What goes on inside a residential rehab program? Inquiring minds would love to know, especially those of us who are treating addicts and counseling concerned family members. Rehab has traditionally been a kind of black box, an opaque entity where addicts enter, and 30 days later exit with an epiphany and a lifelong commitment to sobriety. Until they relapse and go back to another rehab, that is.

Anne Fletcher, who is both a science writer and addiction counselor, has written a book that finally peels back the layers of mystery surrounding rehab. Those of you who are long-time Carlat Report groupies will remember an issue I wrote years ago in which I reviewed self-help books for patients (TCPR, December 2005). Fletcher’s first book about addiction, Sober for Good, won my top prize in the substance abuse category. She brings the same intelligence and perspective to her new project, Inside Rehab.

Residential rehabs have been increasingly criticized for outdated treatment methods, exorbitant prices, and a tendency for graduates to relapse over and over. In order to provide a realistic picture of what people experience in rehab, Fletcher received permission to visit 15 residential rehabs of various types and sizes in different parts of the country. She sat in on sessions, interviewed patients and staff, gave questionnaires to administrators and counselors, and thoroughly reviewed the scientific literature on the efficacy of these programs.
Here are some major take-home lessons that clinicians might find useful.

1. A day in the life of rehab: Groups, groups, and more groups. 
An eye-opening discovery is that regardless of the cost or exclusivity of rehabs, the “treatment” provided amounts to little more than an endless series of group activities, usually managed by counselors without advanced clinical degrees.

Here is a typical day in a residential rehab, according to interviews with patients and staff. The day begins early, around 6 a.m., with chores, breakfast, then a large lecture at 8 a.m., which commonly covers one of the 12 steps of AA. At 9 a.m., there’s a “process group,” covering topics such as 12 steps; how to cope with substance abuse triggers; and relationship problems. After short break, there’s a mid-morning group, followed by treatment work time. “Treatment work” consists of written assignments that are often workbooks or worksheets on 12 steps or on skills that will help people stay sober. One example is a goodbye letter to the drug of choice. After lunch there are two more groups, followed by free time. After dinner? Yep, more groups—usually two process groups and a group lecture.

If you’re keeping track, a typical rehab day consists of about 8 hours of group activities. There’s not much individual counseling—even at the highest-end rehabs, there is typically no more than 5 hours of one-on-one work per week. Clearly, group therapy can be valuable in a variety of ways—patients can learn from one another, and simply sharing one’s personal struggles in a group format can be powerfully validating. However, one gets the sense that rehabs are over-relying on groups as a cost-effective way of filling time. In addition, Fletcher interviews some patients who found the group emphasis off-putting and who felt uncomfortable with self-revelation in a group context.

2. Individualized assessment, but one-size-fits-all treatment. 
A corollary of the reliance on group activities is that treatment tends to be a one-size-fits-all affair. Fletcher found that while the initial assessment of a patient by rehab staff was quite comprehensive, that comprehensive assessment does not necessarily lead to a treatment plan tailored to that patient. Patients, regardless of circumstances and comorbidities, tend to be offered the same treatments as everyone else—mostly based on the 12-step philosophy. Even when patients relapsed, they tended to be offered the same programming over and over, rather than new approaches that might be more beneficial.

3. The cost of rehab. 
Rehabs vary widely in cost. Contrary to popular belief, the majority of rehabs depend on public insurance, such as Medicare and Medicaid, and lower-end rehabs might charge as little as $10,000/month. Private for-profit rehabs are in the minority, and their average cost is around $30,000 for a month—though it can go up to $100,000/month for celebrity-caliber rehabs in places like Malibu. While $30,000 may not sound like an enormous sum for a month of treatment, Fletcher talked to one psychiatrist who pointed out that if you were to pay an addiction psychiatrist $300/hour, you could see him or her 25 hours/week for an entire month for the same amount of money—but insurance would never cover it.

Fletcher’s book ends with a useful consumer checklist for evaluating whether a rehab is right for them or for their family. It includes questions about the program’s philosophy, the credentials of staff, policies on use of medications, and others.

Along the way, she interviews national experts about the problems with the current system and how it can be improved. One of the most disheartening quotes was from Tom McLellan, former deputy director of the Office of National Drug Control Policy under the Obama administration, who says, “There are exceptions, but of the many thousands of treatment programs out there, most use exactly the same kind of treatment you would have received in 1950, not modern scientific approaches.”

Let’s hope things improve.

Inside Rehab: The Surprising Truth About Addiction Treatment—And How to Get Help That Works was published by Viking in 2013 and came out in paperback by Penguin Books in 2014.