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When Does an Adolescent Need a Psychiatric Hospital vs. A Lower Level of Care?

Written by Evolve's Behavioral Health Content Team​:

Alyson Orcena, LMFT, Melissa Vallas, MD, Shikha Verma, MD, Ellen Bloch, LCSW, Lianne Tendler, LMFT, Megan Johnston, LMFT
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How Can Parents Tell What Level of Care Their Teen Needs?

Mental health disorders, like any other type of illness humans experience, come in all types. This is true across the lifespan: children, adolescents, adults, and seniors can all develop mental health disorders. Although the disorders share similar characteristics when they appear in the different phases of life, mental health professionals use slightly different criteria for diagnosing a disorder in a child as opposed to an adult or a senior.

However, when determining a level of care, the criteria for a child, adolescent, adult, or senior remain relatively stable. When assessing an individual to decide what level of care is appropriate for their condition, mental health professionals first think of disorders in three general categories: mild, moderate, and severe. They form their initial opinion on an appropriate level of care based on the frequency, duration, and intensity of the symptoms of the disorder.

Once they have a basic idea of the level of severity of the disorder, they use the following criteria to make a definitive referral:

1. Level of symptom acuity.

This refers to how serious the symptoms of their disorder are at the time of assessment.

2. Level of symptom disruption.

This refers to the level of impact the disorder has on the day-to-day emotions, thoughts, and behavior of the teen who needs treatment. Symptoms that cause significant disruption trigger a recommendation for one of the more immersive levels of care.

3. Treatment history.

A teen who has received treatment at one of the less immersive/intensive levels of care without success will most likely receive a referral for a more immersive/intensive level of care.

Whether they’re mild, moderate, or severe, all mental health disorders are serious. Which means that when left untreated, they can escalate. In the absence of professional support, a mild condition can change to a moderate condition, a moderate condition can change to a severe condition, and a severe condition can become a crisis. A mental health crisis – depending on the specific condition – can be dangerous. With a disorder such as depression, for instance, a crisis can lead to a suicide attempt, which, in some cases, can end in death.

That’s as serious as it gets.

What Are Levels of Care?

The tendency of untreated mental health disorders to get worse over time is one of the main reasons it’s critical for parents of an adolescent with mental health disorder to find the best treatment available at a level of care that meets the needs of their teen. The appropriate level of care can be life-changing in the best possible ways, whereas a level of care that’s inappropriate or insufficient can result in unnecessary emotional and psychological difficulty.

We’ve used the phrase level of care several times already. We’ll explain exactly what it means now and describe the different levels of care, with a special focus on the difference between the type of care offered in a psychiatric hospital – known as inpatient hospitalization – and the less immersive and intensive levels of care. We’ll start by describing the four most common levels of care, which we call the lower levels of care in the title of this article.

Mental Health Treatment: The Four Common Levels of Care

1. Outpatient Treatment Programs

Outpatient treatment is the least immersive level of care. Teens in outpatient programs see a psychiatrist, therapist, or counselor once or twice a week. Teens with symptoms that do not significantly impair their ability to go to school or disrupt their family or peer relationships typically begin with outpatient treatment.

2. Intensive Outpatient Programs (IOP)

Intensive outpatient treatment is the next level up from outpatient treatment. Teens in IOP programs participate in treatment for around three hours a day, three to five days per week. Teens with symptoms that do not impair their ability to live at home or go to school – but are nevertheless disruptive – typically receive a referral treatment at the IOP level.

3. Partial Hospitalization Programs (PHP)

Partial hospitalization programs are the next level up from intensive outpatient programs. Teens in PHP programs receive a full day of treatment, five days a week. Teem with symptoms that disrupt day-to-day living and impair their ability to participate in school typically receive a referral for a PHP program. Teens in a PHP program typically continue to live at home, rather than at the treatment center.

4. Residential Treatment Centers (RTC)

Residential treatment is the most immersive of the four basic levels of care. Teens in RTC programs live on-site at the treatment center. Teens with symptoms that prevent them from participating in family life, social life, or going to school typically receive a referral for a program at an adolescent residential treatment center. These programs give teens the time required to focus on recovery and learn to manage their symptoms so they either return home or step down to a less immersive level of care.

Those are the basic, most common levels of care – the lower levels, as it were. The next level of care up from these four basic levels in inpatient treatment in a psychiatric hospital. Before we move on to that level of care, we want to make sure that parents understand that all the levels are important, and that IOP, PHP, and particularly RTC programs support teens with significant and severe symptoms. Teens in RTC programs need immersive care and monitoring 24/7, but they serve a different purpose than inpatient treatment.

High Acuity Teens in Crisis

The thing that separates the need for an RTC program as opposed to the need for inpatient treatment in a psychiatric hospital is the level of acuity, which we mentioned above. Level of acuity refers to how immediately serious the symptoms of the mental health disorder are at the time of assessment. A teen in danger of harming themselves or others is considered in crisis. That’s the highest level of acuity – and that’s the criteria for a referral to inpatient treatment at a psychiatric hospital. A teen in crisis needs a higher level of monitoring and support than a teen in residential treatment. That additional support is critical, and in some cases, for a teen in crisis, can be the difference between life and death.

We don’t do hyperbole, and that’s no exaggeration: for teens in serious crisis, psychiatric hospitalization may be the only appropriate level of care.

We’ll now talk about why that’s the case – and why we’re not exaggerating.

What is Inpatient Psychiatric Hospitalization?

Inpatient Psychiatric Care vs. Lower Levels of Care: What’s the Difference?

Inpatient mental health treatment at a psychiatric hospital is different than any other level of care. It’s most similar to residential treatment, which is another form of inpatient treatment, and quite different than the outpatient programs, intensive outpatient programs (IOP), and partial hospitalization programs (PHP) we discuss above. Each level of care is appropriate for teens with specific needs related to their diagnosis, whether the diagnosis is for a mood disorder, an alcohol or substance use disorder (AUD/SUD), or a behavioral disorder.

Most people understand the difference between IOP, PHP, and RTC because of one factor: in an RTC program, teens live on-site. In IOP and PHP programs, teens live at home and attend treatment for either a full day or a half day. Most of these programs run Monday-Friday, and are designed to either mirror or accommodate work and school schedules.

In both RTC programs and inpatient programs in psychiatric hospitals, teens live on-site and received 24/7 support and monitoring. That’s why most people don’t immediately understand the difference between RTC programs and inpatient programs.

There are significant differences, though. In general, the differences revolve around:

  • Treatment goals
  • The environment in which the treatment and support occurs
  • The type of admission: voluntary or involuntary
  • Policies around contact between staff and teens, particularly in crisis situations
  • The length of stay

We’ll explain what we mean, beginning at the top of the list.

Treatment Goals

The primary goals of inpatient treatment at a psychiatric hospital are safety and stability. Hospital staff monitors the physical and emotional of a teen until their crisis has passed, whatever that crisis is or may have been. When they’re no longer in immediate danger, hospital staff will assess their condition and release them to a less intensive and immersive level of care, such as an RTC program.

RTC programs, on the other hand, focus on therapy and treatment, rather than short-term safety and stability. Safety at any RTC always comes first: that’s a given. Teens in residential treatment are at a lower level of acuity than teens in inpatient psychiatric care. This means they’re more likely to be in a psychological and emotional condition conducive to therapy. Teens in a psychiatric hospital are most often there to prevent serious harm – and that takes all their energy. Teens in an RTC are past that phase, and therefore use their energy and time learning to manage the symptoms of their mental health disorder.

The Environment

In most cases, a psychiatric hospital looks like a typical hospital. The environment is sterile, institutional, and generally impersonal. Most psychiatric hospitals keep all doors locked, and hospital staff monitor and determine who does what, when, where, and why. Common rooms, bedrooms, and eating areas are locked and off-limits when not in use.

The environment in a typical adolescent RTC is far different. Teen RTCs are often located in residential homes that have been repurposed as mental health treatment centers. While a psychiatric hospital may have dozens of patients at a time, a teen RTC often has a low census – a.k.a. number of teens receiving treatment – and a high staff to teen ratio. RTC staff offer 24/7 support, monitoring, and care. But in an RTC, staff allow teens more freedom of movement. The doors between the common areas, living areas, and bedrooms are not always locked – although staff do monitor teens closely. Treatment is intensive, full time, and immersive. The overall feel of a teen RTC, in comparison to a psychiatric hospital, is less restrictive, more open, and less institutional. Most teen residential treatment centers are designed to put teens at ease and make them feel comfortable and at home, which facilitates treatment success.

Admission Type

While rules regarding admission may vary from state to state, admission to an inpatient psychiatric hospital may be involuntary residential. A psychiatrist can refer a teen for involuntary hospitalization to ensure their safety and the safety of others. In contrast, admission to an adolescent RTC is most often voluntary. When a teen initiates treatment at an RTC, it’s most often the result of a collaborative decision-making process including the teen, their parents, and their psychiatrist/therapist.

Contact: Hands-On or Hands-Off

Like admissions, the rules regarding what kind of contact between staff and patient vary from state to state. In most cases, regulations permit staff in psychiatric hospitals to put hands-on a teenager in when they’re in crisis. This generally only happens when behavior threatens the safety of the teen, the safety of other patients, or the safety of the staff. RTCs, in contrast, however, most often follow hands-off policies. This means that treatment center staff are not allowed to physically touch, control, or restrain a teenager during a crisis.

Length of Stay

A stay at a psychiatric hospital is most often short – a week to ten days at most, and around three to five days at least. An adolescent experiencing a mental health crisis will typically stay between three and seven days. Medical staff ultimately determine the length of stay, based on their professional assessment of the safety and stability of the teen. When the crisis passes and the teen is not a danger to themselves or others, a psychiatrist will release them – most often to a less immersive and intensive level of care, such as a teen RTC.

The length of stay at a teen RTC is typically longer than a stay at a psychiatric hospital. A common duration for an RTC program is around four to six weeks, but some teens need more time, and may stay for three months or more. Factors affecting the length of stay include treatment progress, family input, and insurance coverage or available resources. RTC staff monitor progress closely. When a teen learns to manage their symptoms, tolerate stress, and develop practical, real-world coping skills, they may return home or step down to a less immersive/intensive level of care, such as a PHP or IOP program.

The Bottom Line: A Teen in Crisis Needs the Most Intensive Care Available

That’s the simplest answer to the question posed in the title of this article: an adolescent needs a psychiatric hospital – rather than one of the more basic or lower levels of care – when they’re a danger to themselves or others. Danger to themselves includes suicide attempts or other forms of self-harm like cutting, known as non-suicidal self-injury (NSSI). Danger to others may include the violent or aggressive behavior displayed by teens with severe behavioral disorders, teens with disorders such as psychosis, borderline personality disorder, other related anger/emotional regulation disorders, or teens whose behavior is compromised and dangerous because of alcohol or drug misuse and/or addiction.

Psychiatric hospitalization is an extreme step reserved for extreme situations, but for the health and safety of everyone involved, there are times it may be necessary. And sometimes, it’s the only safe choice. Admission to a teen RTC is also a relatively extreme step – sending a teen away from home to live in a treatment facility is no small thing – but it’s also a step that families take after careful thought and deliberation, rather than in the heat of a crisis.

In both cases – admission to a psychiatric hospital and admission to a teen RTC or lower level of care – the goal is to help a teen heal. Hospitalization can stabilize them and enable them to engage in treatment. Their treatment can help them develop the skills they need to return home and participate in daily life with family and friends.

It takes time and effort to develop those skills, especially with a severe mental health disorder, but the time and effort are well worth it. Treatment can help restore balance to the family and help a teen reset, recalibrate, and rebuild their life on their terms: that’s worth any amount of time and energy.

Finding Help: Resources

If you’re seeking treatment for your teen, please navigate to our page How to Find the Best Treatment Programs for Teens and download our helpful handbook, A Parent’s Guide to Mental Health Treatment for Teens.

In addition, the American Academy of Child and Adolescent Psychiatry (AACAP) is an excellent resource for locating licensed and qualified psychiatrists, therapists, and counselors in your area. Both the National Institute of Mental Health (NIMH) and the National Alliance on Mental Illness also provide and high-quality online resources, ready and waiting for you right now.

Our Behavioral Health Content Team

We are an expert team of behavioral health professionals who are united in our commitment to adolescent recovery and well-being.

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