Do You Really Need to Go to Rehab? Residential vs. Outpatient Treatment

Rehab Helps Thousands of Addicts Quit. It Can Help You, Too.

When Amy Winehouse belted out, “I don’t want to go to rehab” in her Grammy-winning signature song, she may have been onto something. She reportedly did go to rehab for several short stints before alcohol poisoning tragically took her life in 2011, when she was just 27. In a section about the Amy Winehouse Foundation at the end of his book, Amy, My Daughter, Mitch Winehouse noted – with apparent dismay – that “some senior civil servants” told him they viewed residential rehabilitation as “an expensive luxury,” and that their solution was to treat people in the community.

What You Need to KnowResidential rehab or inpatient treatment typically refer to going to a facility 24/7 – you stay there overnight. Residential and inpatient are terms that are often used interchangeably, although residential facilities are typically free-standing while inpatient are usually hospital-based. At outpatient treatment, you usually go to a facility multiple times a week during the day or evening and then leave afterward.)

As it turns out, despite popular thinking that rehab is the sine qua non for addiction recovery, “treating people in the community” – or outpatient treatment – is just as helpful as residential rehab for most individuals struggling with substance use disorders. Multiple studies have documented that the two forms of treatment have similar outcomes, despite the fact that the media and even many professionals continue to perpetuate the notion that if you have a substance problem, “you’ve gotta go to rehab.”

A recent review of scientific studies published in the June 2014 issue of Psychiatric Services, reaffirms that outcomes do not differ significantly between residential/inpatient and outpatient treatment.

Re-Affirmation of Old Findings

Before taking a look at the new study, it’s important to note that treatment – be it outpatient or residential/inpatient – isn’t a prerequisite for recovery. In fact, most people get a handle on substance use disorders completely on their own, by attending self-help groups, and/or by seeing a therapist individually. Of those who do seek treatment, the vast majority wind up in outpatient settings. Often it’s suggested or even required by health insurance companies that you go to outpatient treatment before going to residential. According to the most recent National Survey of Substance Abuse Treatment Services (2012), about 90 percent of all clients in treatment were in outpatient settings, and only 9 percent were in residential non-hospital treatment. (Another 1 percent were in hospital inpatient treatment.)

For the new review, a team of researchers, headed by the Oregon Health and Science University’s Dennis McCarty, Ph.D., examined studies on outpatient treatment of addiction published from 1995 to 2012, only including research that compared effectiveness of what they termed “intensive outpatient treatment” (IOP) to inpatient services for adults. For the purposes of the study, they described IOPs as programs offering a minimum of nine hours of treatment per week in three, three-hour sessions. Dr. McCarty told me that inpatient treatment was generally considered, “staying in a program and sleeping there in a bed – for instance, in some studies it was inpatient care in a hospital and in others it was residential non-hospital treatment [or what most of us think of as ‘rehab’].”

In comparing studies of inpatient treatment and IOP services, they concluded that the results “are consistent and similar: outcome measures of alcohol and drug use at follow-up show reductions in substance use and increases in abstinence, and outcomes do not differ significantly…”

What did they find? First, after reviewing the multiple high-quality studies available to them, the level of evidence for IOPs as a form of treatment was rated by the experts as “high.” In comparing studies of inpatient treatment and IOP services, they concluded that the results “are consistent and similar: outcome measures of alcohol and drug use at follow-up show reductions in substance use and increases in abstinence, and outcomes do not differ significantly between inpatient and IOP settings… Overall, studies found that 50 to 70 percent of participants reported abstinence at follow-up, and most studies found that this outcome did not differ for inpatient versus outpatient settings of care.”

Even though it’s generally thought that people treated in residential settings have more severe substance problems than those treated in outpatient treatment, and a few studies suggest that patients with greater impairment may have better outcomes if treated in inpatient settings, overall, the studies didn’t point one way or the other when it came to suggesting which form of treatment was more favorable for people in this category. The authors concluded that the need for more intensive treatment may apply only to the most severe cases. In the end, Dr. McCarty’s group emphasized that, unlike the traditional 28- to 30-day model of residential treatment (which the rehabs I visited for my book, Inside Rehab, are moving away from – toward lengthier stays), an important feature of outpatient treatment is that it typically lasts much longer. Not only that, but people in outpatient treatment remain in their everyday environments and can recover in their communities and in the context of everyday life.

…an important feature of outpatient treatment is that it typically lasts much longer… [people] remain in their everyday environments and can recover in their communities and in the context of everyday life.

Additional Research

Another study, published in Psychiatric Services in March of 2014, also reviewed the scientific literature from 1995 to 2012 – but this one primarily looked at studies comparing residential treatment to other types of treatment such as IOP. Overall, they found a “moderate” level of evidence for the effectiveness of residential treatment for substance use disorders, noting that “there were many methodological challenges within these studies.” One big problem overall was that there weren’t many randomized controlled trials (the gold standard type) because treatment providers had concerns about randomly assigning individuals in need of treatment to a no-treatment condition or to a type of care that might not be might be clinically appropriate.

The authors concluded that residential treatment “fills a niche for consumers who require stable living environments that incorporate therapeutic treatments to help them move toward a life in recovery.” They added that it shows value for ongoing inclusion and coverage as part of the continuum of addiction care, but that we need rigorous research “to understand how and for whom it best fits.”

What’s Next: Part 2 will take a look at who really needs residential treatment and some other models of treatment.

Photo Source: istock

What Are Your Thoughts on this Topic?

  • William

    What is missing from this article is what was studied, ie 12 step vs non-12
    step. The National Survey is under the auspices of SAMHSA, the
    National Survey does not identify what was studied….the Psychiatric
    article again does not say 12 step or not….however in consideration
    that St. Jude is not a treatment center…yup…it is an EDUCATIONAL
    center…..and when considering that….understanding Rehab, Treatment,
    Recover, etc……..No one needs Rehab, they need education. No one
    needs treatment for a habit, as HAMS and MM suggest Change….trashing
    the words Recover, Recovery, Recovering, Treatment, Rehab for…..drum
    roll please…

    CHANGE and Education….consistent with HAMS and MM…..then there is no need
    to dialogue or discuss this…the question Do you really need rehab or
    treatment…Of course not…no one does…you don’t treat habits, you
    change them, you need to get educated….

    This is the basis for what is called…..REFRAME…..He who reframes the
    conversation….controls the conversation….and to change the
    industry…it should be necessary to understand and realize that when
    you, yup, that means me, you and everyone else start controlling the
    conversation…..then change will occur in the industry……but then
    that is just my opinion…you all are welcome to argue, quote studies
    and if you do….the American Psychological Association in their
    publication Addictive Behaviors point out that inpatient vs outpatient
    have the same results….no argument…have a nice day….

  • Reid K Hester

    our review of RCTs that we published nearly 30 years ago came to the same conclusions. Miller, W.R & Hester, R.K.. Inpatient alcoholism treatment: Who benefits? The American Psychologist, 41, 794-805.

    • William

      Many may not know about your online program that when coupled with SMART has data to demonstrate improvement over SMART alone. I would suggest that this is an important part of the puzzle to what to do with those looking for help. It has been demonstrated that online assessment is as good as in person assessment and with that in mind many looking for help can find help by staying in the safety and comfort of their home while looking to find aid. This site shows the program and the data to support the notion that this program coupled with SMART has benefit over SMART alone…….

      link to

  • msconcerned

    My are of interest was with the statement, “…Multiple studies have documented that the two forms of treatment have similar outcomes,…” I do not agree with that statement because the at the end of the day, it is not the treatment or length of treatment that determines makes a person drug and alcohol free; positive outcomes based on desire of the individual to remain abstinent from mind or mood altering drugs.

    I believe that residential treatment has it’s place for those that need to divorce themselves from their surroundings for a period of time to begin the process of recovery. The out-patient treatment is for those that have not only admitted their lives have become unmanageable and require only minimal assistance in learning how to maintain their recovery.

    Additionally as the writer below named “William” mentioned the 12 step programs can be a viable part of the recovery process and is an aide in continued steps toward recovery.

    • William

      I do not understand your point of contention…you state you do not agree and then say…”because…etc.”..however what follows after because does not tell me why you disagree. Why do you disagree?

      • msconcerned

        Hmmm not contention, my interest is with the statement, “Multiple studies have documented that the two forms of treatment have similar outcomes…” I do not believe that the two forms of treatment can have similar outcomes. The reason is – The outcome of any treatment is driven by the person’s desire to get clean and stay clean. The latter part (stay clean) is not driven by the selection of inpatient or outpatient treatment, it is driven by the person desire to engage in after care programs like a 12 Step or Faith based program – anything that fosters the healing process and the understanding of addiction so the person can manage his/her life without the use of drugs.

        • William

          If as you say “the understanding of addiction” is paramount in resolution, do you believe

          Addiction is a disease?
          Treatment is necessary for an addiction?
          Do you accept 12 steps as Faith based as you say 12 steps OR Faith based or is it your belief that the two are separate? If they are separate how do you categorize 12 steps?

          • msconcerned

            Hello William, Honestly, I when I think of the word disease I think of something of Aids, Diabetes, Ebola or Polio. Diseases with no cure. Folks who are addicted made a choice to use the substance, no matter how much methadone one receives, when the individual is ready to use again they will. I don’t think it is a disease; (1) active addiction is a choice; (2) the person can simply choose not to use (they may need some assistance to make it happen – usually divorcing themselves from their environment. 12 steps programs (focus on a specific drug) are a great way to assist with the desire, I think that Faith Based programs deal with addiction (spiritually). For example using drugs is caused by a negative spirit entering into one’s life via their thoughts.

            • William

              I appreciate your honesty. I am grateful that you understand as I do Disease. I agree that addiction is a choice and with help make better choices.

              You may not understand that in the industry there is what is called The Disease Model and when you invoke the Disease Model or call Addiction a Disease then you automatically imply that Addiction needs treatment. Sadly the treatment is as you point out 12 steps which is a Faith based form of approach.

              I believe that you speak from the heart and are unaware of the jargon that is used in the industry. You may want to look at some books like The Truth About Addiction and Recovery, by Stanton Peele, Phd. You can find it on Amazon…

              link to

              • msconcerned

                Thanks will do, I would be remiss if I did not mention that also using the term, “disease” is/was a catalyst for creating procedure code or a diagnosis and thereby creating a cash cow in the are of addiction services for the medical and behavioral health industry. I understand the need for the programs, but I very much dislike the revolving door…hmm the permissive revolving door. at the sake of folks struggling to not “die” from their addictions.

            • Ralf

              That is just wrong and does not need further comments. Religion or faith will not help me. I can pay for my treatment have a good job and university degree. I can not afford to go into a religious sect while I am also gay and do not want to be away from my work nor home. Methadone is very helpful and if used under doctors supervisions will turn lives around. Until your were addicted to heroin having a stressful job with deadlines to meet, you do not know how it is. It is not a decision to not take it, it is a painful path not everyone can afford to go down…

              • msconcerned

                Hmmm, what’s wrong is that you closed the door to other opportunities of help. What I do know about drugs is that they take you away from home, children, family, work, basically the world. Then your guilt and shame will keep you way even after you stop using. Your world become a dark radius of going to cop, going to use, or thinking about going to cop and use.

                I have great empathy for those who have used, those who are still using, but what I say “no” to is replacing one drug with another, giving up one vice for another and justifying legal using. Methadone does nothing for your emotions and ability to feel better about yourself or provide a way of escape when temptation arises as is it “may” often do especially with this world slaps us in the face.

                Those are my thoughts and what I won’t do is close the door to anyone who wants to talk.

              • Cory Higginbottom

                Hey I need to talk. I don’t know what to do. I’m trying to get help but it’s like the universe is intentionally not allowing me to get the help I need. Why is it so difficult to finally admit that I desperately unimaginably need help and can’t do it alone and can’t get the help I seek cuz I can’t afford tens of thousands of dollars of inpatient rehab. I’ve tried almost everywhere but I keep getting slapped in the face and told iop is my option. I can’t stress enough how much I need inpatient to get the f*** out of here and get serious help. It took me forever to get insurance then to get evaluated then referrals then get evaluated by someone else then have to start over again cuz no one wants to send me to inpatient. I just don’t get it. All the while each n every day I wake up (that is if I sleep) I have this addiction and problems that I feel hopeless n powerless about and I just I don’t know what to do anymore I am losing hope and everything and I feel this utter emptiness n depression is so intense that it could create an actual enormous black hole that would be catastrophic all inside my chest. If anyone could help or some suggestions I am all ears cuz I don’t know how much longer I can last. Help

              • msconcerned

                Please email me I may have a solution for you. Just hold on.

  • johnctoliver

    One would assume that the success rate of successful rehab completion is better for addicts in inpatient care because with outpatient care, they have access to drugs as soon as they leave the facility if they so choose.

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