As 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-Structure
Addiction 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 Staff
A 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 Treatment
One 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.
Virtual 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.
“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-Practice
A 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)
Functional Family Therapy
Cognitive Behavioral Therapy (CBT)
Motivational Interviewing (MI)
Eye Movement Desensitization and Reprocessing (EMDR)
Dialectical Behavioral Therapy (DBT)
Twelve Step Facilitation (TSF)
Spiritual Assessment and Cultural Formulation
Cultural and Spiritual Integration
Rev. Jack Abel, Vice President of Wellness
and Culture at Urban Recovery, has developed specific models for clinical
chaplaincy in substance use disorder care. These models incorporate the very
best in client-centered clinical ethics and practice, attending to the unique
story and preferences of each person in shaping a trajectory for enhanced connection and resilience – for these
are the hallmarks of spiritual fitness.
Adapting a variety of proposals for formal
spiritual assessment in hospital and end-of-life care to the ASAM criteria
which are the “gold standard” for multidisciplinary assessment in use disorder
care, the Urban Recovery client is empowered to relate their clinical and
social experience to cultural and spiritual frameworks, traditions, and methods
of their choosing. Contemplative, nutritional, and fitness practices can play a
vital role in enhancing spiritual fitness, but relationship and community also
figure prominently in shaping belonging and authoring personal meaning and
Flexible Stays and Levels of Care
“How long will I be at Urban Recovery?”
This question is understood differently than it has been in relation to
treatment centers of the past. Clients and families benefit from authentic
estimations of their needs, but these can only be approximate until a
comprehensive assessment is completed and clients and their families are able
to participate in shaping an informed wellness plan.
The bespoke model of care at Urban Recovery
uses measured increments that are approximate and interconnected. “Discharge
planning” from any current level of care – even initial referral – begins as
part of the onboarding process, and “next steps” emerge in an unfolding dynamic
of relationship between the client, the family, and the multidisciplinary
clinical team. Since its inception, Urban Recovery has pioneered “soft walls”
and flexible approaches to stays. A tour in advance of admission is an early
instance. Bringing potential providers for next steps on the journey in for
interviews and question-and-answer opportunities is another. Perhaps the most
significant, however, are the experiences of titration back into the urban
environment that are built from short passes through overnight stays to initial
discharge with planned “recharge” opportunities.
Real world circumstances impact clients on
a day to day basis, and treatment providers in the past have often been
challenged to flex treatment to accommodate these real-world concerns. This
models an inflexibility which can undermine the encouragement provided to
clients to increase their adaptability and resilience. Therefore, Urban
Recovery’s treatment philosophy includes a fundamental commitment to
practicality. Client schedules, lengths of stay, and permissions for
incorporation of on- and off-campus events are not dictated exclusively by
restrictive policies. Instead, as clients progress in stabilization and, if
appropriate, into an inpatient treatment stay, the primary therapist and
treatment team collaborate with clients to provide a rich and focused treatment
experience that also is engaged in appropriate and necessary ways with their
A Timely Alternative
This article does not exhaust bespokeness –
it only begins to open up what is in the end not a method as much as a
commitment. Medical providers report that substance use disorder concerns, when
discovered, often do not result in use disorder care at any level. Many medical
providers are only now learning about models for brief intervention and
referral to treatment. Insurance provisions can be complex and onerous. Focus
on opioids, while laudable, also is obscuring important concerns with alcohol,
benzodiazepines, cannabinoids, and other substances – as well as correlated behavioral
concerns like gambling, disordered eating, shopping, internet use, and more.
Media have presented movies which celebrate
an outdated “28-day” fixed-method approach. Well-meaning insistence by
regulatory and accrediting bodies have moved the top providers to make
adjustments for specific instances and to articulate treatment plan content in
the client’s ‘voice.’ But, these efforts are insufficient to meet the depth and
breadth of the use disorder crises in our midst and the “many and varied” portraits
of those affected by such illness.