ResidentialTreatmentfor IndividualsWithSubstanceUse ... · for individuals with substance use or co-occurring mental and substance use disorders who need structured care. Treatment

Assessing the Evidence Base Series

Residential Treatment forIndividuals With Substance UseDisorders: Assessing the EvidenceSharon Reif, Ph.D.Preethy George, Ph.D.Lisa Braude, Ph.D.Richard H. Dougherty, Ph.D.Allen S. Daniels, Ed.D.Sushmita Shoma Ghose, Ph.D.Miriam E. Delphin-Rittmon, Ph.D.

Objective: Residential treatment is a commonly used direct interventionfor individuals with substance use or co-occurring mental and substanceuse disorders who need structured care. Treatment occurs in nonhospital,licensed residential facilities. Models vary, but all provide safe housing andmedical care in a 24-hour recovery environment. This article describesresidential treatment and assesses the evidence base for this service.Methods: Authors evaluated research reviews and individual studies from1995 through 2012. They searched major databases: PubMed, PsycINFO,Applied Social Sciences Index and Abstracts, Sociological Abstracts, andSocial Services Abstracts. They chose from three levels of evidence (high,moderate, and low) and described the evidence of service effectiveness.Results:On the basis of eight reviews and 21 individual studies not includedin prior reviews, the level of evidence for residential treatment for sub-stance use disorders was rated as moderate. A number of randomizedcontrolled trials were identified, but various methodological weaknesses instudy designs—primarily the appropriateness of the samples and equiva-lence of comparison groups—decreased the level of evidence. Results forthe effectiveness of residential treatment compared with other types oftreatment for substance use disorders were mixed. Findings suggested ei-ther an improvement or no difference in treatment outcomes.Conclusions:Residential treatment for substance use disorders shows value and meritsongoing consideration by policy makers for inclusion as a covered benefitin public and commercially funded plans. However, research with greaterspecificity and consistency is needed. (Psychiatric Services 65:301–312,2014; doi: 10.1176/appi.ps.201300242)

People with substance use dis-orders have a wide variety ofneeds across the range of symp-

tom severity. To address these needs,a continuum of care that includes in-tensive treatment services is in place.Recognition is growing that safe andstable living environments are impor-tant in the recovery process for indi-viduals with substance use disorderswho need structured care. Residentialtreatment is a structured, 24-hour levelof care that enables a focus on in-tensive recovery activities. It aims tohelp people with substance use disor-ders and a high level of psychosocialneeds become stable in their recoverybefore engagement in outpatient set-tings and before return to an un-supervised environment, which mayotherwise be detrimental to their re-covery process. This article describesresidential treatment and assesses theevidence base for this service.

This article reports the results ofa literature review that was undertakenas part of the Assessing the EvidenceBase Series (see box on next page). Forpurposes of this series, the SubstanceAbuse and Mental Health ServicesAdministration (SAMHSA) has de-scribed residential treatment for sub-stance use disorders as a direct servicewith multiple components that is de-livered in a licensed facility used toevaluate, diagnose, and treat the symp-toms or disabilities associated with anadult’s substance use disorder. SAMHSA

Dr. Reif is with the Institute for Behavioral Health, Heller School for Social Policy andManagement, Brandeis University, Waltham, Massachusetts. Dr. George, Dr. Daniels,and Dr. Ghose are with Westat, Rockville, Maryland. Dr. Braude and Dr. Dougherty arewith DMA Health Strategies, Lexington, Massachusetts. Dr. Delphin-Rittmon is with theOffice of Policy, Planning, and Innovation, Substance Abuse and Mental Health ServicesAdministration (SAMHSA), Rockville, Maryland. Send correspondence to Dr. George [email protected]. This literature review is part of a series that will be published inPsychiatric Services over the next several months. The reviews were commissioned bySAMHSA through a contract with Truven Health Analytics. The reviews were conducted byexperts in each topic area, who wrote the reviews along with authors from Truven HealthAnalytics, Westat, DMA Health Strategies, and SAMHSA. Each article in the series waspeer reviewed by a special panel of Psychiatric Services reviewers.

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has defined three levels of clinicallymanaged residential services. All provide24-hour care, but they offer treatmentwith varying intensity and focus depend-ing on the resident’s needs. Table 1 pres-ents a description of the components ofthis service.Examination of the effectiveness of

residential treatment for people withsubstance use disorders and for varioussubgroups is challenged by lack of a cleardefinition of service methods, treatmentduration, and treatment standards. Theobjectives of this reviewwere to describemodels and components of residentialtreatment for substance use disorders,rate and discuss the level of evidence(that is, methodological quality) ofexisting studies, and describe the ef-fectiveness of the service on the basisof the research literature. We focus ontreatment for substance use disorders,although individuals in treatment mayalso have co-occurring mental disor-ders. Effectiveness studies primarilycompared residential treatment forsubstance use disorders to other levelsof care (for example, intensive out-patient treatment). Outcomes mea-sured included drug and alcohol use,psychiatric symptoms, and other mea-sures of psychosocial functioning.

Description ofresidential treatmentResidential treatment for substance usedisorders is a setting in which servicesoccur, rather than a discrete treatment

intervention. A variety of therapeuticinterventions may be implementedacross different residential treatmentsettings; however, a common definingcharacteristic of residential treatmentis that it provides housing for individ-uals who are in need of rehabilitationservices.

Residential treatment occurs in non-hospital or freestanding residentialfacilities. Treatment for substance usedisorders typically takes place in facil-ities that are licensed by each state’sSingle State Agency for SubstanceAbuse Services. Residential treatmentis part of the primary rehabilitationphase of treatment and may be pre-ceded by detoxification, if warranted.Residential treatment should be fol-lowed by less intensive treatment andaftercare services within a continuumof care. A separate article in this seriesaddresses intensive outpatient pro-grams for substance use disorders (1).

Residential treatment for substanceuse disorders is used for a wide range ofpopulations with a range of sociodemo-graphic characteristics. For example,residential treatment is appropriate forindividuals who have co-occurringmen-tal and substance use disorders becauseof the challenges associated with havingmultiple disorders and their commonneed for intensive treatment in a safeenvironment. Residential treatment isalso appropriate for individuals who arehomeless, particularly because of the en-vironmental challenges of achieving

and maintaining sobriety or other as-pects of recovery without stable housing.

The American Society of AddictionMedicine (ASAM) has spearheaded thecomplex task of developing specificationsfor addiction treatment at various levelsof care and criteria to identify whichindividuals are most appropriate forwhich types of services (2,3). The ASAMpatient placement criteria (ASAM PPC-2R) (2) consist of six dimensions:intoxication/withdrawal, medical condi-tions, mental health conditions, stageof change/motivation, recovery/relapserisks, and the recovery environment.Assessments on these dimensions areoften used to place people into thelevel of care that matches their partic-ular needs and provides a framework fortreatment planning.

The ASAM PPC-2R (2) states that“the defining characteristic of all [resi-dential] Level III programs is that theyserve individuals who need safe andstable living environments in order todevelop their recovery skills.” Individu-als are considered appropriate forresidential treatment, in particular,if they demonstrate a need for medicalcare, safe and stable housing, or a struc-tured 24-hour recovery environment.Residential treatment services includea live-in setting that is housed in oraffiliated with a permanent facility;organization and staffing by addictionand mental health personnel; a plannedregimen of care with defined policies,procedures, and clinical protocols; andmutual- and self-help group meetings.The ASAM criteria informed theservice-level definitions that are pre-sented in Table 1. Residential treatmentprograms have specific programmaticand staffing requirements from thestates in which they are licensed, whichfrequently (but not always or wholly)coincide with ASAM criteria.

ASAM describes most residentialprograms as clinically managed, mean-ing that they have a structured envi-ronment with skilled treatment staffbut no on-site physician. Individualsare recommended for residential careif their withdrawal and biomedicalneeds are minimal, meaning that theydid not experience acute withdrawalsymptoms or they have already con-cluded the physical withdrawal processand no longer have a health risk relatedto withdrawal. Residents may have

About the AEB Series

The Assessing the Evidence Base (AEB) Series presents literature reviewsfor 13 commonly used, recovery-focused mental health and substance useservices. Authors evaluated research articles and reviews specific to eachservice that were published from 1995 through 2012 or 2013. Each AEBSeries article presents ratings of the strength of the evidence for the service,descriptions of service effectiveness, and recommendations for futureimplementation and research. The target audience includes state mentalhealth and substance use program directors and their senior staff, Medicaidstaff, other purchasers of health care services (for example, managed careorganizations and commercial insurance), leaders in community healthorganizations, providers, consumers and family members, and othersinterested in the empirical evidence base for these services. The researchwas sponsored by the Substance Abuse and Mental Health ServicesAdministration to help inform decisions about which services should becovered in public and commercially funded plans. Details about theresearch methodology and bases for the conclusions are included in theintroduction to the AEB Series (8).

302 PSYCHIATRIC SERVICES ' ps.psychiatryonline.org ' March 2014 Vol. 65 No. 3


moderate psychiatric and general med-ical needs and significant challengesin the areas of treatment readiness,relapse potential, recovery skills, andenvironmental stability. The length ofstay in nonhospital residential treat-ment has shortened considerably overtime; most planned stays now rangefrom weeks to months, depending onthe program and the person’s needs.Most studies of residential treatment

use an acute care model in whichoutcomes are evaluated after treat-ment, rather than a chronic care modelin which outcomes are evaluated duringongoing treatment—as is the case fora chronic condition such as hyperten-sion or other medical comorbidity (4).Evaluations of treatment effectivenessfor chronic disorders take place duringthe continuing care phase of treatmentwhile patients are still receiving sup-portive care (albeit while living in thecommunity), and permanent change isnot expected in the absence of ongoingcare.Acontinuum-of-caremodel for sub-stance use treatment is critical whereby,after completion of residential treat-ment, participants are engaged continu-ously in less intensive forms of treatmentto promote smooth transitions to self-management in the community (5,6).Residential treatment models vary

widely and have evolved over the years;this evolution presents challenges toefforts to compare research outcomes.The traditional “Minnesotamodel”wasa planned 28-day residential treatmentapproach that is fairly rare today, as isthe traditional hospital inpatient pro-gram with which residential treatmentfrequently has been compared.A specific type of residential treat-

ment setting is a therapeutic commu-nity. Therapeutic communities andother social model programs generallyhave a consistent approach, in whichall aspects of the residential commu-nity are used as part of the treatmentexperience. The National Instituteon Drug Abuse defines care within atherapeutic community as provided24 hours per day in a nonhospitalsetting, with planned lengths of stayof six to 12 months. Treatment focuseson social and psychological causes andconsequences of addiction. Treatmentis structured and comprehensive, to“focus on the ‘re-socialization’ of theindividual and use the program’s entire

community—including other residents,staff, and the social context—as activecomponents of treatment . . . [in] de-veloping personal accountability andresponsibility as well as socially pro-ductive lives” (7). A social modelresidential approach is similar to atherapeutic community.

Leaders in substance abuse and men-tal health policy arenas need informationabout the effectiveness of residentialtreatment for substance use disorders asthey determine which interventionsshould be included as covered benefits inpublic and commercially funded healthplans and as they make policy decisions

about treatment interventions. This re-view aimed to provide state behavioralhealth directors and their staff, purchas-ers of health services, policy officials, andcommunity health care administratorswith an accessible summary of theevidence for residential treatment forsubstance use disorders and a discus-sion of areas needing further research.

MethodsSearch strategyTo provide a summary of the evidencefor and effectiveness of residentialtreatment for substance use disorders,we conducted a literature search of

Table 1

Description of residential treatment for substance use disorders

Feature Description

Service definition Residential treatment for individuals with substance usedisorders is a direct service with multiple componentsdelivered in a licensed facility used to evaluate, diagnose,and treat the symptoms or disabilities associated with anadult’s substance use disorder.

Levels of service intensity:

Low: Clinically managed, low-intensity residential servicesprovide 24-hour supportive care in a structured environmentto prevent or minimize a person’s risk of relapse or continuedsubstance use. This level of care may include services such asinterpersonal and group-living skills training, individual andgroup therapy, and intensive outpatient treatment.

Medium: Clinically managed, medium-intensity residentialservices provide 24-hour care and treatment for persons withco-occurring substance use and mental disorders who alsohave significant temporary or permanent cognitive deficits.This level of care includes services that are slowly paced andrepetitive; services that are focused primarily on preventingrelapse, continued problems, or continued substance use; andservices that promote reintegration of the person into thecommunity.

High: Clinically managed, high-intensity residential servicesprovide 24-hour care and treatment. This level of care isdesigned for persons who have multiple deficits that preventrecovery, such as criminal activity, psychological problems, andimpaired functioning. This level of care includes services thatreduce the risk of relapse, reinforce prosocial behaviors, assistwith healthy reintegration into the community, and provideskill building to address functional deficits.

Service goal Provide individuals with safe and stable living environments inwhich to develop their recovery skills and aid in theirrehabilitation from substance use disorders

Populations Individuals with substance use disorders; individuals withco-occurring mental and substance use disorders; individualswho are homeless

Settings for servicedelivery

Nonhospital residential facilities; therapeutic communities



articles published from 1995 through2012. We searched major databases:PubMed (U.S. National Library ofMedicine and National Institutes ofHealth), PsycINFO (American Psy-chological Association), Applied So-cial Sciences Index and Abstracts,Sociological Abstracts, and SocialServices Abstracts. We used combi-nations of the following search terms:residential treatment, substance use,substance abuse, dual diagnosis.

Inclusion and exclusion criteriaThe following types of articles wereincluded: randomized controlled trials(RCTs), quasi-experimental studies,and review articles such as meta-analyses and systematic reviews; U.S.and international studies in English;studies that focused on residentialtreatment for adults with substanceuse disorders or co-occurring mentalhealth and substance use disorders;and studies that included outcomessuch as measures of substance use.Studies were excluded that exam-

ined residential treatment solely withadolescent populations and that ex-amined residential treatment in crim-inal justice settings. Clients treatedwithin the criminal justice system arelikely to have other motivators forsuccess (for example, to remain out ofjail or prison), and thus the servicesand outcomes examined in thesestudies are not directly comparableto residential treatment services andoutcomes examined elsewhere. Alsoexcluded were studies that focusedonly on cost-effectiveness, did nothave a comparison group, measuredonly length of stay or other effects thatoccurred during treatment, or usedonly pre-post analyses without statis-tical controls for baseline differences.Existing review articles were given

priority in this summary of the evi-dence. Individual articles are detailedhere only if they were not previouslyincluded in a published review.

Strength of the evidenceThe methodology used to rate thestrength of the evidence is describedin detail in the introduction to thisseries (8). The research designs of theidentified studies were examined todetermine that they met the inclusioncriteria. Three levels of evidence (high,

moderate, and low) were used toindicate the overall research qualityof the collection of studies. Ratingswere based on predefined benchmarksthat took into account the number ofstudies and their methodological qual-ity. In rare instances when the ratingswere dissimilar, a consensus opinionwas reached.

In general, high ratings indicateconfidence in the reported outcomesand are based on three or more RCTswith adequate designs or two RCTsplus two quasi-experimental studieswith adequate designs.Moderate ratingsindicate that there is some adequateresearch to assess the service, although itis possible that future research couldinfluence reported results. Moderateratings are based on the following threeoptions: two ormore quasi-experimentalstudies with adequate design; one quasi-experimental study plus one RCT withadequate design; or at least two RCTswith some methodological weaknessesor at least three quasi-experimentalstudies with somemethodological weak-nesses. Low ratings indicate that re-search for this service is not adequate todraw evidence-based conclusions. Lowratings indicate that studies have non-experimental designs, there are noRCTs, or there is no more than oneadequately designed quasi-experimentalstudy.

We accounted for other design fac-tors that could increase or decrease theevidence rating, such as how the ser-vice, populations, and interventionswere defined; use of statistical methodsto account for baseline differences be-tween experimental and comparisongroups; identification of moderating orconfounding variables with appropriatestatistical controls; examination of attri-tion and follow-up; use of psychomet-rically sound measures; and indicationsof potential research bias. The evidencewas rated as stronger when service andpopulation definitions were clear andappropriate, statistical controls wereused to account for baseline differ-ences, and potential confounding vari-ables and research bias (includingattrition) were minimized.

Effectiveness of the serviceWe described the effectiveness of theservice—that is, howwell the outcomesof the studies met the goals of residen-

tial treatment. We compiled the find-ings for separate outcome measuresand study populations, summarized theresults, and noted differences acrossinvestigations. We evaluated the qualityof the research design in our conclu-sions about the strength of the evidenceand the effectiveness of the service.Although meta-analytic techniqueswould be valuable to assess the evi-dence across studies, the wide hetero-geneity of the studies precluded thisapproach.

Results and discussionOverall, we found a moderate level ofevidence in the literature for theeffectiveness of residential treatmentfor substance use disorders. NumerousRCTs and quasi-experimental studieswere identified, but there were manymethodological challenges within thesestudies. However, on the whole, thereviews and individual studies thatwere conducted found that residentialtreatment is an effective service forsome types of patients. The level ofevidence and the effectiveness of theservice are described further below.

Level of evidenceThe literature search identified eightresearch reviews published since 1995that largely overlapped in the studiesthey included. The reviewed studiesfocused on adult participants with co-occurring mental and substance usedisorders (9–11), inpatient populations(12,13), and therapeutic communities(14–16). We further evaluated sevenindividual RCTs that compared someversion of residential treatment to acontrol condition (17–23) and 14 quasi-experimental studies (24–37). Table 2and Table 3 summarize the features ofthe studies included in this review andtheir findings. The level of evidence forresidential treatment for substance usedisorders was graded as moderate, be-cause this service met the criteria ofhaving two or more RCTs with meth-odological weaknesses.

The studies lacked rigorous exper-imental design or quasi-experimentalmethods that controlled for patientcharacteristics. A focus on selected pop-ulations (for example, male veterans)and on a limited number of treatmentsites limited the generalizability of sev-eral studies. Most effectiveness studies



Table2

Review

articlesof

reside

ntialtreatmen

tforsubstanceusedisordersinclud

edin

thereview

a

Stud

yFocus

ofreview

Nof

stud

ies

review

edMainou

tcom

esrepo

rted

Summaryof

finding

sCom

men

ts

Finne

yet

al.,

1996

(12)

Inpatie

nttreatm

entforal-

coho

labu

se(residen

tial

settings)

14stud

ies:12

expe

rimen

tal,

2naturalistic

Drink

ing,

employmen

tSe

venof

14stud

iesfoun

dsign

ificant

effects

forat

least1drinking

variab

le,bu

tthe

directionvaried

;lik

elymod

eratorsare

discussed.

Stud

ieshadmetho

dologicallim

itatio

ns.In-

patie

ntsettings

werevery

differen

tfrom

currentapproaches.M

anystud

iesexclud

edindividu

alswith

moresevere

disordersor

thosewho

requ

ired

housing.

Brune

tteet

al.,

2004

(9)b

Residentialp

rogram

sforpeo-

plewith

co-occurrin

gse-

vere

mentaland

substance

usedisorders;mostly

ther-

apeu

ticcommun

ities

10stud

ies:2RCTs,8

quasi-e

xperim

ental

Substanceuse,

housing

Nineof

10stud

iessupp

ortedintegrated

reside

ntialtreatmen

tforindividu

alswith

co-occurring

men

talan

dsubstanc

euse

disorders.Fou

rstud

iesfoun

dno

differ-

encesin

substanceuseou

tcom

es.

Stud

ieshadmetho

dologicallim

itatio

ns,a

ndsettings,services,andpo

pulatio

nsvaried

.

Smith

etal.,

2006

(15)

The

rape

utic

commun

ities

7RCTs

Substanceuse,

treatm

ent

completion,

prob

lem

severity

Insufficientevidence

was

foun

dthat

thera-

peuticcommun

ities

arebetter

than

otherresid

entialtreatment.

Stud

iesha

dmetho

dologicallim

itations.

Variation

across

stud

iespreven

tedmeta-

analysis.

Drake

etal.,

2008

(11)

bResiden

tial

treatm

entfor

peop

lewithdu

aldisor-

ders;mostlyintegrated

programs(review

article

also

addressedothe

rservices)

12stud

ies:1RCT,1

1qu

asi-e

xperim

ental

Substanceuse,

men

tal

health

Sevenof

12stud

iesshow

edim

provem

ents;

long

er-term

stud

iesshow

edconsistent

improvem

ents

insubstanceuseandothe

rou

tcom

es;2

of10

stud

iesfoun

dim

proved

mentalh

ealth

outcom

es;1

1of

12stud

ies

foun

dim

proved

outcom

esin

otherareas.

Stud

ieshadmetho

dologicallim

itatio

ns,a


pulatio

nsvaried

.

Clearyet

al.,

2009

(10)

bResiden

tial

prog

ramsfor

peop

lewith

co-occurring

severe

men

talilln

essand

substancemisu

se(review

articlealso

addressed

othe

rservices)

9stud

ies:1RCT,8

quasi-e

xperim

ental

Substanceuse,

men

talstate

Sixof

9stud

iesshow

edredu

cedsubstance

use;

4stud

iesshow

edim

proved

men

tal

state.

Stud

ieshadmetho

dologicallim

itatio

ns,a


pulatio

nsvaried

.

Finne

yet

al.,

2009

(13)

Inpatie

ntandreside

ntial

treatm

ent

App

roximately80

stud

ies

overall;nu

mbe

rvaries

byspecifictopic

Variedby

topicandstud

yEvide

ncewas

foun

dto

supp

ortmatching

patie

ntsto

variou

streatm

entsettings.

Evide

ncesupp

ortsreside

ntialtreatmen

tfor

individu

alswith

fewsocialresourcesor

with

alivingen

vironm

entthat

isaseriou

sim

-pe

dimen

tto

recovery.

Detailsof

moststud

ieswereno

tprovided

.

DeLeon,

2010

(16)

The

rape

utic

commun

ities

21stud

ies:4fie

ldstud

ies,3

single-sitestudies,7RCTs,

1qu

asi-e

xperim

ental,6

meta-analyses

(8stud

ies

arecrim

inaljusticebased)

Substanceuse,

crim

inal

justice

Aconsistent

relation

ship

was

foun

dbe

-tw

eenretentionin

therap

euticcommu-

nities

andou

tcom

es.Improved

outcom

eswereno

tedin

therap

euticcommun

ities

across

RCTsandqu

asi-e

xperim

entalstud-

ies.Meta-analyses

show

edmixed

finding

s.

The

review

was

notcompreh

ensive

andin-

clud

edcrim

inal

justice–basedtherapeu

ticcommun

ities.S

tudies

with

outcomparison

grou

pswereinclud

ed,a

ndmetho

ds,set-

tings,a

ndpo

pulatio

nsvaried

widelyacross

stud

ies.

Malivertet

al.,

2012

(14)

The

rape

utic

commun

ities

12stud

ies:7RCTs,2

retrospe

ctive,

3qu

asi-

expe

rimen

tal

Substanceuse

Substanceusedecreaseddu

ringtreatm

ent,bu

trelapsewas

frequent

aftertherapeutic

com-

mun

itytreatm

ent.Outcomes

werebetter

iftheparticipantcompleted

treatm

ent.Noim

-pact

ofpsychiatric

comorbiditie

swas

noted.

Stud

ieshadmethodologicallim

itations.V

ariation

across

stud

iespreventedmeta-analysis.

aArticlesarein

chrono

logicalo

rder.A

bbreviation:

RCT,rando

mized

controlledtrial

bThe

sereview

articleslargelyoverlapp

edin

theindividu

alstud

iesthey

includ

ed.



Table 3

Individual studies of residential treatment of substance use disorders included in the reviewa

StudyDesignand population

Outcomesmeasured Summary of findings Comments

RCTBurnamet al., 1995(17)

Social model residential versussocial model nonresiden-tial versus no intervention;homeless individuals had adual diagnosis of substancedependence and eitherschizophrenia or major af-fective disorder; mostly male

Substance use, severity ofmental illness symp-toms, housing

At 3-month follow-up, nogroup differences werefound except for housing;residential treatment hada positive effect if the anal-ysis also accounted for ser-vices received outside theRCT.

Contamination with outsideservices was noted, al-though outside service usewas tracked. Differentialparticipation rates andhigh attrition were alsonoted.

McKay et al.,1995 (21)

VA inpatient addiction reha-bilitation versus VA daytreatment; male alcoholicveterans; excluded thosewith unstable residence,drug dependence, severemedical problems, recentpsychosis, schizophrenia

Substance use, otherproblems

No main effects were foundacross groups.

The groups were not equiv-alent despite statisticalcontrols, and many exclu-sion criteria were used.

Guydish et al.,1998 (20)b

Therapeutic community ver-sus therapeutic communitymodel day treatment; ex-cluded homeless individuals,those with severe psychiatricproblems, those clinicallyjudged appropriate onlyfor residential treatment

ASI composite scores,psychiatric symp-toms, social support

Both groups improved inemployment, legal prob-lems, substance use prob-lems, and depressivesymptoms. Residentialtreatment participantsalso improved in medicaland social problems, psy-chiatric symptoms, andsocial support.

Exclusions eliminated manyindividuals likely to be mostappropriate for residentialtreatment. High dropoutwas noted in the 2 weeksafter randomization.

Guydish et al.,1999 (19)b

Therapeutic community ver-sus therapeutic communitymodel day treatment; ex-cluded homeless individuals,those with severe psychiatricproblems, those clinicallyjudged appropriate only forresidential treatment

ASI composite scores,psychiatric symptoms,social support

Both groups improved overtime. Those in residentialtreatment had better ASIsocial composite scoresand fewer psychologicalsymptoms.

Exclusions eliminated manyindividuals likely to bemost appropriate for resi-dential treatment. Highdropout was noted in the2 weeks after randomization.

Rychtariket al., 2000(22)

Freestanding residential ver-sus intensive outpatient ver-sus outpatient treatment;participants with alcohol usedisorders; excluded home-less individuals, those withaddiction treatment in past30 days, those with seriouspsychiatric symptoms

Abstinence, substanceuse

Abstinence improved acrossgroups. Interactions werefound for setting for thosewith higher alcohol involve-ment and poorer cogni-tive functioning at baseline;they showed more improve-ment in a residential setting.

Few differences were notedbetween groups at baseline.Exclusions eliminated manyindividuals likely to be mostappropriate for residentialtreatment.

Greenwoodet al., 2001(18)b

Therapeutic community versustherapeutic communitymodel day treatment; ex-cluded homeless individuals,those with severe psychiat-ric problems, those clinicallyjudged appropriate only forresidential treatment

Substance use Abstinence improved in bothgroups. The day treatmentgroup had a higher relapserate at 6 months but not at12 or 18 months.

Exclusions eliminated manyindividuals likely to be mostappropriate for residentialtreatment. High dropoutwas noted in the 2 weeksafter randomization.

Witbrodtet al., 2007(23)

Social model residential ver-sus social model day hos-pital; also examined clientsnot randomly assigned toeach setting; part of healthplan system; no random as-signment if individual hadhigh environmental risk forrelapse or more than min-imal medical or psycholog-ical problems

Abstinence Abstinence was noted forabout two-thirds of eachgroup at 6 months. Nodifference was found bysetting in adjusted modelsfor either randomly as-signed or self-selected(not randomly assigned)clients.

Significant differences werefound across groups in var-ious measures of severity.The authors adjusted forthese measures in regressionmodels. Differential attritionwas noted at follow-up.

Continues on next page



Table 3

Continued from previous page



Quasi-experimentalMoos et al.,1996 (33)

VA community-based residen-tial versus VA hospital-basedresidential; male veteransdischarged from acute in-patient care for substanceuse disorders

Inpatient readmission(for mental or sub-stance use disorder)

A lower probability of read-mission was noted for par-ticipants in communityresidential programs com-pared with hospital-basedprograms.

Baseline differences betweengroups were found for psy-chiatric diagnosis and in-patient care but not fordemographic characteris-tics. Additional treatmentwas documented only ifreceived in VA.

Hser et al.,1998 (27)c

Short-term inpatient and long-term residential versus out-patient treatment; DATOSstudy: patients treated inparticipating communitytreatment programs

Substance use Inpatient and residential pro-grams were best for non-daily cocaine and heroinusers.

There was no control forbaseline patient charac-teristics aside from pre-treatment drug use. Datawere collected after 1 weekin treatment, which intro-duced potential bias by ex-cluding early dropouts.

Harrison andAsche,1999 (26)

Inpatient, mostly Minnesotamodel, and a few thera-peutic communities versusoutpatient; excluded thosewith cognitive impairmentthat precluded consent

Abstinence No difference in abstinencewas found by group.

Group differences were notedin sociodemographic char-acteristics. Analyses con-trolled for many baselinevariables, but group place-ment was based on verydifferent individualcharacteristics.

Pettinatiet al., 1999(35)

Inpatient versus outpatient;alcohol-dependent but notdrug-dependent patients;excluded those with severewithdrawal or serious med-ical problems

Drinking status No effect by group was foundon return to significantdrinking. Survival analysisshowed a steeper initialrate of return to drinkingfor the outpatient group.

Analyses controlled for base-line severity but no otherpatient characteristics.

Schildhauset al., 2000(36)d

Residential (mostly therapeu-tic communities) versus in-patient treatment; SROSstudy: participants treatedin community treatmentfacilities

Substance use, criminalbehavior

No difference in outcomeswas found for participantsin residential and inpatientsettings.

This 5-year follow-up studycontrolled for many vari-ables before, during, andafter treatment using ret-rospective data.

McKay et al.,2002 (31)

“Full continuum” of residen-tial before outpatient treat-ment versus “partialcontinuum” of intensiveoutpatient treatment asentry point; no exclusionsnoted

Substance use, ASIcomposite scores

Both groups improved overtime on all outcomes. A sig-nificant severity 3 modalityinteraction was found, withlarger improvements forthose with high alcohol se-verity scores in the full con-tinuum compared with thosein the partial continuum.

Baseline differences werenoted between groups,including severity scores.Groups had differentialissues with recruitment.High attrition was noted.

Mojtabai andZivin, 2003(32)d

Residential (mostly therapeu-tic communities) versus in-patient and outpatient; SROSstudy: participants treatedin community treatmentfacilities

Abstinence, substanceuse

Overall, no difference wasfound between residentialand outpatient treatment.Some effects were seenwith propensity scorematching.

This 5-year follow-up studyused a propensity scoreapproach to control forbaseline characteristics,but control for othercharacteristics duringfollow-up, such as ad-ditional treatment, wasunclear.

Hser et al.,2004 (28)

Residential versus outpatienttreatment without metha-done; no exclusions noted

Treatment success (in-cludes drug use, ASIdrug severity score,criminal activity, resi-dence in community)

Those in residential treat-ment were more likely tocomplete treatment andhad longer stays, whichin turn predicted betteroutcome.

This study used path analysiswith statistical controls.Nearly half of the samplehad missing data, and theseparticipants were excludedfrom analyses.

Continues on next page



described here evaluated patientswho chose or were referred by clini-cians to a specific treatment modality.RCTs that evaluated specific treatment

modalities for substance use disorderswere rare because treatment providershad concerns about randomly assigningindividuals in need of treatment to a no-

treatment condition or to a lower levelof care than was clinically appropriate.Some RCTs were conducted with alarge limitation: the researchers required

Table 3

Continued from previous page



Ilgen et al.,2005 (30)e

VA “inpatient” (inpatient,residential, or therapeuticcommunity–like domicil-iary) versus “outpatient”(outpatient or intensiveoutpatient); veterans, nosubstance abuse treat-ment in past 90 days;mostly male

Abstinence; suicide at-tempts; ASI alcohol,drug, and psycholog-ical composite scores

At 6 months, inpatient groupshad lower alcohol and drugcomposite scores than outpa-tient groups. An interactioneffect was found such thatindividuals with a recentsuicide attempt were morelikely to be abstinent iftreated as inpatients.

Analyses controlled only forbaseline ASI measures andnot for other patient char-acteristics. Control vari-ables were not specified.“Inpatient” combined sev-eral very different types ofcare.

Brecht et al.,2006 (24)

Residential versus outpatienttreatment as usual; meth-amphetamine users

Methamphetamine use,criminal activity,employment

Reduced methamphetamineuse and crime were notedin the residential group. Nodifference was found foremployment.

Data were collectedretrospectively.

Ilgen et al.,2007 (29)

Residential versus outpatientcommunity settings; no ex-clusions noted

Suicidal behavior The residential setting wasassociated with fewer suicideattempts during treatment.No difference betweengroups was found in theyear after treatment.

Baseline differences betweengroups were noted, butanalyses used statistical con-trols. Substance use out-come was not measured.

Tiet et al.,2007 (37)e

VA “inpatient” (inpatient,residential, or therapeuticcommunity–like domiciliarytreatment) versus “outpa-tient” treatment (outpatientor intensive outpatient); vet-erans; mostly male

Substance use severity No main effect was found fortreatment setting. Somesmall interaction effectswere noted: those witha higher severity of sub-stance use at baseline hadbetter outcomes in inpa-tient and residential thanin outpatient settings.

Significant group differenceswere noted at baseline, butregression models con-trolled for them. Differen-tial attrition and nonresponsebias were noted.

De Leonet al., 2008(25)c

Long-term residential; matchedundertreated and overtreatedpatients; DATOS study: pa-tients treated in participat-ing community treatmentprograms

Substance use, arrests Patients had better outcomes ifthey were matched to res-idential treatment than ifthey were appropriate forresidential treatment but un-dertreated in an outpatientsetting. Similar outcomeswere noted in residentialtreatment if patients werematched or overtreated (ap-propriate for outpatienttreatment but treated ina residential setting).

Data were collected after1 week in treatment,which introduced po-tential bias by excludingearly dropouts.

Morrenset al., 2011(34)

Integrated treatment for pa-tients with schizophreniaand co-occurring substanceuse disorder in a residentialsetting versus treatment asusual; both groups recruit-ed from inpatient psychi-atric hospitals and continuedwith outpatient care; psy-chotic disorder for at least2 years and substance usedisorder; aged 18–45 yearsonly

Substance use, psychi-atric symptoms

At 3 months, the integratedresidential group had re-duced substance use, im-proved psychiatric symptoms,and higher quality of lifeand functioning comparedwith the treatment-as-usualgroup.

No baseline differences werenoted, but differential drop-out limited analyses to 3months. Some tentativeconclusions were drawnfor 6- and 12-month follow-ups. Dropout rates variedbetween groups.

a Articles are in chronological order by type of research design. Abbreviations: ASI, Addiction Severity Index; DATOS, Drug Abuse Treatment OutcomeStudy; RCT, randomized controlled trial; SROS, Services Research Outcomes Study; VA, Veterans Affairs

b–e Articles with the same superscript reported some aspects of the same study.



individuals in the intervention groupto be appropriate for the outpatientcare that was received by the com-parison group, to avoid undertreatingindividuals who might not be treatedsafely if randomly assigned to out-patient care. This design created afalse comparison, because individu-als appropriate for residential treat-ment (and thus not appropriate foroutpatient care) were excluded. Cli-ents with more severe needs (forexample, individuals without stableliving arrangements or individualswith general medical or psychiat-ric diagnoses) were often excludedfrom the intervention group, de-spite the possibility that they werelikely to benefit from residentialservices.Many studies that suggested im-

proved outcomes after residential treat-ment were excluded from this reviewbecause they lacked a comparison groupor used pre-post measurement withoutstatistical controls. Other methodolog-ical concerns in the literature includedretrospective data collection, lack ofcontrol for the amount of treatmentreceived, and lack of detailed de-scriptions of the service components.Comparison groups often varied bycharacteristics of the setting (for ex-ample, type of setting or treatmentduration) and by treatment content(for example, services or theoreticalapproach), thereby confounding thecomparisons. Each of these limita-tions influenced the conclusions thatcould be drawn.

Effectiveness of the serviceThe effects of residential treatmentservices weremixed, with some studiesindicating positive findings and othersshowing no significant differences inoutcomes between clients in residen-tial treatment settings and those inother types of treatment. For example,the Walden House residential thera-peutic community was compared witha therapeutic community model thatused a day treatment program (18–20).At six months, both groups had reliableimprovement in drug and alcohol useand employment. The Walden Housegroup also had significant improve-ments in medical and social problems,psychiatric symptoms, and social sup-port.Most outcomes seen at sixmonths

were maintained through 18 months(19); the day treatment group hada higher likelihood of relapse at sixmonths but not at 12 or 18 months(18). In quasi-experimental studies,individuals receiving residential treat-ment had less methamphetamine useand crime (24), higher treatmentcompletion rates and longer treatmentstays (28), and reduced suicideattempts during treatment (29) com-pared with individuals receiving out-patient treatment. Individuals ininpatient residential treatment hadlower alcohol and drug severity scoresat six months than those in outpatienttreatment, after control for baselineseverity (30). De Leon and colleagues(25) found some evidence supportingtreatment matching; clients matchedto long-term residential care hadbetter one-year outcomes than thoseundertreated in outpatient drug-freesettings. Individuals with co-occurringmental and substance use disorders inintegrated residential treatment set-tings had reduced illicit drug andalcohol use, improved psychiatricdomains, higher reported quality oflife, and improved social and commu-nity functioning than those in treat-ment as usual (9–11,15).

Reflecting the inconsistency in theliterature, other studies showed nosignificant differences between individ-uals receiving residential treatment andthose receiving treatment in compari-son conditions on outcomes such asabstinence from drug use, psychosocialvariables, reduced drug use, criminalactivity, arrest rates, or rates of return-ing to prison (21–23,26,27,32,35–37).In an RCT, researchers comparedtreatment in a residential social modeland in a nonresidential social model forhomeless individuals with co-occurringmental and substance use disorders(17). No significant differences, asidefrom housing, were found betweenresidential and nonresidential treat-ment groups at the three-monthfollow-up. When the analysis con-trolled for total services accessed, theresidential group had significantlyfewer days of alcohol use at the three-month follow-up, but no other signif-icant effects were found.

The inconsistency in findings isdocumented by the literature reviewswe examined. Published reviews of

residential treatment reported on stud-ies that had serious methodologicallimitations, resulting in the need for“an RCT with a well-defined popula-tion, a standardized program, and ablind assessment of outcomes” (9).Finney and colleagues (12,13) con-ducted two reviews that summarizedthe evidence on treatment settings—the first in 1996 and the second in2009. The 1996 review included re-search on “inpatient” treatment com-pared with outpatient treatment ordetoxification only (12). Although com-prehensive at the time, the review wasconfounded for our purposes by theinclusion of both hospital inpatientapproaches and nonhospital residen-tial approaches and the exclusion ofindividuals with severe problems orwithout stable housing. In addition,many approaches described in thereview article are no longer commonlyused in the field; thus the article is notdiscussed further here. The 2009 re-view by Finney and colleagues (13)found evidence supporting the effec-tiveness of treatment that matchedpatients to different treatment set-tings, such as via the ASAM PPC-2R.However, the review provided littleinformation about methods used inthe included studies.

Three reviews examined the effects oftherapeutic communities on substanceuse outcomes (14–16). ACochraneCol-laboration review indicated that in-sufficient evidence exists to state thattherapeutic communities are moreeffective than other levels of care;however, methodological limitationstempered the researchers’ conclusions(15). High attrition was a common lim-itation in the reviewed studies. Someevidence suggested that specific pop-ulations, such as homeless individualswith co-occurring mental disorders orindividuals in prisons, had better out-comes in therapeutic communities thancontrol groups. The second reviewfound that individuals in therapeuticcommunities demonstrated improvedoutcomes compared with individualsin control conditions; however, thefindings were limited by variousmeth-odological issues, such as overlap be-tween the treatment and comparisonconditions and inconsistent programfidelity (16). The third review foundsignificant decreases in substance use



while individuals were in therapeuticcommunities but indicated that meth-odological problems tempered the ex-tent to which conclusions could bedrawn about the long-term effects oftherapeutic communities (14). Similarto other reviews, the third review foundthat therapeutic communities may pro-vide a better treatment option for in-dividuals with severe psychosocialproblems, depending on the length ofstay in the program.Three reviews (9–11) focused on

populations with co-occurring mentaland substance use disorders. The ex-perimental group usually received in-tegrated residential treatment (forindividuals with co-occurring disor-ders), and control groups received“treatment as usual” with less intenseor nonintegrated residential treatment.These reviews found that individualswith co-occurringmental and substanceuse disorders can be treated success-fully in residential settings, whetheror not treatment is integrated. Atminimum, integrated treatment wasequally as effective as standard treat-ment for this population, and mostof the studies found that integratedtreatment was more effective thanstandard treatment in regard to sub-stance use, mental health, and otheroutcomes.

ConclusionsThis review found a moderate level ofevidence for the effectiveness of resi-dential treatment (see box on thispage). Despite the prevalence of meth-odological concerns—primarily the ap-propriateness of the samples andequivalence of comparison groups—some evidence indicates that residen-tial treatment is effective for sometypes of patients. Further, much of theliterature suggests that residential

treatment is equally as effective ascomparisonmodalities, and a few stud-ies suggest that it is more effective.However, until research with morerigorous methods is conducted, theseconclusions remain tentative.

We echo the call of others forfurther research to better determinewhich clients benefit from residentialtreatment, what duration of treatmentconfers positive effects, and what typesof effective clinical interventions areprovided within the program. Furtherstudies should examine the compo-nents of residential treatment thatmight relate to effectiveness, such astypes of clinical staff, use of peersupport, number of beds, or lengthsof stay currently used. To attain idealoutcomes, it is essential for newevaluations of residential treatmentfor substance use disorders to takea chronic care approach to ensure thata treatment modality is not evaluatedin a vacuum and that continuing care isan outcome as well as an essential partof the treatment episode.

Any new research in this area mustbe methodologically rigorous and useappropriate comparison groups toensure that conclusions are valid.Systematic, rigorously conducted stud-ies are essential for policy makers tomake decisions about the inclusion ofresidential treatment in health plansand the allocation of resources toresidential treatment activities.

Specifically, research needs to iden-tify which individuals respond best toresidential treatment programs. Studiesshould use appropriate control groups.Future research needs to reflect cur-rent approaches to residential treat-ment and examine the role of treatmentfactors (such as staffing and length ofstay) in contemporary approaches toresidential treatment. Research must

include posttreatment variables, such asmutual-help participation, when evalu-ating outcomes. Examining effectivetreatments for individuals with sub-stance use disorders requires furtheringour understanding of how to improvetreatment retention, lengthof stay, treat-ment completion, and participation inaftercare.

Finally, it is important to determinewhether treatment services are equallyeffective for different populations.Giventhe significance of health disparities inaccess to and receipt of substance usetreatment, implementing effective andculturally responsive care is essential.Most studies described the demo-graphic characteristics of the sample,and some studies controlled for thesecharacteristics in analyses. However,no studies specifically analyzed race orethnicity through interaction terms,stratification, or other approaches. Ex-amining the effectiveness of treatmentacross different groups requires anal-yses comparing outcomes of specificsubgroups within and across treatmenttypes. Additional work should analyzethe role of culture-specific approaches—for example, multilingual staff. We en-courage researchers to incorporate suchanalyses as we continue to evaluate thistreatment modality.

In addition to calling for rigorousresearch on the current system, wenote that the moderate level of evi-dence for the effectiveness of resi-dential treatment of substance usedisorders has relevance for consumersand their families as well as for policymakers. Consumers have a wide rangeof needs, and they would benefit froma variety of services to address thoseneeds. Residential treatment for sub-stance use disorders fills a niche forconsumers who require stable livingenvironments that incorporate thera-peutic treatments to help them movetoward a life in recovery. Similarly, toreduce the likelihood of treatmentfailure, policy makers should ensurethat a full range of treatments isavailable to meet consumer needs.With research demonstrating a moder-ate level of evidence, policy makers canhighlight the benefit of includingresidential treatment as a key service inthe continuum of care.

As the treatment system for sub-stance use disorders continues to evolve,

Evidence for the effectiveness of residentialtreatment for substance use disorders: moderateOverall mixed results suggest either an improvement or no difference in outcomessuch as:• Drug and alcohol use• Employment• Medical and social problems• Psychiatric symptoms• Social support



particularly within the current contextof broader health care system change,it is essential to understand the roleand effectiveness of treatment options.Residential treatment has been usedfor substance use disorders for manyyears, and there are clear indicationsfor continuing these services. How-ever, for policy makers and payers(for example, state mental health andsubstance use directors, managed carecompanies, and county behavioral healthadministrators) to be able tomake rec-ommendations about which servicesto cover and include in a treatmentcontinuum, they must be able to eval-uate those services as they currentlyexist. Residential treatment showsvalue for ongoing inclusion and cov-erage as part of the continuum of care,but additional rigorous research isnecessary to understand how and forwhom it best fits.

Acknowledgments and disclosures

Development of the Assessing the Evi-dence Base Series was supported by contractsHHSS283200700029I/HHSS28342002T,HHSS283200700006I/HHSS28342003T, andHHSS2832007000171/HHSS28300001T from2010 through 2013 from the Substance Abuseand Mental Health Services Administration(SAMHSA). The authors acknowledge the con-tributions of Kevin Malone, B.A., and SuzanneFields, M.S.W., from SAMHSA; John O’Brien,M.A., from the Centers for Medicare & Med-icaid Services; Garrett Moran, Ph.D., fromWestat; John Easterday, Ph.D., Linda Lee,Ph.D., Rosanna Coffey, Ph.D., and Tami Mark,Ph.D., from TruvenHealth Analytics; ConstanceHorgan, Sc.D., from Brandeis University; andCarol McDaid, M.A., from Capitol Decisions,Inc. The views expressed in this article are thoseof the authors and do not necessarily representthe views of SAMHSA.

The authors report no competing interests.

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