CATR, July / August 2015, Vol 3, Issue 5, Residential Treatment Programs Decoded

Mark Willenbring, MD
Founder and CEO, Alltyr Clinic, St. Paul, MN, Former Director, Division of Treatment and Recovery Research, National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD

Dr. Willenbring has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity.

Learning Objectives
Editorial Information
CATR: Many clinicians don’t really understand what goes on in residential rehab, or even if it works. What goes on in rehab?

Dr. Willenbring: Rehabs vary, but they generally consist of highly structured environments where patients receive lectures and group counseling. There are many lectures on disease concepts and AA principles. A patient might meet with a counselor individually for a half hour a week. There are many videos added to fill up the time.

CATR: What sort of counseling is offered?

Dr. Willenbring: Unfortunately, it is usually not truly therapy in the way we would usually define therapy. 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.

CATR: Do the counselors use any particular therapeutic techniques?

Dr. Willenbring: In most cases they do not, and even when counselors are trained in evidence-based techniques, they don’t seem to deploy them. I’ll describe a couple of relevant studies that were done as part of the NIDA (National Institute of Drug Abuse) Clinical Trials Network. The first study tested whether having a one-hour motivational interviewing pre-session prior to starting the treatment program would improve engagement, retention, and outcomes. It turns out that it did increase engagement and retention, which is great, but it didn’t change outcomes. Which implies that rehab treatment is not particularly effective—since enhancing retention with the treatment program does not seem to improve the chances of response. But the more interesting study was a follow-up study done by one of the investigators, Kathleen Carroll, at Yale. In this study, they 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. Another recent study asked the clients about their views of therapy in rehab, and the percentage of time that the clients felt they were receiving unwanted self-disclosure from the counselor was extremely high. Clients were hearing about things like how the counselor’s dog had to go to the hospital last night, but were not doing much CBT about their substance abuse issues.

CATR: So true evidence-based counseling is not being done much. But I could imagine that the entire package of programming might be helpful, particularly since it is happening 24/7. What sort of empirical research has been done on how effective rehab treatment is?

Dr. Willenbring: We’ve known for a long time that there is no outcome advantage between, say, 30-day residential treatment, a 4-6 week intensive multimodal IOP, and 12 weekly sessions with a therapist. In 1977, Griffith Edwards did the first study of this in England. These were alcohol-dependent patients, and they were randomly assigned to two groups. One group got a research-style evaluation, really comprehensive and then they just got advice. And that was it. They got no more treatment except for whatever effects there might have been due to follow-up visits with research personnel. The other group got a variety of treatments depending on their needs. Some got residential and some got intensive outpatient treatment. The one-year outcomes for both groups in terms of recovery rates were identical. There was no evidence whatsoever that residential or even IOP treatment confers any outcome advantage, compared to simple advice (Edward G, J Stud Alcohol 1977;38(5):1004–1031). 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.)

CATR: Aren’t you being a little hard on rehab? It seems to me that one thing we can say about rehab is that if somebody is using substances to the extent that they are about to wipe out their savings, destroy relationships, and destroy their lives, at least let’s put them somewhere they can be observed all the time so we can prevent further damage. Isn’t that a reasonable idea?

Dr. Willenbring: If it could be shown to work, then it would certainly be reasonable. To your point, there’s no question that some people need a high degree of structured supportive housing and they may need it for a long time or a short time. 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. There is no evidence that intensity of counseling improves outcomes. What matters is the length of engagement. It is like when we used to send TB (tuberculosis) patients to sanatoriums and we put them on big sleeping porches at night so they could get fresh air and then in the daytime we’d park them in the sun. One reason we did this was that there were no other treatments for TB other fresh air and sunshine. Most rehabs are relics of the days when we had no specific treatments for substance abusers. But in fact, we have multiple effective medications and evidence-based therapies—which are not offered in most residential or outpatient rehabs.

CATR: What would be reasonable, in your view, for the average psychiatrist or other clinician dealing with a very sick addicted individual? You are saying residential rehab is essentially worthless—what’s the alternative?

Dr. Willenbring: Substance use treatment should be no different from any other specialty of medicine, such as psychiatry or cardiology. Take the treatment of depression as an example. Depressed patients do not automatically get sent to a 30-day depression rehab. Instead, they are evaluated individually and are offered any of a range of evidence-based treatments. Certainly if someone is suicidal they will have to be closely observed, which might be in a partial hospitalization program or hospital. But there’s not a one-size-fits-all approach. The trouble with addiction treatment is it is like trying to treat a disorder with only one level of care. It is as if all we had for depression was a partial psychiatric hospital program, time-limited—let’s say it’s 4–6 weeks, relatively intensive, and there is no outpatient level of care. So the best thing that a psychiatrist could do, certainly for alcohol, would be to go the NIAAA website, where there is an online training for how to treat this disease. There are many people for whom we can prescribe medications, and who have good prognoses with appropriate treatment.

CATR: Thank you Dr. Willenbring