Inpatient mental health

Inpatient mental health care isn’t for everybody. Most clients that come to psychotherapy are perfectly suitable for outpatient treatment. Their problems can be treated with weekly therapy sessions and community support. However, certain individuals have more serious problems that may require a form of inpatient mental health treatment. These people exhibit instability in their behavior and may not be able to care adequately for themselves. Further, some are in crisis and an active threat to themselves or others. Here is what therapists must consider when contemplating whether clients may need a higher level of mental health care.

Levels of mental health care

Mental health care exists from least restrictive to most restrictive, depending on the client’s needs.

Self-help: Self-help is the lowest level of care. The individual reads books or obtains resources from the internet to help themselves with their problems without professional assistance.

Outpatient care: Outpatient therapy is usually a weekly (more or less) session with a therapist. This can be in-person or through video-conferencing or telephone. Apps have also introduced texting as a possible form of outpatient care. Outpatient therapy is for clients with problems that require the lowest level of professional help. Individual, couples, group, and family therapy are common outpatient treatment modalities. Medication management visits with a prescribing medical professional would also be considered outpatient care.

Intensive outpatient: Intensive outpatient care (IOP) is treatment that occurs more than once a week, usually as part of a program. It is for clients that require a higher level of structure and supervision than regular outpatient therapy can provide.

For example, it is common for people with substance abuse issues to engage in an intensive outpatient program a few times a week in an effort to stay sober and avoid more restrictive levels of care. IOP programs are frequently ordered by the court after individuals have gotten involved with the law. But they can be done voluntarily for issues like eating disorders, serious psychiatric conditions, and addiction. Often, they are the last step before inpatient mental health care is considered.

Partial hospitalization (Day Treatment): Partial hospitalization programs are when you receive hospital services during the day but don’t stay overnight. This type of treatment commonly occurs as a step-down option for those who were recently hospitalized and are rejoining the community. Day treatment is more intensive than IOP and usually meets for several hours every weekday. It is for people who may be having difficulty with everyday functioning due to serious mental health issues.

Residential care: Due to insurance limitations, inpatient  mental health hospital care rarely lasts longer than a few weeks. But, some people require long-term treatment with a high level of supervision. For those individuals, residential treatment is often the answer. 

Residential programs are popular for those with substance abuse issues (i.e., Rehab), eating disorders, and other serious mental health issues. They provide continuous care that likely includes individual therapy, group therapy, and medication management. People in residential treatment recognize that they can’t be successful without round-the-clock structure and support.

Acute inpatient mental health hospitalization: Acute inpatient mental health hospitalization occurs when an individual is in a crisis where they pose a threat to themselves or others. While they may go to the hospital voluntarily, a person can be admitted against their will if they are deemed unsafe. Some hospitals, however, may not have a psychiatric ward. In those cases, a person may be evaluated in the emergency room and transferred to a hospital with psychiatric services. Inpatient mental health hospital stays rarely last longer than a month. The goal is to stabilize the individual and release them to ongoing care, maybe to a partial hospitalization program, IOP, or outpatient therapist. Hospital stays will almost always focus on finding the best medication protocol to ensure stable behavior. Group and individual therapy will also likely be provided.

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Signs that a client may need inpatient mental health care

The following indicators may mean that a client requires a higher level of care than outpatient therapy can provide:

They are a danger to themselves or others

This is the reason that most hospitals look for when considering whether an individual needs inpatient mental health hospitalization. The person may have suicidal ideation, attempted suicide, or be homicidal. In addition, a person may be considered a danger to themselves if they are exhibiting highly risky behavior, as can sometimes be found during a manic episode. Please note that self-harm, such as cutting, does not automatically mean that a person is suicidal.

• The Ask Suicide-Screening Questions (ASQ) Toolkit can be used by clinicians as a quick screening measure for suicidality.

Psychotic episode

Psychotic episodes include hallucinations and delusional/disorganized thinking. Hallucinations frequently put people in perilous situations. For example, a person may hear a command hallucination telling them to act dangerously and want to follow the voice’s directions. Delusional thinking, correspondingly, usually prevents someone from functioning in reality. For instance, a person may suffer from paranoia and not be able to do anything productive because they are afraid of constant imaginary threats. 

A lack of minimal functioning

Certain people get to a point where they are simply unable to take care of themselves and stop functioning at work, school, and home. For example, they may exhibit a total lack of hygiene or stop eating. Behavior like this may be due to several factors, including a severe depressive episode or a mental breakdown.

Out of control addiction

Another reason a client may require a higher level of care than outpatient therapy is when a person’s decision-making is being ruled by an addiction. They make choices that hurt themselves and others just to feed their compulsion. When a person can’t achieve sobriety with just the help of outpatient treatment, it may be time to encourage them to consider a rehabilitation facility.

How does a therapist facilitate inpatient hospitalization?

Just because a client may need a higher level of mental health care doesn’t mean that it is so easy to achieve. This is especially the case with inpatient mental health hospitalization. Therapists, in general,  do not have admitting privileges to hospitals. What that means is that they can only recommend hospitalization, they do not have the power to make it happen. 

Certain medical doctors, such as psychiatrists, can—at least temporarily—have a patient admitted to the hospital for psychiatric reasons. But what if your client does not have a relationship with a  doctor with admitting privileges? Here are some options.

Directly encourage the client

The easiest way to have a client pursue hospitalization is to talk to them about it and have them agree to it. Voluntary hospitalization takes away much of the legal entanglements of involuntary commitment. However, the person evaluating the client at the hospital must agree with your assessment or it won’t happen. Still, having an open and honest discussion with your client about their needs is the healthiest and most productive option.

Engage the family

If the client won’t agree to hospitalization, or they are a minor, enlisting the help of the family is critical. First, family members may be able to encourage your client to pursue hospitalization when you cannot. Additionally, family involvement will be crucial to get the client admitted and facilitate discharge planning.

Call 911

Calling the police is a therapist’s last resort. You want to encourage the client to voluntarily go to a hospital or engage the family first. It will make the process so much easier. In a true emergency, however, a therapist can call 911, explain the situation, and let them take it from there. If the hospital deems it appropriate, they will seek an involuntary hospitalization. 

For an involuntary hospitalization to occur, a patient must present as a clear threat to themselves or others. Each state has different laws about involuntary commitment, so it isn’t always a slam dunk. Many clients who probably should be in a hospital are not admitted due to bed availability, red tape, and legal issues.