Inpatient vs. Outpatient
Substance abuse treatment offers multiple levels of care to meet the needs of people in recovery. While some individuals require intensive, round-the-clock care (also known as inpatient rehab), others are able to meet their goals by attending scheduled activities on certain days of the week (known as outpatient treatment). Some clients will start this process at the inpatient level, then advance into outpatient programs that offer more autonomy and require more accountability. Others will go directly into outpatient care, where they will receive many of the same services during the day while returning to their homes or other residential facilities at night.
During the admission stage of rehab, incoming clients are evaluated by the treatment team to determine which level of rehab will produce the best outcomes. Throughout the process, the client will be assessed to determine whether the current level of care is the most suitable.
Providing structure and creating stability for clients are two of the primary goals of inpatient substance abuse treatment. In an inpatient setting, the atmosphere is carefully controlled so clients can focus exclusively on the tasks of rehab. Inpatient care takes place in a facility such as a hospital or dedicated rehab center, where the clinical staff is devoted to monitoring clients and ensuring their wellbeing. Clients follow a schedule of recovery-based activities that begins first thing in the morning and end in the evening. These activities may include:
- Morning meditation
- Individual therapy sessions
- Group therapy
- Substance abuse education
- Experiential therapies (art therapy, recreational therapy, animal-assisted therapy, and more)
- Exercise sessions
- Nutritional counseling
Inpatient treatment programs include onsite meals and overnight accommodations. Clients sleep at the facility in private or semi-private rooms, and eat at a designated dining facility. In their free time, clients in many rehab programs are limited in their access to smartphones, computers, and TV. The purpose of these restrictions is to create an environment that supports healing on all levels, while minimizing the intrusion of triggers or stressors from daily life.
- Hospital programs: Hospital-based programs take place within a medical facility that has other departments, such as medical, surgical, and psychiatric units. Some hospitals house a substance abuse treatment unit that provides medical detox and other rehab services. These programs are ideal for patients who have an extensive history of heavy substance use or who have serious coexisting medical or psychiatric conditions.
- Residential treatment programs: Short-stay residential treatment programs offer recovery services that that usually range from two weeks to 28 days. Clients live at the facility while participating in activities like therapy, support groups, 12-Step meetings, and relapse prevention classes. Short-stay programs are appropriate for clients who have high levels of motivation to recover, but who need a period of brief, intensive treatment before they advance to outpatient care.
- Long-term residential treatment facilities: Long-term residential programs offer lengths of stay of 30 days or more. A typical length of stay is 90 days; however, there are many substance abuse treatment professionals who believe that stays of six months or more are ideal. Longer stays give clients more time to acquire and practice the coping strategies they will need to stay sober once they make the transition to the community.
Outpatient services are generally defined by the fact that clients do not reside fulltime at the facility. However, depending on how intensive the program is, they may spend most of their time going to therapy sessions, participating in 12-Step meetings or group sessions, and meeting with case managers or social workers. Most of the same services that are offered in inpatient programs are available in outpatient treatment, including detox, therapy, family counseling, self-help support groups, and medication management. The basic levels of outpatient treatment include:
- Partial hospitalization programs (PHPs): In partial hospitalization programs, clients meet at a hospital, treatment center, or other facility for recovery services during business hours, then return to their homes or a sober transitional residence at night. Clients usually attend several therapy sessions per day. PHPs vary in length, but many last for 2-4 weeks. For many clients, a PHP is the next step down in care after finishing a detox program or inpatient rehab program. PHPs offer more flexibility and independence than inpatient treatment centers, but they are more structured than regular outpatient programs.
- Intensive outpatient programs (IOPs): Intensive outpatient treatment often follows a successful stay in a residential treatment facility. At an IOP, clients may live in a sober residence or stay in their private homes while going to therapy during the day. The length of time spent in daily treatment sessions is usually shorter, and clients have more autonomy at this level of care. IOPs may last 2-4 weeks, and the emphasis of the program is often on preventing relapse and helping the client make the transition back to the community.
- Regular outpatient programs: Regular outpatient treatment programs offer the most freedom and the least amount of structure and restrictions. These programs are ideal for working adults who have a high level of motivation to remain sober, and who have work or family commitments that prevent them from participating in more intensive levels of outpatient care. Therapy sessions, medication management, 12-Step meetings, and case management services are provided on a more flexible schedule to accommodate the client’s needs and responsibilities. As with intensive outpatient programs, the focus is on planning for a successful aftercare period and reducing the chance of a relapse as much as possible.
Advancing through the Continuum of Care
In a comprehensive recovery plan, detox, inpatient treatment, and outpatient treatment are not isolated services. Instead, they are part of a continuum of care, which culminates in an aftercare program that helps the client bridge the gap between rehab and “real” life.
Clients who have a relatively short history of substance use, who are committed to recovery, and who have no co-occurring psychiatric conditions or medical illnesses may be referred to an intensive outpatient program immediately after detox, without going through residential treatment. For a client with a history of heavy substance abuse, the typical progression of treatment is as follows:
- Medical detox
- Inpatient or residential rehab
- Partial hospitalization
- Outpatient treatment
- Aftercare planning
In the aftercare phase, clients may no longer attend daily therapy sessions or classes; however, many individuals in recovery take part in 12-Step meetings, support groups, or counseling one or more times per week. On a monthly or quarterly basis, they may attend alumni programs sponsored by their rehab facility, such as intensive family weekends, workshops, barbecues, or charity events.
Which Type of Treatment Is Most Effective?
There has been a lot of debate among substance abuse treatment professionals over the effectiveness of inpatient and outpatient treatment. The National Institute on Drug Abuse recommends residential treatment with stays of 90 days or more for the most positive outcomes. While many studies suggest that long-term residential programs are more effective at ensuring long-term abstinence, the fact is that residential treatment is not necessarily the best option for everyone. In fact, statistics indicate that far more Americans enroll in outpatient centers than inpatient programs. The National Survey of Substance Abuse Treatment Services (N-SSATS) reports that as of a specific date in 2013:
- There were a total of 1,249,629 clients enrolled in specialized rehab programs in the US.
- Out of this number, 81.6% (11,542 people) were receiving outpatient services.
- Among those receiving care, 24.4% (3,450 people) were receiving inpatient services at residential facilities.
- Among those receiving care, 5.3% (753 people) were receiving inpatient services in hospital programs.
Out of the individuals enrolled in outpatient programs, 76.1% were participating in regular outpatient programs, while 45% participated in IOPs, and 12.3% participated in PHPs. Out of those enrolled in residential treatment, 12.3% were receiving treatment for 30 days or less, while 20.2% were receiving treatment for more than 30 days.
Although these statistics show that outpatient services are more popular in the US, they do not necessarily prove that outpatient treatment is more effective. The individual’s substance abuse history, personal commitments, co-occurring medical conditions, payment status, and other factors must be taken into account when choosing a rehab program. In addition, the client’s motivation to recover and remain abstinent is one of the most important factors in determining whether the person will stay sober.
Finding the Right Level of Care
How can a prospective rehab client tell which level of care will provide the best results? This decision should be made with the help of a treatment team, including the client’s therapist, physician, and other professionals involved in the recovery process. These professionals will only be able to determine where the client should start in the continuum of care after a complete evaluation of the person’s medical, psychological, and psychosocial status.
In general, inpatient treatment is best suited for clients who need the support and structure of 24-hour clinical care. The advantages of inpatient treatment include:
- Round-the-clock monitoring by clinical professionals to ensure that the client is medically stable during the withdrawal period
- A structured, supportive environment with minimal distractions
- The opportunity to focus on therapy and other recovery services fulltime
- Access to integrated therapeutic services for individuals with co-occurring mental illness
- Comfortable amenities and specially prepared meals (at select residential facilities)
For those who are medically and psychologically stable, and who have commitments that prevent them from attending treatment fulltime, outpatient treatment may be more appropriate. The benefits of an outpatient program are as follows:
- Fewer restrictions to impinge on one’s time and outside commitments
- More opportunities to practice coping skills in a “real world” setting
- A greater sense of self-efficacy and autonomy
- More flexibility in one’s choice of recovery services
- Faster integration back into the community
- Lower overhead costs and higher coverage rates by insurance companies
Although payment should not be the primary concern of a client choosing a rehab program, the fact is that many individuals choose outpatient care because it is more affordable than inpatient treatment. The costs of a long-term stay at a residential facility — including overnight accommodations, fulltime staffing, meals, and amenities — make inpatient care more expensive. To compensate for the higher costs of inpatient treatment, many residential facilities make an effort to keep their expenses as low as possible and to accept payment from a variety of sources, so their services are within reach of the average person seeking help for addiction.
In the end, the best treatment program is a plan that is tailored to individual. Whether this plan includes inpatient care, outpatient treatment, or a combination of both, the services provided, therapies utilized, and length of stay should reflect the client’s needs.