The defining difference between an inpatient treatment program and an outpatient treatment program is very basic: Inpatient treatment programs have living facilities, and clients remain on the premises 24 hours per day, whereas outpatient treatment programs allow clients to receive treatment during the day and then return home each evening. Inpatient treatment typically provides much more intensive and prolonged forms of care than most outpatient treatment programs. For example, the majority of outpatient treatment programs for substance use disorders typically last 2-3 hours per day. Clients in residential or inpatient treatment programs often receive 4-6 hours of therapy per day.
The benefits of residential treatment are many; however, not all individuals are able to leave their families or jobs for several weeks in order to participate in intensive treatment. Different types of outpatient programs attempt to bridge the gap between the intensity of treatment offered in a residential program and the ability to remain connected with the major areas of one’s life that is offered in outpatient treatment. One of these programs is an intensive outpatient program (IOP).
Why an IOP?
Intensive outpatient programs are designed to provide intensive treatment interventions that are similar to the types of interventions delivered in residential units. The traditional definition of an IOP is one that provides nine hours of treatment per week, most often delivered in the form of three different three-hour treatment sessions. However, different programs offer more hours, depending on their specific offerings; in some instances, IOPs may involve fewer hours of weekly treatment than the average nine hours of care.
The American Society of Addiction Medicine issued a joint policy statement with the American Psychiatric Association and the American Academy of Addiction Psychiatry that defined the basic tenets of an IOP for substance use disorder treatment. Treatment programs that scheduled daily treatment interventions for six hours per day or more should be differentiated as partial hospitalization programs, and the contact hours for IOPs typically range from six to 30 hours per week. ASAM defines IOPs as programs that offer nine hours of treatment or more per week, although there is no minimum weekly treatment duration that is specified.
- An initial valuation: Prior to enrollment in treatment, the individual is thoroughly assessed and evaluated to determine the severity of their substance use disorder and to identify any co-occurring medical or mental health disorders.
- The use of licensed professionals: During treatment in an IOP, a qualified professional is in charge of the treatment (e.g., a physician, psychologist, or some other licensed mental health professional).
- The development of a formal approach A formal treatment plan is developed once the individual has been fully assessed.
- Responsible treatment: The treatment professional or program is held responsible for delivering appropriate treatment and for referring the client to any additional services they need.
- Ongoing treatment: The treatment provider or program maintains contact with the client until recovery is stable.
- The use of adjunctive treatments: Support groups or community groups (e.g., 12-Step groups) can be an important adjunctive component of treatment, but they are not substitutes for formal treatment.
Intensive outpatient programs will typically last a minimum of 90 days, but they can last far longer. In some cases, they may have a shorter duration. Individuals in these programs should also be provided with family services, 24-hour emergency case management services, and formal medical treatments as needed for the individual case.
The 14 Basic Principles of IOPs
The Substance Abuse and Mental Health Services Administration (SAMHSA) has outlined 14 formal principles that are associated with successful IOP programs. These 14 principles are based on the National Institute on Drug Abuse’s (NIDA) Principles of Drug Addiction Treatment. Anyone interested in becoming involved in an IOP should ensure that the specific program of interest follows these 14 principles. The 14 principles are outlined below.
- Treatment is readily available: At one time, the belief in clinical circles was that only individuals who were motivated, relatively well educated, and relatively high functioning (without any significant co-occurring medical or psychological conditions) could be successful in an IOP. The current viewpoint is that any individual can be successful when enrolled in an IOP program, provided that the program follows empirically validated treatment techniques (see below) and is adjusted to fit the specific situation/needs of the individual in treatment. Treatment is readily available for individuals who are willing to become involved in these intensive programs. Other than being motivated to get involved in treatment, there should be few requirements for admission.
- The program should be relatively easy to get into. Eliminating as many hurdles as possible for individuals who wish to become involved in these programs is an important step to ensure the programs will be effective. The current stance on enrolling individuals in IOPs is to make the process as easy and streamlined as possible and to avoid complications, long waiting lists, specific requirements for admission (other than needing to be treated and being motivated to participate in the treatment program), etc.
- The program should use the client’s motivation: Whenever a person freely chooses to be admitted to an IOP, there is obviously some level of motivation that is involved in that person’s decision. IOP programs need to recognize the specific motivating factors for the person that led them to get involved in intensive treatment and build on these motivating factors to help the individual recover. In addition, the program should build on the client’s initial reasons for wanting to be involved in treatment and expand on them to increase their motivation in recovery.
- The program should build on the therapeutic alliance: A crucial factor in the success of any form of therapy is the working bond that the client and therapist have together. The therapeutic alliance describes the amount of commitment that both the therapist and client have to helping the client reach their goals as well as the relationship and respect that both therapist and client have for one another. One of the goals of the IOP program is to build this alliance and focus on it in order to help the individual be successful in recovery.
- Retention is important: SAMHSA, ASAM, and NIDA all report research that indicates that the success of any substance use disorder treatment program is highly related to the amount of time the person spends in treatment. Keeping people in treatment is one of the major goals of a focused IOP. This includes helping individuals work through problems, keeping them motivated, and providing a treatment format that can help them build on and expand their recovery.
- Treatment should be personalized: While there is certainly a general format or blueprint that substance use disorder treatment providers follow, it is also extremely important to ensure that individuals in treatment have their personal needs addressed. Understanding the individual’s personal needs begins with the assessment that is performed before the person is formally accepted into the treatment program, and this assessment process continues throughout treatment. Addressing the individual’s specific needs, such as dealing with co-occurring medical conditions, mental health disorders, family issues, cultural background, etc., is an extremely important facet in a successful substance use disorder treatment program. IOPs should offer clients a general plan of success as well as a personalized treatment approach.
- The program should involve ongoing care: Care should be continuous and ongoing until the individual has completed the program. Treatment providers should continue to provide support and assistance even after an individual has completed any formal therapy. Individuals in recovery from any substance use disorder often require many years of some type of involvement in a formal recovery program, and this should be provided.
- The program should monitor the client’s abstinence: Individuals in treatment for substance use disorders obviously need to abstain from using drugs or alcohol. It is extremely important for treatment providers to objectively monitor abstinence, particularly for individuals in IOPs. This often means using random drug tests like urine tests to ensure clients are remaining abstinent. This provides motivation for clients as well as an objective record of treatment success.
- Support groups should be used: Support groups, such as 12-Step groups, community-based groups, volunteer groups, etc., can be extremely useful for individuals in recovery from any type of substance use disorder. While they are not the primary treatment delivered in an intensive outpatient program, treatment providers are encouraged to use support groups as an adjunctive form of treatment. Treatment providers should either strongly suggest or require that individuals attend at least one type of support group in addition to their participation in the IOP.
- Medical treatments should be used when indicated: Even though the major focus of substance use disorder treatment is some form of substance use disorder therapy, many clients require medical treatments (e.g., medications) in addition to therapy. Therapists should partner with psychiatrists, addiction medicine physicians, and other physicians to ensure that proper medical treatment for the specific needs of the client is provided while the person is in the IOP. Therapists should be able to provide referrals for individuals who need medical assistance.
- Psychoeducation should be available: One of the major components of any treatment program should be an educational program that helps the individual understand the nature of substance abuse, the nature of recovery, and the facets associated with relapse. Therapists and physicians should provide education to individuals in treatment regarding the latest theoretical information about substance use disorders.
- The program should involve social support: Individuals in recovery should not feel as if they are alone. IOPs should engage the client’s family members, friends or peers, and even employers in the individual’s recovery program. A concerted effort should be made to get as many people on board as possible and to support the individual as they go through the difficult task of recovery from a substance use disorder.
- Evidence-based treatment approaches should be used: Treatment should not be haphazard or based on unsupported beliefs. Instead, IOPs should focus on treatment interventions that have significant research support to justify their use. Using empirically validated treatment approaches for substance use disorders has been demonstrated to produce far greater success rates and far less trial and error in recovery.
- The program should focus on continued improvement: Intensive outpatient programs should endeavor to improve all facets of their operation in order to make them run smoothly, increase success rates, reduce instances of relapse, and provide empirically validated and personalized treatments for their clients.
Who Might Best Benefit from an IOP?
Anyone can benefit from becoming involved in an intensive outpatient program. Most IOPs are designed for individuals who could benefit from a residential program but cannot attend one for some reason.
- Have just been released from a residential treatment unit or partial hospitalization program and still want or need intensive treatment
- Need intensive treatment but cannot afford residential or partial hospitalization treatment programs
- Have co-occurring disorders or a dual diagnosis (a psychiatric diagnosis and a substance use disorder)
- Have attempted recovery numerous times and relapsed, and need more intense treatment
- Deal with significant stressors on a daily basis and need more focused treatment to assist in their recovery
- Have significant domestic issues, such as abuse issues, other members of the family who use drugs or alcohol, issues with unemployment, etc.
- Do not have well-established social support groups
- Lack confidence in their ability to recover from their substance use disorder
Some individuals who have very severe co-occurring mental health disorders or extremely toxic environmental conditions may not be suited for an IOP.
The decision as to whether a person should enter a residential program or an intensive outpatient program should be jointly made by the client and the treating physician or therapist during the initial assessment process.
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