Foreword

Mette Marie Boarding House was established in 2001. The idea with this housing initiative was to give people who are psychotic and who abuse intoxicants, and who also have severe and comprehensive social problems, a place to stay, a place to get support, and a place to build up their reserves to continue their life in a more independent form if this is at all possible.

It was clear from the start what values we would work from and the methods that the social work should use. But over the last few years, it has been the burning desire of both the staff and the Board to have an analysis and description of the methods we use in our work.

Our basic idea was to create an accommodating home with respect for diversity, where the methodological work was based on values such as recognition and co-humanity.

We were very conscious that a home is not just a physical structure for providing a roof over our head. It is an important symbol of our life and living conditions, and the home also symbolizes a feeling of security and stability. Having a home gives Mette Marie's residents the chance to have a private life and a sense of belonging. And at the same time it means that residents can enjoy peace and stability in their lives and, with the support of the staff, get new opportunities for life-expression.

We knew that working with people with both mental illness and addiction problems is no easy task. It requires time, patience and perseverance to change old habits and to build the necessary trust that makes change possible. People with both mental illness and substance abuse problems are people who have long lived outside society and who need to heal the wounds that their hard-lived life has brought them. At Mette Marie we believe that care precedes treatment and that a precondition for care is inclusiveness. Mette Marie has the aim of accommodating the quirky and the different, so not only the many, but also the few have a place in the world and a place to come home to.

All this has been described in this report, which we are both happy with and proud of, and in addition to using it in our own daily work we would also like to offer it to others to read and be inspired by.

Preben Brandt Chair, Mette Marie Boarding House

Marlene Kryger Engel Superintendent, Mette Marie Boarding House November 2014

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… In order to survive in the world and be able to fulfil his tasks there, man needs a space providing security and peace, to which he can retreat, in which he can unwind and become his normal self again, when he has worn himself out in battle with the outside world.

Bollnow 2011: 130

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Table of Contents

Chapter 1: About Mette Marie Boarding House Background and Purpose 7

1.1 The physical setting 7 1.2 The boarding house's residents 8 1.3 The purpose of Mette Marie Boarding House 9 1.4 The structure of the methodological description 9 1.5 About the methodological description 10

Chapter 2: Space for the marginalized Harm reduction and homeliness 12

2.1 Why harm reduction? 12 2.2 Home and homeliness 13 2.3 Substance abuse 16 2.4 Motivational work, autonomy, and resident involvement 17

Chapter 3: Relationship work Development through human contact 19

3.1 Good relationships 19 3.2 Role models 21 3.3 Authenticity - the personal in the professional 22

Chapter 4: Working with people A reflexively grounded practice 24

4.1 The reflexive culture in practice 25 4.1.1 Informal practices: Immediate reflection 25 4.1.2 Formalized practice: Supervision and staff meetings 26

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Chapter 5: Small changes that lead to big changes The systemic approach 29

5.1 Recognition of the resident's reality 30 5.2 Change through sufficient disruption 32 5.3 Systemic work in practice: context switching and behavioural changes 32

Chapter 6: Mette Marie in the outside world Turning social work outwards 35

6.1 Bridge building 35 6.2 Interdisciplinary collaboration and the open model 37 6.3 Integration and participation in the local area 37

Chapter 7: Ethics and quality in social work Concluding remarks 39

Bibliography 41

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Chapter 1 About Mette Marie Boarding House Background and Purpose________________________________________________________________________________________

Mette Marie Boarding House is a private housing unit for 16 people with mental illness and addiction problems. The boarding house is run under the Social Services Act §1071 and is one of 18 independent institutions affiliated with the Mariehjemmene Fund – a fund established to provide support and assistance for the elderly, the sick, the mentally ill, and other vulnerable people.

Mette Marie is not a 24-hour manned treatment centre, but a residential facility which requires that residents be physically self-reliant. There are seven permanent staff members – four social workers, one social and healthcare assistant, a social advisor and an unqualified worker with long experience of working with the target group. A fixed group of replacement workers is also connected with the house.

1.1 The physical setting The property itself is a two-storey building from the 1930s located in a residential area with both detached houses and apartment buildings in Vanløse, in the west of Copenhagen. Each floor has eight resident rooms (16 rooms in total) of 22 to 24 m2 with private bathroom. These rooms are regarded as the residents' private homes and can be decorated as desired.

In addition to the residents' private accommodation, the house consists of common areas such as a kitchenette, training rooms, workshop, dining room and living room. The house has a large back garden with a greenhouse, where there is the opportunity for growing plants and herbs. The basement houses the personnel office, music room, laundry room and a large communal kitchen, where the day's meals are prepared.

A crucial factor for Mette Marie's physical environment is that the residents should feel themselves at home. Residents can come and go as they wish and can invite guests to the house. Public areas are for everyone, both staff and residents alike. At Mette Marie it is not forbidden to drink alcohol in public areas.

1Social Services Act, §107: The municipal authority may offer temporary accommodation to persons who are in need of it due to significantly reduced physical or mental function or special social problems.

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Proposal and referral to Mette Marie is through Copenhagen Municipality. Each resident enters into a lease agreement with the boarding house, which largely resembles an ordinary lease agreement. Each resident's own payment covers rent, heat, electricity, joint expenses, and food. All residents receive their own key for their private accommodation, the house's front door and the mailbox.

1.2 The boarding house's residents The residents of Mette Marie constitute a very particular target group: disadvantaged people with mental illness and substance abuse problems in the age group 35-65.

This means that the house's residents, in addition to having one or more mental disorders also have an active abuse of one or more psychoactive substances. In addition, the residents also have a number of social problems as a result of their diagnosis, prolonged abuse, and hard life.

Mette Marie's residents are people who are already familiar with various institutions and systems of treatment. Many of them have spent much of their lives on the streets, in orphanages, in prison, in closed wards, and in other institutions. For many years, they have been in and out of different treatment systems, and many of them have experienced being evicted from former accommodation as it had not been able to accommodate them. Most of the residents have few relatives or none at all. The staff at Mette Marie are often the primary caregivers in the resident's life.

The long-term intake of psychoactive substances, over 20-25 years on average, has greatly affected the residents' memory, sense of time, self-regard, and social skills. Many of them suffer from social anxiety and find it difficult to engage in social communities. They have a basic distrust of other people and expect others to show distrust of them. The residents have a very strained relationship to authorities and often feel ostracized and excluded from society.

Of the 16 current residents at Mette Marie, 14 are men and 2 women. A large proportion of the residents have lived in Mette Marie for many years. Some have been there since its foundation in 2001, while others have arrived in the last four years. All residents have an early retirement pension. Some of the residents have a treatment order, which means that they are obligated to follow outpatient psychiatric treatment.

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1.3 The purpose of Mette Marie Boarding House

The purpose of Mette Marie is to create a homely environment for people with mental disorders and addictions who need support and care to maintain their everyday life. The board, Mette Marie Boarding House

The foundation for Mette Marie is a revolt against an ideology of normalization and adaptation, where it is expected that the mentally ill with substance abuse problems should be able to adapt to standardized norms and values. Instead, Mette Marie adopts a humanistic view, where the individual's unique character and personality are recognized. Instead of the residents having to adapt to the requirements and regulations of the residence, the basic idea is that the residence, to the greatest extent possible, adapts to the residents' lifestyles, values and needs.

Everyone needs a place to live where they feel secure and recognized for who they are – even the most difficult people. Mette Marie's purpose is to provide a framework for each resident to experience security, and, through care and support from the staff, get the opportunity to create their own life.

At Mette Marie the residents' freedom is valued very highly. Mette Marie believes that everyone has the right to make decisions about their own lives and therefore the desire is to give residents the greatest possible freedom by reducing systems of power and control. The residents are encouraged to take responsibility for themselves and to see themselves as the key player in their own lives.

1.4 The structure of the methodological description In the following methodological description, Mette Marie's working methods and specific practices will be set out, based on the residence's values and theoretical underpinnings.

Chapter 2, Space for the marginalized, will introduce the aims of Mette Marie's work based on harm reduction and the importance of the home.

Chapter 3, Relationship work, addresses one of the central cornerstones of Mette Marie's work, namely good relationships, including role models and authenticity, as methodological tools.

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Chapters 4 and 5, Working with people and Small changes that create big changes respectively, are more theoretically based. In the former, Mette Marie's methodological approach is treated as a reflective practice, based on anthropologist Leif Kongsgaard's concept of multi-theoretical practice in social work. The latter sets out how, with the help of systemic theory, Mette Marie creates a framework for understanding the residents' social problems, and on this basis tries to help them to solve them.

Chapter 6, Mette Marie in the outside world, describes the work of building bridges between the residents and the surrounding community, as well as Mette Marie's interdisciplinary collaboration with other institutions, health services, and the local area.

Chapter 7, Ethics and quality in social work, serves to provide both a perspective and a rounding off.

1.5 About the methodological description The basis of the methodological description is a qualitative study where the data is based on qualitative interviews, participant observation, and document analysis.

The various methods form the basis of different types of data. The focus of the qualitative interviews have been staff members' own descriptions of the educational work they carry out at Mette Marie and which values they emphasize in their work. All of the house's staff members have been interviewed – a total of seven staff. None of the house's 16 residents were interviewed. The reason for this is that the primary focus of the methodological description is on the house's working methods – how it works – and not on the results. Therefore, this is not an evaluation of the work of Mette Marie, but rather a description and justification of its methods and practices.

The aim of the participant observation has been to get access to observable knowledge of the house's culture. That is, how staff members act in certain situations, what they say and what they do, and the relation between staff and residents. The participant observation includes observations of everyday informal activities such as meals, cooking and doctor's visits, as well as more formal situations such as supervision, staff meetings, overlap meetings, and residents' meetings.

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The document analysis has provided background information about Mette Marie's basic foundation, values and theoretical basis. The documents used included Mette Marie's development plan and business plan, cooperation contracts with the Copenhagen Municipality, as well as various monitoring and evaluation reports.

The methodological description has been prepared by Henriette Lund Skyberg, MSc in Anthropology, and Stephanie Østergaard Christiansen, MA in Philosophy and Science.

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Chapter 2 Space for the marginalized Harm reduction and homeliness ________________________________________________________________________________________

At Mette Marie the goal is to work towards harm reduction. This means that the central focus is reducing the harmful effects that a life of substance abuse, mental disorders and severe social problems can bring. This chapter explains and justifies Mette Marie's harm-reduction practice based on the quite particular target group that the residents represent. Central to this work is the importance of creating a home where care, support and recognition provide a framework for a more harm-free and dignified life for each resident.

2.1 Why harm reduction? Harm reduction can be seen as an alternative to a recovery-oriented approach where mentally ill people with addictions get support to become drug-free and live a life as near 'normal' as possible. Although Mette Marie recognizes the ideal of being drug-free, a recovery approach is not directly applicable in relation to Mette Marie's target group. Most of the residents at Mette Marie have lived with substance abuse for 20-25 years and have already been through various treatment institutions and initiatives. The residents have developed a lifestyle over many years that is markedly different from the majority of society, partly because of their mental illness, substance abuse, isolation, etc. It is not reasonable or effective to require that these particularly disadvantaged mentally ill people must adapt to a set of norms and values that are not possible for them to live up to.

As these people cannot and will not stop their substance abuse, they are often excluded from public housing and residences. Many of them find it difficult to cope with highly structured environments as it requires them to adapt to the environment and thereby give up their lifestyle. This means that they often abandon their accommodation, wander around, and end up in increasingly marginal areas, where their situation slowly but surely deteriorates.

At Mette Marie the residents' social problems are approached with a large amount of acceptance and inclusion for the target group's unique character and ways of life. Rather than focusing on normalization and adaptation, Mette Marie emphasizes the importance of a view of humanity where the marginal and

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different is recognized, and where every individual has the freedom to act and live according to their own wishes and needs.

2.2 Home and homeliness The starting point for working on harm reduction is to provide a home for the residents. The home gives residents the opportunity for peace and stability in their lives and, with the support of the staff, the opportunity to carry out their daily activities. In this way, the residents have the chance of finding some extra reserves of energy that can help to create small and big changes in their lives. It is all about creating the best conditions for the residents to have a dignified and meaningful existence, and to allow them the chance of self-realization in whatever different areas of their lives they might wish it. And this is all in spite of their continued substance abuse.

Mette Marie's residents are people who have long lived a life outside of society – often homeless or socially isolated from the outside world. Many of them have had a difficult childhood with major social problems and lack of stability and security. The residents are very conscious of the fact that they fall outside of society, and they are generally marked by a low self-esteem. It is therefore the wish at Mette Marie to create a home where residents experience a sense of belonging and security, and where they feel accepted for who they are.

There are a number of conditions that must be met in order for us as people to experience a feeling of home. Social scientist Carsten Schjøtt Philipsen describes in his Ph.D. Home Feeling (2013) that these include: absence of stress, control over the immediate environment, freedom from other people's rules, recognition of one's presence, and the possibility of withdrawal. In many ways these conditions reflect Mette Marie's attempts to create a home for the residents and establish a feeling of home.

The residents at Mette Marie have their own private accommodation, to which they have their own key. Although staff also have keys to the private accommodation, they do not enter without consent unless they suspect that the resident is unwell. A verbal agreement is worked out between the staff and the individual about the extent to which staff members may enter the resident's room. This is also written into a documentation system so that everyone is aware of what agreements have been reached. However, it is important that staff members always knock first and do not just go straight into the residents' private accommodation. It is very individual from resident to resident how much they want the staff to come and visit, and agreements are often adjusted on a

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running basis as the resident builds up more trust in the staff. The residents have their own private room where they have a high degree of control over their surroundings; where they can be themselves and withdraw from the community. However, control will never be absolute, as noise from other residents can penetrate the private space, for example, and also there might be the fear of break-ins.

Mette Marie puts a high price on residents' freedom and strives to create an environment where there are as few rules and requirements as possible in order to meet the residents in the best way. Home feeling is all about being able to recognize yourself in the rules that exist around you (Philipsen 2013: 301). For the residents, this means that they have the opportunity to express their lifestyle in the home. Therefore, there are no rules on what residents can do in their room. If residents destroy property in public areas in anger, they must pay the repair costs, but are not given any further sanctions. Instead, an informal behaviour-corrective conversation will be held, where staff and residents, in dialogue and community, find possible solutions so that it does not happen again. Most often, residents are very sad about their behaviour and want to find another way to deal with their anger without it coming to physical expression.

The residence should not just be seen as a kind of container for their existence, but possess a meaningfulness that goes beyond security and preservation of the self (ibid.: 302). Residents must be able to have a private life, but it should not result in solitude. Therefore, community is also important at Mette Marie. The celebration of Christmas, Easter, New Year, birthdays and other joint events also helps to create this meaningfulness. It is likewise the case that travel, daily walks and excursions, and especially the shared meals are important. For many of the residents, the staff are their closest caregivers, and being together at meals reinforces a feeling of homeliness, both by being a substitute for friendship and family relationships and also by being a relaxed setting in which small talk can unfold. Some of the residents prefer to stay in their rooms most of the time, but they are still in daily contact with staff members who come up to greet them and possibly bring food or medicine. This human care and contact is just as much help in creating a feeling of home as the individual's withdrawal and time for themselves.

The feeling of home is very much about being recognized; that there is a positive acceptance of one's presence. At Mette Marie this is expressed, among other ways, by the staff members always greeting the residents and saying good

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morning, meeting them with smiles and humour, and always having an open door. Often the residents come down and sit in the principal's office and have a chat, or just take care of their own business. The knowledge that you cannot be thrown out of Mette Marie also helps to show recognition. The residents know that they are welcome just as they are, for better or worse.

At Mette Marie people do their best to make the physical surroundings homely. The aim is that the furniture should not all look the same or appear too institutional. Residents can also arrange their private accommodation as they wish. Some of them have a lot of different knickknacks while others just have a bed and a table. It is up to the residents themselves. Other things associated with homeliness are also important elements in the accommodation. Among other things, this is about having food in the fridge, coffee in the coffee pot, staff-free nights, kitchen knives that are not chained up, and no special arrangements with the police. The house's appearance and location also helps to create a homely setting and atmosphere. However, rules from outside can sometimes restrict residents' freedom and their feeling of the residence as a home. This has been the case with the labour inspectorate's smoking directives, which mean that residents are no longer allowed to smoke in public areas. In this case, the residence is seen as a workplace and not as a home.

The staff are also very conscious about their choice of clothes and the way they present themselves. Mette Marie wants to express humanity and to break down the symbols of power relationships between residents and staff in the best possible way. Therefore staff members wear completely ordinary clothes, for example, jewellery and scarves. In contrast, a uniform or other institutional features would constantly remind residents of the power relationship, thereby hindering sustainable contact. Residents should not feel like patients in their own home.

At Mette Marie staff members prepare all meals themselves, and residents can take part in cooking if they so wish. The smell of food wafting up through the house creates a homely atmosphere and stimulates the residents' hunger. Often the residents come down to the kitchen to see what is for dinner and to have a chat. Residents have the opportunity to decide themselves what they should have for dinner. The staff always eat together with the residents. As the residents have a poor sense of time and often switch night and day, it is of great value for them to know when meals will be. Therefore, the meals are at fixed times of the day. For all meals, there is a knock on the residents' door to ask if they want to

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come out and get some food. This helps to ensure that residents get something to eat and is part of the harm-reduction work, as it contributes significantly to the residents' physical well-being. At weekends, 'Sunday sweets' are also organized in the common room.

Mette Marie is primarily based on the individual's need to have a home. The home is considered to be the central starting point for creating the possibility for self-realization for each resident. By offering a bed, food, medicine, care and support, the damage resulting from the impact of the residents' mental illness and addiction is reduced. Having a home means that the resident has the chance both to have a private life and to be part of an accepting community.

2.3 Substance abuse Mette Marie accepts that residents are involved in substance abuse. There is open discussion about the consequences and damages which may arise in connection with the misuse, and the staff always encourage residents to limit their misuse or find less risky alternatives, for example, by avoiding injecting. Among other initiatives, Mette Marie has offered residents guidance on how to avoid bad fixes. It is the residents themselves who are experts in their abuse and the staff therefore use the residents' own knowledge of the subject and ask about what ideas the residents themselves may have to curb substance abuse or its consequential damage. If a tenant becomes motivated to get out of his substance abuse, Mette Marie does everything it can to help. Together with the resident, contact is made with an addiction centre or district psychiatrist, in order to find out how to address it. Then the resident is supported with regard to the agreement reached.

The work at Mette Marie is very much about putting good experiences in place of substance abuse. This can be anything from playing music, going on day trips or on smaller trips in the local area, painting or travel. Every year at Mette Marie there is both a trip within Denmark and a trip abroad that residents have the chance to go on. Many of the residents had never been on holiday before they moved into the house. Getting away from everyday life and having a lot of experiences creates a positive energy that can be transferred to other areas in the residents' lives. The holidays also help to build good relationships, both between the staff and residents, as well as among the residents themselves.

Most of the residents do not get out of the house very much, so there are also various initiatives within Mette Marie's own walls. One of these is music therapy.

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Every Wednesday a music therapist comes out to Mette Marie and plays music together with those residents who wish to do so. Here a musical community is created where residents, by listening to each other and creating a common sound, achieve a strengthening of their social skills. At the same time the music gives residents the opportunity to express themselves in a creative way and create a positive self-image, where mental illness and substance abuse fades into the background. The music also helps with the restlessness which many of the residents experience from time to time.

Another method in substance abuse work is to create the conditions for residents to spend their money on other things than substance abuse. Therefore, it is also possible for residents to borrow small amounts for Mette Marie for things such as the purchase of television, new furniture or to come along on trips. The resident and Mette Marie enter into an instalment agreement where the money is paid back over a number of months.

One of Mette Marie's most important duties is to care about the residents. The residents of Mette Marie have problems both physically and psychologically, as well as all having huge social problems. Therefore, they also need care and support to maintain their everyday life. The care is a prerequisite for the residents being able to create a meaningful daily life for themselves, and helps to give a positive extra energy to the resident that can be directed towards other things or areas in the resident's life, including the substance abuse. When residents get stability, security and good experiences in their daily life, it creates a new foundation for them to have more opportunities to create the life that they want.

2.4 Motivational work, autonomy, and resident involvement Work at Mette Marie is based on the residents' own wishes and preferences about what changes they want to make in their own lives. The role of the staff is to motivate, support, and guide the residents to achieve these changes. It takes time and patience to listen to and understand the individual's preferences, so that the resident, with support, can identify the options for action. Relationship work is therefore a key component of the harm-reduction work.

In a collaboration between the staff and the residents, every three months targets are set for each resident's development. At the same time a plan is made for how the staff member can as best as possible support the resident in achieving these goals. An example could be that a resident wants to lose five kilos in weight. Here the staff member's support could consist, among other

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things, of asking the resident once a week whether they want to go out for a walk. As it is difficult for many of the residents to handle even the smallest tasks, it is important to emphasize that the targets often consist of completely banal things such as throwing old milk cartons out in the rubbish bin. The main thing is that it is the resident's own desires for change that are reflected in the different targets. At the same time the staff do everything they can to motivate the residents to make such changes. Much of the motivational work is expressed by the staff members being role models.

At Mette Marie, autonomy-based social work is carried out. This means that the staff care about the residents' personal freedom and try, as far as possible, to give the responsibility back to the residents. Residents have a high degree of influence on Mette Marie as a residence. The aim of the staff is to offer support and care, so that it is possible for the individual to build a home on their own terms. Therefore, the residents also have a representative on Mette Marie's board, and similarly a resident is present in job interviews with future staff members.

It is essential to downplay the use of control and power, and instead to use dialogue and negotiation if inappropriate situations arise. Here the staff find the best solution in cooperation with the individual resident. For Mette Marie it is all preparing the residents in the best way possible to enter into relationships and networks outside of Mette Marie, and to give help and support to the residents so that they are able to organize their life within the given structure of initiatives.

In the harm-reduction work, it is essential to start with the individual and their desires for change. Similarly, it is important to motivate and support these desires, and constantly present opportunities to the resident, who can then create the basis for a better life.

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Chapter 3 Relationship work Development through human contact ________________________________________________________________________________________

Relationship work is about the way as a staff member and specialist one meets the residents through language, actions, and general appearance. At Mette Marie, good relationships are seen as a prerequisite for being able to work with people with mental illness and addiction problems. It is through the daily contact that the staff member looks for insight into the individual resident's wishes and needs, as well as their physical and mental state.

Mette Marie justifies its focus on relationship work from the conviction that it is through social relations that it becomes possible to create security and stability for the people who have continually had the experience of standing outside of society. Relationship work thus becomes the starting point for the resident's social development and learning, as the good relationships become the educational ideal through which all initiatives acquire their meaning. This chapter describes the importance of good relationships and the methodological work in the form of role models and authenticity.

3.1 Good relationships A hard life and the experience of being repeatedly let down are contributing factors in the struggle of Mette Marie's residents to form social relationships. A persistent distrust of other people means the residents have difficulty participating in social communities and they often feel excluded and different.

Good relationships do not just arise in passing, they require time and persistence. At Mette Marie, recognition is seen as a prerequisite for the formation of good relationships. By meeting each resident with recognition and respect for their personality, uniqueness and ways of experiencing the world, Mette Marie works towards building up the residents' self-esteem, social skills, and quality of life. The recognition approach may comprise both verbal and nonverbal communication. This could, for example, be getting a hug and a calming hand on the shoulder when it is needed, or praise when a resident shows initiative or positive behaviour. Praise and recognition in social relations helps to give residents an increased confidence and a deeper self-esteem. Recognition may also be staff members daring to speak out when a tenant

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violates the limits of acceptable behaviour. Recognition in the form of confrontation is about showing residents that they are considered as equal human beings who can take responsibility for their own actions.

At Mette Marie the relationship work is always based on the individual resident, and their wants and needs. All relationships are unique, and no two relationships are the same. Good relationships are formed through everyday events, both small and large, for example by helping a resident clean their room, everyday conversations while cooking in the kitchen, in celebrating birthdays, shared holiday experiences, etc. For many of the residents, Mette Marie is the place where they have lived for the longest time in their lives. It is the place where they experience security and stability, and where the staff fill the role of being both caregivers and friends.

Establishing good relationships is not primarily about staff members' ability to use certain methods or techniques, but rather their ability to care and respond to emotions in a professional framework. When residents are admitted to hospital, the staff make sure to visit them and bring them cigarettes, clothes and other things they might need. Getting a visit from "home", just like a hug or a pat on the shoulder, helps to create a good contact between the staff and the residents, while the care and the experience of being missed can help to strengthen the residents' feeling of belonging and recognition.

Trust is an essential foundation in the relationship and in the contact between residents and staff. Many of Mette Marie's residents show signs of being very institutionalized after many years in orphanages, in prison, and in locked wards. This makes it difficult for many of them to trust that the staff's concern is genuine and without reservation. Often it takes more than a year before a new resident settles into the house. It is the professional responsibility of the staff to build trusting relationships with the residents. At Mette Marie it is believed that good relationships and close daily contact with residents is better at reducing risk than formal security measures and rules. So the house has deliberately chosen to have few staff, not to have night shifts or attack alarms, and not to lock away knives and other sharp utensils. This has a large signal value as it shows the residents that staff have confidence in them and do not consider them to be dangerous. The trust acts as a mirror in which the residents are able to see themselves, not as addicts or the mentally ill, but as people. Through these good relationships, staff members try to motivate residents to think and act differently. In this way, relationships can help to prolong the residents' good periods, both psychologically and in terms of their substance abuse.

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In addition to the daily contact, each resident has a primary and secondary contact among the staff. The contact person scheme has most of all a practical function, which is used in connection with diagnostic tasks and annual status reports. Because many of Mette Marie's residents have a poor sense of time and find it hard to postpone their needs, it is important that staff members are able to be available right at that moment – not a couple of days later. In this context, a characteristic of Mette Marie are the short lines of communication, both between staff members and between staff members and residents. One reason that this can be achieved is because it is a priority to have a small team of staff. In everyday life, the staff members do not differentiate with regard to who is whose contact person. A key part of the work is that staff members are constantly informed of all the residents' states of mind, agreements, and about the various things that have happened in the house. This is done through digital documentation, overlap meetings, and staff meetings. In this way, all the staff can look after the residents' needs at any time.

3.2 Role models Mette Marie's residents see themselves reflected in the staff and the staff members have a major responsibility to act as role models. To act as role models in an educational context means that as a professional you start from yourself, and reflect on how you present yourself, through body language, speech and actions.

Role models are used in relation to learning and the development of social skills. For many residents, it is for example a big challenge to be accommodating, patient and respectful to others, which is a precondition for being a part of a social community. Small, and sometimes large disagreements arise in the house where the staff members have to step in to provide support, advice, and guidance. By acting as role models in a conflict, the staff show how disagreements can be handled in a more appropriate manner. The staff at Mette Marie always work to present themselves as good examples by being welcoming and respectful to each other, residents, and visitors in the house. Positive and open communication among staff members rubs off on the residents and contributes positively to the general mood and atmosphere in the house.

The residents of Mette Marie struggle to find reserves of energy for even the smallest things, which is why most initiatives for activities must come from the staff members. At Mette Marie the staff attend to many of the practical tasks in the house themselves – for example, cooking, cleaning, painting, and gardening.

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The fact that staff perform much of the practical work themselves can inspire residents to take responsibility for the home and perform minor tasks. As an example, when a resident had his room painted by the staff, another resident then said that he would also paint his. Another example of how staff members act as role models is in the eating situation. Here it is about showing how to behave around a dining table by asking for things, rather than reaching over the table, giving thanks for food, putting your dirty dishes in the dishwasher, and so on. The staff have the opportunity to take some exercise during working hours, which also helps to inspire residents to take better care of their health and makes it easier for them to participate spontaneously if they so wish.

Changing the behaviour of the residents is time consuming and requires persistence. By acting as role models, staff members are constantly looking to challenge the residents' self-image. Being a role model is not just about showing tolerance. It is also about setting boundaries and giving responsibility back to the residents. The residents' tone towards staff members can at times be harsh and disrespectful, where residents take the staff members' helpfulness and care for granted, swear at them, and make threats. This is behaviour that Mette Marie does not accept. Being a role model is also about setting boundaries and saying no, so that residents learn social norms for how to behave in a community and in the world outside of Mette Marie.

3.3 Authenticity – the personal in the professional Mette Marie's residents are people who have long experience with various treatment interventions and an institution-dominated culture. To reduce the distance that naturally arises between residents and the staff, Mette Marie lays the emphasis on authenticity in any contact with the resident, where the staff member's personal qualities are important.

To a large degree, relationship work refers to something personal, as it is about being a human to another human. However, displaying authenticity is not about staff members being private or "just themselves" in their meetings with the residents. Rather, it is about the staff members' ability to deal with the complexity between the personal and the professional. For residents to experience contact with staff members as authentic, it requires, among other things, that staff members do not insist on talking a pedagogical method language, which the resident will have met with many times before. It is about meeting residents at eye level, from the language point of view, and inviting

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them into dialogue. For example, the staff can show themselves to be people through the use of humour.

The act of authentication is not just achieved through language, but also through behaviour and actions. In connection with one of the house's holiday trips in Denmark, a visit was organized to a staff member's family home, where residents were invited in for coffee and cake. Being invited to a private family home made a big impression on the residents, as they experienced a genuineness and authenticity in relation to the staff. Touching, such as a much-needed hug, a pat on the shoulder, or a calming hand when a resident is feeling frustrated or sad, is also a way to show compassion. However, it is important to emphasize that the personal relationships between residents and staff are professional relationships. When staff show care or anger towards the residents, it is done on the basis of professional considerations. The staff always maintain their professional integrity in relation to the residents. This applies both in relation to the caring and also in relation to saying no and setting boundaries.

In working with people it is not always easy to find the balance between the personal and the professional. If you are only a professional, you can quickly create a distance between yourself and the residents. If it is just personal, you lack the professionalism that the educational field requires. At Mette Marie great emphasis is placed on the staff member daring to give of themselves, but also daring to set limits. When a resident meets a staff member who exhibits compassion, commitment and authenticity, it has great significance for the relationship work. Residents then experience the staff as people who want the best for them.

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Chapter 4 Working with people A reflexively grounded practice ________________________________________________________________________

At Mette Marie there is a reflexive culture at the core of the methodological work, in which the staff are constantly challenged to think in non-traditional ways, to be adaptable and willing to take chances to meet the residents' different needs and changing states of mind. The reflexive culture at Mette Marie is organized systematically, but it is also just as much a part of the informal everyday talk.

The description of the reflexive practices used at Mette Marie is inspired by Leif Kongsgaard's definition of social work as multi-theoretical practice (2014). This practice is defined through continuous professional reflection, examination of one's actions, and a professional method responsibility.

According to Kongsgaard, the majority of the problems that social work deals with can be characterized as wild problems. Wild problems are those that are unpredictable and complex problems in the sense that it is difficult to establish fixed guidelines for how the problem should be solved and to predict whether an intervention will have the desired result. The residents of Mette Marie are characterized by their mood, motivation and energy levels changing constantly, so that they appear to be impulsive and unpredictable. It is therefore difficult, if not impossible, for staff to create standards for which actions will bring about which effects. In this context, Kongsgaard writes:

There is a growing recognition that the question of "what works?" is a complex one that requires answers that do not reduce the complexity, but on the contrary maintain it. Rather than answer unequivocally what works, we must tentatively respond with "what works for whom, and under what circumstances?"

Kongsgaard 2014:40

The methods used at Mette Marie depend to a large extent on the staff member's decoding of the residents and their state of mind in each situation. This does not mean that this is not a professional assessment, on the contrary, the essence of professionalism is precisely to assess and qualify what methods are most appropriate and productive at any given moment. This is a method

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responsibility2, which means that staff must be reflective practitioners who are educated and trained to make informed choices in different situations. The staff must have the ability to select the right combination of methods and interventions and execute them in ways that match the situation (ibid.: 289).

Working reflexively is about analysing and reflecting on one's actions in a professional light, and then changing one's future actions based on this reflection. When a staff member acts in a particular situation, the action will also contain a reflexive dimension. When the action is carried out, it is also being tested, and is thus turned into knowledge material for future practice. This requires a staff culture where people are not afraid to express uncertainty and doubt, and where each staff member's actions are not criticized, but instead become the subject of constructive reflection.

The method concept in the context of social work can thus be seen as a multi-theoretical and reflectively grounded practice, where staff use their professional toolbox, including experience, methods and theoretical foundation, to evaluate what should be done in each situation.

4.1 The reflexive culture in practice In the work at Mette Marie, both a formal and an informal discussion and reflection culture is used – for instance in the form of daily overlap meetings, staff meetings, and supervision. Both of these approaches ensure that the professional work at Mette Marie is being constantly developed and improved and that staff feel comfortable and free in their work.

4.1.1 Informal practices: Immediate reflection Working at Mette Marie requires that the staff keep abreast of how the residents are doing and can act in good time before a situation escalates. It is therefore essential to have a continual transfer of knowledge between staff members. The day, evening and weekend teams ensure that information about the residents' mood, episodes, agreements and other issues is recorded in an electronic documentation system. Each shift starts with a meeting of an hour's duration, where information from the previous shift is reviewed and a plan made for the day/evening. In the changeover between day and evening shifts, there is an oral handover between the staff members.

2 Kongsgaard highlights method responsibility as an alternative to the question of method freedom and method requirement.

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This practice means that all the staff are informed about the residents and can meet them in the best possible manner. If a resident has shown signs of an incipient psychosis, it is important for the staff to keep a special eye out for this resident. It could also be that a resident has made a deal with the day staff to wait to take his Antabuse in the evening. The more staff know about the residents' state of mind and situation, the easier it is to act appropriately towards them. These overlap meetings between the shifts also give the opportunity, in addition to an update, for a general chat about the different residents and how different situations should be handled. If a resident is not feeling good, the staff can arrange to ask him or her about going for a walk as the staff experience that it helps the resident's mood to get out of the house.

Because the residents are so changeable and responsive, it is necessary for staff members to be very adaptable. A situation can quickly arise or change without notice, and the staff must be able to act in a split second. Here the staff have to read the resident and the situation on the basis of past experience, and act on the basis of what the staff themselves call 'fingertip intuition'. The reflexive work is carried out over a long period of time, but also in each individual situation.

4.1.2 Formalized practice: Supervision and staff meetings

Supervision is a space where the staff have the opportunity to share their work experiences, talk about the residents, get rid of frustrations and reflect on work processes. The supervision takes place every fortnight and is led by an external supervisor.

Residents can fluctuate daily between being either welcoming or angry towards staff. Professional work requires that time after time the staff meet the residents with inclusiveness and understanding. Therefore, it is important that the staff have the chance to vent any frustrations that build up, so that they do not grow, but are instead recognized and processed. It requires great reserves of mental energy from the staff to be sworn at and at times threatened, and then to be able to meet the resident again in an accepting way and with an open mind.

The personnel policy at Mette Marie is based on openness. In the supervision, there is a discussion about the employee's well-being and how each employee is feeling. Because the work with the residents can be very demanding, it is important that the supervision is also a space where the staff can talk about personal things. It is essential that the staff always know where each other are, as there can often arise unpredictable and difficult situations in the work with residents. It is always possible to take some time off from day to day and have a

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longer holiday if necessary. It may also be the case that for a period a staff member has had a particularly wearing contact with a resident and therefore needs to take care of more administrative duties until their reserves of energy have returned. Employees are divided into a paired team working in the evenings and weekends, whereby a strong relationship can be formed. Every 24 weeks there is a change of pairing, so that all the staff members get to experience a close working relationship with each other. The fact that the staff members know each other well is one of the reasons that people feel secure in their work.

There is no given way as to how to act in certain situations, and therefore there will always be a degree of doubt in one's work with the residents. It is important that this doubt should not be ignored or set aside, but is instead the subject of constructive reflection between staff members. At Mette Marie one does not refer to mistakes, but rather learning processes. Doubt is recognized as part of the complexity that social work requires. The recognition of the doubt is essential for the staff member daring to act and daring to go into conflicts. The questions asked in the supervision are: "Could we have met the resident in a different way?", "Is there anything else that works better?", "What experiences have other staff members had with this resident?" and so on. The supervision has the purpose of articulating some of the doubts that inevitably arise in working with people. The supervisor guides the reflections and makes perspective shifts, so that the staff are continuously challenged in their ways of thinking. Through the use of various exercises, the supervisor gives the staff member an opportunity to view residents and problematic issues from new angles. For example, work is done with picture cards and empathy exercises to better understand the feelings and reactions that the residents have. Supervision is always based on topics that staff members want to talk about themselves.

At staff meetings there is also discussion about the individual residents and the house in general. If for a while there has been an increasing tendency for a harsh tone from residents, the staff talk about how they can try to change this behaviour. For example, staff can agree to set clearer boundaries for when a behaviour should be accepted and accommodated, and when there is behaviour that is both inappropriately wearing to the staff and is not otherwise beneficial to the residents themselves. Often behaviour trends spread rapidly among there residents, where residents also experience of adopting behaviour that they do not want themselves. This can also result in staff members acquiring an unintended behaviour, and therefore behavioural changes often start with the staff members themselves. At staff meetings it is also agreed as to who should go

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on which courses, major activities, news from the board, and other things. Staff meetings are held every second week.

All in all, staff meetings, and especially supervision, help to give a formal framework for the reflective practice. In this way, Mette Marie ensures that reflection is always central in the work, and that it also challenged and developed through the supervisor's guidance and perspective shift.

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Chapter 5 Small changes that lead to big changes The systemic approach ________________________________________________________________________________________

Mette Marie bases its methodological work on a systemic approach. This means that the acts, statements, reactions and problems that the resident has are considered to be part of a larger context and not merely isolated phenomena. When you are working systemically, it means that you are trying to see connections between the different areas of the resident's life which mutually influence each other. Instead of looking for a specific cause for a specific behaviour, you look for different patterns (Kongsgaard 2014: 75). A resident's behaviour may be connected to various factors such as the physical environment, relationships, frame of mind, time of day, mood, external pressures, medication, and many others.

The residents at Mette Marie are involved as parts of different systems, depending on where you direct your attention. This could be the health care system, the psychiatrist, a group of friend, the local environment, residents at Mette Marie, etc. Residents can have different identities depending on which system you see them in, for example, as 'a difficult patient', 'mentally ill', 'a good friend', 'sick' or 'independent'. For staff members, it is about keeping an eye on the different resources or problems that residents can have in the different systems, and looking at how the different systems can affect each other. If residents have had problems with their medication or owe money, it affects their mood, so they may exhibit inappropriate behaviour in the local environment. Similarly, good experiences with the other residents, or stable medication, can have a positive impact on the residents' mood and make them more accommodating patients when they visit the dentist. The systems can affect each other both positively and negatively.

It is only when you understand the contexts in which any situation occurs that you have the opportunity to influence and change the situation by changing the contexts. A conflict-ridden doctor's visit may be related to various different factors. One factor could be that the resident has not been able to afford cigarettes and is therefore very irritable and restless. At the same time, the visit to the doctor is perhaps at a time of day when the resident is often lethargic. It may also be the case that the resident has previously had a bad experience with a doctor, and the resident takes this with him to the meeting with the new

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doctor. There is a whole pattern of different factors that make up the context in which the doctor's visit appears. To remedy the problem, the staff members would in this case make sure that the resident has cigarettes, and that the timing of the appointment is changed. The resident could, upon request, be joined by a staff member from Mette Marie to create a safe space for both the doctor and the resident.

One of the working methods used at Mette Marie is bridge building, and this could be called in addition 'staffed bridge building'. Here the staff member works as a bridge between the resident and the various systems which the resident is part of. It is very much about creating good contact between the doctor and the resident, that is to say, between the various different systems and context understandings.

5.1 Recognition of the resident's reality In systemic thinking one talks about autopoiesis (self-creation), which means that every single person is a system in themselves, creating an interpretation of the world from their own unique context, based on their history, upbringing, cultural context and biological composition. Therefore, one can never completely understand another human being – because we all perceive the world from our own unique context. It is therefore important to constantly be curious about other people in order to continually get a better understanding of them, their perceptions and actions. We should never think that another person thinks, perceives and interprets the world exactly as we do (ibid.: 79). Residents have a cultural background which means that their language can have a different meaning to that of the normative one. As mentioned before, residents have long experience with educational and institutionalized language, which does not always create good associations. At the same time, a resident's expressed desire for help in cleaning may in fact be a desire for more care. Conversely, an expressed desire for more care may in fact mean that they want help cleaning. Therefore, the staff are trying all the time to decode the residents' 'language' and are aware of their own, in order to build an authentic and sustainable relationship.

Consequently, this also means that what is true in one context may not be so in another. A caseworker may experience the resident as being rude and accusatory, while the resident experiences the caseworker to be not taking him seriously and that he is rejected when he tries to express his frustrations. Both

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the caseworker and the resident can in principle be "right" in their interpretations, and both their experiences of the situation are relevant to resolving the conflict.

In a meeting with a resident, the staff try to put themselves into the interpretation that the resident has of the world. When a resident reacts with suspicion to a staff member, the staff member asks himself or herself why this might be. For example, the staff at Mette Marie have learned that the sound of a bunch of keys can remind residents of institutions and prisons and so creates a bad feeling in the house.

A central element in the work at Mette Marie is to meet the residents where they are, to recognize the residents' perspective and try, as far as possible, to understand the context they come from, in order to be better placed to address the problematic issues that arise. Often when a staff member gets sworn at by a resident, it is because the resident is angry about something else that he or she needs to vent. The staff are a safe place for residents to get rid of their anger, because it does not mean that they will be thrown out or that staff members will not want to talk to them again. The staff will also sometimes represent the established and 'normal' system, which the residents struggle to be part of and which frustration can be directed towards.

When staff members arrive at work at 8 in the morning, the residents are usually impatient for their medications and because of this they may exhibit anger towards staff. Employees can accommodate this anger, as they know that some of the residents will have woken at 4 am with severe withdrawal symptoms. In this situation, it is about recognizing the residents' needs and the situation, for example by saying to them: "I don't know how it is, but I can see that you are feeling really bad". None of the staff can imagine what it is like to hear thousands of voices in their head every day, but they can recognize the resident's experience and try to understand the frustration it causes. The frustration may arise, for example, if the resident's medication is reduced. This increases the effect of the voices, and the resident will perhaps increase the abuse of drugs. In this way, the resident is not only stressed by the voices in their head, but also by having to procure and pay for drugs every day. It is by trying to understand the residents' world and the relationship between the different factors going on in their lives that it is possible to find the tools to help them.

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5.2 Change through sufficient disruption In order to change the resident's system needs to be disrupted. This is achieved through a 'sufficient disruption'. This means that the disruption must be sufficiently small that the resident can manage the disturbance and not feel under negative pressure from the staff member. In such cases, residents can distance themselves from the staff member, and so the disturbance has no effect. Similarly, the disturbance should be sufficiently large that it actually has a meaning.

A characteristic of the residents at Mette Marie is that small disruptions in their daily life can create great anxiety, uncertainty, and frustration. Such small chores as taking a bath, cleaning their room, or going to the bank can be quite unimaginable, almost insurmountable projects. Even small changes in the residents' medications, for example, changes in the dose or the colour of the pills, can cause considerable frustration, which is turned on the other residents and staff. This is therefore a target group where the least disturbance has a maximum effect. In working with the residents, it is therefore essential to constantly assess when a disturbance is comfortable. Here the context is paramount. The disturbance depends on both the staff members' relationship to the individual resident and the resident's state of mind at the time.

In working with residents, the staff try to find out what difference may prove to be the crucial difference that makes the resident feel better able to achieve a better quality of life. This difference is not easy to identify, and therefore it is all about keeping on trying again and again. Thus, a systemic approach is also added to the multi-theoretical practice. Every action is based on a qualified professional assessment, but is also at the same time an experimental action. One might see the work process as a circular motion: action – reflection – new action – reflection, and so on.

5.3 Systemic work in practice: Context switching and behavioural changes

One of the ways in which staff work with a systemic approach in practice is by using context switching (ibid.: 92). That is, an attempt is made to change the context of a conversation or a meeting, for example, by going for a walk instead of sitting in an office.

At Mette Marie there is a continual, conscious and very broad use of context switching in the daily work. This is expressed by changing the circumstances surrounding a situation or a person, or a change of behaviour by the staff

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themselves. The staff are themselves included as part of the resident's systems. Therefore, a change of the staff member's own behaviour can create a sufficient disruption in the system, which leads to changes in the behaviour of the resident.

By talking nicely, and being accommodating and trusting with a resident, the staff member disturbs the system which he represents in relation to the resident. Many of the residents have a perception of the world which is marked by mistrust. Being given a gift without having to give anything back and to be greeted with immediate trust can in the long term change a resident's view of the world and other people and create a more positive self-image. The behaviour of the staff acts as a mirror in which the residents see themselves. Therefore, changes in the behaviour of the staff go hand in hand with the behaviour of the residents.

Another way to meet the residents is to change the circumstances of a particular situation, as in the previous example with the doctor's appointment. As the staff members change some of the contexts surrounding the situation, a more fruitful relationship develops between the resident and the surrounding community. Such positive experiences generate positive energy and will eventually be able to create long-term changes for the resident.

This way of working is connected with a pragmatic approach to practice. It is about finding out 'what works'. As an attempt is made to meet residents, residents can more easily meet their surroundings. One example is when the residents at one time had their habit of throwing their garbage under the table. To accommodate this behaviour, the staff members put the rubbish bin under the table.

Although it is about adapting the surroundings to the residents, it is just as much about teaching residents how to behave in a home, in the community, and with other people. Of course, it is eventually about the residents throwing their rubbish in the rubbish bin, wherever it might be, and that they are themselves able to interact with society, for example in the form of doctor's appointments. Therefore, there is also a lot of emphasis about talking to residents about the behaviour that is expected.

The central point of this constant trade-off between adaptation and requirements is about having a feeling for the residents and their state at the time. If one of the residents is having a bad time, and it is a positive development in itself that they come and sit down at the table and have some food, it is not appropriate to impose any more requirements. However if it is a resident who is

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doing well and it is just through forgetfulness or laziness that they are not cleaning up after themselves, it makes sense to give some of the responsibility back to them. It is about what makes sense for each resident in each situation – if the resident needs peace, support, or a push towards taking on more responsibility.

Because the residents are so situation-defined and changeable, it is often they who set the scene for discussions, rather than a talk framework being set for the resident. As part of the work of being involved with residents, there is a monthly residents' meeting at Mette Marie where welfare and other issues are on the agenda. However many of the people do not show up, and it is often difficult to keep the conversation on track. By contrast, good discussions often arise in informal settings: at mealtimes, doctor's visits, when you go for a walk with a resident or help them to clean the room. The idea is to let the conversation flow from the context, and meet the residents where they are.

When you talk about change and development for the residents, it is essential to take the target group into account. For many of the residents, small changes mean a great deal. The changes can be anything from showing more trust in the staff, cleaning up their room, saving money for a new bookcase, talking in a nicer way, shouting less, eating a more varied diet, becoming more mobile, becoming more confident, taking their Antabuse, or cutting down on their medicine. It is very different from resident to resident what is a sufficient disruption and a potential change. Ultimately, it is about the small changes that can lead to a higher quality of life for each resident.

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Chapter 6 Mette Marie in the outside world Turning social work outwards ________________________________________________________________________________________ Mette Marie works on an open model in order that the boarding house does not close in on itself. The staff put the emphasis both on supporting the resident making use of the public health services and making the boarding house visible in the outside world – both in relation to the local community and partners. Turning social work outwards is a way of creating a holistic approach and a good and safe environment for residents, neighbours and the local community. This chapter sets out Mette Marie's work with bridge building, interdisciplinary cooperation, and integration into the local community.

6.1 Bridge building Mette Marie focuses on its residents' health and well-being – with respect to their mental disorder, physical health, and social life. Many residents find it hard to participate in society, as they cannot decode social norms and act within them. A lot of resources are required for residents to concentrate for long periods of time. Often 10 to 15 minutes is more than they can handle. Therefore, making agreements with the doctor, dentist, physiotherapist etc., can present a major challenge – for both the resident and the health professionals they encounter.

Mette Marie puts a very high value on the residents' autonomy and tries as far as possible to give the residents responsibility for their own lives. However, the staff are aware that, due to their mental state, residents do not always manage to take on this responsibility. In such cases, the responsibility moves on to the staff, who will have to step in as bridge builders in cooperation with the public systems that the residents belong to.

There are various degrees of bridge building. It depends on how much support each resident wishes and requires, which can change from day to day. The majority of the bridge building work involves supporting residents in their contact with the health care system, so that they have the benefit of the public initiatives that they are entitled to. A great deal is done to prepare residents in good time for their appointments outside the house – usually the day before. This avoids conflicts when the appointment will take place, and the staff have

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time to cancel the appointment if a resident still cannot or does not have the energy to attend. The fact that the staff assume responsibility for cancelling the appointment means that instead of being excluded the resident is given the opportunity to make new appointments at a later date.

Another type of bridge building is when the staff – where they see a need for it, and where the resident consents – go along to the appointments that the resident has, for example, at the dentist. When a staff member from Mette Marie goes along, the staff member can have a calming effect on the situation as well as contributing by listening and translating what is being said to a "language" that the resident recognizes and understands. In this way, the resident has a better experience of the meeting with the official world, while health personnel experience better cooperation with the resident. This kind of bridge building, where staff actively act as a joining part, can be called staffed bridge building.

The different degrees of bridge building are always based on an assessment of the individual resident's needs for support. It is not all residents who want a staff member to go with them as they see it as a form of disempowerment. On the other hand, Mette Marie has the experience that doctors, dentists, etc. refuse certain residents because they have previously acted in a threatening manner to the medical professional. Bridge building refers to an ethical balance in relation to the resident's autonomy: The right to take responsibility and control over their own life, and the staff member's care for the resident's health and wellbeing. At Mette Marie there is always an awareness of involving residents to as great a degree as possible. In the way that Mette Marie works with bridge building, it is the staff member's primary role to act as a caring person and not the responsible persons. The staff's responsibility is to assist the resident in having access to public welfare services on an equal basis with others, rather than to speak on behalf of the resident.

As a result of Mette Marie's work on bridge building, the majority of residents today use dental and other treatment services (doctors, physiotherapists, chiropodists, etc.), which greatly contributes to a better quality of life. The staff also work with bridge building in other situations and arenas, for example, by organizing holiday trips for the residents, where some of the staff come along. Holiday trips are a way of supporting and encouraging residents to have a social life outside Mette Marie.

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6.2 Interdisciplinary collaboration and the open model Many of the interventions and treatments for Mette Marie's residents are located outside the boarding house's walls. This is a very conscious choice, as the house's primary focus is on being homely and caring, rather than on treatment. As Mette Marie receives many services from outside, it is dependent on good cooperation with all the various agencies and disciplines that are involved in each resident's life, in order to be able to establish a holistic approach. There are various professional attitudes and methods for working with people with mental illness and addictions. A holistic approach requires good collaboration in which all parties want to understand and adapt to different approaches. Here communication and respect for each other's professionalism is important.

At Mette Marie there is a holistic approach based on an open model. An open model means that the boarding house's doors are opened up so that partners can gain a better understanding of – and insight into – how Mette Marie works, while the boarding house itself wants to find out about its partners. This is a method which forms the basis for an effective dialogue and better interdisciplinary cooperation which is continually evolving.

Mette Marie has a wide range of different partners, including Frederiksberg Psychiatric Centre, doctors, dentists, health visitors, social advisors, and pharmacists. The challenges in this cooperation can be a lack of understanding of the residents' complex of problems and recognition of Mette Marie's ways of working. Conversely, a good working relationship is where both parties show an openness and curiosity about each other's different working methods, and include mutual visits and an open and informal way of communicating.

The vision of Mette Marie is to be a well-known and preferred home for people with mental illness and addiction. As part of the open model, Mette Marie therefore aims to be visible and actively participates in conferences and debates about the target group. As an active contributor, Mette Marie wants to be a role model and an inspiration in the development of initiatives towards people with mental illness and addiction problems.

6.3 Integration and participation in the local area Mette Marie is part of a neighbourhood, a local area, and a local community. Therefore, having a good working relationship and a good dialogue with neighbours and the local community is a high priority.

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Mette Marie works with integration in the local area by making the house visible in local life. Both staff and residents participate in local festive events, where Mette Marie's music and rock band 'Open Air' has also performed. Mette Marie also participates in the annual flea market in Vanløse. Here the house is represented by its own stall with various products. When celebrations and large events are organized at Mette Marie, the neighbours are also invited, and often people come along who show interest in the place.

The fact that Mette Marie is working hard to create a positive connection with the local community is of great importance both for the residents of the house and for its neighbours. The purpose of opening the house up to the outside world and taking part in local activities is to give residents a greater sense of security and belonging to the community. Openness and dialogue also gives the neighbours a more nuanced picture of people with mental illness and addiction problems, which in turn can lead to residents feeling less like a burden on the area and that they feel increasingly at home.

Although from day to day Mette Marie receives few complaints from neighbours and local communities, there are sometimes difficult situations that arise. Most often these are less serious cases with complaints about noise and loud music, but there have also been a few incidents in which residents from Mette Marie have behaved aggressively, being verbally threatening or violent against random passers-by. Mette Marie takes all feedback seriously. However, it is central that the house cannot be held accountable for the residents' behaviour and actions, but rather is able to help the residents, in the best possible way, to maintain a good relationship with the surrounding community. One example is when one resident, in frustration, displayed threatening behaviour against a random person on the street. The situation was dealt with here by the resident, with the support and accompaniment of a staff member, subsequently going to the person in question with a bouquet of flowers and an apology. Mette Marie's experience is that meeting conflicts with openness mostly leads to positive reactions and understanding from neighbours and the local community.

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Chapter 7 Ethics and quality in social work Concluding remarks ________________________________________________________________________________________

The residents of Mette Marie constitute a highly marginalized group in society, since they are not only characterized by one or more mental illnesses, but also have a massive misuse of psychoactive substances. Good quality in social work requires an approach where every individual both receives good treatment and is treated well. For mentally ill people with addiction problems the latter is especially the case, as they need a particularly recognizing and inclusive environment to be able to maintain an existence. In his book The mentally ill and the professional – draft towards an understanding of interaction (2000), specialist in psychiatry Preben Brandt suggests four elements for ensuring quality in social work; risk management, resource use, user satisfaction, and finding the best balance between a professional and compassionate approach.

In working with people, it is crucial first and foremost to be aware that it is another person's fate you are holding in your hands. This means that as a professional you must constantly assess the extent to which your actions can be more detrimental than beneficial to the resident. Here it is possible to speak of a form of risk management, in which the quality of the social work is ensured through constant reflection, based on each resident's specific situation. Rather than focusing on general principles, procedures and formulas, it is about having a pragmatic approach that aims to create the best opportunities for self-realization for each resident. In other words: what is appropriate in one case, is not necessarily so in another.

Quality in social work is also a matter of use of resources, which means that as a professional one has a responsibility to show the due respect, time and patience that is required to understand and meet another person's problems, thoughts and needs. For example, you should not enter into conversations or similar with a resident without being sure that you have the time to go through with it in a proper way. Similarly, user satisfaction is an essential element in the quality assessment of social work. This can be ensured by involving the resident to as great an extent as possible, so that the quality, relative to the individual's preferences and desires for change, is constantly maintained.

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Quality is also about finding the best balance between compassion and professionalism and to recognize that achieving the balance will always be difficult. Professionally-based compassion is an important part of social work, because security, warmth and recognition are a precondition for a person to be able to create major changes in their life. As a professional, by meeting residents as an authentic human being, as far as possible, you can more quickly gain a sustainable relationship based on openness and trust. And it is here, in the meeting of people that any possible changes can be made.

Risk management, resource use, user satisfaction and finding the best balance between a professional and compassionate way or working, are ways to capture the dynamic context that is needed to assess the quality of social work (Brandt 2000: 22). This does not change the fact that this is a complex issue.

Like all social work, working with mentally ill addicts involves a number of paradoxes: When is it most beneficial to the residents that the staff prioritize peace over conflict? When and how should the conflicts be made? How can you find the balance between providing residents with both responsibility and care? When is it beneficial to accept a resident's behaviour, and when should you try to change it? How do you weigh the individual resident's best interests in relation to those of the collective? These paradoxes will always exist. Social work is about taking care of complexity, not diluting it. Therefore, social work is very demanding. As a staff member, you will constantly experience being in doubt, since there is no one correct answer to adopt.

When all is said and done, you have to make choices based on ethical considerations and reflections. At Mette Marie, inclusiveness has been chosen above all else. This means that the choice has been made to house all residents, no matter how difficult and unreasonable they might be. It is clear that it can sometimes affect the general peace and security in the house when individual residents have very inappropriate behaviour. Other residences might argue that what is professionally sound is to prioritize the collective and the majority, rather than the individual maladjusted resident. At Mette Marie another choice has been made. Here it has been chosen to accommodate even the most difficult, although this sometimes creates tough periods, and to insist that with the help of persistent care, recognition and trust you can, and should, offer everyone the possibility of a dignified and meaningful life.

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Bibliography _________________________________________________________________________ Bollnow, Otto Friedrich 2011 (1963), Human space, London: Hyphen Press.

Brandt, Preben 2000 Den sindslidende & de professionelle – Et udkast til en samspilsforståelse [The mentally Ill & the professionals – A draft for an interplay understanding], Frederikshavn: Dafolo A/S

Kongsgaard, Leif Tøfting 2014, Multiteoretisk Praksis i Socialt Arbejde [Multi-Theoretical Practice in Social Work], Frederiksberg: Samfundslitteratur

Philipsen, Carsten Schjøtt 2013, Hjemfølelse [Feeling of home], PhD thesis at Roskilde University: Institute for Environmental, Social and Spatial Change