Residential rehabilitation: literature review

6. Conclusions and Recommendations for Future Research

6.1 Overview

There is a wide-ranging and highly varied body of literature relating to residential rehabilitation and although some evidence is mixed and of weak quality, some robust evidence does exist to suggest that residential rehabilitation is an effective form of substance use treatment. Residential rehabilitation has been evidenced to produce positive outcomes relating to substance use, mental and physical health, social life and criminal activity. There is similarly some evidence that residential rehabilitation comprises a cost effective form of treatment when considering long-term outcomes, and that residential rehabilitation can be more effective than other treatment modalities.

While there is a substantial body of literature internationally, there is a dearth of evidence that pertains directly to residential rehabilitation across Scotland. The following section offers suggestions for potential research themes, based on areas which are currently under-explored in literature.

6.2 Areas for Future Investigation in Scotland

From this review of the existing literature on residential rehabilitation, it is possible to make a number of recommendations as to areas for future research. The review identified several areas that would benefit from further exploration in the Scottish context, and which would further develop the evidence base in an international context.

6.2.1 Defining and measuring outcomes

• Exploration of what constitutes a positive outcome from residential rehabilitation, the efficacy of existing measurement tools, and how best to measure outcomes across a broad range of domains (e.g. abstinence/ stabilisation of use; wider impact on relationships, employment status, housing situation, general emotional and functional wellbeing, etc).
• Such research may make use of data linkage between health, welfare and justice administrative data to better understand outcomes of residential rehabilitation.
• Such research would also benefit from addressing methodological issues of research on residential rehabilitation, such as heterogeneity of models and practices.

6.2.2 Mechanisms of Effect

• Mechanisms through which residential rehabilitation generates outcomes and the ways in which these differ from other treatment modalities.
• How mechanisms through which residential rehabilitation produces outcomes differ across different population groups (including by substance use severity, socioeconomic position, gender etc).

6.2.3 Individual characteristics and demographics

• Impact of characteristics/demographics like gender, age, socioeconomic, exposure to adverse childhood experiences (ACE)/trauma, substance use histories, psychiatric histories on experiences of residential rehabilitation and outcomes.
• The role of a whole families approach across the system.
• Comparative complexity of needs of those seeking residential treatment as opposed to non-residential, community-based treatment.

6.2.4 Differences between residential rehabilitation programmes

• Comparisons of different programme models within residential rehabilitation and of residential treatment with non-residential treatment, including analysis of outcomes for different population groups.
• Potential benefits and disadvantages for service users receiving opioid substitution therapy (OST) and residential treatment simultaneously.
• Efficacy of programmes for different demographics.
• Approaches to service provision sensitive to race, gender, class, disability.
• Exploration of the mechanisms through which different models of residential rehabilitation produce outcomes for different population groups.

6.2.5 Addressing Trauma/Mental Health

• Ability of different residential rehabilitation programmes to address PTSD, trauma and mental health comorbidities.
• Service understandings of 'trauma informed care' and its application in practice.

6.2.6 Attitudes towards residential rehabilitation

• Attitudes towards residential rehabilitation among practitioners, people who use drugs, families, Alcohol and Drug Partnerships (ADPs) and other key stakeholders, and the consequences of these attitudes on funding, referrals and placements.
• The motivations for seeking residential rehabilitation among people who use drugs.
• The role of stigma in acting as a barrier to accessing residential rehabilitation.

6.2.7 Pre-residential rehabilitation (Identification, Selection, Referrals, Assessment, Preparation)

• Processes of candidate identification, selection, referral and assessment for residential rehabilitation.
• Identification, selection and referral of people with multiple or complex needs, including complex mental health comorbidities and/or complex substance use (e.g. polydrug use, benzodiazepine use).
• Factors determining the likelihood of referral, including stage in recovery journey, drug use profile, possession of 'cultural capital', unconscious bias and stigma.
• Practices of determining who is most likely to benefit from residential rehabilitation and association of both identification process and individuals' characteristics with outcomes.
• Practices of informing and managing client expectations and association of preparatory work with outcomes.

6.2.8 Funding pathways

• Awareness of funding pathways among people who use drugs, their families, potential referrers and other key stakeholders.
• Factors determining likelihood of accessing statutory funding for residential rehabilitation.
• Association between different funding pathways and outcomes for different demographics of people.

6.2.9 Detoxification

• Impact of different detoxification experiences consequent outcomes from residential rehabilitation.

6.2.10 People's experiences of residential rehabilitation

• People's experiences of the therapeutic relationship and facilitators/barriers to its development.
• Impact of interpersonal dynamics, social hierarchies and social relationships during the programme on outcomes.
• Impact of multiple journeys on outcomes.

6.2.11 Period following residential rehabilitation (departure, aftercare, continuity in care planning)

• Exploration of the potential risks presented by planned or unplanned departure from residential rehabilitation and how best to mitigate risks.
• Outcomes and risks of harm associated with early departure.
• Factors associated with sustained abstinence or returns to substance use on leaving residential rehabilitation.
• Factors predicting attendance at aftercare services.
• Comparisons of the efficacy of different aftercare interventions, such as 12-Step, mutual aid and structured therapy.
• Ideal timeframes for employment/volunteering for the individual.
• Best practice for housing/aftercare planning.

6.2.12 Workforce

• Relationship between workplace satisfaction and treatment provision/therapeutic alliance.
• Needs of workforce in terms of retention, training, capacity.
• Association of increased presence of peer workers with outcomes.

6.2.13 Mortality

• Mortality rates during and in the short, medium and longer-term following residential rehabilitation, including comparative analysis with other treatment modalities.

6.2.14 Wider Societal Context

• Impact of wider social, historical and cultural context on experiences of residential rehabilitation and programme provision.
• Effect of pre- and post-treatment housing, employment, social relationships on experiences of residential rehabilitation.
• Impact of Scotland's specific context of drug use, particularly patterns of poly and complex drug use, on the suitability of residential rehabilitation as a treatment intervention.