Individualized care has been a concept that has been widely used, and at times, I fear that it might have lost some of its meaning. I write this for all of us in the field, including myself. When we commit to a concept in our practice we can, without regular accountability to these values, start to believe that our alignment to these values in the past ensures its existence in the present. For all of us in the field, myself included, the following is a review and recommitment to the effective principals of individualized care.
At its most basic, individualized care starts with the size of the milieu and therapeutic groups. I’m not here to dictate the optimal group size. There is plenty of research on this topic that can be reviewed and applied and individually adjusted to various programs. What remains important is that we are conscious of group size in our programs and accountable for it. It won’t matter how dedicated I am to the concept of individualized care if my practice is running process groups with too many people. People can only be attended to in an individualized way if the number and structure of the staff can be set up to actually allow for individualized care.
Residential treatment is effective much of the time not because of its part that is “treatment” but rather its part that is “residential.” It’s the discussion after group, the support that can be offered passing a patient in the hallway, the meal that can be shared where it’s just two people talking. When our staff is so structured with the “treatment” by having groups and therapy appointments back to back all day we would do well to consider the relational costs this has had on the “residential” part of treatment. Individualized care means when someone is in a crisis moment of change that the staff has the freedom to adjust their schedule to show up for that patient when the moment is there in front of them. I have always tried to structure this at Ascend by making sure that our team has at least 25% of their time that is unaccounted for by the organizational schedule. With this built into the structure no one can say they did not have time or were simply not present for all the unscheduled moments of change that can come from attending to the “residential” part of the care we provide.
In his seminal book, Group Therapy and Practice, Irwin Yalom articulates the key therapeutic group therapy forces. Under his discussion of interpersonal learning, he addressees one of the key therapeutic forces being the social microcosm. Summarized, this concept means that our groups should and will be a representative sample of society at large. This concept is important to individualized care because it reminds us who we don’t accept as a patient can be as important as we do accept as a patient to the group and its influence on individualized care. Examples of questions I find myself asking with regard to this concept when considering a particular patient profile for admission are, “Do we have the right gender mix to accept this particular patient?,” “Do we have the right balance of mental health diagnosis to be effective with this patient?,” “Do we have the right mix of age and background to give this patient good care?” Our groups in residential programs are in constant flux. We might generally ascribe to good tenants of individualized care in our programmatic philosophy but at any particular moment be less equipped within our current group to provide individualized care to a particular patient. Individualized care means asking yourself these hard questions, facing the reality of the answers, and having the courage to act on them.
At the end of the day, when the foundational elements discussed previously are attended to, we are left with the actionable practice of individualized care. The actionable practice of individualized care is more difficult to pin down because it is so, true to form, individualized. As we experience at Ascend it will come down to things such as, can the program bring in a specialist to give more expertise help on a particular diagnostic profile? Can it accommodate a job or school schedule that is best for the patient but harder on the program? Can the program reorganize some of how the team delivers treatment to accommodate different learning styles? Can the program flex to accommodate a gender identity issue that might be in flux during the course of one’s treatment? In summary, are we asking the patient to fit into the program or asking the program to fit around the patient? That’s easy to say. Though we are committed to the philosophy of fitting the program around the patient, we have at times caught ourselves falling into the natural human desire for convivence in fitting the patient into the program. Admitting this tendency, being accountable for it, and addressing it with the patient its most effective for in the moment is how the concept of individualized care stays alive in programs on a day to day basis instead of being dead on the wall in a list of value statements.
In conclusion I would make one more theoretical point of summary. Individualized care is a word we use with laymen to address the psychological practice concepts of attachment and therapeutic alliance. These concepts must be values and areas of direct practice focus. If this happens in our programs much of what we have discussed as the concepts of “individualized care” will be direct results of our attendance to attachment and therapeutic alliance. Attachment creates the motivation and creativity to make individualized care visible in our programs and the results of our patients lives. It is at this point that their care will be theirs. It is only when it is their care and not our care of them that the care has been individualized.