Why do drug abusers leave the therapeutic community? Problems with attachment and identification in a hierarchical treatment community

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Abstract
High drop-out rate is a major problem in all kinds of treatment modalities for drug abusers. With regard to the hierarchical therapeutic community, which is a very popular treatment model for substance abusers, the one year retention rate of 8-30% indicates that relatively few clients complete the programme. Attachment to and identification with co-residents, staff, and the treatment programme, are corner stones in the ideology of the hierarchical therapeutic community model. The retention rate of 8-30% may therefore indicate that the majority of clients have problems with attachment to and identification with each other and adherence to the programme. We therefore conducted a process-oriented and qualitative study, where we followed different samples of clients, in interaction with each other and with the staff, from intake until they dropped out or completed the programme. We wanted partly to evaluate how the actual model provided the conditions for learning new role behaviour, attachment to and identification with the programme, and partly how the observed practice in the actual study period contributed to promoting new role behavior, attachment and identification. The results indicate that lack of attachment to and identification with co-residents, staff and/or the ideology of the programme influenced retention negatively. Attachment and identification were not, however, necessary conditions in order to complete the in-patient year. On the whole it was a problem that clients with poor social skills and relationships problems were not sufficiently taken care of according to their own capacities. This was especially evident in relation to drop-out. As for the model on which the Phoenix House programme is formulated, and as for the observed practice, our findings indicate several conditions which could possibly have been modified in order to promote attachment to and identification with co-residents, staff and/or the programme norms and values.