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The Ecological Context of Substance Abuse Treatment Outcomes? Implications for NIMBY Disputes and Client Placement Decisions

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Most admissions to drug treatment end in client dropout. Although scholars have examined a number of factors related to client characteristics and program components, location-the physical, social, and economic attributes of neighborhoods where treatment clients live and receive treatment-has largely been ignored. The author develops hypotheses of the influence of "treatment ecology" on retention, characterize the residential and treatment environments of the population of treatment clients in Los Angeles County in the period 19982000, tests for an association between neighborhood-level factors and client retention, and derives bounds on the expected impact of location-oriented policies on individual and countywide retention. Clients' residential environments are significantly worse than those of the non-client household population, particularly with respect to social stressors and drug availability, that the neighborhoods of treatment centers are worse still, and that homeless, African American, and other minority clients face the worst environments overall. Failure to complete in both outpatient and residential settings is associated with neighborhood-level social stressors. A policy that matched all clients with the most appropriate neighborhood could increase the countywide rate of retention by up to 30 percent.