A Guide to Addiction Treatment Services
By Tom Horvath, PhD
There are many types of addiction treatment and many places to participate in it. The US government lists well over 15,000 treatment facilities:
US government listing of services
There are also many services associated with addiction treatment. By comparison, if you admit to a hospital for surgery, in addition to the surgery (of which there are many types) the hospital will also provide x-ray, laundry, food service, chaplain service, physical therapy, insurance billing, patient billing and other services.
A general guideline about seeking addiction treatment services is the concept of “stepped care.” Start with the lowest level of care that might be helpful, then work your way up levels of care if needed (perhaps by first having more intensity of treatment at the level you started on). Similarly, it can be valuable to step down your care over time, such as discharging from residential treatment and entering the combination of sober living and intensive outpatient treatment.
Although many are interested in finding the “best” treatment or the “most effective” treatment, these terms are misleading. So much of the effectiveness of treatment is based on the client’s commitment to it, it is often better to find an approach the client is interested in (“enthusiastic about” might be unlikely).
There is also little evidence that one approach is more effective than another. And you can ignore any facility that quotes a success rate. They do not have the funding to conduct scientifically valid outcome studies. The “success rate” you are told is for marketing purposes, unless it is published in a peer-reviewed scientific paper (I have yet to see one).
The categories listed below are a commonly used in the US:
1. Assessment only
This type of provider only assesses (evaluates, diagnoses) you, and typically also provides a range of treatment recommendations if you might benefit from addiction treatment services. This provider will NOT treat you once assessed. The advantage of independent assessment is that the conflict of interest that can be associated with assessing then treating the same individual is eliminated. If the assessor also provides treatment, was the assessment biased in favor of suggesting treatment the provider also provides? Unfortunately, there are few “assessment only” providers. In medical care, assessment and treatment generally go together. If there is concern about conflict of interest it can be addressed by getting a second opinion. Because the field is so diverse, I often recommend getting 2-3 independent opinions about what might be helpful.
2. Residential treatment
Residential treatment provides both living quarters and treatment on site. If this treatment occurs in a hospital, it is also termed inpatient treatment. Only a few inpatient treatment centers exist, and often only provide detoxification (detox). Residential treatment may also be termed “rehab.” Residential treatment is generally an expensive approach to treatment, and fortunately most individuals do not need it. However, in specific situations residential treatment, with its intensive focus on change and a temptation free environment, can be a powerful positive experience. Like any powerful experience, it can also cause harm if not conducted well and sensitively.
3. Sober living
The related terms include sober housing and recovery residence. These homes provide a non-using living environment. There is often a house manager, possibly who lives in the facility. Some homes are managed entirely by the residents. Treatment, if it occurs, is off-site (in some cases a licensed professional may do a home visit). These homes range in price widely depending on the number of residents per bedroom, the additional services provided, and the presence of a house manager or other support staff. In most homes the residents are expected to have a regular schedule of outside activities (including treatment, work, school or volunteer work). Sober living is much less expensive than residential treatment, but it is a high-risk environment if not well run. A hospital is where the help is, but also where the germs are. If a hospital does not practice good infection control, being in hospital can make you worse not better. If not adequately supervised, individuals in early recovery (when recurrence to substance use is more common) can “infect” one another.
4. Housing first
This form of housing is normally run by a government and is rare in the US. There are few or no restrictions on substance use, in the hope that providing stable housing will lead to other improvements. When abstinence is required before housing, many individuals end up homeless because of their difficulty abstaining. Housing first has been controversial because it appears to “enable” continued use. Studies of housing first suggest it reduces substance problems.
5. Detox (detoxification)
If you suddenly stop using a substance you may experience a withdrawal syndrome as your body adjusts to the substance’s absence. Detoxification is the medical process of managing this adjustment safely. Some substances have milder withdrawal syndromes and do not require medical management. However, if you are using any substance daily, it is wisest to seek medical consultation before stopping abruptly, except for stimulants (nicotine, methamphetamine, cocaine, ADHD medications and similar drugs), marijuana, psychedelics or inhalants. Alcohol and sedative, sleep, anti-anxiety and pain (opiate) medications can lead to harmful or fatal withdrawal syndromes if not medically supervised.
6. Medications
There are a handful of FDA-approved medications for addiction treatment, and many more that are used off-label. Both family doctors and psychiatrists may regularly prescribe them. The highest level of care for medications would come from an addiction medicine specialist. Again, it might be useful to obtain multiple opinions initially. In some cases, the medications are so effective that other services might be minimal. However, it is generally recommended that medications be supported by other services.
7. Intensive outpatient (at various levels)
There are several levels of intensive outpatient treatment, including IOP (intensive outpatient), typically nine hours per week, day treatment, and partial hospitalization (which could occur 6-10 hours per day all or most days). Typically, these programs are highly structured and group based. Some providers have more flexible structures that emphasize individual and family sessions. Intensive outpatient treatment may be associated with residence in a sober living home. In some cases, this level of care is used after residential treatment, or to prevent needing residential treatment.
8. Outpatient
Outpatient treatment is typically one or a few hours per week, including individual psychotherapy, group or family sessions. Typically, only one or two providers are involved. Fortunately, this level of care is the least expensive, and suitable for most people (especially if the seek care earlier rather than later in the development of addictive problems). The largest listing of therapists in the US is at www.psychologytoday.com, where one can search for “addiction” as a focus of the provider. As already noted, getting several first sessions might be a good idea.
9. Services for families/significant others
When family members are ready to seek assistance sooner than the identified patient (IP) is, they can seek consultation with an outpatient professional, seek an interventionist, attend a mutual help group specifically for loves ones, or use a specific form of consultation called CRAFT (Community Reinforcement and Family Training). In many cases consultation with an addiction professional for one or a few visits is the most available and least expensive option (perhaps by looking for outpatient providers). Intervention can be much more expensive and time consuming, but an option to consider if the individual is not making progress. CRAFT is an evidence-based and highly effective approach to changing one’s own behavior, to increase the motivation to change. Unfortunately, CRAFT-trained professionals are not widely available.
10. Recovery coaching and related services
In addition to licensed or certified treatment providers (facilities and individuals), individuals who have sought levels of care higher than outpatient may benefit from the involvement of a recovery coach. On the other hand, a highly structured recovery coaching plan and related services might be an alternative to residential or outpatient treatment. Similar terms include sober companion and recovery assistant. Services can include help with transportation (e.g., not drinking on an airplane), a companion for activities, and someone who regularly checks in with you (in person or by phone) to help you keep on track.
11. Mutual help groups
12-step groups (Alcoholics Anonymous, Narcotics Anonymous, Cocaine Anonymous, etc.) and other powerlessness-based groups are easily found. The “second wave” groups are harder to find. They include SMART Recovery, LifeRing, Women for Sobriety, Recovery Dharma, HAMS, Refuge Recovery, Moderation Management, and others. Some individuals find little difference between any of these groups, and others find the differences crucial. As a practical matter, if the 12-step groups work well for you, they are the most easily available, and few will argue with that choice. However, I am writing as someone who has worked for over 40 years to increase access to alternative groups (especially SMART Recovery, which I am a co-founder of). You can choose these groups with confidence, because the evidence to date indicates that they are as effective as 12-step groups.
12. Other services
As already noted, there are many additional options for addiction treatment services. This category includes psychedelic (entheogenic) experiences, wilderness experiences, educational approaches, TMS, books (but you need to read them), etc.
In conclusion, as you can see, there is much to choose from. As I suggested at the beginning, if you can start small, see how it goes, and modify accordingly.
