“Drug Rehabs With the Highest Success Rates” grabbed my attention when it appeared as the subject line of a recent email. However, clicking on the “read more” button led me to information that seemed misleading and inconsistent with research I’d conducted for both Inside Rehab and my Pro Talk columns.
The claims illustrated how easy it is for consumers to be misled by Internet information about addiction treatment – outcomes and success rates in particular.
Reaction to Success Rate Claims
For expert reaction to some of the claims, I turned to Harvard associate professor of psychiatry, John Kelly, Ph.D. who is also Massachusetts General Hospital’s Director of the Recovery Research Institute, Program Director of the Addiction Recovery Management Service, and the Associate Director of the Center for Addiction Medicine. Here’s what he had to say:
A facility’s success rate will tell you how many patients at that facility recovered from their addiction and completed the program. For example, a drug rehab facility claiming a 92% success rate means that 92 out of 100 patients recovered from their drug addiction.
Dr. Kelly's Response:
This doesn’t tell us over what period they are talking about. Does the proportion “recovered” mean in the past three months, past year, past five years?
Also, what exactly does “recovery” mean? Are they using criteria for a full, sustained remission as established in the Diagnostic Standards Manual [the DSM 5] used by professionals in the field? I hope that they don’t consider their example of a “92% success rate” in any way realistic or credible. If we saw anything that approached even a 70% full remission rate at one year following a single residential treatment in a rigorous scientific study, we would all be flocking to the place to find out what they’re doing and starting to adopt those practices, given how many lives are lost and families shattered because of addiction.”
And what exactly is “success?” Traditionally, it’s been keeping track of how many people continuously stay abstinent after a treatment episode. But what about those who, after treatment, wind up using significantly less or who those who periodically have a few using days interspersed with much longer drug- and alcohol-free periods?
Some studies actually look at outcomes by tracking percentage of days people are abstinent during a period of time following treatment. Researchers sometimes group subjects into such categories as “abstinent” and “non-abstinent recovery,” the latter describing those who were once considered addicted but subsequently resumed using without having any problems.
...it can be helpful to ask questions about how many clients drop out of treatment as well as how long participants typically stay.-Anne Fletcher In short, many experts believe it’s a mistake to look at abstinence from alcohol and/or drugs as the only marker of success. Other important indicators have to do with how people are functioning in other areas of life – for instance, having to do with relationships and social functioning, health, legal issues, getting back to work, and continuing their education. In other words, experts who study outcomes of various treatment interventions often examine how people are doing in multiple areas of life.
The claim also mentioned program completion rates, and it can be helpful to ask questions about how many clients drop out of treatment as well as how long participants typically stay. Dr. Kelly notes that nationwide, about half those who enter treatment don’t complete it, so if a program’s completion rate is less than that, it may be an indicator of lower quality. That stated, the clientele typically treated by a facility should be taken into account. For instance, completion rates may be higher at a facility with a high proportion of court-ordered clients because they are mandated to remain in treatment, not necessarily because the program is of high quality.
It has been statistically proven that patients that stay more than 30 days at an inpatient rehab double their success rate for long-term sobriety. Why are inpatient rehabs so successful?” (This claim appears after a discussion of the differences between inpatient [often referred to as residential] and outpatient addiction treatment, which is followed by the question “But which type of treatment has the better success rate?")
Dr. Kelly's Response:
What they may be claiming here could well be attributable to a self-selection bias. In other words, patients who stay more than 30 days are more likely to do better than those who stay a shorter time because they are ready and strongly motivated for recovery. Consequently, it would be unclear whether a better outcome is attributable to the longer length of stay or because of the individual’s greater commitment to sobriety.
I doubt they are talking about any study that randomly assigned individuals to receive different lengths of treatment. Once again, it’s unclear what they are referring to when they say “success rate” and “long-term sobriety”. If it were really true that 30 days or more of residential treatment resulted, for example, in double the typical abstinence rates over a one year period, that would be huge. This could save a lot of lives. Because they don’t cite any scientific literature supporting their claim, it is impossible to verify and evaluate their basis for such claims.
I do not think it is correct to assume that inpatient rehabs are substantially more successful than anything else, implied by their question “...why are inpatient rehabs so successful...” Existing research suggests that inpatient/residential addiction treatment facilities overall have no better outcomes than outpatient ones. That said, we do need more research in this critically important area as some individuals are just not able to succeed in outpatient care and need a period of stabilization and abstinence that only a residential facility can provide.
For more information on these topics, see my previous Pro Talk columns Do You Really Need to Go to Rehab? and Who Really Needs to Go To Rehab?
If you have tried other forms of treatment, but they haven’t been effective, you may want to consider holistic drug rehab. Inpatient holistic drug rehabs [of] 30 or more days offer patients the chance to focus on healing their mind, body, and soul. In holistic treatment, you can choose to participate in acupuncture, yoga, meditation, exercise, massage therapy, and spiritual counseling. Holistic drug rehabs also use 12-step programs and medications to help individuals achieve sobriety as well... Recent scientific studies have shown that patients have dramatically improved their success rates with the addition of holistic treatment approaches.
Dr. Kelly's Response:
Again, I do not know the scientific studies they are referring to here. If there was a “dramatic” improvement in “success rates” (however the “success” is defined), we would know about it.
So many people die each year due to alcohol and drug misuse that if any sound scientific evidence showed “dramatic” improvements in treatment outcomes, it would result in widespread adoption and implementation of any practices involved. I have never seen “dramatic” improvements in outcomes for any “holistic” addiction treatment. With certain holistic-type interventions, such as exercise, some studies have shown enhancements in carefully controlled research, but none are “dramatic.”
I would add that, with any holistic, alternative-type therapy clients have a right to know, “How well does this therapy work and what are the risks?” In other words, they have the right to informed consent and then to decide whether to take part.-Anne Fletcher
Faith-based drug treatments focus on healing physical, emotional, and spiritual aspects of addiction and are highly popular and successful. In fact, studies have shown that bringing faith into rehab has been shown to increase a person’s success rate, especially if they are a true believer.” (Obviously, it’s really unclear what they mean by “faith-based” or if this includes 12-step practices.) Finding faith for new believers or regaining faith for those who have gone astray from their beliefs can be a powerful force to restoring your mind, body, and soul from addiction.
Dr. Kelly's Response:
We do not have any type of rigorous data to support this claim. Even though they may be popular and may be effective for some individuals, we don’t know whether, overall, faith-based treatments could be implemented as a mainstream treatment and produce observably better outcomes. It is unclear if they include AA, NA, and other 12-step groups as faith-based.
It is true that professional 12-step facilitation treatments (see “Setting the AA Record Straight” for a description) that systematically link individuals with mutual-help organizations, like Alcoholics Anonymous and Narcotics Anonymous, are evidence-based approaches and those organizations ostensibly have a spiritual focus, but I would not classify these interventions as “faith-based.”
Religion and 12-Step Recovery
It should be noted, however, that multiple higher courts have ruled, while AA is not an actual religion, it is – with the 12-steps’ multiple references to “God” – considered to contain enough religious components to make coerced attendance unconstitutional. In other words, mandating people to attend AA or NA is considered a violation of first amendment rights, which guarantee the government may not coerce anyone to participate in religion or its exercise. For additional information on this topic, see my Pro Talk article You Can’t Make Me – Or Can You? Mandated AA Attendance and the Law.
Interestingly, in doing the research for my book, Sober for Good, about 222 people who had recovered from alcohol problems for at least five years, comments related to spirituality were among the five most frequent responses to open-ended questions about key things they did to get sober and stay sober. But spirituality means different things to different people, and "faith-based" can certainly be defined in various ways.
...multiple higher courts have ruled, while AA is not an actual religion, it is – with the 12-steps’ multiple references to “God” – considered to contain enough religious components to make coerced attendance unconstitutional.-Anne Fletcher When it comes to religion per se, William Miller, Ph.D., Emeritus Distinguished Professor of Psychology and Psychiatry, University of New Mexico, and author of Integrating Spirituality Into Treatment, said that although religiousness has been shown to be a “protective” factor for developing substance use disorders, “I don’t know of a single study to support the claim that bringing ‘faith’ into rehab increases ‘success rates’ (whatever those are.)”
Miller and several co-authors published what he believes to be the only randomized clinical trials concerning spiritual direction in addiction treatment. Spiritual direction in the two studies was defined as a one-to-one relationship “between a seeker and a spiritual companion/guide,” analogous to therapist-client or AA-sponsor. Patients were offered a menu of 13 spiritual disciplines from which they could choose to explore and discuss in sessions and practice between sessions.
The researchers found “absolutely no benefit of adding spiritual direction to an inpatient program.” Nevertheless, Dr. Miller believes we need further study concerning the role of religion and spirituality in substance use disorder recovery.
In future articles, I hope to further explore both “success rates” and the role of faith and religion in addiction treatment. Please share your thoughts.
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