Retreat rolls out new treatments

Psychiatric hospital puts new emphasis on mindfulness and quality for adolescents

BRATTLEBORO — The Brattleboro Retreat's “Tyler 3” unit offers Vermont's only inpatient mental-health beds for adolescents.

In many ways, it's considered “our most challenging unit,” says Retreat President and CEO Louis Josephson. And efforts to find funding for physical upgrades have thus far been unsuccessful.

Nevertheless, Retreat administrators say they're making some big improvements on Tyler 3 - and elsewhere on the sprawling campus - by implementing two new programs that change how patients are treated for mental-health and substance-abuse problems.

The switch requires retraining hundreds of employees including doctors, nurses, social workers, and mental health workers. The Retreat has invested about $250,000 so far, but Josephson said the early returns are well worth it.

“It's just very intentional and thoughtful. I'm really proud of the staff. They just embraced it, and I think we're going to see a lot of gains for our patients,” Josephson said. “That, to me, has been the real bright spot this year.”

It's been about a year since Josephson took over as the Retreat's top administrator following the departure of President and CEO Rob Simpson at the end of 2015.

Josephson has worked to continue the hospital's emergence from regulatory problems while also lobbying for investment and reform in the state and national mental health systems.

Aiming for consistent quality

As he examined the Retreat's operations early in his tenure, Josephson said one thing stood out.

“I didn't think we were providing the kind of consistent quality I'd like to see in the inpatient services,” he said. “I think we've got great doctors. Nobody was trying to do a bad job. But it just wasn't consistent.”

A staff survey helped inform the Retreat's decision to invest in two new treatment models. One is dubbed acceptance and commitment therapy, while the other is called dialectical behavior therapy.

Both involve a new emphasis on mindfulness, defined by one Retreat staffer as “choosing to notice what is happening right now, in the moment.”

In a practical sense, the new programs change the way Retreat staffers go about their business. For example, acceptance and commitment therapy tries to get patients to “change their relationship with their symptoms” through a process of accepting painful experiences while also moving toward more positive goals.

The program has been shown to help treat a wide variety of psychiatric issues and also can be used to treat substance abuse, administrators say.

And there have been documented upsides such as decreased reliance on medication; increased patient satisfaction; and fewer uses of restraints and seclusion, said Kirk Woodring, the Retreat's chief clinical officer.

“Our initial findings are that all of those things are true,” Woodring said. “And we've only just begun to roll those programs out.”

Tyler 3, with its population of adolescents facing severe mental health issues, was chosen as the Retreat's first unit to implement dialectical behavior therapy. The process started about nine months ago.

“Now, if you go up on the unit, it feels completely different,” Josephson said. “We've got programming that starts in the morning and goes through to the evening. We're engaging the kids. We're giving them tools to use when they leave here.”

Most significantly, Josephson said he's seen a dramatic decrease in the frequency of Tyler 3's behavioral health “codes” - situations in which staffers must respond quickly to a crisis.

He acknowledges that some of that improvement could be attributed to patient turnover and other circumstances. But both Josephson and Woodring are convinced that dialectical behavior therapy is making a difference in the unit.

“It's very structured,” Woodring said. “There's sort of a prescriptive process for it. And that structure, for adolescents, is very important.”

Work in progress

It's also important for staff. Retreat administrators are hoping the new programs have positive effects on those who are engaged in the stressful business of providing inpatient mental-health treatment.

There have been some signs of that, with Woodring citing a simple example of a relaxation exercise during a shift change on Tyler 3. “The staff who were leaving felt more relaxed, and the staff who were going into the unit felt less like they were walking into a crisis situation,” he said.

The Retreat's new treatment programs aren't a finished product. Administrators said training has been intense and time-consuming, and about 300 staffers are expected to undergo training this year.

While the Retreat has brought in outside help, Josephson said there are valuable in-house resources including Frank Gallo, a Retreat manager who is the former director of the hospital's Uniformed Service Program.

The Uniformed Service Program, which treats emergency responders and veterans who suffer from post-traumatic stress disorder, already had been using acceptance and commitment therapy, Josephson said.

The Retreat has spent about $255,000 on the new programs so far, with the bulk of that money going to training. A spokesman estimated the ongoing cost of training to be about $250,000 a year.

That's not an insignificant investment in tight budget times. And while the treatment programs could lead to shorter inpatient stays and fewer patients returning for care, there's no direct, immediate financial reward for implementing them.

But Josephson said he believes that “we owe it to patients and funders to be able to say, 'Here's what we do and how we do it and the results we get.'”

“It's a big undertaking,” he added. “It's got to be sustained over time. But I think we're seeing a lot of benefits.”

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