The Intensive Outpatient Program

At the end of the post regarding Nathan’s experience in the Partial Hospitalization Program at the Loma Linda University Behavioral Medicine Center, I mentioned that his next step was the Intensive Outpatient Program (IOP). This post will be about our experience with the IOP program. I’m writing about it with the thought that even if you can’t use this particular program, you may want to know what goes on in programs like this.

The webpage for the IOP says that the program is for adolescents whose needs are somewhere between partial hospitalization and having a couple of office appointments per week. This means that a teen can go into the IOP as a step up from office visits, or as a step down from partial hospitalization (as was the case with Nathan). The program sometimes has a waiting list.

The IOP is mostly about group interaction between teens and their counselor. (From what I could see, psychiatrists were not directly involved in the program.) However, the program also requires significant parent participation. And that makes sense, because we can be more effective parents if we have better insight into our kids’ conditions, our families, and ourselves.

The program takes nine hours a week for the patients, from 3:30 to 6:30 pm on Mondays, Wednesdays, and Thursdays. Parents spend four hours a week in meetings. A teen typically spends 6 to 8 weeks in the IOP. Attendance policies are fairly strict: only three excused absences are allowed. There are also restrictions for dress code, contraband (including cell phones!), patient conduct, and contact between patients outside the program (including social media).

The IOP has three separate tracks:  Chemical Dependency, Dual Diagnosis (a mental health diagnosis plus abuse of drugs or alcohol), and Mental Health. A group for teens engaged in self-injury has been added in recent years. Nathan was in the Mental Health track, which according to the webpage “… is designed for adolescents struggling with depression, suicidal thoughts, mood swings, ADHD, ADD, anger, anxiety, and impulse control. Patients and their families learn healthy coping skills and communication.”

Patients are assigned to a particular group of 6-10 teens and a counselor. Nathan knew some of the teens in his group because they had overlapped in the Partial Hospitalization program, but the composition of the group changed as some patients finished and were replaced by new patients.

Each afternoon they meet, the groups usually spend an hour learning about social skills and an hour discussing the individual situations of group members.

As I mentioned in the Partial Hospitalization post, group therapy was not a good fit for Nathan. He did not care about, and would not comment on, the issues other group members were facing. And, he really disliked it when people who basically didn’t know him gave their opinions about his situation! Especially given that (in his way of thinking) they would never understand his worldview, mostly due to lack of intellect. He remained aloof from the other teens throughout the program.

One of the exercises in Nathan’s group was to draw a picture showing “what they saw themselves doing two years from now.” We know this, because the counselor showed us Nathan’s picture in a private meeting not long after the assignment. The picture featured stick figures. One was holding a gun, and the rest were lying on the ground with x’s for eyes and pools of blood all around. Yes, that was cause for concern! We figured it partly reflected his mental state, but mostly was drawn out of boredom and for shock value (mission accomplished, that’s for sure.)

Anyway, the groups meet until 5:30, and then the parents arrive for an hour-long Multi-Family Therapy Group. Our group talked about things like Ways to Show Love, Who Owns the Problem?, and Dealing with Conflict. One of the more significant exercises was for parents and teens to compose a “Love Letter – The Complete Truth”, with prompts including “I’m fed up with …”, “I feel hurt when …”, “I feel scared that …”, “Please forgive me for …”, “I wish …”, and “I love you because …”. Reading those love letters aloud often resulted in teary eyes all around.

The large size of the group meant there wasn’t time in an hour to go in depth on each family’s issues. Our counselor was skilled in sensing when a family needed extra time during the hour, and also realized that it was generally better to keep Nathan’s time in the spotlight to a minimum.

In our group, one family who’d been there awhile had a teenage daughter. She was lively, insightful, supportive of others, and seemed to get along well with her family. Her mother told us that not long before, her daughter had been a lying, combative problem child. How encouraging to witness that success story, and see the family leave the group with hope for the future! In other families we could see hints of progress in the patient, and sometimes the parents also seemed to be getting a better handle on things. But then there were teens who maintained a sturdy “I-don’t-care” barrier, making progress difficult at best.

If a patient was leaving the group, he or she was asked to share what they had gained during the process. All multi-family meetings would end with the counselor asking each patient whether they were “safe to go home.” If someone was having a birthday or was leaving the group, the family might bring pizza or snacks to share once the session was over.

Another component of the IOP is the Parent Support Group (aka Parent Survival Skills Group), which meets for an hour (4:30-5:30) before the Multi-Family Therapy Group. A parent from each family is supposed to attend at least one of these meetings each week. Parents from all the groups gather to learn coping skills, ask questions, or vent. I recall that the people leading the meetings I attended were staff members who also had personal experience with troubled teens in their own family, making what they had to say carry that much more weight. One saying that stuck with me from these sessions is: “You didn’t CAUSE it; you can’t CONTROL it; you can’t CURE it; but you can CONSEQUENCE it.” Different parts of that saying have been valuable for me at different times.

When Nathan started the IOP, I didn’t think I had much to learn about improving our family dynamics – but of course, I did, and was glad to have learned it through all those hours of meetings. Sadly, Nathan himself appeared to gain little from his weeks in the IOP. His counselor recognized it, and one day recommended to us that we call it a day.

The counselor didn’t announce to the group when it was Nathan’s last day, sensing that it was better to let him go without fanfare. However, after the meeting she quietly gave him a metal token inscribed with the words “You are a Miracle.”

Although Nathan did not appear to benefit from the program at the time, we’ll never know if things would have been worse if he hadn’t been in it. Sometimes, lessons and experiences can end up paying off months or years in the future. Possibly, his time in the partial hospitalization program and the IOP have contributed to the relative stability we are seeing in him today. So, no regrets.