Portions of this article are excerpted and adapted from the upcoming book Hope Against Hope, authored by Renascent’s Clinical Director Michael Lochran and consulting Psychotherapist Laura Cavanagh. Hope Against Hope’s anticipated release is in 2022.
Since the New York State Inebriate Asylum opened in 1864, inpatient residential treatment has been the gold standard intervention for substance-use and addictions. Often called “rehab”, inpatient rehabilitation treatment is when clients live and sleep at a treatment centre, offering an immersive and transformative intervention experience.
But more and more often, people are seeking outpatient treatment for substance-use disorders like addiction as well as for other psychological and mental health issues. Outpatient treatment, like Renascent’s Virtual Intensive Outpatient Program, allows people to receive comprehensive and intensive treatment with less disruption to their daily lives.
You may be surprised to learn that success rates for inpatient and outpatient treatment are comparable! Many people assume that inpatient is better, but as we’ll discuss here, actually both inpatient and outpatient treatment options are effective—if the program is the right fit. Treatment success depends on goodness-of-fit between the client’s needs and the program’s strengths. If the fit is right, both inpatient and outpatient are similarly effective.
So how do you know which one is right for you?
A Brief History of Addiction Treatment
In the mid-1800s, inebriate homes and asylums opened along the Eastern seaboard of North America. These could be considered the first therapeutic inpatient rehabs. In the 1890s, however, shifting political and economic tides led to the closure of these facilities. People with alcohol addictions (the most common substance use disorder at the time) were relegated to hospital wards, prisons, and “drunk tanks” . The first wave of addiction treatment was over.
Bill Wilson, co-founder of Alcoholics Anonymous, was hospitalized four times for his excessive drinking. Unable to maintain sobriety, he was convinced he would die from his alcoholism until a profound experience which he likened to a spiritual awakening brought him relief from his addiction. Out of a desire to help other problem drinkers and to stay sober himself he established the mutual support fellowship known as Alcoholics Anonymous (AA) in 1935. The widest and most influential mutual-help society, AA operates in 150 countries and has an estimated membership of over two million worldwide. Its impact and that of its offshoots—including Narcotics Anonymous (NA), Gamblers Anonymous (GA), Cocaine Anonymous (CA), and Sex & Love Addicts Anonymous (SLAA)—is enormous. Some might consider it the original outpatient treatment program!
Encouraged by the examples of recovery in AA, a renewed wave of interest in addiction treatment was launched. Alcoholism, recently thought to be untreatable, was suddenly viewed as curable once more. Intensive inpatient rehabilitation programs began to launch in the 1940s, including the famous Hazelden Centre which opened its doors in 1949 and is still in operation today. A similar program for people with narcotics addictions was opened at the Lexington, Kentucky Addiction Research Center, designed “to quarantine addicts far from urban temptations”. . Timelines were extended compared to today’s 28-day treatment standard: the Lexington Addiction Research Center residents lived at the facility for years.
For the next 40 years, inpatient treatment was recommended for those with the most severe cases of substance use and addiction, while community 12-step programs were thought to provide adequate support for those with less severe cases. In practice, this was not always the case. Many people with severe drug and alcohol addictions achieved and maintained recovery in 12-step programs. For many of these people, inpatient treatment was neither logistically nor financially feasible.
In the 1980s and 90s, interest in outpatient treatment options was revived. “Treatment on demand” became a guiding principle for access to addictions treatment. It was noted that many people with addictions had mixed feelings about seeking treatment, and low tolerance for waiting for access. In fact, even today, it is known that up to half of applicants will drop off a waiting list if there is a significant delay between their initial assessment and treatment entry. And, longer wait times further decrease the likelihood of treatment completion. What’s more, people with addictions tend to continue to use drugs and alcohol while waiting for treatment access. In the 80s and 90s, the concern over the high-risk consequences of HIV transmission at that time prompted a desire to provide treatment “on-demand”—in other words, as quickly as possible after the client requested it.
A review of the service system led to a renewed openness towards outpatient addiction treatment as a means of managing the difficulties of waitlists for inpatient treatment centres.
But Does Outpatient Actually Work?
Studies of these new outpatient treatment programs began emerging shortly after. Initially feared that they might exist as only a “holding station” before clients could get “real” inpatient treatment, scientific reviews and research-based evidence showed that outpatient treatment yielded similar outcomes as the more intensive inpatient experience . Although initial comparison studies focused mainly on alcoholism, outpatient and inpatient treatment comparisons show similar effectiveness for other addictive disorders too. This includes outpatient treatment for opioid addiction, gambling, and poly-drug use.
A caveat remains though: outpatient care works if the client is well-suited for the program. The same research showed that treatment effectiveness depends on goodness-of-fit between the client and the therapeutic program. When the right clients ended up in the right program, outcomes were positive. However, therapeutic mismatch between client and program yielded poorer results. This was particularly true for clients that needed inpatient but attended outpatient instead.
So How Do I Know Which Addiction Treatment is Right for Me?
Here are some factors to consider when choosing between inpatient and outpatient addiction treatment.
Can I Stop Drinking or Using?
This might sound obvious, but drinking or using interferes with treatment. Sometimes, people will seek treatment in the hopes that it will stop them from wanting to drink or use. But, as we discussed in our two-part series on the Neurobiology of Addiction, the therapeutic benefit of treatment is negated by continued substance use which is acting to further the progression of the disease of addiction.
You might wonder: Why would I need treatment if I could stop? Sometimes people with addiction can stop for a few days or weeks on their own. Without any treatment, however, relapse is almost always inevitable. But for people who can stop for a period of time on their own, outpatient and inpatient treatment show similar success rates in maintaining their recovery.
For people who cannot stop drinking or using, even for a few days, inpatient treatment may be preferable. For some people the enforced period of abstinence that occurs in inpatient residential treatment is necessary in order to achieve remission from the disease of addiction. The separation from their drug of choice may be a necessary component of treatment for people who cannot go any length of time without using.
What if you strongly prefer the outpatient option but cannot stop drinking or using? Well, outpatient treatment is still not necessarily ruled out. Research shows that for clients who cannot stop using substances, outpatient treatment is still effective if they are provided with stabilizing detox treatment prior to starting the program. Many hospitals and detox services offer short-term programs of stay that would provide you with stabilization before transitioning to a longer-term outpatient program.
If you are strongly committed to outpatient over inpatient, your intake team at Renascent can help you find detox services near you.
How Severe is My Addiction?
In general, inpatient treatment is recommended over outpatient care for people with severe addictions to alcohol or drugs. Your intake team at Renascent will conduct an assessment to determine whether your addiction would be classified as mild, moderate, or severe. This can help you to decide which course of treatment would be best. Indicators of severity include length of time using or drinking, amount and frequency of use, patterns of use, and number of substances used.
Am I Struggling with Issues Other Than Substance Use?
People with co-occurring mental health issues often fare better in inpatient treatment. Concurrent psychological diagnoses, for example depression, post-traumatic stress disorder or bipolar disorder, tend to make addictions more difficult to treat. In addition, co-occurring mental health issues are associated with an increased severity of addiction. The immersive and intensive support of inpatient treatment can therefore be preferable for people with more complex needs like a mental health issue. It is also known that inpatient treatment results in better outcomes for people that have involvement with the law when compared with outpatient programs.
Do I Have Good Social Support?
Clients with good support networks tended to thrive in outpatient settings: having apartner or spouse, family, friends and other extensive social network support predicts success in outpatient programs. This is in part because outpatient treatment allows you to build your recovery program where you live, work or study while you are still in treatment. On the other hand, people who scored low in their social supports fared better in inpatient treatment where the intensive residential experience allowed for support in building social networks within the treatment setting.
Am I Able to Make the Transition to Continuing Care?
Whether inpatient or outpatient, treatment provides stabilization and offers an opportunity for self-discovery. True recovery happens in our real lives.
Addiction is a chronic relapsing disease : it is not cured, but only ever in remission. Remaining in remission depends on transitioning to a recovery program that is sustainable and that provides ongoing relief from a disease that if untreated or poorly treated will eventually come out of remission. Good treatment programs, including both the inpatient and outpatient programs at Renascent, will help you build a sustained program of recovery that will ensure you maintain the gains that you made in treatment—and continue to grow and thrive.
At Renascent, we offer a Continuing Care program that provides on-going support after graduation. This program is less-intensive than inpatient or outpatient treatment, but it is an important part of your ongoing success.
The transition from inpatient to real life can be difficult. It is a high-risk relapse time. One medical study reported that almost 60% of opioid users who successfully completed inpatient treatment relapsed within one week of graduation). An advantage of outpatient addiction treatment is that you are building your post-recovery program in your own community while you are still in treatment, making the post-graduation transition easier.
If outpatient treatment is not an option for the reasons listed above, you might consider following inpatient treatment with an intensive outpatient treatment session before making the transition to continuing care. Studies show that this can be a very effective combination, and we have seen this approach work for our clients as well.
Renascent Can Help
At Renascent, we are committed to excellence across all our programs. This begins with your intake experience, where your assessment with an experienced intake counsellor will help you in selecting the right treatment choice for you: inpatient, outpatient, or a combined approach.
Contact us today to find out which choice is right for you. Recovery is possible. As a trusted leader with 50 years of experience and expertise, we understand addiction. We’ve helped more than 50,000 people, and we can help you too.