The Role of Intensive Residential Psychotherapy in Depression | The Retreat at Sheppard Pratt

The Role of Intensive Residential Psychotherapy in Depression

March 24, 2010 —

Don Ross, MD
Medical Director

In this modern world of psychiatric treatment, what is the role of intensive residential treatment for a person who is suffering from depression? In the hands of well trained professionals, depression is often amenable to outpatient treatment that utilizes a combination of antidepressant medication and weekly psychotherapy. Both psychodynamic and cognitive-behavioral (CBT) approaches to therapy have proven to be effective in relieving depressive symptoms and achieving lasting changes in many cases. However, some patients find even the best outpatient care does not alleviate their depression or that depression recurs despite such treatment. In today’s medical environment, inpatient hospitalization is a treatment for suicidal crises. The inpatient unit provides a safe holding environment, an opportunity to change a medication rapidly, and perhaps a chance to address some relationship crisis through a few marital or family sessions. Most inpatient stays are very short. They rarely last more than a week, only allowing time for a narrow focus on the acute crisis.

Between outpatient therapy and inpatient crisis, there remains a middle ground where intensive residential psychotherapy is indicated. This may provide the opportunity to break through persistent depression or use a crisis situation to initiate longer lasting changes that will hold up over time.

If one has 3-12 weeks to work intensively in the setting of a therapeutic environment, much can be accomplished. A careful diagnostic evaluation should be done. Perhaps this type of depression requires a different approach. For example, bipolar depression responds differently to medications than unipolar depression. Anxiety or obsessive compulsive disorder can complicate the treatment of depression and may need their own specific therapeutic approaches. Trauma from earlier in life may feed depression and need psychotherapeutic attention. Substances, such as alcohol or pain medications, can make it very difficult to recover from depression. Their role may be subtle and unaddressed.

In a residential setting, expert consultations are available on a timely basis and rapidly integrated into the treatment, rather than the patient having to wait weeks for outpatient specialist appointments. Medications can be changed rapidly and more safely with 24 hour nursing observation. New and safe treatments, such as Transcranial Magnetic Stimulation (TMS) may be utilized as a way to begin recovery. The setting itself can be a catalyst to recovery from depression. By allowing the patient time away from the environment where she or he has been depressed, stress is reduced and negative patterns can be changed more easily. Furthermore, there is therapeutic power in being part of community of peers who are also struggling with similar problems.

The intensive psychotherapy of depression over 1-3 months has the potential to move the patient past their stuck position. A strong alliance is formed with an experienced psychotherapist, who works with the patient to identify the key areas to focus their in-depth inquiry. Meeting 3 or more times per week often generates therapeutic momentum that is hard to develop on an outpatient basis. Multiple approaches are used together in synchrony. Mindfulness training helps reduce the need for destructive or futile patterns of behavior. This allows a deeper look at the nature of the emotional pain. Art therapy can tap into the non-verbal experience of difficult emotions, allowing aspects of the depression to become available for psychodynamic work. Movement therapy, yoga, acupuncture, and body work can free trapped energies, making them available for therapeutic work. Dialectical behavior therapy (DBT) skills training in emotional regulation and interpersonal effectiveness can allow new patterns of behavior and relating to occur in a relatively short time period. Attention to a damaged sense of self can organize some of the experiences that perpetuate depression, allowing for positive changes to begin and be sustained. Family therapy can assure that the key people in the patient’s life are brought into the work in the way that will best sustain recovery. In summary, a period of residential work can provide the needed integration of neurochemical adjustments, psychological understanding, new skill development, and attention to how the patient engages with his or her family.

Finally, with an intermediate length of stay, one avoids the regressive pull of a longer-term residential treatment. The treatment team and patient keep the goal in sight of reintegrating back home. The stay is long enough to get some significant and lasting therapeutic work done, with positive momentum towards full recovery from depression. However, attention needs to be paid to how this momentum will be sustained as the patient returns to family, work, and outpatient therapy.