When you think of therapy, you likely envision sitting on a couch in a therapist’s office or at your home computer in a zoom room once a week, talking with them about life’s stressors. Though this picture may be accurate for some and effective in many cases, it is just one example of what mental health treatment can look like. While this once-a-week level of support can be effective for many, it is helpful to understand the full continuum of mental health care so that you can choose treatment that will be right for you or your loved one. The type of care needed depends on various factors, such as the type of symptoms experienced and their severity.
Mental health care is not a one-size-fits-all system. Multiple levels of care and treatment modalities are available to meet a variety of strengths, needs, and preferences. With the large number and potential combination of options available for care, it can feel overwhelming. However, understanding the continuum of care and the treatment types involved can also engender a sense of hope and empowerment that there are effective options available for everyone. When considering the different levels of care, note that each is designed for people with varying mental health needs that involve different clinical professionals, treatment modalities, and lengths of time spent in treatment. The continuum of mental health care is like a staircase or ladder on which you can step up or step down depending on your level of need. In this example, individual outpatient therapy is the first step, and residential treatment is the last, most intensive step.
Outpatient treatment includes individual, family/couples, and group therapy, and/or psychiatry. The frequency you meet with an outpatient provider varies but often ranges from every other week to twice weekly for therapy. For psychiatry, the frequency may be less, such as once a month to every three months. Outpatient therapy is a starting point for many people, as it offers a personalized and time-limited environment to explore one’s sense of self. It may be brief in terms of duration to address a specific concern or may take place over a longer period of time. Individual outpatient therapy is the right fit for those who struggle with mild to moderate mental health symptoms and who want to improve their relationships, and self-esteem, or navigate a life transition. Group therapy may be skills, process, support, or psycho-educational in terms of form and content and typically brings together a cohort of participants who share a treatment issue or goal and/or are of a common demographic.
When outpatient treatment is not enough to make meaningful progress toward treatment goals, a higher level of care on the mental health treatment continuum is recommended.
IOP is an ideal setting for people who need support beyond what is offered in outpatient therapy. The IOP level of care typically involves multi-disciplinary and group-based treatment with a heavy focus on coping skills and strategies. Patients generally attend between 3-5 days per week depending on need and based on recommendations from treatment providers. IOP programs are typically 3 hours per day. In addition to being more intensive, the multi-disciplinary, one-stop-shopping approach to care is a benefit of this higher level of treatment. In addition to group therapists, patients enrolled in an IOP program will typically have a team of care providers, including individual and family/couples therapists, psychiatrists or psychiatric nurse practitioners, nurses, and other specialty staff working collaboratively as a team toward mutually agreed-upon treatment goals. Patients at this level of care are typically able to function adequately in their daily lives at work, at school, and/or at home.
IOP is a desirable treatment option for many people because they can continue to attend school or work while receiving comprehensive treatment. IOP is more intensive than traditional outpatient visits and should be considered when talk therapy is no longer meeting your needs. The IOP level of care gives patients more opportunities to practice new skills outside treatment when faced with their typical stressors. IOP is often the next step down for patients who have completed a PHP program and are ready to re-engage in their typical daily routines at home, work or school while being scaffolded by a level of care that is a less drastic decrease in intensity than jumping straight to outpatient. Treatment team members in IOP coordinates care with the individual’s outpatient providers unless the person has a preference against this.
Many people feel anxious or uncertain about group-based programming. For some, the idea of sharing and being vulnerable with a group of strangers seems like it would be uncomfortable. Others might worry that they or their loved one in treatment might be in a group with others who experience different or “worse” symptoms than they do and the impact that this might have. Research shows that group therapy is extremely effective in treating individuals at this level of care. According to the American Psychological Association, “many people experience mental health difficulties, but few speak openly about them to people they don't know well. Oftentimes, you may feel like you are the only one struggling — but you're not. It can be a relief to hear others discuss what they're going through and realize you're not alone.”
Learning and practicing coping strategies and processing struggles and treatment with a small cohort of people in a safe and confidential environment is incredibly impactful. Receiving support or being challenged by a groupmate who can relate to another participant’s situation or feelings and has been able to make progress helps move other group members forward in a powerful way. Groups are run by skilled clinicians who are experts at creating safe, confidential, and therapeutic environments that facilitate treatment progress for each individual group member as well as the group as a whole.
It is a common misconception that PHP involves overnight stays and locked facilities, often because the word “hospitalization” is in its name. This is not the case. PHP, often referred to as “day treatment,” is the level of care between IOP and inpatient or residential treatment.
PHP is a common “step down” from an inpatient hospitalization or residential stay. Still, it can also serve as a step up from IOP or as a first line of treatment for some individuals who require short-term stabilization but not hospitalization. In fact, in many cases PHP can prevent hospitalization when a patient is experiencing a mental health crisis but does not need round-the-clock inpatient care. Like IOP, PHP is multi-disciplinary and group-based. It offers a safe, structured environment that includes robust group sessions, individual therapy, medication monitoring, education support for school-aged patients and resource or job readiness support for the adult population. Individuals in a PHP program attend 5 days or evenings a week, typically for 5-6 hours per day. PHP participants are typically experiencing severe symptoms that impede their daily functioning in one or more key areas of life such as home, work, or school. PHP programs are often targeted toward mood and anxiety disorders; some offer other specialty programming. For example, Compass offers PHP and/or IOP programs for Trauma, Mental Health and Substance Use Disorders, OCD and Complex Anxiety Disorders, Mental Health, Pain and Illness, and School Anxiety and Refusal.
Most PHP and IOP programs are group-based, and many utilize or draw from Cognitive Behavioral Therapy (CBT) and Dialectical Behavior Therapy (DBT). Compass also utilizes Acceptance and Commitment Therapy (ACT), Exposure & Response Prevention Therapy (ERP), Cognitive Processing Therapy (CPT), and Motivational Enhancement Therapy (MET). By incorporating multiple modalities, PHP and IOP programs increase engagement and provide multiple ways for patients to learn, practice, internalize, and apply treatment to their unique strengths, needs, and situations. In addition to individual, family, and group therapy, Compass employs various experiential therapies, including art therapy, animal-assisted therapy, dance movement therapy, drama and improv therapy, recreational therapy, and more.
When the PHP level of care cannot meet a patient's needs and/or there is a mental health emergency where a person is an imminent threat to themselves or others, it is recommended that the person be taken to the nearest emergency room. This may be via ambulance, or, if the person is calm and willing to go to the ER, a trusted and responsible friend or family member might take them. In the ER, a clinician will evaluate the patient and recommend whether they need to be hospitalized in an inpatient facility or whether they are safe to return home to begin or continue engaging in treatment; typically, PHP or IOP.
Inpatient psychiatric hospitalization is the highest level of mental health care and generally results from an Emergency Department evaluation. This type is treatment is designed to stabilize those experiencing a mental health crisis safely and who may be unable to seek support in a PHP or IOP setting. This level of care involves round-the-clock supervision and is the most restrictive setting. It is typical that inpatient care consists of medical monitoring, medication management, group and individual therapy, family therapy, and recreational activities. Once a patient is stabilized in inpatient care, they often step down to the PHP level of care.
Residential treatment is also around-the-clock care but is longer term than an inpatient stay. Residential care is often recommended for individuals who have historically struggled to make progress at the other levels of care. This type of treatment is considered long-term on the behavioral health continuum and the average length of stay is between 30-90 days. There is a range of residential programs across the country, each utilizing different treatment modalities to treat a variety of mental health diagnoses and concerns. Due to the number and variety of programs, patients and families may work with a placement consultant to help navigate all the options and find the best program for them.
The goal is to identify the least intensive and most effective level of care that will keep the patient safe and meet their treatment needs.
The behavioral health care continuum is meant to be flexible and offer multiple options. Some people may “step up” or “step down” the ladder of care as they engage in treatment, and others may only need to complete one step depending on their individual situation and via the guidance of their providers.
If you are seeking care for yourself, your treatment team will help determine this trajectory as your symptoms improve or if more support is indicated. The goal is always to keep an individual at the least disruptive level of care for the shortest length of time, while also ensuring they stabilize, and their symptoms improve. The right level of care corresponds to the severity of your symptoms.
To recap, acute inpatient care is for people at risk of imminent harm. They may have made statements about hurting themselves or others or acted on those urges, or they need medical monitoring, like with alcohol or drug withdrawal or with some severe eating disorder behaviors. Residential treatment is considered the highest level of care and ideal for patients who need a longer-term, supportive living environment with medical monitoring. The least intensive levels of care, outpatient therapy or psychiatry, are ideal for individuals who want to gain insight into a specific problem or make a positive change in their lives, but they are not in crisis and are functioning in their day-to-day lives. PHP and IOP, like what we offer at Compass, are considered more intermediate levels of care and fall somewhere in between.
It is important to have a basic understanding of the behavioral health care continuum if you are supporting a family member in their treatment journey or enrolling in a program to address your own mental health symptoms. Finding the right level of care can keep you from feeling stuck in your treatment journey and can propel you forward.
You shouldn’t have to navigate the decision on your own. If you’re not sure what level of care is appropriate for your needs, lean on your outpatient psychiatrist or primary care provider to help decide, or your partner or another loved one who can provide an outsider's perspective on your symptoms. Not all levels of care are available in every town; however, with virtual treatment offered at places like Compass Virtual, it helps to know the menu of options so you can move forward in making an informed choice.
Quick access to care is essential for successful outcomes when you or a loved one needs treatment. This is why Compass strives to schedule intakes within 24 hours of the initial phone call inquiry, and a psychiatric evaluation takes place within 48 hours of starting a program.