Levels of Care in Mental HealthCare

Many people think of two things when they think of therapy: traditional outpatient therapy, where you meet one-on-one with a therapist, or inpatient therapy where you are admitted to a hospital for safety reasons. However, there are actually several in-between options that may be a good match for your needs depending on the “dose” of treatment you need. The more severe the symptoms and the more impairment the symptoms cause, the more likely a higher level of care will be indicated to best help you get better. 

A “Needs Assessment” usually refers to the kind of assessment done by a mental health provider, specifically in higher levels of care, to ascertain the “needs” of an individual seeking services. This assessment will include a recommendation for the level of care indicated for that client depending on a variety of factors including severity, duration, and intensity of symptoms, and level of distress and impairment caused by those symptoms.

​An outpatient mental health care provider may recommend a higher level of care for their clients if they are concerned that they need a greater “dose” of therapy, if they are concerned about their client’s safety, if treatment progress is limited or stalled, if there is evidence of a significant deterioration of functioning or increase in symptoms, etc. Higher levels of care may afford greater support, especially outside of normal business hours, access to a diverse interdisciplinary team of professionals, access to community resources, etc. The goal would be to “step down” care back to outpatient services once the client is feeling better.

Levels of Care

Outpatient Treatment: This is the most traditional level of care and will fit most people’s needs. Usually in this setting you see a mental health therapist once or twice a week for between 40-53 minutes or a medication manager (e.g., psychiatrist, primary care physician, nurse practitioner) every few weeks to few months. Examples of outpatient facilities include private practices (groups of providers or providers who work independently), community mental health centers, outpatient behavioral health services through hospitals or healthcare centers, etc. There are also varying degrees of support offered through outpatient centers/resources.

Some facilities are able to offer something sometimes referred to as "wrap-around services." This means that the outpatient facility offers various forms of outpatient services to help support the individual such as traditional therapy, medication management, therapy groups, on-call crisis services, etc. 

Intensive Outpatient Programs (IOP): At this level of care, client’s would attend a therapy program anywhere between 3-4 hours a day, sometimes only a few days a week. The therapy program might include group therapy, psychoeducation presentations, meetings with an individual therapist, meetings with a psychiatrist, and an experiential component (e.g., music therapy, art therapy). At this level of care you go home at the end of the day and your participation is voluntary. 

Partial Hospital Programs (PHP): This level of care is very similar to an IOP settings (and most of the time client’s start in a PHP and then “step down” to an IOP setting within the same location and program). With this level of care a client might attend anywhere between 5 and 6 hours a day, 5 days a week. At this level of care you go home at the end of the day and your participation is voluntary. 

Residential Treatment: This level of care is similar to PHP programming; however, the client’s sleep on a unit in the program and programming might last a little longer throughout the day. At this level of care you don’t go home at the end of the day and your participation is voluntary. 

Inpatient/Acute Care: This level of care is reserved for situations where a client’s symptoms are severe enough that the person’s safety or ability to function are at risk, and therefore the person needs to be closely monitored. This might also include situations where a client needs to make drastic changes to their medications and therefore need to be monitored closely. This is a short-term treatment, and the person is usually “stepped down” to a PHP/IOP program as soon as possible. At this level of care you don’t go home at the end of the day and a person's ability to end treatment is sometimes partially determined by the attending physicians.

It's also important to note, that specialized services (e.g., addiction services) might have an even more diverse range of levels of care services.

What is Happiness?

Happiness is a word we use almost constantly in our daily language.  We are bombarded with advertisements promising that we can pay money to buy this item or go on this trip to be happy.  It is something that we have aspired to for so long, and yet what does it mean to be happy?  Is it a state of being?  Or is it an emotion?  What are your thoughts on happiness?  How permanent of an experience can it be?

According to Harvard professor Daniel Gilbert, “We all want to live happily ever after.  To experience more pleasure than pain.  More delight than despair. More joy than sorrow.”  There is so much truth in that statement, we don’t want to sign up for struggles, however struggles will happen anyway and we just want the good to outweigh the bad.  The reason it can be important to consider how permanent happiness is for you personally, is because it can change your relationship with the idea of being happy.  If you believe that happiness is an emotion, than you would also believe that it cannot exist all the time.  It would have to make room for all of the other emotions that are part of everyday life.  On the opposite side of that spectrum, if you believe that happiness is a state of being, then you may believe that it is an overall contentedness with life and less of an immediate experience.  What do you believe?

So once we define what happiness is for ourselves; how do we encourage happiness in our lives?  One of the first places to begin is by figuring out what we value in our lives.  Everyone has values that are a little bit different, so it is beneficial to consider which ones matter most to you.  Do you really value independence?  How about family?  Peace?  Love?  Wisdom?  Relaxation?  Safety?  Beauty?  Adventure?  If you are looking to find a list of possible values, try searching for a Values Clarification worksheet.  There are a number of them online that may help you to determine what they are for you. There is also a helpful article written by one of our wonderful clinicians, Dr. Pamela Heilman, called Let Your Values Be Your GPS.

There is no wrong answer when it comes to the values in our lives, they just are.  Once you have an idea of what your personal values happen to be, consider which ones are present in your life right now.  Which values are you missing?  Think about ways you better add those values into your life.  If you know the things you feel strongly about or value, you can feel a greater sense of fulfillment and overall contentment.

Another important factor that plays into our overall happiness is our social support.  Humans have thrived because we are connected to one another and don’t do well in isolation.  For many people, the pandemic has worked to further isolate us from the people we care about.  Having friends, family, and/or overall connections with others is very important to our wellbeing.  Give some consideration to how much time you are spending with the people in your life who are supportive to you or even just share similar interests with you.  We have more ways to connect with others than we ever have before, it is just a matter of using them.

No one can tell you how to be happy, it truly is something you must seek for yourself.  By understanding your own definition of what happiness means, finding out and living your own values, and by spending time with others you care for; you have a greater chance at finding your own happiness in your life.  That does not prevent bad things from happening, but it does help you to have a better ability to recover from the bad times.

This blog series will help you understand what to expect in Cognitive Behavioral Treatment (CBT) for a variety of different anxiety disorders, OCD, and PTSD. No matter what you are seeking help for, it can be very scary to start treatment. I assume most of my patients enter their first appointment with me with anxiety. I assume this for several reasons. 1. You are taking a big first step in your life to change something that may feel impossible to change; 2. Most of my patients experience an abundance of anxiety on a daily basis and new experiences make us all feel anxiety.

My hope is that this blog series helps you to have a better sense of what to expect in your treatment if you choose exposure-based CBT interventions. First and foremost, the first appointment will be a lot of data collection. In order to determine how I can be helpful, I must determine what your problem looks like. You can plan on me asking you a ton of questions. My goal is to determine what diagnoses you meet criteria for (to ensure I can treat those diagnoses) and to instill some hope in you that I can help you. Just like we would hope our doctors would evaluate what is broken before treating a broken bone and then tell us how they can be helpful, I want to use a scientific approach in my practice and give you some hope that the science works. Although a one size fits all approach does not work for everyone, I apply all evidence-based techniques or techniques that have been supported by ongoing research. In this series, you will find the general what’s and why’s of treatment with me. Also, if you are struggling with the motivation to get started, I include some information on why it may be worth it to take a chance on this treatment.

Posttraumatic Stress Disorder Treatment

What is Posttraumatic Stress Disorder (PTSD)?

Post-Traumatic Stress Disorder (PTSD) results from witnessing or being exposed to death, threatened death, or actual or threatened serious injury (American Psychiatric Association, 2013). Following such a terrifying event, our brains sometimes recover. Sometimes they do not. This is why PTSD is considered a recovery disorder (Resick et al., 2017). Symptoms include intrusive memories, efforts to avoid memories, increased negative emotions and thinking patterns, and hypervigilance or hyper-arousal (increased alertness and related physical symptoms). These are symptoms we all can experience after a traumatic event for a short period of time. However, PTSD occurs when these symptoms persist and start to impact your life, long term. 

What will we work on?

If you seek PTSD treatment from me, you will have two treatment options:

The first is called Cognitive Processing Therapy or CPT. In CPT, we will focus on challenging unhelpful thoughts and beliefs that have resulted from your trauma (Resick et al., 2017). Additionally, I will help you process the traumatic memory and related emotions. By modifying beliefs related to your trauma and by effectively processing (as opposed to avoiding) the traumatic memory, you can start to recover from the trauma. I see PTSD as a disorder that causes my patients to relive the traumatic event, over and over again. I want you to be able to stop reliving the event. In order to do so, we need to process the event, so that you can put it in long term memory storage. Instead, PTSD asks you to continue opening the worst page of a scary book in your brain. We will take a look at the whole book so that you can close it and only look at it when you choose to, as opposed to when it intrudes into your mind (Resick et al., 2017).

The other treatment I offer is called Prolonged Exposure Therapy (PE). In PE, we will focus on gradually processing traumatic memories and challenging avoidance related to your trauma (Foa et al., 2007). What does this look like? You will talk about your trauma and be asked to do things you have been avoiding. One symptom of PTSD is avoidance of both the traumatic memory and situations, people, and places related to the traumatic event. In order to recover from PTSD, we must challenge this avoidance and re-enter life, despite the continued fear that something bad may happen. Prior to the trauma, you lived in the world and accepted the risks of doing so. I hope to help you learn to do this again. Of note, I will not ask my patients to do something that I myself would not do. I will not ask you to enter situations that are likely dangerous. We will modify all exercises according to CDC guidelines during the COVID-19 pandemic. 

Why engage in this treatment?

For some, PTSD has completely debilitated their ability to live a comfortable and full life. For some, they are reliving their trauma every single day. So, it seems you have two choices. You continue living as if the trauma is still happening, or you decide to face the trauma directly so that you can get back a life without daily threats and fear. I am assuming that you are reading this page because you are tired of reliving your trauma. I am assuming that it is getting in the way of success, health, sleep, or enjoying the present moment. If so, you may want to give treatment a try. 

Why this treatment works.

Every time you think of your trauma, your threat brain (the amygdala) is igniting (Resick et al., 2017). Every time you think of your trauma, your brain is telling your body to fight, flight, or freeze (the three threat response options we have). Both of these treatments aim to adjust this response by processing the trauma, facing the trauma, and returning to your life or to more rationale ways to view it. 

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007) Prolonged Exposure for PTSD: Emotional Processing of Traumatic Experiences: Therapist Guide. Oxford University Press.

Grayson, J. G. (2014). Freedom from Obsessive-Compulsive Disorder: A personalized recovery program for living with uncertainty. Berkley Books.

Resick, P. A., Monson, C. M., & Chard, K. M. (2017). Cognitive Processing Therapy for PTSD. The Guilford Press.

This blog series will help you understand what to expect in Cognitive Behavioral Treatment (CBT) for a variety of different anxiety disorders, OCD, and PTSD. No matter what you are seeking help for, it can be very scary to start treatment. I assume most of my patients enter their first appointment with me with anxiety. I assume this for several reasons. 1. You are taking a big first step in your life to change something that may feel impossible to change; 2. Most of my patients experience an abundance of anxiety on a daily basis and new experiences make us all feel anxiety.

My hope is that this blog series helps you to have a better sense of what to expect in your treatment if you choose exposure-based CBT interventions. First and foremost, the first appointment will be a lot of data collection. In order to determine how I can be helpful, I must determine what your problem looks like. You can plan on me asking you a ton of questions. My goal is to determine what diagnoses you meet criteria for (to ensure I can treat those diagnoses) and to instill some hope in you that I can help you. Just like we would hope our doctors would evaluate what is broken before treating a broken bone and then tell us how they can be helpful, I want to use a scientific approach in my practice and give you some hope that the science works. Although a one size fits all approach does not work for everyone, I apply all evidence-based techniques or techniques that have been supported by ongoing research. In this series, you will find the general what’s and why’s of treatment with me. Also, if you are struggling with the motivation to get started, I include some information on why it may be worth it to take a chance on this treatment.

Social Anxiety Treatment

What is Social Anxiety Disorder? 

Social anxiety disorder often appears as anxiety in social situations where one could be evaluated by others (American Psychiatric Association, 2013). This could involve meeting new people, being observed by others, or even having to perform in front of others. Fear of negative evaluation is a big part of social anxiety. My patients often ask “will I embarrass myself? will I be rejected or humiliated? will I offend someone?” Individuals with social anxiety disorder want to stay away from social situations that could involve evaluation or will do so with a ton of anxiety. 

What will we work on? 

• Cognitive Restructuring: Our thoughts are very powerful, particularly during and after social interactions (Hope et al., 2019). We all have had moments of anxiety during or following a social encounter. For instance, it is fairly normative to reflect on our performance following an interview. However, for individuals with social anxiety disorder, their anxiety extends beyond a bit of doubt and appears more as automatic, extreme thoughts, such as “They didn’t like me” or “Because I didn’t answer perfectly, I will never answer perfectly, therefore, I will never get a job” or “I looked anxious and stupid” (Hope et al., 2019). I will ask you to become a scientist. I will ask you to dispute these assumptions using questions like “do you know these things for certain?” and “what evidence do you have that such assumptions are true?” (Hope et al., 2019). 

• Exposure Therapy: To overcome a fear, we must face it (Hope et al., 2019). To overcome social anxiety, I will ask you to do things that make you socially anxious or uncomfortable. Why? Because you can tolerate it. Social anxiety will not harm you. In fact, the opposite is true. Avoiding important social situations will likely cause some detriment in your life. Saying the wrong thing and being embarrassed is just a part of life. We will practice easier tasks, such as having conversations, and then harder tasks, such as doing things that make you feel embarrassed. You will learn that you can cope with these feelings and find ways to move into social situations with bravery and acceptance of uncertainty. 

Why Engage in this Treatment?

Outside of meeting our basic needs, our relationships and our ability to engage with others is likely the next most important aspect of human functioning. Is it painful for you to enter new situations or to make new friends (Grayson, 2014)? Does your fear of negative evaluation keep you from pursuing your goals? Do you avoid important social events because you just can’t tolerate the anxiety? Are you lonely because you avoid social situations? Has this pandemic led to even more isolation and exacerbated your social anxiety? If so, you may want to give treatment a try. 

Why this treatment works?

Right now, your threat brain is signaling danger during social encounters. However, for the most part, social encounters do not pose danger (as long as you are following proper COVID-19 precautions). If you repeatedly examine the thoughts during social encounters and repeatedly place yourself in uncomfortable spaces, your comfort will grow with time. You can tolerate anxiety. You do not need to run from it anymore. During the COVID-19 pandemic, we will modify the social exposures to abide by CDC guidelines. However, even now, there is a way to become more present focused in your relationships and life. 

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Hope, D. A., Heimberg, R. G., & Turk, C. L. (2019). Managing Social Anxiety: A Cognitive-Behavioral Therapy Approach: Therapist Guide (3rd ed.). Oxford University Press.

Grayson, J. G. (2014). Freedom from Obsessive-Compulsive Disorder: A personalized recovery program for living with uncertainty. Berkley Books.