How to Choose The Best Rehab

By Constance Scharff PhD 04/08/14

What you need to know when choosing an addiction treatment center.


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You’re thinking about rehab. You or someone you love has a serious problem with drugs or alcohol, or what is called a “process” disorder, like gambling. He or she may also suffer from depression, anxiety, or another psychological issue on top of addiction. It’s not getting better on its own…and it isn’t going to. You have to do something now. Right now. But you don’t know what.

This report was put together to help you with the task of finding a quality rehab for you or your loved one. It was compiled to help you know exactly what the addiction rehabilitation process looks like – from beginning to end – and to help you ask the right questions of the addiction treatment center you have chosen. Choosing an addiction treatment center is not a task to be taken lightly. This report gives you a place to begin, so that you will find the best treatment center for your needs. 

Since cost is usually one of the first questions posed when someone inquires about rehab, let’s first consider money. 

The Financial Impact of Addiction

The financial impact of addiction cannot be underestimated. Addicts have trouble maintaining employment. Most move from job to job, then work intermittently and are finally unable to work at all. The vast majority of employees can be easily replaced, and therefore are replaced when their work output is no longer sufficient to meet expectations. Entrepreneurs are often among the first to lose their careers, because businesses can be fragile and if not given the proper attention, fold. This impacts not only the business owner and his or her family, but the business’ employees as well. A few who are in fields requiring a great deal of talent that cannot easily be replaced – professional athletes, “A” list actors, music stars, and heads of companies – may be able to maintain their work lives longer than others because of the specific role they play. But even these people will eventually lose their jobs when they become a liability to the group, company, or project. 

Once income has been lost, addicts turn to conventional means of obtaining money. They will pawn or sell items they own. They will max out credit cards and take out loans. Lines of credit will be added to houses. This process will buy the addict some time, but will create a mountain of debt that is not easily overcome. 

During this period of obtaining money through legal means, the addict will often begin to miss bill payments. Sometimes a spouse or a parent will step in to ensure that bills are paid. But most of the time, late fees and other penalties will begin to rack up. The utilities may be shut off. Cars may be repossessed. Some bills will fall into collections and the addict and his or her family will be harassed. All this creates turmoil and stress for the addict and those who share his or her life. This stress further pushes the addict to use more.

Eventually, when legal means of obtaining money are exhausted, the addict will look to family and friends for “loans.” These are not really loans because the addict knows that s/he will not be able to pay them back, at least in the short term. Some family members or friends will give in to the addict’s demands for cash, not wanting to see the one they love end up on the street with nowhere to go. But unless the addict comes from a wealthy family, this period of being bailed out will be short lived. Families often struggle simply to take care of themselves. While they may be able to afford the living expenses of another person in addition to supporting themselves, the cost of addiction – living expenses and the high price of most drugs – is more than most family budgets can take. The addict will frequently find him/herself cut off before the entire extended family goes down. In those cases where s/he is not cut off financially, many family members may have to make sacrifices to keep the addict clothed, housed, and high. 

At the end of the road, the addict will be forced to become involved in illegal or degrading activities in order to maintain his or her drug habit. This does not always mean homelessness. There are women who will get involved in pornography, which can pay decently, in order to survive. Others may find wealthy people to support them. Some addicts, whether they call it prostitution or not, will trade sex for drugs or money. Many will steal, first from family and friends and then from others. Some will sell drugs. Some will become identity thieves and steal in that way. This is how the cycle of going to jail or prison begins for addicts. Once this part of the cycle has begun, it is terribly difficult to stop. But when all legal opportunities to earn money are gone, illegal activities are the addict’s only option.

The truth is that most addicts are broke when they are ready to seek treatment. Few will be employed and fewer still will have access to great insurance that will cover their treatment. Families may or may not be financially exhausted by the time the addict is ready to seek treatment. Not only has addiction destroyed an individual or family’s financial stability, this financial ruin can impact the quality and duration of treatment available to the addict. 

The Cost of Rehab

Sticker shock is the first response most people have to addiction treatment services. Mid-price treatment centers run around $30,000 per month and many in that range are not-for-profit. High end or luxury treatment centers are more expensive and can easily cost $60,000 per month or more. Keep in mind too that it is a myth that treatment should run 28-30 days. This was a designation created by insurance companies, not addiction treatment professionals, psychologists, or physicians. To get a real grasp on recovery, in the best case scenario, most people require longer-term treatment, with 90-120 days of residential treatment followed by a comprehensive aftercare program. In reality, to give yourself or your loved one a solid foundation in recovery, expect to spend between $100,000 and $250,000 in the first year, assuming insurance covers none of the treatment costs. 

Take a moment and breathe. Now that you’ve pulled yourself off the floor, think about what you are undertaking. If your loved one had heart disease or cancer and required specialized treatment, you would expect to receive medical bills to go along with the treatment. Addiction is no different. To get out of paying for quality addiction treatment, many insurers require addicts to “fail out” of outpatient treatment before higher levels of care will be covered. The problem with this is that those who “fail” frequently do so by overdosing and dying. Can you imagine what you would say if your insurance company required that your loved one with cancer “fail” a treatment known to have a very low success rate before providing a treatment with a higher success rate…all the while the cancer is growing and progressing? This is one of the hidden financial repercussions of addiction. Treatment costs money, and the family, just as it paid for the addict’s addiction, will need to find a way to pay for his or her recovery. 

What to Look for in a Residential Addiction Treatment Facility

It is estimated that people spend more time researching what kind of new car they want to buy than they do researching which addiction treatment center they will send their loved one to. This may be due in part to not knowing what to look for in an addiction treatment facility.

The most important aspect of an addiction treatment facility to consider is its treatment protocol. Inexpensive or high-end, the best treatment facilities offer evidence-based treatment protocols. 

Evidence-based treatment means that research has been done into the various therapies the treatment center uses. The research has usually been done at universities and published in peer-reviewed journals. These therapies are then used by treatment centers. These are therapies that are proven by outside sources to be effective at helping people maintain their sobriety. Evidence-based treatments are generally used in low-cost treatment facilities that rely on grants and donations to keep their doors open and in a handful of high-end treatment facilities. 

Be wary of treatment centers that do not track or do not give their long-term success rates. Some treatment centers make a business of repeat clients. They promise results in 30 days and keep patients coming back for 30 day stints at every relapse. This is not recovery. You want to send your loved one to a treatment center with a proven success rate, a treatment center that wants you or your loved one to get a solid grasp on recovery the first time, then free the bed up for someone else. There are enough addicts in this world that no treatment center needs to rely on repeat business to keep its doors open. 

Be careful when considering treatment centers that are 12-step based or that use “medical” or “pharmaceutical” recovery tools. 12-step programs are no longer the gold standard in addiction treatment. They are also free and widely available outside of addiction treatment centers. 12-step programs are wonderful as part of recovery support and provide an invaluable system of friendship and accountability for those who use them. But as a primary or sole place to get sober, they are estimated to have a poor long term success rate. It is believed that at one year, only 8-13 percent of those who have tried to use 12-step programs as their primary treatment are still sober. Evidence-based treatment programs are significantly more successful. 

Pharmaceutical or medical recovery programs avail themselves of the long-term use of drugs like methadone, Suboxone, and Subutex. Essentially, these treatment programs just switch the addict from one type of addiction to another, without giving them the tools to get completely sober. Some physicians, insurers, and of course pharmaceutical companies like this type of “treatment” to “manage” addiction, but it fails to recognize and encourage the addict’s willingness to live a completely drug free life. Recovery is about living the life of your dreams, not a half-baked, half-drugged life. Certainly these medications have some value, but for anyone with a desire to truly experience life, drug dependency needs to end. 

Treatment programs that are highly individualized are preferable to those that are not. It is commonly accepted that quality treatment involves helping the addict find and heal from the underlying causes of addiction. This is generally some sort of deep-seated emotional or spiritual pain. Treatment protocols that shuffle a person between groups throughout the day are relatively inexpensive for treatment centers to run, but do not give the addict the resources to look at his/her very personal and individual problems. Daily or near-daily one-on-one psychotherapy and access to a personalized treatment plan is optimal. This does not mean that groups are bad. All treatment centers provide some group therapy and these groups are an important part of the recovery process. The best treatment is a combination of these modalities and a focus on your or your loved one’s individual needs. 

Finally, look for treatment facilities that are non-punitive. It’s easy to be angry with your loved one for being an addict. But addicts already feel incredibly low about themselves. They don’t benefit from being in facilities that confiscate their telephones, restrict their access to the internet, or force round after round of chores. Those are punitive measures that serve only to belittle the addict. These practices are demeaning and play no role in treatment. If you want to leave treatment, you will do so whether you have access to your cell phone or not. If your loved one doesn’t know to make his/her bed in the morning, s/he can learn to do that for free from a sponsor in a 12-step program. Treatment should be a time to make a commitment to focus on the underlying causes of addiction. Let the treatment center staff keep the bathrooms clean while you or your family member spend every minute in treatment getting better. 

What to Expect in Rehab

If you find a quality rehab – and there are quality residential treatment centers in every price range – you will be warmly greeted by people who genuinely care about you. They won’t know you or your loved one yet, but they do understand the suffering every addict endures and they want that to end. They know what transformed lives look like. They want that for you and the ones you love.

Addiction treatment is certainly work, but it is much, much easier than the life of active addiction; in many ways, treatment won’t feel like work at all. Though addiction treatment is emotionally draining, waking up every day in a safe, comfortable room, being provided with delicious, nutritious meals, and being helped to face and move beyond the most difficult experiences of your life will most of the time feel like a relief. Drug seeking is hard. Blowing up and regretting the damage caused in relationships is hard. Dodging all the people you’ve harmed in your addiction is hard. Seeing the disappointment in your parents’ or children’s eyes is hard. By comparison, addiction recovery is easy; it is an opportunity to set right the wrongs in your life. You will find time to begin to rebuild family relationships and the self-esteem that will allow you to re-engage in life – on personal and professional levels. If you have trouble with the law or with creditors, you will be able to make plans and have support in meeting those challenges head on. The treatment center staff will be your support through the entire process.

Day by day, your time will be filled with healthful activities. You will awaken at a particular time to engage in many different activities: meditation, exercise, psychotherapy, 12-step meetings, yoga, group therapy, and other complementary therapies. With your personal psychotherapist, you will engage in the deeply personal work of figuring out why you began using in the first place and repair those old wounds. You will also reach out, when appropriate, to your family, so that healing those relationships can begin. You will have time for personal reflection, for journaling, for stress-relief practices like art or massage (if your treatment center offers it) and recreation. And you will find camaraderie. You will get to know the people who are in treatment with you and odds are, you’ll begin to care about a few of them as they will begin to care about you. You may attend 12-step meetings where you will also develop relationships. These friendships can play an important role in helping you stay sober. Everything you do in a day at the treatment center will be designed to help you build and maintain your recovery. That’s what quality treatment is all about. 

There will be times in treatment when you will want to quit. You will have uncomfortable feelings that will make you want to return to drinking, using, or acting out in general. You may be tempted to form inappropriate sexual relationships into which you can escape instead of doing the work of putting your life in order. This happens to almost everyone. Addiction treatment is fraught with challenges. Do not be discouraged. The staff at the treatment center will be available to help you through these difficulties. The important thing is to recognize that these feelings are normal and you will get through them. Addicts don’t know how to deal with discomfort. Part of the recovery process is learning to live through normal emotional fluctuations and challenges without having to use. These feelings too shall pass. Your treatment team will help you. 

Withdrawal Need Not Be Frightening

One aspect of recovery that tragically keeps many addicts from attempting to get sober at all is detox. All addicts have had a taste of withdrawal symptoms. They are horrific and terrifying. Whether it’s the shakes, nausea, hot or cold flashes, or arguably the worst of all – experiencing emotions – no one wants to experience withdrawal. But this need not be a concern any longer. Almost every treatment center now uses medically supervised detoxification for all patients. 

Withdrawal is what occurs when the body detoxifies from a substance that has been abused. Depending on what drugs were used, how long, and in what dosages, the symptoms and severity of detox can vary. What does not vary is an addict’s fear of detox. S/he “knows” it will hurt and wants no part of it. It is these withdrawal symptoms themselves that are part of the addict’s trigger to use drugs again. Every addict knows to take another hit or drink before s/he starts to feel the first twinge of withdrawal symptoms. 

In the past, addicts just had to “sweat it out.” We’ve heard horror stories of alcoholics with the shakes or delirium tremens being locked up in psych wards. That may have happened in the 1930s, but addiction treatment has advanced considerably since then. The standard practice is for medical doctors to use a combination of pharmaceuticals to support a safe, pain-free detoxification from drugs. Some addicts can be put to sleep for the worst of the detox symptoms. Others will remain awake, but kept relatively comfortable with pharmaceutical assistance. Medical doctors will administer a variety of drugs to ease all physical and psychological withdrawal symptoms. Addicts will be monitored to avoid problems, like seizure, whenever possible. The level of discomfort to be expected should be no more than experiencing a mild flu. Diarrhea, constipation, anxiety, sleeplessness, muscle aches, nausea - all the typical symptoms to be expected can be comforted and diminished if not avoided during the detox period. 

Why do treatment centers use medical detox? Not only is it humane, but it also gets and keeps addicts in treatment. Why would an addict come to treatment and stay if s/he had to experience horrifying withdrawal symptoms? That’s exactly the kind of experience that would send an addict back to using. Few can go through unassisted withdrawal without breaking and in some cases, such as from alcohol, withdrawal can be deadly if not medically supervised. Rehabs want addicts to succeed. In order to get to the heart of the addict’s problem, the treatment center must get the addict through withdrawal as comfortably as possible, to give him/her the strength and courage to make the changes necessary to lead a sober, meaningful life. The physicians who specialize in detoxification know the latest medications and therapies available to help addicts through withdrawal. You or your loved one will be in good hands with an experienced medical detox specialist. 

Also, please note that detox is commonly covered by many medical insurance policies. Be sure to look into this when you’re asking questions of your rehab facility.

The Various Types of Rehab

Addiction treatment facilities are not all the same, and each type of rehab has a different idea about what constitutes quality treatment. Each facility’s treatment protocol will be based on its particular philosophy. These categories are not mutually exclusive. For example, you can have a faith-based facility that uses some evidence-based therapies. However, a single philosophy underlies or is emphasized in each treatment center; that is how they are categorized. Here are descriptions of the six most common types of addiction treatment centers:

Evidence-based: Evidence-based treatment facilities underpin their treatment protocols on the science of addiction recovery. They offer treatment, usually psychologically-based with adjunctive therapies, based on scientific research into what works for addicts. Their treatment protocols change consistently, depending on the results of the latest research. Abstinence from mind-altering substances is the goal.

Faith-based: Faith-based rehabs focus their attention on the spiritual aspect of recovery. Most will use 12-step programs in conjunction with religious ritual and practice. Their underlying belief is that God is the one who grants recovery. Most faith-based treatment programs in the USA are Christian, though there are a handful of recovery centers for individuals of other religions. Organizational treatment programs funded by religious groups, such as the Salvation Army’s recovery programs, often fall into this category. These are abstinence based programs.

12-step-based: 12-step-based programs base their therapies on the 12-step philosophy and literature of Alcoholics Anonymous and its offshoots. Through group work, attendance at meetings on and off site, work with a sponsor, and “working the steps,” individuals will look at their addiction through a 12-step perspective. Again, 12-step based programs will include other treatment modalities, such as one-on-one psychotherapy and complementary therapeutic practices, but the foundation of the recovery program is 12-step-based. These programs are abstinence programs.

Medicine-based: These treatment centers view addiction as a disease that needs to be medically managed, similarly to diabetes. The long-term use of medication such as methadone or Suboxone is prescribed to manage addiction. Many classify these types of programs as harm-reduction programs, because they are transferring the addict’s drug dependence from one drug to another. Medicines like methadone or Suboxone replace heroin or other opioids. 

There are some medicines that deter drug use. For example, Antabuse is a drug that makes alcoholics ill if they drink. These kinds of medicine-based treatments are used to help prevent relapse. These are harm-reduction or addiction management programs; they do not require drug abstinence. 

Other (non-12-step-based): There are some treatment centers that do not fit into any of the previous categories. These treatment programs offer “cures” without using evidence-based treatment protocols. They are generally anti-12-step and non-religious. These centers suggest that they have worked out their own way of treating addiction unlike anywhere else. The problem is that they may not have the proof of success to back up their claims. These may or may not be abstinence based.

Harm-reduction based: These treatment centers believe that addicts may not be capable of complete abstinence or may not want to stop using entirely. They work from the philosophy that an addict may be able to lessen the amount of a substance s/he takes. From this point of view, it’s okay to have a glass of wine with dinner and they work to teach you or the one you love how to do just that – keep a lid on the addiction, but allow some substance use. These types of programs, for example, will suggest that smoking marijuana now and again is fine so long as it isn’t leading to other problems. 

Some harm reduction programs are found outside treatment centers. An example would be needle exchange programs. The idea in this scenario is understanding that not all addicts want or are ready for help, so to try to stop the spread of life-threatening diseases such as HIV and hepatitis, communities will provide free, clean needles to IV drug users. The risk of disease transmission is reduced, even though the addict continues using. 

Does Evidence Support Rehab?

The answer to this question is both yes and no and depends on the quality of the care and the length of stay in rehab. Poor quality care or insufficient time in treatment will result in failure. Willingness also plays a role. Is the addict willing to do what is asked of him/her? Getting sober means facing the pain that holds a person back from being his/her best self. Even reluctantly, the addict must be willing to address those issues in order for treatment to work. 

What does the scientific evidence say about treatment? Several things: 

1. The most effective type of treatment is evidence-based. Evidence-based treatment centers are the most likely to track and share their long-term success rates. This may be because they are consistently looking for best practices and cutting-edge therapies that will improve their treatment outcomes. Evidence-based treatment does not adhere to a specific philosophy about what works. Rather, its goal is to consistently improve outcomes. These improved outcomes will fill beds, so there is no fear of changing protocols. However, these treatment centers tend to be more expensive, because providing top-quality treatment providers for all the different treatment modalities and complementary therapies is a relatively expensive endeavor. 

2. The evidence suggests that highly individualized programs are superior to managed-care therapies. Imagine if your loved one had cancer and was in a cancer treatment facility. What if all the people with cancer – with no concern at all for type, advanced stage, or anything else – were given the exact same treatment? You would remove your loved one immediately from this hospital and seek out a treatment facility that helped your loved one based on the exact nature of his/her problem! Expect no less from an addiction treatment center. Managed care keeps costs down and profits up, but does little to help the addict long-term. 

3. The research is very clear that longer term care is superior to shorter term care. The idea that quality treatment can be completed in 28-30 days has no basis in science. In fact, the 28 day treatment model was developed because that is what insurance would pay for, not because it works. Most addicts, to get a firm foundation in recovery, require 90-120 days of residential treatment and a solid aftercare plan that continues post-treatment support for the first year of recovery. Addicts are broken when they enter treatment and fragile when they leave residential care. They need a supportive plan to keep them on the path of recovery. 

4. After residential treatment, a quality aftercare plan is critical to long-term success. Who hasn’t heard about a person who went to rehab and then immediately returned to using? Others relapse a little later on, after slowly slipping back into their old lifestyle. An aftercare plan, which most treatment centers provide in one form or another, suggests exactly what an addict needs to do outside the treatment center to continue his/her lifestyle of recovery. Some treatment plans are simple or generic, suggesting attendance at 12-step meetings and perhaps some psychotherapy. Others are detailed and individualized, expecting that the individual will continue with most of the activities begun in the treatment center, including intensive individual psychotherapy, group therapy, acupuncture, exercise, proper nutrition, attendance at 12-step meetings and other activities. For many people, moving to a sober living situation is also suggested. It isn’t the number of activities that is important in the aftercare plan, but the creation of a quality plan that outlines activities that are designed to give the addict enough support and guidance to maintain recovery outside the safety of the treatment center.

5. More than anything else, support is key to an addict’s success outside a residential treatment setting. For some individuals, this support comes from family and friends. For others, they will find the support they need in 12-step meetings. Still others will find a team of professionals – psychotherapists, physicians, clergy, etc. – to guide them. Most will depend on a combination of these people. In all cases, addicts require people they can turn to in times of trouble. All addicts will experience troubling moments after treatment. That’s the nature of life. There will be times when situations arise that the addict does not know how to handle. A healthy support network can cocoon the addict and help keep him/her from harm, many times simply by being available to talk. When cravings or fears are put out in the open and discussed, they are much harder to act upon than when they are kept secret. 

Are All Rehabs the Same?

As you’ve noted by this point, all rehabs are not created equally. They have different guiding philosophies and different treatment protocols. They also vary with regard to expected length of stay and price. Further, some treatment centers will treat addicts punitively, by taking their phones and forcing them to do chores while others will focus entirely on recovery, not on domestic competence. 

In addition to these differences, you will find marked differences between treatment centers both in the quality and competency of the staff and the relative comfort of the surroundings. Some treatment centers keep costs down by employing staff who have lower levels of skill than others. Find out if the rehab you’re interested in uses “techs” or fully licensed psychologists to run groups, for example. Techs are generally individuals who have recently gone through treatment themselves and who have no qualifications to run groups other than being alcoholics or addicts in recovery. Often, these individuals are early in recovery (less than five years sober). They run 12-step style meetings, meditations, and other peer-style support groups. Higher quality centers will employ licensed psychotherapists to facilitate group therapy in very small groups, so that all individuals get a true chance to share. This is only one example of the difference between staff members at treatment facilities. 

The type of accommodations varies from facility to facility as well. Will you or your loved one stay in a dorm style room with three or more beds in it, or a private room? Will bathrooms be shared? How are rooms cleaned? Do you have any control over whom you room with? The amount of privacy an individual has during treatment can make a big difference to those who need time alone. Others enjoy having company. Some rehabs provide hotel-style rooms or bungalow cabins and others a line of cots. Food may be gourmet or cafeteria style. The setting may be urban or rural, with access to gardens, hiking trails, beaches, forests – or none of the above. Type and quality of living conditions is perhaps not the most important feature of choosing a rehab, but it can be the difference that makes a difference. If you have specific needs, make sure that the facility can meet them. 

Rehab vs AA or Other 12-Step Programs

Rehab is great. 12-step programs are great. But they are not the same thing and they are not interchangeable. 

Rehab is designed to help addicts detox from the substances they are abusing and give a foundation for recovery in a protected environment. This setting provides a high level of care and most major influences of the “outside” world are kept out of the treatment setting. The safe environment allows the addict to become vulnerable and really focus on the work of overcoming the pain of his/her past. A lot of addicts can’t do that kind of deep work outside the safety of a treatment center. They need more time and space than even intensive outpatient psychotherapy can give. They don’t have the skill to open up and put everything back in place in an hour session so that they can function in the world. Residential treatment provides the opportunity to go into the deepest places of the addict’s emotional and spiritual life with the safety to make changes. It can give a foundation for recovery in the first few months that nothing else can provide.

12-step meetings are a type of self-help or peer support group. The rooms of 12-step programs are full of people who have recovered from addiction and seek to keep themselves sober and help others do the same. In 12-step meetings, an addict will find peers and guides who understand his/her struggle with addiction. They will make themselves available day or night to help when times are rough. They will listen to problems and good sponsors or others will help find solutions. They will help members find a spiritual path and volunteer activities with other addicts that add meaning to the addict’s life. In short, they “get” what you or your loved one is going through. They will not judge, but also won’t put up with a lot of acting out. 12-step programs can provide a lifetime of support. 

There need not be an either/or relationship between treatment and 12-step programs. 

What are the shortcomings of each activity? Rehab is short term – a few months at most. It is for people in the first hundred or so days of recovery (or for addicts in recovery who have taken pain medication for a medical condition and may need a short stay in a treatment center to prevent a relapse into full-blown addiction). Though it provides tools for living, the main goal of treatment is to provide the skills necessary to live fully and freely outside the facility and to handle the difficulties of life with grace and dignity. Recovery is a life of freedom, not institutionalization! 12-step programs provide outstanding support, but they have a very low recovery rate for those who use them without any other adjunctive therapies – about 8 – 13 percent at one year. Nine out of ten people who use 12-step programs as their only form of treatment will not remain sober for a year. 12-step groups cannot buffer “newcomers” from the challenges of life or the temptations of the world in which the addict lives. They provide relative safety only for the duration of the meeting. Many addicts need more support and a greater variety of therapies than 12-step programs alone can provide. 

Outpatient Treatment – Why It Fails to Work

Outpatient treatment programs attempt to provide the therapies of a residential treatment program without the insulation and safety of being secluded in a treatment setting. In an outpatient treatment program, you or the one you love might spend the day engaged in exactly the same type of activities you might in a residential setting: one-on-one psychotherapy, group therapy, 12-step meetings, yoga, mindfulness meditation, etc. But then the individual is sent home, after being vulnerable and open all day, intensely looking at the raw and wounded places in his/her psyche that caused his/her addiction, and is expected to live in the environment in which he or she used drugs without succumbing to ingrained patterns of using again. Does that make any sense at all? 

If an individual can get sober without the safety of a residential treatment program, s/he will likely be among the 10 percent or so of people who can find recovery with 12-step meetings alone. These people will find that their lives and the quality of their recovery will improve if they also see a psychotherapist and engage in activities that promote a healthy lifestyle, such as exercise and healthy eating. For all others, residential treatment is optimal. 

Outpatient treatment would be appropriate as a stepped-down level of care after residential treatment has been completed. For some, 90 days of inpatient treatment may be enough to give them the tools to live outside the safety of a residential facility, but not enough to return to their homes. A good combination of care for those who have struggled to recover many times and have a history of relapse is residential care followed by outpatient care and residence in a sober living facility. They can then transition out of outpatient services and get a job while continuing to reside in sober living. Only after that will the addict have the skills and experience to transition back home. 

The demand of insurance providers that the addict “fail out” of outpatient treatment before being given residential treatment is inhumane and kills people. It is not the level of care most addicts need to recover. Again, the addict who will thrive in outpatient treatment is a member of the 10 percent who will do well with 12-step programs. Most addicts need more care in the initial days of recovery than outpatient treatment provides. 

Determining Your Length of Stay

It has already been established that 30 day programs are most often insufficient in duration to help the addict address the underlying causes of his/her addiction and to provide the skills and confidence necessary for the addict to remain clean in his/her community. On average, most people need 90-120 days in treatment to be able to safely step down to a less restrictive level of care. How will you know when you have been in treatment long enough to make a change? 

The truth is, you won’t. No matter how comfortable and luxurious the treatment setting, and there are some that are pretty fantastic, few people want to stay in rehab any appreciable length of time. Most addicts want to leave early and many do. 

To know when you are ready to leave treatment, you will have to rely on your treatment team; primarily the opinion of your case manager or primary therapist, depending on the facility. They will have a comprehensive and unbiased view of your recovery and will know when you are ready to be discharged. 

Some addicts challenge that the rehab wants people to “extend” (stay longer) simply to make money. This is patently false. Quality treatment facilities very often have wait-lists. There is frequently someone waiting for a bed to be vacated. Furthermore, licensed treatment staff members are trained to evaluate readiness to move to a different level of care. The only reason staff members suggest an individual stay in treatment is because they are unconvinced that the individual has the skills to be successful outside the treatment center. 

Keep in mind too that rehabs will discharge individuals who refuse to do the work of recovery. They want people in the beds who not only need treatment, but want treatment. That is what creates the optimal environment for all the people in the recovery center. 

Special circumstances may warrant a longer or shorter term stay in residential treatment, but expect going in that you will be asked to stay in the range of three to four months. 

How to Get the Most Out of Your Inpatient Stay

1. Do what is suggested of you. You might never have touched a horse, but if equine therapy is suggested for you, try it. If you are asked to keep a journal, do it. If you’re asked to draw a picture of your feelings, what do you have to lose? Remember, you signed up for this! While some of the things you’re asked to do might seem silly, they are designed to work together to help you develop the resilience to live addiction free. Try everything. It just might work.

2. No matter how you feel, stay in treatment. If there is one thing addicts hate, it is feelings. Emotions are not something addicts are equipped to deal with. In speaking with your therapist and uncovering the reasons you needed addiction to cope with your feelings, you will walk through uncomfortable places. Don’t give up. This is part of the process and it will pass.

Sometimes too, good feelings will come up. After detox and a short period in treatment, addicts often feel so much better physically that they think they are “cured” and ready to go home. Just like the negative feelings, the “pink cloud” of health is an experience that is short-lived too. Don’t think that just because you’ve felt good two days in a row that you are prepared for all that life will throw at you outside the treatment setting. Listen to the facility staff. If they say to stay, even though you feel great, believe them that you’re not ready to go, especially if you’ve only been in treatment a few weeks.

3. Use the safety of the treatment center to your advantage. At the treatment center, there are no parents, bosses, spouses, children, or others placing demands on you. You will be provided with all your basic needs and a supportive community. You will not walk through your old playgrounds where you know every dealer or bar on the street. You will be surrounded by people who genuinely care about you and your recovery. Don’t squander this gift. Use this time selfishly – to focus on you and what you need to overcome your addiction. The safety of residential treatment will undoubtedly be one of the greatest gifts you receive from treatment.

4. Expect feelings to arise. Addicts use substances and behaviors to push away feelings. Without those substances and behaviors, feelings are going to come up. They will at times seem overwhelming. You will be uncomfortable and you will not like the experience. But with each experience, you will become stronger and more capable of understanding and moving through your emotions. In a short time, you will begin to experience pleasurable emotions – joy, self-respect, and a sense of well-being. This too is part of the process. 

5. Don’t judge your process. Someone else in rehab with you is going to be richer, smarter, prettier, or get better faster than you are. Alternatively, there are going to be people who are worse off than you and you might be tempted to feel superior. Let the judgment go. You are who you are. They are who they are. You’re on different paths. The truth is you are neither the highest nor the lowest form of life on the planet; you’re just a person doing the best you can under very trying circumstances. If you have to cry, cry. If you want to scream, do it. If you find yourself feeling inferior or superior, tell your therapist about it. Then move on. Judgment only gets in the way of the work and of your recovery.

The Reality of Life after Rehab

Perhaps the greatest disservice done to addicts and their families is that society has the expectation that the addict will go to treatment and somehow emerge “healed” after 30 days. That is not at all how treatment works. Families also very often have the notion that the addict is the “broken” one and if s/he stops using, all will be well. This also is false. All members of the family system must change the way they interact with one another or the addict will return to using. If the family dynamic supported addiction, it must change so that addiction is no longer a viable way of diverting attention away from the family’s problems. 

The truth is that in addition to the addict needing serious help, the entire family system is damaged. The addict goes to treatment to learn ways to bring him/herself into recovery, to build a new life in which s/he has the skills to cope and thrive. Meanwhile, the rest of the family must seek its own treatment and change in ways that provide room for the addict to return to different circumstances. This changed dynamic is critical to the addict’s recovery.

Expect the addict to remain emotionally fragile for the first year of recovery. There will be many firsts to be experienced. The addict will have to learn how to interact, work, be intimate, make future plans – all without relying on substances or behaviors to shield him/her from feelings and insulate him/her from the outside world. There also will likely be tremendous stressors in the addict’s life – from legal or financial problems to mending broken relationships. Dealing with these issues is not easy; far from it. Give your loved one the room to stop, breathe and focus before and during the process of dealing with these issues. The addict must know when to take a break and choose to get support when needed. 

Treatment does not “fix” the addict. Recovery is a process that takes time. Rehab only sets the foundation for recovery. There is much more to be done after leaving the treatment center. Be kind to yourself and the ones you love. One day, the trials before you now will all be a memory.

Staying Sober and Preventing Relapse

Going to rehab is by no means a guarantee that you or the one you love will stay sober. Treatment is just the beginning of the process. Yet relapse is neither imminent nor necessary. You can do things to stay sober and prevent relapse. Most importantly, keep in mind that it is easier to prevent a relapse than to come back from one. Use every tool available to you to remain sober in difficult moments. 

1. Take the option to relapse off the table. There is a saying in 12-step programs – “We don’t drink or use no matter what.” Relapse does not need to be an option for you. If you find yourself wanting to use, seek immediate help. Don’t let embarrassment get the better of you. People who relapse are more prone to relapse in the future. Don’t become a statistic. Use the tools you have to stay sober. The obsession will lift. 

2. Develop a support network. It may be members of your 12-step group, your family, friends, or professionals such as your therapist or psychiatrist. It may be an anonymous help-line or a member of the clergy. Have a list of people you can call and talk to at any hour of the day or night. Yes, you might feel the obsession to drink or use at a less-than-perfect hour. That doesn’t matter. There are people who will be there for you even when it isn’t convenient. Ask for help.

3. This too shall pass. Most relapses happen quickly. The urge to use comes up and the addict puts up little resistance. However, these periods of intense feeling usually do not last long. While you are seeking help, recognize that your feelings are going to change quickly and you will soon feel better.

4. Help someone else. 12-step programs understand this concept very well. If you are helping someone else, you’re not thinking about yourself and your problems. Call a sick friend and ask how they are doing. Go to a 12-step meeting and talk to a newcomer; ask about their day. Volunteer to do work that involves your hands – like building a home with Habitat for Humanity or grooming/walking dogs at the animal shelter. Not only will you build self-esteem by doing esteem-able acts, but you won’t have time to think about yourself or wallow in self-pity. 

5. Pray and/or meditate. There is a lot of power in prayer and meditation. That’s why so many treatment protocols suggest it. Life is tough and we are not usually in control. People get ill. Accidents happen. Circumstances change. There’s nothing anyone can do about any of it but learn to face these challenges with humility and compassion. In such circumstances, prayer or meditation can offer solace, a sense of well-being, right-sized responses to the situation, and sometimes even a feeling of direction and purpose.

Family Involvement in Rehab

Though some addicts have burned all their bridges and enter rehab with no family relationships, most addicts are members of robust – and often troubled – families. 

Families are systems. Members interact in a fluid dance which can be beneficial or detrimental to the system. The addict’s role is supported by the family system. In general, the addict’s acting out is the system’s way of saying, “Hey, there’s something really wrong here! We need help!” 

If the addict goes to rehab and returns to the same family system, s/he will relapse. It is almost inevitable. Why? Because the unchanged family system supports and expects addiction. It doesn’t work without the addict using. So the addict will use, because that is his/her role in the system. That’s how families work. 

For the addict to recover and the family as a whole to become a more productive and happier system, every member of the family must look at his/her role in the family. Through individual or group therapy and/or attendance at 12-step programs such as Al-Anon, every member of the family can develop skills for living that are healthier, more productive and serve to create positive interactions more frequently than in the past. In particular, family members will need to learn to set healthy boundaries, argue in respectful ways, and maintain realistic expectations of one another. This process allows the entire family, not just the addict, to grow, which benefits everyone in the family unit. 

How the family is involved in rehab will vary from treatment center to treatment center. Recognize, however, that the bulk of the work for the family is not done in the addict’s residential treatment setting, but can be begun while the addict is in rehab. 

Considering Rehab? Here are 10 Questions to Ask before Choosing a Facility

1. What is your treatment philosophy? You want to know if the facility uses a treatment plan that agrees with your sensibilities. If you’re an atheist, a Christian faith-based center would not be the right fit for you.

2. What is your success rate? Treatment centers that don’t track or disclose their success rates have no idea if what they do works. Choose a treatment center that cares enough about its alumni to know what happens to them at least one year post treatment. 

3. What is my expected length of stay? Quality treatment centers will tell you up front what their average stay is. Being asked to “extend” beyond 30 days should not come as a surprise.

4. What is the cost per day or month for treatment? While there are some charges that are additional, such as medications for medical detox, most of the fees for treatment are included in a monthly price.

5. Do you take insurance? The Affordable Care Act has decimated coverage for addiction treatment. Much of the “treatment” that is covered is low quality and short duration. Ask the treatment facility to work with your insurer to find out whether or not you are covered and to what degree. Find out if they have payment plans; some do. 

6. What role will my family play in treatment? Choose a facility that includes your family at a level that you are comfortable with and one that makes recommendations for family members to do work on their own while you are in treatment.

7. What level of licensure, if any, do group leaders have? While it is fine for 12-step type groups to be led by techs, you want a treatment facility that provides significant access to fully licensed therapists so that you can work with skilled professionals on uncovering the root cause(s) of your addiction.

8. What does a typical schedule look like? The purpose of this question is to find out whether or not your treatment will be individualized. The more individualized the treatment plan – choosing therapies and treatment modalities to fit your specific needs – the more likely you are to build the foundation you need for recovery. 

9. Is your facility licensed for dual-diagnosis patients? Approximately half of all addicts enter treatment with addiction and another co-occurring psychological or psychiatric disorder. This is called “dual-diagnosis.” Very often, the co-occurring disorder is anxiety or depression. If you believe you may have a co-occurring disorder, be sure that the treatment facility is prepared to treat both issues. 

10. Do you have a wait list? Many of the top treatment facilities will sometimes have a wait list. However, it is important to be able to get into treatment right away, while the willingness is there. A wait of a few days is considered acceptable. A wait of a few weeks is not. You want to go the best treatment center you can get into right way, not some time down the road. Addiction is deadly. Treatment cannot wait.


Bio: Constance Scharff has a PhD in Transformative Studies, specializing in addiction recovery.  She is the Senior Addiction Research Fellow and Director of Addiction Research with a private treatment center and coauthor of the bestselling book, Ending Addiction for Good. 

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Constance Scharff has a PhD in Transformative Studies, specializing in addiction recovery. She is the Senior Addiction Research Fellow and Director of Addiction Research with a private treatment center and coauthor of the bestselling book, Ending Addiction for Good You can find Constance on Twitter and Linkedin.