Sundial House was opened in September 2008 as a long-term accommodation project for people who have been living on the streets for a long time and are alcohol-dependent. These people usually have difficulty finding stable housing, as alcohol-related health and behavioral problems cause them to move from one shelter to another. The project opened its doors to offer a home to people who are not yet able to solve their alcohol problems, but who are more likely to do so if they can live in a stable home environment. It is the first project of its kind in Ireland. The main idea of the project is that if we first provide people with a home, we can then reduce the risks associated with life on the streets. Once they are settled, relationships can begin to develop and they can be given appropriate support and help with their problems, including alcohol dependence and health difficulties. Sundial House consists of 20 single rooms and 5 double rooms, and is currently home to 30 people, both men and women, as well as couples and individuals. Since September 2008, 44 people have used the services of this facility. From our experience, we can say that residents genuinely enjoy their stay and especially appreciate the accommodation standard we provide. When building Sundial House, we focused especially on a large number of social spaces, plenty of light and space, and large private rooms for its residents. Some people, however, decided to move out voluntarily. One person found transitional housing, two were moved to hospital due to serious health issues, four were excluded because of persistent violence, two decided to leave on their own, and one was transferred to a residential social-care home. Since the group mainly consists of older people who have had long-term drinking problems, five of our clients have died. We believe that they spent the final days of their lives with dignity and in a supportive community around them.

As for the amount of alcohol consumed by our clients, we have two people who used the facility and did not drink any alcohol. When they are ready, we move them to a higher-level accommodation service. We also have 10 people consuming 30 units or fewer, 7 people with 40–50 units, and 6 people with 60 units or more. One unit can be understood as a small glass of wine. A can of beer equals 4 units and a 750 ml bottle of vodka equals 30 units.

Individual residents have multiple health problems, which we address as needed with the help of our healthcare staff, general practitioners for adults, mental health expert teams, and hospitals. Health problems include epilepsy, inadequate wound care, gastritis, malnutrition, reduced mobility due to falls, incontinence, and hepatitis. This aspect, in particular, represents a major challenge in healthcare service provision and management in the group.

Our staff consists of 22 employees, including managers, healthcare workers, nurses, case-management staff, night staff, head cooks, and kitchen and cleaning staff. The variety of required tasks means that, in general, we follow the rule of prioritizing the most important tasks. The project requires a larger number of staff members who would provide residents with full support and respond to their needs. We found that many different types of interventions and support for our residents are needed. In cases of frequent intoxication, accidents, stumbles, and falls caused by alcohol, a high level of conflict management is required. We also found that many residents need much more care than we originally anticipated. Many need help with bathing or dressing, and some even with additional activities. We estimate that a daily 42-hour project worker can be split into 3 hours devoted to alcohol management, 7 hours to behavior management, 1 hour to budgeting, 12 hours to personal care, 4 hours to specific healthcare such as medication administration, and 2 hours to visits. The remaining time must be spent on project management, completing core tasks, managing individual cases, preparing and serving meals, cleaning, and general administration. According to our estimates, if we wanted to provide comprehensive care, we would need 53 hours per day. When providing a home environment, it is important to create a culture that also reflects clients’ values. That is, not only providing housing, but also trying to create a community in which each resident belongs. We offer staff various trainings, conduct supervision, and try to provide the personal direction they need so they feel confident when carrying out interventions. Because many clients had often been excluded from their community and had negative experiences in public areas such as healthcare, including doctor visits or hospital stays, we work on reintegrating them into their original community. We also strive for the core focus of our project to be alcohol dependence work. Residents may drink alcohol in the project, but they also have the option of many therapeutic activities focused mainly on distraction, such as art workshops or gardening, which we run to create a better life experience and reduce harm.

Problems and challenges in service provision

As with any project, challenges also arise when operating and developing the Sundial House facility, which we try to address carefully and creatively. In Ireland the financial situation is currently difficult, mainly due to the economic problems the country is facing, which has put the homelessness sector under considerable pressure. We receive contributions for Sundial House from Funds for housing and healthcare services, but in truth we would need much more resources for our work. In addition, many of our residents need home-care support, but it is very difficult to place them in such homes because of their ongoing alcohol problems. Many clients also require care that can be provided only in our facility. This is often personal and healthcare care that we did not originally factor in when launching the project. We continually work on resolving these issues. Another challenge we face is managing domestic violence, especially in the case of couples living in our facility. We have several couples for whom this is the main issue. We found that if one partner is accused of violence and discharged from our facility, the other partner always leaves voluntarily with their partner, which means we end up losing both partners. And finally, we work in an environment where residents are encouraged to take responsibility for their lifestyle. We try to involve clients in various support services. However, this sometimes requires changing the mindset of individual residents who were used to having everything prepared and done for them within the project. They often therefore need support in their effort to take responsibility for their own lifestyle.

Besides the problems and challenges we face in running the facility, we also experience positive aspects that help us successfully lead the entire project. The current built environment has a positive effect on our clients, since our goal is to create buildings where it is possible to feel safe and which are designed to meet the needs of this group. The fact that this service was jointly commissioned by the Health Services Department and the Dublin City Council meant that both parties actively contributed to the success of the project. It took 6 years for the idea of founding Sundial House to become a reality, mainly thanks to senior management and the relevant organization, who committed themselves to ensuring barriers were overcome, to build relationships with key decision-makers, and to get the project finally opened. Staff and volunteers who are comfortable working in a low-threshold, harm-reduction setting are also a key element of success. The environment and model of work can greatly motivate staff. Another key factor in shaping these kinds of services is to ensure principles and procedures that support leadership and create operational management of the project within a low-threshold model. In the end, services work well if they are rooted in values and ethos and are clearly formulated and understandable to all employees.

Staff work in low-threshold facilities

In a facility where many residents may come with very chaotic prior lifestyles and where issues such as addictions and physical or mental health problems are also addressed, it is very important that the project has a high level of tolerance for residents’ behavior. However, to achieve this goal, staff structure must be strictly observed. Staff especially need clear instructions regarding their tasks and need to know what the organization expects of them. In addition, an adequate support system should be in place for staff in the form of supervision, work meetings, case meetings, or various trainings supporting their professional development. All this leads to the need to develop many key principles and procedures that support the low-threshold harm-reduction model.

The HR principles that, according to our experience in Ireland, can support low-threshold work are as follows:

  • Ethical code – clearly states the type of attitude, behavior, and values that the organization expects from its employees.
  • Boundary adherence – ensure that staff protect themselves and service users through professional team-based work rather than individually.
  • Recruitment and selection principles – should be designed to attract mainly people who understand this type of work and are continually engaged and share the organization’s common values.
  • Complaints procedures – which allow service users to voice their opinion if they feel they were not treated with respect and dignity.
  • Supervision principles – which ensure staff have space to reflect on the pressure placed on them at work, to learn from practical experiences, and to be constantly reminded of the low-threshold character of the project.
  • CCTV principles (camera monitoring) – were very important for us when training staff in using non-violent methods when working with service users. Here, however, the question arises of where and when incidents involving violence occurred, which management can assess objectively. Even in services where there is a high occurrence of incidents and conflicts, CCTV rules helped us focus when resolving disputed questions, supporting our decision-making and conflict management.

In addition, there are many key operational principles and procedures that can be introduced to help staff decide on issues related to low-threshold service management. We found that the main principles that improve this area are: Recommendation principles - a clear set of guidelines on who will be accepted into the project and what boundaries will be set. In addition, ensure that selecting suitable service users is based on need. Risk assessment and management – strong policies and procedures in this area mean taking into account and assessing the fact that residents may have high demands and all risks associated with that. Residents are the ones carrying the risk, but because this is a properly planned and structured program, we can work on minimizing those risks. Resident engagement in project activities – since residents do not have to be active in running the project and have many past experiences of social exclusion due to violence and drinking, we found that their gradual involvement in various activities makes them feel more secure in the new environment and helps them understand what is expected of them. All these aspects reduce their chaotic behavior. Core content of work and case management – they form the central part of work with this group of service users. Emphasis is placed especially on involving them in developing support plans aimed at improving their life situation. These include the areas of alcohol and drug use, and their physical and mental health. We also seek to improve residents’ relationships with their families and other key life issues. Clear expectations around staff interventions and their authority help us deliver services focused on harm-reduction interventions. Warnings and exclusions – maintaining low-threshold status also means finding ways to avoid having too many rules and minimizing the number of warnings and exclusions. In practice, this can be difficult, as many incidents and problems can arise that the lead staff consider grounds for exclusion. If agreed procedures are in place so that warnings or exclusions happen only in serious conflicts and problems, and a high-tolerance behavior management system is used, many exclusions could be prevented. Other methods, such as time-out and cooling-off in a room or outdoors, can also prevent the need to exclude an individual. Conflict and violence management – In Ireland, our staff undergo various trainings focused on intervention methods in conflict situations, which we collectively call Crisis Prevention Intervention. This means staff can resolve a crisis situation and will not physically intervene in cases of violence. Many scenarios can arise, but they are much easier to handle if staff know and follow predefined rules. Active participation of service users – ensure that residents are as involved as possible in the project’s activities, such as mutual meetings or satisfaction questionnaires. The fact that residents themselves lead some activities contributes to meeting their current needs, which in turn reduces stress and turns the project into a place where they feel much more responsible, aware that they contribute to greater mutual solidarity. Drug use – the way drug use is addressed on the project is a key part of low-threshold work. The disposal of used needles presents a risk to staff and requires serious sanctions, but a person who uses drugs responsibly can be accommodated. Decisions about drug dependence treatment and sanctions linked to irresponsible use can be included among principles that should be clear to all staff. It is always necessary to consider needle exchange, and it would be useful to write instructions for how to manage an exchange. This is one of the most complex principles and must be guided by the legal requirements of the given country. Guidance for managing alcohol issues – as with drug dependence, it is essential to set rules for residents about alcohol use, with the aim of improving their health where possible while respecting their choices. Alcoholism is a complex issue that, as we found, can also be addressed by setting a set of instructions that covers many questions and problems and forms a key method through which staff and line managers can be sure they are acting according to the best-developed standards in this area.

Managing alcohol consumption and building internal standards

We also developed standards on managing alcohol consumption. We introduced these standards last year to ensure that projects work in line with a harm-reduction philosophy. It was found that sometimes admitting a client as they are and accepting their drinking during their stay on the project meant that harm was merely being observed, and that we did not always intervene and encourage the client to reconsider their habits. It was important for us to ensure that through our interventions clients can change. When we reviewed all situations, we also found that some of our services were not operating according to the previously mentioned alcohol management standards and that our clients’ rights had not always been respected. Staff needed a much clearer theoretical framework that they could put into practice, and in each service they had not equally worked to manage alcohol consumption. It was very important to create a shared vision across the whole organization that described how to intervene in alcohol problems and then to create a model of best-practice procedures valid at the organization level.

To meet this goal, we brought together representatives from all projects in Northern Ireland and Ireland to discuss contentious issues regarding clients’ problematic alcohol consumption. Last summer we met several times to review all the difficulties and problems we encounter in our work. To also understand our clients’ views, we consulted each issue with them and asked what they thought adequate support should look like and where they thought services should improve. Clients’ views contributed greatly to developing the core rules.

We also drew on proven practices introduced in Ireland and abroad, and consulted each issue with other organizations from whom we could learn something new each time. Thanks to these factors we captured all the principles we believed needed to be included in the main organizational rules. Because not all projects are identical in terms of services for specific clients, it was very important that each project developed its own plan based on these core rules. One of the key benefits of this approach is that all clients with alcohol problems could participate in creating this plan together with the main project staff and ensure that, in the area of alcohol reduction, improvement or at least harm reduction could occur. If a client is used to drinking vodka, we can suggest switching to cider or beer, which are less harmful. If a client wants their alcohol intake to be controlled by another person, they can ask us to meter their alcohol.

We agreed on a set of principles that the organization wants to promote in work linked to addressing alcoholism. These principles will form the basis from which work will develop on all projects. They are:

  • In applying alcohol management rules, each individual will be assessed against values recognized by Depaul Ireland, especially with regard to the rights and responsibilities of each client and the affirmation of human potential.
  • Depaul Ireland wants to house and support individuals in their current life situation. This acceptance, however, is not unconditional and applies only if there are interventions to reduce harm and improve real support in the physical, social and mental health of our clients.
  • Individuals’ outcomes will not be deterministically based on substance use; instead, a holistic approach will be applied when measuring outcomes.
  • In implementing alcohol problem management, it is necessary to be informed by principles from medical, pharmaceutical, and psychological practice and always keep in mind the individual’s rights regarding their future and health.
  • Depaul Ireland is aware of the ethical dilemmas that can arise when working with vulnerable individuals who use psychoactive substances, and will seek to discuss this with its staff, volunteers, and clients. This may or may not include adjusting an individual’s substance use.
  • Depaul Ireland is obliged to ensure that clients adopt a structured approach within care and case management so that harm is prevented as much as possible while supporting individual potential.
  • Every individual project is required to adopt a structured approach to managing alcohol use in relation to its services, local environment, community, and residents’ needs.

Within the Standards for managing alcohol problems we focused on the following areas:

  1. Clients’ rights – how to ensure clients’ right to choose how much alcohol they drink, acceptance with dignity and respect, while also doing everything possible to ensure the greatest possible reduction of harm within their choice.
  2. Service guidelines – how to ensure serving smaller doses, dilution, purchasing, and exchanging for cash.
  3. Clients’ health – how to ensure clients with alcohol problems receive adequate nutrition and healthcare.
  4. Medication and alcohol management – how to ensure clients do not drink alcohol while taking medication, and what to do when clients refuse to take medication.
  5. Stabilization and detox – how to provide understanding from staff if a client decides to detox and how to relate to a client who returns after detoxification.
  6. Care planning and alcohol management – how to set expectations that clients should meet so we can support them and include various organizational interventions in the plan.

Author: Wendy Crampton, Senior Services Manager / Depaul Ireland

This contribution was published in the conference proceedings ,,Inclusion of the socially excluded and models of functioning of low-threshold facilities in Slovakia', organized by Depaul Slovakia, a non-profit organization in Bratislava on 26 October 2010. Reviewers of the proceedings: Ing. Mgr. Juraj Barát, Mgr. Jaroslava Poloňová, PhD. Publisher: DEPAUL SLOVENSKO, a non-profit organization, Bratislava 2010 ISBN: 978-80-970578-2-4