Residential Addiction Treatment: Who, How, Why
Addiction treatment is highly segregated by socioeconomic status– perhaps more so than any other type of health care. And one aspect of treatment in which class segregation is particularly glaring is in access to, and use of, residential treatment. I have never held a dedicated residential job, but I have some insight from covering shifts for colleagues in inpatient and residential settings.
Residential treatment for addiction is not the same as an inpatient hospital stay. It includes medical monitoring, but at a much lower level, meaning that anyone needing to complete withdrawal ("detox") or stabilize on medication must be referred for that first before starting a residential program. The general format for residential care is surprisingly consistent up and down the market: it typically involves a lot of group therapy, some recreation, and 12-step meetings both at the facility and in the community. Length of stay is largely determined by how long the patient's insurer is willing to pay. Beyond these commonalities, the landscape of residential treatment is highly determined by wealth and access.
For wealthy and privately insured patients:
Facilities compete for admissions nationwide with luxurious grounds, state-of-the-art amenities, and special ancillary services. Upscale facilities do not take Medicaid, ensuring that patients "with a lot more needs" or "from a different background" will not be there to make you uncomfortable. (Yes, people really say things like this, and with no apparent embarrassment.) Some people are coerced to attend, but it is by their spouses or families and not the criminal legal system.
For low-income, poor, Medicaid and uninsured patients:
You likely need to "fail" outpatient treatment first to demonstrate that you really need residential. This means continued substance use during or after outpatient care while sustaining interest in residential. Make sure you don't give up or die while you're waiting. These more accessible residential facilities do take legally-mandated patients, and accordingly their physical conditions may resemble prison. (The Drug Policy Alliance assembled a photo series asking "can you tell the difference?")
The sum effect is that most addiction treatment today occurs in outpatient settings. Payers prefer this in order to contain costs, but patients often prefer it as well. In my experience, most patients do not want to suspend their everyday lives to go to residential. They may fear losing their jobs, or lack reliable care for their kids or pets. Patients may also hesitate to go to residential because they recognize its chief function as a treatment for addiction: cutting off access to substances. Outpatient is a much looser commitment, merely to explore the concept of change for a few hours at a time while the rest of your life remains as-is– including, if you choose, substance use.
Another compromise we are seeing is recovery residences, or "sober living" facilities, which are typically led by peers. My first job in this field was in recovery residences. They vary widely in quality because they are subject to even less monitoring than treatment facilities, and as shown in Rehab: An American Scandal, many residential treatment programs have switched to running recovery residences to avoid even the laxest regulation. As for the clientele, people may feel less disrupted in their work and social lives by moving into sober housing compared to going to residential. However, sober living– even at its best– is not treatment and cannot keep anyone sober in and of itself.
So what does residential addiction treatment actually do? As in the rest of the treatment industry, we have very little data on patient outcomes, and basically none that is unbiased. However, certain categories of people have been shown to fare better with residential care as opposed to outpatient. These are people with:
- Relatively severe substance use patterns (likely meeting most or all diagnostic criteria for substance use disorder as opposed to just a few)
- Acute medical or mental health needs
- Tendencies to endanger themselves or others while using (think driving or acting out violently under the influence)
- Low social support
- Unstable housing or living in a setting that does not support changing their substance use
I believe anyone who feels they would benefit from residential treatment should be able to go. But if we absolutely had to ration it, these would be the patients to prioritize. This is why I get angry when the state refuses residential citing patients' rights to the "least restrictive" treatment environment. Some people desperately want to be restricted– as in 4 walls and a roof, with no drugs in sight. The state's real objection is that providing such a service is much more expensive than office visits. And even when a patient does get coverage for residential treatment, its benefits likely won't last after discharge if their other basic needs remain unmet.
As for the many people who meet one or more of the above criteria but do not want residential: we don't believe in forced treatment here, no prison-like atmosphere can be therapeutic, so we shouldn't refer them. Where they are ending up, for now, is in mandated outpatient programs like those I have worked in. The nonsensical compromise is that they receive much less treatment than is clinically indicated– to save money– while receiving much more treatment than they actually want– which may be none. Lack of access to residential paired with rampant forced outpatient demonstrates that addiction treatment today ignores people's wishes and also people's needs.
