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Types of Treatment

Unless you or someone you know has been in treatment before, there is a good chance that you donít know about the different types of treatment. What is even less understood is the reason that one type of treatment is recommended rather than another. Here is an explanation about the types of treatment  and the criteria that are used in making treatment recommendations.

But for those of you who are in a hurry, here are the more common names of the different treatment types:

  • Outpatient Treatment
  • Intensive Outpatient Treatment
  • 23-Hour Observation (Emergency Room Observation)
  • Detoxification
  • Partial Hospitalization (Day Program)
  • Inpatient Rehabilitation Program (Intermediate Care Facility)
  • Residential Treatment
  • Half-Way House and Shelter.

I also want to assure you that I know and appreciate how emotionally charged this whole topic is. When the person you care about is referred to a type of treatment that you believe is inadequate, feelings run high.


Let me start with some basic facts that affect treatment referrals that no one ever talks about. Treatment is provided by programs that care about people. But, like every organization in existence, they have to be concerned about their continued existence. The same is true for the various insurance companies, HMOs and legislatures that supply the money to pay for treatment. Everybody involved has an incentive to see that good treatment is provided. But, unfortunately the incentives from organization to organization are rarely aligned. Here are some examples.


Employers want their employees to have the best health care benefits possible within the budget allocation. They will "shop" health plans to find the best coverage within their price range. They may not be able to offer a full range of treatment types because of budget limitations.


Health plans that win contracts must provide treatments for every subscriber that is covered by the plan for the specified benefits. They must manage premium payments to provide treatment for every subscriber. If the estimates of costs do not cover the actual costs, the health plan must still pay for the treatment. This is a "risk" contract. Because mental health and addictions are separate treatment specialties, many health plans will "bid out" that part of the coverage to behavioral health care managers. They hope to manage less predictable expenses by using specialists familiar with those issues.


Behavioral health care managers contract with health plans to provide a range of treatment services within a specified geographic area. Contracted services are based on budget considerations and provider availability. In addition, the behavioral health care manager may also have to assume financial risk in providing services for all of the subscribers covered in the bid.


The providers contract with the behavioral health managers for defined services. They negotiate for the highest payment per service and work to keep costs per service low. This is true for each organization in this chain of service delivery.

Each organization tries to insure that it can provide the needed service Ė within the allocated funds. One incorrect calculation by any organization can result in financial disaster. For this reason, there are multiple types of treatment, with variable associated costs.


It is easy to assign bad intent to any of the organizations within the chain of delivery. But the reality is, every organization must try to provide needed services at the lowest possible costs. Not one is immune to the need to contract cautiously and guard whatever advantage it possesses. Otherwise they will go out of business. In the last twenty years almost 80% of the intermediate care facilities have gone out of business.


With all of that in mind here is a description of the types of treatments that may be identified in benefit contracts. Please understand that some of the names for these types of treatments may be different but the basic description of the level of care is the same. These levels of care are listed from the least intensive to the most intensive levels of care. Finally, I have added Half-way houses and Shelters at the end of the list. They are not treatment per se, but they are part of the path to community-based recovery for some individuals. But remember, they are not included as primary treatment providers.

Outpatient Treatment

Outpatient treatment is the least intense level of care. Usually sessions occur once per week for 1 to 1.5 hours. The vast majority of outpatient treatment is in a group treatment setting. Group treatment is preferred because of the power of the group. A group can model acceptance and responsibility for treatment outcomes for its members. Outpatient treatment is indicated for individuals who are not actively addicted, who need support, motivation, information, or after-care.

Outpatient treatment is generally not recommended as the initial treatment for active dependence except in special circumstances. Examples of this would include individuals with a diagnosis of dependence without evidence of a need for detoxification, such as an ability to abstain three or more days per week or weekend-only use. Using this guideline, an individual with a binge pattern of use could also be appropriate for outpatient treatment if detoxification is not indicated.

In this setting supervised urinalysis and breathalyzer testing is essential. Also, consistent attendance is vital for success. Attendance is the single best predictor of successful treatment.

Treatment is directed by non-physicians and addresses five major treatment goals. They are; abstinence (verified by random urinalysis and breathalyzer tests), an understanding of the disease of addiction, lifestyle changes to support abstinence, development of a community-based support system, and relapse prevention strategies.


Intensive Outpatient Treatment

Intensive Outpatient Treatment is the treatment of choice for the majority of individuals seeking addiction treatment. Intensive Outpatient Treatment is documented to be as effective as inpatient treatment with fewer transition problems for individuals and their families. Individuals in this level of care do not need medical supervision or daily medication adjustment as a part of daily treatment. Treatment is directed by non-physicians and addresses the same major treatment goals of outpatient treatment; abstinence, an understanding of the disease, lifestyle changes, development of a community-based support system, and relapse prevention strategies.


23-Hour Observation

The 23-hour observation bed is a secure, time limited, inpatient level of care used to evaluate individuals who do not clearly meet the criteria for inpatient care but who are judged to be at undo risk if immediately placed in lower levels of care. Skilled medical evaluation is required to adequately assess the individual's treatment needs or stabilize the individual. Most commonly this treatment is used to evaluate the need for inpatient detoxification for individuals who present with extensive histories of alcohol use, or prior medical complications in withdrawal, but are not showing current evidence of withdrawal symptoms due to present intoxication. It may also be used in situations where the individual is judged to be at risk for mortal harm to self or others in addition to their need for addiction treatment. The question of which level of care is most appropriate for ongoing treatment is decided within this time.


Detoxification

Ambulatory detoxification is a level of care that is appropriate when critical safety conditions are met. These include a history of prior withdrawal without risk factors such as medically verified seizures, cardiac and circulatory risk factors. The individual must also have support and supervision during non-treatment hours, and transportation to treatment. Individuals who have been using prescription drugs such as narcotics, sedatives, anaxiolitics and alcohol are candidates for this treatment modality. Indications for the need for detoxification include elevated vital signs; (BP 140/90 or greater, P 85 or greater, T 99.9 or higher) without medication or substance use within four hours.

Strong cravings, emotional displays, and mood swings accompany withdrawal but are not indicators for an inpatient admission. Disruption of appetite and sleep, tremor, restlessness, irritability, and lack of concentration also accompany withdrawal but can be treated in ambulatory detoxification. While in ambulatory detoxification individuals are involved in daily groups, individual sessions, and medication management. Transition plans for the next level of care are arranged at the initiation of detoxification.


Inpatient detoxification is not a protective devise to save individuals from their own behavior. (For example, an individual makes a threat to continue using drugs or alcohol if admission is not granted immediately, regardless of the withdrawal symptoms.) It is a level of care in the continuum that provides 24 hour medical supervision for individuals who are experiencing medically dangerous withdrawal symptoms such as significantly elevated vital signs (BP160/100, P 90, T99.9), impending delirium tremens (transitory tactile or sensory stimuli), withdrawal seizures, and symptoms requiring 24 hour medical intervention (medication for elevated vital signs or redirection to control cravings).

Individuals who do not have critical supports, have significant medical risk factors, who lack support or supervision during non-treatment hours, or who do not have access to transportation will need to utilize this level of care.

Individuals who will not contract for abstinence as one of their treatment goals are not yet engaged in the treatment process. They are in a pre-treatment level of intervention and need skilled counseling to assist with motivation, reality testing, consequence review, individual information about addiction, and monitoring of their commitment to treatment. This is usually done in weekly, individual sessions for about four weeks to increase treatment readiness.( There is more about Pre-Treatment Readiness in the Audio report:) When Is Someone "Ready" for Treatment?


Partial Hospitalization

Partial Hospitalization is a level of care provided by a multidisciplinary team that is directed by a physician for up to eight hours per day. Similar to ambulatory detoxification, critical safety supports must be available for the non-treatment portion of the day. Individuals are involved in daily groups, individual sessions, and medication supervision. Treatment includes abstinence verified by random urinalysis and breathalyzer tests, an understanding of the disease of addiction, lifestyle changes to support abstinence, development of a community-based support system, and relapse prevention strategies Partial hospitalization may be accompanied by sleepover arrangements as a safe alternative to inpatient care. Partial hospitalization may also be utilized as an alternative to ambulatory detoxification in some geographic areas.


Inpatient Rehabilitation

Inpatient rehabilitation is a medically directed level of care for individuals who have a history of severe and continuous dependence on alcohol or drugs. This individual is unable to utilize a lower level of care to achieve abstinence or their danger of relapse is such an immediate a danger to their health (pancreatitis, endocarditis, cirrhosis for example) that a relapse would produce direct physical harm. Individuals are involved in daily group treatment, individual sessions, and daily medical supervision. The goals in treatment include an understanding of the disease, completion of a consequences inventory, introduction and familiarization with 12 Step programs, planning for community re-entry, developing a recovery support system, and relapse prevention planning.


Residential Treatment

Residential treatment is a 24-hour level of care to provide support and structure for individuals likely to suffer serious harm or an immediate risk of serious harm as a direct consequence of their addiction. The individual's external support system is inadequate to sustain treatment at a lower level of care. Individuals are involved in daily group treatment, individual sessions, and medical supervision. Their treatment includes structured daily schedules, an understanding of the disease, completion of a consequences inventory, introduction and familiarization with 12 Step programs, planning for community re-entry, use of recovery support systems, and relapse prevention planning.


Half-Way House

The Half-Way House is not so much a type of treatment as it is a supportive residential placement. Individuals admitted to a Half-way house have admission requirements that include a specified number of days of current abstinence and recent treatment completion. The Half-way house is composed of abstinent individuals, living in a common residence, who mutually follow a recovery based life-style as part of the process to re-establish independent living. House meetings, 12-Step meetings, communal maintenance of the facility, structured personal schedules, planning for independent living, and employment are requirements for continued residence.


Shelters

The shelter is not treatment; it is a temporary arrangement that permits protection from the elements and provides a point of stability. There are "wet" shelters for the homeless that will permit occupancy as long as the individual is not using drugs or alcohol on the premises. There are "dry" shelters that require abstinence as a pre-condition for occupancy. Some shelters will provide limited continuity of occupation while plans for a more permanent residential arrangement are completed. Other shelters are available on a day-to-day, first come, first served basis. Some shelters are closely affiliated with social service organizations and advocate for their residents, while other shelters are available only for evening and night occupancy.

Individuals using shelters are very much on the fringe of security. Existence is focused on day-to-day survival and the energy and time available for recovery is limited. Stabilization on several simultaneous levels is needed; residential stability, financial sustainability, abstinence, recovery activities, structured living skills, transportation, medical stability, and social networking are some of the initial areas. It is a difficult list to master and external supports are a vital component for re-integration.

In some instances, individuals who have abandoned themselves to the disease process are utilizing shelters as a terminus point. In others, shelters are the initial point of stabilization that stops the downward spiral of destruction.


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Copyright © Stephen Buchness 2005