Day Hospital and Residential Addiction Treatment: Randomized and Nonrandomized Managed Care Clients Jane Witbrodt, Jason Bond, and Lee Ann Kaskutas Alcohol Research Group Constance Weisner University of California, San Francisco Gary Jaeger Kaiser Foundation Hospital David Pating Kaiser San Francisco Medical Center Charles Moore Sacramento Kaiser Permanente Male and female managed care clients randomized to day hospital (n = 154) or community residential treatment (n = 139) were compared on substance use outcomes at 6 and 12 months. To address possible bias in naturalistic studies, outcomes were also examined for clients who self-selected day hospital (n = 321) and for clients excluded from randomization and directed to residential treatment because of high environmental risk (n = 82). American Society of Addiction Medicine criteria defined study and randomization eligibility. More than 50% of followed clients reported past-30-day abstinence at follow- ups (unadjusted rates, not significant between groups). Despite differing baseline severities, randomized, self-selecting, and directed clients displayed similar abstinence outcomes in multivariate longitudinal models. Index treatment days and 12-step attendance were associated with abstinence ( p  .001). Other prognostic effects (including gender and ethnicity) were not significant predictors of differences in outcomes for clients in the treatment modalities. Although 12-step attendance continued to be important for the full 12 months, treatment beyond the index stay was not, suggesting an advantage for engaging clients in treatment initially and promoting 12-step attendance for at least a year. Keywords: self-help, Alcoholics Anonymous, ASAM patient placement criteria, selection bias, social model With few exceptions (Finney, Hahn, & Moos, 1996), reviews of treatment outcome studies have found that less costly, intensive outpatient programs may yield substance use and social outcomes similar to those of more costly inpatient programs for all but the most severely medically and psychiatrically compromised patients (Belenko, Patapis, & French, 2005; Miller & Hester, 1986). A landmark study by McKay (McKay, Alterman, McLellan, Snider, & O’Brien, 1995), which contributed to policy makers’ decisions regarding the trade-offs between inpatient and day hospital care, recruited and followed both randomized and nonrandomized male alcoholic veterans to examine treatment effects on outcomes under experimental and nonexperimental designs. Despite its impor- tance, this study has not been replicated with samples that include women and that are more representative of the general population of treatment seekers or with potentially less costly types of com- munity residential treatment that offer fewer structured treatment hours per day than traditional inpatient programs. This article presents findings from a study that addresses these gaps. In their meta-analysis of relevant research on treatment setting effects, Finney et al. (1996) found that inconsistent findings be- tween inpatient and day treatment programs could be explained largely by factors that had not been adequately explored and had little to do with the treatment setting per se, such as methodolog- ical decisions, including exclusion criteria and naturalistic versus experimental research designs. It also is possible that conflicting findings are caused because clients are sent to more intense treat- ment than is indicated by their problems at intake; treatment- matching studies show that undertreatment predicts poorer out- comes compared to matched treatment and that overtreatment provides no additional benefit (Magura et al., 2003). Since ethical considerations compromise studies’ ability to randomize high- severity clients to lower levels of care, creative study designs are Jane Witbrodt, Jason Bond, and Lee Ann Kaskutas, Alcohol Research Group, Emeryville, California; Constance Weisner, Department of Psychi- atry, University of California, San Francisco; Gary Jaeger, Addiction Medicine Department, Kaiser Foundation Hospital, Harbor City, Califor- nia; David Pating, Chemical Dependency Recovery Program, Kaiser San Francisco Medical Center, San Francisco; Charles Moore, Chemical De- pendency Recovery Program, Sacramento Kaiser Permanente, Sacramento, California. This study was supported by National Institute on Drug Abuse Grant R01 DA 12297. The opinions expressed here are those of the authors and do not necessarily reflect those of the managed health care organization sites that participated in the study. Requests for further information can be made at www.arg.org. Correspondence concerning this article should be addressed to Jane Witbrodt, Alcohol Research Group, 6475 Christie Way, Suite 400, Em- eryville, CA 94608-1010. E-mail: jwitbrodt@arg.org Journal of Consulting and Clinical Psychology Copyright 2007 by the American Psychological Association 2007, Vol. 75, No. 6, 947–959 0022-006X/07/$12.00 DOI: 10.1037/0022-006X.75.6.947 947