As outpatient therapists, one of the most challenging yet crucial responsibilities we hold is recognizing when our clients need more support than we can provide in weekly sessions. Whether it's recommending an Intensive Outpatient Program (IOP), a Partial Hospitalization Program (PHP), or even hospitalization, these conversations can feel intimidating for both therapist and client.
Handled well, this conversation can empower clients and strengthen the therapeutic alliance. Handled poorly, it can lead to feelings of shame, resistance, or disengagement from treatment. Here’s how to navigate this pivotal moment with professionalism, empathy, and clarity.
Why Higher Levels of Care Matter
Outpatient therapy is often sufficient for managing mild to moderate symptoms. However, when symptoms escalate—whether it’s increased suicidal ideation, self-harm, severe depression, eating disorder behaviors, or substance misuse—a higher level of care can offer the intensity and structure necessary for stabilization and progress.
Programs like IOP and PHP at Innerspace Counseling are specifically designed to provide comprehensive support without requiring full hospitalization, offering multiple therapy sessions per week, psychiatric oversight, group work, and crisis planning.
Your ability to confidently and compassionately recommend these options can make all the difference in your client’s journey toward wellness.
When to Refer to a Higher Level of Care
Therapists should always monitor for clinical signs that outpatient therapy is no longer sufficient to ensure client safety and therapeutic effectiveness. Common reasons to refer include:
Indicators for IOP/PHP:
Persistent suicidal thoughts or self-harm urges without a concrete safety plan.
Escalation of symptoms despite consistent outpatient therapy.
Inability to maintain daily functioning at work, school, or in relationships.
Worsening mood, anxiety, or substance use that is not responding to outpatient interventions.
Frequent crises between sessions.
Need for more structured, intensive, and multidisciplinary support.
Indicators for Hospitalization:
Active suicidal ideation with intent, plan, and means.
Imminent risk of harm to self or others.
Severe self-injury that requires medical attention.
Psychotic symptoms that impair judgment or safety.
Substance use or withdrawal symptoms requiring medical supervision.
Complete inability to function in daily life or care for oneself.
When these situations arise, a higher level of care is not just a clinical option—it is a critical step to ensure safety and provide the support necessary for stabilization and long-term healing.
Key Steps for Navigating the Conversation
1. Prepare Yourself First
Gather clinical observations and clear evidence supporting the need for a higher level of care.
Know the options and next steps: Is there immediate availability at a trusted program? Can you provide contact information and support during the referral process?
Anticipate emotional responses such as fear, shame, or defensiveness.
2. Create a Safe, Collaborative Environment
Ensure the conversation happens at a time when neither you nor the client is rushed.
Approach the topic with openness and without judgment.
3. Validate and Normalize the Recommendation
Emphasize that needing more support is not a failure—it’s a responsible, courageous step.
Reinforce that higher levels of care exist because many people need them at various points in their mental health journey.
4. Be Direct but Gentle
Avoid vague language. Be clear that you are recommending a specific change in care to better meet their needs.
Use "we" language to emphasize partnership.
5. Provide Concrete Next Steps
Offer a warm handoff when possible, including helping schedule a screening or consultation.
Remind the client that you will continue to support them—whether through care coordination, future outpatient work, or simply being part of their ongoing team.
Sample Scripts
Example 1: Recommending IOP or PHP
“I want to talk with you about something important because I care about your safety and your progress. Based on what you’ve been experiencing—especially the intensity of your depression and the difficulty coping between sessions—I believe you would really benefit from more support right now than I can provide in weekly therapy.
I’d like to recommend an Intensive Outpatient Program, like the one offered at Innerspace Counseling. It’s a step up in care that can offer multiple therapy sessions each week, along with group and psychiatric support, while you still live at home. This doesn’t mean you’ve failed or that you’re doing something wrong. It actually means you’re taking your healing seriously and getting the right kind of help at the right time.
We can talk through this together, and I can help you get connected to the program. What’s coming up for you as you hear this?”
Example 2: Recommending Hospitalization
“I’m really concerned about your safety based on what we’ve been discussing today. When someone is experiencing [active suicidal thoughts/self-harm behaviors/other immediate safety risks], the safest and most effective step is often short-term hospitalization. This would give you 24-hour support to help you stabilize and begin to feel safe again.
This isn’t a punishment or something to be afraid of—it’s the most intensive level of care because sometimes, that’s exactly what’s needed to protect you and help you heal. I want you to know I’ll stay with you through this process. I can help contact the hospital and talk through what to expect. You won’t be alone in this.”
Additional Tips
Practice Transparency: Explain what the IOP, PHP, or hospital process will actually look like, so the unknown feels less intimidating.
Acknowledge Loss: Clients may feel grief about pausing their work with you or stepping away from their regular life. Honor that.
Stay Connected: Offer to participate in discharge planning, communicate with the new care team, or resume sessions after a higher level of care.
Final Thoughts
Your recommendation can be a powerful turning point. When approached with empathy, clarity, and clinical confidence, you can help your client see this next step not as a setback, but as an essential investment in their well-being.
If you're looking to refer to a trusted IOP or PHP, Innerspace Counseling offers immediate availability for adults, teens, and children. Contact us at 732-332-8270 to schedule a free screening.