Retention in therapeutic community in the first 30 days:

qualitative approach

Eleni Anagnostou, , MSc, Head of therapeutic program KETHEA PAREMVASI

Athens, Greece

12th EFTC Conference, “Eyes on the Future”, 2-5 June 2009, The Hague, Netherlands

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Introduction The majority of dropouts (30%-40%) usually occur

during the first month of treatment (DeLeon, 1991, Baekeland and Lundwall, 1975).

Since the highest dropout rate occurs earliest in treatment, most clients leave programs before being exposed to the cumulative effects of TC treatment (Lewis, Ross, 1994).Therefore, retention has received attention in research literature (DeLeon, 1991, Kooyman, 1992).

Traditionally, research designs focused on clients’ issues in order to indicate factors associated with dropouts. This one-sided approach tends to be replaced with the attitude that retention in treatment reflects a good fit between client and setting. (Carroll, 1997).

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Aspects of treatment environment were also related to drop out. Clients’ experiences in the early stage of treatment can modify their decision to remain in or leave treatment prematurely (McKellar et al, 2006).

During 2006 -2007 there was an increase in early drop out in TC Paremvasi. Therefore, we decided to examine clients’ experiences during 30-day retention because that was the period of highest drop out.

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Method

The aim of the study was to investigate difficulties related to drop out thoughts and supportive for retention factors, according to TC members, during the first 30 days at TC treatment.

Sample consisted of 32 clients, who were admitted in TC PAREMVASI during the period of 24/05/07 – 29/11/07.

Sample characteristics : • men 87,5% and women 12,5%• 62,5% were between 26-30 years old (mean age 28,5)• new TC clients were 59,4% and re-admitted clients

40,6%

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Method

Data selection: Questionnaires were administered in TC, when

participants had completed 30 days in treatment. Data selection was carried out through self-

administered questionnaire with open-ended questions.

Questions were designed at bringing to light clients’ experiences during the first month of stay: events, thoughts and emotions.

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Method

Data Analysis: A qualitative analysis was performed. The method

used is content analysis based on the sentence and paragraph analysis.

Data were codified and two core categories and their subcategories were formed.

Limitation: The questionnaire was self administered, so an in-depth data analysis was not permitted.

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Results

A. Difficulties related to drop out thoughts

A.1 Individual factors A.1.1 Poor motivation A.1.2 Re-admission to treatment A.1.3. Absence of significant others

A.2 Factors associated with treatment environment

A.2.1 Well-ordered activities’ program A.2.2 Hierarchy -Limits A.2.3 Interaction between members

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Results

B. Supportive factors for retention B.1 Individual factors B.1.1 Motivation B.1.2 Personal changes

B.2 Factors associated with treatment environment B.2.1 Well-ordered program B.2.2 Educational and recreational activities B.2.3 Therapeutic procedures B.2.4 Supportive environment

B.3 External factors B.3.1 Extrinsic motivation B.3.2 Role models

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A. Difficulties related to drop out thoughts A.1 Individual factors

A.1.1. Poor Motivation Some individuals declare that they don’t have a serious drug

problem and they are able to quit drug use on their own. The previous “drug life style”, lack of “rock bottom experiences” and personal evaluation of low severity of their conditions are related with poor motivation and thoughts of dropout.

«I have thought of it [to drop out] many times…I thought that I am not running out of time and things in my life are not so bad after all».

«…sometimes I think that I can stop using drugs on my own».

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A. Difficulties related to drop out thoughts A.1 Individual factors

A.1.2. Re-admission to treatmentRe-admitted clients relate current difficulties in TC with their previous

therapeutic experience. The experience of the same therapeutic procedures, the induction in the lowest peer group and the personal belief that other TC’s members have different/higher expectations on them are among the issues that re-admitted clients point out.

«The fact that I am starting over again, from the lowest position in community’s hierarchy, makes it difficult…».

« I feel very stressed by the label of readmitted….I’m feeling that other members believe that I know everything about the community function, I don’t need any help, I cannot make any mistakes ….I’m ashamed of asking for help….”

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A. Difficulties related to drop out thoughts A.1 Individual factors

A.1.3. Absence of significant Others

The absence of significant others (parents, siblings, partners) due to the residential type of treatment evokes feelings of sadness and lack of intimacy. Especially the separation from partners, is related more often to thoughts of dropping out.

«I’ve thought to drop out because I miss my girlfriend a lot».

«Μy mind is on my girlfriend, my family….I feel sad and isolated….».

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A. Difficulties related to drop out thoughts A.2 Factors associated with treatment environment A.2.1. Well-ordered activities’ programMost clients express their difficulty to adjust their selves

to TC environment. They experience pressure due to time-based, strict program’s activities and the daily early waking up.

«I’m under pressure from early in the morning and I have to follow a specific program during the whole day ».

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A. Difficulties related to drop out thoughts A.2 Factors associated with treatment environment

A.2.2. Hierarchy – LimitsThe TC’s hierarchical model is the main issue that clients concentrate on

their answers since they have to adhere to strict and explicit behavioral norms. The most mentioned behavioral norm is that the new members have no privilege to communicate with peer group members in the absence of senior members.

«Limits and controlled conversations that you have to follow…the fact that I am not allowed to talk with my peer group unless someone in charge is present».

«Hierarchy is a difficult thing for me. It is not easy to feel that you are under control all day».

The constant control and sometimes the power abuse they are subjected to, from senior members with greater privileges and responsibilities, lead “new” members to have negative feelings.

«They yell at me for no reason, just to show off to senior members. That makes me

feel angry».

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A. Difficulties related to drop out thoughts A.2 Factors associated with treatment environment

A.2.3. Interaction between members The sudden co-existence with other TC members is

also a difficulty that new TC members are faced with. Communication and interaction with unknown individuals brings feelings of insecurity and cautiousness.

«When I came in the community I was among strangers and I was feeling alone».

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A. Difficulties related to drop out thoughts

The above difficulties (individual and treatment environment) that members experience bring strong emotions and negative thoughts such as fear, lack of trust, loneliness, and anger which are causal related with thoughts of dropping out.

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B. Supportive factors for retention B.1 Individual factors

B.1.1. Motivation Intrinsic motivation as a desire to get better for one’s

own sake is a related factor for retention. Clients express their desire to protect themselves from more drug addiction side effects and to improve aspects of their lives: physical health, social and family relationships and employment status.

«I couldn’t stand the mess I was in….I want to change

my behavior, to learn how to deal with my life, to protect myself… and finally to live like a normal person».

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B. Supportive factors for retention B.1 Individual factors

B.1.2. Personal changes

During the first 30 days in treatment clients have already experienced significant positive changes in behavior, attitude and their physical condition. These changes are of great value for them because they empower their decision for keeping treatment on.

« I like to live without drugs, to overcome my difficulties without drug use, to laugh without being stoned…».

«…I feel my body stronger and I feel satisfied…».

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B. Supportive factors for retention B.2. Factors associated with treatment environment

B.2.1. Well-ordered programThe well-ordered program is experienced not only as a

factor associated with clients’ difficulties, but also as a supportive factor for retention. The structure of the community function and the participation in daily organized activities help some clients keeping their mind occupied and avoiding negative feelings and thoughts of drug use.

« …the strict daily program keeps my mind out of negative thoughts of dropping out».

« I go to bed every night very tired and I can sleep without thoughts….».

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B. Supportive factors for retention B.2. Factors associated with treatment environment

B.2.2. Educational and Recreational ActivitiesActivities that don’t have a direct therapeutic character

are among clients preferences. Educational seminars and recreational activities such as movies, sports, coffee time etc. are experienced to be as ways for reducing “pressure”. These activities due to their group based character facilitate communication and interpersonal skills training.

«I like seminars because you get away from daily routine…you do something you like and you have the chance to know people you live with better. I like the fact that we have free time and we can relax…its very nice to watch movies with other 55 persons».

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B. Supportive factors for retention B.2. Factors associated with treatment environment

B.2.3. Therapeutic ProceduresAccording to some members, therapeutic procedures

such as (encounter groups, therapeutic marathon, community meetings etc) are factors supportive for treatment. These therapeutic procedures facilitate emotional expression, individual change and members’ interaction.

« I like encounter and peer groups because all members are equal and I can speak to and towards others openly…».

«…encounter group, peer groups, community meetings make me feel closer to other TC members and my peer group…and help me to change my behavior».

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B. Supportive factors for retention B.2. Factors associated with treatment environment

B.2.4. Supportive environment Supportive therapeutic environment is considered an important factor for

retention. Other TC members’ attitude (especially senior members’) towards new

clients creates a sense of “concern”, “support” and “security”. Senior members also provide useful information of TC function, they help new residents to deal with withdrawal syndrome, to express their emotions and to adjust to the new environment.

Assimilation in the therapeutic environment is facilitated by the group character of the community (people with a common goal) and the sense of belonging.

« …all this concern and help from other members made my adjustment easier… they explained limits and procedures of the community, I started to learn…».

« …there are members that ask me how I feel if I need something ... I don’t feel alone».

« I like living in a place with so many people, people with common problems and a common goal to stay away from drugs».

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B. Supportive factors for retention B.3 External Factors

B.3.1 Extrinsic motivationSome clients seem to be motivated from external

sources. They feel pressure from family, legal, financial problems and lack of other choices in their lives.

«I remain in the community because I want to make my parents happy, to stop worrying about me… after all these things they have been through because of me».

« I have no other choices…all the doors are closed. Ι’m 34 years old and I still have time to do something for myself…»

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B. Supportive factors for retention B.3 External Factors

Β.3.2. Role models Friends or family members who have completed TC

treatment appear to act as role models for many clients. Clients look up to those persons, want to be like them and think that treatment completion is actually an achievable goal.

«…there is a person that gives me power to carry on. He is a friend and he is now completing treatment».

«…I feel that I can make it since people that I knew from my previous admission are now clean».

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Discussion During first month of treatment, clients experience difficulties

which can induce strong feelings and thoughts of dropping out. These difficulties concern client’s issues and also can be detected from therapeutic environment and the “new type of life” that they are introduced to.

It’s important to point out that we cannot safely conclude that these kind of difficulties can lead to drop out, since these clients were still in treatment while the study was carried out.

The fact that participants had completed 30 days in TC means that some helpful for them factors did exist.

Clients’ motivation, internal or external, can be accepted as important but not sufficient for treatment retention.

Self changes already experienced, role models and treatment factors seem to reinforce their decision.

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Discussion They perceive the well-ordered program’s activities and the

limits as having both positive and negative contribution. This could lead to the conclusion that some clients are able to recognize, due to treatment exposure, that even if these treatment features are causing personal difficulties at the same time they are important for their therapeutic improvement.

On the whole, retention in treatment can be understood as a dynamic interaction between client and treatment environment.

The first 30 days are crucial because the new member learns TC procedures, establishes trust and begins to understand attitudes and behaviors related to drug use.

So, it is important to take into account these issues because if we improve the quality of treatment environment it is likely to reduce early drop out rates from residential treatment.

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Suggestions for Improvement

Findings revealed several issues that seem to help clients smoothly adjust to early treatment. Emphasis should be placed in:

Providing new clients with sufficient information for TC function (rules, procedures, daily programme, rights and obligations).

Reinforcing relationship development between new and senior TC residents.

Reducing incidents of power abuse from privileged TC members. Creating and maintaining a structured, supportive and less rigid

setting. Focusing on re-admitted clients: a) to evaluate each readmitted

client and to exploit (develop) their needs and achievements and b) to educate the rest TC members about readmission issues.

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Future Research

We also examine the individuals, who were admitted in TC PAREMVASI during the same time period, dropped out before the end of the first month and re-approached the Induction Center.

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