Opinion: You Probably Don't Need Rehab

By Ian McLoone 02/23/17

Studies have called into question long-held notions such as "once an alcoholic, always an alcoholic" and that long-term recovery requires abstinence from all substances.

Ian McLoone

Going to rehab has become today’s penance ritual. When a celebrity gets caught cheating on his wife, a politician gets in trouble for sexting with an underage teen, or a pop star gets busted for DUI, the next step in the image-repair playbook is heading off to rehab.

It's almost cliché at this point, even though these are hardly the right reasons to enter an addiction treatment program. But what if you find yourself drinking too much or feeling unable to kick your opioid habit on your own?

Surely the next step for you should be a 28-day rehab program, right?

Not necessarily.

Turns out, you might not need rehab either, even though you won't find many people willing to tell you as much. 

It's a dirty little secret in our industry that outcomes for residential programs are essentially similar to outcomes for intensive outpatient programs. In fact, a famous 1977 study seemed to put this question to rest, when researchers found a single session of alcohol-related “advice” produced equivalent outcomes to several weeks of inpatient and outpatient treatment, among men with serious alcohol use disorders.

Among researchers and academics, it doesn't seem there's much debate as to whether rehab is the best treatment for addiction (it isn't), so why is it still the go-to approach for the entire spectrum of substance use disorders, whether mild, moderate or severe?

To answer this, one has to understand the history of modern addiction treatment in the US. Alcoholics Anonymous started back in 1935 when Dr. Bob took his last drink. He and Bill W., over the course of the next several years, developed a 12-step process for alcoholics to achieve recovery. The program spread across the country as the medical field was happy to allow AA members to use wards of the hospitals that were sitting empty, thanks to the advent of antibiotic and vaccine treatments for tuberculosis.

Then, between 1948-1950, three Minnesota facilities, Hazelden, the Pioneer House, and Willmar State Hospital, came together and developed the first replicable model for the treatment of alcohol use disorder: what would become known as “the Minnesota Model.”

The approach involved approximately four weeks of residential care, during which patients would first “dry out” and stabilize, get oriented to the 12-step program via groups and lectures, and then be discharged into the community to begin the “real work” of 12-step recovery.

They acknowledged that, while a period of stabilization was helpful, it was the long-term work of building a recovery program and learning to live a life without addiction that truly mattered - only so much can possibly be achieved in such a short time.

But here we are, 65 years after the advent of this model, yet it still forms the basis of 80% of all programs in the US. This wouldn’t necessarily be such a bad thing, except for the fact that we have devoted millions and millions of dollars into high quality, taxpayer-funded research into cutting edge and effective treatments for addictions that has not made its way into the community.

We also know that some of the ideas and wisdom which form the basis for this model do not stand up to scientific scrutiny, which means that people are at risk of conflating myth and lore for sound medical advice.

One example of the massive, taxpayer-funded research that totally shifted how we see substance use disorders is the National Epidemiologic Survey on Alcohol and Related Conditions (aka, the NESARC Survey), performed by the National Institute on Alcohol Abuse and Alcoholism (NIAAA). The largest study of its kind, it is comprised of in-person, structured interviews with a nationally-representative sample of over 43,000 US adults.

The first wave of data was collected at the beginning of this century and additional waves have been, and continue to be, collected over time. The information gathered has resulted in an enormous paradigm shift, as we had not previously had a good understanding of very basic questions:

  • What is the typical course of addiction and substance use in general? 
  • What are common drinking patterns among US adults? 
  • What types of drinking patterns tend to put people at greater risk of developing substance use problems?

Turns out, the conventional wisdom surrounding alcohol use and alcoholism was deeply flawed in the majority of cases.

For example, the notion that “once an alcoholic, always an alcoholic,” that abstinence from all substances is the only way to achieve long-term recovery, or that most people need some kind of specialized help in order to overcome substance use problems were all thrown into question.

In fact, this study told us that, among people who had meet criteria for a severe alcohol use disorder 20 years ago, the most common outcome for people was non-abstinent recovery.  

It told us that people who achieve recovery from one addiction are at the same risk of developing a second, new addiction as the general population. It also told us that some 75% of people with a substance use disorder achieve remission on their own, without any form of specialized help - including a 12-step group.  

Unfortunately, much of this insight has not made its way into the conventional wisdom of greater society, or even into the field of addiction treatment itself. We are still stuck in this idea that residential treatment must remain a first-line approach for problematic substance use, and that the only way to achieve recovery is a commitment to lifelong abstinence.

While this is definitely true for many people, and that residential rehab has helped save a lot of lives, the entrenched nature of these ideas also keeps a lot of people from seeking help - as they would rather wait until it was no longer humanly possible to put it off any longer, because doing so would mean saying goodbye to your career, family, and life for an entire month.

But we can make addiction treatment more appealing, while still making sure it is scientifically sound and actually effective, so why aren’t more programs following suit? That’s a question for another column.

In the meantime, call around and talk to any programs before committing the time and the money. Find out what their approaches are and what outcomes they produce. You might just find that you don’t need rehab after all. 

Ian McLoone, LPC, LADC is the Lead Therapist at Alltyr Clinic in St. Paul and holds a master's degree from the University of Minnesota's Integrated Behavioral Health program, where he teaches a course on applied psychopharmacology for addiction counselors. He is dedicated to promoting paradigm change in the field of substance use disorder care and making scientifically-informed treatment available to all.

Disclaimer: The viewpoints expressed by the author do not necessarily reflect the opinions, viewpoints and official policies of The Fix.

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Ian McLoone, LPC, LADC is the Lead Therapist at Alltyr Clinic in St. Paul and holds a master's degree from the University of Minnesota's Integrated Behavioral Health program, where he teaches a course on applied psychopharmacology for addiction counselors. He is dedicated to promoting paradigm change in the field of substance use disorder care and making scientifically-informed treatment available to all. You can find Ian on Linkedin or follow him on Twitter.