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Choosing a Rehab Based on Outcomes

It’s high time people act more like consumers when selecting an addiction treatment program, be it residential or outpatient.

Wouldn’t you want to know what your odds are if you are about to undergo any expensive surgical procedure? But I can find no evidence to show whether or not most people choose an addiction treatment based on facility outcomes – that is, on how well clients do after completing treatment.

Few places have outcomes, or reliable ones, to share. And in most cases, facilities have little or no data to offer.

Making an Important Decision

When seeking help for themselves or a loved one, consumers are typically in panic mode, trying to find a place quickly and efficiently, giving little thought to, “How effective are you at what you do? What are your outcomes, not only immediately after treatment, but down the road?”

When I asked participants of Inside Rehab how they made their treatment decisions, responses were widely mixed. One woman, whose daughter needed to get into a rehab quickly because of legal pressures, told me, “I had to scramble, not even knowing what rehab is, what a good program would entail, or how much it would cost. I got on the phone, called everyone I knew and got names of places.”

As well-educated professionals, she and her husband wound up choosing a residential program that “a lot of people said was good.” She told me,“I called there, and everyone sounded nice. What did I know about what a good program was?”

Common Methods of Choosing a Facility

The most common way people said they chose a treatment facility was after getting advice from a professional, which may or may not be a good source of information. Many professionals don’t really know what goes on inside specific programs.

For instance, Dorothy D.’s short-lived stay at her first rehab came after a recommendation from her family physician. The experience was so negative that she lasted there for less than a day. She said, “Oftentimes, family physicians just don’t have the knowledge to really help make a good decision for the patient.”

In asking people about how they chose their treatment facilities, there was no mention of “success rates” or program outcomes.-Anne FletcherThe next most common way that people made rehab choices was via the Internet. After going to three different programs, Aurora S. made her choice that way. She said, “Unfortunately I don’t think you can get an authentic idea of a place from the Internet because they make themselves look better [than they are], like an advertisement for a Big Mac.”

Some people made their selections on the basis of what they’d heard about programs’ reputations. Others chose places their relatives had attended. One person even went to a particular rehab because a famous athlete had gone there.

Quite a few made their choices out of cost or convenience – for instance because it was affordable or near home. Dirk B., who initially attended a traditional outpatient program, said, “I chose an affordable center that was located between my office and home.” But after three weeks, he had concerns about their approaches, did more research, and switched to an entirely different kind of experience.

Keep in Mind…

As mentioned in my last column, How Rehab Claims About ‘Success’ Can Steer You the Wrong Way, treatment outcomes have traditionally been tracked by keeping tabs on how many people continuously stay abstinent. This occurs partly because it’s much easier to track abstinence than on-again, off-again use or “cutting back” and also because traditional treatment facilities recognize only abstinence as success.

Note, however, that the criteria (from the DSM-5) used to diagnose people with substance use disorders – and also to decide whether they’re in remission – do not mention quantity and frequency of alcohol and drug use (aside from the criterion having to do with using more or longer than intended.)

If you want some idea of how people typically do following treatment, Thomas McLellan, Ph.D., co-founder of Philadelphia’s Treatment Research Institute (TRI), reviewed more than one hundred studies on how people fare in abstinence-oriented addiction treatment programs – both high- and low-end – and concluded that, overall, roughly half of clients use again over the course of the year following treatment. (He concluded that, overall, “that isn’t a bad track record.”)

Anytime you see treatment program claims about how clients did following treatment, it’s important to ask whether the figures take into account everyone who entered treatment at a particular time – if dropouts or people who are unreachable at the time of the survey aren’t included, then “success rates” are likely to be falsely inflated.

In other words, the reachable people are more likely to have had a positive experience.

Some rehabs I visited told me they send “satisfaction surveys” to program completers. The problem with such surveys, according to Adam Brooks, PhD of TRI, is that “they are generally not a very good way to measure quality of care because clients typically give high ratings regardless of the quality of treatment they’re receiving.” For instance, he explained that, even though they’re not very effective treatment approaches, clients may like (or even prefer) common rehab activities such as seeing films and hearing lectures.

As John Kelly, Ph.D. mentioned in my previous column, it can be helpful to know what percentage of clients complete a program and that nationwide, about half of those who enter treatment complete it. So, in general, one should look for programs with completion rates of at least that. I found that the high-end residential rehabs I visited had completion rates of about 90 percent, while some of the outpatient programs were in the 55 to 60 percent range. But there’s no way of knowing whether the differences have to do with program quality or other factors, such as the very different backgrounds of the clients in the programs.

Bear in mind that completion rates aren’t that relevant to programs that don’t have “set” schedules or programs with policies that encourage people to come indefinitely or on an “as-needed” basis.

Finally, licensed treatment programs in some states report yearly “performance
outcomes” having to do with various aspects of patient treatment. To find out if your state has any such reports, locate your state’s drug and alcohol agency by going to SAMHSA’s Substance Abuse Treatment Facility Locator and clicking on this link, then clicking on “State Substance Abuse Agencies” on the left-hand side.

Where There’s a Will, There’s a Way

I found it interesting that a number of administrators – one of them the director of an expensive high-end program – raised the issue of cost as a reason for not doing outcome evaluations. While conducting outcome research certainly can be a hardship for time, and for financially strapped programs, I find it curious, now that I work in the field, that the small facility at which I work has made it a priority to fund outcome research.

I found it interesting that a number of administrators – one of them the director of an expensive high-end program – raised the issue of cost as a reason for not doing outcome evaluations.-Anne FletcherMinnesota Alternatives, an outpatient facility outside of Minneapolis, largely caters to low and middle-income people with co-occurring substance use and mental health disorders. In a typical year, about 100 clients are served. Yet shortly after I began working there on a part-time basis (about 18 months ago), director Paula DeSanto, M.S., L.S.W., made it a priority to bring a researcher from the University of Minnesota on board to polish up the outcome surveys we were already conducting so our data would be ready for publication in a scientific journal – all for the cost of about $6,000.

Each client entering treatment completes a short survey that asks questions about current levels of alcohol and/or drug use, harms substance use is causing in life, current quality of life, and readiness for change. The discharge outcomes survey asks those same questions, plus questions specific to programming and staff, as well as whether service needs were met. Finally, a short 12-month post-discharge outcome survey is offered with questions about quality of life, substance use, hospitalizations, and further treatment episodes.

All of this data is currently being analyzed with very encouraging outcomes thus far. Minnesota Alternatives hopes to publish these findings soon.

If this small program can make an attempt to measure, publish, and pay for outside help with outcomes, I wonder why more treatment facilities aren’t willing to follow suit?

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