The effectiveness of residential treatment services for individuals with substance use disorders: A systematic review
Introduction
Substance use disorders are a major contributor to disability and death worldwide (Institute for Health Metrics and Evaluation, 2016). In the United States, an estimated 8% of the population (over 12 years old) had a substance use disorder in the past 12-months (Substance Abuse and Mental Health Services Administration, 2016). Similar figures have been reported in Australia, where an estimated 5.1% of the population aged 16–85 years had a substance use disorder in the previous 12-months (Australian Bureau of Statistics (ABS), 2008).
Residential substance use treatment services provide intensive care and support for individuals with severe and complex substance use disorders within an alcohol and drug-free, and 24 -h residential community setting (Reif et al., 2014). While treatment interventions vary, residential therapeutic programs generally include Alcohol and Other Drug (AOD) withdrawal or maintenance management in a hospital or supervised residential facility, individual and group psychological support, mutual self-help and peer therapeutic communities, and supported reintegration into the community. Length of stay in residential treatment can be relatively short, to longer-term (four weeks up to 12-months). One example of a short-term residential treatment model is the 28-day Minnesota Model (Borkman et al., 2007). Typically based on the 12-step Alcoholics Anonymous (AA) program, it incorporates addiction education, small group meetings, and individual interviews (Borkman et al., 2007). Longer-term residential treatment models ranging from 6 to 12-months can include therapeutic communities (De Leon, 2000). In this model, responsibility for recovery rests on the individual as well as the residential community. Patients and staff are considered the primary change agents, through social learning processes and the community support of peers. This structured model, generally involves community meetings, facilitation of self-help and mutual self-help, encounter groups, stage progression and/or a hierarchical structure (Magor-Blatch et al., 2014; Reif et al., 2014).
A significant amount of research has evaluated the effectiveness of residential substance use treatment services. Since 2000, there have been seven reviews of residential drug treatment studies that predominantly focused on community-based residential services (i.e. not based in hospital or prisons), and collectively examined 68 studies published between 1981 and 2013. Three reviews focused on the effectiveness of integrated residential treatment for co-existing mental health and substance use disorders (Brunette et al., 2004; Cleary et al., 2009; Drake et al., 2008), two focused on therapeutic communities (Malivert et al., 2011; Vanderplasschen et al., 2013), and two reviews compared therapeutic communities to (i) non-therapeutic community residential treatment (e.g. Minnesota Model) (Smith et al., 2006) and (ii) other treatment types (e.g. day programs) (Reif et al., 2014).
Findings from these reviews generally provide limited quality evidence for the effectiveness of residential treatment for AOD problems. Contributing to the difficulty in comparing different studies in this field is the variation in measures of substance use outcomes, with some studies measuring abstinence while others measured reductions in use. Relatively few RCTs have been conducted, and the results of RCTs reviewed prior to 2013 found therapeutic communities had a negligible treatment effect (e.g. Malivert et al., 2012), or provided insufficient evidence to determine which treatment model was superior (when compared to other treatment modalities) (Smith et al., 2006). More recent reviews have found some limited support for the effectiveness of therapeutic communities for substance use, and a range of outcomes across other life domains (Reif et al., 2014; Vanderplasschen et al., 2013). Reviews of integrated mental and substance use residential treatment have also found inconclusive evidence of effectiveness (Brunette et al., 2004; Cleary et al., 2009; Drake et al., 2004).
While prior reviews provide some support for long-term residential treatment, the quality of studies reviewed have been predominantly poor, with a number of significant limitations remaining an obstacle to determining effectiveness. These limitations include: heterogeneity across studies regarding design, participant characteristics, treatment setting, measures of substance use, and timing of follow-ups (Cutcliffe et al., 2016). Further, while length of treatment has frequently been identified as essential in predicting the likelihood of recovery (i.e. longer treatment time related to better outcomes), high attrition at follow-up presents a significant limitation when interpreting study results. Those that are followed-up are likely to have better outcomes, as they are contactable (i.e. not in prison, hospitalized, deceased or simply uncontactable) which introduces attrition bias. Multicomponent treatment models and the varying descriptions reported in previous studies have also contributed to gaps in knowledge of the key components driving the therapeutic effect. These limitations impact on the ability to determine if residential treatment services are effective (and cost-effective), and if so, under what conditions (King et al., 2016).
This systematic review aims to provide an update on the evidence base for the residential treatment of substance use disorders in order to identify the most effective models of care, their core components, and promising directions for future research and clinical practice. Studies published between 2013 and 2018 reporting substance use, mental health, mortality, crime, and/or social outcomes were included. The methodological quality of studies was assessed.
Section snippets
Search strategy
To identify published studies reporting on the effectiveness of residential treatment for substance use disorders, a systematic literature search of public health and psychology databases was conducted. Databases included Medline, CINAHL, PsycARTICLES and PsycINFO. Search strings did not place any restriction on study design. Two search strings were used—one for the title, and one for the abstract—using truncation, and Boolean and proximity operators. The search was limited to title and
Search results and quality assessment
An initial search of literature published between 1 January 2013 and 31 December 2018 located 830 publications through database searching that met keyword search criteria, and a further four using snowballing techniques. Of these 834, 415 were duplicates. Of the remaining 419, 364 were excluded based on the abstract review, resulting in 55 publications for full-text review. An additional 31 were excluded as the population, intervention, or outcomes did not meet inclusion criteria, or they did
Discussion
Twenty-three studies evaluating the effectiveness of residential treatment services (published between 1 January 2013 and 31 December 2018) were identified and reviewed. Overall, some evidence that residential treatment (including therapeutic communities) improves substance use and mental health was found. There were less studies reporting on offending and social outcomes (i.e. social engagement, employment). Results largely suggested that residential treatment is associated with significant
Conclusion
Despite the growing need for effective residential substance use treatment internationally, the field continues to lack consensus-based best practice treatment guidelines. In line with previous reviews, this review on the most recent studies in the field (2013–2018) provides moderate quality evidence that residential treatment may be effective in reducing substance use and improving mental health. There is also some evidence that treatment may have a positive effect on social and offending
Contributors
Dominique de Andrade designed and conducted the search strategy, assessed full-text papers for eligibility, rated the methodological quality of included studies, conducted data extraction, and drafted the paper. Rachel Elphinston assisted with the drafting of the introduction and abstract, screening studies eligible for final inclusion (second study rater), contacted authors for program details and provided edits on the drafts and final manuscript. Catherine Quinn and Julaine Allan assisted
Role of funding source
Nothing declared.
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2023, Journal of Criminal JusticeCitation Excerpt :Taken together, these results suggest that for young people on these no or low and moderate incline conviction trajectories prior to PALM referral, substance dependence issues may be less intertwined with their offending compared to those with a high-incline conviction trajectory, and importantly that AOD treatment alongside young people with a high-incline conviction trajectory showed no evidence of what has been called the ‘peer contagion’ effect. Ample evidence highlights the beneficial effects of TC's across numerous domains such as health, psychosocial functioning, and employability (de Andrade et al., 2019; Edelen et al., 2007; Staiger et al., 2020). These positive outcomes tend to manifest regardless of prior offending history (de Andrade et al., 2018; Sacks, McKendrick, Sacks, & Cleland, 2010; Whitten et al., 2022), although these outcomes were not examined in the current study.