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Conversation with Timothy Cook

2003; Wiley; Volume: 98; Issue: 8 Linguagem: Inglês

10.1046/j.1360-0443.2003.00471.x

1360-0443

T. Cook,

Crime Patterns and Interventions

AddictionVolume 98, Issue 8 p. 1029-1038 Free Access Conversation with Timothy Cook First published: 08 September 2003 https://doi.org/10.1046/j.1360-0443.2003.00471.xAboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat In this occasional series we record the views and personal experience of people who have specially contributed to the evolution of ideas in the Journal's field of interest. From 1966 to 1974, Timothy Cook was the first director of Rathcoole House and the Alcohol Recovery Project, a pioneering British initiative that aims to help the homeless drinker. Addiction [A]: Could you just start by giving me a bit of your background up to the time you came into the alcohol field. Timothy Cook [TC]: I was born in 1938, educated at Loughborough Grammar School and then studied law at Cambridge University. I lectured in law for a year at Sheffield University but then enrolled in a new postgraduate criminology course at the Cambridge Institute of Criminology. It was there that I became very interested in the practical issues concerning the treatment and containment of offenders rather than more theoretical criminology. On completing that course I secured a job as assistant warden at Norman House in north London, a hostel for homeless ex-prisoners. It had been founded by Merfyn Turner, who was a great influence on me. I worked there for 2 years and it was an extremely fast learning curve, very much hands-on work, living in and running the hostel along with the warden and his wife. We worked extremely long hours but I learned a great deal both about myself and about the world of prisons and prison after-care. I then spent 2 years, 1964–66, as a prisoner welfare officer at Blundeston prison in Suffolk. This was a new prison for long-term offenders and was run by a very inspiring governor, Eric Towndrow, another great influence on me. What I soon discovered both at Norman House and Blundeston was the number of men with serious drinking problems going through the prison system. A: So that was a serious introduction to the world of drinking problems? TC: I spent many long hours at Norman House dealing with men under the influence of drink with no drinking offences on their record, who when interviewed in prison all protested ‘drink, I can take it or leave it’, which turned out to mean they couldn’t leave it. We had lots of problems with drinking behaviour. At Blundeston it was clear from a close examination of the records that a significant number of men had drinking problems. We started an Alcoholics Anonymous group, which for some men was a remarkably influential piece of intervention. I remained in touch over 20 years or more with several men from the group who never drank again after they left prison. So I found myself becoming increasingly interested in the men with drinking problems and responded to an advertisement for a warden at Rathcoole House, one of those adverts that talked about ‘a challenging and exciting opportunity’, which I now know means only a madman should consider the job! I applied, was successful and moved into Rathcoole in south London on 1 May 1966. A: Did you have GPs or other doctors involved with the men at Blundeston? TC: There was a visiting GP but no psychiatric services and certainly nothing in the way of treatment to address alcoholism. Almost all the interventions were like AA. For example, a Gamblers Anonymous was also started. The prison was run on very therapeutic lines and a lot of time was spent talking with individuals, a third of whom at least had serious drinking problems. Many denied this despite their criminal records repeatedly saying ‘when arrested he was drunk’. For a few coming to realize that drink was at the heart of their criminal career was a revelation and a release. As one man said, ‘I became free in prison’. All these men had spent many years in prison with no previous attempt to look at their drinking. Hence the sense of revelation. A: Was there a moral approach in society in those days to men with drinking problems? TC: I think the answer to this depends on whether the person with the drinking problem needed help or not. Generally, drinking too much was not regarded as too terrible. We always used to say in my family, ‘every family has a drunken uncle’. Such people were seen as characters, very amusing and everyone shut their eyes to the problems they were causing for others. For the public drinkers such as the drunk on the streets they undoubtedly were seen as the ‘undeserving poor’. They really could do something about their condition if they wanted to. People did wonder why I was spending so much time trying to help the drunks when there were so many other deserving people in difficulties. I think my parents thought that on more than one occasion. For those of us working with the alcoholics there was little point in moralizing, as the men were able to do that quite well for themselves; they were their own harshest critics. ‘We always used to say in my family, “every family has a drunken uncle”. Such people were seen as characters, very amusing and everyone shut their eyes to the problems they were causing for others.’ A: The other thing that was happening at that time was that the disease concept came to the UK in the early 1950s. You mentioned AA and they obviously worked within that idea. Did you think along those lines at all, or were you aware of this influencing how people with drink problems were treated? TC: Certainly during most of the 1960s the primary model was the disease model. To some extent it helped alcoholics feel less bad about their drinking and was a valuable corrective to the notion of them being undeserving. The model arrived at a valuable time. But then the sociological perspective emerged and passionate arguments developed about whether the disease model was right or appropriate and wasn’t it really the medical profession colonizing another area of human behaviour. But in reality the best psychiatrists had an enormous contribution to make. For me, whatever was being written and talked about the disease model dealing with alcoholics, day in and day out I tended to be much more pragmatic. I didn’t find it helpful to operate from a model mainly because the patterns of the men's drinking and their responses to Rathcoole were so very different. I recall one man who came to Rathcoole and said, ‘I just want to stop drinking. Nobody has ever told me that if I don’t take another drink I will be alright.’ I found him hard to believe but he was right. He went to AA, left the house after a year or so and 30 years later he died from natural causes with I’m told one of the biggest funerals AA has ever seen. He stopped drinking, he worked. It seemed scarcely relevant to agonize about a disease model. A: What did the men themselves make of the disease model? TC: In practice many of the men at Rathcoole were not enthusiastic about the disease model. As I said earlier, they were quite hard on themselves—‘it's nobody's fault but mine’. They were angry about the facilities such as the Salvation Army or the Camberwell Reception Centre, with the implication that if better facilities were provided they could straighten themselves out. Their response to the disease model tended to be: ‘of course I’m bloody ill, the stuff I’ve been drinking and sleeping out, who wouldn’t be ill?’. They were as a group curiously resistant to making excuses for themselves, which was how they perceived the disease model. Medical help was provided by an excellent GP, Dr Benno Pollak, and a psychiatric registrar from the Maudsley hospital came on a weekly basis. These services were of a very practical nature and I do not recall that the professional team was ever really exercized by any particular model. BEYOND THE DICKENSIAN: RATHCOOLE HOUSE ESTABLISHED AS A CENTRE FOR HOMELESS DRINKERS A: Can we set the context within which Rathcoole was emerging? You mentioned the Salvation Army and the Camberwell Reception Centre. Can you tell us something about how they operated and what their approach was? TC: Following the establishment of Norman House in the 1950s, which was the first ever prison after-care hostel, a few smaller hostels had developed in London. But the core provision for homeless men and women in the big cities, and in London more than anywhere else, was large lodging houses and government reception centres. Some had dormitories for a hundred people. Dickensian is an overworked term but that describes them, they were in effect warehouses for people. Provision on that scale has now disappeared. The Camberwell Reception Centre was run by the Department of Health and Social Security and was part of a national network of such centres. Camberwell was the largest and took up to 900 people. For homeless people there were few if any alternatives, and many of the men I saw at Rathcoole said they would rather sleep out than use such facilities. For them to go to the reception centre was to have given up. The lodging houses run by bodies like the Salvation Army were extraordinary places. However humanely they were run, the amount of care and attention that could be given to any individual was minimal. There were no records and no analysis of the people staying in them. They simply kept people off the streets. There were a few inspired staff at Camberwell but they were working in impossible conditions. In contrast, a place like Rathcoole, taking 10 people in a well-furnished house, was a totally different concept. The real practical difficulty was to move people from the street into Rathcoole when they were so resistant to using a large lodging house, even as a holding station until a place became available. Hence, it is not surprising that many men came to us straight from prison or hospital. A: So Rathcoole was quite an important new development? TC: Yes. It wasn’t the very first small hostel for homeless ex-offenders, as I have indicated, but it was the first project that specialized in the habitual drunkenness offender. Many had a hundred or more drunkenness convictions. They were crude spirit drinkers, homeless, absolutely the archetypal skid-row alcoholic as the term was then. They were almost universally seen as hopeless, so the idea of a small hostel working in as helpful and as therapeutic a way as possible with this group was certainly a radical development. A: Who initiated this? TC: Rathcoole, in my view, was established because of the coming together of a few key individuals at a time when government was interested in trying to tackle the much-neglected problem of prison after-care. Until 1963, the after-care of prisoners was in the hands of voluntary organizations. It was then made the responsibility of the Probation Service, renamed the Probation and After-care Service. It was quickly realized that a key provision had to be the establishment of voluntary after-care hostels. The Home Office established a committee, chaired by Lady Reading, to examine the residential provision for homeless discharged offenders. Griffith Edwards submitted proposals to that committee for tackling the problem of the chronic drunkenness offender, building on his own research at the Alcohol Impact Project (the forerunner of the Addiction Research Unit)—set up in 1964—and the work of the Camberwell Council on Alcoholism—founded in 1962—in both of which he was instrumental. There is no doubt that Lady Reading, a dynamic and powerful figure, was impressed by Griffith Edwards and his ideas. It was not surprising, therefore, that when the Carnegie Trust gave the Home Office Committee funds for a special After-care Trust to promote four new projects, the Edwards proposal for the skid-row alcoholic was chosen as one of the four. The committee reported in 1966 (Home Office 1966). Rathcoole opened on 1 May 1966. It is hard to imagine today that personalities, policies and funds could so perfectly come together to bring about such rapid action in an area of such neglect and unpopularity. It is worth noting that the Prison Service was making its own efforts to tackle the problem. Drunkenness offenders at Pentonville prison were sent to the open prison at Springhill, possibly in the hope that the modest therapeutic effects of open-air and sunshine would be beneficial. But as on release the men were returned to London by bus and deposited in south London, near one of the city's major skid row areas, it became evident that more was needed and that Rathcoole was timely to say the least. RATHCOOLE HOUSE: OPENING THE DOORS AND THE ISSUES THAT THEN EVOLVED A: Once you were in post how did things go after that? Did you get a full house? TC: I had intended to spend quite a lot of time thinking, planning, visiting possible referral agencies and beginning to decide on the ways in which the house would be run. In fact, within a few weeks I was asked to take in a man leaving Springhill on the day before the late May bank holiday. The person referring him was Ken McBride, an inner London probation and after-care officer charged with dealing with the habitual drunkenness offenders in Springhill. McBride was a great supporter of Rathcoole and was destined to become one of the major sources of referral. I agreed to take ‘Manchester Fred’, as he was known. Griffith Edwards advised that my life would never be the same again as the hostel was now open and we should ensure all systems were in place and all policies clear. How right he was. Fortunately, Fred turned out to be a great success but I wonder what might have happened had the very first referral been a total disaster. A: So what were the practical issues that then emerged? TC: Within a month the house was full. There were two key issues that emerged immediately. Firstly, should residents be made to get a job? Secondly, if residents drank what should our policy be? I decided, and the committee agreed with me, that it should not be compulsory to go to work. I vividly remember one man who did not work for the first 6 months and then suddenly one day he got a good job, and never drank again. But during those 6 months when he spent a lot of time in bed the men were hostile to him and confused about our approach. They had quite a strong puritanical streak and argued that all ought to be out at work. One was always wrestling with the impact of one person's behaviour on the others and struggling to achieve a balance. Men needed to stay sober in their own individual ways. Interestingly, getting a job for the men was never difficult so no-one had to be unemployed and the majority were keen to be in work. A much bigger problem was whether men should be evicted once they began drinking or be allowed back in. Initially we took a tolerant approach. We did not allow them back into the house when drunk and we certainly did not allow them to drink in the house. If they came back drunk I would probably take them to the Camberwell Reception Centre or tell them to go away and return in the morning when they would be re-admitted. Some of course disappeared forever. This ‘policy’ led to considerable confusion as to our purpose. If we really wanted to help them to stay off the drink (and for them one drink was the killer), then our approach was, to say the least, a mixed message. It all really came to a head at the very first Christmas in 1966. We had a full house. All the men were in work but by Christmas day there was not a single man left in the house. All were drinking. Some returned and we took them back. Some I went out to find and invited them back. But then we realized this was a very chaotic way to proceed. We decided that we had to engage the residents much more in developing an appropriate policy. This was the key development in the history of the house in my time. As a whole group we decided that the policy should be ‘if you drink you are out’ and there was to be no immediate re-admission. It was clear that the effort to stay sober was colossal enough without the confusion of thinking ‘well, if I drink for a couple of nights they will have me back’. So within the first year we had developed a policy that if you drank you left. For some of the referring agencies and other facilities that took a different view, such as St. Mungo's and the Simon Community, we were viewed as highly punitive. They argued that if you are dealing with alcoholics you must expect them to drink. This seemed to beg the question as to whether they could be helped to stop drinking altogether and rather assumed they could not, even perhaps we should not try to stop them drinking—this was the liberal 1960s. But we only had 10 places and we knew there were other facilities where men could stay and go on benders from time to time. We were not short of referrals. The new policy reinforced the men's own commitment. They wanted to be somewhere where people did not return having been drinking. Either the house was different or it wasn’t. We tried on this, as on many other issues, to be different. The Christmas of 1966 was a total disaster. We rebuilt and learned from that and certainly there was never a disaster on that scale again. RATHCOOLE: WHAT WAS ITS TREATMENT APPROACH? A: So, they went out to work and were expected to be alcohol-free. What else did the treatment approach—if you can call it that—consist of? TC: This was always the most difficult question that visitors put to me. Partly because Griffith had great faith in us and partly because we were tackling such a neglected problem, there were often visitors: from the Home Office, the probation service and some from the USA. The Americans always asked immediately just what was the treatment programme. I always felt acutely embarrassed because I could not, hand on heart, talk about a treatment programme, as I assumed the term was understood. Although I have to say when I actually read accounts of American Skid Row projects I was not at all sure that they had clear programmes either. The core of what we were trying to do was to engage the men as much as possible in the responsibilities of the house. This began in quite small ways but gradually expanded during the initial years. A: House meetings? TC: There was a weekly house meeting, which the psychiatrist attended but which was in no way a treatment group; it was often much more to do with the practical issues in the house. But even very practical matters such as organizing the cleaning could produce some challenging discussion. The men were resistant to responsibilities for the cleaning and evaded them by saying ‘someone will clean the stairs’. The ‘someone’ was ubiquitous. At one such discussion I recall Tommy saying ‘how much rent did “someone” pay and which room was he sleeping in?’, so forcing the group as a whole to take real responsibilities. Attempts to prompt discussions about motivations to stay sober or what sobriety might consist of were less frequent and I am not sure what impact they had on the residents. Discussions about why they drank were always very matter-of-fact. It never seemed an area that really interested them, certainly not in a group setting. For almost all of them the drinking had begun 25–30 years ago, so was rather lost in the mists of time. A not uncommon response when asked why they drank was, ‘well, we all just did where I came from’. A: The house seems to have worked on cultivation of self-responsibility? TC: We certainly tried to develop the theme of responsibility as far as possible. I referred earlier to the whole house being involved in deciding on the policy of ‘if you drink you are out’. As I described, such an approach may not seem particularly taxing yet I remember vividly one resident who said plaintively, ‘I came here to get sober not for all this responsibility’. He actually turned out to be one of our great successes! Then I was married in 1967 and went to live in the second house, which was just being opened, so we took the opportunity to gradually phase out residential staff at Rathcoole, having begun with two, me and a community service volunteer. Within 2 years there were no residential staff at all. As we developed this, one committee member said, ‘they will burn the house down’. All one could say in response was, ‘I don’t think they will’. They certainly did not and we were all eventually convinced that in fact there were fewer problems with drinking than previously. ‘Within 2 years there were no residential staff at all. As we developed this, one committee member said, “they will burn the house down”. All one could say in response was, “I don’t think they will”.’ We then took this a stage further by having all prospective residents interviewed by the house as a group and the admission being determined by that meeting. In reality, very few were ever rejected but it was extremely interesting to hear the exchanges; the questions asked were every bit as perceptive as any I had asked in the early days. This eventually led to a resident being elected onto the management committee. A: What was the GP's role? TC: This engagement in responsibility was backed up by the men being given a great deal of personal attention and nowhere was this better demonstrated than by the support and interest of the GP, Dr Benno Pollak. On admission to the house Dr Pollak gave each man over an hour's medical examination with blood tests and all the works. There was also an interview and assessment by the psychiatrist. The men always spoke very highly of these procedures and in particular of the medical support of the GP. In practice, very few serious medical or psychiatric problems ever emerged. Dr Pollak was always astonished at how basically healthy the men were and how very matter-of-fact they were about disasters that had been befallen them: one had no idea where or how or when he had lost an eye. But behind all this lay employment. Despite a lifetime of drinking many of them were very keen to get into work and saw that as the backbone of their recovery. Their enthusiasm for work could always take me by surprise. One man was admitted one evening and left the house very early the next morning and by late evening had not returned. I assumed he had gone drinking. But he returned having already started work—he even had had the choice of two jobs! A: Looking back, do you think that more intensive treatment might have been helpful? TC: Whether a more intensive and focused treatment programme would have been more effective is difficult to judge. Certainly, much later on in the history of the project there were much clearer attempts to introduce specific therapeutic programmes. Over the years, I have met many of the men who came through the houses in those early years and asked them what worked or what was the reason for them staying sober. Without exception, they all come up with something rather idiosyncratic and certainly never came up with a main cause. What they don’t ever say is things like ‘it was the insight you gave us into our drinking’. It would be extremely difficult to construct a programme on the basis of what I learned from those who were successful in those early years. Given the nature of the men and their drinking histories, I suspect that the services provided—which were light years away from anything else available at the time—were appropriate and apposite. A: But in other places were they getting counselling? TC: Not to my knowledge. There was certainly no reference to it in any of the literature I read. In the few hostels there were for homeless people, including alcoholics, no-one ever really talked about counselling in the way the term is now understood. There was advice, support, argument and discussion far into the night with individuals, but that would not be recognized by anyone as counselling. As far as the homeless alcoholic was concerned, much of the work focused on how to get them to the facility in the first place and what to do when they were sober. As one resident famously said to the psychiatrist, ‘I have been sober 6 months, worked, saved money and bought a bicycle, what do I do now?’. Trying to cope with a sober life and more independent living was a huge challenge for them, and that was why AA was so powerful for some of them. I went to a lot of open AA meetings and they were highly instructive, and entertaining. It was certainly an excellent way of spending one's evenings. I was always surprised that very few of the men ever went to the cinema or a football match. So there was a huge challenge around life as a sober being. It is exactly the same challenge currently facing the government's Rough Sleepers Initiative, when every effort is being made to move hardened rough sleepers into settled accommodation. The problem is the boredom. It is quite clear that the excitement of the first steps in most kinds of rehabilitation is almost palpable, but then comes the huge ‘what next?’ question. I am not sure that the answers to that can be boxed into neat programmes. But, again, I have to say that my experience was with a very specific group of men and approaches I am sure were and are very different, say, for women or young people. EXPANDING THE FACILITIES A: You said you moved to another hostel? TC: After Rathcoole had been running a year it was clear that some men were doing extremely well. We had two who had been there virtually the whole year. When I married in March 1967 it was not possible to live in my one room/office. At that time the committee was wanting to buy a second house. They bought a house near Clapham Common and Margaret and I had a flat at the top of it. The men who had done well at Rathcoole moved into it. About a year later we bought another house with independent bedsits not far away. So within 3 years we had two hostels and a group of independent flats but exactly the same number of staff that began in 1966. All these facilities are still operational, and of course many more. A: It grew quickly in a sort of progression? TC: In terms of the houses it certainly did. Then in 1968 we began to discuss whether we could do more in the way of outreach to the men on Skid Row and how we could support men who wanted to get sober but were still drinking. We were conscious that men could be referred to the house as much by luck as design and that we needed to have a point of access that was close to where the men were drinking. We developed the notion of the ‘shop front’, a concept and service that is now part and parcel of the provision. ‘We developed the notion of the “shop front”, a concept and service that is now part and parcel of the provision.’ To develop this facility we obtained a very generous grant from the City Parochial Foundation (where, incidentally, I ended my working career), which was sufficient to open up three shop fronts and appoint a research worker. The shop fronts opened in 1970 and from then on we were called the Alcoholics Recovery Project (ARP), later the Alcohol Recovery Project. This work was really pioneering and was a positive and constructive facility. They were open 2–3 hours a day and were staffed by one worker, usually helped by an assistant who was a recovered alcoholic. They would talk with the men to see what they wanted, refer them to hospitals and keep them on the waiting list of one of the houses. It also developed into a very valuable facility for men who had left the houses because of their drinking but who could then be supported and eventually admitted back into a house without being lost totally to the streets. Shop fronts are still very much part of the core services of the ARP and offer a very wide range of help. There is counselling, groups, real treatment programmes as well as just a drop-in. Some have women-only days and one is for black drinkers. The experimental nature of those early days continues, so that for example in one shop front acupuncture is offered as a treatment. I visited one of the shop fronts last year in Camberwell, a facility vastly superior physically to those early days but still retaining the same ethos of outreach and a manifestly positive response to a wide range of people with drinking problems. A: So over the first few years you achieved remarkable expansion? TC: Almost 4 years to the day after I moved into Rathcoole House we had three residential houses, three shop fronts, a research worker and a small office. We were well supported financially by government and charitable trusts. Progress indeed. Incidentally, when I went to work at the City Parochial Foundation in 1985 I was quite surprised to see from its records, carefully minuted since it began in 1891, that the ARP grant in 1968 was the first ever made to a voluntary organization dealing with alcohol problems. In the previous 80 years there had simply not been voluntary bodies engaging with alcoholics in the way that was to become so much a feature of the 1960s and beyond. Of course, there were missionary societies, the Salvation Army and the like, but this was a different order of things from charities like the ARP. The 1960s marked a turning point of constructive charitable endeavour as far as many groups in society were concerned, not least the homeless alcoholic. MAKING THE RESEARCH CONNECTIONS A: Can we go back a little and talk about the research. You mentioned that there was a research worker attached to the ARP. There was some research done at Rathcoole as well,