Hi, All:

 

I would add that retention is an issue in all therapy—most people drop out within a couple of months, so far as I know regardless of the modality. 

 

In peace,

 

--Keith

 

 

Well said Rowdy…and I’m sure the thousands in the ‘silent majority’ of former drug and alcohol misusers out there, who have benefitted from TC’s and residential treatment in the last 50 years, would agree…

 

Cheers

 

Bob

 

 

Mike

 

The problem with this study (and with a number of similar studies) is that it assumes that low retention levels are only an issue for residential treatment.  Actually, if you look at the wider evidence base, it would appear to be the case that retention is an issue for ALL addiction treatment services.  See:

 

D'Ippoliti, D., Davoli, M., Perucci, C.A., Pasqualini, F. and Bargagli, A.M. (1998). Retention in treatment of heroin users in Italy: the role of treatment type and of methadone maintenance dosage. Drug & Alcohol Dependence 52, 167-171.

 

Simpson, D.D., Joe G.W. and Rowan-Szal, G. (1997). Drug abuse treatment retention and process effects on follow-up outcomes. Drug and Alcohol Dependence 47, 227–235.

Both studies recorded huge drop-out figures for methadone maintenance treatments.  In fact, if you look at Morris and Schultz’s study of patient compliance across the board, they estimate that most disorders where recovery has to incorporate a behavioural change element, around 50% drop out – so drug treatments are not alone and it’s definitely NOT just a residential rehabilitation issue:

 

Morris, L. and Schultz, R. (1992) ‘Patient compliance: an overview’, Journal of Clinical Pharmacy and Therapeutics, 17(5), 283-295.

As for the comparative costs, frankly, I’m sick of seeing poorly constructed and poorly executed cost studies being used to hype up the “excessively high” costs of residential treatments.  A critical examination of most of these studies shows that there are a number of reasons for disparate cost findings.  Foremost is usually the failure to compare like with like.  Frequently, such studies include accommodation, food and clothing costs for residential services but not for community services; an odd anomaly since the vast majority of community drug service clients are receiving state benefits for these items.  So they may not be coming from a pot marked “drugs budget” but the tax payer is still paying for them.  Then there’s the timeframe.  Frequently these studies are undertaken over a timeframe that fails to account for the savings accrued by the higher rates of recovery in residential treatments.  They certainly never take into account employment contributions of ex-residential rehabilitation clients in full time employment.  When they do (as in Berg and Andersen, 1999), the picture can look quite different:

 

Berg, J. and Andersen, S. (1999). Drug addict rehabilitation: a burden on society. International Journal of Rehabilitation Research, 15, 301–309.

 

A further issue is the assumption that residential treatments and community treatments are dealing with the same populations.  There are numerous studies which show that populations in residential treatment are significantly more damaged and therefore – presumably – have far worse prognoses:

 

De Leon, G. Melnick, G. and Cleland, C. (2008). Client Matching: A Severity-Treatment Intensity Paradigm. Journal of Addictive Diseases, 27(3), 99–11.

 

Yates, R. (2008). Different strokes for different folks: results of a small study comparing characteristics of a therapeutic community population with a community drug project population. International Journal of Therapeutic Communities, 29(1), 44–56.

 

Holt, T., Ritter, A., Swann, A. and Pahoki, S. (2002). Australian Treatment Outcome Survey (ATOS). Fitzroy, VIC: Turning Point Alcohol & Drug Centre.

 

But comparative studies rarely weight their findings to take this difference into account.  They also generally assume that the treatment dosage is the same when it patently is not.  One hour a week (if you’re lucky – or maybe unlucky!) with a counsellor in a community drug service is clearly not the same dosage as 8 hours per day in a therapeutic environment in a TC and to assume that they would cost the same is patently absurd.

 

Finally, very few studies take into account the in-treatment savings.  When we reviewed the Scottish pilot Drug Courts (where most clients were on MMT) we found reductions in crime and illicit drug use.  BUT we were unable to find any clients where these behaviours had ceased entirely.  My reading of the evidence base is that this is repeated in the majority of such studies and that the continuing cost of this (reduced) offending and drug taking tends to be minimalized.  When James Pitts and I looked at the data from a survey of Australian TCs we found that drug-taking and offending had been virtually eliminated altogether.  Taking that as our baseline for comparison, we estimated the cost of their lifestyle behaviour in the 12 months prior to their residence, we found that residential rehabilitation saved the state a considerable sum per resident during this time (with the cohort we studied, their in-treatment costs were less than 5% of their year-prior costs – drug purchasing & crime costs; healthcare costs; enforcement & court costs; and welfare benefits):

 

Pitts, J. and Yates, R. (2010) Cost benefits of therapeutic community programming: results of an updated survey, International Journal of Therapeutic Communities, 31 (2), p. 129-144.

 

Sorry if this comes across as a bit of a rant but I’m really, really tired of this stuff never being challenged.  In fact, the failure of the therapeutic community movement to challenge these cost and retention myths are a major factor in the marginalisation of TCs in the past decade.  For a really detailed analysis of TC outcomes, costs and comparative strengths, see George De Leon’s paper in the International Journal of Therapeutic Communities – I just wish Findings would review papers of this kind!!:

 

De Leon, G. (2010) ‘Is the therapeutic community an evidence-based treatment?  What the evidence says’. International Journal of Therapeutic Communities, 31(2), 104-128.

 

 

 

 

 

Rowdy Yates

Snr. Research Fellow

Scottish Addiction Studies

School of Applied Social Science

University of Stirling.

 

W: http://www.dass.stir.ac.uk/groups/showgroup.php?id=4 (home)

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-----Original Message-----
From: Therapeutic Communities [mailto:[log in to unmask]] On Behalf Of Mike Ashton
Sent: 10 August 2012 11:40
To: [log in to unmask]
Subject: [EFTC] EFFECTIVENESS BANK alert: Residential rehabilitation in England weakened by early drop-out

 

RESIDENTIAL REHABILITATION IN ENGLAND WEAKENED BY EARLY DROP-OUT

 

An audit for the English National Treatment Agency for Substance Misuse finds residential rehabilitation services so entwined with non-residential in the treatment careers of residents that it is not possible disaggregate their contribution. Since a few months of such care costs as much as five years of non-residential care, evidencing value for money is critical, yet many services are undermined by early drop-out.

 

To view this entry click on the link below or paste it in to your web browser address box, being sure to enter the whole address:

http://findings.org.uk/count/downloads/download.php?file=NTA_25.txt

 

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