As a substance abuse counselor for over 27 years, I think it’s time for me to come out and admit that I am not, nor have I ever been, a big fan of Intensive Outpatient Programming (IOP). According to DASA rule, when a client is seen for 9 or more hours per week, they are considered to be in level-II, IOP. This typically requires a client to attend treatment 3 to 5 days per week to meet this requirement.

In some cases, this is the best recommendation and can be beneficial however, I feel it is overused and in many cases clients are inappropriately placed in IOP for the wrong reasons. One of those reasons (though I’m sure many providers wouldn’t be too quick to admit it) is to meet the program’s fiscal goals rather than the client’s clinical needs. Let’s face it IOP is more lucrative for treatment providers. This is not to say that programs are completely unethical and placing people in IOP who have no real substance abuse issue, but, programs are required by DASA Rule to place clients in “the least restrictive level of care possible”. If we apply this license requirement, it is hard to justify many of the admissions to IOP that occur. Consider this statement for ASAM dimension-IV for IOP placement; “Resistance high enough to require structured program but not so high as to render outpatient treatment ineffective”. When clients don’t have the skills or resources to be successful they become resistant.

I also believe that many of us (referral sources, and providers alike) get sucked into the title “Intensive Outpatient” and believe that this type of “Intensity” automatically translates to better quality and better outcomes. Dealing with some of our clients may make the word “Intensive” sound like a good thing and even necessary, but when we take a closer look at what it actually entails and takes to engage a client in this level of care, we may begin to get a different perspective.

Here are some typical issues that I see that make IOP ineffective for many clients :

Many substance abuse clients are not the highest functioning people and have low motivation. As such, it’s hard enough to get them to show up somewhere that they don’t want to be once or twice per week, let alone 3 to 5 times per week.
IOP can be overwhelming and stressful for clients, especially when they don’t have good organizational or other necessary skills and when you consider all of the other places they may be required to show up (i.e. community service, probation and court appointments, jobs and sometimes school, etc.).
Putting too much “on the plate” of clients can often be a set-up for failure. We have to assess and consider the lack of skills, resources and other practical barriers there may be to their success.
IOP isn’t necessarily an effective deterrent to drug and alcohol use. Whatever triggers and resources for drinking or using there may be, they don’t just disappear because someone goes to a 2 or 3-hour group 3 to 5 times per week.
Not all clients have any or adequate insurance coverage and this recommendation would create an overwhelming and in some cases, unnecessary financial burden.

This is not to say that IOP is never good or necessary. For some of our clients it is an effective treatment approach. So when is IOP a good option? The following are some conditions that may make IOP the best option:

As a step-down from a higher level of care such as inpatient treatment
The client must meet the ASAM 6-dimension criteria for placement in IOP (Level-II)
A judge has ordered IOP which supersedes ASAM placement criteria
When clients don’t work full-time and/or have a lot of free time on their hands
When clients don’t have too many other requirements (i.e. community service, work, etc.)
When it’s financially feasible

Another issue is that even when IOP is the right placement for a client initially, providers are required to re-evaluate through the Continued Stay Review the client’s appropriateness for that level of care every 30-days. If they no longer meet the criteria, they are supposed to be moved to a less intensive level of care.

Again, there are times when IOP is the right recommendation but we must consider other methods and be more creative with making treatment more “Intensive” without overwhelming the client. There are ways of doing this such as behavior contracts, homework assignments, revised treatment goals or other interventions that specifically address the identified issues that the client is struggling with. I like to sit down with a client who is failing in treatment in an individual session, assess the problems and develop some strategies to intervene. At times I find that some extra individual counseling was all the client really needed to get them back on track.