Drug rehab and group therapy: do they work?

Rehab is the short name for residential rehabilitation, the best known treatment for drug and alcohol problems. It involves living with a group of people with the shared goal of changing drinking or drug habits.

There are regular media reports of celebrities being sent to rehab by the courts, or choosing to “check themselves in”. Rehab is even the subject of television shows such as Celebrity Rehab with Dr. Drew, that aired from 2008 and 2012 in the United States; and Intervention.

But rehab is more than a celebrity phenomenon. Thousands of Australians go to residential drug and alcohol rehab programs every year.

Group therapy

Rehab emerged out of developments in social psychology and psychiatry in the 1940s. At that time, large institutions based around practices of punishment and isolation, were being dismantled in favour of rehabilitation.

In his 1948 novel Walden Two, behaviourist B.F. Skinner described a utopian communal lifestyle that included developing self-control through positive and negative reinforcement instead of punishment. Residents of Walden learned to work together for the good of the group.

Later research on group processes and dynamics promoted the therapeutic benefits of living and participating in groups and contributing to shared goals. During the 1950s and 1960s, therapy in general was about giving people a good experience of membership in a group.

Drug and alcohol therapy was no different. Alcoholics Anonymous (AA) – a mutual aid group - began in the United States offering group support in a shared struggle against alcohol dependence. AA, that started in Australia in the 1950s, has been one of the most influential approaches to drug and alcohol treatment around the world.

Today many rehabs follow AA philosophy, using the 12 steps as the basis for their treatment programs. Some operate as therapeutic communities - a model consistent with Walden Two and starting at the same time.

In the therapeutic community drug and alcohol treatment and personal growth comes from adhering to the group rules and participating in daily activities that support the community.

There are strong critics of AA as a rehab approach. They see it as a one-size-fits-all program that blames lack of success on those who don’t follow the rules.

Research on outcomes of AA is not permitted under the rules of the fellowship, so its success rate is unknown. The effectiveness of the 12 step approach or any other therapy method delivered in groups has very limited research. One study comparing the outcomes of a therapy delivered to individuals and to groups found the reduction in drinking and drug use was about the same, but group therapy was cheaper to run.

Some rehabs take a different approach to the 12 step model. They rely on individualised treatment plans that help the patient work through their substance abuse problems, as caused by mental distress, trauma or dysfunctional relationships.

How do rehabs work?

Regardless of the philosophy, all rehab programs operate in similar ways. The main feature is an extended period of abstinence from drinking and drug use.

In her popular 2006 song Rehab, Amy Winehouse said she didn’t have 70 days or ten weeks to stay in rehab. Treatment guidelines suggest about that length is required to have a significant experience of life without intoxication.

Eight to ten weeks is the most common length of programs in Australia. Although they vary from four weeks to 12 months.

Other consistent features of rehabs are educational and therapeutic group work, individual counselling, and structured daily routines that typically include cooking, cleaning and exercise. However, there is little evidence for a positive effect of any of these activities on drug or alcohol dependence.

Investigating residential drug and alcohol treatment programs, researcher Rowdy Yates said:

Very little is known about how it [rehab] works or who it works best for. It is […] therefore, not entirely surprising that many treatment plan decisions are, in practice, based more upon individual beliefs and assumptions than upon any scientific evidence.

Instead, success in rehab is usually measured by how many finish treatment. Private facilities post completion rates on their websites – some as high as 96%.

One study from England and Wales found completion rates varied widely, from 3% to 92%; the average was 48%. Higher completion rates were related to lower counsellor caseloads, fewer beds, single rooms, shorter treatment length, higher fees, and a program containing individual counselling and free time with only moderate demands for domestic duties.

How much they cost

Private rehabs are most likely to cost a lot. In Victoria, it costs A$32,000 for a three-month program at The Hader clinic, while a week at Innisfree will set you back A$3,500.

Thailand is sometimes a cheaper option. A month at The Cabin in Chang Mai will cost from A$14,000 but at DARA, the cheapest option is US$4,995 (A$6,680). These fees will be unaffordable for many.

Cheaper publicly funded programs are limited. There are about 800 funded beds in residential rehabilitation centres in New South Wales and 200 in Victoria, with waiting times varying from three to six months.

At these centres, residents pay a contribution towards the cost of accommodation, meals and staff. At Lyndon in Orange NSW, for instance, each resident pays A$240 a week, but it costs an additional A$700 per person per week to run it. Government funding covers some of the difference; donations cover the rest.

People often report feeling desperate to stop using drugs before they die or go to jail, or equally desperate to help their family member or friend get their use under control. A rehab’s supervised drug and alcohol free environment offers some safety and security.

But trying a different treatment could be a better option than rehab. Substance dependence is usually a recurring chronic condition not easily fixed. Reports of treatment effectiveness vary according to treatment types, types of drugs and types of people.

However, a study from Scotland found three years after treatment of any kind, 58% of people are no longer substance dependant. So treatment works for about two thirds of people, eventually.

Julaine Allan has received funding from the NHMRC, ARC and RIRDC for research related to drug and alcohol use. Julaine works for Lyndon, a not for profit drug and alcohol treatment, research and training organisation.