Intensive Outpatient Programs: When More is Better

The world of substance abuse treatment has gone through a great deal of change in the last decade. In the past, when a person entered substance abuse treatment, there was an immediate assumption that they needed a 28-inpatient rehab in order to “recover”. However, this standard has been changed due to managed care restrictions as well as research that indicate that people can improve and reach their goals with outpatient treatment. While there is the necessity for inpatient treatment, there also needs to be more creative outpatient options.

Outpatient options need to address the complexity of the clients we are attempting to engage in treatment. For many outpatient programs, there still exists the dilemma of how to provide significant structure and support to clients who are just beginning to make changes in their use. Often these clients have very limited supports and have a multitude of substance abuse problems (e.g., legal issues, lack of relapse prevention skills) as well as mental health concerns (e.g., depression, anxiety, PTSD). In addition, they may be struggling with concrete problems like vocational issues such as lack of work or dissatisfaction with their profession as well as housing concerns. Some treatment centers use intensive outpatient programs which include 2-3 hours of treatment several times a week (IOPs) and outpatient rehabilitation programs (4+ hours a day; five days a week) to address the multitude of issues and provide much needed support.

In addition, in an age where we are looking to integrate substance use and mental health care, the intensive programs seem perfect in the way they address addiction from a variety of angles. They allow us to address the unique needs of a person by offering a variety of group options while also using individual therapy and psychopharmacology as well.

These programs can be tailored to address the population being addressed. They may provide much needed support for clients who have co-morbid psychiatric issues and who have difficulty getting into psychiatric day programs that require stability in terms of drug use. They not only can help to stabilize these clients in terms of their use, but they begin to build skills for these clients to manage depression, anxiety, etc. and to work on affect regulation. They may provide education regarding mental illness and around medication, medication management and the interaction of emotion and drug use.

More specifically these programs provide “traditional” drug treatment such as CBT, relapse prevention, 12-step facilitation, and motivational interviewing and “orientation” to drug treatment. They also can offer DBT, skills building, and socialization groups. More holistic treatment can be incorporated such as yoga, exercise, and arts and crafts. Clients have also benefitted from medically oriented groups that involve psycho-education about the impact of their use and about topics related to addiction such as hepatitis, STDs, and HIV as well as nutrition and exercise as clients begin to care again for their bodies. These groups can provide psycho-education about a variety of topics that relate to drug use and psychiatric functioning. Having supervised these programs for over 15 years it has also been helpful to have “open” groups that can be tailored to a particular community. Therefore, community members have at times asked for more meditation and mindfulness, journaling, as well as other topics.

In addition, it can be useful to have a group that helps people transition from these programs as they transfer to less intensive care and ongoing therapy groups once they stabilize or return to school or work. Though these programs can be powerful, they can be difficult to transition from with regard to ongoing treatment. Clients can process their feelings about leaving this level of care and returning to work and continuing in ongoing less intensive care.

In my experience, there is also a healing power to these programs that is somewhat intangible but quite powerful. Walant (1999) discusses the need for clients with drug problems to wean off their powerful attachment to a substance and to engage intensively in a replacement. She discusses how a therapist may notice that clients need greater support from their therapist early in the therapeutic process. These intensive programs can provide this new, healthier attachment. A powerful sense of community can build in these programs that allows people to connect to something larger then themselves and to also build a support system. This process may be similar to self-help programs. Members often want to attend and do better for themselves and to not let the community down.

Because most of the treatment is group psychotherapy, therapists can see their clients in an interpersonal context and better understand how they relate with others. This helps us look at the barriers towards great social support. In addition these communities provide role models for clients early in this process. More senior, stable community members can provide hope for clients who are just beginning to make changes. They also teach clients to utilize therapy and groups in order to understand themselves better (Washton, 1999). They help members become better therapy clients.

Community meetings are often parts of these programs and provide roles and jobs (e.g., making coffee, community leader) for people in order to connect to the community. These roles help members who may not be as comfortable with verbal processing and facilitate greater connection to the community. The roles have therapeutic value and can allow members to build a sense of responsibility in their lives and to their community.

There are always ways that these programs can get problematic. As opposed to traditional group therapy where clients often do not connect outside of group, clients in programs may interact in ways that are concerning such as using together, having sexual and romantic attachments, as well as financial ones. In my experience, the pros of these programs outweigh the possible problems. When assessing new clients, a question of the level of support and structure a client needs is as important as assessing psychiatric issues, legal and vocational issues. When clients are in need of greater support, these intensive programs may provide the support, the repetition, and variety of care that people may need.

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