THE GUIDE TO REHAB
WHAT REALLY WORKS
20 research facts everyone should know about rehab treatment for alcohol and drugs dependency
This article first appeared in Addiction Today, January 2001
In late 1999, Dr David Best (who was working with the National Addiction Centre), Addiction Today editor Deirdre Boyd and the then-CEO of EATA met to initiate an easy-to-use reference document about addiction treatment which could be used by professionals and general public, and which not only covered the key issues but were based on incontrovertible research addressing those issues.
EATA requested Addiction Today to publish in full the key research findings about ‘what works’ in the rehabilitative treatment of substance dependency. “We have been guided throughout by a broad range of experts in the field, and are indebted to Professors Nick Heather, Michael Gossop, Norman Hoffmann, Tim Leighton, Alex Georgakis and Dr Doug Lipton for their contributions,” said EATA. “We hope this publication will be of benefit to all those involved in the field, including commissioners, care managers, policy makers, providers and practitioners.”
1. REHABILITATIAVE TREATMENT WORKS
The research evidence shows that rehabilitative treatment can help tackle dependency on drugs and alcohol. The evidence also shows that, in so doing, treatment can help improve the client’s mental and physical health, reduce offending, improve employability and enhance social functioning generally, whilst also reducing the demands made on health and social services and bringing significant benefits to families and loved ones. Overall, substance dependency treatment appears as successful as medical treatments for a range of chronic conditions, such as diabetes, hypertension and asthma, and the costs of treatment are more than outweighed by the financial savings it brings. However, it is essential that people are referred to the right type of treatment. Further, not all services are equally effective – many could be more effective than they are and some, in spite of the very best intentions, might even make matters worse.
2. TREATMENT SHOULD BE READILY AVAILABLE
The harder it is to access treatment and the greater the hurdles placed in the way of potential treatment applicants, the greater the proportion of people who will fall by the wayside before they get a chance to take up any available treatment opportunities. And the longer any delay between assessment and admission, the less likely someone is to take up a place in treatment and the less effective that treatment is likely to be. However, care should be taken to ensure clients are adequately prepared for treatment, before admission.
3. ‘LOW MOTIVATION’ SOULD NOT BE A BARRIER TO TREATMENT
It is often assumed that treatment must be ‘voluntary’ to succeed and that it will be effective only for those who are highly motivated from the outset. In fact, outcomes do not appear to be related to pre-treatment motivation levels, and pressure from families, employers or the criminal-justice system can enhance treatment effectiveness. It is unnecessary and counterproductive to restrict access to those who are deemed to be self-motivated: motivation to change and maintain change can be enhanced in treatment.
4. IF AT FIRST THEY DON’T SUCCEED…
Substance dependency is often described as a ‘relapsing condition’. Many people, perhaps even a majority, relapse after receiving treatment – but even a number of previous ‘unsuccessful’ treatment episodes should not be a bar to further treatment. Many people require a number of attempts before they finally overcome their dependency. There is evidence that even an apparently unsuccessful treatment episode can contribute toward someone overcoming their dependency in the longer term.
5. ABSTINENCE AND CONTROLLED USE BOTH HAVE THEIR PLACE
For some people with less severe problems, controlled use can be a viable and appropriate treatment goal. Controlled use is rarely sustainable in the long term, however, for people with severe dependencies. For such people, abstinence should normally be the ultimate goal – although even here services aimed at reduced use and harm minimisation should be available for those who are not ready or are unwilling or unable to achieve abstinence.
6. APPROACH SHOULD REFLECT CLIENTS’ BELIEFS AND EXPECTATIONS
Taken overall, the available evidence shows that no one theoretical approach yields treatments which are more effective than any other. There is evidence that some approaches might be slightly more effective overall for particular categories of client. But it would appear that the most important consideration in this regard is the client’s own views and beliefs, and these should be taken into account where possible.
7. TREATMENT SHOULD BE BASED ON INDIVIDUAL NEEDS
The length of treatment, setting, approach, range of issues addressed, use of medication, etc, should be tailored to the individual, based on a clear assessment of the individual’s needs and expectations. Clients are not a homogeneous group. A standard, one-size-fits-all approach is of limited value and might actually make matters worse. People’s needs can change during treatment and treatment plans should be continually reviewed and updated where appropriate.
8. TREATMENT SHOULD ENHANCE MOTIVATION AND SELF-EFFICACY
Many clients’ attempts to overcome their drug or alcohol dependency founder because they do not have the motivation they need to make and maintain the changes that are required. Similarly, many clients have very little confidence in their ability to change, and this also undermines their likelihood of success. Both motivation and self-efficacy can be enhanced through treatment and should be a central focus of treatment programmes.
9. TREATMENT SHOULD ADDRESS UNHELPFUL ATTITUDES AND BELIEFS
Many clients have a range of unhelpful attitudes and beliefs which, if left unaddressed, will undermine their long-term chances of overcoming their dependency. Common examples include “I can’t have fun without using” or “I need to use to cope with life”. Efforts should be made to uncover and address problematic attitudes and beliefs, and tackle them in a non-aggressive way.
10. RELAPSE PREVENTION IS AN IMPORTANT ELEMENT OF TREATMENT
Practical skills training for avoiding and coping with situations which might otherwise lead to a lapse can improve long-term outcomes for clients. Exploring how a client might respond to a lapse in order to minimise the risk of it leading to a full-blown relapse can also be helpful. However, care should be taken to avoid fostering a belief in the inevitability of a lapse. And the dangers of a lapse ending in relapse should be underlined.
11. TREATMENT MUST ADDRESS ASSOCIATED CONTRIBUTORY FACTORS
As well as focusing directly on clients’ substance use, any medical, psychological, social, vocational, and legal problems which the client might have and which would otherwise increase the probability of relapse should also be addressed. A full assessment should therefore include an examination of each of these areas. Steps should be taken to ensure that any problems identified are addressed within treatment or, where appropriate, after discharge.
12. CO-EXISTING PSYCHIATRIC DISORDERS SHOULD BE ADDRESSED
Co-existing psychiatric conditions are common among people with dependencies. A full assessment should look for evidence of any psychiatric conditions. Where this is found, treatment should focus on both the client’s substance use and their mental-health problems in an integrated fashion. Services should draw on specialist psychiatric support as required.
13. A SUPPORTIVE, NON-AGGRESSIVE STYLE IS MOST PRODUCTIVE
In the past, much treatment was confrontational [AT’s note: meaning aggressive rather than the strict therapeutic sense of the word] in style and in some facilities this is still the case. Whilst it is important to avoid collusion and to challenge manipulative and inappropriate behaviour, research demonstrates that such a style might be countertherapeutic and less effective than approaches which focus on internalising motivation for change.
14. CLIENT ENGAGEMENT AND COMPLETION RATES MUST BE MAXIMISED
Incomplete treatment is, typically, of little benefit. Efforts should be made to retain people in treatment where possible, provided their ongoing involvement does not threaten the outcomes of others. High client engagement is generally associated with high completion and good long-term outcomes. Factors associated with high engagement include: clear and explicit treatment plans, positive relations between clients and counsellors, high levels of client confidence in the treatment service, broad range of high-quality ancillary services, and inhouse provision of transport for those who would otherwise have difficulty attending treatment.
15. TREATMENT LENGTH MATTERS, BUT…
Overall, the longer people remain in contact with professional services the better their outcomes are likely to be. There is some evidence to suggest that a total treatment length of less than 90 days is of little value with severe drug dependencies. However, even very brief interventions can often be of benefit, especially in the case of less severe dependencies. In addition, it will typically be more cost-effective to extend the total treatment episode through aftercare services of reducing intensity, rather than retaining people in intensive treatment for extended periods.
16. THERE IS A ROLE FOR BOTH RESIDENTIAL AND DAYCARE PROGRAMMES
Structured daycare programmes can be highly effective and can be the setting of choice for many people. There is evidence, however, that residential placements can bring added benefits to a number of groups including: those with more severe dependencies, the homeless, people with unsupportive home environments, the socially isolated, the medically unwell, people who are psychiatrically disturbed, those with severe personality disorders, and those who ‘failed’ previously in daycare settings.
17. MEDICATION CAN ENHANCE LONG-TERM OUTCOMES
There is evidence that, though they are of limited benefit on their own, pharmacological interventions can complement rehabilitative treatment and enhance outcomes. For example, disulfiram can help people with an alcohol dependency. Naltrexone can be of benefit to those with an opiate dependency and those with a co-occurring alcohol dependency. Where co-existing psychiatric conditions are present, appropriate medications for these conditions can be critical to outcomes.
18. SELF-HELP GROUPS AND PROFESSIONAL AFTERCARE IMPROVE OUTCOMES
Intensive treatment, whether in residential or daycare settings, should be followed by ongoing professional aftercare. Without such follow-up, treatment is likely to prove of limited value. While it should not be seen as a substitute for professional aftercare, attendance at self-help groups can significantly enhance outcomes.
19. TREATMENT STAFF ARE KEY
Treatment staff are central to the success of treatment. Research shows that staff should be well trained, closely supervised, confident in their work and empathic towards their clients. A high staff:client ratio is important, as is close support and supervision. Whether or not counsellors have themselves had a drug or alcohol problem appears to have little bearing on their professional abilities. However, there is some evidence that a staff team which brings together counsellors who are in recovery with others who have no history of problematic substance use can be particularly effective.
20. GOOD ORGANISATIONAL STANDARDS ARE ESSENTIAL
It is important for a treatment service to have high organisational standards. QuADS, developed by DrugScope and Alcohol Concern, and EATA’s Auditing Standards both set out clear guidelines in this regard. Services with poor organisational standards are likely to have poor outcomes, no matter how good the staff or how well designed their treatment programme.