Retention in Treatment—Indicator or Illusion: An Essay

Abstract

This article poses questions about the meaning of retention in substance user treatment. Retention has become a “gold standard” for substance user-treatment programs, suggesting it has become more than an indicator of positive outcomes, but a positive treatment outcome in its own right. Retention has been studied in numerous ways and has been associated with positive treatment outcomes, but questions remain about whether it has assumed greater importance than it merits. For example, it may be an artifact of other client personality characteristics that are also associated with more positive outcomes. Conversely, it may be a function of the interaction of treatment environment and client. This article suggests a need to broaden the scope of treatment-retention studies and to compare retention rates across other medical treatment environments to see if failure to complete treatment is a function of substance user treatment or of all treatment processes as well as other types of planned change processes.

Keywords:

• treatment retention
• treatment attrition
• treatment engagement
• treatment outcomes

Notes

²The drug user's treatment site's psychosocial dimensions and environmental “atmosphere” are rarely noted as actual/potential facilitators or barriers for therapeutic engagement. Such dimensions include, amongst others, a relationship dimensions, personal development dimensions, maintenance and change dimensions, emotional catalyzer dimensions, information catalyzer/processing dimensions, environmental perceptions, attitudes and values dimensions, problem-solving/adaptational dimensions, dimension definer, and boundary definer (Tuan, Yi-Fu, (1974) Topophilia: a study of environmental perception, attitudes, and values. Englewood Cliffs, NJ: Prentice Hall). Editor's note.

³A caveat is necessary. This is a. “judgment call,” which involves paying attention, perception, interpretations, awareness of options and their actual/potential “demands” and “costs,” weighing and judging decisions, planning, implementing, a feedback system, correcting or not correcting, etc. within a de facto reality that limits, promotes, distorts, etc. Daniel Kahneman recently received the Noble Prize for documenting the irrational underpinnings of man's judgments (Kahneman et al, Judgment under uncertainty: heuristics and biases. Cambridge, UK: Cambridge University Press). The reader is also reminded that substance use and its interventions have been and continue to be highly politicized (MacCoun, R.J. and Reuter, P. (2001). Drug war heresies: learning from other vices, times and places. London, UK: Cambridge University Press; Courtright, D. T. (2001) Forces of habit. Cambridge, MA: Harvard University Press; Porter, R. and Teich, M. (eds.) (1995) Drugs and narcotics in history. Cambridge, MA: Cambridge University Press).