Key Points:
- The accepted goal of treatment is recovery—pursuit of a self-directed life, not just crisis stabilization.
- Those having difficulty pursuing recovery in outpatient treatment should consider residential treatment.
- Residential treatment ideally occurs in a community over months with group and intensive individual therapy.
- Residential treatment adds social learning to individual treatment.
Yolanda and Vi met when they arrived on campus and were assigned as roommates in the freshman dorm. As they got to know one another, they learned they each struggled with depression and suicide, early trauma, and both had been in a psychiatric hospital in the past. Both had histories of alcohol and drug use as well.
As a result of pandemic isolation, both Yolanda and Vi had lost out on social experiences, learning how to develop relationships with others and being part of a group. Both also had the experience of family members being concerned about their pattern of substance use.
Despite her challenges, Yolanda thrived in the first semester. With the help of therapy and medication, she attended sessions regularly, built a strong rapport with her therapist, addressed past traumas, stayed drug-free, attended classes enough to earn good grades, and developed friendships that reduced her isolation.
Vi struggled to attend sessions or use them effectively, having difficulty trusting her therapist. Once a good student, she now missed classes, neglected assignments, and became isolated, spending time on video games or social media. While her drug use decreased, her struggles continued, and she eventually left school after a suicide attempt and hospitalization.
Back home, Vi had trouble holding a part-time job, getting to therapy sessions, or to the groups that were part of an intensive outpatient program (IOP). She remained isolated, with few social contacts. A course of transcranial magnetic stimulation (TMS) offered little benefit. Vi tried returning to school after a semester away, but her difficulties recurred.
The stories of these two fictionalized college students might leave one wondering why Yolanda seemed to thrive while Vi continued to struggle, though they had similar struggles, access to good therapy, and appropriate medications.
Should a person like Vi give up her dream of graduating from college? What other options might help her take charge of her life?
Treatment Means Recovery, Not Just Crisis Stabilization
According to SAMHSA and the federal courts, the generally accepted goal of treatment is not mere crisis stabilization but recovery. Hospitals are essential for crisis stabilization, but the pursuit of recovery is generally the focus of outpatient treatment.
Consider a comparison from the world of medicine and surgery. After a stroke, patients are first hospitalized for crisis stabilization, then transition to outpatient care for recovery. If they have lost basic abilities, they go to an intermediate-care level to regain skills before returning to outpatient treatment. A similar approach applies in mental health, where residential treatment acts as an in-between phase after crisis stabilization. It’s like using training wheels on a bike—helping patients build skills for independent recovery.
Outpatient Treatment Doesn’t Always Work
As a result of her successful pursuit of recovery as an outpatient, Yolanda did not need a bike with training wheels. She had mastered two important skills by the time she got to college.
First, she was able to show up reliably and form an alliance with her therapist. Treatment included meetings about medications as well as weekly psychotherapy sessions. Second, Yolanda’s recovery as an outpatient succeeded because of her ability to function adaptively between sessions.
Vi, on the other hand, struggled with those skills, and increasing outpatient therapy, medications, and skills training was not enough. She needed more support than outpatient care could offer. A residential program provided the necessary support for her challenges, allowing her struggles to become a focus of her treatment.
The combination of therapy and medications just wasn’t enough for Vi. She needed more than outpatient treatment.
Social Learning
For many individuals like Vi, adding social learning as a third form of treatment can make a difference. Learning in a twosome-like therapy extends to learning in the rest of life beyond the twosome.
However, as in the case of infants, development requires more than just face-to-face learning in a twosome with the mother. Infants also learn about the social world while safely held in a parent’s arms, and they later learn much from peers.
The same holds true in the world of mental health treatment. Adding social learning to learning in a twosome (as in individual psychotherapy) and medication can boost mastery of skills in sessions and functioning adaptively between them. Adding outpatient group experiences may help, but Vi’s work in an IOP while living at home just didn’t provide her enough support.
Residential Treatment, Social Learning, and Medical Necessity
Social learning often requires immersion in a residential treatment center that combines peer support and group learning with individual learning in psychotherapy. Such settings focus on interpersonal growth and community-building, helping individuals break the cycle of loneliness and isolation.
Given Vi’s lack of progress in IOP, a 24/7 residential program was recommended. The decision was supported by her score on the LOCUS (Level of Care Utilization System) assessment, which evaluates a person’s mental health needs and indicates an appropriate level of care.
Residential treatment offers the best chance for Vi to overcome isolation and despair, fostering a sense of belonging. Over time, such an environment can help her address challenges that hinder outpatient treatment, improving her ability to engage in individual sessions and function better at school.
Difficulties Accessing Care
Access to residential treatment remains limited despite the federal parity law, which mandates coverage for mental health and substance abuse treatment equal to medical/surgical coverage, including intermediate care. Insurance companies often classify residential treatment as a short-term, crisis-focused service and resist covering it for recovery. This conflicts with nonprofit professional standards.
Vi’s insurer initially denied coverage for residential treatment, but since she lived in a state like California or Illinois, where medical necessity is based on nonprofit professional standards, coverage was eventually approved. Vi’s high LOCUS score demonstrated the need for residential care, helping her return to school and outpatient treatment better prepare her for success.
Unfortunately, no federal law links medical necessity to generally accepted care standards. Vi was lucky to live in a state that does. Does your state ensure access to medically necessary residential care based on professional standards? If not, consider advocating for laws that align medical necessity with nonprofit standards, not insurance company guidelines.
This article has been republished with permission. You can view the original source, published on December 5, 2024, at www.psychologytoday.com/us/blog/psychiatrys-think-tank/202412/when-outpatient-psychiatric-care-is-not-enough.
Thomas Franklin, MD, President and CEO of MindWork Group, and Eric M. Plakun, MD, former Medical Director and CEO of Austen Riggs, are both members of the Psychotherapy Committee at The Group for the Advancement of Psychiatry.
Group for the Advancement of Psychiatry (GAP) is a think tank of top psychiatric minds whose thoughtful analysis and recommendations serve to influence and advance modern psychiatric theory and practice.
References
Plakun, E.” Clinical and insurance perspective on intermediate levels of care in psychiatry,” J. of Psychiatric Practice Vol 24, No. 2, March 2018.
Plakun, E. “Psychotherapy, parity & ethical utilization management,” J. of Psychiatric Practice Vol 23, No. 1, Jan 2017
