Kaskutas Lee Ann, Ammon Lyndsay, Witbrodt Jane, Graves Karen, Zemore Sarah, Borkman Thomasina, Weisner Stephanie
Alcohol Research Group, Berkeley, California 94709, USA.
J Stud Alcohol. 2005 Sep;66(5):682-7. doi: 10.15288/jsa.2005.66.682.
To address unanticipated results from randomized trials, researchers often focus on client-level data about services received during treatment. Program-level observations can also be helpful, especially in understanding treatment delivered in groups. Using both approaches, this article strives to better understand inconsistent results from a trial comparing medical and nonmedical group-format day treatment.
Dependent treatment seekers were randomized to a hospital-based medical day-treatment program or to one of two community-based nonmedical day treatment programs. Services received during treatment were captured from clients using the Treatment Services Review (N = 230 subjects; 78 women), and group sessions were observed to measure therapeutic style using an Event Form (N = 48 observations).
The trial had found better medical outcomes at the hospital than at either nonmedical program, but most other tests had demonstrated similar outcomes at day hospital and one of the nonmedical sites and worse outcomes (psychiatric, family/social and employment) at the other nonmedical study site. Our analysis of services reported by study participants found a pattern of fewer substance misuse-oriented groups and less serious discussions about medical, psychiatric and family/social problems at the same nonmedical site that had worse outcomes. The way that services were delivered at that site further helped to explain the poorer outcomes there: Groups tended to be more didactic, classroom-like and less discussion-oriented.
Although services received are helpful in explaining treatment outcome, treatment observation adds explanatory value. Without increasing the cost of service provision, programs that rely heavily on didactic approaches might improve their outcomes simply by encouraging more interactive discussions that engage the clients.
为了解决随机试验中出现的意外结果，研究人员通常关注治疗期间接受服务的个体层面数据。项目层面的观察也可能有所帮助，尤其是在理解团体治疗方面。本文运用这两种方法，力求更好地理解一项比较医疗和非医疗团体日间治疗的试验中出现的不一致结果。
依赖治疗的寻求者被随机分配到一个基于医院的医疗日间治疗项目或两个基于社区的非医疗日间治疗项目之一。使用治疗服务审查从患者那里获取治疗期间接受的服务（N = 230名受试者；78名女性），并使用事件表单观察团体治疗课程以衡量治疗方式（N = 48次观察）。
该试验发现医院的医疗效果比任何一个非医疗项目都好，但大多数其他测试表明日间医院和其中一个非医疗场所的结果相似，而另一个非医疗研究场所的结果（精神、家庭/社会和就业方面）较差。我们对研究参与者报告的服务进行的分析发现，在结果较差的同一个非医疗场所，以药物滥用为导向的团体较少，关于医疗、精神和家庭/社会问题的讨论也不那么深入。该场所提供服务的方式进一步有助于解释那里较差的结果：团体往往更具说教性，类似课堂，且讨论较少。
虽然接受的服务有助于解释治疗结果，但治疗观察增加了解释价值。在不增加服务提供成本的情况下，严重依赖说教方法的项目可能只需鼓励更多能让患者参与的互动讨论就能改善其结果。
