Who Really Needs to Go to Rehab? What Are Some Alternatives?
In my last column reviewing evidence that outcomes overall are no different between outpatient and residential/inpatient treatment I said I’d next address “who really needs residential treatment,” as well as other models of care. Some experts I interviewed for Inside Rehab went so far as to say that residential treatment is passé and that we should do away with it altogether – noting that for other chronic medical conditions, we don’t send people away from reality for a time-limited burst of intensive treatment, expecting a change leading to permanent recovery.
However, after visiting 15 residential and outpatient programs, interviewing scores of people who had been through treatment – and now that I work in an outpatient program – I can certainly see that there are times when people need help in a more intensive setting. One treatment professional I interviewed said, “We need that safe harbor for some people. There are advantages to having addiction, medical, and mental health care available all in one place. Sometimes, people just do better when they go away for 30 or 60 days and get right with themselves.” The director of that same program added, “Sometimes, people need to go away when they just can’t stop.”
How Do We Know Who Belongs in Rehab?
When I first started writing Inside Rehab, I turned to Thomas McLellan, Ph.D., co-founder of the Treatment Research Institute in Philadelphia, thinking he could point me to a tool that determines who belongs in rehab and who belongs in outpatient treatment. I was dismayed when he told me, “There is no assessment tool or test that definitively determines who should go where.”
There is no assessment tool or test that definitively determines who should go where.-Dr. Thomas McLellan
Treatment programs widely use what are known as “ASAM criteria,” designed by the American Society of Addiction Medicine to provide a common language describing the severity of clients’ substance problems and to guide their placement in the most cost-effective level of care (e.g., outpatient versus residential). However, John Cacciola, Ph.D., an expert in the assessment of substance use disorders and co-occurring problems at TRI, informed me that the placement criteria are very complicated to implement and generally not employed by treatment programs in any sort of rigorous manor.
I noted in my last column that although people with greater impairment are generally thought to have better outcomes if treated in inpatient rather than in outpatient settings, research overall doesn’t point one way or the other. The authors of a recent review of the literature as well as others I’ve consulted suggest that the need for more intensive treatment probably applies only to the most severe cases. An expert on who should be placed where in the addiction treatment system, James McKay, Ph.D., director of the University of Pennsylvania’s Center on the Continuum of Care in the Addictions, said that in his opinion, the limited segment of people who belong in residential care includes individuals who meet the criteria for a severe substance use disorder along with any of the following:
- Current and significant major mental illness that is not reasonably well controlled, such as severe depression, bipolar disorder, schizophrenia, or an “axis II disorder” (for instance, borderline, antisocial, or obsessive-compulsive personality disorders) along with behavior that poses a significant risk to the health or safety of themselves or others
- Suicidality, regardless of the nature of the underlying psychiatric disorder
- Significant medical problems that will be made much worse by further excessive alcohol and/or drug use and recent inability to stop using*
- Inability to achieve abstinence in an outpatient program, especially with a recent history of significant danger to themselves or others while intoxicated (for instance, by committing acts of violence or driving while under the influence)*
* Dr. McKay said that residential treatment would be recommended over outpatient in these cases, assuming there is no availability of a safe, well-run sober or halfway house option.
The Outpatient/Sober Living Combo
For people needing more structure than outpatient treatment alone, a number of experts advocate staying in a quality sober living facility while attending a good outpatient program. As Dr. McKay points out, this combination can result in much longer treatment for a fraction of the cost of residential. (A problem with this option is the wide inconsistency in how sober living facilities are regulated and run. The National Alliance for Recovery Residences offers some standards for various levels of recovery residences.)
Eight months later, after she’d completed five months of outpatient treatment but was still living in the sober house, she said of the entire experience, “This was probably the best treatment I had – it was the longest.” She reacted favorably to “still living on the outside, being part of the community and not confined to an inpatient facility.” She added, “Residential rehab is like you’re almost institutionalized and then they boot you out. Here, you have time to look for a house. You’re not kicked out of treatment to go back to only what you knew before.” (Using a holistic approach, the facility had clients do community service and regular exercise, take parenting classes, and work on living skills.)
About a year later, Anna had bought a home and was enrolled in college. I just re-contacted her, and not only is she less than a year away from receiving her degree in corrections but she recently received her five-year medallion for being drug-free.
Some outpatient programs will facilitate a “supportive living” experience for out-of-towners. Minnesota Alternatives (I work part-time there) has accommodated clients from out-of-state who want to take part in its unique harm reduction outpatient program. Director Paula DeSanto, MA, LSW said, “Clients who come from out of state have not done well in sober homes, so typically they need to get low-cost studio apartments or hotel or motel rooms.” For those who want or need a more intensive experience, treatment time can be increased according to individual needs, and drug and alcohol testing is available.
Rehab That Comes to the Client
…some addiction treatment agencies are teaming up with health care providers to bring comprehensive care to the client in his or her own living setting.-Anne Fletcher
With increasing recognition that people with severe addictions (commonly coupled with mental health problems) don’t have the resources or wherewithal to get the help they need, some addiction treatment agencies are teaming up with health care providers to bring comprehensive care to the client in his or her own living setting. As a Minnesota-based addiction counselor working at a large HMO, Jason Hoffman runs such a program – one that’s designed for individuals who “are constantly in the system.” He explained that they’re people who often do well when they’re in treatment programs but not when they go home. Some have anxiety in group settings while others can’t access treatment programs. Others still don’t find Alcoholics Anonymous to be the right fit. Treatment with Jason is highly individualized, with a focus on life skills. And his relationship with clients can go on for months or years. As for cost, Jason told me that this model “can be just as cost effective as sending people to treatment and then sending them home.”
John Bollig is a behavioral health nurse who works in a similar capacity with Minnesota Alternatives through a pilot project with Medica HealthCare. Using what’s termed an “integrated service network,” he provides mental health and substance use disorder counseling, primary care coordination, and intensive community outreach and support for high-risk clients with severe substance use disorders. He meets them one-on-one in their living environments, assisting them essentially with whatever they need – be it help with psychiatry, medical care, housing, spiritual needs, etc. – to stabilize their lives in the community and become self sufficient. (After all, “rehab” stands for rehabilitation.)
Parts of this article were adapted from Inside Rehab (Viking/Penguin 2013)
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