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The State of the Rehab Union

Results of an exclusive new survey conducted by The Fix reveal why people check into rehab today, why they choose where they go, how long they stay—and the recent and troubling rise of poly-substance abuse.

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Is the state of the rehab union strong? Photo via

By Hunter R. Slaton

08/05/12

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For the past six months, The Fix has been amassing and analyzing a wealth of information volunteered by people who have been through all manner of residential addiction treatment centers across the country. As part of its unique-in-the-industry Rehab Review, The Fix asked 20 questions about what is most important to people who went to rehabs, and patients sounded off on everything from how they liked the food or their sleeping situation, to whether or not their treatment was 12-step-based, to how well staff handled rule-breakers.

A few of these questions covered some basic and important info about what factors were most important to people when choosing a rehab; what addictions, issues or crises led them to check into a treatment center; and for how long they were in residence at the facility in question.

The No. 1 factor affecting rehab choice was treatment quality, selected by 24% of respondents. No. 2 on the factors list was location, selected by 14% of respondents, followed by accommodations quality (10%).

The biggest new and growing trend in the rehab world, according to experts who spoke to The Fix for this story, is people checking into treatment for poly-substance abuse. Especially over the last five to 10 years, people admitted to rehab “just don’t seem to have straight-out one drug of choice anymore,” said Austin Recovery President and CEO Jonathan Ross. He speculated that this could have something to do with the mobility of modern American society, or perhaps instant gratification, with younger drug addicts being somewhat less discriminating with respect to what they use to get high. He imagined their rationale: “If it’s accessible and easy, I want it and I want it now. If it’s not my drug of choice, that’s fine.”

Our survey supports evidence of this trend, with 17% of respondents reporting seeking treatment for more than one substance. Yet this is even lower than the nearly 56% who said the same to CASAColumbia, the National Center on Addiction and Substance Abuse at Columbia University, as part of a five-year study, the controversial results of which were made public in June.

factors affecting rehab choice

This discrepancy in percentages reporting poly-substance abuse could be a result of the way The Fix's question was worded, or it could have something to do with one hallmark of addicts entering treatment that Ross has noticed: Namely, “that they won’t often admit that prescription drugs are an issue until they get here, and they fully disclose or are drug-tested and we find out all the different things that they’re on.” So the person who went to rehab thinking they were just an alcoholic could come out realizing that they were in fact addicted to, say, alcohol, benzos and marijuana.

The Fix did not, however, ask about poly-substance abuse directly. Rather, the first set of data (see the chart, above) concerns what mattered most to people when choosing a treatment facility. Three hundred and thirty-three respondents selected one or more factors from a list of 13, including price, location, insurance, co-ed or single-sex, gay-friendly, food quality, accommodations quality, treatment quality, religious affiliation (or lack thereof), amenities and recreation opportunities, whether smoking was allowed, privacy and “other” (with an attendant fill-in-the-blank field). Collectively, these 333 respondents chose 1,066 factors that were important to them in choosing where to go to rehab, for an average of 3.2 factors per person.

The No. 1 factor was—as many rehab execs who spoke to The Fix for this story said they were happy to see—treatment quality, selected by 24% of respondents. “I believe that’s really the core of the issue,” said Ross, who noted that what constitutes good-quality treatment is changing. “It used to be that if you had a solid program and you were covering the basics of addiction … that was fine,” he said. But no longer. Now the disease is acknowledged to be more complex, encompassing process addictions and co-occurring psychiatric issues, and with the family component more important than in the past.

Although treatment quality was the most commonly chosen factor, the fact that only a quarter of respondents chose it struck Susan Foster, MSW, VP and director of policy research and analysis for CASAColumbia, as “not surprising—but disturbing.” CASAColumbia's recent study concluded that “addiction treatment is largely disconnected from mainstream medical practice,” and that “of those who do receive treatment, most do not receive anything that approximates evidence-based care.” Foster said that a quarter of respondents citing treatment quality as an important factor was, sadly, consistent with what CASAColumbia found in its report.

Foster noted that there are “enormous misperceptions” about addiction treatment among the general public—at least one reason for which is that most people don’t have much experience with it, and therefore don’t have much knowledge as to what constitutes quality treatment. So it’s unsurprising, then, that “quality of treatment” was only cited by a quarter of respondents.

No. 2 on the factors list was location, selected by 14% of respondents, followed by accommodations quality (10%), amenities (9%), price (8%), insurance and privacy (both 7%), smoking policy (5%), food quality and co-ed or single-sex (both 4%), reputation (3%) and religious affiliation (2%), with gay-friendly, “family decision,” non-12-step and “medical advice” bringing up the rear with 1% each.

Location being near the top of the list makes sense to Andrew Rothermel, executive VP and COO of Caron Treatment Centers, CEO of Hanley Centers and president of Caron’s Florida market, who noted that as the family component has become more important, so too has choosing a rehab that isn’t logistically difficult for the family to visit—not to mention the addict. “If people can’t get there, they can’t get well,” quipped Dr. Deni Carise, senior VP and chief clinical officer of the nonprofit Phoenix House, which has rehab programs in 10 states.

Furthermore, as the vast number of rehabs in Florida and Southern California—Los Angeles and Malibu specifically—makes apparent, people consider the climate when choosing a rehab. “We get asked, ‘How’s the weather?’” said Cassidy Cousens, founder of Authentic Recovery Center (ARC). (Cousens also speculated that California’s licensing laws have encouraged a proliferation of rehabs in that part of the country.)

The largest number of people, 37% percent, reported that they sought treatment for alcoholism. The No. 2 cause, opiates and prescription pills, reported by 15% of respondents, fits with national news stories about the prescription-pill epidemic currently sweeping the nation.

The fact that accommodations and amenities ranked so highly on the list (Nos. 2 and 3) jumped out to Phoenix House President and CEO Howard Meitiner. Demanding high quality in these areas is a luxury that most people who go to treatment can’t afford, as Meitiner noted that, historically speaking, the majority of people in treatment are mandated there. (Individuals who responded to The Fix’s survey had been to treatment at 19 different rehabs, 16 of which had a base price of $11,000 or more.)

Two related factors, price and insurance, occupy spots five and six. The latter is something that Ross sees increasing in importance, especially with the Affordable Care Act having been upheld by the US Supreme Court. “Whether it be Medicaid or the new focus on substance-use-disorder benefits, [insurance] is going to be more and more of an issue,” he said, adding that, with the economy in the limping-along shape that it’s in, “people can’t afford not to use insurance benefits if they have them.”

One more factor worth special mention is smoking, which came in at No. 8 on the list, cited by 5% of respondents. That number struck The Fix as low, given the cliché of chain-smoking rehab denizens. Ross, whose Austin Recovery banned smoking campus-wide this spring, said that he feels people care a lot about smoking under certain circumstances. “It may not affect their decision to go, but not being able to smoke may affect their decision to stay,” he added.

The next big survey question was simple: What brought you to rehab? While some had snarky answers (“a plane and a limo”; a trip to Whataburger with one’s father that served as cover for telling the person to go to rehab or move out of the apartment complex his dad owned), most respondents were deadly serious about what addictions or problems led them to seek treatment.

The same number of individuals, 333, was posed this question. Not everyone answered in a way that was readily classifiable or valid (“plane and limo”), but 438 substantive responses were given, with some respondents reporting more than one reason why they needed rehab.

what led respondents to seek rehab

It came as no surprise to Foster that the largest number of people, 37% percent, reported that they sought treatment for alcoholism. CASAColumbia’s own study found that 38.6% of rehab admissions were linked to alcohol. The No. 2 cause, opiates and prescription pills, reported by 15% of respondents, fits with national news stories about the prescription-pill epidemic currently sweeping the nation, supplanting (and in fact surpassing) more traditional drugs of abuse such as heroin, cocaine, crack, meth and so on. (The unspecified category of “drugs and drug addiction” was a close third, with 14%.)

Rothermel noted that Caron, with more than 200 beds in South Florida, is smack in the middle of the opiates epidemic, which he said is affecting even patients who don’t fit the traditional mold of addiction. In the program for Boomers and seniors at The Hanley Center, Rothermel said they are seeing an influx of people who, although they’ve lived a lifestyle where addiction was not prevalent, maybe had an accident and were prescribed painkillers, after which “they are off to the races on these pills.”

Nos. 4, 5 and 6 on the list were cocaine/crack, heroin and depression/mood disorder, respectively, each of which were cited by 5% of respondents. (Meth, pot and psychedelics didn’t get much love in this survey, with just a handful of people citing each.) A relapse after a period of sobriety led 4% of those surveyed to seek rehab, while an intervention was what prompted 3% to check in.

Bill Morrison, co-founder and CEO of the Bay Area rehab Alta Mira, said the relatively low numbers for depression/mood disorder stood out to him, given that studies have shown that 50–75% of those who end up in addiction treatment have a dual diagnosis—which, when untreated, is a contributing factor to relapse. So it's a positive trend that, as Morrison said, "A lot of treatment centers understand that now, and those who haven't in the past are becoming able to treat dual-diagnosis." He added, "The problem is it's expensive."

As for pot and psychedelics, one reason why they didn’t score higher could be that they are not often “precipitators of crisis,” which Rothermel said is what typically leads people to seek treatment. “Pot very rarely creates a crisis,” he said. “That doesn’t mean it’s not a serious component of someone’s addiction. It’s just not something that causes the family to get an intervention together.”

A little more than a quarter of respondents, 26%, said they were in rehab for 28 days or a month, while 43% said they stayed in rehab for longer than a month, up to and including 90 days.

Meanwhile, the low levels of reported heroin, meth and crack addictions could also be a result of the population surveyed. “It says more about the upper-middle-class sample as well as availability,” said Dr. Carise. “They don’t have siblings or cousins or neighbors who are using heroin or crack that you see in more impoverished areas.” Carise went on to note that alcohol and pills are different, too, in that both are legal, and are much more socially acceptable than traditional street drugs.

Meitiner, for one, saw this statistic as an argument against the legalization of drugs. “When it’s more difficult to get things, there’s less usage,” he said. But there isn’t general agreement on this topic: Somewhat in line with Dr. Carise’s opinion, Ross said that he believed accessibility to particular individuals, rather than legality, is what determines use and abuse—and that illegality could even encourage experimentation. “These days with the Internet, so much is accessible,” he said. “Does it deter people because it’s illegal? No. Does it attract people because it’s illegal? Maybe so.”

A third survey question had to do with length of time in treatment. This question was answered by 355 respondents, who reported a wide range of time spent in residential facilities, from just two weeks to more than a year. A little more than a quarter of respondents, 26%, said they were in rehab for 28 days or a month, while 43% said they stayed in rehab for longer than a month, up to and including 90 days. Fourteen percent of respondents reported being at rehab for 90 days to six months; 8% from six months to one year; and the smallest group, in treatment for more than one year, had 2% of respondents.

length of time in treatment

Experts The Fix spoke to were pleased to hear that such a large number of people had been in treatment for longer than a month—because, as a result of the influence of the cost-cutting insurance industry, the length of time in treatment is becoming ever shorter. Furthermore, as Dr. Carise pointed out, many different studies have shown that 90 days is an ideal length of treatment—which of course calls to mind AA and other 12-step programs’ emphasis on 90 days.

“Did AA know stuff we didn’t know, or did AA get lucky?” asked Dr. Carise. “Over and over, a 90-day length of stay is a better predictor of success in terms of sobriety.”

Hunter R. Slaton is the Rehab Review editor for The Fix. Special thanks to all-star intern Gabi Wuhl for compiling the data used in this report, and to Product Manager Jason Gotlieb for creating the charts and graphs.

Our research into the rehab industry is ongoing. If you've been to treatment, The Fix wants to know how it went. Click here to complete a Rehab Review survey for the treatment center you attended.

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