Tim and Graham will explore how addiction treatment has evolved since Clouds rst opened its doors in 1983, and how the impact of austerity and changes to the regulatory environment challenge traditional notions of rehabilitation and call for new approaches in the creation of communities of recovery. Drawing on evidence of e ectiveness, this presentation will examine the respective roles of residential treatment, community-based approaches, and mutual aid in supporting sustainable recovery.

1. Clouds in the Community
Graham Beech, Chief Executive
Tim Leighton, Director of Professional Education & Research
ICAAD 2018
Royal Garden
Hotel
London
May 9th 2017

2. 20th century residential treatment: the big old country house

3. A new home for inebriate cases (1926)
Evidence for effectiveness: three truck-loads of bottles were
later recovered from the attic of the grand hall

4. 1926-1983
CLOUDS HOUSE

5. A familiar environment
CLOUDS HOUSE – The Main Stair Case

6. Clouds House produced and still produces miraculously transformed people

7. Residential treatment for addictions in the UK
A few significant events:
Caldecote Hall 1926
Warlingham Park Hospital (Max Glatt) 1952 (first NHS unit for alcoholism)
St Bernard’s, Ealing (Max Glatt) 1962
Broadway Lodge 1975 (first Minnesota Model)
Clouds House 1983

8. Residential treatment under fire in the 1990s
Managed Care in the U.S. In the 1990s
(cost control for healthcare insurers)
resulted in a 50% closure of residential
centres nationally.
(Bill White – Slaying the Dragon)
Randomised trial evidence emerged in the
1990s that for some populations including
people with primary cocaine dependence
as well as alcohol dependence did as well
or a bit better in intensive day
programmes as they did in residential.

9. Curson, D. A. (1991). Private treatment of alcohol and drug problems in
Britain. Addiction, 86(1), 9-11.
Dr Curson had been medical director of the Charter Clinic, Chelsea.
Residential treatment under fire in the 1990s
The situation today is much worse as
austerity has stretched the NHS and
local authority budgets to breaking
point.

10. Residential treatment is still needed
Some people are too ill to manage day programmes.
Some may be so dependent that they can only remain abstinent in a
residential setting to start with.
There is some evidence that opiate detoxes are more likely to be completed
in a residential setting, and . . .
The outcomes of “detox only” (for alcohol as well as other drugs) with no
extended psychosocial treatment are very poor, so a residential
rehabilitation programme can combine a more secure detox with a first
stage abstinence-based psychosocial programme.

11. Residential treatment is still wanted
Some people want the extended respite offered by a residential
programme.
Some people want the opportunity to just focus on recovery from addiction
without the distractions and obligations of everyday life.
Some people will form closer bonds with their peers in a residential setting.
Some people like the ambience, which is usually some combination of a spa
retreat and a boarding school.

12. Early day programmes
• Day programmes are not new
• Minnesota Model type day programmes were developed in the States in
the 1980s, including evening and weekend programmes for those
remaining in work.
• “Out-patient drug free” treatment programmes were common in the
U.S. during the 1980s and 1990s, and were a major modality for large
research studies such as DATOS, along with long-term residential “TCs”,
and methadone programmes.
• However these programmes varied quite widely in terms of contact
hours per week and treatment elements.
• Outcomes generally comparable with residential settings

13. The rise of the recovering community
0
100
200
300
400
500
600
2006 2008 2010 2012 2014 2016 2018
Cocaine Anonymous meetings in UK plus considerable rises in
Narcotics Anonymous
meetings, SMART
meetings, arrival of
Lifering.

14. The rise of the recovering community

15. The rise of the recovering community

16. The rise of the recovering community
Glasgow 2010
(Liverpool & North-East contingents)
Brighton 2012

17. The rise of the recovering community
Recovery cafes, mentoring training, recovery coaching, volunteering,
recovery role-models, recovery champions, family support organisations,
websites, online forums and chatrooms etc. etc.
Blackpool 2017

18. Leighton, T. (2013). Counselling in intensive structured day treatment – the co-production of recovery, in Mistral, W.
(ed.). Emerging Perspectives on Substance Misuse. Chichester, John Wiley & Sons.
Leighton, T. (2016). SHARP intensive day treatment. In Mistral W. (ed.). Integrated Approaches to Drug and Alcohol
Problems: Action on Addiction, London, Routledge
The SHARP Programme
The original SHARP programme opened in 1992, in Redcliffe Gardens London.
Inspired by American models and British residential centres, especially Clouds House
Run by the Chemical Dependency Centre (CDC)
Main driver to get programme started
SHARP London 1992 TM-D and colleagues
SHARP Liverpool 2005 Local champions, TM-D
SHARP Bournemouth 2007 Continuation of Clouds Day Programme (started 1998)
SHARP Essex Braintree 2013 Commissioner
SHARP Essex Wickford 2018 Commissioner

19. The SHARP Programme
• 9-11 weeks’ duration
• Run on a cohort model (Essex) or as a rolling programme (Liverpool)
• Daily attendance 5 or 6 days per week
• Integrated family activities
• Entry post-detox (if required) – expectation of complete abstinence
• Embedded in the local recovery community and in the local recovery-oriented
treatment system
Connections and relationships with:
• Local recovery support groups
• Recovery spaces and activities
• Pre-abstinence support and information – motivation and preparation for
change
• Post-SHARP recovery opportunities – volunteering, mentoring training
• Referring agencies in the area

20. The SHARP Programme evaluated
Independent evaluations of SHARP Essex
2014 Tim Elwell-Sutton & Sarah Senker Quantitative and qualitative
2015 Sarah Senker Qualitative (thematic analysis)
2016 Sarah Senker Qualitative (addressing 3 research questions)
2017 Essex CC Organisational Intelligence Quantitative
All extremely positive!

21. The SHARP Programme evaluated
• The future of SHARP

22. The SHARP Programme evaluated
• Essex County Council Organisational Intelligence
November 2016
Re-presentation to substance misuse treatment system
“Of the 95 graduates tracked, 75 (79%) did not re-present to
substance misuse treatment by September 2016, 18 (19%) had
re-presented and 2 (2%) had not yet been discharged from
treatment. For cohorts 7-12, no more than 1 graduate had re-
presented to treatment.”

23. An alternative is not the same as a replacement
We are not arguing that intensive day rehab is “better” than residential and
should replace it.
We need both, each has pros and cons
Assertive linkage to the community of recovery is key
The “structured day programme” is a recognised modality – some look quite
good – but a day programme modality which is genuinely equivalent to a
residential rehab (treatment goals, degree of structure, group cohesiveness,
outcomes) is not yet properly acknowledged in this country.
This is why we have emphasised the success of SHARP programmes in this
presentation.

24. Why “Clouds” in the Community?
35 years of success, high reputation and goodwill
Tristan, the prime mover behind the first SHARP programme, started his
counselling career at Clouds House.
The magic of Clouds is at the centre of everything Action on Addiction does.
Intensive structured treatment in the community and residential treatment are
not mutually exclusive, they are and should be intimately linked.
The continuum of care is a concept in need of revival, emphasising the
relationship between the recovering community and the best possible
treatment interventions.

25. Why “Clouds” in the Community?
It is obvious that the 20th century model of residential treatment, while still
relevant, cannot reach the numbers in need of such support.
Neither privately funded treatment alone nor statutorily funded treatment alone
will be able to achieve anything like this reach for different reasons.
A truly recovery-based treatment system needs everyone working together.
How can we make this happen when the field is competing for business?

26. Why “Clouds” in the Community?
We need active and coherently linked interventions
At the pre-abstinence stage information, support, problem analysis, options, preparation, family
support
At the treatment preparation stage motivation through information, taster experiences, role-models
At the intensive treatment stage medical detoxification and stabilisation, psychosocial change, relapse
prevention, initiation of social network change, family work.
Post-treatment Development of social network, aftercare groups, recovery roles,
counselling/therapy, interpersonal group work, intensive family work,
renewal

27. Why “Clouds” in the Community?
Integration of private and state-funded models
Certain modalities are firmly associated with a particular client set:
Private residential programmes private clients
Charity-run residential programmes private and statutory in various ratios
“Structured day” programmes statutorily-funded clients
Psychotherapy for recovering people private clients
This needs to change!

28. The Essex system (as it could be)
RECOVERING
COMMUNITY
Open
Road
Clouds
House
SHARP
Braintree,
Wickford
Local mutual
aid
AA/NA/CA/
SMART
SUD
sufferers
Foundation 66
mentoring
training
Aftercare
Private
therapists
Private
self-
referral
statutory
services
referral Family
services

29. The Liverpool system (as it could be)
RECOVERING
COMMUNITY
Clouds
House
SHARP
Liverpool
Local mutual
aid
AA/NA/CA/
SMART
SUD
sufferers
Volunteerin
g
Mentoring
training
Aftercare
Private
therapists
Private
self-
referral
statutory
services
referral Family
services
Brink based
D-PASS
A-PASS
Brink of Change
The Brink
Wirral
services

31. Audit to Action
• Identify local problems
• Draw together a key group of local partners
• Plan together
• Deliver and performance manage the process
• Ensure that the process is sustained where
possible at a local level.

32. If change is an internal process…..

33. It rarely happens without external support.

34. Recovery can be contagious….

35. Building communities of recovery

36. Building communities of recovery

37. Building communities of recovery: audit to action
• What does a recovery community look like and feel
like, and how does it work?
• What are the key elements of a recovery
community?
• What are the links between these key elements?
• How can we build and sustain resilience?

38. Loose change

39. Some of the research evidence

40. Some of the research evidence

41. Some of the research evidence

42. Some of the research evidence: DATOS 1 year outcomes

43. The SHARP Programme evaluated
Dr Sarah Senker’s second evaluation (2016)
3 Questions:
• What makes SHARP a success?
• How has SHARP contributed to a community of recovery in Essex?
• How could SHARP be improved?
Interviews with:
• 7 clients from (then most recent) cohort 12, plus a focus group with remaining
clients
• 4 family members of clients in cohort 12
• 11 clients from cohorts 1, 5, 7, 9 and 10
• 4 staff members at SHARP
• 2 managers from referring agencies in Basildon and North Essex

44. The SHARP Programme evaluated
• What makes SHARP a success?
A legitimate and viable alternative to residential rehab :

45. The SHARP Programme evaluated
• What makes SHARP a success?
A legitimate and viable alternative to residential rehab

46. The SHARP Programme evaluated
• What makes SHARP a success?
A legitimate and viable alternative to residential rehab

47. The SHARP Programme evaluated
• How has SHARP contributed to a community of recovery in Essex?

48. The SHARP Programme evaluated
• Essex County Council Organisational Intelligence
November 2016
10.45
13.79
15.26
0
5
10
15
20
TOPScore
TOP Score for Psychological Health
Start Review Exit
10.90
13.00
15.32
0
5
10
15
20
TOPScore
TOP Score for Overall Quality of Life
Start Review Exit
12.28 12.64
14.53
0
5
10
15
20
TOPScore
TOP Score for Physical Health
Start Review Exit
27.27
36.23
39.91
0
5
10
15
20
25
30
35
40
ARCScore
ARC Total Strengths Score
Start Review Exit
19.90
9.71
5.97
0
5
10
15
20
25
30
35
40
ARCScore
ARC Total Threats Score
Start Review Exit
3.37
3.79
4.04
0
1
2
3
4
5
CESTScore
CEST Self-Efficacy Score
Start Review Exit