Every year, people with addiction and mental health concerns are urged to seek help. Yet when they reach the treatment door, many encounter a cruel contradiction: they are expected to be stable enough to access the care intended to help them become stable.
According to the Substance Abuse and Mental Health Services Administration’s 2024 National Survey on Drug Use and Health, approximately 21.2 million U.S. adults lived with both a mental illness and a substance use disorder.
More than four in ten received neither mental health nor substance use treatment. More than four in ten received neither mental health nor substance use treatment.
Those numbers should force us to question the familiar assumption that people simply “do not want help.” Often, the system has designed help in ways that are nearly impossible to use.
As a social worker and addiction counselor, I have seen how quickly barriers created by systems are renamed as failures of motivation.
Intensive outpatient programs, commonly called IOPs, can provide meaningful structure while allowing people to remain at home, work, care for children, and stay connected to their communities.
But IOPs typically require attendance several times a week, reliable transportation, insurance authorization, extensive paperwork, emotional participation in groups, and consistent communication with providers.
For someone managing trauma symptoms, depression, cravings, unstable housing, court obligations, childcare, or a job with little flexibility, those expectations can become barriers rather than supports.
When a person misses sessions, relapses, appears guarded, or struggles to complete paperwork, treatment systems often label the behavior “noncompliance.” That word makes a complicated situation sound like a character flaw. It shifts attention away from transportation failures, poverty, fragmented services, untreated symptoms, and fear of legal consequences.
It also echoes the long history of treating substance use as a moral and criminal failure rather than a health condition.
This does not mean standards and accountability should disappear. IOP is an intensive level of care, and participation matters. But accountability should not be confused with rigidity.
A person can be responsible for engaging in treatment while the treatment system is responsible for making engagement realistically possible.
Behavioral health agencies should adopt low barrier, integrated IOP models for adults with co-occurring substance use and mental health concerns. “Low barrier” does not mean “no expectations.” It means removing unnecessary obstacles that prevent people from entering or remaining in care.
A low barrier IOP would begin with a no wrong door intake process, whether a person arrives through self-referral, a hospital, a therapist, probation, or a recovery court.
Assessment would address both clinical needs and real-life barriers, including trauma symptoms, transportation, housing, insurance, work schedules, caregiving responsibilities, and legal involvement.
Treatment would integrate substance use and mental health services rather than forcing clients to navigate separate systems.
The model should also build in transportation planning, evening or flexible scheduling, peer recovery support, medication coordination, case management, and structured opportunities to reengage after missed sessions.
Relapse or absence should prompt outreach and reassessment before automatic discharge.
Courts and probation departments should receive information about attendance and engagement when appropriate, but providers should explain barriers and reengagement efforts instead of reducing a person to “compliant” or “noncompliant.”
Funders and Medicaid managed care organizations also have a role. They should reimburse the practical supports that keep people connected to treatment, not only the therapy hour itself.
Programs should be evaluated not just by completion rates, but by how many people successfully enter care, return after setbacks, connect with medications or peer support, and improve over time.
We cannot keep telling people to seek help while designing treatment for those who already have transportation, stable housing, flexible jobs, organized paperwork, and symptoms under control.
Those with the greatest needs should not be the least likely to qualify as “ready.”
A just treatment system does not require people to prove they are stable enough to deserve care. It helps them build stability because they deserve care.
Nicole Crone is an Ohio-based licensed clinical social worker and addiction counselor whose work focuses on trauma, neurodivergence, and behavioral health access.
Nicole Crone, MSW, LISW-S, LICDC
Ashland, Ohio