Residential rehabilitation: literature review

Key Findings

Summary

• Previous research has explored a number of aspects of residential rehabilitation, including its overall effectiveness in producing positive outcomes; mechanisms that impact on outcomes; the effectiveness of different treatment models; and cost effectiveness.
• A relatively robust body of evidence suggests that residential rehabilitation is associated with improvements across a variety of outcomes relating to substance use, health and quality of life.
• There are a number of areas that remain under-researched, particularly within the Scottish context, and which require further exploration.

Overview of effectiveness of residential rehabilitation

• Demonstrating the association between residential rehabilitation and specific outcomes is complicated by the widely varied nature of provision in terms of programme length, treatment philosophy, the provision of throughcare (including preparatory work and aftercare) and quality. Further, with residential rehabilitation typically forming one of multiple interactions with alcohol and/or drugs treatment services, delineating which of these treatments has produced specific outcomes in the short, medium and longer-term is challenging.
• There is relatively robust evidence that residential rehabilitation is associated with improved substance use outcomes, although there is considerable variation in the quality of this evidence.
• Some evidence suggests that residential rehabilitation can improve mental health outcomes, particularly when programmes integrate treatment for substance use and mental health.
• While relatively few studies have explored social outcomes in the context of residential rehabilitation, results broadly suggest that residential rehabilitation is associated with improvements across domains such as offending, social engagement, and employment.
• While there has been limited robust research on mortality outcomes, there may be some indication that residential rehabilitation carries increased risk in comparison with other treatment models. However, mortality rates are affected by a number of confounding factors which are difficult to control for. Further, there is evidence to suggest that people accessing this form of treatment often have higher problem severity, which may lead to increased risk.
• There is scant research that considers the perspectives and experiences of people who have accessed rehabilitation, or which explores and measures outcomes important to them.

Factors associated with improved outcomes

• A relatively large body of literature explores factors associated with improved outcomes, with these factors including pre-treatment preparation; treatment characteristics, such as programme length; treatment retention/completion rate; characteristics of the individual accessing residential rehabilitation; and aftercare.
• Relating to aftercare, there is a strong evidence base around the importance of ongoing support following placements, as well as the attainment of employment and a stable housing situation, as predictors of positive outcomes following residential rehabilitation.

Effectiveness of therapeutic communities and 12-Step approaches

• There is a relatively robust evidence-base for the effectiveness of the therapeutic community (TC) approach to residential rehabilitation, which suggests they can be highly effective in reducing substance use and criminal activity. However, there is variation in the quality of this evidence.
• Most research relating to 12-Step programmes concerns the efficacy of 12-Step on leaving residential rehabilitation, or as an intervention undertaken concurrently with residential treatment. However, some studies, largely US-based, show that 12-Step can impact positively on a variety of substance use, mental health and social outcomes.
• Very few studies have directly compared the effectiveness of different models of residential treatment programmes. Such comparisons are challenging as facilities often employ a blend of multiple treatment models.

Comparisons of residential rehabilitation with other treatment models

• Relatively little research explores the effectiveness of residential rehabilitation in comparison with other forms of treatment, such as outpatient or community-based treatment and Medication Assisted Treatment (MAT). The majority of the small existing evidence base suggests that residential rehabilitation produces more positive outcomes in relation to substance use than other treatment modalities, although conflicting evidence exists in some cases.
• It is also worth noting that comparative analysis of residential rehabilitation and community interventions is challenged by the aforementioned factors.

Cost effectiveness

• While residential rehabilitation is typically a more expensive treatment option than other forms of treatment, a limited evidence base exists which demonstrates its long-term economic benefit in comparison with other treatment modalities. However, such comparison is complex given the different models of residential treatment, the wide array of potential outcomes, and – given that residential rehabilitation typically forms one of multiple service encounters for the individual – challenges in terms of associating outcomes to a single episode of treatment.

Workforce

• There is limited research that focuses on issues in relation to the workforce within residential rehabilitation, both in Scotland and internationally.
• There is recent survey evidence of 20 residential rehabilitation providers across Scotland that explores the composition of the Scottish workforce across the sector.