The Recovery Curriculum - 201
Many people approach treatment with expectations shaped by everything except firsthand experience...and that picture rarely matches what they find. Sometimes, it's considerably better than imagined, and sometimes it fails to meet expectations.
This is the second piece in the Recovery Curriculum, a series on how recovery works and who it’s actually built for. If you’re new here, start with Article 1: Recovery at the Margins. The series runs across seven pieces from 101, which opened with equity, access, and who recovery is built for, through 401, which will close with advocacy and systems change. Some levels have more than one piece. This is the second article, at the 201 level: what treatment actually is, how it works, and why it often doesn't.
What Treatment Actually Is -
Many people approach treatment with expectations shaped by everything except firsthand experience. Some arrive voluntarily. Some are pushed by a court order, a family ultimatum, or a moment of crisis that finally broke through. But nearly everyone carries a picture in their head of what treatment looks like, and that picture rarely matches what they find. Sometimes, it's considerably better than imagined, and sometimes it fails to meet expectations.
In my time doing this work so far, I typically see two versions of that picture more than any other. One imagines something close to a jail, cold and institutional, where they will be trapped. The other imagines some spa paradise removed from the world under palm trees, where you get sober next to movie stars. The reality rarely matches the brochure, especially when insurance is footing the bill. They’re expecting comfort and they receive reams of paperwork, strict schedules and group work, the insurance fight, and discharge planning that begins almost before they’ve unpacked. Not every facility offers the same thing for the money.
That picture isn’t wrong, exactly. It’s just incomplete, and the gap between what people expect and what they find is where a lot of them get lost. It's where the system can fail them most of all.
Levels of care, and how people actually get to them.
The American Society of Addiction Medicine — ASAM — developed a framework that describes treatment not as a single destination but as a range of settings and intensities. The framework has four main levels:
Level I is outpatient — typically an individual session a week, group counseling, living at home. Level II is intensive outpatient or partial hospitalization — more hours, more structure, still living in the community. Level III is residential — varying levels of medical monitoring and structure, 24-hour support. Level IV is medically managed intensive inpatient — acute medical stabilization. Depending on where you live, Level IV can be completely non-existent.
The idea is that someone moves through these levels based on clinical need. Higher intensity when the situation requires it, stepping down as stability increases.
In practice, what someone actually accesses depends heavily on what their insurance will cover, where they live, and what exists within reasonable distance. The continuum can look very different in a city than it does in a rural county with one outpatient clinic in a 50-mile radius and a two-month waitlist. I’ve had clients who needed a higher level of care and the only available bed was on the other side of the state. How to get them there is often as much of a hurdle as getting them access in the first place.
About those 28 days.
The 28-day residential model has a specific origin. In the late 1950s, a researcher named Daniel Anderson was working at a Minnesota state hospital where people with alcoholism lived in locked wards, leaving only to work on a farm (doesn't this sound familiar to recent proposals from the federal level??). To get them stable and out of that setting, he developed a month-long model. It spread and became what’s known as the Minnesota Model. It was designed for alcoholism specifically. The model doesn't seem to have been chosen because of evidence, but it was long enough to do something meaningful, short enough to be manageable, and it worked well enough in that specific institutional context that it spread. It was a reasonable clinical guess at a time when almost nothing else existed.
What cemented it as the national standard was insurance. Payers agreed to cover approximately that length of stay, and the field organized itself around what insurance would fund. As Marvin Ventrell of the National Association of Addiction Treatment Providers has noted, it “became the norm because the insurance industry was willing to pay for that period of time.” The clinical tail stopped wagging the dog a long time ago. Arguably, due to the moral failure view of addiction for so many years, it never began to wag it.
What the evidence actually says is that longer engagement in treatment is associated with better outcomes. Not 28 days specifically. Not any fixed number. Sustained connection to care over time — whatever form that takes — is what moves the needle.
Good step-down looks like a bridge, not a cliff. Residential to intensive outpatient. Intensive outpatient to standard outpatient. Ongoing peer support woven through all of it. The structure reduces gradually as the person’s own footing strengthens. Sober living homes — transitional housing where residents live alongside others in recovery, maintain sobriety as a condition of residency, and continue outpatient treatment — are another piece of the continuum that works when it exists. They fill the gap between the structure of inpatient care and the full independence of going home. Some of the best treatment models in the country are built around exactly this kind of layered step-down. In rural areas, sober living options are scarce or nonexistent — and accessing one often means leaving your community entirely. There’s a real argument for that, however. We often tell clients to change their people, places, and things, and in small towns where everyone knows everyone, the people and places tied to use are everywhere. But leaving also means leaving behind whatever support exists — family, employment, the early threads of a recovery community. It’s a tradeoff the system rarely helps anyone make thoughtfully.
In practice, most providers know what good step-down looks like and work toward it. Quality benchmarks call for outpatient follow-up within 7 to 14 days of residential discharge — and the research is clear that follow-up within that window reduces overdose mortality. Clinicians know this and work toward it, but in rural communities, that referral often lands on an already enormous caseload. Sometimes, depending on the discharge coordination and the intake coordination, folks get lost. The outpatient program down the road might have one counselor carrying sixty clients. The meetings — the ones that cost nothing and require only showing up — may meet once a week in a church basement, twice if the town is lucky. The bridge for care exists, but what’s on the other side of it depends entirely on your zip code. And when the infrastructure isn’t there to catch someone coming out of treatment, a plan that looked complete on paper can become a mess in practice.
Harm reduction belongs in this conversation.
Harm reduction is the set of practices and philosophies aimed at reducing the negative consequences of drug use without requiring abstinence as a precondition for care. Needle exchanges. Naloxone distribution. Fentanyl test strips. Medication-assisted treatment (MAT). Meeting people where they are.
Harm reduction is not giving up on people. It is not enabling. It is evidence-based public health practice with decades of research behind it. In communities with robust harm reduction infrastructure, people have options while they're contemplating abstinence-based treatment. They can stay alive long enough to find their way to whatever recovery looks like for them.
Harm reduction and abstinence-based recovery are not opposites. They serve the same people at different points in their relationship with substances, and they're vital to quality of care.
A note on peer support.
One of the most consistent findings in recovery research is that connection to others in recovery matters. Certified peer support specialists, recovery coaches, and the like — people with their own lived experience of addiction and recovery, trained to support others — show up in more treatment settings now than they did a decade ago. They fill gaps that licensed clinicians often can’t. They bring something a credential cannot confer: the credibility of having been there. To many of us in recovery this is an important element.
Peer support works. It is also consistently underfunded, underutilized, and placed at the bottom of treatment team hierarchies despite the evidence that supports its necessity. That is a system problem, not a peer support problem.
Wrapping up
What I've tried to do here is give you a roadmap of care and the systems behind it. The map is not definitive. Your experience, or the experience of someone you love, or someone you treat, will not follow these lines cleanly. Treatment is messy and human and inconsistent. The system that delivers it is underfunded and fragmented and shaped by forces that have little to do with what people actually need.
Knowing how it works doesn’t fix any of that. But it makes it harder for the system to tell you something impossible is your fault.
Gus Raymond
Sources: The history of the 28-day model draws on reporting by NPR and KFF Health News, a 1999 article in the Journal of Addictive Diseases on the Minnesota Model, and a 2002 study in Psychiatric Services on treatment duration and outcomes. ASAM levels of care criteria are publicly available at asam.org. The SAMHSA director’s statement that “there’s nothing magical about 28 days” appeared in KFF Health News reporting. Evidence on harm reduction effectiveness draws on published public health research and CDC resources.
