Scotland has the highest rate of drug-related deaths in the United Kingdom. The Scottish Government has poured millions into expanding its residential rehabilitation network as part of its National Mission on Drug Deaths. Yet a newly published study in the journal Addiction raises a troubling question: does residential rehabilitation actually reach the people most at risk?

Academics at the University of Glasgow led the research, following residents at River Garden, a work-based substance use rehabilitation community in South Ayrshire. What they found challenges some of the core assumptions about how these programmes work and who they truly serve.

How This Residential Rehabilitation Model Works

River Garden takes a different approach to most residential rehabilitation programmes. Rather than structured therapies or clinical group sessions, it centres on social enterprise activities such as gardening, construction, and skills development within a working community. The Scottish Government awarded the programme £6 million in 2021 to expand its capacity, modelling it loosely on the San Patrignano recovery community in Italy.

Residents progress through three stages over up to three years, moving from volunteer to trainee to paid staff. The idea is that meaningful work builds self-esteem, purpose, and the vocational skills needed to sustain long-term recovery. It sounds compelling on paper. In practice, the benefits did not reach everyone equally.

Who Actually Benefited from Substance Use Rehabilitation

Researchers conducted a mixed-methods process evaluation, combining participant observation, qualitative interviews, and admissions data collected between April 2019 and November 2020. Nine of ten residents took part. All were male, aged between 20 and 47, and all arrived unemployed. Eight reported mental health problems. Five had spent time in prison.

By the end of the study, only four residents remained. Five had left before completing the programme. All five relapsed shortly before or after leaving. Two suffered near-fatal overdoses on the very day they departed. Both required naloxone and emergency medical treatment.

The residents who stayed shared certain traits. They had longer periods of abstinence before arriving, better physical and mental health, and more stable socioeconomic backgrounds. One resident put it plainly: “I’d say I’m reasonably middle class. I’ve not struggled as much as other people. Whether it’s nice to admit it or not, it’s probably true.”

Staff recognised the same pattern. “Anybody that we’ve had that has come from a poorer background, haven’t lasted,” one staff member said.

The Mechanisms Behind Residential Rehabilitation Outcomes

Researchers identified six key mechanisms that determined whether residential rehabilitation worked for each individual. These fell into two categories: instrumental and relational.

Instrumental mechanisms concerned how residents engaged with the work itself. Motivation proved to be the most critical factor. Residents who saw the long-term value of building a vocational identity within the community tended to thrive. Others felt the work was repetitive and lacked real development opportunities. Some grew disengaged and, eventually, left. One described the setting as a “work camp for addicts.”

Relational mechanisms centred on trust, respect, and motivation within the community. These proved more fragile. The programme’s focus on independence left some residents isolated, particularly new arrivals who needed closer peer support. In one cohort, a group of new residents actively resisted integration and created a culture of verbal bullying that unsettled the whole community.

The programme did not include structured group therapies, which most residential rehabilitation settings treat as standard. Researchers flagged this as a significant gap. Without formal sessions to build group cohesion, the relational side of recovery was left largely to chance.

Recovery Capital: The Hidden Barrier in Substance Use Rehabilitation

The concept of “recovery capital” sits at the heart of this research. Recovery capital refers to the personal, social, and structural resources that help a person sustain recovery. River Garden was specifically designed to build those resources through work and community life.

But the study found the opposite dynamic at play. Successful engagement in the substance use rehabilitation programme already required a strong baseline of recovery capital. Residents with fewer resources, those from deprived backgrounds, with more severe addiction histories or complex health needs, consistently struggled to meet the programme’s demands.

Rather than levelling the playing field, the model appears to have reproduced the same inequalities found in untreated recovery. Research shows that people from more advantaged backgrounds are already more likely to recover without formal help, because they have more resources available to navigate a different path in life. River Garden, without active therapeutic support, may have simply reflected that reality back.

This has serious implications. Scotland recorded 1,172 drug-related deaths in 2023, according to National Records of Scotland. The people most at risk are those with the highest problem severity, the poorest health, and the greatest socioeconomic disadvantage. These were precisely the residents the study found least likely to benefit.

What Needs to Change

Researchers are not writing off the model. They note that River Garden was still in its early stages during the study period. The social enterprises had not yet fully developed, which limited the quality of meaningful work on offer. As the programme matures, sustaining instrumental motivation may become more achievable.

But they argue that structural changes are needed if substance use rehabilitation is to genuinely serve those with greater barriers. They call for structured therapeutic group work, drawing on approaches such as 12-step or SMART recovery, alongside the existing work-based activities. More specialist staff, a better staff-to-resident ratio, and stronger links to wider treatment services would all help.

The researchers also flag the danger of unplanned exits. When residents leave residential rehabilitation abruptly, overdose risk rises sharply. The body loses tolerance during abstinence, making a relapse potentially fatal. Better integration with the broader treatment system could make those transitions safer.

A Wider Wake-Up Call for Drug Policy

Scotland’s drug deaths crisis shows no sign of resolving quickly. Residential rehabilitation forms one part of the government’s strategy, but this study raises a pointed concern: expanding capacity will not reduce deaths if the most at-risk individuals cannot access or sustain treatment.

The researchers put it directly in their conclusions: “Expansion of the programme would not be likely to contribute to aggregate reductions in mortality rates, but could continue to support improvements in health and social functioning for suitable residents.”

That is not a reason to abandon residential rehabilitation. It is a reason to build it better, so that it reaches the people who need it most, not just those already closest to recovery.

Source: dbrecoveryresources