Models of Co-Occurring Mental Health and Addiction Treatment | Counseling Continuing Education

Hi everybody and welcome to today's class on the models of treatment for co occurring disorders. Over the next little while we're going to identify the most common settings for co occurring disorders treatment. Now you remember co occurring disorders means that person has an addiction and a mental health issue, among other things. A lot of times there's also physical stuff going on, but we want to look at the fact that addiction and mental health are both co occurring. As the name implies, we'll differentiate between the levels of treatment from intervention to residential level 4, identify specific characteristics of treatment in problem solving courts and jails. And we're going to talk about, you know, the caveats, the benefits and the drawbacks to each type of treatment and each treatment setting. So settings, health departments and social services centers. A lot of times that is just your regular outpatient. Now I've had the privilege of working in all of these settings. So we're going to talk about some of the my experiences that you know, may help you figure out where you might want to work in health departments and social services. I was stationed at the food stamps office in order to be able to connect with people who were receiving services, you know, food stamps, any TANF services who also needed counseling. So that was really rewarding and I enjoyed working with those people. They came in. Like we will talk about when we get down to jails, there was a reason, there was an emphasis, there was consequence if they didn't come see me. So it helped a little bit to ensure people were coming. Now whether we were ensuring that they were interactive is a little bit of a different story. And if you like working with involuntary clients, then jails and social services are really good places to be. And I happen to enjoy that population because it's, it's always sort of a, I don't want to say game because this is people's lives, but it's always sort of a puzzle to me to try to figure out what's going to motivate somebody to continue to do the next right thing, at least for as long as they're required to. Behavioral health care centers. Now this is by far the most common. Most of you have probably done internships at some sort of behavioral healthcare center, residential treatment facility, and obviously you can serve a whole bunch of different types of services. Where I worked, we had a crisis stabilization unit, a detoxification unit, a methadone clinic, residential intensive outpatient, regular outpatient and regular outpatient mental health. So we had a whole range of services that we offered and you could kind of move between the different departments if you decided you wanted to change a pace for a while. Private practice offices are another place that you can see clients and a lot of clinicians in private practice, LMHCs, LCSWs, LMFTs see people who present primarily for depression or anxiety or something like that. But there is a strong rate of co occurrence between mental health issues and substance abuse issues. So, you know, it's important that clinicians in private practice at least be aware of the fact that there is a good chance that the person you're working with has an addiction of some sort or will struggle with that during some period in their life. What does that mean? That means clinicians ideally should have a general understanding of addiction, addiction treatment recovery principles because they work together. Cognitive behavioral works really well with addiction as well as, as well as mental health. So what we want to do with addiction is help people identify the reasons that they're using and find better ways. Because a lot of times addictive behaviors are ways of dealing with emotional or physical pain. Now that emotional pain can come when people start using. Maybe they're using, using recreationally, then they start using a little bit more. When things get tough or whatever, their brain chemistry changes. So now their brain is used to having that substance in their body in order to regulate the neurotransmitters. So in order for the person to feel what they consider to be normal baseline for them, they need to have that substance which is going to prompt them to want to use and to crave the drug until the body gets used to not having it anymore. So it's important to help people figure out, you know, what's prompting these cravings. Some of it's physiological, but some of it is often psychological. Different people, places, things, emotional states may trigger people to want to use, but that's a whole different presentation. Hospitals provide co occurring disorders treatment. A lot of hospitals have a wing for patients with psychiatric or addictive issues that have to be monitored 24 hours a day, seven days a week by medical staff because they are that medically unstable. Schools. When I worked at the schools it was great. I would go in and meet with the guidance counselor who would set me up in an office. They'd go get the kid, the kid would come, we, we would talk for a while and do our thing. Now schools are wonderful and providing co occurring disorders treatment in schools is helpful because a lot of times juveniles can't drive. So even if they want to get to appointments, they can't because a lot of times mom and dad are busy they're working, they're doing something else. So this removes one of the accessibility barriers. And I found that when I would go to work with kids in schools, they enjoyed it because, number one, they were getting pulled out of class, so bonus. And number two, they didn't feel like, okay, mom's on the other side of the wall. Is she listening in? So they felt a little bit more relaxed than they would in a clinic sort of setting. So schools can be a really good place to provide interventions. Jails. Now, I really happen to like working with the correctional population. People who are in jail or who are on probation and parole, you know, they're on what we call papers. They have to participate, they have to stay clean, they cannot test dirty. But when people are in. Let's talk about jail and prison, specifically when they're still on lockdown. A lot of jails and prisons unfortunately will discontinue medication when somebody is admitted to the jail or prison, just to see how they make it when they're not on meds, because the jail or prison does not want to pay for their medicine, which means people tend to destabilize pretty quickly in jail. So, okay, let's say this is a good jail and the people who came in on meds stay on meds. Even if that's the case, you can imagine what it's like living with the same people day in and day out. And most of the people there probably have some interpersonal skills deficits. So there's going to be tension, there's going to be occasional anger, there's going to be depression because the person who's incarcerated may be missing their kids, graduation or whatever. So there are a lot of situational mental health issues that come up, as well as just the fact that people may have already been depressed or anxious. On top of that, you've got substances. And I would like to say that jails are substance free, but I'm a realist and I've worked in them long enough to know that substances do get in. You know, sometimes it's cocaine, pcp, lsd, morphine. You know, there I've seen pretty much every drug get into the jail. You know, they can't have the things that can be. They have to be smoked. So it has to either be able to be snorted or eaten most of the time because it's hard for them to get access to needles as well. So smoking and injecting methods are out. But the point being, when people are in jail, it doesn't mean they're necessarily clean. The people who are clean, the people who aren't using their brain may be restabilizing and getting used to being without the drug, but they've got a lot of stuff to deal with. They need to develop alternate coping skills. So when life hands them lemons, they don't want to relapse. They need to be provided the skills and tools that they need. So when they get out, when they do have access to those substances, again, freely, they're not tempted to use them. And so while they're in jail, when they do have access to the substances, they. They're not tempted to use them. So jails provide an opportunity to provide in a relatively controlled environment, to provide people with the skills and tools they need now. Well, we'll talk about these when we get a little bit further. But I will say with residential treatment in a behavioral health care center, hospitals and jails, the skills people are learning are wonderful. But when they're in those environments, those are very controlled environments. They're not having to pay bills, they're not dealing with traffic, they're not dealing with landlords or significant others or other things that could trigger them. So going from a controlled environment to being released, like once a week outpatient is really not a good idea. People need to step down. And the best analogy I can make for most people is think about when you went from high school to college. You know, that was just culture shock. And you went from having a curfew and having mom and dad supervising you, living under their roof, having teachers henpeck you for your homework every day and all that kind of stuff to nobody really took attendance. It didn't matter if you went to class or not. And you could stay up until 2 or 3 in the morning partying if you wanted. So it was very tempting and it was very easy to not do what you were supposed to do when you got to college if you didn't have some structure going into it. When I was a freshman in my sorority, we had to put in a certain number of study hours every week, and we had to maintain a certain gpa. So that helped me learn better study habits. And, you know, eventually when I got out of my sorority, I didn't have somebody telling me, you have to study for two hours today. But. But I already had those habits ingrained, so it wasn't a big deal to me to continue with those things. We want to see the same thing with people who are coming out of jails or residential facilities. We want them to step down. It may only be for A month or so where they're in intensive outpatient and they're checking in every single day. And then they can step down and maybe check in twice a week and then step down again to one once a week, individual therapy or something. But it's always good to scaffold that step down to make sure that they can deal with life on life's terms in the world out there. So prevention is one level of treatment and it's not really treatment. It's obviously prevention, but there are multiple types of prevention. Now prevention, like most people think about it, is ever get the problem? Okay, that's your traditional prevention. And yes, it's great. The goal is to avert problems before they begin through modifying risk and protective factors in the following domains. Individual risk and protective factors like we want to modify the depression, we want to make sure they've got good coping and interpersonal skills, we want to make sure we screen for any learning disabilities, etc. Family risk and protective factors. They found that families that are closer knit where there's stability, where there's consistency in parenting, and where there's adequate social support is obviously a protective factor. Schools we want schools that encourage interaction. We want schools that encourage students to partake in activities and feel like they're connected with the school. And we want schools that emphasize helping students learn. And in the community, prevention can start out with working with law enforcement and legal officials to make sure that the community enforces the drug free standard in the community. It can work to clean up drug ridden areas in the community. Not only getting rid of the drugs, but we want to give some people something else to do. We can start having social events, we can start having movies on the lawn at the, you know, downtown plaza. We can start having activities at the library in order to get people engaged and again feel connected. Those are all ways that we can help prevent problems. Along with this, we can do some education about drugs and substances and how easy it is to get addicted and that it's not just willpower. Once people start using, it actually changes their brain chemistry, which can revert, but it takes time. So it's important that people are aware of that. So that's prevention and you can use this. Other examples are educating children about drugs and their effects, improving communication among families, ensuring children are able to engage in school. That doesn't mean just go, that means engage. They've got enough clothing, they're warm enough or cool enough as the case may be, and they've got enough food in their bellies that they're not hungry. And they're able to. They have a safe home environment, so they're not exhausted when they get to school because they were just too terrified to sleep all night long because they were sleeping in the car or in the middle of a domestic violence. Domestic violence episode or something. So we want to make sure that children are happy, healthy and engaged. And we can improve community stability, organization and attachment by offering things that the community can do. And we can also make sure that things like transportation are available to help people get to work and that there are jobs available. I know around here right now there are jobs. Just everywhere I go, there are signs up saying, you know, now hiring. And there almost always are. Unfortunately, in this community where I live now, there's no transportation. So. And it's a pretty rural community. So unless you've got a friend who can drive you or you live in close. And there aren't very many apartments. So, you know, it's a, it's a double whammy. But, you know, we want to make sure people not only can earn a living to keep a roof over their head, but they can also get to that job to earn a living. So those are all things we can do for primary prevention. We can also educate the community about mental health issues. The chances of somebody developing an addiction increase if they have depression or anxiety or bipolar disorder. So these are things that we want to make sure that the community is aware of and that they know where resources are. Another type of prevention is called secondary prevention, which means, okay, we didn't prevent the first thing from happening, that stinks, but we can keep it from getting any worse. You know, let's stop it in its tracks, prevent it from getting worse. And this is when we have intervention level services, outpatient services available, hotlines available. This is when the services at the social services offices as well as schools can become really helpful to stop it in its tracks before it becomes a big problem. The third type of prevention is called tertiary prevention. And that means we're going to prevent this problem from causing more problems in other areas of the person's life. So, okay, maybe they've developed a full blown addiction and you know, they're really struggling with it. All right, that's a problem. But tertiary prevention would say, let's make sure we prevent you from getting hepatitis because that's going to be a whole other ball game. Let's make sure we prevent you from going to jail because legal issues are going to complicate the picture. Let's make sure we prevent you from Becoming homeless, because again, that'll complicate the picture. Let's deal with this addiction. You know, we didn't prevent it, we didn't stop it in its tracks. But let's prevent other problems from happening because you've developed this addiction now. So prevention has primary, tertiary or primary, secondary and tertiary aspects to it. Intervention provides resources to prevent worsening of an addiction or other biopsychosocial issues that could lead to addiction. Methods include psychoeducational groups and classes. When you do the groups on self esteem development and coping skills and dialectical behavior therapy, acceptance and commitment therapy. And those can be done. They don't have to be clean clinic based things. A lot of times people don't feel comfortable going to a clinic. So if you offer workshops and you call them workshops in community education, offer workshops at libraries, offer go to different festivals and have tables where you provide handouts that help people learn about resources that are available. Early identification of persons with risk factors for mental health, stress related or substance abuse issues are also effective methods of intervention. Early intervention, this is when they might be using, but it's not a problem yet, or they might be getting kind of blue, but they're not clinically depressed yet. Early identification can happen at the doctor's office. It can happen at schools, you know, school counselors or even the teachers. It can happen at wellness fairs, at employers wellness fairs. It can happen at, you know, any sort of festival that the community has. If you have a table out there, then people are able to, you know, come up and get information. You can also identify people early nowadays online, if your facility has a online screening that people can take and if they score a certain level, it sends a referral to, you know, whomever or it gives them a referral so they know that they can call a clinic in town and get services. Intervention services are typically either once, like in a screening or once a week. You're not going to have something that's meeting a whole lot and it's generally in a group situation. So it's affordable for people, whether it's free, you know, offered at a library or a church or a community center. Or it is, you know, something that is low cost and you know, generally 5 to $15 per group is, seems to be the steady going rate. I know around here sometimes they charge like $40 per group. But for intervention we, we really want people to come. We don't want finances to be a barrier. So, you know, it's better to have 15 people in a group at $15 per group than to have six people in a group at $40 per group. As far as reaching people and actually doing prevention, you know, the money you could, I didn't check the math on that, but either way, you can, you can kind of make it work. You can also do intervention via the phone or online, you know, via telehealth. So if you have people, if you live in a rural area like I do, you know, you can reach out to people this way. And obviously you have to have their account. You know, you have to be able to connect with them. So they would have had to reach out to you because they got a referral from their doctor or their pharmacist or somebody. But you can provide intervention services that way. You can even do psycho educational groups online through something like Zoom or GoToMeeting, as long as you get a business associate agreement signed in order to ensure HIPAA compliance. Outpatient is individual and group counseling sessions. And this typically meets one to three times per week. And depending on the level of impairment of the individual, sometimes you can get insurance companies to pay for up to three times per week, but a lot of times they want you to move them down to traditional once a week outpatient pretty quickly. Now the caveat with that is you can often get one hour groups three times a week. So if somebody really needs to be checking in a couple times a week, trying to implement groups in your practice can be a way to do it, to make sure you can serve the most people and get reimbursed for it and all that kind of stuff. Outpatient groups can be held in a clinic, at a school, online. Like I said, you can do groups or in the person's home. Now group in the home is going to be more like a family multifamily group where the primary family, mom and dad are there and then maybe grandma and grandpa come and you have that kind of counseling session. But there you can do outpatient counseling in a variety of ways. I even know one therapist who got an RV and converted it to an office. And she drives around to different neighborhoods and provides training or provides counseling so people don't have to worry about finding transportation issues that can be handled in outpatient include coping skills, maladaptive emotions or reactions, thoughts or behaviors. So pretty much anything that you would qualify as a mental illness or a mental health issue, relationships and interpersonal issues, and past traumas and losses. In addition to addiction, outpatient counseling can address addiction. Everything from Internet addiction to smoking cessation to alcohol and drug addiction. Intensive outpatient involves Both individual and group counseling sessions. Generally it meets three to five times per week for a minimum of three hours per day. So how does that work? Well, generally in iop, you start out at five days a week for three hours a day plus an individual with your primary therapist each week. Then as you have a certain number of clean urines, the longer you're clean, then you get to step down so you're not having to come as often. So if you go a month and you haven't relapsed, then you may get stepped down. So you're only coming four days a week and then the individual with your therapist and then three days a week and two days a week, et cetera. The biggest thing is the clinician wants to see and make sure that you are that the person is safe. This can be done in a clinic or online. The Substance Abuse and Mental Health Services Administration has done a lot of research with the effectiveness of online counseling and they found that for doing iop, if you do it online, you want to have video for every single participant. That way you can see how people are doing and how they're reacting and you're not losing the non verbals and they have to have a good Internet connection. So there's not a big lag. But other than that, online can work pretty well. Issues for intensive outpatient the same things that you would treat in regular outpatient, just for people who are struggling and have a more acute problem. Coping skills, mental health issues, substance abuse issues, relationship and personal issues, and past traumas and losses. Partial hospitalization. Now this is a little bit more intense. So instead of being five days a week for three hours, this is five days a week for typically six to eight hours, the patient sleeps on campus. This is always offered either in a hospital or a clinic setting. And it treats mental health and substance abuse issues, interpersonal issues and trauma. Short term residential has individual and group counseling sessions. Now, if you've been in residential or if you've worked in residential, you know that their residential facilities are required to provide a certain number of group hours per day. Where I worked it was four hours of group per day, seven days a week and one individual counseling session minimum per week with their primary therapist. Short term residential is considered short term. Up to 60 days, the patient sleeps on campus. In short term residential, there is awake staff 24, 7, but a lot of times the nighttime staff are technicians. There is not counseling staff, it's not a doctor. Some states require that there's an LPN on the premises during that period of time. Other states only require that the medical staff be reachable during during the night. So depending on your situation. But short term residential is just what it sounds like. The person is living there for up to 60 days. Short term residential is really helpful for people who are struggling to stay clean and sober, who are struggling with suicidal ideation or their anxiety issues. We want to make sure that they're in a safe environment. And this provides supervision 24 hours a day, seven days a week. Long term residential provides individual and group counseling sessions with the same frequency. You know, about four hours a group a day, seven days a week and at least one meeting with a primary therapist every week. It can last for up to a year. And places like oh golly, Phoenix House and some other therapeutic communities qualify under long term residential. And there are some non therapeutic community long term residential programs. They're fewer and farther between. Long term residential is really good for people who have had difficulty. They've been in other programs before, they haven't succeeded. They really need that kind of structure. It's beneficial for people who have cognitive difficulties in addition to their other mental health and substance abuse issues. In long term residential, the person can get their medication managed a little bit better. Short term residential, you know, a lot of your SSRIs and things are just really getting into your system and getting stabilized in 60 days. So the doc's really not sure at this point whether it's the right set of medications for the person. If they're on medication. In long term residential, the doctor has a much longer period to see is this the right set of medications for this person and will it work Long term. And in long term residential people are also able to establish wraparound services. Generally after about the sixth month, the person is encouraged to go out and start looking for part time employment and establishing themselves. They have time to figure out where they're going to live and do those sorts of things. So there are a lot of other things that can be accomplished in long term residential because you're not having to cr, you know, so much treatment like we do in short term residential. Short term residential is a lot of treatment in a very short period of time. Long term residential can space it out a little bit more so people can solidify their skills. In the criminal justice environment. Individual and group counseling sessions can be offered. It's daily is sometimes appropriate. Sometimes you meet with the person once a week. A lot of times in the criminal justice environment, the criminal justice system is paying for this kind of service. So it's not what the insurance company is saying is warranted. It's what the probation officers or the. Or the jail is saying is warranted. This can happen in the jail or intensive outpatient, like with problem solving courts or even just regular outpatient in the jails we talked about a little bit earlier, groups can be done. One of the caveats in with providing treatment in the jail is the fact that not everybody's getting the treatment. So you're going to have 90% of the population in the jail who is not functioning healthfully, and then you're going to have this other 10% that's trying not to adopt criminal criminogenic behaviors. And they're trying to change their ways and they're trying to improve their life. And so it's. They're. They're kind of fighting against the milieu that exists. So providing treatment in jail can be a real challenge. So you want to make sure you set reasonable, achievable goals and help the person embrace those goals. You also want to make sure that they know that what they're learning now it may be hard to apply in jail. You know, hopefully it'll help them be put in solitary less often, But a lot of it will be extremely useful when they get, when they get out. Intensive outpatient. You know, problem solving courts are like your mental health court, your domestic violence court, and your drug courts. They are courts that basically require the person to go to intensive outpatient, stay clean. And if they don't, when they report for their weekly report in front of the judge, if they haven't stayed clean, then they can go to jail for a certain period of time to be determined by the judge. So it has some teeth to it. For mental health courts, generally, the requirement is the person stay on their medication and attend all of their sessions. For domestic violence courts, obviously it's avoiding having another domestic violence incident. A lot of times domestic violence and substances go hand in hand. So domestic violence may also require the person to be staying clean and sober in regular outpatient. And I worked with people in probation and parole in regular outpatient. And you know, most of them did not want to be in my program. And I don't blame them. You know, they didn't want to be in my program because they didn't see where they had a problem or they didn't think I understood or didn't think I could help them. So what I did was tell them, you know what, in order for you to get off probation, which is what you want, you have to go through this and you know, it's just one of those things. So let's make it as pleasurable as possible, you know, tell me what it is, if anything, you want to work on. You know, we don't have to focus on drugs. Do you want to work on your self esteem, your parenting skills, communication skills? What is it, you know, since the court is paying for you to see a therapist for 16 weeks, what is it that I can help you with and how can I help this benefit your life? When we would talk about staying clean, you know, I'm not talking about stopping using forever if that's not what you want to do. What I am talking about is you need to stay clean while you're on probation or you're going to get violated and go back to jail. So let me help you stay clean while you're on probation. And then when you're off papers, you can make whatever decision you want to make. And putting the power back into their court really helped a lot. In the criminal justice system, issues, like everything else, it can work with. Coping skills, mental health, substance abuse issues, relationship and interpersonal issues, traumas and losses. Now, in the criminal justice system, there's also the additional issue of changing criminogenic thinking. And there are a lot of thinking styles and cognitive distortions that go along with being involved in the criminal justice system. So that's something else that needs to be addressed. Reintegration services are another huge part of providing services to the criminal justice population. They need case management and linkages with wraparound services. A lot of times people are discharged from jail and they've got $10 in their pocket, they've got no job, they may not have anywhere to go back to, or if they do, it may be a problematic situation. So we want to make sure, we try to get people started off right. We want to make sure they've got a good resume. We want to make sure they've got good interviewing skills. We want to make sure that they've connected somewhere so they've got decent clothes to go interview for a job. We want to make sure that they know where they're going to go to start interviewing for a job. We want to make sure they've got transportation, we want to, you know, all those things that a person needs. You know, you basically have to think of somebody coming out of jail and as starting with nothing. And you've got to say, okay, what do you need to function? You need food, you need shelter, you need employment to pay for electricity and shelter and all that stuff. So let's figure out how to get you signed up. That way they have everything they need when they walk out. Instead of just $10 in their pocket and a wish and a prayer. Along with reintegration services and case management, we want to provide job and life skills. They may not know how to manage their money very well. People who've been in and out of the criminal justice system most of their life have become institutionalized, if you will, and they may not know how to function as well on the outside. They may feel more comfortable in jail because they know the routines and they know how to get three hots and a cot. And it's important that we make sure that we help people figure out, you know, what's going to make living, you know, not in jail beneficial and productive and a good experience for you and how can I help you achieve that? Problem solving courts were created to assist consumers whose illegal behaviors or problematic behaviors are thought to be the result of an underlying substance abuse or mental health issue. It involves weekly monitoring by the court, daily contact with the counselor, provision of sanctions based on non compliance. Remember, I said if they weren't compliant, the judge could sentence them to 30 days, up to 30 days in jail, and progression through phases based on demonstrated improvements in behaviors, reactions, and relationships. The nice thing with problem solving courts is it tends to have some teeth to it, so you get a little bit more compliance and buy in. Consumers should be placed in the least restrictive environment. And when you do the asam checklist, you know, there are a lot of dimensions that you're looking at, from relapse potential to recovery environment to behavioral issues, emotional issues, physical issues. All of those things add up and you want to figure out at what level can this person be managed? And, you know, start out with the lowest level and say, you know, can we do it with early intervention? You know, a group a couple of times a week for a few weeks, Will that do it? If not, do we need to go with individual. If we meet once a week for individual counseling, will this person be able to stay okay, know, clean, sober, and, you know, their mental health stuff stable the other six days of the week? If not, move up to intensive outpatient. Can they do it if they're meeting three, three hours a day for five days a week? If so, great. If not. And a lot of my clients really would benefit from partial hospitalization initially because the weekends used to be their bugaboo. The two days they didn't come in were their bugaboo, and they would end up relapsing, getting into some drama Whatever that would trigger problems. So, you know, we really want to look at can this person get by on the weekends? Because most programs don't offer IOP services on the weekends. So clients are not only not at work, but they're also not in treatment. So they've got a lot of free time. If you don't think they can make that, then look at partial hospitalization or short term residential. If they've been through short term residential multiple times and haven't succeeded, then you may consider long term residential. And long term residential isn't, you know, an option for a lot of people because insurance often doesn't cover it. But especially for the criminal justice involved, long term residential often is an option. So look at what may be available. Sometimes you can get sentences reduced for people if they do their last year at a long term residential facility instead of doing it in jail, which means, you know, they're getting out of jail a year early, but they're going to this facility that's going to set them up for success. There are benefits and drawbacks to all levels of care in outpatient. You know, it's cheaper, it's less traveling for the person, it is less imposition on them, but it may not be enough intensity. Intensive outpatient, a lot of people struggle because it requires so much time that they don't feel like they, they can do it in addition to their family and their jobs and everything else. Short term residential, it's great because it provides people a break from the stresses out there where they can just focus on their recovery. But the bad thing is it doesn't transition them unless they step down to intensive outpatient. It doesn't transition them and prepare them as well to handle life on life terms. Long term residential does a better job of transitioning people, but a lot of people don't want to be away from their families for an entire year. So you want to look at the benefits and the drawbacks and again, really consider what is the least restrictive environment that your client can maintain sobriety and their mental health issues. Problem solving courts have demonstrated a lot of success. So if you have a client who has done okay in intensive outpatient before, but not wonderfully, if they can get involved in a problem solving court. And obviously this is only if they're involved in the criminal justice system, but if they are, then a problem solving court might be the next step before residential. If they don't want to go to residential, alrighty. Well, that is our summary of models of treatment or basically where you can get treatment and hopefully you learned a few things and you've started to figure out what might be a good fit for you as a clinician. If you enjoy this podcast, please like and subscribe either in your podcast player or on YouTube. You can attend and participate in our live webinars with Dr. Snipes by subscribing at allceus.com counselortoolbox this episode has been brought to you in part by allce.com, providing 24. 7 multimedia continuing education and pre certification training to counselors, therapists and nurses since 2006. Use coupon code counselortoolbox to get a 20% discount off your order this month.