Pathways To #Addiction #Recovery – Residential Rehab

RehabIt’s time for some more general observations about addiction rehabilitation, something I’ve covered before (here) and on several occasions previously…

But more specifically; when impacted by addictions, how do people consider the possible advantages (or disadvantages) of the ‘rehab’ process, as a viable and efficacious pathway for individual recovery?

The Rehab Default

Two questions: (1) Is residential ‘rehab’ the only viable pathway for realising recovery from addictive behaviours? And (2), is residential ‘rehab’ always the best route, for achieving long-term sustained recovery from those addictive behaviours? In simple terms – the answer must be a resounding NO (or at least not necessarily).

What factors underpin these common (incorrect) assumptions? Adoption and maintenance of these beliefs are drivers of opinion and decision making process, for many but also, even amongst some who really should know better.

But, for many, residential rehab is not only seen as de rigueur amongst varied social circles (particularly the wealthy) however; many now see rehab as the default option when facing any substance use issues, the de facto solution for all addiction recovery journeys. This almost dogmatic mantra presents unforeseen consequences and negative impacts for people impacted by addictions, and their subsequent recovery journeys.

Rehab Feedback

I don’t have personal lived-experience of the residential rehab process however; almost all the feedback I have ever received from people ‘in recovery’ who have, mostly denounces the overall validity and efficacy of the process.

Residential rehab is mostly a short-term support mechanism, all be it one that can support addiction recovery. But contrary to popular belief, it isn’t the magic-pill medication that will provide a quick-fix for addiction. As with all other associated resources that support harm-reduction, provide clinical stabilisation or substance detox and effective after-care support, residential rehab is merely one resource in the recovery toolbox.

Residential rehab is time limited, costly and may or may not combine all of the above. One aspect that is so often lacking in many facilities, despite the industry marketing to the contrary, is the treatment after-care process. Something that is fundamental to the efficacy of any long journey towards sustained recovery.

In general, the rehab process tends to be a prescriptive process of enforced incarceration. One that often approaches recovery from dogmatic perspectives.

Removing individuals from even limited family and social support structures they may have in place, whilst denying them their personal choice has always appeared to be counterproductive to me.

Could these issues be fundamental reasons behind the constantly ‘revolving doors’ of many rehab facilities?

Thought Process Factors

Many people who are impacted by addictions, and subsequently make an individual choice to address their behaviours, often look for support in their longitudinal recovery journeys.  Despite the default thinking outlined above, the concept of Residential Rehab also carries differing perceptions in different people. Society has been conditioned to expect total efficacy of process and, despite the variables of delivery and individuals being ‘treated’, the prominent expectation of the rehab process is for successful outcomes… “Once I’ve been treated I will be better” – sadly not always the case.

These variables in the thought process often revolve around;

  1. which side of the North Atlantic you happen to reside
  2. your personal perception or understanding about addictions and how people are impacted by addictive behaviours
  3. your personal expectations formed from those perceptions dictated by social/media bias or miss-information, rather than science-based clinical facts and sadly,
  4. your personal financial where-with-all, when looking for support; irrespective of whether or not you are the person paying rehab fees.
  5. if you’re a family member, an employer, or an agency providing addiction treatment and/or recovery support.
  6. your responsibilities if you hold a remit for managing organisational budgets or, as is often the case,

Additionally, there also are many differences in the associated expectations held amongst potential patients. This quandary often comes from; where do your beliefs sit within the ongoing disease/treatment model for addiction recovery?

Treatment providers get a similarly skewed view of addicts: the people who keep coming back aren’t typical – they’re simply the ones who need the most help. Basing your concept of addiction only on people who chronically relapse creates an overly pessimistic picture. (Maia Szalavitz)

And all this before we even start to look at any of the financial considerations behind the issue about; how much should it cost, who should pay (if at all) and who’s responsibility is it any way… all of which are often rooted in media induced political rhetoric, rather than clinical, societal or individualised health-care provision considerations and focus.

Perceptions and expectations are (too often) so heavily influenced by emotive media content, rather than medical knowledge and in turn, these are consequently conveniently seized upon by commercial entities, seeking to capitalise upon the financial income opportunities.

Rehab Marketing

Too often, some Rehab providers hide facts, and answers to perfectly valid questions, behind layers of very clever marketing and hype, all designed to improve the commercial opportunities of their business.

You only need to Google to see how ‘aggressive’ marketing hype, SEO tactics and paid for advertising has raised many commercial organisations to the top of the search results. Many of these links purport to be offering factual and unbiased advice about addictions, and seek to provide guidance about how to realise recovery from addictive behaviours. However, when you start to dig a little deeper, or even possess a modicum of understanding around the (mostly) linear time-scale progression of any addiction recovery, they’re actually doing little more than marketing and selling their business services.

Rehab Morality & Populism

Taking money from desperate and vulnerable people, who may well have been misinformed in the past, and can ill afford the financial impacts of rehab, is ethically and socially wrong. Not everyone who suffers from an addictive behaviour previously enjoyed high flying selfie status (or wealth) and popular support, prior to falling from grace. Funny how a trendy populist following can also fizzle away when you fall off the wagon… unless you’re able to develop strength from the common sympathy votes that are often displayed by any respective group of social-media followers!

American ‘Rehab’ Recovery

But which one of the options returned by your Google endeavours will turn out to be, the best option to support your recovery journey, if any? Another unhelpful susceptibility of Dr Google is when the internet bombards British ‘patients’ with (mostly) American information.

If you are searching for information about the pros and cons of the rehab process (or addictions support), as part of your own recovery journey – in the UK, wouldn’t you prefer to receive information that is relevant to the UK and importantly, provides factual clinical guidance?

Financial Politics of Recovery

One reason for the increase in the ‘aggressive’ marketing techniques, used by (some) rehab centres is; past sources of ‘easy’ money (from local authority referrals) has all but dried-up in recent years.

This is something that the ‘industry’ has been quick to grasp upon. An industry that needs ‘patients’ is happy to feed from (self-generated) emotive headlines that suggest; many/more people are dying due to a lack of rehab beds… something that (in reality) is untrue, despite how the mainstream media love to dress things up.

The number of people dying from drug and alcohol misuse has almost doubled in the five years since councils were given responsibility for providing treatment, according to official figures. (The Times)

Yes, drug-related death rate statistics are in the ascendant and yes, the government and local authorities have significantly and continually reduced funding for addiction support services during recent years. This is something the Advisory Council on the Misuse of Drugs (ACMD) has warned about (below) recently.

ACMD warns ministers of falling local funding for drug treatment services
Funding cuts are the single biggest threat to drug treatment recovery outcomes, a report published by the ACMD has warned. (Gov.uk)

Yes, there has been a fall in the use of ‘expensive’ rehab referrals from the commissioned treatment services of many councils. But these are organisations who are constantly struggling to maintain their services, in the face of these swingeing funding cuts however; is a commercial rehab place always the best use of these depleted and limited public resources? Often, the answer has to be NO, much to the chagrin of the rehab industry!

I would argue that there is little or no correlation between increasing drug-related deaths and the decline in residential rehab beds. Sadly, the same can’t be said about the loss of all the remaining addiction treatment, recovery and associated social support resources.

Based on research, financial data and stakeholder surveys and testimonies, the UK government’s official drug policy advisers warn that without significant efforts to protect investment and quality, in England “loss of funding will result in the dismantling of a drug misuse treatment system that has brought huge improvement to the lives of people with drug and alcohol problems”. (Drug & Alcohol Findings)

The drug-related deaths statistics have sadly set new records. Each year for the last four years across the UK however; there are many variable factors behind these statistics, not simply the decline of residential rehab facilities.

Consider all the societal factors that lead to addictions such as; the increasing levels of poverty, an increasing understanding of the scale of mental-health issues and the associated lack of required support structures, or even the rising abuse of potent opioid painkillers and prescription drugs. And all that before you start to factor in any of the public-health impacts of an ageing cohort of lifelong problematic drug use. Worryingly, the headlines still tell us that;

…spending on both residential rehab and detox services, as well as community rehabilitation schemes, has fallen by as much as £135m according to an analysis of council spending by private rehabilitation provider UK Addiction Treatment Centres. (The Independent)

Blind Following Blind

The UK has a tendency for (almost blindly) following addiction trends that have grown in and ravaged America. Yet, we constantly try to mitigate against most of those problems with tired, outdated and dogmatic American ideology, especially when it comes to recovery. That’s unfortunate because in many respects, the way we look at addictions and support recovery in the UK is often streets ahead of much in American efficacy.

Fears UK could follow the US into opioid crisis: Addiction experts, patient and health groups want more done to prevent the UK from seeing a US-like opioid crisis. (news.sky.com)

Another issue is that (in the UK) we also have a propensity for reinventing the wheel. Mostly for expedience driven by political populous and the financial constraint of budgetary factors (see previous post).

We constantly seek new ideas and nuanced methods, delivered by sometimes self-promoting new-age ‘experts’ – whilst failing to maintain real investment in [their] newly denounced past process success. I’m not opposed to change, neither am I against developing new process (based upon science) but I am against change for the sake of [political] change.

It appears that previously tried and tested processes (e.g. 2008 Recovery Agenda & the Harm Reduction policy of 2017) were proven methodologies that have been (mostly) sidelined in (some) services. Despite having previously been supported with evidence and delivering efficacious results.

Perhaps outcomes didn’t always match political/societal expectations around the speed of delivery. But were desired outcomes of politicians and the media clearly defined or realistic? Some also argue that it’s questionable who’s ‘harm’ any policy has been seeking to reduce; the individual, our society, or both? (see here).

But should anybody realistically hold an exception that; the myriad long-term entrenched societal causal factors, often decades in the making, would get fixed easily, in a timely (quick) manner, any time soon? Certainty not me!

What Price Recovery?

Contrary to popular belief, often generated by our emotive (misinformed) media, assisted by the commercial interests of the rehab industry, you don’t actually have to pay for your recovery; anybody impacted by addictions can still gain access to comprehensive treatment and support. Services that are totally free (at least for now) at point of delivery, despite all the beliefs or best efforts of politicians, commercial entities and (some) clinicians.

If you need treatment for drug addiction, you’re entitled to NHS care in the same way as anyone else who has a health problem. With the right help and support, it’s possible for you to get drug free and stay that way. (Read more)

Additionally, those charitable organisations up and down the UK, who are commissioned by UK Public Health agencies, to supply addiction treatment and support, do so without any charge to the individual seeking support. Unfortunately, the ‘charity’ status definition has also been blurred over recent years, in they eyes of many. This leads to further confusion around which organisations are commercial entities and which ones are actually charitable.

Yes, many organisations are struggling to deliver some of the important support functionality they provide, or would like to provide however; the provision of effective (free) addiction treatment and recovery support is still available (for now). But (understandably) that isn’t something likely to feature very highly amongst any commercial rehab marketing blurb.

Many problems can be encountered when trying to admit someone to rehab. Perhaps the biggest challenge lies with individuals who are addicted to a substance but may not be willing to consider options for recovery. (wikihow.com)

Many treatment and support models, particularly but not exclusively in America, revolve around dogmatic prescriptive cash generating methodology. Services that operate within a system and framework of coercion and control, based upon religious or morality based directions, rather than purely clinical processes, ones that have been developed from medical science.

There are many paths to recovery – and if we want to help people get there, we need to explore all of them. That means recognising that natural recovery exists – and not dismissing data we don’t like. (Maia Szalavitz)

I’m not saying that the American system is totally flawed, at least not from the perspective of all clinical interventions, far from it. Merely that the overall situation is; the focus for treatment provision in the USA differs in so many ways to the UK, so as to make the two (mostly) incompatible. The American services aren’t something we should consider importing into the UK any time soon… even as part of our new free-trade world, post Brexit.

Irrespective of how much the Commercial Captains of American Rehab believe in the seaworthiness and capabilities of their ships; the efficacy of their vessels don’t voyage well across the Atlantic… at least not without taking on substantial quantities of water during that journey. Given responsibility for coastal defences, I’d be sorely tempted to sink most of that American fleet, long before their crews came ashore!

Additionally, I’m also not saying that self-supported recovery from addictions is the panacea, or efficacious for all people and all issues. But there is a danger that, mostly from political and financial perspectives, significant moves towards the predominant American belief models could easily undermine the availability of our already limited support resources.

From the UK experience in both Scotland and England, there is the risk of a coalescing of recovery enthusiasm with a self-help mantra that encourages reduced central spending and so cutbacks in specialist treatment services and expert jobs. (Best et al 2017)

Going back to 2002, it was recognised that there will often be a  ‘risk environment’ underpinning the framework of understanding in reducing drug-related harm (see here). And in 2016, it was argued that despite the widespread [American] implementation of compulsory treatment modalities for drug dependency, there was limited scientific evidence to support the effectiveness of compulsory drug treatment (see here). Yet some still seem to push people towards (and believe in) the American model for incarceration and compulsory ‘treatment’ – something advocated by many residential ‘rehab’ facilities.

Residential Rehabilitation – The Best Option?

Reviewing recent academic studies Drug & Alcohol Findings asked; “Has enough high-quality evidence accumulated over the past five years to improve confidence in the effectiveness of residential treatment?” (Read more)

The effectiveness of residential treatment services for individuals with substance use disorders (A systematic review): Residential treatment is a standard treatment for individuals with severe and complex substance use problems. However, there is limited evidence on best practice approaches to treatment in these settings. (Read more)

In summary of their review Findings concluded by saying there was; “moderate quality evidence that residential treatment may be effective in reducing substance use and improving mental health, and some evidence that treatment may have a positive effect on crime and social outcomes.” Is this limited evidence sufficient to drive direction, often to the detriment of other social and clinical investment?

Simple Strategy Solutions

OK, so the word ‘simple’ is trite; there are no ‘simple’ solutions that will mitigate against all the causal factors within substance misuse and addictions. Any Government strategy (see latest) will always be up against it, when it comes to tackling the complex issue of substance misuse and alcohol use disorders.

  • UK Drug Strategy 2010 – ‘Reducing demand, restricting supply, building recovery: supporting people to live a drug-free life’
  • UK Drug strategy 2017 – new action to tackle drug misuse and the harms it causes.

Most ‘officially’ formulated policy is never far from [required/appropriate] challenge; either from internal Home Office direction, or from external experts who could/should be advising government policy and strategy.

I was blocked from advising on UK drug policy – because I criticised UK drug policy (The Guardian)

Our Government in the UK, like many others across the world, have a historic tendency for ignoring the expertise that is available to them (e.g. the sacking of Prof. David Nutt from the ACMD). More following of prominent American thinking.

Governments rarely want to listen to available evidence that can (and should) inform strategic decision making process. Apparently evidence is only ever appropriate when it fits the current political agenda, or that certainly appears to be the case. Hence the continued pursuit of the failed War On Drugs policies that abound.

All said, and I will undoubtedly be accused of a personal ‘marketing’ interest, which really isn’t the case, however; I truly believe we need to start getting SMARTer about how we look at addictions. We need to look at treatment and recovery support in different ways. We need to distance ourselves from [American] treatment models; those that advocate prescriptive or enforced and incarcerated methods, irrespective of who is paying the bill. In short, we need to get past all the commercial and political interest in play, before those interests present additional negative impacts on an already difficult process.

We should also distance ourselves from all the ongoing failures that were born in the [American] War On Drugs, issues that still too prevalent and have resulted in so much of our often dogmatic approach, for the delivery of recovery support. We would also do well to remember…

The Surprising Truth About Addiction: More people quit addictions than maintain them, and they do so on their own. That’s not to say it happens overnight. People succeed when they recognise that the addiction interferes with something they value—and when they develop the confidence that they can change. (Psychology Today)

The above article serves to highlight the fact; “change is natural” and that over time, many people “probably overcome or ameliorate certain behaviours” – without ‘treatment’ or support.

The process of ‘recovery’ is not something that can be prescribed or enforced. Yet, for reasons possibly evolved from commercial and/or political interests; “we exempt addiction from our beliefs about change.”

It is a fact that for many individuals; guided by some support processes within – “popular and scientific models” – we see addiction as something that locks people into “an inescapable pattern of behaviour” …for life!

This common but heavily advocated folk wisdom, as represented by Alcoholics Anonymous et al often forms the foundations and tenets of many support resources within the [American] rehab industry. Do we really want that here? But this thinking is not confined to the rehab industry, it’s also seen within some neuroscience understanding that says; “addiction is virtually permanent brain disease.”

This dogma is also one of the main reasons why we (incorrectly) label people as ‘alcoholic’ or why some people choose to self-identify as ‘alcoholics” who are ‘suffering’ from “alcoholism” – even if they haven’t taken a drink for decades, in some cases. Non of these labels really have any reliable basis in science. All they serve to do is create stigma and skew social beliefs and perceptions.

For many, once they understand themselves, their life circumstances and impacts, along with the environment in which they live,  they find that this thought process is mostly unhealthy and perpetuates a recurring ‘victim’ belief. One that can and does stand in their way of recovery pathway progression. It stands in the way of any ‘graduation’ from their journey of recovery.

Dependence on prescription medicines linked to deprivation: PHE has published the first-ever evidence review of dependence and withdrawal problems associated with 5 commonly prescribed classes of medicines in England. (Gov.UK)

In addictions to illicit substances, or increasingly those involving prescription drugs, people are often seeking ways in which to deal with (or disguise) the difficulties that they are facing. Or, they are seeking emotional connections, in an increasingly disconnected society.

Addiction often results from us reaching out for a psychological crutch or comfort blanket; a form of support that serves to help us manage our difficult situations where often, no alternative support is available… or perhaps doesn’t actually exist. These situations, coupled with the support of our chosen [unhealthy] ‘little helper’ often serves to exacerbate many of our problematic thoughts, feelings, emotions and behaviours.

If addiction really were a primary, chronic, progressive disease, natural recovery rates would not be so high and addiction wouldn’t have such a pronounced peak prevalence in young people. (drugfoundation.org.nz)

Like many others, I prefer to see addiction as more of a learning or developmental disorder, rather than taking the classical disease view. The very word ‘addict’ confers an identity that admits no other possibilities actually exist. It incorporates the (mistaken) assumptions that lead to an ingrained social belief that says; you can’t, or won’t, change. This fatalistic thinking about any addiction doesn’t sit well within the facts.

The First Rule of Recovery: You don’t recover from an addiction by stopping using. You recover by creating a new life where it is easier to not use. If you don’t create a new life, then all the factors that brought you to your addiction will eventually catch up with you again. (www.addictionsandrecovery.org)

Most people with addictions simply grow out of them but this fact is widely denied, why so?

The idea that addiction is typically a chronic, progressive disease that requires treatment is false, the evidence shows. Yet the ‘ageing out’ experience of the majority is ignored by treatment providers and journalists. (drugfoundation.org.nz)

Finally, I’m not saying that spending time in a residential rehab facility, to support recovery from your addiction, is always a flawed decision. For some it may well be an appropriate option. I’m simply asking… is residential rehab always the most effective choice that can or should be made in support of your long-term sustained recovery?

Perhaps our society, politicians and the many commercial interests are the real causal factors of addictions, rather than the results of our individual moral or health failings?

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