By Cassandra Roos
My first experience in IOP was rather short and I was recommended through my individual therapist at Vanderbilt Psychiatric Hospital. Interestingly, though, it was the first time I was correctly monitored and given a better medication that had more proven research to successfully treat people with my symptoms. The reason that IOP enabled this to happen is because you are monitored for a longer period of time 3-4 days a week so symptoms are tracked more accurately than they are during a 15 minute medication management appointment. I did not quite understand what types of therapy I was undergoing during my first IOP, however I felt an enormous relief being around other people who felt in as much pain as I did and we were able to openly and most importantly confidentially talk about it within the boundaries of a structured environment.
My second IOP was a follow up program at the Yale St. Raphael’s Campus I attended after I was discharged from a month at the inpatient hospital. I still was in a state of complete emotional dysregulation and had no idea what was happening in this IOP until a month or so passed. But I attended religiously and I would never have been able to get back on my feet without attending that program. Sometimes patients in IOP are in such a haze that their only goal is to try to get to the program and get back home. It was like that for me. It is scary at first giving up your whole life for such an intensive form of therapy. It makes absolutely no sense. You feel like you are losing control over everything, that you are a failure, you feel like your life is over, that nobody will ever understand or talk to you again.
Sometimes, like in my case, a person has to bottom out and realize that the inpatient hospital stay followed by an IOP program may be the only way they can find a way to survive. Other times, as in criminal cases and involving substance abuse, IOP can be required. I am just discussing my experiences, however, in participating in a completely voluntary program. Once I accepted that I had no other choice, that I could not face going on living the way I was, I realized that being in the IOP program was the only way I could get through my days.
Having recently had my fourth manic episode at age 32, my worst, with no extra life triggers or circumstances to blame, it became finally glaringly obvious that I have Bipolar 1. Bipolar disorder is a beast that I will not go into for this article, but needless to say it can hide under the mask of depression for years and go unnoticed especially when it’s easy to attribute seemingly higher functioning symptoms as just someone’s “personality”, that is until they get out of control and it’s too late. In my opinion, the Bipolar 1 sufferer will rarely end up in an IOP program without first crashing and ending up in inpatient, mainly because it can be really fun to be that high. Anyway, I am in my third IOP program following my most recent inpatient stay, and I am finally more aware of what actually occurs in IOP. I have gone through euphoria, grandiosity, hourly rapid cycling, crying, laughing, yelling, screaming and anguish with this group of people watching me closely over the past three months. It says a lot to spend 12 hours a week with people who truly see what you are going through as you try to cover a lot up to survive in the outside world. This program has validated my symptoms and shown me my progress and made me realize that I am not imagining what is happening to me, that this illness is real, because it can appear invisible as everyone around you keeps telling you that you “seem fine” and you “are fine.”
Upon learning the skills and participating in discussions of various aspects surrounding DBT, CBT, mindfulness, distress tolerance, emotional regulation, radical acceptance, validation, and interpersonal relationship skills, everything starts to sound like common sense, like simple ideas. It is mind-blowing to read simple ideas and realize they make perfect sense and feel that you must have known them, but you somehow ignored them or did not utilize them. The key is to fight off the human propensity for glibness and just think about what you are learning, because it isn’t random, a lot of science and research has gone into these programs.
Learning the skills in IOP is not enough, one needs to attempt to apply them outside of the program and come back and share with the group specifically what techniques they applied when they were confronted with difficult emotional situations. The method does not need to work and may not work, but the point is you are supposed to practice anyway. I see IOP as an invaluable educational experience many people have not had the luxury of having. Because anyone on the face of this earth would benefit from these skills in some way.
IOP for me has been an educational experience, but only truly during this third time, because I have reached the level of clarity where I find it necessary to spread awareness about it. I feel like once you complete an IOP you are part of a gang of insiders who understand the system. Some people view it as “what can help you” others view it as a nuisance, some as an escape, who knows…but I have always viewed it as a requirement for me to go on living when I am ready to accept that I need to attend one again.
Of course, there are problematic parts of this conversation. First off, insurance. Private insurance companies do not like to pay for IOP and do not often see its value. Clinicians have to often constantly persuade companies to continue coverage. In Connecticut, Medicaid will usually cover the entire duration of the prescribed IOP. But insurance is a terribly troubling big issue, and frustration and costs will limit access to this type of treatment for many. The second problem is financially this type of treatment is not an option for many. In order to get the benefits of treatment, one really needs to attend the IOP for the prescribed amount of time and this does involve daytime hours multiple times a week that are hard for many working people to adjust their schedules around. Sometimes people in IOPs have lost their jobs already due to mental illness or can apply for various government programs that give them allowed time off of work (usually unpaid). Some people remain homeless and still attend IOPs or move back in with family members and lose a lot of what they had. Most of the time when someone has reached the point where they are attending an IOP they are not well enough to be working full time anyway.
Sometimes I see group members, myself included, getting upset or enraged by the clinical social workers or other members of the group. You have a right to stand up for yourself and voice your opinion. It may seem like you want to leave the IOP and give up after one conflict because you are already living a life of constant emotional distress. I had a fairly big conflict with one of the social workers in my recent IOP and I went home typed up a four-page letter with personal background, scientific research and evidence as to why she crossed the line. Obviously not everyone will have the capacity to take such a bold measure, but I think participants need to know they can speak up about grievances and work with the clinicians to solve problems because they always arise.
Another drawback (or benefit) to IOP is group dynamics. It is important to understand that patients are admitted to IOPs on a rolling basis, so some people are ending their treatment, some are in the middle of it, and others are just beginning. This is helpful because older members can offer insight and explain to newcomers how they have progressed. Some IOPs have better cohesion based upon personalities and diagnosis. It has been difficult for me this time being manic and in a group with all depressed people (or bipolar patients who are not currently manic) because I am always doing all the talking and often nobody can really relate to me. Sometimes the age gap can be challenging because many of the groups I have been in did not have enough young people who stuck with the program.
In my current situation, I have tried my best to work within the restrictions of the group and benefit where I can by helping others see things they cannot see about themselves. Other times clinicians are not a good fit for patients and may not run a group in a therapeutic way. It is best, in my opinion, when IOPs have alternating clinicians for groups. Nothing is ever ideal and frustrations will at times give someone the illusion that there has been no progress, but it is normal and okay for these conflicts to occur.