Crossroads Intensive Outpatient Program Offers a lifeline of hope and recovery for those in Mental Health Crisis

Johnny is 16 and has always been a bit of an anxious boy. Sitting in the hospital emergency department, he was really anxious and desperate. In middle school and then high school he has been bullied and had few friends. After the isolation of the pandemic he returned to school, but everything felt off. He couldn’t keep up with his studies or homework. Without good grades, he couldn’t play hockey. He got to feeling tired a lot and nothing seemed interesting. He had trouble focusing and got frustrated quickly. His teachers and mother were always arguing with him.

Johnny started to sneak out of the house to drink with friends which felt better for a moment but afterward the stress came rushing back in and somehow things seemed worse. He worried his mother and grandmother might get COVID. Johnny thought about killing himself and even wrote a note but then decided to tell his therapist.

Johnny agreed to go to a hospital for a week to help with the suicidal thoughts and urges. He hoped it might help him feel better and it did when he was there. But after leaving the hospital he felt miserable again.

Johnny’s mother Janice, a single parent working full time, cares for her elderly mother, too. She was concerned that he was isolating himself and that every interaction they had turned into an argument like when she tried to push him to go to school but he wouldn’t go. When she tried to be supportive by offering suggestions, Johnny seemed to get more irritated. Janice desperately wanted to help Johnny and was feeling lost about how to do that.

The doctor at the emergency department, Johnny’s therapist, and pediatrician, all recommended he do something called an Intensive Outpatient Program (IOP). Johnny had no idea what all those letters actually meant, but everyone kept saying it would be helpful. He hoped the program could help him finally start to feel better, but after years of therapy and hospitals, it was hard for him to imagine anything could actually work.

Northeast Family Institute (NFI) Crossroads, an Intensive Outpatient Program (IOP) in Essex Junction, provides comprehensive mental health treatment for adolescents and adults. It accepts referrals from hospital emergency departments, inpatient units, and residential programs. The IOP is a step between once-a-week outpatient therapy and 24/7 inpatient care. IOP treatment at Crossroads is 3 to 5 times a week (9-15 hours) for 4-6 weeks. The IOP helps people who have tried outpatient treatment or inpatient care but have not found the lasting improvements they need. For the 225 folks a year it treats, it decreases the need for inpatient and emergency department visits.

Crossroads serves adults and adolescents as young as 13; even the youngest have often been doing therapy for years, and the adults, sometimes for decades. Many have met with several therapists and tried several types of therapy. They have often spent time in hospitals. The pain they have endured is hard to describe and harder to imagine. Many experience levels of depression and anxiety that are so severe they struggle to live their lives. Tasks like getting out of bed, working, and getting to school can seem impossible. Many have seriously contemplated or even tried to end their own lives because they don’t know how else to end the pain. There is a deep sense of hopelessness when someone has tried so hard to feel better and continues to feel pain. Most who come through the door don’t really believe that this treatment could help them feel better. And how could anyone believe that this experience will be different, when their entire lived experience says otherwise?

For many, something sounds different about DBT from the very beginning. When DBT is the right fit, the explanation of the model – referred to as the biosocial theory – communicates empathy, understanding and a glimmer of hope. Often, the person lets out a slow exhale as they quietly reflect, they begin nodding or their eyes well up with tears. Many ask how a therapeutic framework could possibly understand and accurately articulate their entire existence so well.

Dialectical Behavior Therapy (DBT) was created by Marsha Linehan, PhD in the late 1980’s. At its core, DBT is a balance of acceptance and change. Therapists use validation and mindfulness to fully understand and be present with a person. The treatment integrates strategies for change necessary for a person to live a more fulfilling life. DBT has been heavily researched and is considered an evidenced based treatment for many disorders. The process includes individual DBT therapy, DBT skills training, phone coaching and a consultation team for the therapists.

Washington County Mental Health Services (WCMHS) began to implement DBT starting in the early 1990’s and were one of the first community mental health agencies to provide DBT anywhere. Then Matrix Health Systems started and ran Crossroads for nearly 20 years. Afterwards in October 2019, NFI took over and collaborated with WCMHS to develop DBT treatment for adolescents at Crossroads. In 2021, WCMHS opened Polaris, an adolescent IOP in Montpelier. All the DBT IOP services at NFI and WCMHS have run throughout the Covid-19 pandemic but do have waitlists.

The idea that profound change can happen in six weeks, after years of debilitating suffering, seems impossible unless you’ve witnessed it or experienced it yourself. The change can start small, with very subtle shifts that could be missed if you weren’t watching carefully. There’s a slight shift in body language. A head tilts up a little bit more. Eyes make direct contact for a moment. Shoulders lift as the enormous weight starts to lighten. The face starts to soften and becomes more animated. The glimmer of hope in the eyes starts to grow.

DBT IOP treatment is very intense and challenging. Most who come with intense symptoms leave with low levels. By the end there is more control over risky and often life-threatening behaviors. People begin to connect with others differently, and most importantly, they start to envision their lives with hope and without suffering.

Johnny was extremely anxious when he came in for the initial meeting. He was very quiet and mostly nodded in response to questions. Johnny’s upper body remained very tight and still while his left leg bounced up and down throughout the meeting. When the DBT model was explained he nodded more frequently. Janice’s eyes welled up with tears. “I can see how some of the things I have been doing to try to be helpful were accidentally making things worse.” she said, “I want to learn how to change that.”

At the start, Johnny thought six weeks of treatment would drag on forever, but he really enjoyed some parts of the program like expressive therapy group, especially making Zen Tangles. He liked connecting with other people and understanding himself better, but making changes was also very difficult.

Johnny was shocked when he was told three weeks had passed and he was halfway through program. He had been working hard to understand his own emotional experience and articulate that clearly to others. Johnny was discovering that his anger was often secondary to his sadness, hurt and disappointment. He had also been working hard to act opposite to his depression urges. He felt a little bit better but worried that he would never feel completely better.

Janice was also working hard. She learned to validate Johnny’s experience and to tolerate her own emotions when she could see Johnny was hurting. She started to notice small changes in how Johnny interacted with her. He started to tell her more about his day and didn’t disappear into his bedroom as soon as he walked in the front door. Discussions didn’t become arguments as often.

During Johnny’s fifth week in the program, he noticed a big shift. He had more energy and enjoyed interacting with people more. His witty sense of humor started to reemerge. He became more animated when he was talking with peers. He reached out to a friend to go snowboarding.

Johnny became more aware of his emotions in the moment and more readily communicated his experience to others. Johnny began to integrate the skills he was learning into all areas of his life. He started attending school again, reaching out for phone coaching when he had the urge to leave part way through the day.

Johnny hasn’t self-harmed, drank alcohol or thought about suicide since his second week in the program. He is tracking how long he has gone without self-harming or drinking on a sober app on his phone. He checks the app daily and feels a deep sense of pride when he sees the time ticking up.

After his sixth week of program, Johnny graduated from Crossroads with a clear plan of what he wanted from meeting with his therapist and was looking forward to life. During his graduation, Johnny reflected that at the start of program he had been convinced it wouldn’t work. He told his peers who were just starting program that he couldn’t believe how quickly the time went and how much had actually changed during that time. “I honestly didn’t think this program could help and I’m telling you it did.”, he said, “It can be really hard at times. Put the effort in. Do the work. It’s worth it because it actually works”

The American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the Surgeon General of the United States have all declared the state of children’s mental health a national crisis. That’s because a great many kids and their families in the US and in Vermont are experiencing issues in life like those described in this article. Families have never before been in such distress as they are these days.

This description of Johnny is not one person but a composite of people who typically use Crossroads. In addition to the experiences described here, children of color, those who are gay or are questioning gender identity and in other traditionally marginalized groups or maybe just being or thinking differently often get bullied or made to feel less than.

More mental health treatment resources for children are desperately needed across Vermont. More of existing resources and additional alternatives are needed to help meet families’ needs. The Department of Mental Health and the Designated Agency/Specialized Services Agency Network are working hard to retain existing services because of the staffing shortage crisis affecting all work sectors.

Providing trauma informed, innovative mental health and education services to Vermont children and families.

This article is part of a collaboration produced by members of Vermont Cre Partners. Vermont Care Partners is a statewide network of sixteen non-profit, community-based agencies providing mental health, substance use and intellectual and developmental disability support