14. Residential treatment and intensive structured day programmes
Residential treatment and intensive structured day programmes for alcohol dependence aim to help people achieve abstinence and begin recovery through evidence-based interventions. This includes group work, individual support and planning for continuity of care in the community.
Residential and intensive day programmes are an important part of a recovery-oriented system of care.
Services should be trauma-informed and have clear clinical governance structures and policies including for staff supervision.
Programmes may be based on different therapeutic approaches and these should be explicit to enable service user choice.
Residential treatment focused on abstinence should be available for people with the most complex needs, particularly people experiencing homelessness.
Structured day programmes can provide intensive support to people in their communities and are a useful addition for people living in supported accommodation.
There should be as seamless transition as possible into residential and intensive day programmes for people completing medically assisted withdrawal.
It is important to prepare people for residential and intensive programmes but not at the expense of making it hard for them to access.
Multi-agency planning involving the person should take place to help the person integrate back into community treatment and recovery support in their local community before they leave residential treatment.
This section provides guidance on residential treatment and structured day treatment.
Intensive structured treatment programmes can be provided in either a residential treatment setting or a community treatment service or a day hospital. These programmes are designed to meet the needs of people who need a higher level of support to achieve their treatment and recovery goals than they could receive through standard community alcohol treatment (Orchowski and Johnson, 2012; Coco and others, 2019).
Residential treatment programmes are one of the longest established forms of treatment for alcohol and drug dependence. A recent systematic review of research published between 2013 and 2018 found moderate quality evidence for the effectiveness of residential treatment in improving outcomes across a number of substance use and life domains (de Andrade and others, 2019).
The National Institute for Health and Care Excellence (NICE) clinical guideline Alcohol-use disorders: diagnosis, assessment, and management of harmful drinking (high-risk drinking) and alcohol dependence (CG115) recommends residential treatment for people who are experiencing homelessness.
The NICE clinical guideline Drug misuse in over 16s: psychosocial interventions (CG51) recommends considering residential treatment for people who are seeking abstinence and who have significant co-occurring physical health, mental health or social (for example, housing) conditions and have not benefited from previous community treatment. The clinical consensus of the alcohol guidelines development group is that these criteria are also applicable to people with alcohol dependence.
There are mixed findings on the effectiveness of residential treatment compared with structured day treatment of a similar intensity and duration. NICE CG115 recommends more research in this area because studies are limited, and no recent comparative studies have been reviewed.
14.3.1 Types of intensive structured treatment programmes
Intensive structured treatment programmes, whether in a residential or day setting, support people to achieve abstinence and encourage their recovery. Intensive programmes usually provide daily structure and a focus on health, personal and social functioning, as well as treatment and recovery goals.
The programmes are varied because they are based on different therapeutic approaches and use a range of different treatment components. Programmes are usually abstinence based and include:
- individual sessions
- structured group work and participating as a member of a community
- social and recovery-oriented activities
- encouragement to join mutual aid groups, peer networks and peer support services
- family support and involvement where appropriate
There is no clear evidence about optimal treatment length, although several studies have found that longer programmes (lasting 3 months or more) are associated with better treatment outcomes (Eastwood and others, 2018; Helena Kennedy Centre for International Justice, 2017).
The length of time somebody should be in an intensive treatment programme should be tailored to their needs but should also allow enough time for them to:
- engage with the programme
- build trust with the staff
- commit to the treatment community
- work on individual change
- get ready for reintegration to their community after treatment
The time needed for all of this will vary from person to person.
14.3.2 Residential treatment
Residential treatment services are an important part of a recovery-oriented system of care. Every local area should provide access to this treatment option for the minority of people who require intensive support to achieve abstinence and begin their recovery.
Residential treatment services are facilities where residents stay overnight, usually for several months. They are run by voluntary and private sector organisations and in Scotland there is also some statutory provision.
Residential treatment provides a daily structure and safe place for people who may have come from unsafe circumstances, including rough sleeping or living in an abusive situation. It provides a complete break from current social networks that revolve around alcohol use or from high-risk situations in the community. People who are susceptible to returning to drinking or who have vulnerable mental health may need the 24-hour support that these services can provide, beyond the formal programme interventions. A placement in residential treatment can give people the space to build their recovery resources and develop the skills they need to sustain longer-term recovery and reintegration into the community.
Entering residential treatment and returning to the community can both be challenging transitions. Both these transitions require preparation and planning to minimise people’s risk of leaving treatment unplanned or returning to problematic drinking after they leave (see section 14.4).
Some residential services provide medically assisted withdrawal before the person moves on to the main part of the intensive structured programme.
You can find guidance on medically assisted withdrawal in chapter 10 on pharmacological interventions, chapter 11 on community medically assisted withdrawal and chapter 12 on inpatient medically assisted withdrawal.
14.3.3 Intensive structured day treatment
A structured day programme may be a more accessible treatment option for people who do not want or need residential treatment, such as those who have a good local support system and stable and secure accommodation.
In the UK, intensive structured day treatment programmes generally require the person to attend for 4 or 5 days each week and normally last between 4 and 12 weeks. Ideally the length of treatment should be tailored to the needs of the person.
Intensive day treatment provides a high level of structure and support, while allowing the person to maintain day to day contact with their support networks and remain in their accommodation. People usually attend intensive day treatment while living at home, but some programmes are designed for people living in supported accommodation for the duration of their treatment, which can offer additional stability to support recovery.
Intensive day programme participants typically return home each evening and have to manage weekends without access to treatment activities. Real world exposure to everyday issues or drinking cues during the treatment programme may help them to practice their new skills and techniques and link in with local recovery support networks as these challenges arise (Leighton 2016).
14.3.4 Core elements of intensive structured treatment programmes
All intensive structured treatment programmes (day or residential) should have:
- a coherent treatment programme with a clear rationale and therapeutic framework
- a consistent risk assessment process, both for medically assisted withdrawal (if the service provides this) and the psychosocial programme
- a comprehensive assessment process that fully involves the person with alcohol dependence, and leads to a personalised treatment and recovery plan
- clear links between the assessed needs of a person and the interventions they receive
- evidence-based group interventions delivered by trained staff who receive clinical supervision for a groupwork approach and for the specific interventions
- individual key working support with a named keyworker that runs alongside the group programme
- a focus on community reintegration throughout the programme, encouraging people to build recovery resources by getting involved in mutual aid groups or peer support networks or services
- individually agreed plans for ongoing treatment and recovery support after the person has left the programme (sessional, day or extended residential depending on assessed need)
- strong links with community alcohol treatment services who should contribute to planning for ongoing treatment and recovery support after the person leaves the programme
14.3.5 Therapeutic approach
Intensive structured treatment programmes use a range of therapeutic, recovery-focused approaches. These include programmes where the central focus is therapeutic community, the 12-step model, and programmes based on cognitive behavioural therapy. Other approaches used in UK settings have included faith-based programmes, or personal and skills development-based models. Most residential treatment programmes are now fairly eclectic and draw on a range of interventions. There is no strong evidence to support one evidence-based approach over another.
The perceived quality of the programme is an important indicator of outcome. For example, one study reported that people who saw their residential treatment programme as more involving, cohesive, well-organised, and oriented toward independence and self-understanding had better drinking-related outcomes (Moos and Finney, 1983).
In both residential and community settings, evidence suggests that an effective programme has a welcoming, accepting ethos and a highly structured and predictable programme. These factors are likely to be more important than the theoretical basis or exact content of the programme because they provide the context for building trust, commitment, and starting to make significant change (Leighton, 2017).
Intensive structured treatment programmes tend to be based on the therapeutic value of being part of a community. This can include formal structured activities in which staff and residents are expected to participate (such as community meetings), and peers offering support to each other. Peers can support one another as part of formal group therapy. Peers who are further on in the treatment programme can also act as role models as they interact with newer participants during daily shared activities. Participating in the community helps people to gain social skills in an alcohol-free, recovery-oriented environment.
14.3.6 Trauma-informed care and cultural competence in intensive structured treatment programmes
Services and practitioners should apply all of the core principles of care outlined in chapter 2 to intensive structured treatment programmes.
Services should recognise the importance of trauma-informed care and related staff competencies. Intensive structured treatment programmes have the potential to trigger traumatic memories because of their intensity and their focus on groupwork. And, in the worst case, can seriously retraumatise participants. This may be particularly relevant in residential settings where shared living arrangements mean that people are always near one another when they are feeling vulnerable. Providers of intensive structured treatment programmes should develop and maintain a trauma-informed treatment environment. All staff should be trained in trauma-informed care.
Cultural competence is essential for all services and practitioners. Given the intensity of day and residential structured programmes, services should make extra effort to make sure they are inclusive, safe and effective, taking into account differences in:
- culture
- ethnicity
- religion
- sex
- gender identity
- sexual orientation
- age
- physical ability
Services should provide training in cultural competence and regularly review their staff’s cultural competence.
14.3.7 Quality governance
There should be a strong focus on the overall service quality and on quality governance for intensive structured treatment programmes.
You can find guidance on quality governance in section 2.4 in chapter 2 on principles of care.
Residential treatment services should be registered with national regulatory bodies and comply with their standards.
The national regulatory bodies are:
- Care Quality Commission (England)
- Healthcare Improvement Scotland and the Care Inspectorate (Scotland)
- Healthcare Inspectorate Wales
- Regulation and Quality Improvement Authority (Northern Ireland)
Intensive structured treatment programmes are complex to deliver. Staff should have training and competencies in:
- counselling, psychotherapy or psychology
- groupwork
- the therapeutic approach the service uses
The service should provide regular clinical supervision by a professional trained in supervision and also trained and experienced in the interventions being supervised.
Where residential treatment services offer medically assisted withdrawal, it is vital they have the appropriate facilities and staff competence to work with the people they offer this intervention to.
There is guidance on medically assisted withdrawal in chapter 10 on pharmacological interventions, chapter 11 on community-based medically assisted withdrawal and chapter 12 on specialist inpatient medically assisted withdrawal.
Residential services offering medically assisted withdrawal should be aware of the guidance on distinguishing specialist inpatient medically assisted withdrawal and residential medically assisted withdrawal in section 12.6 in chapter 12.
14.4.1 Assessment for an intensive treatment programme in community alcohol treatment services
Comprehensive assessment and treatment and recovery planning
Community alcohol treatment services should consider intensive structured day treatment programmes as a treatment option during comprehensive assessment, and during treatment and recovery plan reviews.
Most people who would benefit from residential or intensive day treatment programmes will have previously engaged in standard treatment interventions in the community. Some people, such as those experiencing homelessness or multiple disadvantage, might not be able to respond to less intensive interventions. So, intensive structured treatment may be appropriate for them from the start of their treatment journey.
It is complex to assess whether a person should be referred to an intensive treatment programme. There should be input from the multidisciplinary team or a clinician with experience of assessing people for residential treatment. The decision to refer should be reached collaboratively with the person, based on clinical assessment and discussion about their preference.
Co-occurring mental and physical health conditions
You should invite other services involved in the person’s care and their family members to contribute to the assessment, with the person’s consent. In cases where a person has a co-occurring severe mental health or physical health condition, practitioners need to work closely with the community mental health team or the physical health treatment team to make decisions about the suitability of a placement.
A person may be assessed as suitable for residential treatment who is also receiving treatment for their physical health or mental health. In these cases, involved professionals from those services will need to agree who will lead on communicating with the residential treatment service. This is to make sure that appropriate physical health and mental health care can be provided for the person in the local area of the residential service.
There is some evidence that outcomes are improved when residential settings offer treatment for both mental health conditions and substance use conditions (Brunette and others, 2004).
For more information about working with co-occurring conditions, see chapter 18 on co-occurring mental health conditions and chapter 19 on co-occurring physical health conditions.
Medically assisted withdrawal
Intensive structured treatment usually follows medically assisted withdrawal, which can be provided in a community, residential, specialist inpatient setting, depending on the person’s assessed need. If medically assisted withdrawal is not provided in the residential treatment setting, or if the person requires specialist inpatient medically assisted withdrawal, the referrer and the person will need to plan for the medically assisted withdrawal. And where possible they need to arrange for an immediate transfer to the intensive structured programme after the medically assisted withdrawal.
Section 10.2.4 in chapter 10 on pharmacological interventions provides guidance on criteria for considering specialist inpatient medically assisted withdrawal.
Section 12.6 in chapter 12 on specialist inpatient medically assisted withdrawal provides guidance on differentiating specialist inpatient medically assisted withdrawal and residential medically assisted withdrawal.
No unnecessary delays
It is important to prepare with the person for both medically assisted withdrawal and for a residential or intensive day programme, but you should also consider the urgency of the person’s need, based on their physical and mental health and social circumstances. The preparation should be based on the person’s assessed needs. There should be no standard requirements that everyone attends a set number of groups or appointments before accessing intensive structured treatment, because these requirements can create barriers to accessing treatment.
Once the person has made a fully informed decision to undertake medically assisted withdrawal followed by residential treatment or intensive structured day treatment, services should work together to make sure there are no unnecessary delays. People who are assessed as needing intensive structured treatment are likely to be vulnerable and have the highest levels of need and risk. So, it’s important that they can access residential and intensive structured day programmes as easily as possible. Delays can be demotivating to a person with severe dependence or with complex needs and risk people changing their minds about joining an intensive programme. Commissioners and services should make sure that processes for agreeing funding and related arrangements are as streamlined as possible.
People referred to intensive structured treatment programmes often have poor health. If there are any unavoidable delays before admission, a clinician in the referring service should regularly review the person’s physical and mental health. If their needs and risks change, the service should consider different interventions. The keyworker should continue to provide support to the person throughout this time, to keep them engaged in the treatment journey and monitor any risks.
14.4.2 Preparation in community treatment services
It is good practice to prepare people for intensive treatment. Effective preparation can help improve people’s retention, engagement and their awareness of the benefits of the programme they are going to enter. You should do this by:
- giving them up to date, accessible information (verbal and written or video) about available options
- arranging visits to the programme where possible
- discussing relevant concerns or questions about the programme
If a person is assessed as needing an intensive treatment programme, the keyworker should help them think carefully about whether or not they want to engage in it. They should consider:
- the intensity of the groupwork experience
- how the staff delivering the programme help people to manage the pressures of participating
- how the person might respond to this experience
For people considering a residential placement, keyworkers should help them think about the potential impact of leaving their home community and living close to other people with complex needs. If they have specific cultural needs, they will need to consider how these can be met within the programme.
Arranging visits can help people to make a decision and the keyworker should encourage them to visit the service before accepting a place. It may also help the person to talk with someone who has been through the programme.
The keyworker should ensure they have the person’s fully informed consent before making a referral.
Services should only refer people to residential treatment services that are registered with national regulatory bodies and comply with their standards (see section 14.3.7).
14.4.3 Assessment in residential or community intensive programmes
Staff who deliver intensive programmes also have an important role to play in assessing people’s suitability and preparing them for admission to their programme. These staff should help people prepare by giving them pre-admission advice about:
- behaviour boundaries and how to interact with others on the programme
- the kind of emotional experiences that joining the programme can evoke and how the staff can support people to manage these
- how the programme is balanced to offer formal therapeutic activities, social activities and activities that contribute to recovery
- how group therapy works, including rules for confidentiality and acceptable behaviour and how a new participant will be inducted into the group
- how groups can be run in a safe way
- how a person’s family or wider community can be involved in the programme
Research shows that if a person stays in the treatment programme and completes it, this is associated with improved treatment outcomes (Eastwood and others, 2018). There is emerging evidence that particular practices can help enhance engagement and retention in a residential setting. These include:
- motivational interviewing (Carroll and others, 2006)
- using senior staff to induct new residents into treatment (De Leon, 2000)
- increasing the focus on the therapeutic relationship in staff training and supervision (Meier and others, 2006)
14.4.4 Personalised treatment and recovery planning
It is important that anybody taking part in an intensive structured programme sets and agrees their own personal treatment goals and timelines for the programme in consultation with their keyworker. They should also get to regularly review their own progress against their goals. This allows the treatment and recovery plan to be personalised to meet their own needs in the context of the overall goals of the programme.
You can read guidance on treatment and recovery planning in section 4.10 in chapter 4 on assessment and treatment and recovery planning.
When a person is in an intensive structured programme, it is good practice that they keep in regular communication with a named keyworker in their home community alcohol treatment service about their progress, priorities for action and next steps.
There are a number of issues that might affect the success of the person’s eventual re-integration into the community, and you should consider these when developing their treatment and recovery plan during their time on the intensive structured programme. These issues can include:
- finding accommodation for people without housing
- encouraging them to develop new skills, such as helping them access education, training and employment opportunities
- engaging with recovery support services including peer support networks and services and mutual aid groups
- re-establishing or maintaining family links (where appropriate) so they have family support when they leave the programme
14.4.5 Preparing for discharge from community or residential intensive programmes
Inter-agency communication is vital during the treatment programme and when the person leaves, whether in a planned or unplanned way. It is good practice to agree confidentiality, boundaries and information sharing arrangements with the person at the start of their treatment, so you can discuss arrangements for ongoing treatment and support and put these in place, regardless of how the placement ends. You need to plan with the person for their ongoing treatment and recovery support in good time to enable a smooth transition to a reduced level of support.
All intensive programme providers should develop policies to reduce the risk of negative outcomes for people who do not complete the treatment programme.
14.4.6 Considerations specific to discharge planning in residential programmes
Successful outcomes after residential treatment
There is good evidence for the importance of ongoing treatment and support, as well having a job and stable housing, as factors that predict successful outcomes after residential rehabilitation (Helena Kennedy Centre for International Justice, 2017). There is also evidence of positive outcomes for people who engage with 12-step support when they leave residential rehabilitation (de Andrade and others, 2019).
There is often a high risk of the person returning to problematic alcohol use in the period immediately after residential treatment. So, it is very important that there is a plan in place for continuous care between the residential and community alcohol treatment services. The plan should also include arrangements for other support, including:
- housing
- welfare benefits
- mental healthcare
- physical healthcare
People should be actively supported to access peer support and mutual aid in their home community.
Re-engaging with community-based alcohol treatment services
At the start of a person’s residential treatment, you should agree pathways for them to re-engage with community-based treatment services as soon as possible after they leave the programme. This includes agreeing relevant pathways and agreed actions keyworkers will take if people leave the programme before completing treatment.
Planning for continuity of care may include arrangements for transporting the person back to their home, or how local treatment and recovery support services will be notified when they are about to be discharged. It will be useful to have an agreement so residential staff can quickly contact the community treatment keyworker to let them know when somebody is being discharged. Verbal communications at the point of discharge should be followed up in writing. The residential service and the community based keyworker should also agree who will contact the person’s GP and other services such as mental health services, with current health information including details of any medication they are taking. They should provide information in writing to the GP immediately following discharge.
Contact and support after residential treatment
If people have complex needs and less social stability, you should be clear with them about what contact and support they can access after the formal end of residential treatment. You should make every effort not to discharge anybody from the programme if they have no secure accommodation to return to.
Resource
The Scottish Government published the good practice guide Pathways into, through and out of residential rehabilitation in Scotland to help improve residential rehabilitation pathways. Although it was developed for Scotland, it sets out principles of good practice for pathways that are useful to all 4 nations.
Brunette MF, Mueser KT and Drake RE. A review of research on residential programs for people with severe mental illness and co-occurring substance use disorders. Drug and Alcohol Review 2004: volume 23, issue 4, pages 471 to 481.
Carroll KM, Ball SA, Nich C, Martino S, Frankforter TL, Farentinos C, Kunkel L, Mikulich-Gilbertson SK, Morgenstern J, Obert JL, Polcin D, Snead N and Woody GE. Motivational interviewing to improve treatment engagement and outcome in individuals seeking treatment for substance abuse: a multisite effectiveness study. Drug and Alcohol Dependence 2006: volume 81, issue 3, pages 301 to 312.
Coco GL, Melchiori F, Oieni V, Infurna MR, Strauss B, Schwartze D, Rosendahl J and Gullo S. Group treatment for substance use disorder in adults: a systematic review and meta-analysis of randomized-controlled trials. Journal of Substance Use and Addiction Treatment 2019: volume 99, pages 104 to 116.
de Andrade D, Elphinston RA, Quinn C, Allan J and Hides L. The effectiveness of residential treatment services for individuals with substance use disorders: a systematic review. Drug and Alcohol Dependence 2019: volume 201, pages 227 to 235.
De Leon G. The therapeutic community: theory, model, and method. Springer Publishing, 2000.
Eastwood B, Peacock A, Millar T, Jones A, Knight J, Horgan P, Lowden T, Willey P and Marsden J. Effectiveness of inpatient withdrawal and residential rehabilitation interventions for alcohol use disorder: a national observational, cohort study in England. Journal of Substance Use and Addiction Treatment 2018: volume 88, pages 1 to 8.
Helena Kennedy Centre for International Justice. Residential treatment services: evidence review (PDF, 792KB). Sheffield Hallam University, 2017.
Leighton T. SHARP intensive day treatment. Integrated approaches to drug and alcohol problems. Routledge 2016: pages 43 to 55 (registration and subscription required for full article).
Leighton T. Inside the black box: an exploration of change mechanisms in drug and alcohol rehabilitation projects. University of Bath, 2017.
Meier PS, Donmall MC, McElduff P, Barrowclough C and Heller RF. The role of the early therapeutic alliance in predicting drug treatment dropout. Drug and Alcohol Dependence 2006: volume 83, issue 1, pages 57 to 64.
Moos RH and Finney JW. The expanding scope of alcoholism treatment evaluation. American Psychologist 1983: volume 38, issue 10, pages 1,036 to 1,044 (registration and subscription required for full article).
Orchowski LM and Johnson JE. Efficacy of group treatments for alcohol use disorders: a review. Current Drug Abuse Reviews 2012: volume 5, issue 2, pages 148 to 157 (registration and subscription required for full article).