River House Redesigns Program to Enhance Treatment of Emotion Dysregulation

At Silver Hill’s River House, the newly renamed and enhanced Resilience Program concentrates on treating emotion dysregulation. Established in 2006, the program has undergone several evolutionary changes in the last year, including a variable length of stay, a formal assessment phase, additional treatment modalities, and the utilization of an alternative model of personality disorders.

The Resilience Program treats personality disorders, including borderline personality disorder (BPD), narcissistic personality disorder (NPD), histrionic personality disorder (HPD), and dependent personality disorder (DPD). Depression, both unipolar and bipolar, as well as anxiety, are also treated. “We really focus on the core symptom of emotion dysregulation,” says Ryan Flanagan, MD, Director of the Resilience Program.

Although the program is designed for all adults 18 and older, the Resilience Program population often trends toward young adults.  “We work to maintain a balance of ages as much as possible,” says Dr. Flanagan, “and we also focus on those who are personally motivated to be in treatment. With young adults who are legally adults but also closely tied to their parents, it’s important they are here of their own accord.” 

Patients also need to be willing to have a roommate, live in a therapeutic community, and engage in a group setting.

Previously, River House’s program was 28 days long, though patients were given the option to extend their stay if needed. Now, during a formal assessment phase that occurs in the first seven to 10 days of treatment, the length of stay is determined in collaboration with the patient, the family, and the treatment team. The assessment phase also involves determining both a solid diagnosis and a robust treatment plan.

Additional Treatment Modalities

Dialectical behavior therapy (DBT) continues to be the core of treatment at River House and is presented in four week-long modules — mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. Residential counselors trained in DBT are also available 24/7 at the house.

To further enrich the program, two additional approaches have been integrated — mentalization-based therapy (MBT) and good psychiatric management (GPM). “We are adding these evidence-based modalities to the DBT program to make River House and the treatment we provide as all-encompassing as we can,” says Dr. Flanagan.

MBT is an approach that helps patients navigate social interactions and relationships, as well as interpret their own thoughts, feelings, intentions, and beliefs while differentiating them from others. These are skills that are often lacking in people with personality pathology, severe anxiety, and mood disorders.

One of the creators of MBT, Dr. Peter Fonagy, a Professor of Contemporary Psychoanalysis and Developmental Science and Head of the Division of Psychology and Language Sciences at University College London, is on the Silver Hill Hospital Board of Directors and has been instrumental in overseeing and guiding the transition of the Resilience Program to include MBT. “DBT and MBT are different approaches for treating Cluster B personality pathologies or emotional dysregulation, but they can work synergistically,” Dr. Flanagan says.

The program incorporates MBT through daily mentalization groups. In these group sessions, patients discuss their current interpersonal issues and interpret them through a mentalizing frame.

Recently, Adaptive Mentalization-Based Integrative Treatment (AMBIT) was introduced as well. “It’s basically a framework based in mentalizing principles that teams and systems can use when dealing with complex patients and patient populations,” says Dr. Flanagan. “Ultimately, the goal is to prevent burnout and help patient care in the long term.”

The main principles of GPM are situational pragmatism, interpersonal hypersensitivity, a focus on education for patients and their families, and psychopharmacology if needed. “These core tenets make so much sense and are often overlooked in how we handle and treat patients with Cluster B* personality pathology,” says Dr. Flanagan.

Practically, GPM is implemented into the everyday management of patients through interactions, therapeutic sessions, case management, expectation management, and discharge coordination. Additionally, Dr. Flanagan runs a weekly “Ask the Doctor” group in the River House living room where patients can ask questions about their diagnosis, treatment, and other mental health issues.

He also hosts a monthly seminar for family members to give them an overview of personality and mood disorders and answer their questions. “That has been really beneficial in getting family involved,” he says.

Psychopharmacology on an as-needed basis is another aspect of GPM. “You certainly can give medications to individuals with personality disorders to target the symptoms. You’re not treating the core disorder, you’re giving Tylenol for a fever in somebody who has the flu,” explains Dr. Flanagan. “We have to balance that with the reality that polypharmacy in these individuals can often become counterproductive.”

*These personality disorders deal with issues with emotion regulation, impulsivity and relationship issues

Rather than a classical categorical approach to personality disorders, the Resilience Program embraces a dimensional approach. Patients are still diagnosed categorically, but pathological traits and functioning are assessed via the Level of Personality Functioning (LPF), Personality Inventory (PID), and Difficulties in Emotion Regulation Scale (DERS) on admission and every two weeks.

“Trying to incorporate these dimensional approaches can help individualize treatment and our understanding of patients in a more nuanced and also faster way, which in turn helps with their treatment,” Dr. Flanagan says.