What Level of Mental Health Care Does My Child Need?

Five years ago, my teenage daughter faced a mental health crisis, and I didn’t even know where to ask for help. Intake workers questioned if she had an LPC, if she’d tried a PHP/IOP, or if I thought she needed HLOC, and I started to feel like I was trapped in a nightmarish game of alphabet soup. Where was my magic decoder ring?

If you find yourself questioning, “What level of mental health care does my child need?” schedule a consultation with The Maples today. We strive to help teens struggling with a range of mental health conditions find the path to recovery.

The Shift from Long-Term Institutions to Different Levels of Care

The first thing parents need to understand about our current mental health care system is that it’s composed of five different levels of care.

Mental health care has come a long way since the 1990s, when my dad worked in a psychiatric institute as an LPC (that stands for Licensed Professional Counselor, by the way). Leading up to that time, teenagers with mental health struggles might find themselves institutionalized for months, even years, sometimes without symptoms that warranted such a long stay.

Therapists, legislators, and other advocates at that time pointed out that adolescents should have a right to treatment in the least restrictive environment possible. Maybe all they needed was to see a therapist once a week. Maybe they needed long-term stabilization in a psychiatric hospital. Maybe they needed something in between.

These experts suggested offering different intensities of mental health treatment based on client needs. Insurance companies, which had grown tired of footing the bill for long-term hospitalizations, were quick to agree. Throughout the 1990s, state hospitals all over the country started closing their doors, replaced by a new system including several escalating “levels of care.”

What level of care does your child need? That depends on their current symptoms and the services required to meet those needs.

Level 1: Individual or Group Therapy (Outpatient)

The lowest level of care is individual or group therapy on an outpatient basis. If your child is beginning to show signs of struggle in the areas of depression, anxiety, academics, socialization, substance use, etc., it might be time to consider finding them a therapist.

As you select a therapist, pay attention not only to their licensure but also to their areas of experience. Each diagnosis, age group, and area of concern requires a different skillset. As professional therapists, we’re obligated to provide services only within our areas of competence and to offer you referrals if we feel another therapist can better meet your needs.

If you’re currently looking for a therapist, you could search a database such as psychologytoday.com or speak to others who have worked with therapists in your community. I’ve found it’s helpful to get your child involved in the search, and definitely in the selection, of that therapist.

Licensing

You’ll notice different licensure letters after a therapist’s name. In addition to the LPCs previously mentioned, you’ll find LCSWs (Licensed Clinical Social Workers), LCDCs (Licensed Chemical Dependency Counselors), LMFTs (Licensed Marriage & Family Therapists), PsyDs (Doctors of Psychology), etc.

State councils issue these licenses, which may vary from state to state. For example, the LPC license in Texas is known elsewhere as a Licensed Mental Health Counselor (LMHC), Licensed Professional Clinical Counselor (LPCC), and other titles. An LCDC license in Texas may be known in other states as a Licensed Addiction Counselor (LAC), Certified Alcohol and Drug Counselor (CADC), etc. Every license has similar variations. Drowning in the alphabet soup yet?

Areas of Expertise

Each license also specializes in its own area of expertise. LPC equivalents generally focus on mental health disorders and treatment. LCSWs focus on social work, which includes connections to resources in the community. LCDCs address chemical dependency issues. LMFTs specialize in relationship work, which often involves more than one person in therapy together at a time. Psychologists focus on testing and diagnosis.

We haven’t even mentioned psychiatrists or PCPs (Primary Care Physicians), the doctors who provide prescription management for those who benefit from medications to support their work in therapy.

Many therapists, such as myself, carry multiple licenses. I’m licensed in the state of Texas both as an LMFT and an LCDC. Each therapist also has their own unique areas of study and experience. For example, I’ve spent the past several years supporting couples facing high-conflict situations, including affairs and potential divorce, as well as parent-teen relationships affected by eating disorders or substance use.

State licenses grant therapists the right to practice only with clients who reside within their own state borders. Some therapists secure licenses in multiple states, but for the most part, your child will need a therapist located (or at least licensed) in your home state, even if you plan to engage in telehealth or other digital services.

Clients often start individual therapy on a weekly basis, although you can always increase or decrease the frequency based on individual needs—and insurance coverage, of course. Many therapists also offer groups that meet once or twice a week, where clients learn skills or address specific issues together.

Outside of counseling, you may be able to find support groups led by nonprofessional members of your community. This is particularly true for substance use support, where groups such as Alcoholics/Narcotics Anonymous, Celebrate Recovery, or SMART Recovery offer free meetings run by peers and facilitators rather than mental health professionals.

If your child begins therapy once a week, escalates to more frequent sessions, and still doesn’t seem to respond to treatment, you may need to consider the next level of care.

Level 2: Intensive Outpatient Program (IOP)

IOPs are facilitated by mental health professionals and usually meet 3-5 days a week for 3-5 hours/day. Programs vary in length from just a couple of weeks to up to 2-3 months and usually culminate in some kind of “graduation” experience.

In an IOP, your teen engages with other teens in several different group therapy activities. Sometimes IOPs meet during the day and include online or in-person school. Sometimes IOPs offer services in the evenings, either in-person or virtually, so your child can continue attending their usual classes. Many also include weekly individual sessions with a therapist or offer family therapy as either a requirement or a supplement.

Not all IOP programs are alike. Make sure you find a program that offers the services your child needs and addresses the specific challenges they are facing.

When your child successfully completes an IOP program, I highly recommend they return to regular individual sessions with their therapist. It can be jarring to go from several hours of mental healthcare and group participation weekly to absolutely nothing. Consider supplementing their regular therapy with group therapy, support groups, and family therapy. The idea is to transition smoothly between levels of care.

If your child engages in an IOP program for multiple weeks and still shows signs of struggle, or if the mental health professionals working with your child recommend it, you may need to consider the next level of care.

Level 3: Partial Hospitalization Program (PHP)

PHPs are IOPs on steroids. They offer many of the same services but meet more often (usually 5-7 days/week) and for longer stretches of time (typically 6-8 hours/day). Since they take up the majority of the day, adolescent PHPs often include online or in-person school as a requirement for participation.

At this level of care, your child will need to make more extensive life changes to participate. They’ll need to enroll in school through the PHP program, which will involve coordinating with school counselors to transfer credits and may also require them to take a break from extracurricular activities. Keep in mind that PHPs can run longer, sometimes requiring several months of participation before graduation.

If your child successfully graduates from a PHP program, I recommend stepping down to an IOP if they still need regular services. Some are ready, or claim they’re ready, to step down to individual sessions with their therapist—but I would advise against skipping levels of care in most circumstances.

If your child continues to struggle at the PHP level, particularly if you worry they are a danger to themselves/others or if the program facilitators recommend it, you may need to consider stepping them up to the next level of care.

Level 4: Residential Treatment

This is the first level of care where your child sleeps away from home. Most residential programs last 1-4 months, but some do offer extended services. The length of stay, even within the same program, will vary from child to child and depends largely on insurance coverage (unless you’re wealthy enough to consider private pay costs, which usually amount to hundreds of dollars/day).

While your child is in residential treatment, the facility will work with your insurance to demonstrate the continued need for services. Insurances typically approve 1-2 weeks of coverage at a time. If they feel your child no longer meets the criteria for 24/7 care, the insurance company can drop coverage at any time. You’ll typically get a few days of warning, but not always. Stay on your toes!

Residential care is intended to help adolescents who need 24/7 monitoring and support. It’s most suited to those who experience regular bouts of suicidal thoughts combined with a tendency toward impulsive actions that may put them suddenly in danger or those who find themselves trapped in unsafe patterns of behavior, such as substance use, that create life-threatening risks.

If your child is able to engage in a residential program and meet graduation requirements prior to the termination of insurance coverage, a celebration is in order. Welcome them home (and directly into a PHP program) with open arms.

While your child is in residential care, if they report suicidal or homicidal thoughts with a plan and intent to act on that plan, or if they experience audiovisual hallucinations or other acute psych symptoms, the residential facility may choose to step them up to the highest level of care at a behavioral hospital. Most residential facilities will accept your child back when they are discharged from the behavioral hospital to continue their residential stay, but not always. Stay in close contact with the residential facility to determine next steps.

Level 5: Hospitalization for Crisis Intervention

Whether your child is completely outside the mental healthcare system or in one of the other levels of care, if they report active suicidal/homicidal thoughts with plan and intent or experience acute psychiatric symptoms such as hallucinations or overdose, they may jump directly to hospitalization. Typical stays at behavioral hospitals run 5-14 days.

Behavioral hospitals are sometimes referred to as HLOC (pronounced “H lock”), which stands for “higher level of care”—although the term is also sometimes used to indicate a higher level compared to the one where your child is already receiving services. For example, if your child is engaged in an IOP program and their therapist tells you they may need HLOC, you could ask to clarify if that therapist is recommending a PHP, residential program, or hospitalization. (See how much you’ve learned?)

The goal of hospitalization is to stabilize meds and symptoms until your child is no longer a danger to themselves or others. Once stabilized, I highly recommend you consider enrolling your child in an IOP/PHP at least. If they have experienced multiple hospitalizations or demonstrate a continued need for 24/7 care, consider a residential facility.

Navigating the Levels

Now that you understand the different levels of care, try to envision them as a funnel of connected services. The goal is to move your child up and down the funnel using smooth transitions. If they go from 24/7 monitoring and support at a residential facility to one weekly therapy appointment, I foresee problems.

Make sure the professionals who work with your child at each level of care communicate with each other. If you decide to step your child up from a PHP to a residential facility, that residential facility should request records from the PHP. When your child is ready to step back down and return to their PHP program supplemented by weekly therapy, both the PHP and the individual therapist should coordinate care with the residential facility.

Understand Which Level of Mental Health Care Your Child May Need With Help From The Maples

The transition in mental health care from long-term institutions of the last century to our current levels-of-care system has helped to individualize treatment. Unfortunately, we haven’t done a great job educating the public on how to navigate the new system. I know I felt lost as a parent. Now that you know, spread the word! A lot of adolescents and parents out there need help. Let’s make sure they know how and where to get it. If you are wondering what level of mental health care your child needs, contact The Maples to schedule a consultation.