Inpatient or Intensive Outpatient?

As the director of our intensive trauma-focused therapy service, I receive a lot of phone calls from people who would like to be feeling better and/or doing better. Some are in extreme distress. I’m often asked, “Should I be checking myself into an inpatient program, or going for intensive outpatient therapy?”

Here are the questions I ask, to determine how to respond:

• Are you safe? If left to your own devices – e.g., in the evening after your day’s therapy is done – are you at risk of hurting yourself, drinking, or drugging?
• If you are at risk, is there someone who can accompany you, whose presence would eliminate the risk?

When the immediate concern is safety, I recommend inpatient placement. An outpatient therapist cannot provide 24/7 monitoring and intervention to ensure that you don’t do something dangerous or destructive. The other main reason to consider inpatient placement is to experiment with a change in medication regimen, when such a change is potentially destabilizing. Again, the external supports to ensure safety may be essential.

The rest of what occurs during an inpatient stay is either unnecessary or can be done more efficiently and/or less expensively in other ways. The following activities tend to be offered in the better trauma-informed inpatient facilities:

• psycho-education, to help people better understand what is going on with them, why, and what to do about it
• training in coping skills, potentially including meditation, yoga, cognitive-behavioral strategies for self-management, etc.
• trauma healing via EMDR or other methods

I have written before about symptom management vs. trauma healing. Although coping skills are useful, it’s far more useful to heal from the trauma, so you no longer have symptoms that need coping with. Even in the best inpatient programs, you’re unlikely to get more than an hour or two of EMDR per week. And the trauma healing is where the big change happens.

This is why, when the client is safe, or can arrange companionship to ensure safety, I recommend intensive outpatient therapy. In our intensive trauma-focused therapy program, typically the first morning is spent on orientation, psycho-education, (sometimes) motivational work, and (sometimes) attachment work. By lunch time, give or take, you’re likely to be starting in on your trauma work, with EMDR or PC. On subsequent days you’re probably doing EMDR or PC for five to six hours per day, until the job is done. Each day of intensive therapy is equivalent to about two months of hour-per-week therapy, assuming the latter is using the same methods (EMDR or PC). So you can make a lot of progress in a short time.

Here is a (disguised) example of someone who could have gone either way.

“Amanda” was a 30 year old woman who was holding her own in a high-pressure job, but unsure how long she would be able to sustain this. She frequently experienced debilitating anxiety, triggered by very minor stressors. She had coped with severe anxiety all her life, but since her older sister’s death in an auto accident six months before, it had gotten much worse, affecting her sleep and eating as well as her work. She had also begun to feel depressed in recent months, and worried that she would fall apart and never recover. Her therapist recommended hospitalization, but Amanda did not want to be in a hospital if she could avoid it. The therapist had also been recommending medication for some time, and Amanda had also resisted that, so far.

Amanda’s childhood was marred by frequent exposure to her father threatening, insulting, and assaulting her mother. Following a particularly bad incident when Amanda was 11, her parents divorced. Amanda rarely saw her father after that. Before and after the divorce, her mother maintained a constant low level of inebriation, and was sometimes affectionate to Amanda but also emotionally neglectful. Amanda’s sister, five years older, was her main source of comfort and support. Amanda managed to excel in school, which was a haven for her, and later also in work. She dated but had never had a serious romantic relationship, which was another source of distress for her.

In the telephone interview, Amanda acknowledged suicidal ideation but stated that she would not actually hurt herself; it was just a vague-for-now “Plan C” if things got much worse and she should lose hope. She denied ever drinking or using drugs. She said she was worried about “falling apart,” losing her job, and becoming homeless. The idea of hospitalization appealed to her, on one hand, because she felt out of control and imagined that professionals asserting control might provide some relief. On the other hand, she was afraid of becoming a career mental patient: going to the hospital but not getting better.

I recommended the intensive outpatient trauma-focused therapy for Amanda, because I felt that she could do it (safely). As it turned out, she could, and she did. She worked with one of our therapists for five full days, and did PC with all of her childhood trauma and neglect memories as well as the recent death of her sister. A number of additional trauma/loss memories remained untreated due to time constraints. Amanda left feeling more relaxed and confident, and two weeks later told her therapist that she had been sleeping and eating normally again, and was no longer fearful about losing her job.

Several weeks after that, Amanda contacted the therapist to report that a) she had never felt better in her life, and b) wanted to complete the therapy. She noticed that she no longer experienced anxiety on a day to day basis, but still found herself overly cautious and avoidant regarding potential opportunities for romance. She returned for two more days of treatment, getting through the remaining trauma/loss memories and also applying the same trauma resolution procedure to anticipated feared events regarding romantic interactions. A month later she reported that the absence of anxiety had persisted, and that she had improved her dating-related behaviors, to allow for relationships to progress.

What if she had gone to the hospital instead? It might have been a good experience, and it might have gotten her on a better track. But that better track would, at best, lead to her doing the rest of her trauma therapy anyway, over time. And meanwhile, continuing to struggle. In my opinion, she was better off just getting through her therapy in the first place, as she did.

Bottom line: If you’re not safe, get safe. If you are safe, or can be safe with help, get your work done.