When we are contemplating treatment for help with addiction or alcohol use disorders, we are faced with an enormous task of deciding where to start and where to turn for help.  Googling services opens up ad after ad of businesses pushing their brand of treatment.  Most of them claim that their treatment and plans are individualized and personal to meet your needs, yet almost all of them will begin with a placement into an Intensive Outpatient Treatment Program if a detox program is not recommended first.  

Sounds pretty cookie cutter, doesn’t it?  I recently reviewed a large, federally funded outpatient program and was informed that all clients entering the program would be placed into IOT.  Period.  No questioning if the client would meet the criteria for that level, just a blanket statement that all clients would be assessed at that level.   Unfortunately, this is more the norm than an exception.   True, many people need the intensity of an IOT program, and there are many benefits from an IOT program, but a blanket statement, often combined with a subjective assessment to meet the criteria, is not best practice and can be detrimental to treatment successes.  

What is the Continuum of Care?

“Continuum of care” refers to a treatment system in which clients enter treatment at a level appropriate to their needs and then step up to more intense treatment or down to less intense treatment as needed. “ (SAMHSA, Treatment Improvement Protocols).  What this means is that clients should be assessed through an objective (not subjective) process to determine their individual needs for treatment.  Substance use treatment programs should be admitting clients through their program rather than admitting the client to their program.  In addition, clients should receive frequent and comprehensive assessment updates to determine their individual progresses and treatment should be reflective of those progresses.   An effective, client-centric Continuum of Care focuses on supporting the individual through their personal transitions of levels of care.

What are Levels of Care for Substance Use Disorders Treatment?

The American Society of Addiction Medicine (ASAM) has established five main levels in a continuum of care for substance abuse treatment:

  • Level 0.5: Early intervention services
  • Level I: Outpatient services
  • Level II: Intensive outpatient/Partial hospitalization services (Level II is subdivided into levels II.1 and II.5)
  • Level III: Residential/Inpatient services (Level III is subdivided into levels III.1, III.3, III.5, and III.7)
  • Level IV: Medically managed intensive inpatient services

These levels of care are considered points in a continuum of treatment services, and might be tailored to fit the population of who the program is serving:  the treatment philosophy, services and settings for the services may be based on the general client population of the area served.   

“Despite variability in the specific features of intensive outpatient treatment (IOT) or Level II care in programs across the country, the continuum of care model tries to ensure consistency throughout treatment and to ease the process of moving clients through treatment.” (SAMHSA, Treatment Improvement Protocols)

What is Level II / Intensive Outpatient Treatment?

IOT programs are diverse and flexible with respect to the spectrum, intensity, and duration of services and the settings in which services are delivered. They are, therefore, well suited to meet the varied needs of persons with substance use disorders. Conceptually, IOT is an intermediate level of ambulatory care that serves the following functions:

  • An entry point into substance abuse treatment. The client comes to the IOT program, an assessment reveals that the client would benefit from IOT , a treatment plan is developed, and services are begun.
  • A step down level of care. The client is transitioned to the IOT program from an inpatient or residential facility. In this case, the client may have been stabilized in a hospital facility or residential treatment program and now needs intensive treatment services to achieve or maintain abstinence as well as address other problems.
  • A step-up level of care. The client is referred to the IOT program if he or she has been unsuccessful in outpatient treatment or continuing community care and is assessed as needing an intensive and structured level of care to regain abstinence, work on relapse prevention skills, and address other issues.

Goals of IOT programs vary based on such factors as the treatment population, program comprehensiveness, and the program’s philosophy. Although programs differ, all IOT programs attempt to address the following general goals:

  • To achieve abstinence
  • To foster behavioral changes that support abstinence and a new lifestyle
  • To facilitate active participation in community-based support systems (e.g., 12-Step fellowship)
  • To assist clients in identifying and addressing a wide range of psychosocial problems (e.g., housing, employment, adherence to probation requirements)
  • To assist clients in developing a positive support network
  • To improve clients’ problem solving skills and coping strategies

The actual number of hours and days per week that clients participate in IOT varies depending on individual client needs. State licensure bodies may require 9 treatment hours; ASAM defines IOT as 9 hours of treatment per week for adults.  Although IOT programs generally provide structured programming for 9 hours or more per week spread over 3 to 5 days, some IOT programs provide fewer hours.

Types of Groups

Most IOT programs place clients in several different types of groups during the course of treatment. These include psychoeducational, skills-development, support, and interpersonal process groups.  Some IOT programs also add specialized groups and clubs for job-seeking or recreational activities.

Psychoeducational Groups
These groups provide a supportive environment in which clients learn about substance dependence and its consequences. These time-limited groups may be initiated at the beginning of treatment. They feature
• Low-key rather than emotionally intense environment.
• Rational problem solving mechanisms to alter dysfunctional beliefs and thinking patterns.
• Various forms of relapse prevention and skills training. Didactic components often are supplemented by videos or slides to accommodate different learning styles.
Skills-Development Groups
These groups offer clients the opportunity to practice specific behaviors in the safety of the treatment setting. Common types of skills training include
• Drug or alcohol refusal training. Clients act out scenarios in which they are invited to use substances and role play their responses.
• Relapse prevention techniques. Using relapse prevention materials, clients analyze one another’s personal triggers and high-risk situations for substance use and determine ways to manage or avoid them.
• Assertiveness training. Clients learn the differences among assertive, aggressive, and passive behaviors and practice being assertive in different situations.
• Stress management. Clients identify situations that cause stress and learn a variety of techniques to respond to stress.
Support Groups (e.g., process-oriented recovery groups)
These groups include clients in the same recovery stage—usually a middle to late phase of treatment—who are working on similar problems. Members focus on immediate issues and on
• Pragmatic ways to change negative thinking, emotions, and behavior
• Learning and trying new ways of relating to others
• Tolerating or resolving conflict without resorting to violence or substance use
• Looking at how members’ actions affect others and the function of the group
Interpersonal Process Groups
• Single-interest groups. These groups—usually organized at a later stage of treatment—focus on an issue of particular significance to and sensitivity for group members. The issues include gender issues, sexual orientation, criminal offense, and histories of physical and sexual abuse.
• Family or couples groups. These groups assist clients’ relatives and other significant individuals in learning about the detrimental effects of substance use on relationships and how these effects can be ameliorated or resolved. 

What is the placement criteria for Intensive Outpatient Treatment?

Substance use disorder programs complete an in depth assessment prior to placing a client in a level of care for treatment.   This assessment is based upon the Diagnostic Statistical Manual  of  Mental Health Disorders (DSM V) and the American Society of Addiction Medicine (ASAM) criteria.  

  • The severity of the substance use disorder(s)
  • The type of substance(s) abused
  • The duration (time)  of alcohol or drug abuse
  • Medical and psychological background
  • The presence of co-occurring disorders
  • Life situation, environmental factors and logistical factors

This is a multi-dimensional approach for clinicians and care managers that allows for:

  • Objective decision-making
  • Individualized care
  • Improved client outcomes
  • A bio-psychosocial approach to treatment decisions

The ASAM criteria helps people struggling with substance use disorders obtain the tools and services that will promote long-term recovery for their individual situation.


ASAM criteria helps determine what level of care you need. The ASAM encourages patients to walk through the criteria with their therapist so they can be an active and educated participant in their treatment plan. These are the six dimensions of ASAM criteria used by clinicians to help guide treatment decisions:

#1 Acute Intoxication and Withdrawal

This ASAM criteria dimension considers substance use patterns and risk for drug or alcohol withdrawal symptoms. This may include:

  • How often drugs or alcohol are used
  • The last use substances
  • Current withdrawal symptoms
  • History of severe withdrawal symptoms such as seizures
  • Extent of support if severe withdrawal symptoms occur

Level II Intensive Outpatient Criteria:  Minimal Risk of Acute Wihdrawal.

#2 Biomedical Conditions and Complications

Identifying factors that could impact withdrawal and addiction treatment is the focus of the second dimension of ASAM criteria. This includes any current physical illnesses and chronic conditions. Guidelines help determine the ability to self-manage these conditions or if additional support is needed during the recovery process.

Level II Intensive Outpatient Criteria:   None, or Not a distraction from treatment and manageable in Level II.

#3 Emotional, Behavioral, or Cognitive Conditions and Complications

The third dimension of ASAM criteria looks at psychiatric and mental health issues that can complicate treatment or create risk. Considerations include:

  • Identifying any co-occurring mental health disorders
  • Evaluating the severity of co-occurring disorder symptoms
  • Assessing if mental health symptoms are autonomous or as a result of substance abuse
  • Determining if psychiatric symptoms require specific mental health treatment
  • Identifying coping skills and ability to manage everyday tasks

Level II Intensive Outpatient Criteria:   None, or mild severity; with potential to distract from recovery; needs monitoring.

#4 Readiness to Change

The fourth dimension of ASAM criteria assesses the degree for readiness to make a change. This includes both internal and external factors that have motivated seeking help. The clinician may refer to The Stages of Change, which can help determine readiness and how awareness of the relationship between addictive behaviors and negative life consequences.

This considers factors like:

  • Awareness of the need for change
  • Readiness and level of commitment to change
  • Participation and cooperation in treatment
  • Recognition of negative consequences tied to drug and alcohol abuse

Level II Intensive Outpatient Criteria:  Resistance is high, or high enough to require a structured program but not high enough to render outpatient treatment  ineffective.  

#5 Relapse/Continued Use, Continued Problem Potential

This fifth ASAM dimension identifies the risk for continued relapse. Clinicians look at  impulse control capabilities, coping skills, and past patterns of substance abuse. ASAM criteria for dimension five evaluates :

  • Risk of immediate danger from substance abuse and mental health issues
  • Skills to cope with addiction, mental health disorder, or suicidal thoughts
  • Awareness of triggers
  • Severity of substance use and mental health issues and probability that they will continue without treatment
  • Ability to cope with cravings, impulses, and triggers

Level II Intensive Outpatient Criteria:   Intensification of addiction symptoms despite active participation in Level 1, and high likelihood of relapse or continued use without close monitoring and support.

#6 Recovery and Living Environment

The sixth dimension of ASAM criteria assesses the environmental aspects of recovery, including living situation and the level of support or roadblocks to recovery.  For instance:

  • Living with other people who are using substances
  • Who is in the support system
  • Is there involvement  in community support programs like Alcoholics Anonymous, Narcotics Anonymous, or SMART Recovery?
  • Do any loved ones, work, school, or living situations limit ability to engage in treatment?
  • Are there supportive people, adequate finances, and vocational or educational resources to help facilitate and support success in sobriety?
  • Are there legal, vocational, or criminal situations that are driving the motivation for treatment?
  • Are there issues with employment, childcare, transportation, or housing that need to be addressed?

Level II Intensive Outpatient Criteria:   Environment unsupportive, but with structure and support, the patient can cope.

Addiction treatment occurs on a continuum, with a range in the level of structure, intensity, and monitoring. The ASAM criteria puts addiction treatment on a continuum of five levels of care that are designated in Roman numerals from 0.5 to IV.   Within each level of care, there are decimal number rankings from .1 to .9 to signify the intensity of services within those designations.

ASAM criteria is not a one-time assessment. It’s used to assess and reassess needs throughout the course of care. It not only helps you enter the appropriate level of care but can also guide your ability to “step up” or “step down” in treatment.

If you are considering treatment, research the program well.   Are they Person-Centered?  What do reviews on Google, Yelp, or other formats look like?  The Hazelden/Betty Ford Clinic recommends asking these questions:

  1. What type of accreditation or licensing does your facility have?
  2. What credentials or licenses does the clinical staff hold?
  3. Is treatment done by a multidisciplinary team?
  4. What is the patient-to-counselor ratio?
  5. Do you use evidence-based practices?
  6. Do you have gender-specific programs?
  7. How successful is your treatment program?
  8. Are you in-network with my insurance?
  9. Do you provide mental health services?
  10. Do you offer medical detox or other medication-assisted therapies?
  11. Do you offer treatment specific to teens, young adults, older adults or other populations? (as it applies to your situation)
  12. How long does the program last?
  13. What kind of post-treatment support do you provide?
  14. Do you offer family support?
  15. How long have you been providing addiction treatment?

If you have any further questions, please reach out to me!  I care!  

As Always, my hopes are for your hopes and dreams………T


To read the full SAMHSA Book, click here