The Multi-Modal Treatment of Psychiatric Disorders | The Retreat at Sheppard Pratt

The Multi-Modal Treatment of Psychiatric Disorders

October 4, 2011 —

“The [hospital’s] purpose was to be curative, combining science and experience for the best possible results” -Moses Sheppard

When Sheppard Pratt was founded over 100 years ago this was our charge, and continues to be here at the Retreat at Sheppard Pratt. While many settings by choice or necessity have a more limited mission, we have developed an intermediate length of stay program that not only provides for a comprehensive diagnostic assessment, but also exposes suffering people to various therapies and experiences that they might find useful. This multi-modal psychiatric treatment requires not only a dedicated multidisciplinary staff with a wide range of perspective and expertise, but also a team that respects each other’s point of view and potential to help people.

Recently in the Journal of Affective Disorders (Vol 131, 2011, 92-103) researchers in the UK looked at people suffering from treatment-refractory affective disorders in a specialized program that offered multidisciplinary care for 4-6 weeks. These patients by definition had failed at least one previous adequate medication trial (and often failed many, extensive treatment efforts) and had depression rating scores that were severe. The clinical program they were exposed to incorporated expert psychopharmacological consultation, cognitive therapy, occupational therapy, couples work, and somatic treatments such as electroconvulsive therapy if needed. At the end of treatment 69% of people improved significantly and half of these sustained their improvement after discharge. These results were obtained in a group of people that were suffering greatly, many of whom were unresponsive to multiple efforts at outpatient and short-term inpatient treatments for their depression.

At the Retreat, we were not surprised when we reviewed these findings, since for almost a decade now we have treated people in a similar specialized setting and seen results in cases where the patient and their family had almost given up. The immersion in a residential program designed to approach complex depression from multiple angles has proven worthwhile and even lifesaving for many of our patients.

Here at The Retreat, we regard multi-modal treatment as encompassing 4 main areas:

1) Psychodynamic Psychological care, including expert psychodynamically-informed individual psychotherapy provided by psychiatrists, art therapy, experiential therapy, family therapy, as well as integrative milieu treatment supervised by a highly trained nursing staff that is involved in all aspects of care. These treatments focus on a greater depth of understanding of how the past affects the present and results in maladaptive patterns of behavior or a disturbance in intrapsychic structures.

2) Dialectical Behavior Therapy focusing on maladaptive behaviors and skill-building to help people overcome these difficult behaviors and affect states, as well as an introduction to the dialectical approach to life, accepting differing, often opposite points of view and being able to embrace and hold both of these in mind at the same time.

3) Expert medical psychiatric care, including a complete physical examination, state-of-the-art psychopharmacology and use of somatic treatments as needed including transcranial magnetic stimulation (TMS) and electro-convulsive therapy (ECT).

4) Eastern approaches including mindfulness meditation, yoga, movement therapies, nutritional supplements, and for some people acupuncture.

We find that the ability for people to take advantage of this array of treatments in an integrated, residential environment allows for the overall treatment to be greater than the sum of its parts. The various ingredients may be of a high quality themselves, but when combined in this way by the resident and treatment team are able to construct an informed, individualized, and therapeutically rich treatment program. Occasionally someone will come to the Retreat expecting a “magic bullet,” usually a pill, to make them better. This is seldom the case. One great advantage of multi-modal treatment is that people have the opportunity to benefit from several things which by themselves might not be enough, but when taken together lead to a significant improvement. It is far more common for someone to find 4 treatments that help 20% each than to find a single treatment that makes them 80% better. While our minimum stay is 20 days, enough people see the utility of what we offer that our average length of stay is about 5 weeks, perhaps owing to folks needing to find or fine tune those 2 or 3 extras that make the difference between a little better and an improved quality of life.

While intensive treatment is costly in terms of the staff required to initiate it, and the time out of people’s lives to avail themselves of it, many see the reduction in their level of disability to be a long-term value that it is hard to put a price on. Over the past 30 years psychiatric care has fallen prey to a false reductionism that has taken the human being out of the center of the treatment situation. Here at the Retreat, we put the individual person back into focus using all the tools that both modern and classical theory suggests might be of use.

-Tom Franklin, MD, Associate Medical Director, The Retreat