Hope Adult Program

Protocols

Who we treat
Menninger offers individualized treatment for adults with mental illness that has substantially compromised their quality of life or whose illness has become unmanageable or unresponsive to outpatient treatment.

The Hope program serves persons with long-standing mood, anxiety, and psychotic disorders that are often coexisting with personality disorders, substance-related disorders, or other conditions. Our treaters provide a quality, cost-effective alternative to acute hospitalization with evidence-based (research-supported) and rehabilitative treatment approaches.

Approach to treatment
Many of our patients have had their mental illness for a number of years. Often, they have either not fully developed, or have lost, the healthy life and coping skills they need and desire. Our staff blends therapeutic and educational approaches to teach and coach the use of adaptive skills.

We also rekindle the patients' Hope that they can reach their potential and manage their symptoms.

First, we begin by stabilizing their symptoms and conducting a thorough assessment of their current and historical medical, psychological, and social needs. Patients proceed through a four-part admission evaluation that includes interviews with:

1. a psychiatrist
2. an internist
3. a primary nurse
4. a primary clinician (either a psychologist, a social worker, or an advanced registered nurse practitioner)

The primary clinician will also interview family members, referring clinicians, and other important individuals in the patient's life to complete the assessment of the patient's broader social context.

Equipped with this insight, the treatment team develops and implements an ambitious, realistic treatment plan.

Our goals are to:
Promote stabilization

• Rekindle Hope through psychotherapeutic methods and rehabilitation
• Design and implement a multi-dimensional treatment plan based on research-supported interventions
• Assist patients in making a successful transition to their home community and in re-establishing and leading a rewarding lifestyle
• Evaluate diagnoses

With these goals in mind, patients collaborate with their team in defining the problems and goals that will form the focus of their treatment and the markers by which progress will be measured.

Treatment team
Treatment is conducted from a biopsychosocial framework by multidisciplinary teams. The breadth of expertise among the treaters enables them to provide comprehensive services. The team continues to expand specialty interventions that, when possible, are supported by empirical research.

Patients participate in the evaluation process, the planning, and the implementation of treatment as a core member of the multidisciplinary team. This team consists of the patient, the primary clinician, the psychiatrist, the primary nurse, and an associate nurse.

The primary clinician stays in touch with the family and referring professionals, providing information about the patient's progress and aftercare planning.

Upon admission
Within the first few days of admission, patients are oriented to the program by members of the nursing staff and their primary clinician. Primary clinicians also introduce patients to the program schedule. This schedule, which includes both therapeutic work and leisure time, forms the framework of the rehabilitative approach of the program. Patients begin with a core set of rehabilitation groups that include:

• Goal setting (twice weekly)
• Readiness for rehabilitation (twice weekly)
• Community reintegration (twice weekly)
• Spirituality (once weekly, optional)
• Family issues
• Supportive group psychotherapy (twice weekly)
• Women's group and men's group (each once weekly)
• Hope patient community meeting (weekly)
• Relapse prevention (once weekly)
• Roles and relationships group (once weekly)

The program schedule also includes recreation skills planning and activities, as well as weekend planning and review meetings. Community skills outings are available three times a week to patients who have achieved the level of responsibility that allows them to join their peers in going off the hospital grounds with nursing staff.

The structuring and constructive use of free evening and weekend time is often a daunting task for patients in the program. The weekly schedule is designed to recreate the combination of structured and unstructured time that people ordinarily face in their lives. Throughout their stay, patients are encouraged to use the combination of scheduled and unscheduled time during the week and on weekends to develop and practice the capacity to follow a schedule and make constructive use of free time.

Individualized treatment planning
During the first week to 10 days, treatment team members evaluate the patient's additional rehabilitation needs. As a result of further evaluation, and in consultation with the patient, additional rehabilitation groups may be added to the patient's schedule:

• Self-esteem Building
• Overcoming Depression and Anxiety
• Overcoming Perfectionism
• Anger and Stress Management
• Cognitive-behavioral Therapy

The rehabilitation approach that drives the program groups listed above assumes that there are many issues and challenges that are shared in common by most, if not all, patients who come to the program. Treatment in the Hope Program is also guided by the belief that all individuals are unique; we are treating individuals and their social systems and not simply a disorder or a symptom. As such, treatment plans are individualized rather than entirely standardized.

Treatment is guided by the evidence indicating that the therapeutic alliance between the patient and the treaters is one of the single best predictors of outcome. With this evidence in mind, patients are encouraged to be active and collaborative members of their teams, increasingly developing a sense of agency in relation to their problems and lives.

Specialty services
To meet the individual clinical needs of the patient, a variety of group and specialty treatment options are available to Hope patients, including:

• Power Issues
• Dialectical Behavior Therapy Skills Training
• Psycho-social Rehabilitation
• Exposure and Ritual-response Prevention
• Social Phobia
• Trauma Psychoeducation
• Body Image
• Nutritional Counseling and Meal Planning
• Pain Management
• Individual Psychotherapy
• Grief Issues
• Cognitive-behavioral Therapy

When chemical dependency or addiction is involved
Patients who suffer from problems involving the abuse of or dependence on substances receive an addictions assessment from a certified alcohol and drug counselor. When addiction is identified, weekly individual drug counseling is prescribed with a certified alcohol and drug counselor. Random drug screenings are integrated into treatment.

Additionally, the patient attends 12-step meetings and participates in the following weekly groups:

• Addictions weekend review
• Addictions first step recovery
• Addictions relapse prevention
• Dual diagnosis educational group

Immediate family members are encouraged to participate in a two-day family workshop, while their loved one is in treatment at Menninger. The educational workshop is offered every six weeks.There is a mental health track and an addictions track. Instruction addresses the disease of addiction, treatment, the role of the family in recovery, coexisting disorders such as depression, and related topics.

Discharge planning
Because successful transition back to and sustained tenure in the community is a major challenge for our patients, discharge planning is a major focus of the program. From the beginning of the treatment process, the team is thinking about the challenge of finding appropriate follow-up care for Hope patients. Primary clinicians communicate with referring treaters as soon as possible after admission in order to begin finding the best available combination of ongoing treatments for the patient once they leave the Menninger hospital. In the rehabilitation groups, patients are encouraged to think actively about their return home for planning treatment, as well as daily and weekly life after discharge.

Empirically supported guidelines by disorder
Current multi-modal treatment approaches for Hope patients are detailed below by specific type of disorders. These protocols are supported by the current research evidence as defined by organizations such as the American Psychiatric Association and the American Psychological Association. The psychiatric evaluation, psychiatric management, and treatment planning described above are integrated into the appropriate disorder-specific protocol.

• Borderline Personality Disorder
  
  Biological therapy

1. Medication treatment adjunct to psychotherapies
   Prescribed medications are primarily Selective Serotonin Reuptake Inhibitors (SSRIs) for mood and behavioral dysregulation. Low-dose anti-psychotic medication may also be integrated into treatment for cognitive-perceptual symptoms.
   
   
2. Emotional self-regulation may be assisted with development of biofeedback skills

Psychological therapy

1. Psychodynamic and Dialectical Behavior Therapy (DBT) groups, as well as individual psychotherapies
   These groups emphasize the importance of the therapeutic alliance, communication, and consistency among the patient and the clinicians.

Social therapy

1. Family casework, including educating the patient and family about the disorder and its treatment
   
   
2. Family therapy, as indicated

Additional therapy

Treatment of coexisting conditions such as substance abuse, psychiatric rehabilitation, and cognitive-behavioral therapy treatment to modify core beliefs and cognitive distortions



Milieu management, incorporating modeling and attention to contingency management to promote and shape adaptive skill usage

• Posttraumatic Stress Disorder (PTSD)
  
  Biological therapy

Medication for symptom relief and management
Medications may include antidepressants, mood stabilizers, and anti-psychotics, as indicated. The addictive potential of certain medications is carefully considered. Medications serve as an adjunct to group and individual psychotherapies.



Development of self-regulation skills, including management of physiological arousal symptoms through biofeedback training

Psychological therapy

1. Emotion regulation and stress reduction skills training, including dialectical behavior therapy, biofeedback, and relaxation skills, as indicated
   
   
2. Psychotherapies, including Eye Movement Desensitization and Reprocessing (EMDR) and exposure therapy or graded exposure therapy, as indicated

Social therapy

1. Safe milieu, community reintegration, and wellness planning, incorporating aspects of cognitive-behavioral therapy
   
   
2. Family casework and family therapy, as indicated

Additional therapy

Psychoeducational trauma groups, treatment of coexisting conditions such as addictions, Dialectical Behavior Therapy, and skills training, particularly for individuals with complex PTSD

• Bipolar Disorders
  
  Biological therapy

Medication treatment, including the use of mood stabilizers and potential adjunctive medications, as needed

Psychological therapy

1. Range of psychotherapies, including cognitive-behavioral therapy, interpersonal therapy, and brief psychodynamic psychotherapy

Social therapy

1. Family casework to provide education and healthy interactions, family therapy as indicated, and referral to support groups such as Depression and Bipolar Support Alliance support groups

Additional therapy

Psychoeducation about the disorder, its treatment, and symptom management to promote a sense of agency



Treatment of coexisting conditions, such as attention deficit-hyperactivity disorder, substance abuse (which occurs in 50% of our patients with bipolar disorder), or personality disorder

• Major Depressive Disorder
  
  Biological therapy

1. Medication treatment
   If the patient has never been treated with medications for depression before, prescribed medication may follow sequential steps starting with antidepressant medication(s) and adding a potential adjunctive medication. The treatment process includes full education about benefits, risks, alternatives, and the importance of awareness and collaboration. In cases where many medications, combinations of medications, and adjunctive medications have not been helpful, we may recommend and coordinate referral for Electro-convulsive Therapy (ECT).

Psychological therapy

1. A range of psychotherapies, including cognitive-behavioral therapy, interpersonal therapy, and brief psychodynamic psychotherapy

Social therapy

1. Family casework to provide education and healthy interactions, family therapy as indicated, and referral to support groups such as depression support groups

Additional therapy

1. Psychoeducation about the disorder, its treatment, and symptom management to promote a sense of agency
   
   
2. Treatment of co-existing conditions, such as attention deficit-hyperactivity disorder, substance abuse, or personality disorder

• Substance Abuse/Addictions
  
  Biological therapy

1. Medication and medical monitoring to manage detoxification and withdrawal
   
   As necessary, medications are used to decrease the effects of abused substances and to discourage the use of abused substances.
   
   
2. Behavioral therapy to counteract triggers and medications to treat coexisting psychiatric conditions

Psychological therapy

1. Relapse prevention planning and education about substance abuse
   
   
2. Individual drug and alcohol counseling to address specific aspects of addiction, sobriety, abstinence, craving, and relapse prevention
   
   
3. Cognitive-behavioral therapy, interpersonal therapy, and psychodynamic therapy especially in the presence of a coexisting psychiatric condition such as depression, anxiety, and personality disorders

Social therapy

1. Group and family therapies
   
   
2. Regular participation in the 12-step groups Alcoholics Anonymous, Narcotics Anonymous, and Al-Anon

Additional therapy

Comprehensive addictions assessment



Two-day family workshop every six weeks that addresses the addiction as a disease, the interaction of addictions with a variety of coexisting psychiatric conditions, psychological and family issues in addictions, and related topics

• Schizophrenic Spectrum Disorders
  
  Biological therapy

Medication treatment to evaluate and treat psychotic and related depressive symptoms or substance abuse conditions

If first-line anti-psychotic medications do not alleviate psychotic symptoms and behavior, augmentation with a mood stabilizer or another anti-psychotic medication from a different class may be warranted. Or a trial of an atypical anti-psychotic medication, such as Clozaril, may be warranted. Antidepressant medication may be added, if needed, after the positive symptoms of schizophrenia are contained.



A complete psychiatric and general medical history

Mental status and physical exams will be ordered, including neurological evaluation and basic lab tests, to rule out conditions that can mimic psychosis and provide baseline measures needed for certain medications.



Risk of self-harm, harm to others, and command hallucinations continually assessed

Psychological therapy

1. Development of a vital alliance with the patient who is often frightened by his or her psychotic symptoms
   
   
2. Individual supportive, psychodynamic, and/or cognitive-behavioral psychotherapies
   
   These therapies promote various goals such as awareness and acceptance of the disorder, retention of dignity and respect as a person, incremental progress in daily life functioning, and agency in management of the illness. This work also addresses the patient's general health, including prevention of secondary disorders such as addiction or water intoxication/excessive thirst.
   
   
3. Psychosocial rehabilitation to promote learning or relearning of skills needed for adaptive daily life functioning and community tenure

Social therapy

Family casework to provide education, especially about subjects such as low expressed emotion, and to reinforce realistic expectations, the importance of medications, long-term planning, and referral to the local chapter of the National Alliance for the Mentally Ill (NAMI)

Additional therapy

1. Psychoeducation about the disorder, its treatment, and symptom management to promote a sense of agency
   
   
2. Treatment of coexisting conditions especially posttraumatic stress disorder (which coexists in 19% of patients with a psychotic disorder) and substance abuse (which coexists in 50% of patients with a psychotic disorder)