How Rehab Works

The idea of rehabilitating addictive behavior has existed since the beginning of the early temperance movement in 19th-century America. This movement, which began in the 1800s, gave rise to our modern notions of addiction and the need for our society to help alleviate the suffering of its addicts.

The goal of the temperance movement was abstinence, or the complete disuse of a substance -- in this case alcohol. Eventually, alcohol became identified as an agent of social decay, and the movement increasingly believed that it was up to society to care for its alcoholics by doing away with any spirituous beverage.

The organization gave birth to the first rehab centers in the United States, called "sober houses," where men lived collectively, sequestered away from the temptations of the world. Sober houses were set up as early as 1840 in cities like Boston and New York by the Washingtonian society, a branch of the temperance movement.

The temperance movement began to focus on the general public. If society could be free of alcohol, they reasoned, then it could then be free of alcoholics.

After a century of gaining momentum in their beliefs and membership, the temperance movement helped to get the Prohibition Act -- the law that outlawed the sale, possession or consumption of alcohol in the United States -- passed in 1920. But American society as a whole wasn't prepared to give up its booze, and the law was repealed 13 years later. The experiment had a lasting effect: If America couldn't provide its alcoholics with a country free of temptation, alcoholics needed a refuge within the larger society where they could be free from the temptation of alcohol: rehab.

Eventually providing treatment for addicts was taken from the hands of goodwill societies and placed in the trust of the medical field. As medical science came to play a larger role in caring for the world's addicts, treatment came to be moved into more of a clinical setting. Rehabilitation now took place in hospitals, psychiatric wards and sanitariums.

This isn't the only contribution that temperance made to our modern rehabs. It also gave rise to fraternal organizations, like the International Order of the Good Templars, which served in part as support groups. These groups set the stage for America's first organized support-group treatment program, Alcoholics Anonymous (AA). Cofounded by Robert Smith and Bill Wilson (Dr. Bob and Bill W.) in 1935, AA created the 12-step program.

Throughout the 20th century, thanks to the success and popularity of programs like AA, it became clear that treatment programs were a viable solution to the nation's substance-abuse problems. As a result, President Richard Nixon was the first commander in chief to create federal funding for treatment programs. The budget for his antidrug policy, which would serve as the origins of the War on Drugs, was divvied up, with one-third toward eradicating the supply (police enforcement), and two-thirds toward getting rid of the demand (treatment). When his successor, President Gerald Ford, came to office he cut the budget for federal funding of treatment programs, making the division fifty-fifty.

­This is ironic, because it was President Ford's wife who founded one of the United States' iconic rehab facilities, the Betty Ford Clinic. Mrs. Ford developed an addiction to alcohol and prescription medication in the 1970s, and as a result, she opened the Clinic in 1982 as a way to help others who shared her problem.

In the 1980s, the proliferation of private residential treatment facilities mushroomed. The peak of the War on Drugs fueled fears of addiction, and fueled the demand for rehab treatment. Interestingly, as the War on Drugs was showing a major effect on reducing drug usage in the United States, the use of rehab facilities in the country continued to increase.

So what kind of treatment is offered at these facilities, and how do they help addicts recover from their dependency?

In the next section, we'll learn how rehab works.

When we hear the term "rehab," we usually think of a residential treatment facility where celebrities go to "dry out." As it turns out, there are a variety of types of programs, and even more methods of treatment.

There are several settings where treatment can take place. Hospitals often serve as rehab facilities, treating people who come into the emergency room with an acute drug overdose. This treatment usually doesn't last long; however, some hospitals do offer longer-term and more expansive treatment programs. Rehabs can range in appearance from a very clinical setting in a prison to a luxurious day spa on an exotic island, and everything in between. What most treatment facilities have in common is that they are divided by the length of the service they offer.

Treatment generally takes place as inpatient, outpatient or partial-hospitalization:

Prison is another place that can serve as a rehab treatment center. In this setting, substance-dependent patients are removed from the general prison population to diminish the possibility that they'll be exposed to drugs or alcohol. Treatment facilities are becoming popular in American prisons, as they have increasingly been shown to be effective.

Regardless of whether treatment is received in prison or in a spa, the treatment programs are similarly structured.

In the next section we'll learn what kind of treatment methods are in use at rehab facilities.

To understand rehab-treatment methods, we must first understand how addiction works. Our understanding of addiction has evolved over the past two centuries, and we've arrived at the conclusion that addiction is a "brain disease." Under this model, addiction is a chemical transition that takes place within the brain's processes. This transition takes the decision of whether to abuse a substance or engage in a compulsive behavior out of the hands of the addict.

­To this end, addiction researchers have concluded that treatment is a long, multifaceted process that takes time. How much time is debatable; some say a month, some say a lifetime. But most modern researchers have concluded that treatment should consist of a combination of methods in order to achieve the highest potential for lifetime abstinence.

When an addict enters rehab for a substance-abuse problem, the first order of treatment is to help him through the withdrawal process. Some rehabs end there, while others include them as part of a larger treatment program including other aspects detailed below.

Twelve-step programs are considered by many addiction researchers to be the most effective form of treatment. The 12 steps to recovery, originally created by AA cofounders Bill W. and Dr. Bob, have been shown to increase sobriety rates over two years by 30 percent compared with Cognitive Behavioral Counseling (more on that later). Though it's repeatedly been shown to be effective, it's often criticized as being too indulgent to the addict's ego and too reliant on a belief in God. As a response to this, Narcotics Anonymous, one of the many 12-step programs that has roots in AA, has molded its program to support both believers as well as atheists.

Cognitive Behavioral Counseling (CBC) is a type of psychotherapy that's used for a variety of mental disorders, like depression and post-traumatic stress disorder. CBC practitioners believe that concentrating on the reasons for the addict's behavior can help eradicate addiction from his life. Most rehabs include CBC as part of an overall treatment program, and counseling is usually offered in group, individual and family settings.

Medication is another aspect of modern dependency treatment. Medications may be used to help alleviate the physical and psychological symptoms of withdrawal. Heroin withdrawal is considered particularly excruciating, so methadone is often administered during the weeklong withdrawal period, but it's also used as a long-term treatment.

Antidepressants are also commonly used in the rehab setting. Depression may exist in conjunction with an addiction -- either a substance dependency or a compulsive disorder -- and may be used as part of treatment in both cases.

There's also a wide variety of nontraditional methods of treating addictive behavior. Some are ancient-- acupuncture is one good example of this kind of treatment. Others are relatively new, like the detox treatment created by Scientologist founder L. Ron Hubbard. This treatment is purported to rid the body of toxins and addictive substances through a regimen of vitamins, exercise and exposure to saunas.

Some conventional rehab facilities incorporate nontraditional methods of treatment into their wider program. High-end facilities sometimes include as treatment wilderness survival programs to build self-confidence and activities like helicopter rides to inspire awe and humility.

Other nontraditional programs stand alone. The Jude Thaddeus Program uses no medications and operates on the notion that addiction is a learned behavior that can simply be unlearned. Rather than viewing the battle against addiction as a lifelong process, this program aims to completely free its patients after a six-week stay.

But do these programs -- in conjunction or alone -- have any affect on addiction? In the next section we'll learn whether or not rehab works.

Complete abstinence is the goal of rehab, and as such, this is how rehab's effectiveness is measured. For decades, a bounty of studies on how well rehab treatments work have been conducted, and what they've shown is that the most effective treatment is a combination of different treatment types.

Using Cognitive Behavioral Therapy counseling along with medications, for example, has provided higher success rates than either of the two alone. Perhaps the most effective treatment combination is a treatment regimen consisting of a treatment program (residential, outpatient, etc.) along with attendance of a 12-step program, and weekly counseling sessions, either individual or group.

­A study conducted in 1994 called the Target Cities Project showed that people who had completed a drug dependency treatment program, attended one 12-step program per week and had one counseling session per week had an 87 percent chance of abstinence six months after completion of treatment.

The study shows that 12-step programs and counseling play an important role in an addict's rehabilitation. Even among treatment dropouts who attended weekly 12-step meetings and engaged in counseling five times per week, the abstinence rate was 74 percent. Conversely, those who completed a treatment program but did not attend 12-step meetings, yet did attend counseling sessions five times per week, had an abstinence rate of 62 percent [source: American Journal of Drug and Alcohol Abuse].

Another study found that a person who attended four more group or 12-step sessions and one more individual counseling session per month than another person has a 40 percent less chance of relapse [source: NIDA].

The length of time spent in a treatment program also affects the probability for success. Three months is the minimum recommended length of a treatment program in order to gain the best chances of achieving abstinence down the road. There are also other factors that have been shown to make rehab most effective. Coexisting psychological problems, like an anxiety disorder or depression, should be treated in a program that addresses both the dependency and the disorder together. This approach is especially important in treating compulsive disorders like sexual addictions and binge-eating disorders. These types of addictions are often the result of an underlying, related psychological disorder. Many cases of gambling addiction also coexist with substance abuse problems, and both problems should be addressed simultaneously.

It's also been widely held that rehab works best if the patient is willing and ready to discontinue his substance abuse. But recent studies of inmates at correctional facilities who are forced into prison treatment programs have shown that rehab in jail can lead to not only abstinence after release, but also lowers rates of criminal recidivism -- repeating an offense after having been punished for it before. As a result, confidence in involuntary treatment programs has increased. In some U.S. states, "drug courts" have been organized; judges can choose to sentence offenders to treatment programs rather than prison. In 2004, the court system referred 36 percent of Americans who received treatment.

Some nontraditional treatment programs also boast of impressive success rates. The Jude Thaddeus Program at the St. Jude Treatment House in New York says that it has produced a 65 percent success rate from its exclusive program.

Despite the success that some treatment programs have demonstrated, for many people, rehab isn't an option. In contrast to the 3.9 million Americans who received treatment in 2005, an estimated 20 million more needed treatment but did not receive it [source: Dept. of Health and Human Services]. Chief among the reasons why people didn't seek treatment was the cost of rehab.

In the next section, we'll learn about rehab's costs, both to the patient and to society.

Rehab can be a costly proposition for many people. Even though the cost to the individual patient and his family has declined in recent years, treatment programs often reach into the thousands of dollars. In 2002, the average cost of a rehab treatment program was around $1,400. Residential treatment rates stood around $3,800, and outpatient methadone treatments cost an average of about $7,400.

Some rehab facilities' inpatient treatment programs can cost into the tens of thousands of dollars. Crossroads Centre, a rehab center in Antigua, West Indies, founded by guitarist Eric Clapton, charges an average of $15,000 per month for treatment [source: Addiction Resource Guide].

When the length of time required by a treatment program is factored, the perception of cost shifts. For outpatient non-methadone treatments, the cost averaged $26.72 per visit. Non-hospital residential treatments cost an average of $76.13 per day, while methadone treatments, usually the longest-term treatment cost an average of $17.78 per visit [source: SAMHSA].

How rehab is paid for has changed somewhat over the past two decades. In 1986, private insurers paid nearly 30 percent of the total cost of rehab. Patients paid nearly 14 percent of the total cost that same year. In 2003, however, both patients and insurers paid less for treatment, changing to just over 10 percent and 8 percent, respectively.

The burden of paying for rehabs has shifted largely to the public sector, namely states. Medicaid, state-sponsored insurance programs for the poor, and other state agencies paid almost 60 percent of the total cost of rehab in 2003. That year, a total of $20.7 billion was spent on treating individuals with a substance dependency.

Supporters of treatment programs point out that there is a cost/benefit analysis that should be conducted when viewing the expenditure of state money on rehab for individuals. One study concluded that the cost to society for alcohol and illicit drug use (including tobacco) totaled $500 billion in 2002 [source: NIDA]. This cost includes health care, loss of property, crime and other factors that society as a whole pays for, like prison systems. A 1993 Mothers Against Drunk Driving (MADD)-funded study determined that the total cost borne by society for alcoholism came to $148 billion.

Some studies have shown that treatment programs have a tendency to actually offset some of that cost to society. One study by the NIAAA showed that for every dollar spent on rehab, three dollars were saved in other costs associated with the effects of addiction [source: ENotAlone].

Another study pointed out the human cost of alcoholism. Working off of the estimate that there are about 12 million alcoholics in the United States (an estimated 30 million in the United States, Japan and Europe combined), and calculating that each alcoholic may have a spouse, children and other close family members, the researchers concluded that as many as 60 million Americans were affected by alcoholism [sources:ENotAlone, Biotie].

For more information on rehab and related topics, check out the links on the next page.

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