Intensive Outpatient Programs for Alcoholics
People with differing levels of severity of an alcohol use disorder will often require different levels of treatment. For instance, individuals with significant medical needs or requirements and a comorbid (co-occurring) alcohol use disorder may require inpatient treatment; this can include individuals who need to be placed in a supervised withdrawal management program for severe alcohol withdrawal. Other individuals may require intensive treatment and supervised living facilities, but may not require 24-hour medical care or monitoring. Then, there is a group of individuals who do not require placement in a supervised living facility, but still need the type of intensive treatment that is given in treatment environments that also provide living arrangements for clients.
Basically, the level of care provided to individuals who need intensive treatment for alcohol abuse can be divided into several major categories.
- Inpatient treatment consists of intensive treatment for an individual’s alcohol use disorder as well as 24-hour medical monitoring of other conditions. Inpatient treatment is typically provided on a hospital unit or in a clinic that specializes in this type of treatment where the clients stay. Medical personnel are available around the clock.
- Partial hospitalization programs bridge the gap between inpatient and residential treatment programs. These individuals attend intensive treatment services in a clinic or hospital during the day and then go to some other supervised living facility that is close to the hospital or clinic after treatment is completed.
- Residential treatment consists of intensive treatment in a setting where the individual also lives; however, these individuals do not require 24-hour medical management or monitoring. Medical services are available, but medical personnel are not on site 24 hours per day.
- Intensive outpatient treatment programs (most often abbreviated as either IOT or IOP) provide the same type of intensive treatment services that are delivered in inpatient units and residential units, but individuals do not live on site. Once treatment is completed, the individual returns to their normal living routine as with any other type of outpatient treatment service.
- Standard outpatient treatment programs provide far fewer hours of treatment than IOPs. Many individuals who are in IOPs, residential treatment, or inpatient treatment units will eventually transition to standard outpatient treatment.
Who Is Appropriate for an IOP?
Essentially, anyone will benefit from involvement in an intensive outpatient program. Individuals who are relying on insurance benefits to cover the cost of their alcohol use disorder treatment or who must pay out of pocket for the entire cost often need to weigh the cost and the benefits of the treatment. The types of people who will benefit most from being involved in an IOP include those who:
- Are being released from an inpatient treatment program, a partial hospitalization treatment program, or a residential treatment program who still require intensive treatment services but are deemed safe and able to care for their own needs outside of a supervised environment
- Require intensive treatment for their alcohol use disorder but are unable to afford the cost of inpatient, partial hospitalization, or residential treatment
- Have a history of numerous relapses
- Have co-occurring disorders (dual diagnosis) of an alcohol use disorder and some other mental health disorder, such as a major depressive disorder, an eating disorder, a personality disorder, some other substance use disorder, etc.
- Have some significant environmental stress that can potentially interfere with their recovery, such as issues with domestic abuse, drug use within the individual’s family, lack of a strong peer or support group, etc.
- Lack confidence in their ability to benefit from standard outpatient treatment protocols and desire more intensive treatment, but did not wish to be placed in an inpatient, partial hospitalization, or residential treatment program
The decision to engage in an intensive outpatient program or inpatient treatment is often made by the individual’s supervising treatment providers on the basis of their ability to function outside of a supervised living facility, benefit from intensive treatment services, and afford the services in question. Typically, the supervising physician must demonstrate that the treatment in an inpatient or residential type program is a medical necessity before insurance companies will authorize coverage. For instance, an individual who has a very complicated withdrawal syndrome from alcohol may require inpatient treatment initially as it would be medically necessary to monitor the person around the clock; however, an individual who only has a mild level alcohol use disorder without significant withdrawal symptoms and no complicating factors may not require close supervision outside of the treatment environment.
Insurance companies often have very stringent criteria that must be met in order for an individual to be placed in these more expensive treatment facilities. Using an IOP can get an individual the type of intensive treatment they need, satisfy the insurance provider and treatment providers, and offer a viable compromise in cases where medical necessity may be questionable.
What One Should Look for in an IOP
Both the National Institute on Drug Abuse (NIDA) and the American Society of Addiction Medicine (ASAM) provide and describe the standards for the different levels of treatment and the principles of effective treatment for substance use disorders, such as alcohol use disorders. According to ASAM, the definition of an IOP is an outpatient program that provides a minimum of nine hours of treatment per week (no maximum) and allows the individual to return home after treatment is completed. Thus, the first standard that an individual should look for in an IOP is that it meets this minimum treatment requirement.
Other specifications that are used to define successful treatments as determined by both NIDA and ASAM include the following:
- Prior to being placed in any treatment program, the treatment providers should perform a thorough assessment of the individual, including a thorough physical assessment, psychological assessment, and an assessment of the individual’s social conditions, or be able to refer to the results of a recent assessment that has been performed by qualified healthcare professions. This can help to identify the specific needs of the individual and the appropriate treatment for those needs.
- The intensive outpatient program should rely on evidence-based methods and procedures. These are treatment protocols that have been demonstrated to have success by research-based evidence.
- Treatment programs should mainly rely on the use of licensed professional treatment providers for formal treatments. Adjunctive personnel should be used sparingly.
- There should be a formal treatment approach, and the treatment plan should be developed to fit the needs of the individual. Treatment for an alcohol use disorder generally follows an overall plan or blueprint; however, each person is different. An extremely important factor in the success of an IOP is to follow the empirically validated treatment approach, but to make sure that it is individualized to suit the specific needs of the individual.
- There should be a sense of responsibility held by the treatment provider. The treatment provider should be held responsible for developing the treatment plan and delivering the appropriate treatment to the client.
- The treatment should be available for the client. It is not productive to put individuals on waiting lists. The individual should be able to get into the IOP without experiencing significant complications, such as having to wait for weeks or months, fulfill certain requirements, etc. Successful treatment should be readily available.
- The level of motivation that the individual displays can help to facilitate the progress that the person experiences in treatment, but research has indicated that individuals who are forced to attend treatment for alcohol abuse or other substance abuse have similar success rates to individuals who voluntarily enter treatment. Simply getting them into the treatment program is the main goal.
- Treatment programs should focus on keeping the person in the program. Research has also indicated that there is a positive relationship between the time an individual remains in treatment and the overall success rates of treatment.
- Treatment programs should concentrate on the use of alcohol use disorder therapy. This can be delivered on an individual therapy approach, in group therapy, or in a combination of individual therapy and group therapy. Psychotherapy for substance use disorders is the mainstay of any treatment program.
- Successful treatment programs work with the individual’s level of motivation to produce positive treatment outcomes. This means that a successful IOP would concentrate on the individual’s strengths, help to strengthen their weaknesses, and use positive reinforcement and encouragement over the use of punishments and sanctions (although these can also be effective in the right cases).
- A crucial factor in successful treatment outcomes is the development of the relationship between the client and their treatment providers. This is often referred to as the therapeutic alliance in psychotherapy. Successful treatment providers show respect and positive regard for clients, and therapists and clients work together toward a set of goals that are mutually agreed upon.
- Supports and assessments should continue even after the individual has completed the IOP. Individuals should be provided with appropriate referrals and aftercare once the IOP is completed.
- The intensive outpatient program should also provide accessibility for the client to participate in social support groups, such as Alcoholics Anonymous. Social support groups are not run by licensed therapists or medical personnel, but can help to increase the effectiveness of the IOP.
- The IOP should be operating in close conjunction with some medical treatment provider, such as an addiction medicine physician or psychiatrist. Medically assisted treatments should be available when needed.
- The intensive outpatient program should also have strong connections with a medical facility to deal with medical emergencies. Individuals in an IOP who need immediate medical attention should be able to get it without delays.
- The IOP should have a significant educational component to it that allows individuals to learn about substance abuse in general, alcohol use disorders, etc.
- Intensive outpatient programs should engage the individual’s family, friends, and peers in treatment when possible. Efforts should be made to get people who are close to the client involved in their treatment program. This can facilitate the overall success of the program.
- The intensive outpatient program should have some objective method of monitoring the client’s abstinence from alcohol. This often means the use of random urine or breath tests. Many individuals do not like this stipulation; however, keeping clients in IOPs accountable can increase the effectiveness of the program quite dramatically.
- The administration of the program should operate in a manner that allows the program to run smoothly and concentrate on helping the individual remain abstinent from alcohol.
Most intensive outpatient programs will last for 90 days, although they can certainly continue for far longer depending on the needs of the individual as well as their insurance coverage and other variables. IOPs often do not focus on complementary and alternative treatments, such as art therapy, music therapy, etc., but may include these. Complementary and alternative therapies can be useful adjunctive treatments to medical management, psychotherapy, and social support group participation, but should not be the main focus of treatment.
The focus of the treatment in an IOP should be on psychoeducation, psychotherapy or counseling, and social support for the client and the continued use of medically assisted treatments when appropriate. IOPs that consist of concentrations on complementary and alternative therapies should be avoided in favor of those that concentrate on empirically validated treatment approaches.