Urban Recovery NYC: Wednesday, June 26, 2019As the nation and world examine the challenges of opioid use and a proliferation of other use disorders and related behavioural concerns, old models that are more rigid and inflexible need to be replaced with more nuanced and integrative approaches. Insights in behavioural health and other clinical settings demonstrate that alliance with the client is paramount, and that “you should” is simply not an effective formula for eliciting successful behavioural and personal transformation. A term once best-known for its relevance to tailor-made clothing, the team at Urban Recovery in Brooklyn has adopted “bespoke” as a cornerstone of its treatment philosophy for persons and families affected by addiction. Although addiction treatment best practices have argued for decades on behalf of “patient-centred” practices, a truly bespoke model grounds itself in the client and builds its content around that centrepiece, rather than ‘tweaking’ a formulaic program to add customized elements.
Storied Treatment: Liminality, Structure, and Anti-StructureAddiction treatment is a liminal experience. There is a sense of “edge” to the crises that precipitate treatment admissions, but also to the quest to find a way out of the personal, familial, legal, educational, or professional dilemmas faced by clients and their families. There are dynamics of the unknown, of a turn from the past, of necessary engagement in the substantive struggle, and the authoring of a new beginning, a path forward. Such journeys are not solitary, nor generally time-bound; instead, they require support, wisdom, and patience. While historic observations of a common meta-structure that underlies quest certainly apply, each heroic journey is its own. This is the heart of the bespoke model, authoring the next part of one’s movement toward lifelong wellness in spite of whatever obstacles life may present. Having reached some awareness of a need for significant behavioural, intrapersonal, and social change, clients embark on a journey that is necessarily disorienting. Clients can find it meaningful and helpful to think of this change process as a “rite of passage.” In this context, “bespoke” is not structure-less, but recognizes an intricate balance is needed: elements of dismantling the familiar are juxtaposed with dynamics of regularity. Circadian, weekly, and other rhythms, expressed in routine wake-up, meals, check-ins, and wrap-ups before closing the night: these natural elements provide a temporal and nutritional structure that supports the authoring of a “bespoke” clinical experience. Yet another element of balance between structure and flexibility is found in thematic elements which shape the phase of treatment and link to the shape of the week, but which must be aligned in each case with the particular challenges and objectives of the client and family system involved.
Scheduling: Looking at Clients rather than StaffA fundamental component of the reversal of thinking developed at Urban Recovery involves scheduling. Beyond the circadian rubrics of daily and weekly meal and sleep/wake cycles, truly bespoke treatment inverts its orientation to scheduling. Clients are not fit into schedules. Instead, clinical resources are allocated to clients. At Urban Recovery, the scheduling of client days is authored from that vantage point – not starting with a bank of clinician’s calendars looking for openings, but with client opportunities waiting to be filled. This open real estate on the daily client calendar is the canvas on which truly customized care emerges. Clients are not fit into schedules. Instead, clinical resources are allocated to clients.
Permeability: “Soft Walls” of Urban TreatmentOne of the great growth challenges of the addiction treatment industry is the movement away from a limited notion of ‘products’ to which all clients are recommended, fixed ‘containers’ that have been labeled as “IOP, detox, residential, extended care, and sober living” — with 8-week, 3-5 day, 28-day, 90-day, and 3-6 month commitments respectively. Each level structures its “inside” as a type of “treatment bubble” and specifies how permeable or not that “level of care” is. One used to hear, “There are no phones in detox.” Or residential. “There are no passes until extended care.” “You don’t get a job until you get to sober living.” In locating a facility in New York City, the model for “stabilization” and “inpatient” care that Urban Recovery has developed for its clients is conceived differently. While initial commitments are encouraged in order to provide clients and their families some guide around which to base their participation and support, the design of daily programming, the ongoing development of treatment planning, and the incorporation of elements either within or outside the walls of the facility that in other settings are often segregated to “after” is at the heart of Urban’s bespoke care. Examples include visits to one’s apartment, office, or food and beverage establishments, or specific visits with wellness, medical, or behavioral health providers – permeability means that the latter professional and services opportunities may also occur on the facility premises.
TechnologyVirtual reality (VR), biofeedback, teleconferencing, and video journaling are among the technology resources that are also used at Urban Recovery to expand and modify the context of treatment. Clients can use VR to visit meditative or challenging spaces, even to revisit past sites of important life experiences. Clients benefit from biofeedback tailored not only to provide information about their wellbeing, but to retrain the brain in relation to anxiety and other mental states. Video journaling and augmented reality present yet further frontiers that are being incorporated for appropriate clients into the Urban Recovery bespoke experience.
Embracing Complexity“Dual diagnosis” and “dual-addicted” are among terms explored in the past generations of work with clients suffering from substance use disorders. Each of these binary categorizations are in less common use, as the American Society of Addiction Medicine and other influential bodies have called the industry to view clients in a holistic way, to understand addiction as a presentation with biological, psychological, social, and spiritual manifestations. If there are other forms of illness present which predate an active use disorder, they are significant as such. If other forms of illness emerge in the context of an active or in-remission use disorder, they too are significant. The entire person, and their social relations, suffer. Together the person-in-system and system-of-persons move toward greater wellness. One of the fundamental shifts in embracing client complexity is to view treatment as at once individual and systemic. Urban Recovery integrates this as foundational thinking through the pairing of key individual and social focal elements in treatment planning. Educational and behavioral interventions rooted in a “practice-based evidence” approach see clients as unique, particular, and complex, not as “population-based health care” constituents subject to global algorithms which are linked to media and political focal concerns.
Tracking Outcomes in Methods-Based-PracticeA clinical model that embraces complexity and seeks to be accountable documents and measures as it applies practices that are rooted in the best clinical reasoning and experience. Behavioral health concerns can benefit from the long and complex journey of randomized, controlled studies in some instances, but clients deserving our best should not be limited to exclusively those systems and methods which allow for and have benefited from a double-blind, controlled examination that holds limited variables in view. Therefore, the clinical philosophy of Urban Recovery places Acceptance and Commitment Therapy as one of its favored models, but not as an exclusive offering. Urban clients explore their values and acquire competencies in mindfulness; at the same time, they are examined from a systems perspective and offered opportunities to engage in specific methods and practices that are determined by their primary therapist and treatment team as best suited to their current staging and objectives in care.
|Acceptance and Commitment Therapy (ACT)||Mindfulness|
|Functional Family Therapy||Systems-Based Practice|
|Cognitive Behavioral Therapy (CBT)||Motivational Interviewing (MI)|
|Eye Movement Desensitization and Reprocessing (EMDR)||Dialectical Behavioral Therapy (DBT)|
|Twelve Step Facilitation (TSF)||Exposure Therapies|
|Spiritual Assessment and Cultural Formulation||Wellness Assessment|