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Witbrodt J., Bond J., Kaskutas L.A. et al.
Journal of Consulting and Clinical Psychology: 2007, 75(6), p. 947–959.
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By selecting clients at the very edge of ethically requiring referral to residential care, this US study confirms that unless there are pressing contraindications, intensive non-residential options deliver equivalent outcomes. Often of course, there ARE pressing contraindications.
Summary Male and female managed care clients randomised to day hospital (154 clients) or community residential treatment (139) were compared on substance use outcomes at six and 12 months. To address possible bias in naturalistic studies, outcomes were also examined for clients who self-selected day hospital (321) and for clients (82) excluded from randomisation and instead directed to residential treatment because their home environments placed them at high risk of alcohol and/or drug use. American Society of Addiction Medicine criteria for referral to residential care defined whether clients were eligible for the study and for randomisation. More than 50% of followed-up clients reported past-30-day abstinence at follow-ups (unadjusted rates, no significant differences between groups). Despite differing baseline severity, randomised, self-selecting, and directed clients displayed similar abstinence outcomes in multivariate longitudinal models. Number of days spent in the initial treatment episode and 12-step attendance were associated with abstinence. Although 12-step attendance continued to be important for the full 12 months, treatment beyond the initial episode was not, suggesting an advantage for engaging clients in treatment initially and promoting 12-step attendance for at least a year. Other prognostic effects (including gender and ethnicity) were not significant predictors of differences in outcomes for clients in the treatment modalities.
commentary Studies of whether residential care betters non-residential are limited by the ethical requirement that clients assessed as being at high risk in the absence of a protected environment cannot deliberately be denied it. As a result, studies usually only randomly allocate clients who can practically and with reasonable safety be referred to either setting. Not surprisingly, such studies rarely find an advantage for residential/inpatient options. However, some studies have suggested that high severity Factors relevant to the decision to provide residential/inpatient care probably include drug problem severity, psychiatric problems and perhaps especially suicidal tendencies, the degree of support for non-use (or non-problem use) in the home environment and among the client's family and social circle, housing, and the client's ability to support themselves in the community. How severe and multiple these problems need to be to justify residential care will depend partly on the intensity and adequacy of the non-residential alternatives. Most studies have compared inpatient versus outpatient settings rather than residential versus non-residential rehabilitation. clients do differentially benefit from residential/inpatient care.
The featured study went as far as it could to overcome this methodological limitation by including only clients who met at least five of the six standard US criteria Most were to do with not needing to be hospitalised but one criterion also required a history suggesting the potential for relapse if referred to non-residential programmes and another required there to be an unacceptably high risk of substance use due to the home environment. for residential care, but who fell short of criteria for hospitalisation. Clients who also met the optional sixth criterion – an unacceptably high risk of substance use due to the home environment – were directed to residential Generally up to three months with daily group therapy and practical activities. care. The rest were asked to accept randomisation to this or to intensive Clients spent from three to five and a half hours a day in group therapy over an intended two or three weeks. non-residential care, ethically as close as the study could get to randomising clients judged in need of residential care. Despite this profile, most refused randomisation and opted instead for the less disruptive (to their family, social and working lives) non-residential services, a sign of how important it is to maintain both residential and non-residential options.
In line with earlier research, the study confirmed that unless there are pressing reasons for residential care, non-residential alternatives result in equivalent outcomes at lower cost and less disruption to the client's life. It also confirms that at least in the short-term (often the extra benefits dissipate), the protection of a residential setting enables the most needy In this case, those who met all six criteria for residential care. and least promising clients to do as well as more promising clients, perhaps by eliminating the extra environmental risks they face out in the community.
What the balance should be between these options will depend on the population being served. In some areas most of the referred caseload do have a pressing need for residential care; in others (as in the featured study, all of whose subjects were beneficiaries of prepaid health care plan) this will be a minority.
Thanks for their comments on this entry in draft to Jane Witbrodt of the Alcohol Research Group. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 05 January 2009
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