Understanding Levels of Care in Mental Health Treatment
By Whitney Graff, Licensed Clinical Psychologist and Psychotherapist at Wildflower Center for Emotional Health
The beginning of psychotherapy is time when, as many people are aware, the therapist performs a clinical assessment of the patient seeking services, asking a range of questions to understand their symptoms, personal history, past treatment (if any), and important aspects of their social and psychological development. In actuality, this process is an ongoing part of psychotherapy, with the therapist continually fine-tuning their understanding of the patient’s symptoms and how they are progressing in treatment. Consequently, at any time during treatment, the therapist may become aware that the type and intensity of care the patient is receiving need to be adjusted if the patient is going to improve and reach his/her treatment goals.
The ensuing recommendation may involve changing what is called the “level of care” at which the patient is being treated. Many people have never heard of this term and understandably find it confusing. By “level of care,” we are referring to the setting, frequency, and mode in which treatment is delivered.
With many medical treatments, the level of care needed is fairly obvious: if you or someone close to you is having a heart attack, you know to go to the Emergency Department at the hospital, and you expect that there is a chance you will need to be admitted and stay awhile. Similarly, you might be told to expect an inpatient hospital stay following major surgery. If you have only a minor or non-life threatening medical complaint, you would see your primary care physician and maybe follow up with a specialist in a few days or weeks.
In mental health, a patient may not readily know what level of treatment is most appropriate, how severe or benign their symptoms are, or what to expect. Clinicians will help determine this based on their assessment and may make recommendations about a patient’s care immediately or at any time in the ongoing treatment. The following is an overview of the levels of care available for mental health treatment. They are described here in order of intensity, from least to most intense, as patients would be recommended to “step up” or “step down” levels depending on their symptoms and needs.
1. Outpatient Psychotherapy
This is often the first contact patients have with mental health providers, and it is what we provide here at Wildflower. Patients usually attend one hour-long psychotherapy session per week; however, they might be recommended to come in twice a week if their symptoms get worse, or they might agree with their therapist to decrease sessions to every other week or once a month when they have started achieving their treatment goals.
Despite the fact that this is generally one-on-one treatment, outpatient therapists might involve other providers in a patient’s care based on what’s needed. If the therapist thinks it necessary, they may refer patients to a psychiatrist for a medication assessment. They might also ask a patient for permission to collaborate with that person's primary care physician or other provider. Furthermore, treatment could involve couples or family therapy instead of or in addition to individual therapy. Outpatient psychotherapy can take many forms based on the approach used by the particular therapist. At Wildflower Center for Emotional Health, we take an active approach to helping our patients achieve their specific goals for therapy.
2. Intensive Outpatient Program (“IOP”)
The therapist will recommend IOP when they have concluded that outpatient treatment would not be adequate for the patient. Possible reasons for this might be to prevent further decompensation if the patient’s symptoms have gotten significantly worse, if the patient has not been helped by outpatient treatment, or when the patient's overall functioning is being severely affected by their mental health condition. By recommending a higher level of care, the clinician is saying they believe the patient would benefit from additional treatment, group support, and psychoeducation.
IOP’s can be stand-alone programs or part of larger hospital systems. Treatment is multidisciplinary, involving a combination of various types of groups and support. In an IOP, for example, a patient with an eating disorder might attend group therapy followed by a nutrition education group, a coping skills group, or a meeting with a dietitian. Patients with substance abuse might attend group therapy based on 12-step or other addiction models along with educational groups or family therapy. At this level of care, treatment days are usually 3-4 hours long, and patients will attend anywhere from 3-6 days per week for a limited time. Many people want to know right away how long the program is, but that is often not an easy answer. Patients are strongly recommended to work with their assigned case manager to identify goals for IOP and to have ongoing communication about their progress. It is important to note that every program is different and tailored to the needs of both the patient and type of issues being addressed.
3. Partial Hospitalization Program (“PHP”)
PHP is considered one level of care higher than IOP and is similarly recommended when the clinician believes IOP would not adequately meet the patient's treatment needs. The patient recommended for PHP would show signs of severe impairment in their daily functioning due to their mental health condition but would not appear to be at immediate risk of harming themselves. Alternatively, PHP is also recommended right after a patient is discharged from inpatient treatment (see #4 below) to help them gain momentum in their recovery.
Attending PHP is very similar to attending IOP except that treatment days are generally longer (6-8 hours on average) and patients attend every day. Treatment might include group therapy, groups in which coping skills or other concepts are taught, individual therapy, art therapy, visits with a psychiatrist, or even meals. Someone would normally attend PHP for at least 1 week and possibly several weeks at a time before “stepping down” to less intensive care. Each patient would be assigned a case manager or individual therapist who, along with other members of the treatment team, would make recommendations based on the progress the patient is making.
4. Inpatient Hospitalization
This is the highest level of care available. It is reserved for patients who are at very serious, imminent risk of bodily harm to themselves or others and is not recommended lightly. In addition, it is extremely rare that someone is given inpatient treatment against their wishes. When a person needs inpatient hospitalization, it means that they stay in a hospital for a few days, or up to a few weeks in rare scenarios. The patient sleeps at the hospital, attends group therapy, has the opportunity to learn concrete coping skills, and takes time to recover from what is always an acute crisis in their mental health. During this time, they are evaluated by a psychiatrist and assigned a case manager to advocate for them and help plan treatment for after they are discharged. While the term “hospitalization” can evoke scary images from movies, modern day hospitals bear little resemblance to mental health treatment of the past. Patients should feel that they are respected and have the opportunity to participate actively in decisions about their own treatment.
5. Residential Treatment
In rare scenarios, a clinician will recommend residential treatment, usually in the case of long-standing, severe functional impairment without imminent risk of suicide or harm. In these situations, symptoms have not improved with most or all other forms of treatment. Residential care resembles a blend between PHP and inpatient treatment, with patients living on the premises of a treatment center, attending various forms of group and individual therapy, and establishing new daily routines that will support them in achieving long-term recovery from their mental illness.
Final note to patients
Keep in mind that this list is meant as a general guide and that every treatment program is different. If your therapist or another provider recommends a particular level of care to you, try to remember that they are thinking of what will best meet your needs based on their assessment of your symptoms and the impact those symptoms have on your life. They are not judging you, nor are they thinking that you are “crazy.” They should be available to answer your questions and help you make informed decisions about your own care. Finally, as with all therapy, predicting how long it will take to get better is always tricky and varies based on a lot of factors. Active participation is the most significant way you can maximize the effectiveness of treatment and make steady progress.
While the process may be confusing and bring up a lot of emotion, your therapist is there to guide you and support you through the experience. Hopefully with this extra knowledge of what to expect, you can approach any treatment decisions openly and without fear.