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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.

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  1. 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. 2. 20th century residential treatment: the big old country house
  3. 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. 4. 1926-1983 CLOUDS HOUSE
  5. 5. A familiar environment CLOUDS HOUSE – The Main Stair Case
  6. 6. Clouds House produced and still produces miraculously transformed people
  7. 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. 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. 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. 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. 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. 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. 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. 14. The rise of the recovering community
  15. 15. The rise of the recovering community
  16. 16. The rise of the recovering community Glasgow 2010 (Liverpool & North-East contingents) Brighton 2012
  17. 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. 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. 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. 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. 21. The SHARP Programme evaluated • The future of SHARP
  22. 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. 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. 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. 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. 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. 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. 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. 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
  30. 30. 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.
  31. 31. If change is an internal process…..
  32. 32. It rarely happens without external support.
  33. 33. Recovery can be contagious….
  34. 34. Building communities of recovery
  35. 35. Building communities of recovery
  36. 36. 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?
  37. 37. Loose change
  38. 38. Some of the research evidence
  39. 39. Some of the research evidence
  40. 40. Some of the research evidence
  41. 41. Some of the research evidence: DATOS 1 year outcomes
  42. 42. 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
  43. 43. The SHARP Programme evaluated • What makes SHARP a success? A legitimate and viable alternative to residential rehab :
  44. 44. The SHARP Programme evaluated • What makes SHARP a success? A legitimate and viable alternative to residential rehab
  45. 45. The SHARP Programme evaluated • What makes SHARP a success? A legitimate and viable alternative to residential rehab
  46. 46. The SHARP Programme evaluated • How has SHARP contributed to a community of recovery in Essex?
  47. 47. 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