Stepping Up for Mental Health: 7 Ways to Help Your Client Progress

Living with a mental health condition such as anxiety, depression or a trauma-related disorder can be complex. However, it is possible for your clients to manage their conditions and have beautiful, fulfilling lives focused on what matters most to them. Sometimes outpatient support is exactly what they need. At other times, a higher level of care (HLOC) is required.

Tip 1: Know the signs that your client needs a higher level of care

As outpatient providers, it can be hard at times to know when our clients need a level of support that outpatient services cannot provide. Despite your client’s commitment to mental health, the outpatient setting may not provide enough support for their needs and goals.

Ask yourself, is your client:

• Experiencing adverse social, educational and/or vocational setting impacts due to their mood, anxiety or trauma-related disorder and/or co-occurring disorders (obsessive-compulsive disorder, substance use disorder, etc.)?
• Exhibiting appetite disturbances resulting in significant changes in weight (increase or decrease) with no known medical cause?
• Struggling with limited motivation or significant ambivalence that would benefit from the external support of a structured environment? 
• Experiencing limited social support, or lack of social support, which contributes to worsening symptoms? 
• Needing or wanting increased caregiver (family/friend) support? 
• Requiring regular assessment of physiological and mental status (more than once per week)? 
• Presenting with self-injury that has not reduced with outpatient interventions? (Note: If self-injury requires regular medical intervention, the client may need inpatient hospitalization.) 
• Presenting with suicidal ideation, including passive without plan/intent, or passive with plan that has not been stabilized with outpatient interventions? (Note: Active suicidal ideation with plan and intent will require inpatient hospitalization.)

Note that this list should not be used as an assessment tool. A comprehensive no-cost assessment  should be completed if you are concerned about your client’s progress and you are considering recommending an HLOC.

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Tip 2: Know how to navigate tough conversations

Once it becomes clear that your client likely needs an HLOC, you may feel a little nervous about broaching this topic with them. Ellie Pike, MA, LPC, senior manager of alumni, family and community outreach at Pathlight, shares her perspective on having this initial conversation:

“Looking back to the first time I recommended a step-up in care for a client, I remember feeling so nervous! I was worried that the client would get angry and leave care -- meaning they might not receive any care,” explains Pike. “I was worried that it was a sign of failure -- maybe I wasn’t doing a good enough job as their therapist. As the clinician, I needed to be reminded that there is hope for recovery through lived experience stories and sometimes I needed to let go of my expectations for myself and my clients.”

Pike continues, “Moving past my ego -- my hopes that outpatient therapy was ‘enough’ -- was only part of the journey. I also needed to learn how to effectively relay to my clients that there is more to recovery, and it is worth their sacrifices, hard work and commitment to treatment.”

Tip 3: Meet your clients where they are

Relaying hope for mental wellness, and the why behind a step-up in care, can be challenging. During these conversations, it is important to meet your clients where they are, partnering with them rather than pushing them. This approach can:

1. Help both you and your clients create more realistic expectations
2. Help your clients create greater success over time
3. Help prevent you from experiencing frustration and burnout

If a client expresses mixed feelings or hesitancy about stepping up to an HLOC, that is completely normal. Motivational interviewing (MI) is an effective technique that can help you partner with your client to create change.

Tip 4: Try motivational interviewing

Motivational interviewing is a client-centered, empowering approach to helping your clients determine their personal goals or “reasons” for change. It encourages warmth, genuine connection, respect and support of the patient’s self-determination and autonomy. Watch an on-demand motivational interviewing training here.

As you are addressing ambivalence with a client, consider these approaches:

• Validate your client’s feelings. “Understand that the version of themselves that is in crisis feels incredibly vulnerable and has a lot of self-doubt and fear,” says Elizabeth Easton, PsyD, CEDS, director of psychotherapy at Pathlight. Acknowledge and validate these understandable feelings so that your client can feel truly heard and understood. This is the first step toward further unpacking their feelings and thoughts about possibly stepping up to an HLOC. 
• Explore their perspective. Ask your client to explain their reasons for ambivalence, and listen with curiosity, warmth and respect. You can explore further by asking your client what they stand to lose by entering an HLOC, and then asking them what they stand to gain. “Walk with your client, not ahead of them,” says Maggie Moore, MA, LMFT, Pathlight’s national family outreach manager.
• Involve their support network (if/when possible). Support persons (parents, spouses, chosen family, etc.) may also have worries or concerns about their loved one stepping up a level of care. By taking the time to meet with them (separately, or with your client, depending on circumstances) you create space to hear and address family system-wide concerns. Educate support persons about opportunities to continue being involved in the treatment process as they may have concerns about being “cut off” or “shut out” during HLOCs.

Learn more about addressing client ambivalence.

Tip 5: Set boundaries

Boundaries are an important aspect of every relationship, both personal and professional. For mental health care providers, boundaries are especially important when supporting a client within the context of mental health treatment. Michelle Cross, LCSW, RD, CEDS-S, senior primary therapist at Pathlight, has a few boundaries she typically puts in place after identifying the need for an HLOC. Cross says she typically considers:

1. Focusing on skills: “Sessions can be spent talking about the fear of moving to an HLOC,” shares Cross. “Focus on what skills they are currently using to stop the maladaptive behaviors, and remind them that they are trying the best they can. It's just that this illness is too hard for anyone to conquer on their own.”
2. Involving friends and family: When ethically and clinically appropriate, Cross holds time for involvement of the client’s loved ones (parents, spouse, chosen family, etc.). This time is focused on identifying the client’s difficulties and what next steps are recommended by the therapist.

While holding these boundaries, Cross says it often helps to lead with compassion and remind her patients that a step-up to the right level of care “is not a win/lose situation” (where she wins, and the client loses). Needing additional support does not mean the client has “failed” or “lost” in outpatient care; it just means a different approach is needed.

While yes, making that initial call to an HLOC can feel so, so difficult, ultimately it can make all the difference for long-term change. Kate Gombach, an ERC Pathlight alum, shares her experience taking that first step -- and the relief that came with it.

“I remember being terrified to make the call and take that first step toward recovery,” Gombach shares. “It’s intimidating to call a stranger and admit your struggles. But I was reassured when they informed me that they were a clinician, and they showed clear compassion and understanding of my experience. I was honestly surprised by how relieved I felt by the end of that initial call.”

Tip 6: Know the benefits of higher levels of care

Each person’s path to recovery is unique. While there is no one single approach that works for every person, there are a few factors that help us individualize your client’s care plan to best fit their needs.  Entering an HLOC:

1. Creates structure: Based on severity of symptoms, your client may require daily (or almost daily) intervention and opportunities to learn and practice coping skills to effectively manage their condition. When the intensity of symptoms is beyond what your client along with their outpatient support network, family and friends can manage, then a higher level of care is likely needed.
2. Provides more intensive therapy: Through a variety of evidence-based psychotherapies and modalities, clients can be effectively treated as the whole, unique person they are. A transdiagnostic care approach considers how clients often exhibit signs and symptoms of multiple diagnoses and can address complex co-occurring disorders. HLOCs can offer your client multiple group therapies coupled with individual therapy (and family therapy when appropriate), plus meetings with their psychiatrist to provide comprehensive treatment.
3. Prioritizes safety: At times, individuals with mood, anxiety or trauma-related disorders may experience worsening symptoms that can put their safety at risk, including increased self-harm or suicidal ideation. When this occurs, HLOCs can provide increased support and observation to ensure your client’s safety.

As providers, it is important for us to be knowledgeable about symptoms, treatment approaches, levels of care and referral guidelines for patients struggling with mood, anxiety and trauma-related disorders. For more information and education about evidence-based treatment, we invite you to check out our no-cost, nationwide continuing education events (both live and on-demand). Learn more at PathlightBH.com/professionals/education-events.

At Pathlight, we are available to partner with you and your clients through a continuum of care model, which includes an integrated care system, progressive levels of support, collaboration across a multidisciplinary team and treatment that takes an individualized approach. Learn more about our treatment approach.

Tip 7: Connect with the right support

At Pathlight, we’re here to partner with you to match your client with the right level of support. You are an integral part of your client’s treatment team, and your experience working with the individual and their family system is invaluable. If your client is considering treatment with one of our programs, our multidisciplinary team will involve you throughout the admission process (and beyond, throughout treatment and discharge).

Connect your client to a no-cost assessment with zero obligation. There are four different ways you can make a referral:

1. Get in touch with our team at 1-877-825-8584 .
2. Email us at [email protected].
3. Fax your patient's information to 425-974-1530.
4. Complete Pathlight ’s online Quick Admit form.

Sources

1. American Psychological Association. (2019). Clinical practice guideline for the treatment of depression across three age cohorts. Retrieved from https://www.apa.org/depression-guideline.
2. American Psychiatric Association. (2023). Clinical practice guidelines. https://www.psychiatry.org/psychiatrists/practice/clinical-practice-guidelines#section_9.
3. Norquist, G., Musher, J., Halverson, J., Pierce, K., Balfour, M., Schneider, M., Batterson, R., & Smith, T. E. (2020, April). APA Official Actions: Position statement on level of care criteria for acute psychiatric treatment. Retrieved January 2024. https://www.psychiatry.org/File%20Library/About-APA/Organization-Documents-Policies/Policies/Position-Continuing-Care-Criteria.pdf
4. U.S. Department of Veterans Affairs. (2019). VA/DoD clinical practice guidelines. Assessment and management of patients at risk for suicide. https://www.healthquality.va.gov/guidelines/mh/srb/index.asp