Why what happens after rehab is vital

Recovery journeys are rarely linear, generally bumpy and often happen over many years. Treatment may or may not be part of the process. People can need several different treatment episodes over time, often re-presenting with different needs and goals. 

Despite a growing evidence base only a small percentage of treatment episodes take place in residential rehabilitation settings in the UK. Access is not easy. In many parts of the country – to get to rehab you need to be wealthy, insured or just plain lucky. If you have the wrong postcode and no funds, you may never get there.

If you are fortunate enough to find your way to rehab, you are less likely to reach your goals if you don’t get sufficient time in treatment and if the intensity and content are not robust. Evidence suggests, that to get the most gains, treatment should last at least three months. 

One thing that predicts positive outcomes is the quality of what happens after rehab. If recovery journeys happen over years, then it makes no sense to put most of the energy into the residential treatment episode at the expense of ‘aftercare’. Any aftercare provided by rehab should be strongly focussed on helping individuals develop their own support systems and connecting them to services which will help in the longer term – and by longer term I mean the rest of their recovery. Yet this area of ongoing support is something that is not always as well developed or as valued as highly as it might be.

The Scottish Government’s Good Practice Guide on residential rehab pathways recognises this: 

Residential detoxification and rehabilitation programmes should not be seen as stand-alone interventions, but rather as components of an integrated package of care. Adequate preparation and after-care provided in community settings are key to the success of residential treatments.

Recently, Professor David Best, writing in his blog, picks up this topic in an insightful way. He emphasises the importance of making new links to community recovery resources like mutual aid and lived-experience recovery organisations (LEROs) which can then generate new, protective social networks. He points out that to do this we need to build effective bridges from treatment to such organisations. Further, nonspecific resources (like clubs, colleges and classes) should also be seen as rich materials with which to build recovery capital.

One challenge with realising this is what Professor Best calls the ‘house on the hill’ model of rehab. This is the traditional set-up where the person is taken away from their environment to treatment in a distant facility. Sometimes people stay in the area where the rehab is situated. Other individuals will return home after treatment. I don’t believe we have data on the division.

While there are positives to out of area placements, one potential disadvantage is that if the person does return to where they came from at the end of treatment, the capacity of the rehab (and of local recovery resources) to support them may be limited, though digital developments can help. Rich local connections which may have been generated and developed during treatment are not going to help someone leaving the area to go home.

The challenge remains that for many people the departure from a residential rehab, is one from high social recovery capital (within the rehab) to low or negative social capital (particularly if returning to areas where most of the available network involves people who are still using).

Professor David Best

There are examples (in Scotland) where local initiatives are overcoming these obstacles (e.g., rehabs which focus on local populations or where a community service supports individuals prior to and after the rehab placement making those connections actively). While good practice exists, there is still a lot of room for development of a joined-up system of care that puts as much effort into what happens after treatment as what happens during it. This is not only a problem for rehabs, but also an issue for commissioners who are allocating funding for distal placements.

Prof Best sets out three measurable conditions to test the benefit of out of area placements:

1. Only commissioning residential treatment providers who have a strategy for engaging community capital in their later stages of treatment. 
2. Building effective bridges from the recovery residence to local community recovery resources for those returning.
3. Having an adequate set of recovery resources available and accessible in your area to sustain and further build the recovery capital gains achieved in residential treatment. 

There is little to disagree with here and so much to endorse. From what I know of rehab providers in Scotland, I think most, if not all, are switched on to the value of active connections to community resources,. The tricky thing is to become aware of and develop links to multiple organisations across a wide geographical area. Perhaps reciprocal arrangements could be developed. The service I work in, for instance, offers aftercare to patients returning to Lothian from out of area rehabs.

There is a further issue with the relocation of out of area rehab clients. Each time this happens, we are losing a huge asset to communities in home towns and cities. A person in recovery acts as a beacon of hope, a role model, and a bridge for those seeking recovery. When recovering people are not available to their own communities, something very important is squandered. 

In the situation where individuals are going to return home from an out of area rehab, commissioners and providers will want to ensure that robust connections are made during treatment and that afterwards these supports continue. Auditing uptake and engagement of local resources in the short/medium term ought to be simple to do and could be reported as quality measures – something that is almost certain to improve outcomes for those going through rehab.

Continue the discussion on Twitter: @DocDavidM

Photo credit: Glencoe, Nathan Chung