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Addiction Treatment Levels: Inpatient vs. Outpatient Explained · RECOVERable: Mental Health and Addiction Experts Answer Your Questions

• 0:13
  SPEAKER_01: Not everyone needs detox level of care.
• 0:16
  SPEAKER_02: Dr.
• 0:16
  SPEAKER_02: Sal Reichbach is an expert in behavioral health and addiction treatment.
• 0:20
  SPEAKER_00: So the highest and most intensive form of care is inpatient care.
• 0:24
  SPEAKER_00: What is that and who needs it?
• 0:31
  SPEAKER_00: Welcome to Recoverable.
• 0:32
  SPEAKER_00: I'm Terry McGuire, your host.
• 0:34
  SPEAKER_00: This is the podcast for which we bring experts into the studio to answer your most searched questions about addiction and mental health treatment.
• 0:42
  SPEAKER_00: And we ask them to break it down into the kind of language we can all actually understand.
• 0:47
  SPEAKER_00: Dr.
• 0:48
  SPEAKER_00: Sale, you're an expert in that.
• 0:49
  SPEAKER_00: And I'm so grateful because today's conversation is going to be focused on the levels of care.
• 0:55
  SPEAKER_00: First of all, I want you to tell us a bit about yourself and then why it's so important that we actually understand this.
• 1:01
  SPEAKER_01: Sure.
• 1:01
  SPEAKER_01: Well, good morning.
• 1:02
  SPEAKER_00: Good morning.
• 1:03
  SPEAKER_01: Thank you for having me.
• 1:03
  SPEAKER_01: My name is Dr.
• 1:04
  SPEAKER_01: Sal Rachback.
• 1:05
  SPEAKER_01: I am a uh doctoral level psychologist.
• 1:08
  SPEAKER_01: I'm also a licensed clinical social worker and a certified uh forensic social worker.
• 1:13
  SPEAKER_01: Been practicing in the arena of behavioral health um for over 33 years.
• 1:20
  SPEAKER_01: Started out as curiosity, uh, loved psychology, liked talking to people, uh, and before you know it, it transcended into a long-term uh career.
• 1:30
  SPEAKER_01: And I specialize uh in mental health services as well as substance use disorders.
• 1:35
  SPEAKER_00: Okay.
• 1:36
  SPEAKER_00: Why is it important for us to understand these levels of care?
• 1:39
  SPEAKER_01: An informed client is crucial in the success of any type of treatment.
• 1:45
  SPEAKER_01: Just like any consumer who goes uh and seeks medical attention, knowing what they're seeking uh and what it entails is part one of quite a few parts in making sure that they get the services that they need.
• 1:58
  SPEAKER_01: It's very important because there are distinctions between different types of levels of care, from the least restrictive to the most.
• 2:06
  SPEAKER_01: And so uh a client stepping into what may be uh first time ever in treatment, it's important for them to know what is going to happen, uh the time, uh, the space, so they can be informed and then make a sound decision as to whether or not this is something they're willing to take part in.
• 2:24
  SPEAKER_00: And I know that you believe there are some risks involved in somebody doing this completely on their own and just saying, I think I have this or I think they have that and need this and need that.
• 2:34
  SPEAKER_00: I'm gonna go on the internet and do my research.
• 2:37
  SPEAKER_01: I I I just like to caution people because people tend to sometimes get an overload of information.
• 2:43
  SPEAKER_01: And the best advice that I can give anyone who's seeking uh services for something that they may think they have or they don't know what they have is to seek professional assistance.
• 2:53
  SPEAKER_00: And of course, lots of us don't have access to that or to what we currently are doing now, which is sitting down with somebody who does have the answers and saying, explain it to me until I understand it.
• 3:04
  SPEAKER_00: So again, really grateful that you're here.
• 3:06
  SPEAKER_00: And I'm gonna start right at the top with the most asked question on the internet, which is about mental health and addiction care.
• 3:14
  SPEAKER_00: What are the different levels of care?
• 3:16
  SPEAKER_01: We start with the least restrictive levels of care, which is the traditional outpatient programs.
• 3:20
  SPEAKER_01: That's normally a step down from what is possibly an intensive outpatient program, which is what is known in the field as an IOP level of care, runs parallel uh and is also a stepping stone uh from the next level of care, which is the partial hospitalization program, or otherwise known as PHP, not to be confused with hospitalization.
• 3:45
  SPEAKER_01: It's just called a partial hospital program.
• 3:48
  SPEAKER_01: And then above that, we have the residential level of care uh followed by inpatient level of care, which is usually a hospital-based program.
• 3:58
  SPEAKER_01: And if we can segue first to substance use uh for one second, uh we also have the detox level of care, uh, which is a medical stabilization unit.
• 4:09
  SPEAKER_01: And where is that in the right above the residential?
• 4:12
  SPEAKER_01: Okay.
• 4:13
  SPEAKER_01: On the side of inpatient.
• 4:16
  SPEAKER_00: How are those levels different for mental health than they are for addiction?
• 4:20
  SPEAKER_00: And I want to know about the when it's both, if somebody has both a mental health diagnosis and an addiction, how that knot is untangled.
• 4:28
  SPEAKER_01: Other than detox for substance use disorders or mental health, those levels of care apply.
• 4:35
  SPEAKER_01: Outpatient, intensive outpatient can be designed for substance use or addiction services as well as mental health.
• 4:42
  SPEAKER_01: Same thing with PHP and even residential.
• 4:44
  SPEAKER_01: It's the detox that normally uh 99.9% of the time tends to serve the uh need for medical stabilization.
• 4:56
  SPEAKER_01: That's not to say that clients who are in need of detox are not with mental health issues.
• 5:02
  SPEAKER_01: Right.
• 5:03
  SPEAKER_01: But we call uh we call that uh dual diagnosed or comorbid, uh, which means that the client has a combination of substance abuse and mental health and may require detox uh level of care to offset potential withdrawals and complications from substance use.
• 5:24
  SPEAKER_00: And is detox a step that has to be taken before other care so that you are more open to it or available to it?
• 5:31
  SPEAKER_00: Yes and no.
• 5:32
  SPEAKER_01: Okay.
• 5:32
  SPEAKER_01: Uh yes, if it requires medical stabilization, no, not everyone needs detox level of care.
• 5:41
  SPEAKER_01: And so again, it depends on the severity of the symptoms, the the substance used.
• 5:46
  SPEAKER_01: Some substances are not detoxable, which means that you won't go to detox uh uh to offset the potential withdrawals because they're not life-threatening.
• 5:56
  SPEAKER_01: Okay.
• 5:56
  SPEAKER_01: To answer your question, detox is and can be part of most clients in need of substance use uh withdrawal symptoms uh and management, but not necessarily a stepping stone or a step down or up.
• 6:13
  SPEAKER_01: It's a little bit on the sidelines of uh when we kind of rate the severity of the levels of care.
• 6:21
  SPEAKER_00: So let's step through the different levels.
• 6:24
  SPEAKER_00: And we will start with outpatient.
• 6:27
  SPEAKER_00: Who needs outpatient?
• 6:29
  SPEAKER_01: Everyone.
• 6:30
  SPEAKER_01: Outpatient therapy is the traditional, least restrictive levels of care when it comes to an interaction between a professional who specializes in a field of, and you can fill in the blanks, whether it's uh depression or uh anxiety disorders or substance use disorders, and schedules a time between the client and themselves to be able to coach, listen, advise, and work collaboratively with the client to reach a goal, whatever the goal is.
• 7:03
  SPEAKER_01: And that's usually is formalized during the sessions when the client comes in and discusses what they want and what they expect and what their needs are, and the therapist is there to assist.
• 7:13
  SPEAKER_00: If I'm in therapy and I am, is that the same as an outpatient program?
• 7:18
  SPEAKER_01: Yes.
• 7:18
  SPEAKER_00: Okay, so being in therapy qualifies as an outpatient program.
• 7:22
  SPEAKER_00: Yes.
• 7:22
  SPEAKER_00: Okay.
• 7:23
  SPEAKER_00: So what's the primary goal of outpatient programs?
• 7:26
  SPEAKER_01: Depending on what the presenting problems are.
• 7:29
  SPEAKER_01: Let's say substance use disorder.
• 7:31
  SPEAKER_01: Maintaining sobriety and dealing with the effects of either long-term use or the consequences of even short-term use.
• 7:40
  SPEAKER_01: Normally, what we see with substance uh dependency, especially in the outpatient program, is a concentration on the uh ability to use the coping skills that they've learned in other higher levels of care or more restrictive levels of care, and be able to continue to live sober and deal with things that normally they weren't able to deal with before.
• 8:07
  SPEAKER_01: And as a result, they use substances to deal with.
• 8:12
  SPEAKER_00: A primary goal of therapy, as I'm understanding you, is to teach life skills that we have not acquired before so that we're able to deal with whatever it is we're dealing with without the use of drugs or alcohol or that is exactly right.
• 8:25
  SPEAKER_01: I mean, it's it's teaching new skills and also strengthening coping skills that the person may have had prior to substance dependency.
• 8:36
  SPEAKER_00: Would there be less substance use and mental health disorders if we were taught management skills and how to regulate our emotions and those things as a routine practice?
• 8:50
  SPEAKER_01: Yes.
• 8:51
  SPEAKER_01: To answer your question, the more a client or the more the a person is involved in any sort of therapy, even if it means not going to a traditional therapist client, but be able to be involved in some sort of self-help, um, self-enrichment, uh, support groups, or talking to someone who is uh a mentor or uh someone who's capable of giving good advice.
• 9:19
  SPEAKER_01: If it means that you are getting better or maintaining a healthier lifestyle, can it minimize and even prevent from others uh or from yourself to get involved in things that normally would yield in negative consequences?
• 9:37
  SPEAKER_01: Sure.
• 9:38
  SPEAKER_00: Okay, let's switch to intensive outpatient.
• 9:41
  SPEAKER_00: You're a provider, so you have a unique perspective on all of this.
• 9:44
  SPEAKER_00: What is intensive outpatient as opposed to outpatient?
• 9:48
  SPEAKER_00: Why is it a step up?
• 9:49
  SPEAKER_01: IOP or intensive outpatient program is time bounded, which means that it's regimented, it's structured, it's three hours a day, three times a week, heavily set on group therapy, including normally what would be one weekly individual, one-on-one therapy session.
• 10:11
  SPEAKER_01: And the focus around IOP or intensive outpatient program is community reintegration.
• 10:19
  SPEAKER_01: The word coping skills definitely starts to come into play with IOP.
• 10:24
  SPEAKER_01: This is field practice, this is where real life starts again after being in what may possibly be a more restrictive level of care where you are under a more of a protective environment for a short stay.
• 10:39
  SPEAKER_01: IOP serves the purpose of allowing clients to absolutely apply coping skills that they've learned, be able to rely on peer support and demonstrate a willingness and an acceptance to seek ongoing therapy for well-being.
• 11:00
  SPEAKER_00: So when we're talking about steps, and somebody can be going up from outpatient to intensive outpatient, they can also be coming down to it.
• 11:08
  SPEAKER_00: How do we should we just keep going from the bottom up?
• 11:11
  SPEAKER_00: Is that the best way for us to proceed?
• 11:14
  SPEAKER_01: There are extenuating circumstances where you would normally think that the next step would be to a lower level, uh, where that lower level was not appropriate.
• 11:28
  SPEAKER_01: Uh client may have had a relapse where we would want to step down, but sometimes step down means we have to also step up.
• 11:39
  SPEAKER_01: And stepping up means a more restrictive level of care as opposed to a lesser level of care.
• 11:45
  SPEAKER_00: What would a likely scenario be where someone who is in therapy or an outpatient program goes into an intensive outpatient program?
• 11:52
  SPEAKER_00: What would necessitate that step up?
• 11:54
  SPEAKER_01: Severity of symptoms.
• 11:56
  SPEAKER_01: Uh, if we're talking about substance dependence, that could potentially be relapse.
• 12:02
  SPEAKER_01: Outpatient therapists normally see their clients once a week.
• 12:06
  SPEAKER_01: And if we're talking about a private setting, if a client is decompensating, client is starting to present some concerns uh on being able to function independently without the intensity of an IOP or partial hospitalization program or even residential, the recommendation would be to come back up and increase the intensity of therapy.
• 12:31
  SPEAKER_01: Uh, and that could apply to any of the levels of care.
• 12:34
  SPEAKER_00: And can IOP or intensive outpatient therapy be done remotely?
• 12:38
  SPEAKER_01: Telehealth or remote therapy, whether it's IOP, group therapy, or individual, is effective.
• 12:46
  SPEAKER_01: Data shows that there is and there's been research done, uh, the effectiveness of, again, it's the willingness and the acceptance of a client, but in some circumstances where the resources that are available for traditional therapy done in a setting uh may not be.
• 13:03
  SPEAKER_01: And so, yes, uh, to answer your your question, IOP, intensive outpatient program uh can be done um in a um sort of a virtual uh way.
• 13:15
  SPEAKER_00: So let's step up to partial hospitalization.
• 13:19
  SPEAKER_00: And as a therapist and a provider, can you explain to us what partial hospitalization programs or PHPs are?
• 13:25
  SPEAKER_01: Yes, I can.
• 13:27
  SPEAKER_01: I need to find out who started the word partial hospitalization program.
• 13:32
  SPEAKER_01: Maybe it was because it started in in hospital-based programs.
• 13:35
  SPEAKER_01: I don't know, but it really is confusing for some to hear partial hospitalization program.
• 13:40
  SPEAKER_01: And the first thing is, well, do I need to be in a hospital part-time?
• 13:45
  SPEAKER_01: Right.
• 13:45
  SPEAKER_01: No.
• 13:46
  SPEAKER_01: Partial hospitalization program is an intensive level of care.
• 13:50
  SPEAKER_01: It is also very structured.
• 13:53
  SPEAKER_01: Um, it is done five, sometimes even six, and in some places, even seven days a week from four to six hours each day.
• 14:02
  SPEAKER_01: Once again, heavily concentrated on group therapy.
• 14:07
  SPEAKER_01: Uh, there is more of a clinical uh interaction uh than the intensive outpatient program because of the amount of days and time that the client is actually engaged in therapy.
• 14:23
  SPEAKER_01: And the expectation from the partial hospitalization program is that you are able to demonstrate a less intensive or the severity of symptoms that were presented at a high level of care.
• 14:39
  SPEAKER_01: You may not require um psychiatric um or medical attention as often as you would be if you were in a highest level of care.
• 14:51
  SPEAKER_01: Partial hospitalization program does focus on medication management, uh, but it's usually assisting.
• 14:59
  SPEAKER_01: It's not dispensing.
• 15:01
  SPEAKER_01: Uh at a partial hospitalization program, you don't dispense medications to the clients.
• 15:05
  SPEAKER_01: The clients are able to function independently and are able to demonstrate that through skills that they've learned uh in higher levels of care.
• 15:14
  SPEAKER_00: So would the typical person, if there is one, in a partial hospitalization program, have stepped down into now this is all they need, or up from an intensive outpatient, and it's like you need a little more than you are getting there?
• 15:29
  SPEAKER_01: Again, there are circumstances where a client may not have been in a higher level of care and um been in a lower level of care and needed to step up to PHP, uh, partial hospitalization program.
• 15:41
  SPEAKER_01: Or typically you'll see clients that are in a high level of care because of their immediate acute need being stepped down because of the severity and the symptomatology that has improved into a partial hospitalization program.
• 15:57
  SPEAKER_01: But again, the focus of the partial hospitalization program is to be able to allow clients the ability to practice skills either acquired in past or more recent.
• 16:11
  SPEAKER_00: Who qualifies for partial hospitalization program?
• 16:14
  SPEAKER_01: A client who has demonstrated an ability to uh subside uh from thoughts of self-harm, someone who is able to now be in the preparation stage when it when it we talk about the the cycle of addiction, someone who's able to refrain uh and practice sobriety skills has the ability to uh partake in either uh employment, schooling, in short, someone who's able to uh demonstrate independent functioning without the need for uh intense psychiatric and medical attention.
• 16:53
  SPEAKER_00: So, in a partial hospitalization program, more intensive, more hours, more days, but you're still going home or wherever you go at night, you can still work if it works with your therapy schedule.
• 17:04
  SPEAKER_01: Sure.
• 17:05
  SPEAKER_01: Absolutely.
• 17:06
  SPEAKER_01: There are a lot of partial hospitalization programs that coincide or work with entities uh outside of the clinical forum.
• 17:15
  SPEAKER_01: Uh we used to call them halfway houses.
• 17:18
  SPEAKER_01: Yes.
• 17:19
  SPEAKER_01: Now they are more properly termed as supportive living, uh, where clients may not be able to return to their home environment uh for various reasons.
• 17:30
  SPEAKER_01: Um maybe the home environment is not conducive, they're not ready, and so they will partake in a partial hospitalization program while residing in supportive living environments.
• 17:43
  SPEAKER_00: Are partial hospitalization programs covered by insurance?
• 17:46
  SPEAKER_01: Yes.
• 17:47
  SPEAKER_01: However, um to be covered by insurance uh means you have to meet uh criteria that are set forth by insurances.
• 17:58
  SPEAKER_01: And the majority of the insurances uh or the payers as I refer to them, um have a sort of kind of like similar criteria.
• 18:11
  SPEAKER_01: Some are a little bit more uh strict than others.
• 18:15
  SPEAKER_01: But yes, insurance does cover partial hospitalization programs.
• 18:20
  SPEAKER_00: So let's go onward to residential treatment, which I think is what most people call rehab.
• 18:25
  SPEAKER_01: Yes.
• 18:26
  SPEAKER_01: Okay.
• 18:26
  SPEAKER_01: So that's a living in environment.
• 18:29
  SPEAKER_01: Uh supervised 24 hours a day, seven days a week, by uh medical nursing, psychiatric, and clinical.
• 18:40
  SPEAKER_01: It is a I would probably say it's one of the top intensive levels of care when it comes to mental health and addiction services.
• 18:50
  SPEAKER_01: The focus for residential level of care is to take someone off the red.
• 18:57
  SPEAKER_01: And by that I mean these are the circumstances where clients are unable to function independently in their community without the risk of either self-harm or harm to others.
• 19:11
  SPEAKER_01: And while not every single client entering a residential level of care is uh experiencing thoughts of uh self-harm, what we do see is the inability to refrain from either intrusive thoughts, actions, or beliefs.
• 19:30
  SPEAKER_01: And so it is a very intensive, very structured, very involved in the types of services that are being delivered.
• 19:39
  SPEAKER_01: It's a combination of both group therapy and individual therapy that runs seven days per week.
• 19:46
  SPEAKER_00: So somebody's never been in residential, believes or is told that that's the level of care they need.
• 19:52
  SPEAKER_00: What should they expect, say, from when you walk in the door?
• 19:56
  SPEAKER_00: What's going to happen?
• 19:57
  SPEAKER_01: Each type of facility may have um uh a different approach to how the intake process is done, but normally quite a lot of assessments at the beginning stages of treatment, because the more information that we have, uh the more informed we are to provide the kind of care that someone needs.
• 20:19
  SPEAKER_00: Is an assessment this, us talking and you asking me questions and what I'm experiencing and how I got here, or is it blood work and all of it?
• 20:27
  SPEAKER_01: It's all of it.
• 20:28
  SPEAKER_01: Okay.
• 20:28
  SPEAKER_01: Um a clinical and a psychiatric perspective, there's a lot of what we call evidence-based assessments.
• 20:39
  SPEAKER_01: There are specific assessments that are being conducted uh that aim at gathering information regarding someone's mental health, someone's psychiatric uh needs, um, just like we would gather um assessment based on medical, like labs and vitals.
• 21:00
  SPEAKER_01: Um the first stage of someone entering a residential treatment is being educated about what to expect, gathering assessments, um, gathering releases of information.
• 21:11
  SPEAKER_01: It's very, very important.
• 21:13
  SPEAKER_01: It's a crucial part of treatment to be able to have, for us as providers and for the client himself, support.
• 21:21
  SPEAKER_01: And that usually comes with either what uh uh uh family members, uh, someone that are dear to the client who's able to provide sometimes information that is not accurately depicted.
• 21:33
  SPEAKER_00: Uh we're not our most reliable narrators sometimes.
• 21:36
  SPEAKER_01: And there's there may be some hesitation in disclosing too much information, but we need to know everything in order to be able to make a sound decision as to how we are going to tailor an individual um uh therapeutic approach to a client's uh treatment.
• 21:52
  SPEAKER_01: But through assessments, uh through the intake process, um, clients are assigned case management.
• 21:59
  SPEAKER_01: Let's not forget the fact that when clients are coming into a residential level of care, they there there are experiences and issues uh that they have on the outside, outside the walls of treatment that are in need of attention, whether it's Legal issues, employment issues, family issues, financial issues that case management usually um identifies and then puts together a plan in conjunction with the actual therapist.
• 22:28
  SPEAKER_01: Because the work will continue when the client leaves.
• 22:31
  SPEAKER_01: And then, of course, the introduction to the program.
• 22:37
  SPEAKER_01: And the program at a residential level of care runs seven days per week.
• 22:43
  SPEAKER_01: There is no break from getting therapy.
• 22:46
  SPEAKER_01: Therapy is all day long.
• 22:49
  SPEAKER_01: Even in the in the later part of the afternoon and evenings when the clinical component kind of minimizes its stance.
• 22:59
  SPEAKER_01: We have other disciplines in the program that are there to provide coaching, mentoring, and support.
• 23:07
  SPEAKER_00: So take me through a typical day.
• 23:08
  SPEAKER_00: I'm in residential treatment, never been there before, really don't know what to expect.
• 23:12
  SPEAKER_00: I've gone through intake.
• 23:14
  SPEAKER_00: I wake up that first morning.
• 23:16
  SPEAKER_00: What's my day going to look like?
• 23:18
  SPEAKER_01: You are going to be involved in uh meetings with your group facilitators or your therapists who are going to be actually conducting the uh the therapy.
• 23:28
  SPEAKER_01: You're going to be introduced to the uh to your peers.
• 23:32
  SPEAKER_01: Uh, you're going to have a schedule at your hand, uh, and you are going to partake in a variety of different types of group therapies.
• 23:42
  SPEAKER_01: Again, in an in an enriched rehabilitation program, you are going to experience a variety of different things from deep psychoeducational groups, experiential types of services, which is art therapy, music therapy, um, you're going to be enriched with uh nursing or medication groups that discusses medical needs.
• 24:16
  SPEAKER_01: And as you go through the kind of like waves of uh doubts or hesitations or uh ambiguity, you're going to meet with your primary therapist who is going to be your point of contact for everything.
• 24:39
  SPEAKER_01: And during that time, this is where a treatment plan is developed.
• 24:44
  SPEAKER_01: And so there is structure.
• 24:46
  SPEAKER_01: Uh, for example, I'll give you uh kind of like what's normal.
• 24:50
  SPEAKER_01: Yeah.
• 24:50
  SPEAKER_01: 24 to 48 hours of a client entering a residential level of care.
• 24:54
  SPEAKER_01: We're already meeting with them for an initial uh clinical note.
• 24:59
  SPEAKER_01: This is where I, as a provider and you as a client are sitting down, and you're going to tell me why are you here?
• 25:06
  SPEAKER_01: What's going on?
• 25:07
  SPEAKER_01: Tell me a little bit more about what drove you to make this decision or what drove others to recommend this decision.
• 25:15
  SPEAKER_01: We're also going to contact someone that's significant to you, whoever it is.
• 25:22
  SPEAKER_01: And I rephrased the word family contact and kind of rewarded it with collateral contact, because not everyone, unfortunately, has a family.
• 25:33
  SPEAKER_01: And so someone that's important to you, who I can call when I'm going to need to support to motivate you when you may lack that motivation.
• 25:44
  SPEAKER_01: Within uh I would probably say within three days, at the very most, we do a very comprehensive assessment called a biopsychosocial assessment.
• 25:58
  SPEAKER_01: And it really, it really is what I just mentioned.
• 26:02
  SPEAKER_01: It's it's getting information about the biology, the psychology, and the social aspects of you, where I now I'm identifying specific problems, discussing them with you, and together creating a treatment plan.
• 26:22
  SPEAKER_01: Because not one single day in treatment can go for a client at a residential level of care without having some sort of a treatment plan.
• 26:32
  SPEAKER_01: And I'll take it a little bit further that it has to be a smart treatment plan.
• 26:39
  SPEAKER_01: And by smart I mean it has to be specific, it has to be measurable, it has to be reliable, it has to be attainable and it's got to be timed.
• 26:51
  SPEAKER_01: We don't have the luxury of time, unfortunately, at residential levels of care because they're not months and months of treatment.
• 26:59
  SPEAKER_01: They're a shorter stays.
• 27:02
  SPEAKER_01: And it has to be attainable, which means that if we're going to come up with a goal based on what you feel is needed and identify the problems, we want to be able to attain those in order to motivate you so you can actually take that, like what we spoke about earlier, and step it down now to the next level of care where it can continue.
• 27:24
  SPEAKER_00: So when people search about residential treatment online, one of the big questions is how long am I going to have to stay there?
• 27:29
  SPEAKER_00: And it's never how long can I stay there?
• 27:31
  SPEAKER_00: How much care can I get?
• 27:32
  SPEAKER_00: It's how long do I have to stay?
• 27:34
  SPEAKER_01: It's a great question.
• 27:36
  SPEAKER_01: And it's an it's an honest question.
• 27:38
  SPEAKER_01: When someone uh unfortunately uh succumbs to some sort of an illness and ends up in the hospital, probably one of the first questions they're gonna ask, if they're capable of asking, right, uh, is hey doc, how long am I gonna be here?
• 27:52
  SPEAKER_01: You know, I have things to do.
• 27:54
  SPEAKER_01: All of a sudden, why I'm here is not as important as how long I'm gonna be here.
• 27:59
  SPEAKER_01: And I always used to say, it's not so much the amount of time spent in treatment, it's the quality of time spent in treatment.
• 28:07
  SPEAKER_01: There's been hundreds and hundreds of stats and and research done that proves that the longer a person is engaged in treatment, the better the outcome.
• 28:20
  SPEAKER_01: But it doesn't mean that the level of care that the client is currently at has to be long-term.
• 28:27
  SPEAKER_02: Okay.
• 28:27
  SPEAKER_01: Well, we say long term means all levels of care.
• 28:31
  SPEAKER_01: But typically you will hear the word or the number 30.
• 28:35
  SPEAKER_01: I hear 30.
• 28:36
  SPEAKER_01: People talk about, you know, 30 days of treatment, 30 days of treatment.
• 28:39
  SPEAKER_01: It's almost kind of like if you did 28, you did not do well.
• 28:44
  SPEAKER_01: But if you did 30, you're graduating now and you're gonna be sober.
• 28:47
  SPEAKER_01: And that's not true.
• 28:49
  SPEAKER_01: That's not the case.
• 28:51
  SPEAKER_01: The number 30 comes from that uh thing I mentioned about insurance.
• 28:56
  SPEAKER_01: I was gonna guess insurance.
• 28:58
  SPEAKER_01: That's subtle and obvious.
• 28:59
  SPEAKER_01: They can cover up to a certain amount, you know.
• 29:02
  SPEAKER_01: Um, but typically at a residential level of care, we we would like to service someone anywhere from uh I would say 21, uh, three to five weeks, uh, where 30 is the norm if we're able uh to get that from the insurance.
• 29:27
  SPEAKER_01: And if the client is presenting the need, obviously, where we feel comfortable because the curriculums that are being built in the uh residential levels of care usually take a couple of weeks to actually take effect.
• 29:43
  SPEAKER_01: Uh, you know, uh the therapy itself is not just an overnight thing, but to prepare someone uh at a residential level of care to be able to somewhat function more independently without the severity, takes several weeks uh to actually see some sort of a change.
• 30:01
  SPEAKER_00: So sitting here today, relatively healthy, my rational mind says, wow, what an opportunity.
• 30:07
  SPEAKER_00: You know, as bad as things can get, and that's pretty bad.
• 30:11
  SPEAKER_00: I can go somewhere, I can get intensive care, I can have a lot of therapy, my meds prescribed, adjusted, monitored, all of it.
• 30:19
  SPEAKER_00: That's an opportunity, and I would be so grateful for it.
• 30:23
  SPEAKER_00: There is the other part of my mind that says, I would hate that.
• 30:27
  SPEAKER_00: I would hate group therapy.
• 30:29
  SPEAKER_00: I would hate someone telling me when I have to get up, when I have to go to sleep, what I can bring and what I can't, all of it.
• 30:35
  SPEAKER_00: How do you how much resistance is there?
• 30:38
  SPEAKER_01: Being resistant to that from the beginning allows us an opportunity to try to educate you on waiting to see how it's gonna be.
• 30:49
  SPEAKER_01: Not everyone is big on group therapy.
• 30:51
  SPEAKER_01: Uh, you know, it's interesting.
• 30:54
  SPEAKER_01: Um, most psychologists, even psychiatrists and therapists who are in their early stages of trainings do partake in uh what we call supervision.
• 31:07
  SPEAKER_01: However, sometimes that supervision was done in a group format.
• 31:11
  SPEAKER_01: And I remember my experience, and I said, I am not sitting around in a circle.
• 31:15
  SPEAKER_01: Yeah.
• 31:15
  SPEAKER_01: I'm a man.
• 31:16
  SPEAKER_01: I don't talk about my problems like that.
• 31:19
  SPEAKER_01: You know, my problem is between me and my therapist behind closed doors, kind of thing.
• 31:24
  SPEAKER_01: You'd be surprised at the power of how group interaction actually feeds and elicit information from someone that the that person that says, I ain't speaking in groups, and comes in and says, I'm, you know, I'm not gonna, I refuse to go to group, that's fine.
• 31:41
  SPEAKER_01: Just listen.
• 31:42
  SPEAKER_01: You don't have to say anything.
• 31:44
  SPEAKER_01: And you'll see the power of therapy.
• 31:46
  SPEAKER_01: A good group facilitator in a group modality intrigues.
• 31:51
  SPEAKER_01: But if someone comes into treatment, meaning on the initial call and the assessments, yes, I'm you're I'm willing to do whatever it takes.
• 31:59
  SPEAKER_01: And they come in and all of a sudden they become resistant, that's not uncommon at all.
• 32:06
  SPEAKER_00: So the highest and most intensive form of care is inpatient care.
• 32:09
  SPEAKER_00: What is that and who needs it?
• 32:12
  SPEAKER_01: An inpatient care is normally in a hospital setting.
• 32:18
  SPEAKER_01: I I hate to refer to it as a lockdown unit because that sounds like you're being incarcerated, but an inpatient unit is necessary for someone who is in an active suicidal, homicidal means of thinking, as well as someone who is so cognitively impaired right now that their thoughts are distorted and disorganized, that they are requiring 24 hours, seven days a week, intense psychiatric stabilization.
• 32:55
  SPEAKER_01: In an inpatient unit, there is less of a self-kind of proclaimed decision as to when I'm gonna leave.
• 33:06
  SPEAKER_01: Okay.
• 33:07
  SPEAKER_01: It's not normally doesn't tend to be voluntary, but it can be.
• 33:11
  SPEAKER_01: And I'll give you a a scenario.
• 33:13
  SPEAKER_01: If someone is in our residential level of care and showing signs of decompensation where something is going on, um, it's reported to the therapists uh by overnight staff or nursing.
• 33:28
  SPEAKER_01: This person is isolating, this person is becoming a lot more withdrawn, uh, they look disheveled, they're not being, they're not keeping with their activities of daily living, brushing hair, grooming, all that.
• 33:39
  SPEAKER_01: They're not eating.
• 33:41
  SPEAKER_01: Clear signs of decompensation.
• 33:43
  SPEAKER_01: The recommendation would be to step up, if applicable to the facility, if the facility has that level of care or refer out to a more intensive level of care.
• 33:54
  SPEAKER_01: Even though clients may seem to be kind of out of it, uh, they're willing to go.
• 34:00
  SPEAKER_01: That would be voluntary.
• 34:02
  SPEAKER_01: But once they're in, they have to demonstrate the ability to be able to be stepped down.
• 34:08
  SPEAKER_01: So not everyone requires inpatient.
• 34:12
  SPEAKER_01: Inpatient is a very selective, very specialized type of a unit.
• 34:15
  SPEAKER_01: And it's a short-term unit.
• 34:17
  SPEAKER_01: People don't stay there for a long time, anywhere from three to five days, unless the symptoms are very, very severe and are prolonged, where it requires a lot more medical intervention, even if the client doesn't want it.
• 34:32
  SPEAKER_01: Sometimes it involves aggression and acting out behavior.
• 34:37
  SPEAKER_01: And so there is some sort of therapeutic constraints and restraints uh to protect the client from possibly hurting themselves.
• 34:48
  SPEAKER_01: But it is a very, very intense and a high level of care.
• 34:53
  SPEAKER_00: So, what should someone expect for their own care in inpatient?
• 34:57
  SPEAKER_00: Or if you are saying this person in my life needs this level of care, what should I expect that person is going to get?
• 35:05
  SPEAKER_01: What normally would happen in an intensive inpatient is a lot of psychiatric and medication interaction and uh interventions.
• 35:15
  SPEAKER_01: And so a lot of trials of medications that may be given, uh higher dosages that normal, a lot more intense assessments and uh that human individual one-to-one therapy.
• 35:30
  SPEAKER_01: Um it's short term.
• 35:32
  SPEAKER_01: And because it's short term, the main focus is to de-escalate and take you off of that ledge where we feel comfortable enough that you are no longer a threat to yourself, and through the assessments being conducted, that your cognition, your ability to think is more rational than irrational.
• 35:58
  SPEAKER_00: Okay, so aside from all of those for substance use only, detox.
• 36:04
  SPEAKER_00: What is detox?
• 36:05
  SPEAKER_00: Who needs it?
• 36:05
  SPEAKER_00: How does it help?
• 36:07
  SPEAKER_01: Detox by itself is a medical stabilization unit.
• 36:14
  SPEAKER_01: Detox also has a presence with clinical, meaning you're not just there to lay down and go through the motions in a safe environment.
• 36:26
  SPEAKER_01: Uh, so whatever withdrawals you're experiencing, depending on the on the type of substance that you're uh is in your system, we do want to offer uh a clinical program, which means that sitting around and getting introduced to the idea of prolonging your treatment when you leave detox, that detox is not rehab, detox is medical stabilization.
• 36:52
  SPEAKER_01: There are some types of substances that are used that could potentially, if abruptly, discontinued, cause severe consequences, severe symptoms, even death, alcohol.
• 37:08
  SPEAKER_01: Alcohol is one of the most detoxable substances there is, meaning it's one of the substances that insurances will look at as a criteria for needing a detox.
• 37:21
  SPEAKER_01: Because if you abruptly stop from using alcohol after a prolonged time and heavy use of alcohol, you can go into severe, severe withdrawals and can even lead to fatality.
• 37:37
  SPEAKER_01: Same thing with certain types of benzodiazepins, which are classified as uh xanox or uh clonopin, anti-anxiety medications that, if abruptly stop, can cause cardiac arrests.
• 37:51
  SPEAKER_01: But then you have marijuana and you have the cocaine, and those are not life-threatening.
• 37:58
  SPEAKER_01: You'll go through your withdrawals, uh, depression, anxiety, you know, cravings is number one.
• 38:05
  SPEAKER_01: But you may not need detox.
• 38:07
  SPEAKER_01: But the person who needs detox is someone who has a detoxable substance in their system.
• 38:13
  SPEAKER_01: And depending on the duration and the amount, may require medical supervision to ensure that you are ridding of the substance in your system at the most comfort level possible, while being motivated and encouraged to learn more about your substance use and possibly motivate you to take the next step, which is normally a step down from detox to a residential level of care.
• 38:44
  SPEAKER_00: Told you we're going to do a deep dive.
• 38:46
  SPEAKER_00: So that is our deep dive into levels of care with Dr.
• 38:49
  SPEAKER_00: Sal.
• 38:49
  SPEAKER_00: We will be back next week.
• 38:51
  SPEAKER_00: We're going to continue this discussion and answer some of the other questions that you search for on the internet related to levels of care now that we have established what they all are.
• 39:00
  SPEAKER_00: Please join us.