Levels to the Game - The Different Types of Mental Health Care

What up, Cadre fam? Evan here, your resident mental health and addiction therapist. So we're doing a live session, and I wanted to choose a topic. And one of the questions I commonly get, whether it's for mental health or addiction, is, okay, what happens when I get an assessment? Let's say I go to therapy. What's the outcome? Let's say I get a diagnosis. Let's say I'm doing a chemical health assessment. What actually happens, especially for addiction? Well, am I going to go to treatment? Am I just going to be able to do therapy?

And often people come in and especially with therapy, like, well, I'm here to do therapy. And most of the time that's what we do. We do an assessment. But sometimes maybe somebody doesn't know what's best or what would be most appropriate for them, or they think something like therapy would be most appropriate. And as we do the assessment, it's like, hey, maybe given what you're going through right now and what you're struggling with, perhaps we need more, or that you would need more support based on my recommendation, right.

Or maybe somebody goes to a higher level of care, like a treatment, and maybe they do an assessment and the opposite happens, saying, hey, you know what? I don't think you'd be appropriate for inpatient treatment. However, something like outpatient, maybe that would be more appropriate for you. But then the question is, all right, well, what are the possibilities? What is the lowest level of care? So we call it the level of care and what is the highest level of care? Right. So I thought what I would do is go down and break down all of the different levels of care and the possible recommendations, at least generally, right.

Because there's all sorts of different programs and it's not always so evenly cut, but there are some general levels of care that are pretty universal, at least, like, throughout the US. And maybe this could help, you know, what resources are out there, the different levels of support, and it maybe could prompt you to say, oh, okay, that sounds like something that would be helpful. Maybe I'll look into it. Or maybe it's for a loved one. Right? A lot of people want to know what options there are for a loved one struggling with addiction or mental health.

So let's break it down. And I think we'll start from lowest level to highest. And another way we call it or refer to it is a restrictive option. So what we do kind of the ethics is to provide or recommend or at least offer the least restrictive option possible. Right. The least restrictive option. So we start, let's say, right now at the least restrictive and go up from there. And the thing is, like, when I make a recommendation, it's not always black and white. Now, some people have more of a style of, okay, this is the recommendation.

This is what you do, and this is the recommendation that I'm giving. And that's that versus what I try to do as much as possible is say, I think you could be appropriate for this. But also this here, let's discuss the pros and cons of this higher level that's maybe more restrictive. I don't love that term because restrictive isn't good, but let's say more supportive or less supportive. Um, you know, so it kind of changes the dynamic based on that language. So let's start with the least restrictive or the lowest level of care, which would be nothing.

I don't know if people usually refer to nothing as a level of care, but I guess technically it is, right? So let's say somebody comes in for an assessment or they want to do therapy. I don't know if I've ever done this, per se, but let's say someone comes in and they're like, no, I'm feeling pretty good. Yeah, I don't have any issues. Okay, well, then there's not much that we could do, right? There's no point. How helpful is this? Right? So technically, I could recommend. No, you seem to be all right.

Just go on your merry way and if things start to become more stressful or struggle or you feel like you could benefit from talking to someone, come on back. So. But, you know, if someone's coming for therapy, there's usually a reason for it. And even if it's not something huge, it's still sometimes, all right, let's do a few sessions and see how it goes. And then maybe from there, then the recommendation. So it may not be off the bat, but often I'm working with a client for a while and they're like, no, I'm doing really well.

We went from once a week to every other week. Now, the recommendation is nothing. So that in and of itself is an option, is not having any services, which makes a lot of sense. And then I would say the next one is doing something like individual therapy, your classic therapy. So people come to my office and they're seeking therapy, and that's the recommendation. All right, let's do every week. Sometimes for folks, it's like, let's start it every other week. Usually with people, I try to start it every week just to kind of build that foundation, and then maybe after a few months, then look at every other week.

But for the most part, there's this spectrum, or what we call it, just a, I'm blanking on a good word, a span of what is appropriate. Right. There's kind of boundaries. They're like, okay, this person may be appropriate for nothing all the way up to outpatient therapy. Individual therapy. Anything more would be excessive based on where they're at. And anything less, we can have less than nothing. But this is a window. There we go. A window of what's appropriate. So let's see. Well, where do you want to go in this window?

I leave that to you. I'm recommending once a week we could do every other week. Maybe they want to do more than once a week. Usually I kind of push folks away from that, but, you know, sometimes it's a little much. But for some folks, maybe really need that and maybe for a short period of time. Okay, let's do that. Until you start feeling like maybe you're out of a crisis or something like that. Right. So that's that lowest level of care, just doing individual therapy once a week, every other week, whatever that may be.

Right now, let's say somebody is really struggling. Let's say we start on that level and that person doesn't feel like they're getting better, and they continually are feeling like they're in survival mode, crisis mode. And, you know, I don't want to just keep doing services that are not helpful. Right. And would actually be considered unethical for me to provide services that are unhelpful. And so maybe then the recommendation would be something like an outpatient group. And this could take many different forms.

Let's just call it outpatient. Sometimes it's intensive outpatient for addiction, and there's different groups. Maybe there's a group that meets something like dialectical behavior therapy. And for some of those groups, maybe it's once a week you do a group, and once a week you do individual along with that. Sometimes for that higher level of care, that person will continue to see me while doing the group. Or we say, all right, look, go do this group. See how it goes when you're done, then come back.

And that's happened a lot because these recommendations change based on where you're at. So these things are always evolving, right. With the hope that we could go less and less and less restrictive to the point where individual therapy isn't necessary or wanted. Sometimes I have people who, let's say we get them to that point. And they still find benefit, even though they're in a much better place. Like, okay, maybe we'll just check in once a month, or we'll check in and they still find benefit, even though maybe it's not, like, necessary, but it is of benefit.

Kind of like a massage. I look at it like that, where, you know, maybe you don't need it, you don't have sore muscles or an injury or something, but massage feels good and it makes you feel better and improves the quality of your life. So, you know, it doesn't always have to be this, like, medically necessary, although the insurance company would see it otherwise, which is a whole nother story. But a lot of that is important to talk about because a lot of it, right, is based on insurance regulations, too, where you have to make the case for why this person needs services and why the insurance company should have to pay for it, why this is medically necessary, right.

So if I'm recommending something that's above and beyond, right, that costs more and they're not going to want to pay for it. So I have to make the case for whatever it is and why that is appropriate. So we have that like outpatient. So when we say outpatient, that means you're like, not living there, right? Like inpatient, you're inpatient treatment, you're living there temporarily. You're like a hospital. Be considered inpatient if you're staying overnight, anything with a bed. So, you know, so those outpatient groups can take many forms, like once a week.

Now, a classic, let's say intensive outpatient for addiction, may, 3 days a week, 3 hours, right. So sometimes it's in mental health called like a day program, they call it. Yeah. And then we'll talk about another form that's higher than that. But, yeah. Intensive outpatient, a day program once a week, right, where you have a mix of individual and group. So usually those higher levels consist of a group therapy and sometimes, too, on the individual counseling. Like I started offering a group for a lot of my clients just as an added bonus, because I think sometimes, even if you're doing individual therapy, even at that lower level of care, there is advantages of having a group dynamic and support from a therapeutic standpoint.

So I think that's something that could always be helpful. I don't necessarily recommend every client to do group, but for some are would really benefit, and then therefore I recommend that. So, you know, that's our outpatient level. Now, there's another type of outpatient that is a little bit more intensive, supportive, and that would be what's referred to as like a partial hospitalization. And basically that means it's like a day treatment, partial hospitalization. That's usually every day, you know, that's kind of like you're in the hospital, but you live at home, you're coming in every day.

And sometimes the groups are mixed where someone's in inpatient, and then when they leave, they still go and do that group. But often it's just, you know, folks who need quite a lot of support, but maybe it's not necessary for them to be in that restrictive option where they're staying in the inpatient setting. Right. So that would be just like an even more intensive form of outpatient, which they just happen to call partial hospitalization. So when I hear that, I'm thinking, okay, you're probably going more like 20 hours a week or close to that than like 9 hours a week.

So often that is people for partial. Often it's folks who are coming out of that hospital based setting, whether it's a, you know, inpatient psych unit, you know, more of a crisis type situation. A lot of times those folks will transfer down in level of care to a partial hospitalization. Then after that, then we're starting to get into inpatient realm and probably the next level of inpatient writing. So we're talking about mental health and addiction. Sometimes it looks a little different for each, but they kind of have these comparable levels of care.

And you just call intensive outpatient versus day program kind of the same thing. Partial hospitalization, they have that too, for addiction, but maybe even a more intensive outpatient, which is more hours, but sometimes those addiction, hospital based will still call it that. So now we get into inpatient, and typically you're going to see this more with addiction than mental health. Right now, if someone has pretty severe mental health, there are programs, let's say, for eating disorders that are inpatient, like severe depression.

You know, they have these, but a lot of those for mental health are going to be hospital based, whereas with addiction, you have plenty of those hospital based. But the, they're more like the classic treatment centers you hear about on tv and the movies where you go, I'm Bill, I'm an alcoholic. Right. And those are often private, like something like, it's a nonprofit, but something like Hazelden. That's like a well known one. Passages Malibu or what other. There's just the Karen. There's just a ton of them.

Every state pretty much is going to have programs like this, um, that, you know, for folks who have more severe addictions is a good option and recommendation because a lot of people have more severe addictions struggle in an outpatient setting. A lot of times we try that first, and insurance makes you try that first, even though we know this is very unlikely this person will be successful, sometimes they surprise you. But if someone's in that outpatient level of care and they relapse, and often they get recommended to the residential setting with the hopes, we're always hoping that we can bring down that level of support for them and make, you know, make these services less intrusive.

Maybe they don't feel intrusive for everyone, but, you know, it's like you got a life, you want to go. You know, you could spend those hours doing other things like work, because a lot of times you can't work while you do these things. You have to take time off while you're getting these services. So how can we, how can we make mental health interventions as least restrictive, as least intrusive, as least intensive as possible? Those are inpatient settings. Again, you see that here in Minnesota we call them residential.

We actually differentiate inpatient from residential. Residential treatment would be kind of what would classically be referred to as inpatient. But here in Minnesota, inpatient is usually that higher level of care of, let's say a psychiatric inpatient unit. Right. More of like a crisis stabilization type unit because, again, you don't have a lot of like, we don't like in Minnesota, we don't really have too many residential mental health programs. Now, we do have, we do have some for adolescents.

Sometimes they're like corrections based, which can be interesting. But for folks with a lot of legal issues, troubled teens, as they would once say. But for teenagers, let's say you struggle with self harm. They have programs and they usually tend to be a little shorter as well. The addiction ones, typically a month plus these may be a few weeks of doing a mental health inpatient for adolescents. And I think they may have that for adults as well. So there are some programs here, but they're a little bit more rare.

They tend to be more outpatient or that, like more severe crisis intervention, which brings us to the next level of care of like inpatient. Right. So you know what they used to call the psych ward or something like that. Right. We'll try to call it an inpatient psychiatric unit. And that often is there's a higher bar to get there. Right. They don't just take anybody even a lot of times I, I believe someone needs to go but then they go to the hospital and they deny them because they're not intensive enough.

And then they say, well, just go get your meds stabilized and go see one of our providers. You don't need to be here, because really, the bar for that is like, are you unsafe? Because once you go into that unit, right, you're placed on a 72 hours hold, where you're legally required to be there, signed off by a doctor, by a psychiatrist, typically, or a nurse practitioner, where they say, no, you can't leave even if you want to. This is a locked unit, even if you go there voluntarily. And then you want to leave, that's up to the doctor.

If they want to let you go before that 72 hours hold. And the purpose there is just safety. But also you get services. Sometimes they have groups, they have social workers, they have, you know, doctors, right. In order to, let's say, let's get you on the proper med regime and, you know, let's get you some outpatient services, whatever. Let's hook you up with a therapist. Let's get you in our day treatment program. And really, the goal is to have them there is less, as little as possible from the standpoint of, well, we don't want to be intrusive on your life, because nobody really wants to be here wearing scrubs and have every minute dictated for them for the most part.

But then also, it's more expensive. As you go up the levels of care, it gets more and more expensive. So the burden, let's say, on our healthcare system or insurance companies. So that is that highest level. Now, what does that look like for addiction? That would probably be more like detox would be the equivalent, right? So someone's coming off of alcohol, a benzodiazepine, and opiates, those are the ones you see the most because they have the worst withdrawal symptoms. And for benzos like Xanax, Klonopin, and alcohol, they actually.

They work on the same brain receptor, so it's actually very similar. And for both of them, you have severe withdrawals that can lead to seizure and death. Those are the only substances because the opiate withdrawal is h*** on earth, but it's pretty probably not gonna kill you. It's not typically considered lethal, but those are. So now, it used to be for detox, and you still can get in, say, around here for opiates, but they prioritize alcohol. A lot of times, they won't let you in. We're not taking any more opiate admissions right now, because with opiates, we have medications like Suboxone, where instantly it's gonna snap you out of withdrawal.

Now, there's some cases where many people are so severely, but it's. It will significantly reduce or get rid of your withdrawal. And if you just give people those medications. Right. The problem is you're sending them on their way and not necessarily giving them an assessment to get the appropriate services. So sometimes it's good to go there and destabilize and get off the withdrawals and get an assessment and then go. Because if you're that addicted to opiates, just an outpatient level of care may just not be enough.

So a lot of people slip through the cracks if they just go and don't get an assessment and they just throw some meds at them. But for, like, the purpose of general safety, right. It's not particularly unsafe. Now, you could, I would probably argue that, you know, with Opie's, especially now with the opiate crisis with fentanyl and just the sheer amount of overdoses, to just send someone without services, right. Especially if they're doing heroin or fentanyl, then that is a danger right. Now. A lot of people are out there doing it.

We don't lock all of them in an inpatient because of how dangerous it is. But, you know, the more services we could get for those individuals, the better. Right. So that's really the highest levels of care. Right. So we have this broad spectrum of different levels of care. And so when I do the assessment for folks, often they're on the border of one or the other. Right. So it's usually, hey, the least intensive right now we could do for any addiction substance issues you have is we can do individual therapy and let's see how it goes.

Or we could do outpatient. Hey, this would be really beneficial. It would be more. Be more intrusive. But, you know, I don't want to say if you're really serious, then maybe serious. But if you really want to address this to a higher degree, I can make the case in my assessment because I write that up here, the recommendations. And usually I base that recommendation off of what you want. Right. So if you say you want an outpatient, okay, I'll write that in the assessment. Or maybe I write for my own sake.

Client would benefit from outpatient treatment or individual therapy. Client prefers client preferences to do individual therapy. Therefore, this is the recommendation. So I try to tailor that as much as possible because I believe that to be more of a client centered approach. Right. I don't want to recommend something that you don't want to do. Sometimes you got to do. Sometimes you don't have a choice where you're like, sorry, I can't make the case for you to go to outpatient. It would be unsafe.

It would be unethical for me to recommend this, something that, you know, if I really believe that this is not going to be successful again, you could prove me wrong. Anyone could prove me wrong. Right. But we're playing the odds here, the safety game. So. Yeah, so I want you to be able to decide. I want you to have buy in to the process. Now, sometimes I do these, like, legal assessments, folks who have duis or people in custody cases, right, who have every incentive to, and they just don't want to do anything yet.

They may have a problem, they may not, but oftentimes they really just don't want to do anything. But the services may still be warranted. So what do we do there? So I try to get them as much buying as possible. I try to offer that lowest level, and sometimes they don't even want that. And sometimes I just got to be, you know, I tried, man. I'm sorry. I can't not recommend this. Right. We have, let's say with addiction, we have severity levels, right? We have the six dimensions, and that is withdrawal, medical complications, mental health, probability of relapse, and your environment that you live in.

And that's just a simple way of breaking it down. But then you get a score one to four, and there's criteria for each one. So it kind of takes a little of the pressure off us. Addiction, sorry, I can't recommend. Here are the numbers. I just can't, you know, and they're like, oh, if you can't do it, he can't do it, right? So it takes a little pressure off of us. But, you know, there are some very specific guidelines and criteria, and it's not just like what I think, you know, but I'd say they line up pretty well, you know?

And again, it's not black and white. There is some gray area there. There is some clinician discretion you can make, just like with diagnosing. Right. And that's another big part of that is diagnosing. And what is your diagnosis? And some diagnoses warrant more services than others. Typically with mental health, there's a lot of that gray area. So it's never black and white. It's never. This is what's going to happen. Unlike, let's say, you have a certain cancer. We're just like, there's nothing we could do.

You're in hospice. There's nothing we can do. This is just going to run its course. And that's an inevitability where with mental health, it's not necessarily the same. It's just probability. Now, that probability could be so high, but it's never, I'm trying to think, like, off the top of my head of, like, what would be 100%. I can't think of anything where it's like, this is what's going to happen. It's more like, this is what's likely going to happen. And probability is probably there's a 95% chance that this level of care where I just send you off is not going to be successful.

95 out of 100 people, people would not be able to reach those goals of symptom remission by not doing this. You know, with the human behavior, the complexity of the mind, it's less black and white. So, you know, we have these different measures that, you know, guidelines that we have to follow. But for those clients who really don't want it, kind of going back to that on a little tangent, but for the clients who, like, really don't want, there's still a level of responsibility that I have and regulations that I have to go by, you know, especially for those legal assessments where people tend to be more resistant, because a lot of times, you know, I have a lot of power, whether I want it or not, that sometimes people, like, kind of are, have to follow the recommendations.

Right? Like, okay, if you want your kids back, if you want parenting time, you have to follow the recommendations of the chemical health assessment. So whatever I recommend, they kind of have to do. They don't have to do anything they don't want, but there's consequences for doing that. Now, what I tell folks as well is that you could always get another one, just like you could get a second opinion if what I'm saying to you, and I believe it, if what I'm saying to you makes no sense, if you don't agree, because I'll tell you the justification of why and why I have to do it.

But again, there's that gray area. Maybe you could go to a different clinician and they'll give you a different answer. So a lot of the assessments that I do, let's say, for a family law case, are, are ones that they've already had multiple assessments. So it's like, I'm kind of like with those, I'm kind of the last stop on the road. You've already had a couple of them, and you can't really appeal like in court and they're probably literally in court, you can only appeal so much. But again, I really believe that I'm trying to follow those guidelines of least restrictive more than other assessors per personally, I believe that I tend to get, I've read other assessments, I tend to give more options and I try to be more client centered but I could only do that to a certain point.

But anyway, I hope that yeah, I hope that highlights I hope that maybe helps you understand the system a little better so that you could better navigate it to find the services appropriate for you to find the services appropriate for your family member or friend. Yeah. If you have any questions, feel free to drop it in and I don't know, maybe I'll do a video on this. Let me know if you want that. Anyways, folks, it's been real as always and I hope to see you soon. Next week I'm out of town, but the following week.