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Levels of Care for Substance Abuse Treatment
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The traditional model of substance abuse treatment is a 28-day (or longer) inpatient program followed by an outpatient program and 12-step groups. While this treatment model is still valid, and helps many people find their way out of addiction every year, it’s not the only valid option.
Some people might need (or want) to start with inpatient rehab, while others can find success starting with an outpatient program. The purpose of a continuum of care is not to make you go through every level in the continuum or to start at a specific level of care. It’s to provide a range of treatment options that can meet you where you are—wherever that might be.
To get a safe, accurate, and comprehensive recommendation for the right level of care, it’s best to reach out to a medical or behavioral health professional to get an assessment. That said, it can help to know a little more about your different options first.
What Level of Substance Abuse Treatment Do You Need?
In general, you need:
- Inpatient (or outpatient) detoxification when you have stopped (or are trying to stop) using substances and are experiencing significant withdrawal symptoms
- Inpatient treatment (or “rehab”) when your substance use has progressed to a severe level and your home environment is stressful, dangerous, or unsupportive
- Intensive outpatient treatment when you don’t quite need inpatient treatment but need extra support in addressing moderate to severe complications of substance use
- Outpatient treatment when your substance use has progressed to a point where you can’t stop on your own but you already have a good support system and a supportive home environment
All of these levels of care use therapy (both group and individual) as their primary intervention. Therapy for substance use disorders is a little different from therapy for mental health disorders. The focus is more on immediate, practical issues than it is on unearthing your past.
One of the biggest things you’ll focus on in therapy is relapse prevention. Cognitive behavioral therapy can help you connect the dots between substance use and the thoughts, feelings, environments, and events that trigger it. After you’ve learned your relapse triggers, you can then start to work with your counselor or therapist to come up with plans for how to limit exposure to them and for how to cope when you can’t avoid them.
Is Individual Substance Abuse Counseling Ever the Right Level of Care?
Does that mean you can just go straight to a therapist for individual relapse prevention sessions? While weekly individual talk therapy may be the "Swiss Army Knife" of mental health care—an effective intervention for a wide range of circumstances and needs—it's not usually the right place to start when you need substance use disorder treatment. This is because substance use disorders come with specific and serious risks, including social, legal, and medical complications, that often require intensive levels of care at the start of treatment to address. Cravings to use substances can be overwhelming in early recovery and can require more structure to stabilize than once-weekly sessions can provide. In many cases, intensive outpatient programs (IOPs) can provide this "just-right" level of care.
If you’re not sure where to start, that’s okay. Most people aren’t, and you don’t even have to do this part on your own. Reach out to a clinician, a local program, or an information or crisis line. They should be able to help you figure out the best place to begin. The most important thing is that you take this first step to get the help you need. Recovery—and all of its gifts—may only be a call or click away.
The traditional model of substance abuse treatment is a 28-day (or longer) inpatient program followed by an outpatient program and 12-step groups. While this treatment model is still valid, and helps many people find their way out of addiction every year, it’s not the only valid option.
Sometimes therapy is a good choice for substance use disorder treatment, and sometimes you need a higher level of care than individual therapy. Read on to learn more about the different levels of substance use disorder treatment.
On This Page
- What Are the Levels of Care for Substance Abuse Treatment?
- Inpatient (or Outpatient) Detoxification
- Inpatient Treatment
- How Does Inpatient Substance Abuse Treatment Work?
- What Kind of Therapy Do You Get in Rehab?
- How Long Do You Need to Be in Inpatient Treatment?
- A Word of Warning About Inpatient Treatment Programs
- Outpatient Treatment
- When Do You Need Outpatient Treatment?
- What Are PHPs and IOPs?
- Which Level of Outpatient Treatment Should You Try First If You're Not Sure?
- How Does Outpatient Substance Abuse Treatment Work?
- How Long Do You Need to Be in Outpatient Treatment?
- When Is Individual Therapy Enough for Addiction Treatment?
- Support Groups, Mutual Aid, and Self-Help
What Are the Levels of Care for Substance Abuse Treatment?
One of the reasons that therapy is overshadowed by other types of substance use disorder treatment is that it’s often not the right level of care at the beginning of your recovery journey.
The traditional understanding of addiction reflected in the 12-step philosophy is that many people don’t start seeking help until they’re at or close to “rock bottom”—a point when their addiction has progressed to a dangerous level of severity where their health or even their lives are at stake.
This isn’t always true, especially now, at a time when more people are aware of the benefits of getting treatment sooner. However, it is often still true that many people first seek treatment at a time when individual therapy doesn’t provide the intensity of care that they need.
So, what are the different levels of care for substance use disorders, and when are they needed? In the information box below, you’ll find the most common treatment options, starting with the highest and proceeding to the lowest level of care.
The Levels of Care for Substance Abuse Treatment
- Inpatient (or outpatient) detoxification
- Inpatient treatment, which includes two sub-levels of care:
- Long-term residential treatment (typically 60 to 90 days)
- Short-term inpatient treatment (typically 10 to 30 days)
- Outpatient treatment, which includes three sub-levels of care:
- Day treatment
- Intensive outpatient treatment
- General or non-intensive outpatient treatment
- Support groups, mutual aid, and self-help
You don’t necessarily need to go through all of these different levels of care or start at the “beginning” with detox or inpatient treatment. So, who needs what, and when? Read on to learn more.
Inpatient (or Outpatient) Detoxification
Detoxification treatment, or “detox,” is short-term medically supervised treatment that’s designed to help you safely stop using substances.
In detox, you’re medically monitored and treated for withdrawal symptoms and other medical complications that arise when you stop using substances you’ve been using for a long time.
Detox lasts as long as it takes to stabilize you medically, which can be as short as a few days or as long as a couple of weeks.
When Do You Need Detox?
In general, you need detox when:
- You’ve been using substances that can cause dangerous withdrawal symptoms, such as:
- Opioids (prescription or otherwise),
- Benzodiazepines (prescription or otherwise),
- Other sedative drugs (prescription or otherwise), and/or
- Alcohol, and
- You’ve been using one or more of these substances in large enough amounts and over a long enough period of time to experience physical dependence or tolerance.
These drugs can all cause medically severe, even deadly, withdrawal symptoms including delirium and seizures. Alcohol and benzodiazepines are especially known for causing dangerous, deadly withdrawal symptoms. Opioid withdrawal symptoms aren’t usually deadly, but they are often severe, and can be deadly in extreme cases. The severity—and treatability—of withdrawal symptoms from these drugs are why they are responsible for most inpatient detox admissions.
However, this doesn’t mean you don’t need detox if you’ve been using something else. Cocaine, methamphetamines, and other stimulants can also cause severe withdrawal symptoms. These can include heart problems and dangerous psychological side effects like hallucinations, delusions, and severe depression. In many cases, these symptoms are treated with “ambulatory,” or outpatient detox rather than inpatient.
Ask For Help If You're Not Sure!
If you’re not sure whether you need detox, please reach out to a clinical professional and ask. Withdrawing from any substance, especially when you’ve used it for a long time in large amounts, can cause psychological effects that put you at risk of harm.
In general, we recommend calling a crisis line, going to a local emergency room or emergency behavioral health service, or consulting a trusted medical or behavioral health practitioner if you’re trying to stop using a substance and are experiencing withdrawal symptoms. If you feel sick, medical monitoring can help keep you safe until the symptoms pass.
Inpatient substance use disorder treatment (popularly known as “rehab”) provides the highest level of structure and security of all the different types of substance use disorder treatment.
It’s where many people begin their recovery. It’s a great choice if your home environment isn’t supportive of recovery or if you feel overwhelmed and like you need time away from everyday stressors to get started on your new path.
When Do You Need Inpatient Treatment?
You need inpatient treatment when outpatient treatment isn’t enough to help you reach your treatment goals. This determination is best left to clinical professionals. (Clinicians are ultimately the ones who will determine whether you meet criteria to be admitted to a certain level of care anyway.)
That said, the following are a few signs you may need inpatient treatment:
- You tried outpatient treatment but it didn’t work for you because
- You couldn’t stop using,
- You relapsed and couldn’t get back on track while in the program, or
- You otherwise couldn’t reach your treatment goals in outpatient care;
- You’re seeking treatment for the first time (or the first time in a long time) and your substance use was or is severe, as indicated by
- Medical or physical withdrawal symptoms when you try to quit or
- Escalating instability and problems in your daily life, as evidenced by legal problems, relationship dysfunction, loss of work and income due to substance use, or homelessness;
- Your home and work environments are dangerous, unsafe, or toxic and you have a minimal support network of people or groups who could help you in your recovery; or
- You don’t feel safe on your own, feel like you need extra help to get stable, and sense intuitively that outpatient treatment isn’t enough right now.
Inpatient care can provide levels of safety, security, and structure that outpatient programs can’t. It can immediately give you a safe respite from the dangers associated with severe, untreated substance use disorders. That said, it is possible to begin your recovery in an outpatient program and never need to go to an inpatient program.
How Does Inpatient Substance Abuse Treatment Work?
Rehab can jumpstart your recovery by giving you the clinical services you need in a safe and secure environment where it’s easier to manage stress and avoid relapse than it is at home.
Medically monitored inpatient treatment can be necessary at the very beginning of treatment or if you’re experiencing prolonged withdrawal symptoms or co-occurring medical conditions. However, medically monitored treatment is not always necessary, and it may or may not be included in your rehab experience.
On the other hand, clinical behavioral health services are always provided in rehab and supportive wellness services nearly always are.
What Do You Do in Inpatient Treatment?
Most of the time, inpatient treatment includes the following:
- Group therapy
- Individual therapy
- On-site support groups
- Recreational activities
- Wellness activities
Supportive therapies and recreational services vary from rehab to rehab. On-site holistic and wellness activities you might have access to include:
- Yoga or other exercise classes
- Art or music therapy sessions
- Free use of art and craft supplies
- Free use of a pool or gymnasium
- Equine or other animal-assisted therapy
The purpose of having wellness activities and facilities at a rehab is twofold. They help you feel better and they also introduce you to activities that can become part of a healthy, sober lifestyle. Learning other ways to regulate your nervous system and feel good is a key element of recovery.
Most rehabs offer on-site support groups (more on those later). All provide daily on-site therapy, usually a mix of individual therapy and group therapy. In other words, therapy is the primary clinical intervention that you receive in an inpatient treatment program.
What Kind of Therapy Do You Get in Rehab?
Therapy for substance use disorders is a little different from therapy for mental health disorders. The focus is more on immediate, practical issues than it is on unearthing your past.
For More Information
You can read our article on therapy for addiction for more details on how it works and how it’s different from therapy for mental health.
One of the biggest things you’ll focus on in therapy, especially early on in your recovery process, is relapse prevention. Cognitive behavioral therapy can help you connect the dots between substance use and the thoughts, feelings, environments, and events that trigger it. After you’ve learned your relapse triggers, you can then start to work with your counselor or therapist to come up with plans for how to limit exposure to them and how to cope when you can’t avoid them.
Many inpatient facilities offer therapy for substance abuse recovery as well as therapy for mental health. Part of the road to recovery from addiction is getting treatment for co-occurring mental health issues, trauma, and past or ongoing emotional harm from unhealthy relationships.
However, while most rehabs seek to immediately treat co-occurring mental health symptoms and conditions, they often avoid delving too deeply into traumatic memories or wounds from your childhood. Treatment philosophies differ, but many clinicians believe it’s better for you to gain some stability in recovery from substance use disorders before confronting potentially destabilizing traumatic memories.
How Long Do You Need to Be in Inpatient Treatment?
Your care team will work with you to determine how long you need inpatient care. Most rehabs offer variable lengths of stay. However, there are generally two types of inpatient treatment programs: short-term and long-term.
Short-Term vs. Long-Term Inpatient Programs
Short-term inpatient programs were originally designed to last for 28 days. Many rehab facilities still have 28-day programs, but many also offer shorter stays—some even as short as one week. Traditional long-term residential programs offer lengths of stay longer than 30 days. Often, they have programs that are 60 to 90 days long (or even longer).
You might start with a longer-term program if you and a referring medical or behavioral health professional agree you need it. However, it’s much more common to start with a shorter-term program if it’s your first time in treatment. (One reason is that many insurance plans require people to try a lower level of care first before authorizing longer-term care. It can be difficult, if not impossible, to get insurance to cover long-term residential treatment.)
A Word of Warning About Inpatient Treatment Programs
Unfortunately, inpatient substance use disorder treatment has been targeted by scammers. The problem is profit.
The good news is not all rehabs are like this and there are ways you can avoid the bad ones and find your way to the good ones. First, trust your intuition and walk away if something feels suspicious or wrong. Next, reach out and seek the advice of people you can trust. If you don’t yet have sober friends you know very well, you can reach out to local non-profits for guidance.
We advise calling a local behavioral health information or crisis line (go here to find the numbers for your state) for information about trusted local inpatient and outpatient programs. You can also get referrals from local outpatient substance use disorder programs. They frequently refer clients to inpatient treatment and monitor what they hear back from clients about the programs they attend.
Outpatient treatment is the most flexible treatment option for addiction. You don’t have to find a way to take weeks (or even months) off from work. It’s also usually more affordable than rehab.
Different types of outpatient programs are designed to suit the needs of a wide range of people. There are so many different options it’s often possible to start with an outpatient level of care even if your substance use disorder has progressed to a high level of severity.
When Do You Need Outpatient Treatment?
You need outpatient treatment when you need more help than you can get on your own or from support groups to address issues in your life that are related to substance use.
Given all the complications substance use disorders can cause, it’s likely you need to start with at least some level of outpatient care. Read on to learn more about your different options and to learn which one might be a good fit for you.
What Are the Different Levels of Outpatient Addiction Treatment?
- Partial hospitalization programs
- Intensive outpatient programs
- Individual substance abuse counseling
What Are PHPs and IOPs?
Partial hospitalization programs (PHPs), also sometimes called day treatment programs, offer the highest level of outpatient care. They usually operate five days a week and provide treatment for four to five hours a day for a total of 20 hours a week.
In fact, the biggest difference between partial hospitalization programs and inpatient programs is that in PHPs, you go home at night and come back in the morning. Day treatment programs are designed to help you transition from inpatient to outpatient treatment or for when you almost—but don’t quite—need inpatient treatment. They are usually only a few weeks long.
Intensive outpatient programs (IOPs) sometimes offer additional activities and supports, but the core of these programs is therapy. A typical IOP has two to three group therapy sessions a week (each of which is usually one to one-and-a-half hours long). Individual therapy may be a required part of the program or may be offered only as needed.
How Long Do Intensive Outpatient Programs Last?
Many IOPs last long enough to take you from the intensive part of the program, when you typically get about 9 hours of treatment a week, to a less intensive phase where you get 3 to 6 hours of treatment a week. The intensive phase usually lasts around 90 days, and a full program that goes from intensive to less intensive phases may last six months to a year.
Programs that are less intensive than IOPs are simply called outpatient programs. Some are full-fledged programs that are structured like IOPs, just with fewer hours of treatment. Individual therapy or counseling for substance abuse also falls in this category.
Which Level of Outpatient Treatment Should You Try First If You're Not Sure?
In our article on levels of mental health care, we recommend individual talk therapy as the “Swiss Army knife of mental health care”: a versatile tool that can help people address a wide range of needs and circumstances. It’s not enough when you’re in a crisis that puts you at immediate risk of harm, but it can be an effective choice for just about anything else.
It’s not quite the same with substance abuse treatment. Substance use disorders come with specific and serious risks, including legal and medical complications, that often require intensive levels of care at the start of treatment to address. Cravings to use substances can be overwhelming in early recovery and can require more structure to stabilize than once-weekly sessions can provide.
So, what level of care is the best place to start by default if you’re seeking treatment for a substance use disorder? According to the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA), that level of care is intensive outpatient treatment:
"[IOPs] are diverse and flexible with respect to the spectrum, intensity, and duration of services and the settings in which services are delivered. They are, therefore, well suited to meet the varied needs of persons with substance use disorders. [They provide] an intermediate level of [outpatient] care that serves [as a good] entry point into substance abuse treatment [and can be both] a stepdown level of care [and] a step-up level of care."
We agree with SAMHSA. It’s certainly possible to start with an individual counselor or a less intensive outpatient program and move up to an IOP if that’s the level of care you need. But an IOP will give you the best mix of freedom, flexibility, and security if you’re not sure where to go. In any case, wherever you go, a clinician will assess you to help determine the right level of care for you.
How Does Outpatient Substance Abuse Treatment Work?
The idea behind outpatient programs is that they give you support and guidance as you face challenges, stressors, and triggers in your everyday life. They are designed to last long enough for you to internalize what you learn so you can successfully navigate these obstacles on your own after the program is over.
While no addiction program operates on the idea that you’ll be “cured” by the time you leave, outpatient programs are designed to accompany you along a significant portion of the road to recovery. By the end of the program, you’ll have gained strength and confidence in your recovery and will feel ready to move on with the help of the community supports you’ve built. (Helping you build a sober support system is an important part of most outpatient programs.)
Expect Regular Drug Tests
Outpatient programs often use frequent or random urine drug screens as a form of ongoing assessment and as an accountability tool. Multiple positive screens can lead to you being placed back into a more intensive phase of treatment or referred out to an inpatient program.
Some outpatient programs offer in-house support groups, recreational activities, and alternative therapies like inpatient rehabs do. All of them provide behavioral health services—usually a combination of group and individual therapy sessions. (They often focus on group sessions in the beginning, and only offer individual sessions as needed or later in treatment.)
As with therapy in rehab, therapy in outpatient substance abuse programs is typically focused on here-and-now issues like helping you develop relapse prevention skills and solve problems that are causing instability in your life.
However, since outpatient programs last longer, it’s possible you could be diving deeper into emotional and psychological issues in individual sessions by the final stages of your treatment. Stable recovery rests on a foundation of emotional healing.
How Long Do You Need to Be in Outpatient Treatment?
Outpatient programs are designed to get you from early recovery to a point where you’ve gained stability in your recovery and have achieved and are maintaining your treatment goals.
When Are You Ready to Complete Outpatient Treatment?
Signs you’ve made significant progress in your recovery and may be ready to graduate or complete outpatient treatment include:
- You’ve been in sustained recovery without relapsing for several months;
- You’ve built a strong network of people and groups who support you in your recovery;
- Your most important relationships with significant others and loved ones have improved;
- You’ve faced challenges or obstacles and successfully dealt with them without relapsing;
- You’ve made progress in dealing with other issues in your life that were causing instability or threatening your recovery; and
- You have stable housing, work, income, and social and emotional support.
Many outpatient programs run for a set length of time, often from several months to a year. Some decide it’s time for you to graduate after you’ve reached some of the above milestones. It usually takes a minimum of several months to do so.
If you have underlying emotional or mental health issues—as many people with substance use disorders do—and you haven’t resolved them by the time you complete an outpatient program, you should consider moving on to individual counseling or therapy as your next step.
When Is Individual Therapy Enough for Addiction Treatment?
Individual therapy isn’t a high enough level of care if you’re in crisis (this is true for both mental health and substance use disorders). It’s also probably not a high enough level of care if you’re unstable in early recovery from a substance use disorder and suffering from (or at risk of) homelessness, medical or physical complications of substance use, or serious legal problems.
However, that doesn’t mean it’s never the right level of care, even at the start of recovery.
When Might Individual Substance Abuse Counseling Be Enough?
Times that individual substance abuse counseling or therapy can be the right choice include:
- When you’re just starting to worry about your substance use and are wondering whether you have a problem, but haven’t yet had any severe social, medical, or legal consequences to confirm that you do;
- When you’ve already completed higher levels of care for substance use disorder treatment and have a strong sober support system, but you are worried that you’re at risk of relapse (or had a small “slip” that hasn’t progressed into a full-blown relapse);
- When you’re doing well with the “staying sober” part of recovery, but are struggling in other areas, such as emotional stability, work or home life, or relationships;
- When you’ve completed a treatment program where you’ve learned you have unresolved emotional issues or trauma that you need to address to fully heal; or
- When you know your substance use is a problem, but you’ve been able to stop on your own, don’t have withdrawal symptoms, and already have strong support systems in place.
If you’re not sure, you can always reach out to a therapist or substance abuse counselor and ask. Everyone’s path and needs are unique. Individual therapy or counseling is a great tool, and there are people who recover solely with the help of a therapist and a strong system of social and community support.
Support Groups, Mutual Aid, and Self-Help
The 12-step program taught by Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and other related groups (including “Anonymous” branded support groups for behavioral addictions) has been helping people recover from addiction since the 1950s.
It’s still relevant and helping people to this day. In some ways, it remains revolutionary: it’s free, it’s rooted in a grassroots network of peer support, it doesn’t rely on central authority figures, it’s spiritually oriented, and it’s a non-commercial venture that sits outside of the pressures of capitalism.
Traditional Twelve-Steps Groups Don't Work for Everyone
That said, it doesn’t work for everyone. While most AA and NA groups offer a flexible approach to the spiritual elements of the program, allowing each individual to define their “higher power” however they choose, not everyone can accept or work within the spiritual framework these groups offer.
Secular support groups like SMART Recovery and LifeRing are one alternative. They have a similar model as AA and NA—they’re non-profit, free, and anonymous. They offer similar structure and support as AA and NA, but they’re based on a different, secular philosophy that is appealing to many people—religious, non-religious, or otherwise.
There are other ways to create a sober support network, too. Many people turn to religious or spiritual communities when they’re seeking recovery. Others get involved in healthy activities that support a sober lifestyle and join communities focused on those activities. (A fully effective sober support system includes at least some people and groups that understand addiction and the recovery process.)
The key reason to build sober social support is that it’s hard, if not impossible, to sustain recovery on your own. Usually, part of what needs to be healed in any kind of addiction is one or more fractures in the area of human relationships. Some people recover from substance use disorders and addiction solely with the help of community support. As Johann Hari said, “The opposite of addiction is not sobriety—it is human connection.”
The purpose of a continuum of care is not to make you go through every level in the continuum or to start at a specific level of care. It’s to provide a range of treatment options that can meet you where you are—wherever that might be. Some people need (or want) to start with inpatient care, while others start in an outpatient program. Some start with individual therapy. Some recover with help from support groups alone.
If you’re not sure where to start, that’s okay. Most people aren’t, and you don’t even have to do this part on your own. Reach out to a clinician, a local program, or an information or crisis line. They should be able to help you figure out the best place to begin—or at least where to go to get an assessment to find out. The most important thing is that you take this first step to get the help you need. Recovery—and all of its gifts—may only be a call or click away.
Stephanie Hairston is a freelance mental health writer who spent several years in the field of adult mental health before transitioning to professional writing and editing. As a clinical social worker, she provided group and individual therapy, crisis intervention services, and psychological assessments.