We’ve all seen the commercials: gentle, soothing music playing over a reassuring voice that tells you that this specific rehab center is going to change your life. Because, after all, it’s changed his.
Inpatient rehab centers offer treatment for people with substance abuse or alcohol disorders. Most are intensive, requiring patients to live in their facility 24 hours a day for 30 days. And it is a gold mine for those who run such addiction recovery centers.
The Carlat Report: Addiction Treatment’s July/August 2015 issue is devoted to the topic of understanding treatment for alcoholism and substance abuse. It also offers an eye-opening interview with the former director of the National Institute on Alcohol Abuse and Alcoholism. Here we run down some of the myths we gleaned from the issue about residential rehab.
6 Myths of Residential Rehab
1. For the price I’m paying, I’m going to get a lot of individualized attention and one-on-one counseling.
Despite having 16 hours a day to fill, a typical day at a residential rehab center will fill 8 of those hours with group activities. While you may get an individualized assessment when you first enter the treatment facility, the personalization of your treatment generally ends there, according to Daniel Carlat, MD (2015):
Fletcher found that while the initial assessment of a patient by rehab staff was quite comprehensive, that comprehensive assessment does not necessarily lead to a treatment plan tailored to that patient.
Patients, regardless of circumstances and comorbidities, tend to be offered the same treatments as everyone else — mostly based on the 12-step philosophy. Even when patients relapsed, they tended to be offered the same programming over and over, rather than new approaches that might be more beneficial.
If you do get individual counseling, expect no more than 5 hours per week (out of a possible 112 waking hours/week). And most rehab centers are 12-step based, or believe that philosophy is best — despite the lack of clinical research evidence supporting that belief.
2. The counselors are all well-trained doctoral or master’s level clinicians.
Not according to Mark Willenbring, MD, the former director of the Division of Treatment and Recovery Research, National Institute on Alcohol Abuse and Alcoholism (Carlat, 2015). You’ll be lucky if you get someone with a college degree, much less someone with graduate school training:
The group counseling sessions are run more like classes. The skill level of the average counselor is very low. In 13 states you don’t need a high school education or even a GED to be an addiction counselor. Many states have requirements that you have to have two years of recovery in AA to be an addiction counselor. There is a 50 percent turnover in counselors per year across the industry. They are paid an average of about $18,000 a year.
So that “addiction specialist” you’re talking to while in rehab may not even have a high school diploma.
3. There must be research showing that inpatient rehab centers use evidence-based techniques.
Sadly, no. Even when counselors had evidence-based technique training in something like cognitive behavioral therapy (CBT), counselors at rehab centers appear not to use them much. Dr. Willenbring notes:
[…A] follow-up study done by one of the investigators, Kathleen Carroll, at Yale […] made many audiotape recordings of counseling sessions during rehab. They looked at motivational interviewing, 12-step facilitation, cognitive behavioral therapy, and others. The counselors knew they were being recorded, so presumably they were motivated to do their best. The researchers used a coding system to determine whether the techniques were actually being used.
It turns out that almost none of the therapeutic time involved any of these techniques. Almost all of the sessions were taken up with what the researcher called “chat,” much of which ended up being about the counselor.
So even the counseling you’re likely to receive at one of these residential rehab centers is likely to be of poor quality.
4. Inpatient residential rehab centers have been proven by research to work.
Unfortunately, the research actually shows quite the opposite — that there’s little advantage in patient outcomes by going to a rehab center. Dr. Willenbring notes the first study demonstrating this lack of differentiation between residential rehab and traditional outpatient psychotherapy goes back all the way to 1977 (Edward, 1977). The research found no difference in outcomes between patients in a 30-day residential treatment center, a 4-6 week intensive outpatient treatment (referred to as IOP, which is usually 9 hours per week of outpatient treatment, divided into
three 3-hour sessions), and 12 once-weekly outpatient sessions with a therapist.
He goes on to note:
More recently, a literature review of a dozen studies published between 1995 and 2012 found no difference in outcome between IOPs and residential programs — both settings led to comparable decreases in substance use. Obviously, IOPs are quite a bit cheaper than residential rehab (McCarty D et al, Psychiar Serv 2014;65(6):718–726.)
5. The reason the treatment length in rehab is 30 days is because research has shown 30 days to be the ideal length of time.
You would think, wouldn’t you? You’d be wrong, though, because there’s little to no research showing there’s any special value to the number “30.”
Here’s what Dr. Willenbring says about those 30 days:
But the current treatment system is built around an antiquated notion that there is something magical about a 30-day rehab. The common view of rehab, and certainly one that is marketed by the high-end programs, is that you go to rehab, and the clouds part and the light shines through and the angels sing, and you have this wonderful transformative experience and you never use again. And that is an extraordinarily rare outcome.
It is the wrong treatment for the disease that they are treating. What works best is separating the need for structured sober housing and for treatment, then individualizing each need.
6. Residential rehab is expensive.
It depends on how you look at it, but it’s generally not as expensive as you might imagine (Carlat, 2015), unless you go to a high-end center:
Rehabs vary widely in cost. Contrary to popular belief, the majority of rehabs depend on public insurance, such as Medicare and Medicaid, and lower-end rehabs might charge as little as $10,000/month. Private for-profit rehabs are in the minority, and their average cost is around $30,000 for a month — though it can go up to $100,000/month for celebrity-caliber rehabs in places like Malibu.
This article was based off of the fascinating July/August 2015 issue of The Carlat Report: Addiction Treatment, which is available as a subscription. Please consider subscribing today in order to read the insightful articles behind this blog post.
Carlat, D. (2015). Book Review: Inside Rehab — What Really Goes On in Rehab Facilities? The Carlat Report: Addiction Treatment, July/August.
Carlat, D. (2015). Q&A with the Expert: Mark Willenbring, MD. The Carlat Report: Addiction Treatment, July/August.