Institutional Dilemmas

• Author: Angela Wang Lee
• DOI: 10.1177/0022042616659756
• Published date: 01 October 2016
• Date: 01 October 2016
• Subject Matter: Articles

Journal of Drug Issues

2016, Vol. 46(4) 354 –372

© The Author(s) 2016

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DOI: 10.1177/0022042616659756

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Article

Institutional Dilemmas: The

Difficulty of Making a Turning

Point in Residential Drug

Treatment

Angela Wang Lee1

Abstract

Because high drop-out rates have long plagued drug treatment programs, researchers have

spent considerable energy searching for risk factors to predict dropout, with only limited

success. In this ethnographic study of a long-term residential treatment program, I argue that

failure in residential treatment does not stem from high-risk individual-level characteristics, but

from the inherent difficulties of making a turning point in drug treatment. Drug users enter

treatment at unstable points in their life course, when they are least equipped to handle stressful

experiences. Yet entrance into treatment introduces new stressors, particularly the adaptation

to a new, demanding environment. I argue that the very characteristics of residential treatment

that enable a drug addict to desist—surveillance, routine activities, rules, and confinement—also

make her want to escape. This article elaborates on institutional dilemmas that make treatment

difficult and unpredictable, presenting an alternative to the risk factors approach to dropout.

Keywords

therapeutic community, dropout, treatment, life course, turning points

“Who’s battling the enemy today?” Reverend Judy looks around at the 60 women in Chapel. Hands

shoot up as Reverend Judy cues the worship music, a song about healing, pain, and using praise as

a weapon. “When you’re battling the enemy, stomp on it!” There are hands in the air, hallelujahs,

tears, and women on their knees by the altar. Some women, eyeing the commotion, remain seated.

During a break, Becky and Natalie disappear. They had both recently arrived at New Life

Home (NLH),1 a faith-based residential drug treatment program for women. Known as the girl

with the blue hair—a faded green with dirty blonde roots, really—Becky made no attempt to fit

in. Natalie did not talk much. She would look at the heart-shaped tattoo inked over her ex-hus-

band’s initials and cry.

When the Chapel service concludes, the women migrate to the dining hall. They find that

Becky has just departed for the train station, after a week in the program. Natalie snaps gum as

she waits for her parents to pick her up, 3 days after she arrived. The women glance at her but

1Harvard University, Cambridge, MA, USA

Corresponding Author:

Angela Wang Lee, Department of Sociology, Harvard University, William James Hall, Room 643, 33 Kirkland Street,

Cambridge, MA 02138, USA.

Email: angelawang01@g.harvard.edu

659756JODXXX10.1177/0022042616659756Journal of Drug IssuesLee

research-article2016

Lee 355

keep their distance. They say in low voices, “That’s why new girls aren’t supposed to spend so

much time together.”

Soon, the hearty Sunday meal is served, chicken and corn with pineapple cake for dessert, and

the momentary uneasiness over the two women’s departure fades. It is just another day at NLH.

Although Becky’s and Natalie’s decision to leave treatment early does not necessarily indicate

relapse into drug use, dropout undercuts the effectiveness of treatment. Substantial evidence

links longer periods of treatment to more favorable outcomes, including a higher likelihood of

abstinence, fewer relapses, decreased psychopathology, reduced criminality, and increased

employment (Hser, Evans, Huang, & Anglin, 2004; Simpson, Joe, & Brown, 1997; Zhang,

Friedmann, & Gerstein, 2003). Particularly in long-term residential programs, post-treatment

success is correlated with completion and graduation (De Leon, 1991).

Attempting to improve program retention, clinical and psychological studies have focused on

identifying risk factors for dropout. Some studies have found that being a minority, young, and

unmarried may be risk factors (e.g., Kelly, Blacksin, & Mason, 2001; Martinez-Raga, Marshall,

Keaney, Ball, & Strang, 2002; Mertens & Weisner, 2000). Impaired coping and low motivation

have also been linked to higher rates of dropout (e.g., Ball, Carroll, Canning-Ball, & Rounsaville,

2006; Joe, Simpson, & Broome, 1998; Melnick, De Leon, Hawke, Jainchill, & Kressel, 1997).

Dropout is also correlated with cognitive deficits, personality disorders, probationary status, and

concurrent psychiatric diagnosis (Brorson, Arnevik, Rand-Hendriksen, & Duckert, 2013; Claus

& Kindleberger, 2002). However, particularly in long-term residential programs, studies yield

mixed evidence about which predictors are reliable: “Like most other studies, we report few

clinical variables that predict those who leave and those who remain in a therapeutic program”

(Mulder, Frampton, Peka, Hampton, & Marsters, 2009, pp. 370-371). Researchers still refer to

dropout as the “black box” of treatment (Hiller, Knight, & Simpson, 1999).

The risk factors approach has fallen short of elucidating treatment outcomes because it focuses

too much on individual-level factors. Its findings confirm commonsense intuitions and yield a set

of characteristics too broad to predict anything meaningful. This approach also does not explain

why people drop out. Implicitly, risk factors are considered to be the reasons for failure: This

client left because she had little family support; that client left because she had mental illness.

Such explanations are simplistic, treating recovering addicts as a collection of determinative

characteristics, instead of agents who make choices based on their situations.

The life course perspective on criminal offending offers a useful contrast by rejecting a predic-

tive framework and positing mechanisms of change. Sampson and Laub (2003) develop this

framework based on a longitudinal study tracking criminal offenders from childhood to age 70.

They find that individual differences and childhood background cannot explain lifetime patterns

of offending; many who persist in crime have the same childhood traits as those who desist.

Rejecting the risk factors approach, Sampson and Laub (2003) instead find that “most offenders

desist in response to structural turning points that serve as the catalyst for long-term behavioral

change” (p. 278). Turning points—in particular a good marriage, steady employment, and mili-

tary service—exert social control and structured routine on the men’s lives, redirecting them

from pathways of crime. In making a turning point, social structures interact with human agency

to produce change: The men are active players in their own desistance process.

In a drug addict’s life course, residential drug treatment is a potential turning point, but of a

different nature than marriage or employment. Treatment offers drug users the opportunity to

make a break from their past by confining them to a new, controlled, and supportive environ-

ment. This limits their mobility and freedom. Marriage and employment both limit freedom to

some extent, but they also confer rich benefits besides desistance. Drug treatment offers few side

benefits besides getting clean. Also unlike marriage and employment, desistance in drug treat-

ment does not happen by default as the offender naturally takes on new roles. Rather, staying in

treatment is a daily choice—one that never gets easier.