Residential rehabilitation: the high road to recovery?
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Residential rehabilitation: the high road to recovery?

‘Hot topics’ offer background and analysis on important issues which sometimes generate heated debate. Asks whether residential rehabilitation is particularly suited to today’s abstinence-based recovery ambitions, and whether nevertheless these services are under threat, treated as a last resort rather than a front-line option.

“I would like to … try to provide – difficult though it will be given the shortage of money we have been left – more residential treatment programmes. In the end, the way you get drug addicts clean is by getting them off drugs altogether, challenging their addiction rather than just replacing one opiate with another.” These comments made by the Prime Minister David Cameron in August 2010 were reiterated in February 2015, when he remained “committed to funding residential, abstinence-based rehabilitation, difficult though it may be in the current climate. Rather than maintaining people on substitutes like methadone, we have to help more people get off drugs and into work.” His comments both reflect and promise to embed in policy the current emphasis on treatment which explicitly aims for recovery, reintegration and abstinence, trends which in turn have focused attention on what has been seen as the treatment best suited to all three – residential rehabilitation. Add the claim that these programmes have been sidelined in pursuit of ‘manage the problem’ objectives, and the fact that they are among the most expensive options at a time of financial cutbacks, and you have a combustible mixture.

So concerned were British residential services that in 2011 some banded together in a Concordat to promote their cause as “providers of full recovery”, defined as moving towards a drug-free, productive and socially integrated life. Their terminology was echoed the following year in a highly contested follow-up to the national drug strategy entitled Putting full recovery first, described by the chair of the Inter-Ministerial Group on Drugs as “the Government’s roadmap for building a new treatment system based on recovery”. What it meant by “full recovery” was never spelt out, nor how it differs from plain “recovery”, but adopting this objective was said to entail an “increased focus on abstinence-based treatment” and a relegation of “indefinite maintenance, which is a replacement of one dependency with another” to the periphery rather than the centre of opiate addiction treatment.

Though there is no immediate prospect of wholesale closure, that residential services had something to be worried about is suggested by a survey in 2014 of services in England and of the commissioners largely responsible for funding them. Funding levels had yet to dramatically change, but 44% of services said adult social care funding had fallen and just 18% that it had increased, while twice as many commissioners (33%) foresaw their funding of these services falling as predicted it to rise (16%). Just how precarious things had become was evident in the finding that six in ten services had recently felt under threat of closure. In what threatens to become a vicious cycle, it seemed service quality was beginning to suffer, diminishing the difference between residential and non-residential provision, and offering further reasons for transferring funding to cheaper non-residential provision. Nevertheless, up to year 2013/14 occupancy levels and numbers in residential treatment had help up well.

What does residential rehabilitation have to offer?

The term residential rehabilitation describes a multitude of programmes, differing by philosophy, intensity, inclusion criteria, programme content, and duration. Often the only common factors are that residents have to stay overnight at the facility to receive treatment, and are expected to be drug and alcohol free before they start the programme (though in some cases detoxification is offered by the rehabs themselves as the first stage of the treatment). However, one simple way to look at what residential rehabilitation has to offer is to break it down into those with rehabilitative and supportive goals: rehabilitative programmes being those which provide accommodation and a structured, care-planned programme of therapeutic and other activities; and supportive programmes which provide accommodation (often following treatment in a rehabilitative programme) with specialist drug/alcohol and non-drug/alcohol related support ( illustration).

Models of residential programmes (National Treatment Agency for Substance Misuse)

Models of residential programmes (National Treatment Agency for Substance Misuse)

In 2006, the National Treatment Agency for Substance Misuse identified that residential rehabilitation, which takes place within a local treatment system, needs to ensure the following to be effective:
• Comprehensive assessment of clients
• Respect of client choice
• Planned and reviewed care (as well as departure and aftercare)
• Attention to housing, education, training, and employment support needs
• Development of social and life skills

A last resort?

Such concerns were evident as long ago as 2011, when the temperature of an already heated debate had been raised by a survey of the then 28 members of the Concordat, of whom 16 provided usable responses. The report on these English residential rehabilitation services highlighted the lack of referrals, meaning that “All but four of the respondents reported that their service was under threat of closure for 2010/11”. In turn this was related to the common insistence (1 2) by local authority funders of residential care that prospective residents must first have exhausted other treatment options, and unrealistically proved their commitment to rehabilitation by complying with preparatory work, when the reason for their referral is precisely that they have been unable to overcome their dependence without the shelter of a residential setting.

Commissioners who insist residential care should be a last resort can and do claim the authority of Britain’s National Institute for Health and Care Excellence (NICE). Based partly on not even a handful of studies recording no overall advantage for residential care over alternatives, NICE’s experts advised that residential treatment be reserved for substance users with “significant comorbid physical, mental health or social (for example, housing) problems”, who should have “not benefited from previous community-based psychosocial treatment.” Critics of NICE’s ‘last resort’ position argue that the reason why some clients are in such poor mental, physical and/or social states is that residential rehabilitation had been denied them earlier in their drug using careers when they had a greater chance of succeeding before the deterioration became too deep. The opposing argument is that trying residential services first risks unnecessary expenditure which drains treatment resources because it is impossible to predict with any certainty who will do well and who badly after their spell at the rehabilitation centre.

Most influential among the studies reviewed for NICE was a randomised comparison of a non-residential day therapeutic community versus a residential version for US crack users. It found no lasting anti-relapse benefits from the residential setting but – as in several other trials – the researchers had to limit the severity of their subjects so that all could safely be sent to either residential or non-residential care. The result was that nearly three quarters of potential participants could not join the study, and those who could were the ones least likely to need and differentially benefit from residential care.

A good investment?

Substance use treatments not only have to prove they are value for money, but “value for taxpayers’ money”. For a government focused on reducing public expenditure and welfare spending in particular, the tables would decisively be turned in favour of residential rehabilitation if despite its greater cost, it could be shown to save the exchequer even more, and that the balance in its favour was greater than for non-residential treatments dominated by opiate substitute prescribing. Based on the 2009/10 treatment intake for England, this was the issue addressed by a study which reported in 2015. It was conducted by the Department for Work and Pensions, whose leader Iain Duncan Smith has forefronted welfare benefit constraints and backed the ‘full recovery’, drug-free rehabilitation options exemplified by residential rehabilitation, while condemning reliance on opiate substitute prescribing.

Net public sector costs or savings associated with treatment pathways for opiate users, for 2009/10 treatment starters to end March 2012. Shows that at all levels of treatment difficulty (complexity) and for residential and non-residential pathways there were net costs, and that these were greater for residential pathways

Though set up to determine whether the public purse would gain by sending more opiate-dependent clients to residential rehabilitation, in the end his department’s study declared itself unable to conclude one way or the other, but did judge it “highly unlikely” that these treatments’ extra expense would be offset by extra savings. If anything, the report suggested that non-residential, prescribing-dominated options are a better deal for society in its attempts to contain public sector costs, when these costs include the costs of treatment itself chart. It must have been a special concern that welfare spending uniformly moved in the ‘wrong’ direction after entering treatment, and the resultant losses to the excehquer were particularly steep in respect of clients on treatment pathways which featured residential rehabilitation, presumed to be due to their stabilisation and the advice and help they received to claim their entitlements.

But if it was not clearly best for the public purse, for the patients and their families, residential rehabilitation might still have been considered a good investment. As defined by the study (entailing planned treatment exit and non-return), patients on pathways which included residential rehabilitation were consistently more likely to register positive treatment completions than those on entirely non-residential pathways. For example, 16% of very high complexity clients left residential pathways successfully with no later records indicative of relapse compared to just 6% whose treatment had not included residential rehabilitation. At the other end of the scale, for low complexity clients the corresponding figures were 31% and 21%. Beyond purely financial considerations is the argument that medical and allied treatments, including the treatment of addiction, are not primarily undertaken to save money for the public sector, but to use that money to relieve illness and distress. On this count residential rehabilitation scores relatively heavily.

One gap in the study was its limited data on the psychological differences between residential and non-residential pathway clients which might have affected their chances of recovery, regardless of the treatment option. Drawing its data from a national study of patients starting drug treatment in England in 2006–2007, an analysis examined this issue for opiate users, the same type of patients included in the study from the Department for Work and Pensions. It found that compared to those prescribed substitute drugs such as methadone, opiate users whose treatment had included residential rehabilitation were from the start more ambitious for their future and more motivated and ready to recover through treatment. The differences were not huge, but enough for the researchers to suggest that “higher treatment motivation in [residential rehabilitation] participants may account for the effectiveness of [residential rehabilitation] compared with other treatment modalities,” and that sending more patients to residential rehabilitation without ensuring they are sufficiently motivated is “unlikely to lead to an expansion of successful treatment outcomes.”

Better nearer home?

Residential rehabilitation is often held up as the holy grail of drug and alcohol treatment, despite the fact that residential rehab cannot guarantee an ‘exit door’ from treatment, might give people with substance use issues a big challenge to overcome in applying their sobriety to their everyday living situation when they leave, and may prove too distressing and disruptive for some clients to even countenance.

The illustration below highlights the proportion of clients successfully completing treatment, which is defined here as “being judged by a clinician to have overcome dependency on the substance for which the user is admitted to treatment, and no longer having a structured treatment need”. This data from a 2012 audit appears to show that “when people complete their treatment at residential rehab they frequently require continued structured support from other parts of the system before they are ready to complete their treatment for drug or alcohol dependency”.

The treatment journey of 3,972 residential rehab residents

The treatment journey of 3,972 residential rehab residents

A distinctive feature of residential rehabilitation is the 24-hour-a-day sheltering of the patient in a setting away from home – a protected environment far removed from the temptations and pressures which helped sustain the client’s addiction. What might sound like ideal conditions was interpreted differently by William White, US guru of re-orienting treatment and allied systems to recovery objectives and principles. In his key work on systems of care he pointed out that the non-recovery oriented systems he seeks to transform “grew out of a tradition of isolating addicted persons from their natural physical and social environments [to] enter a closed therapeutic environment” such as a residential treatment programme or therapeutic community. The problem as he saw it that learning to live without drugs there is likely to be unlearnt on transfer to a different environment: “The greater the physical, psychological, social, and cultural distance between the treatment environment and the natural environment of the client, the greater will be this transfer-of-learning challenge.” Part of the solution, he argues, is a “greater emphasis on delivering home- and neighborhood-based (eg, health clinics, neighbourhood centers) addiction treatment and recovery support services” – the antithesis of the traditional model of residential rehabilitation in Britain. While non-residential rehabilitation in the area where the client lives may initially be more challenging, it may be more realistic for the client and the substance-free behaviour more likely to stick. This argument seems to be reflected in trends of service commissioning, as seen in this survey of commissioners in England in 2014: 70% reported they had recently commissioned more non-residential abstinence-based services, while twice as many (about a third) thought their spending on residential services would decrease than increase.

Finally, there is the consideration that residential treatment might not suit the needs of clients and their families, particularly if it involves separation. A UK report on women’s treatment needs pointed out that placing women in residential services without their children is not too dissimilar to sending them to prison, where travel costs and time may limit the amount of contact with their children. Such stressors could understandably impact on their ability and resolve to complete treatment and rehabilitation (an argument which would apply to others too). NICE states that “the needs of people with children should be considered so that children are appropriately looked after while their parents enter residential rehabilitative treatment”, which according to the National Treatment Agency for Substance Misuse could include accommodation for the whole family, as well childcare facilities while residents are in counselling or groupwork, and family therapeutic and education interventions, such as parenting education – though one would expect these facilities to be hard to come by.

See what the researchers have discovered by running this hot topic search – but beware that no conclusive answer to the residential v. non-residential question can be found. Our reading of the research is that while non-residential care is sufficient for many clients, residential care has particular benefits for the minority who are most severely affected.

Research still in its infancy

Research into residential rehabilitation is still in the early stages. Much more could be gleaned about its effectiveness from research into understudied areas, such as: residential homes for specific populations (eg, criminal justice and women with children); architectural features that influence social interaction and neighbour perceptions; homes that can accommodate low income, inner city residents; and good resident candidates for different levels of service intensity.

Randomised trials are generally considered the ‘gold standard’ in research, but in relation to residential rehabilitation, the random allocation aspect that enables researchers to draw conclusions about cause and effect may be obscuring or eliminating an important step in recovery: the mutual selection process between the applicant and the recovery home, where residents enter the residential environment because they are a good match, not because they were assigned there. Responding to this, a 2015 paper recommended that further research using random assignment should consider “assign[ing] individuals to a broad recovery home condition that allows individuals to pursue residence in different recovery houses rather than one specific house”, allowing for some degree of mutual selection, or “assign[ing] residents to an enhanced recovery house condition versus recovery housing as usual after they enter the house”, which while not constituting a randomised trial of effectiveness, could reveal factors influencing improvement in the effect of residential rehabilitation programmes.

For this topic we are also making available these unpublished notes on studies comparing residential and non-residential care.

Last revised 22 January 2017. First uploaded 29 March 2010

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