Model of Treatment on the Retreat

March 6, 2013 —
Model of Treatment on the Retreat and Ruxton House

Don Ross, MD – Medical Director

The Retreat at Sheppard Pratt provides a continuum of care for individuals who need more mental health treatment than can be provided in today’s world of managed health care. Our model of treatment starts with a therapeutic environment, with caring and compassionate staff. It utilizes an expert group of therapists and doctors. It builds upon a central relationship with the primary doctor/therapist. And it gains momentum from the other residents who support and challenge each other in helpful ways.

The Retreat and Ruxton House (the step-down group home) uses an integrated treatment program that involves 6 different approaches that complement and deepen each other.

1) Careful assessment and use of medications to regulate neuro-chemical abnormalities,

2) Psychodynamic psychotherapy to get to deeper levels of understanding of the key issues,

3) DBT to develop more effective behavioral strategies in managing emotional dysregulation,

4) Family work to help an often beleaguered family system offer more effective support,

5) Holistic and health-oriented therapies to build upon the individual’s strengths and creativity.

For residents who have a co-occurring alcohol or substance abuse disorder, we utilize:

6) Specific addictions treatment through our affiliation with the Kolmac Clinic.

We have found that the sum is greater than the parts. In all of this, the person seeking help is a member of his or her treatment team, a full partner in this endeavor. Our goal is to help each individual overcome the current emotional crisis and regain a life that is less painful, more effective, and worth living. In the paragraphs below, we outline each of these elements of treatment in more detail.

We also believe that each individual is unique and so deserves individualized attention to his or her needs. Consequently, each treatment plan is tailored for the individual resident by his or her treatment team, in concert with that resident. Treatment begins on the day of admission, and we spend the first two weeks on the Retreat learning the needs and abilities of each resident. This leads to a Diagnostic and Treatment Planning Conference, which includes the resident’s entire treatment team and the resident in a collaborative effort to review what has been learned and to design a refined plan going forward. Part of the individual treatment plan includes attention to what the resident will need in the way of aftercare when he or she returns home.

1. Medical Psychiatry – With the many advances in neurobiology and brain research, we do a thorough evaluation of each resident’s diagnosis and medications. This includes a consultation by an experienced and expert psychopharmacologist, lab work, along with other subspecialty evaluations as needed. Psychological testing and/or genetic testing may be done when it is indicated. For appropriate residents, we offer Transcranial Magnetic Stimulation (TMS) treatments on the Retreat. Each resident works closely with a psychiatrist who also is his or her primary psychotherapist. Nursing staff are available 24/7. Medications are reviewed daily and adjusted as needed. Each week, there is a group devoted to education around neurobiological issues, with ample opportunity for residents to ask questions and discuss issues related to their medications.

2. Exploratory Psychotherapy – The treatment philosophy of the Retreat is imbued in a humanistic, psychodynamic approach that goes back to the roots of Sheppard Pratt over 120 years ago. We believe that understanding and caring are the foundations that lead to effective long-term change. We offer individual psychotherapy 3x/week by an expert psychotherapist who is also the resident’s psychiatrist. In today’s fast-faced world, it can be difficult to find a psychiatrist who is also a psychodynamically sophisticated therapist. We have 6 such doctors on our staff. Each takes leadership of the care of his or her patient with empathy and dedication. Understanding deeper conflicts, traumas, and developmental concerns can be a key component to healing a condition that has proven to be resistant to treatment in the past. We also use psychodynamic group therapy and art therapy as additional ways to access and work with emotional issues that often have not been put into words yet. Getting a better handle on these deeper areas of hurt, vulnerability, and conflict can inform the behavioral strategies used in the other elements of our treatment approach. There is special attention paid to the experiences of a damaged sense of self in some residents, with groups focused on exploring pathways to building shame-resilience, compassion, (self)-forgiveness, and hope.

3. Dialectical Behavior Therapy (DBT) – Most of the time, enduring therapeutic improvement requires a change in behavior. We have found that DBT is the most accessible and effective approach to meaningful behavior change for individuals with emotional dysregulation. Emotional dysregulation is a key problem area in patients with borderline personality disorder and with addictions, and it also is a useful area of focus for those with mood disorders and anxiety disorders. Under the leadership of a renowned psychologist and using highly trained staff, the Retreat and Ruxton House integrate DBT with psychodynamic and other approaches. We teach the 4 modules of DBT Skills training (mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness) and provide real world experience of how to use these skills on the Retreat and at home. Individual DBT work is available through structured homework assistance, skills coaching, and via consultation with senior staff. Many residents use their time at Ruxton House to strengthen and generalize their new and more skillful behaviors in the face of emotional distress.

4. Family Therapy – The person who comes to the Retreat for help usually has a family surrounding him or her that also needs support during this period. Frequently, couples work or family therapy is also needed. Our experienced family therapists work conjointly with individual families to make the necessary changes that will support the healing of their loved ones. We also work with the Retreat or Ruxton House residents to help them better engage their families for that support. We have several group therapies that focus upon relationship patterns which use attachment theory in promoting a deeper understanding of problem areas and pathways to healthy change. Once a month on a Sunday, we offer “Family Day”, a half day of educational programs to help residents and their families make the best use of the Retreat experience and learn from each other’s experiences.

5. The Art of Living – Even in the midst of the most devastating emotional crisis, we believe it is crucial to spend some time focused upon creativity and health. There are seeds of positivity in each of us, and by growing these seeds, we promote healing from within. We do a health assessment from a physical, nutritional, and life-style perspective. Our wellness coordinator, who is a recreation therapist and a certified personal trainer, designs an exercise program for each resident to meet his or her individual needs. We offer cardio and strength training along with t’ai chi and yoga -based exercises multiple times a week. Our integrative clinical specialist integrates holistic and conventional treatments to optimize a successful outcome. Our movement and meditation specialist, who is a t’ai chi master, utilizes his deep understanding of Eastern traditions to complement the Western approaches to medications and psychotherapy. There are many activities designed to help Retreat and Ruxton House residents get it touch with their inner strengths and creative resources and develop those alongside their work on painful emotional areas. The ultimate goal for many is building a life that lines up with their core values, a life they know is worth living.

6. Addictions Treatment – For those individuals who need specific help with alcohol and substance abuse, we supplement our Retreat offerings with a joint program with the Kolmac Clinic. Kolmac Clinic is a preeminent outpatient provider of substance abuse treatment in the Washington-Baltimore area, with a branch on our campus. Residents on the Retreat may attend an evening Intensive Outpatient Program (IOP) five days a week, which dovetails nicely with the Retreat program. For those who do not need the full intensity of this option, we offer a weekly therapy group on addictions issues for Retreat and Ruxton residents along with an alcohol education lecture series on campus. Residents with dual diagnosis issues are encouraged to attend AA meetings on the Sheppard Pratt campus each day, along with Smart Recovery and NA meetings as appropriate.

As mentioned above we offer a full continuum of care to match the needs of each patient:

Acute Inpatient → Retreat residential→ Ruxton House → Retreat Outpatient

Acute psychiatric problems that involve safety issues can be treated humanely and effectively on one of the adult inpatient units at Sheppard Pratt. Once such a patient is stabilized and able to make use of the open door and rich therapeutic environment we offer, he or she can be transferred to the Retreat.

Most residents who seek treatment with us start at the Retreat. This is a residential program that provides a multi-focal approach to complex emotional problems such as depression, anxiety disorders, bipolar disorder, dual diagnosis conditions (substance abuse in conjunction with psychiatric problems), and personality disorders (including borderline personality.) The Retreat’s residential setting provides a holding environment which allows residents to engage in intensive psychotherapeutic work. The caring and support of staff and peers creates a therapeutic climate that complements the structure and expertise of the doctors, therapists, and program. The minimum length of stay on the Retreat is 20 days and most residents stay 1-2 months.

Ruxton House is a group home that provides a step down from the Retreat. At Ruxton House, residents can continue their therapeutic work in a caring milieu over an extended time period, while working to integrate back into community life. This provides a necessary stepping stone for many residents who have begun productive therapeutic work and need a longer period to heal in a supportive environment. The minimum length of stay at Ruxton House it is 28 days. Residents who transition to Ruxton House typically stay an additional 2-6 months there.

For individuals who decide to remain in the Baltimore area, there are opportunities to continue beyond this in the Retreat Outpatient Programs with both individual and group therapy. At each transition, we work collaboratively with the resident to craft and refine an individualized treatment plan that meets his or her needs.