Institutional Dilemmas

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.