that women need to focus on themselves first, then move gradually towards reunification with their children. Non-residential programmes tend to be organised in this way. Some programmes offer child care on site, though other service providers believe this is too distracting for programme participants (see discussion in Fairweather, Loucks, and McIvor, 2003). Other programmes provide child care allowances for the women. The Asha Centre for Women in Worcester, for example, gives women the option of an on-site crèche or an allowance to arrange their own child care (Rumgay, 2004). The on-site crèche enables staff to watch the children's behaviour and to offer mothers information and assistance if necessary.

5.58 The logic behind 218's decision not to provide facilities for children has been based on a number of practical considerations. First, the staff noted that the women who come to 218 need time to concentrate on themselves rather than on dealing with their children. Second, they believed child care facilities should be designed specifically for children and not as an 'add-on' to a facility designed to address criminal justice issues: the belief was that children should have support in their own right as children rather than because of the status of their parents. Child protection was a concern here, not least because of the chaotic and unpredictable behaviour of the client group.

5.59 Perhaps surprisingly the clients agreed with this approach, and only one (above) expressed difficulty in making arrangements for their children:

"My mum and dad have got my wee boy… for a few years now, em … 'cause I've been staying in the homeless units and that… so it's [given] me a chance to go into supported accommodation…." (Exit 29)

5.60 Some of the women did, however, have very mixed feelings about arrangements for family contact in general at 218.

Family contact

5.61 218 runs a confidential service, meaning staff were not at liberty to tell anyone who enquired whether a client attended the service at 218, residential or otherwise. Clients were however allowed to provide staff with a list of 'safe' contacts, in other words people who were allowed to ring and to visit the client. The main comments regarding family contact at 218 related to provision for visits for women in the residential unit. Visits were limited to half an hour once a week - less than the provision for women in prison: "… aye, half an hour my wee laddie comes every time and sits down and give us a wee kiss wee cuddle 'what you been up to', time to go." (focus group 1).

5.62 While visits took place in a comfortable room with facilities for tea and coffee, a member of staff usually remained in the room for the duration of the visit ³⁸:

"[You're] Not to make contact with anybody [on visits]. A cuddle, that's all I'm wanting…. There's a worker, plus you're no allowed to sit and cuddle or nothing. So what's the point in having them? It's worse than a prison actually." (Exit 5)

5.63 In addition to the precautions taken on visits, letters and parcels were opened in front of clients to prevent any prohibited articles being sent in, and telephone calls took place with a member of staff present.

5.64 In terms of family involvement at 218, nothing specific was in place, though one client thought provision for family group conferencing or mediation would be a useful addition to the service. Staff at 218 did however provide active support in assisting women with family contact more generally, such as for visits with children, custody disputes, contact with social workers, and participation in the Children's Hearings System. Family support and involvement at 218 is due to be reviewed in January 2006.

Addressed needs

5.65 Responses were universally positive about 218 in terms of its ability to address their needs and offer support. Services at 218 were thought to be very comprehensive and staff believed that these met the needs of the women who came to them. The most effective aspect of 218 was believed to be the way that services were delivered and the environment 218 provided, in terms of the integration of programme content and modes of delivery. Most of this again seemed to be due to the staff rather than due to any specific aspect of the programmes. Clients felt that staff were readily available for them and provided a genuinely client-centred approach. They also emphasised the non-institutional atmosphere and sense of safety as beneficial. The clear perception was that women using the services of 218 were valued and treated with respect. The ability of 218 to address the needs of the people who used the service is discussed more fully in Chapter Seven.

Summary

5.66 218 offers both residential and community-based support as well as 3 distinct programmes, depending on the client's stage of recovery. Programmes are designed both to address immediate needs and, alongside this, root causes of offending. The intended overall outcome is a reduction in reoffending, but this is approached primarily through non-criminal justice issues such as addiction, physical and emotional health, housing, budgeting, and relationships. Clients take an active role in their own care plan and programmes are flexible enough to address their personal circumstances. While services are now designed as time-limited 'packages' with time to apply what they have learned in the community, clients may return to 218 for further assessment and repeat programmes where necessary. This is a positive development which means that programmes are focused within a set period of time, but clients have the option of revisiting any area of personal development as deemed necessary. Concerns were expressed that a time-limited service relegated the residential unit to crisis intervention, though longer-term support was available through the day programme. On the whole, clients and staff understood the reasoning behind restrictions on the length of time a woman could be accommodated at 218 and appreciated the importance of avoiding creating a dependency on the service itself.

5.67 Clients actively praised the regime at 218 and believed it addressed their needs. Some criticism was made of policies regarding family contact and time out of the building for residential clients, but most also understood and accepted reasons for restrictions. Key stakeholders were clearly of the opinion that 218 provided a valuable service and were generally impressed by the way it operated. The Centre was viewed as offering a unique service in terms of focus and philosophy. The emphasis given to the development and quality of relationships within the Centre was significant. Staff believed the support at 218 was appropriate and that its strength lay in the emphasis on relationships with clients. Client input was crucial and was viewed as a means of empowering women through the development and maintenance of positive relationships. Clients appreciated this and equally stressed the importance of relationships within 218 and the support this provided them with both in the Centre and in the process of moving on. The voluntary attendance at 218 was viewed as important, while clients who were attending as part of a court order but who did not actively engage with the service were often viewed as potentially jeopardising the recovery of others.

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