When it comes to trying to improve access to residential rehabilitation in Scotland, one thing I’ve heard too often from doubters is: ‘there’s no evidence that rehab works’. Ten years ago I was hearing the same thing about mutual aid, which was recently (at least in terms of Alcoholics Anonymous) found to be as effective, if not more effective, than commonly delivered psychological interventions.
There are a some problems with the ‘there’s no evidence that it works’ line. The first is that even if we accept the faulty premise that there is a poor evidence base, this is often taken as evidence that rehab doesn’t work, which is illogical. The second problem is that while there is evidence, some people don’t know about it or, for a variety of reasons, choose to dismiss it. What we can say is that the evidence base is weighted towards some areas (e.g., medical interventions) at the expense of others. The third issue for me is that while we need to find ways to balance the evidence base, we will not find more evidence if we’re not looking for it.
In order to add to the evidence base, we published a paper in 2017[1], evidencing one-year outcomes following therapeutic community (TC) residential rehab in Scotland. In a review of recent literature it was good to see that our study was rated to be methodologically strong, Those patients going through TC rehab saw improvements across a range of domains. This was in keeping with previously published research.
Therapeutic community (TC) treatment is a particular type of rehab. In a TC, the community of patients itself is the main agent of change. In a highly structured programme, residents live together, share meals, participate in groups, undertake tasks within the service and share leisure activities. Lived experience in the staff team and in peer volunteers is an important component and a variety of interventions and scheduled activities offer opportunities to identify and change unhelpful thinking and behaviours, but more importantly, help to reduce psychological problems, improve social functioning and help individuals reach their goals.
Australia is producing research on residential treatment. Petra Staiger and her colleagues down under followed up 166 individuals going through TC treatment at two sites[2] and took stock of where they were nine months after discharge. They scoped out wellbeing, substance use, dependence, mental health, physical health and social functioning.
The commonest problematic substances were alcohol, cannabis, heroin and amphetamines. At baseline, participants had high levels of dependence, compared to treatment-seeking population norms. (Incidentally, we found the same in our study, in keeping with the observation that those referred to TCs have high problem severity). At baseline, individuals had very low levels of wellbeing and substantial socio-economic disadvantages.
It is critical when examining TC outcome research to understand that people accessing TC treatment tend to have more complex psychosocial concerns than people attending outpatient treatments and other shorter-term residential treatment
Petra Staiger & Colleagues,
The researchers followed up 90% of the original sample – an extremely high follow up rate for a study of this kind. At nine months post-treatment they found that 68% of individuals reported complete drug abstinence in the prior ninety days and 32% reported complete alcohol abstinence. Alcohol quantity and frequency of drinking was reduced by more than 50% and both alcohol and drug dependence scores were reduced by over 60%. Wellbeing scores doubled and psychiatric severity scores halved. Longer stays in the TC had better outcomes.
This study chimes with what we found in our outcome study from TC treatment in Scotland – high baseline problem severity but significant improvements in a range of measures one year after treatment. There are good reasons to be positive about the impact of rehab and plenty of evidence with which to challenge the naysayers.
Having said that, and while very welcome, such findings need to be seen in the context of a wider treatment system where a full menu of options is available. Not only that, but the components of the treatment system need to be linked in a way that makes navigation between them simple and as safe as possible. When rehab is seen as separate from mainstream treatment – a remote silo – then the chances of individuals getting there easily is reduced and the risks are likely to be higher. We need an integrated system of care and I hope we are moving towards that here. As we can see, according to the evidence, there are good reasons to make rehab an integral part of treatment systems.
Based on their methodology, high follow-up rates and outcomes, the authors conclude:
The findings reported can be viewed with confidence and are likely to generalise to the TCs within Australia and beyond.
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Main photo credit: Nazarkru@istockphoto under license
[1] Rome AM, McCartney D, Best D & Rush R (2017) Changes in Substance Use and Risk Behaviors One Year After Treatment: Outcomes Associated with a Quasi-Residential Rehabilitation Service for Alcohol and Drug Users in Edinburgh, Journal of Groups in Addiction & Recovery, 12:2-3, 86-98,
[2] Staiger PK, Liknaitzky P, Lake AJ, Gruenert S. Longitudinal Substance Use and Biopsychosocial Outcomes Following Therapeutic Community Treatment for Substance Dependence. Journal of Clinical Medicine. 2020; 9(1):118.