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Smith College Studies in Social Work
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Evidence-Based Practice and the Purpose of Clinical Social Work
Margaret Arnd-Caddigana; Richard Pozzutoa a School of Social Work, College of Human Ecology, East Carolina University, Greenville, North Carolina Online publication date: 08 February 2010
To cite this Article Arnd-Caddigan, Margaret and Pozzuto, Richard(2010) 'Evidence-Based Practice and the Purpose of
Clinical Social Work', Smith College Studies in Social Work, 80: 1, 35 52 To link to this Article: DOI: 10.1080/00377310903504965 URL: http://dx.doi.org/10.1080/00377310903504965
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Smith College Studies In Social Work, 80:3552, 2010 Copyright # Taylor & Francis Group, LLC ISSN: 0037-7317 print / 1553-0426 online DOI: 10.1080/00377310903504965
Evidence-Based Practice and the Purpose of Clinical Social Work

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MARGARET ARND-CADDIGAN AND RICHARD POZZUTO

School of Social Work, College of Human Ecology, East Carolina University, Greenville, North Carolina, USA
The problematic that oriented this study is the response of clinical social workers to the state mandate to use evidence-based practice (EBP) for Medicaid-supported clients. The portion of the study that is explored in this article answers the research question, how does the mandate affect the provision of services? Data was collected from three clinical social workers who were identified as successful by their peers. The data was analyzed by means of thematic analysis, and evaluations of research methods were conducted. The data demonstrate the way in which the mandate to use EBP excludes many clients from receiving potentially helpful services. KEYWORDS evidence-based practice, policy and practice, clinical social work practice
INTRODUCTION
This article is part of a larger study aimed at elucidating the ways in which clinical social workers have adapted to a state mandate to employ a narrowly defined version of evidence-based practice (EBP) in the treatment of individuals receiving Medicaid (see, for example, Perloff, 1996; Ozawa, 1995). EPB has fervent supporters and opponents. As an approach to psychotherapy EBP has been questioned on philosophical, theoretical, and methodological grounds (see, e.g., Houston, 2005; Westin, Novotny, &
Received 27 July 2009; accepted 27 August 2009. Address correspondence to Margaret Arnd-Caddigan, School of Social Work, East Carolina University, Rivers West, 326, Greenville, NC 27858, USA. E-mail: arndcaddiganm@ ecu.edu 35
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M. Arnd-Caddigan and R. Pozzuto
Thompson-Brenner, 2006). A more specific critique of this orientation to practice is the degree to which treatment outcomes are limited to symptom relief rather than the well-being of the client. As the data will show, some clinicians believe that the goals identified by the company (pseudonym HelpServ) that manages Medicaid for a particular state under study effectively prohibits comprehensive treatment. This leaves the therapists in the position to choose between doing that for which Helpserv will pay for those clients who cannot afford self-pay, or finding a way to provide thorough treatment. This portion of the larger study explores how mental health professionals handle this dilemma. The concerns of the larger project inclusive of this article were explored by means of a constructivist qualitative study. The researchers bias is an important factor in the study. Both researchers are clinicians, and, based on anecdotal evidence from colleagues as well as personal experience believe that policies which mandate the use of a narrowly defined version of EBP unnecessarily constrains treatment, in terms of the social workers use of self (Furman, 2009), hence the development of a therapeutic relationship (Scheyett & McCarthy, 2006) and the possible outcomes for clients (ArndCaddigan, 2005; Moxley & Manela, 2001; Scheyett & McCarthy, 2006). The sampling plan in the study was purposive, centered on the experiences of experienced successful clinical social workers. The data collected included an interview between each participant and a simulated client, the assessment and treatment plan required by Helpserv, and an interview between each participant and the researcher. The data was analyzed by means of Boyatziss (1998) method of thematic analysis. The researchers also conducted checks for consistency of judgment (reliability) and legitimacy of findings (validity). The themes that emerged in the data analysis include the following: participant profile; participants behaviors and attitudes relative to EBP; goals of treatment; case conceptualization; and other factors that influence the course of treatment. This article focuses on goals of treatment compared to the ways that the participants conceptualize the case presented by the simulated client. Based on the data, the participants view is that the mandate to use the form of EBP required by the state limits the goals of therapy and excludes many clients from receiving potentially helpful services. These services would not only be helpful to the individual but may also stem social costs. The participants also revealed the ways in which clinical social workers who wish to provide comprehensive treatment find ways to do so.
THE STATE POLICY UNDER EXAMINATION

While there are many definitions of EBP, the state in which this research was conducted uses a definition that is in keeping with the spirit of dominant usage (e.g., Gray, Elhai, & Schmidt, 2007): mental health treatment that
Evidence-Based Practice
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employs methods that have demonstrated effectiveness in reducing the frequency, intensity and duration of symptoms of a diagnosis that is listed in the American Psychiatric Associations (2000) Diagnostic and Statistical Manual of Mental Disorders (DSM) in three independent clinical trials (personal communication [1], February 4, 2005). This definition departs from many of the theoretical formulations about EBP, and is also consistent with many usages of the term. A full exploration of the multiple definitions of evidence-based practice and empirically validated treatments, and the attendant controversies, is beyond the scope of this article. The focus of the study is not on an abstract notion of EBP, but rather the actual practice of clinicians in response to a specific state policy.
REVIEW OF THE LITERATURE

Currently in social work there is a great deal of support for EBP (Gambrill, 2003). This includes a push for the adoption of this practice in clinical social work (Arnd-Caddigan, 2005; Witkin, 1991). As many and varied as the definitions of EBP may be, there are a number of writers who identify a host of problems with the philosophy and methods associated with it. Perhaps the most severe critiques of EBP have been leveled at the values and assumptions of positivism, upon which EBP is based (e.g., Houston, 2005; Witkin & Harrison, 2001). However, there are criticisms with a more narrow scope as well. One specific difficulty with the use of EBP associated with the state policy of interest here is the manner in which treatment goals are limited. For example, Scheyett and McCarthy (2006) explored the degree to which EBPs in adult mental health were or were not able to provide for basic needs, including appropriate mental health services, for clientele. Participants in the research, who were clients of public sector mental health agencies, indicated that EBPs limited the choice and voice of clients due to the prescriptive and proscriptive nature of service provision. The participant-clients indicated that they would prefer more individualized treatment plans than EBPs are able to provide. The participants also indicated that the need for a relationship based on mutuality between themselves and their mental health provider is important to them, but EBPs were limited in this respect. Moxley and Manela (2001) and Arnd-Caddigan (2005) have challenged the narrow scope of outcomes for EBP in more theoretical works. Moxley and Manela discussed the issue of power differentials between those who chose the desired outcomes of human servicesthe policymakersand those who receive the service. Moxley and Manela (2001) argued that ultimately the push to produce outcome measures in human services is a covert method of imposing the values of the powerful on service providers and recipients.
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Arnd-Caddigan (2005) demonstrated how adult survivors of childhood abuse are prevented from receiving comprehensive treatment as a result of therapy being aimed exclusively at the symptoms of a DSM (American Psychiatric Association, 2000) diagnosis. Adult survivors of childhood abuse often have symptom constellations that are not consistent with a specific diagnosis, as well as symptoms that are not part of any diagnostic category (Arnd-Caddigan, 2005). Therefore, treatment aimed solely at symptoms of diagnoses may be incomplete. Given that EBPs in psychotherapy are targeted at the frequency, intensity and duration of symptoms of a DSM diagnosis (Kielbasa, Pomerantz, Krohn, & Sullivan, 2004; Moxley & Manela, 2001), the mandate to use EBPs may result in incomplete treatment. This very point is at the heart of the assertion that some clinicians feel that the values of EBP are at odds with the values of clinical social work. The Code of Ethics of the Clinical Social Work Association (formerly the Clinical Social Work Federation, 1997) stands in clear distinction to the type of practice dictated by EBPs. The authors of the Code of Ethics made apparent that the social work clinicians primary responsibility is for the welfare of the client, in spite of any limitations managed care may impose. Wineberg (1998) clarified that this means that it is unethical to offer treatment that is inadequate for the presenting problem, and it is unethical to abandon a client before the presenting problem has remitted. The difference in language between the presenting problem and a diagnosis is important. As noted by Arnd-Caddigan (2005), presenting problems often go far beyond diagnostic categories. If clinical social workers values require that they provide comprehensive treatment regardless of what the people who manage Medicaid are willing to pay, and managing agencies such as Helpserv will only pay for symptoms of diagnoses, the social worker is left to decide how to best help clients. Thus practitioners have two contradictory imperatives. On the one hand they are constrained to engage in evidence based practice as a condition for reimbursement for services, while concurrently they must provide comprehensive treatment. How do they resolve this conundrum? One possible solution was discovered by Floresch (2004). His research demonstrated that in many cases social workers wrote reports that reflected evidence based practice, however they actually formulated cases and provided interventions based on reflective practice. The research reported here, in exploring how clinical social workers experience the Medicaid EBP imperative in one state, considers this solution.
METHOD
In keeping with the dictum of Clifford Geertz (1973), Fielding, Crawford, Leitmann, and Anderson (2009) have observed to understand a practice it is
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necessary to study what it is that practitioners do (p. 155). The problem explored in the larger research from which this data was gathered is the ways that experienced successful clinical social workers who provide mental health services supported by Medicaid work under the constraint to use EBP. The research questions that are explored in this article are: How do practitioners conceptualize the treatment of a simulated client in the face of the state mandate to use EBP for clients receiving Medicaid benefits? What do they identify as appropriate goals for therapy? How do they report to the managed care company if the goals diverge from EBP?
Researcher Reflexivity
The current constructivist study is based on a relational ontology and epistemology (Slife & Richardson, 2008). The researchers are acutely aware of their role in the dialogic process of knowledge creation: they do not assume the role of the disinterested observer. Thus, the way that the researchers came to the research problem and the researchers biases are important to disclose. In terms of the former, the authors have been clinical social workers for many years. As EBP became more the norm, and was finally enforced as policy, the researchers gained a great deal of anecdotal evidence from colleagues concerning how they continue to provide what they consider to be comprehensive treatment under the restrictions attendant to EBP. The strategies of these clinicians may be passed on as clinical wisdom, but to the authors knowledge is not represented in the literature. The researchers therefore wanted to explore clinicians response to the EBP policy through more formal procedures, and include the clinical wisdom of experienced clinicians in the literature. As stated above, it is the researchers bias that EBP unnecessarily constrains treatment, by limiting the social workers use of self (Furman, 2009), hence the development of a therapeutic relationship (Scheyette & McCarthy, 2006) and the possible outcomes for clients (ArndCaddigan, 2005; Moxley & Manela, 2001; Scheyette & McCarthy, 2006).
Sampling Plan
The sampling plan is purposive. In keeping with Glesnes (1999) observations about the unit of analysis in qualitative work, the researchers were sampling for the experiences of clinical social workers in relation to the state policy to use EBP for Medicaid clients. The researchers enlisted three clinical social workers who treat clients under the state Medicaid provisions and are thus familiar with the policy for in-depth interviews. The three clinical social workers were chosen because they were identified by other social workers in the community as highly experienced and successful as defined by the referring sources.
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Anecdotal evidence suggests a wide range of quality in the services provided to Medicaid recipients. The current study focuses on the approaches of highly skilled clinical social workers serving Medicaid recipients. This sampling plan has an inherent bias: the researchers asked clinicians to identify clinicians whom they saw as successful. The emphasis is on a practitioners perspective and an emic view of success, rather than an academicians or researchers understanding of what constitutes good clinical social work.
Participant Profile
The identities of the participants have been obscured. Lee (a pseudonym) had been a licensed clinical social worker (LCSW) for 12 years at the time of the interview. He worked in a private psychiatric practice and saw clients from a variety of socioeconomic strata, including those whose services are subsidized by Medicaid. Prior to becoming an LCSW he worked closely with adolescents as a social worker, and at the time of the interview taught social work classes at a small state university. He has also taught some continuing education courses for LCSWs. During his Master of Social Work (MSW) field placement he worked in a hospital and was able to take classes at the medical school with psychiatry students. Terry had 23 years experience in mental health at the time of the interview, 18 of those as an LCSW. He also worked at a private psychiatric practice and saw clients from a variety of backgrounds, including those who received Medicaid benefits. After receiving his degree he completed an externship at a family therapy center and completed certificate programs at both the Beck and Albert Ellis institutes. Early in his career he worked in a community mental health center where he saw exclusively clients who did not have private insurance. Jesse had been an LCSW for 18 years at the time of the interview; for 15 of those years she had been in private practice. Prior to becoming an LCSW she was in education, and is currently teaching anthropology. Prior to opening her practice Jesse worked in community mental health and had field placements in a hospital and hospice.
Data Collection
After obtaining Institutional Review Board (IRB) approval and appropriate consents, the participants each interviewed a simulated client in an intaketype interview, which was audiorecorded and transcribed. They were instructed to treat this client as a typical intake. The LCSWs also completed the assessment and treatment plan reports that Helpserv requires for compensation for the services. Finally, the mental health professionals were
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interviewed by the researcher. This interview was also audiotaped and transcribed. The interview was unstructured, based on a constructivist use of the grounded theory method of data collection (Charmaz, 2000).
Data Analysis and Evaluation Criteria

Data was analyzed by means of thematic analysis. The researchers specifically followed Boyatziss (1998) method of rendering narrative data into meaningful categories. Boyatzis has observed that a qualitative corollary to reliability is consistency of judgment; one form is consistency of judgment across viewers. The two researchers independently coded approximately 10% of the data. Agreement in coding between the researchers acting independently was 92%. They both coded the remaining 90% together. Credibility or legitimacy of findings is the qualitative corollary of validity (Maxwell, 1992). This was determined by participant validation (Horsburgh, 2003). Bradshaw (2001) suggested that in some cases giving the participants the analyzed data in the context of the research report is not appropriate. In keeping with this observation, the researchers instead gave the participants the formers summary of their interpretation of the data, divided into the final categories. The interpretations did not include any evaluative context. The participants were asked if the summary divided into categories was a fair representation of their views. All three participants responded and stated that the researchers interpretive summary was reflective of their views.
RESULTS
The following categories emerged during the data analysis: participant profile (professional experience and training); participants behaviors and attitudes relative to EBP; case conceptualization; purpose and goals of therapy; and other factors that influence therapy. This article will explore two of those categories: the goals of treatment and case conceptualization.
The Purpose and Goals of Therapy

EBP is aimed at the amelioration of symptoms of a diagnosable mental illness (Kielbasa, Pomerantz, Krohn, & Sullivan, 2004; Moxley & Manela, 2001). One participant endorsed the notion that the goal of psychotherapy is only to reduce symptoms of the diagnosis of a mental illness. The other two participants perceived other legitimate goals of therapy. Terrys position on this was implicit in his interview and the Medicaid forms he completed. For example, on the forms he gave the simulated client (Raygan) a Global Assessment of Functioning (GAF) of 71, which indicates that therapy is not warranted. In the interview he stated:
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T [Terry]: but just based on that one assessment, she didnt seem like she was saying anything that was really clinically significant. I [Interviewer]: OK, and can you define clinically significant for me? T: The DSM IV diagnosis, you know, I said adjustment disorder unspecified. Apparently there is something that is bothering her, but she wasnt letting me know what I: Absent a DSM one diagnosis, is that presentation in and of itself sufficient and/or amenable to therapy?
T: It would have more to do with whether there was some invasive emotion, such as depression or substance abuse going on with her[or] anxiety disorders.
In fact he made the point more forcefully during the participant validation: Need to establish a group of SXs [symptoms] that would be consistent with a DSM IV [TR diagnosis]. Terry suggested in the interview that without a DSM diagnosis, Raygan may benefit from an advisor or a school counselor or someone on a level that wouldnt be clinically oriented, but not psychotherapy. Lee and Jesse had a different understanding of the ultimate goal of psychotherapy. For Lee, the goal is client well-being as defined by the client. He recognized that this is often at odds with agency and state goals:
L [Lee]: Sometimes the agencies have to go with what is, What risk assessment should I do to reduce liability for the agency and the state? and those kind of things. Those dont always bode well in the way of assessing for clients. The clients may have a different pain going on than the state feels that they have going on. So I think my clients perspectivetheir subjective perception on the worldis more important than the form that I have to fill out.
When pressed about the role of symptoms and diagnosis in treatment he related this:
L: Youre familiar obviously with how they come up with a DSM IV diagnosis. They get all these wonderful, bright individuals in a room and they all raise their hand to signify a diagnosis. So they all actually democratically vote that this, um, this symptom belongs to this diagnosis I dont always think that thats the best process in the way of understanding an individual.
He went on the say:

L: Now, that said, again it goes back to what youre talking about in the way of translating, that sometimes we have to translate to satisfy certain entities
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if you actually guide the client to go, These are your goals, that is more important to their treatment because its their way of viewing the world. If you go with their goals, thats more important and will be more advantageous than, say, whats mandated by risk management or by what insurance companies need rather than whats medically right what will help the client help themselves is more important than what is mandated by the state government The client my focus is on the clients well-being.
Jesse, like Lee, saw a much larger goal for psychotherapy than the amelioration of symptoms of a DSM diagnosis: I guess I feel like you work with people about their lifes situation. I guess I focus more on that. Jesse perceived that precisely what needs to change in ones life is not always immediately apparent at the beginning of therapy. Instead, the ultimate goals emerge over the course of time and cannot occur while the client is experiencing symptoms of a mental illness:
J [Jesse]: but I think over time clients become more aware of kind of changing their life, and so I tend to have clients who Ive seen for years and years But I like seeing people when theyre well, and I try to encourage people to continue, you know, when theyre well because I think when youre ill, Im not sure thats the best time that people really make significant changes in their life.
She gave a long example of a client who did not discuss domestic violence for the first year of treatment. The client, several years later, is just beginning to identify specific changes she wants to make in her life. Thus, rather than being the end-point of treatment, symptoms and diagnoses are the starting-point:
J: Im always aware kind of with young therapists And you know, theres all that fascination about the diagnosis, and it just kind of makes me chuckle. And Ive said Thats like the first baby step. But maybe it depends on how you see therapy, I guess. If you see therapy as helping people get over symptoms, like the general practitioner whos just making sure you dont have a cold or your blood pressures OK. I guess thats one kind of therapy. If you think about therapy as really helping people live a fuller life, you know, and that the goal is to be the best we can be, then thats a different.
The participants thus presented with three very different views of the purpose of therapy: the amelioration of symptoms, well-being as defined by the client, and life changes that emerge over the course of treatment rather than being established or even identifiable at the beginning of treatment. These differences in the goal of treatment are particularly cogent in light of the participants conceptualization of the case presented by the simulated client.
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Case Conceptualization
The therapists who engaged in the study were experienced and successful. It must be clear then that this was not an exercise in testing the therapists to see if they got the case right. Rather, the purpose of the research was to look at actual practice in light of the state governments mandate to use a form of EBP. In light of this the perceptions of the therapists about the simulated clients functioning are impressively consistent with the simulated clients instructions regarding her role play for the participants. The strongest instruction for the simulated client (Raygan) was to portray a person with a self-concept and relational patterns that are consistent with a masochistic personality pattern (McWilliams, 1994; Million & Davis, 1996; PDM Task Force, 2006). That is, her own well-being was to be virtually unimportant to her, with her focus always being on the well-being of those around her, even to her own detriment. The simulated client was also instructed to present with a subclinical presentation of bulimia nervosa (not meeting the duration/ frequency criterion, only binging and purging 4 or 5 times per year). Finally, the simulated client was instructed to have a back-story of significant verbal/ emotional abuse from her mother, and a father who was absent due to constant work. She overinvolved herself in care-taking behaviors vis-a-vis ` her father (e.g., doing his ironing), and was given positive attention by her father when she engaged in these behaviors. One important point Terry made in reference to his conceptualization of this case is that one session is not adequate for a comprehensive assessment. In spite of this limitation, he identified Raygans chief dynamics and issues with great insight. This summary is from the participant validation that he ratified as representative of his case conceptualization. He noted that the client overidentified with her father, prioritized his needs over hers, and engaged in excessive caregiving. Terry used the term parentified and referred to Raygan as her fathers pseudo-wife. Terry suggested that Raygan is repeating this pattern with her boyfriend. He suggested that Raygan is externalizingacting out her problems with otherswhich creates difficulty in resolving those problems. He also indicated the following issues: Raygan is not able to handle stress; she allows people to use her; she has poor frustration tolerance; and she tolerates behavior on the part of her boyfriend that carries a risk to her. He stated that there may be an Axis I diagnosis operating, but if so Raygan is unable to verbalize a symptom profile that would warrant a diagnosis. According to Terry, addressing Raygans issues would have social benefit: if these problems are not addressed Raygan may use social resources (e.g., may end up in a domestic violence shelter or homeless shelter) versus working, paying taxes, and having a mortgage. Given this presentation, Terry stressed that Raygans issues are related to social interactions and do not constitute a medical necessity. He stated that while addressing these
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issues would enhance Raygans functioning, doing so is not the purview of psychotherapy. The issues would best be addressed through case management, vocational rehabilitation, and possibly a school counselor if client returned to school. There is one other aspect of Raygans functioning that Terry noted. This is that Raygan is
T: the type of person that I was accustomed to working with at the Mental Health Center, where people came in, but they really didnt give you very much to go on. Sometimes they were forced to come in; sometimes they came in because there was no other place to go. And in a private setting, people usually come in because they really know from the jump what it is they want to work on. Theres a lot of financial investment and time investment. So shes a little bit different than the normal patient that would come through a private practice, but very similar to a lot of patients who come through the public sector. I: OK. Thats interesting to me because these are the patients that Medicaid is supposed to support. T: Yes, and theyre the harder ones.
In other words, Raygan, who either did not have a specific Axis I diagnosis, or was not able to identify or demonstrate symptoms consistent with a diagnosis, is similar in her presentation to the kinds of clients Medicaid is designed to serve. And yet, because of her presentation, she would not receive psychotherapy. One may infer from this that for some practitioners, the effect of the mandate to use EBP for Medicaid clients is to limit the access these clients have to psychotherapy, in spite of clearly disturbed functioning and the belief that not helping these clients would have social costs. Lee also indicated that one session is not sufficient to complete a comprehensive assessment. Having said that, Lee characterized Raygan as giving herself up to important relationships to a fault. Additionally, he sees Raygans relationship with her mother as a mitigating influence. The treatment goals for Raygan as stated in the interview are: to help Raygan deal with how frustrating her boyfriend is; increase coping mechanisms (bulimic symptoms were framed as a negative coping mechanism); and increase Raygans level of independence, in terms of future goals like returning to school, and in terms of her current relationship with her boyfriend. Lee listed the following treatment goals on the paperwork required by Helpserv: how to deal with how frustrating boyfriend is; coping mechanisms; going back to school; independence; past/present/and future relationships. His diagnosis was Adjustment Disorder. Jesse reiterated that there is too much unknown after the first interview to formulate an accurate or comprehensive conceptualization of this case.
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Nonetheless she observed that Raygans functioning is poor: she is not in school or working, and her daily activities are compromised. Furthermore, Raygans relationship with her boyfriend is problematic, and there is a cutoff with her family of origin. Jesse noted that the possibility exists that Raygan may have a serious/chronic mental illness, like schizophrenia, although such an assessment is premature. Alternatively, she may be suffering from typical adolescent issues. Where Raygan may fall in this considerable range is unclear partly due to the fact that she was not forthcoming or trusting during the interview. Jesse suggested that this may be due to her lacking sufficient insight to identify her concerns, or perhaps it may be indicative of insufficient communication skills to articulate her concerns. Jesse also suggested that family treatment may be pursued to help Raygan reestablish a bond with her parents. In communication with the managed care company Jesse listed the following treatment goals:
J: engage in psychotherapy on weekly basis to establish therapeutic relationship; facilitate the resolution of nagging problem in the process trying to get more insight into the nature of interactions and the way the relationship is working for Raygan; pursue establishment of her personal goals and attempt to facilitate a plan for initiating the implementation for those goals; assist client in re-evaluating her relationships with her family members and to reconnect with them in a meaningful way if appropriate.
She also diagnosed Raygan with an Adjustment Disorder. In looking at the relationships between the goals of psychotherapy and Raygans specific treatment needs, we see that for Terry there is no conflict. The managed care company requires that the treatment be targeted at the symptoms of a DSM diagnosis, and unless a diagnosis becomes apparent during the assessment phase, Terry does not believe that Raygan requires psychotherapeutic treatment. Jesse and Lee, on the other hand, believe that Raygan requires treatment aimed at goals that are more far reaching than the mandates of the managed care company that administers Medicaid. How do they handle this apparent conflict? Lee observed that Helpservs policy to reimburse for V-codes gives him greater latitude in pursuing appropriate treatment goals than many private insurance companies provide: Medicaid gives you the latitude, the wonderful latitude to do [DSM] V-codes. I have much less translating to do with public mental health than I do private mental health. As this quote suggests, Lee feels that sometimes he must translate what he is actually pursuing with a client into language that is acceptable by Helpserv. In discussing his disagreement with the validity of certain diagnoses, he stated that sometimes we have to translate to satisfy certain entities. The use of this term implies that he does not prevaricate on his reports, but likewise he cannot report on the treatment in the same way that he conceptualizes it.
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Overall, Lees strategy is to mentally separate the processes of billing and treatment: Unfortunately, in this world therapy and money are associated, but really as my philosophy as a therapist is, my therapy money is not associated [with treatment]. Jesse sees the information required by the managed care company as just the surface of treatment:
I: So its those facts [Raygans daily functioning abilities] that you report back to the managed care company? J: Probably not; I dont think theyre interested. And those facts, I think I would be reporting back toif you mean just filling out that form, you know, that form is really rather superficial to whats really going on. I: So the form really is not a reflection of therapy. Its just what you need to say to get the money? J: Thats right. And for that I would be using the diagnosis the GAF score, I guess, would be important. And Im sure that for anybody in therapy there are some depressive symptoms, theres anxiety. Who lives without anxiety? So you feed that information in, but thats not the heart of whats going on.
At another point the interviewer asked, Do you ever feel that you translate what you actually do into language that the managed-care companies find acceptable? To which Jesse responded:
J: I would say I always feel like Im having to and thats where I may use a standardized manual, looking at the wording that I might put in something. Thats helpful to me in that way, because I dont feel like I think in that wording.
Thus, for both Lee and Jesse the reports submitted to the management company reflect merely a part of the process of therapy. They tell Helpserv those minimal aspects of treatment in which the company is interested, but this part of treatment does not fully depict the work that is actually taking place; it is simply the tip of the proverbial iceberg. In addition to being a partial representation of their actual work, Jesse and Lee find the need to translate, or find wording that the managed care company will not question. They do not feel they are being misleading or misrepresenting their work, but simply finding ways to communicate their work in a way that is acceptable to the managed care company. Jesse has another strategy for resolving her departure from symptomfocused treatment. This is to provide treatment in stages. She engages in the symptom-focused treatment first, which she termed the first baby step of therapy, and bills Medicaid for this treatment. When the symptoms are under control, she engages in the real therapy, with the understanding that the managed care company may not pay for this extension. The client may have
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to contract for some private-pay treatment for this work. It is a given that Medicaid-supported clients are not able to pay very much. Thus she works outside of the restrictions of managed care in order to provide what she considers to be comprehensive treatment to her clients, to her own economic detriment.
DISCUSSION
A point that emerges from this data is that there appears to be a significant bifurcation in the purpose of psychotherapy. One the one hand, there is the medical model, which is supported by the proponents of EBP. The goals for this form of treatment are the frequency, intensity, and duration of the symptoms of a DSM diagnosis. On the other hand, there is therapy aimed more broadly on the quality of the clients life. Whether termed well-being or life changes, there are a host of issues that therapists help clients resolve outside of the aegis of mental illnesses and managed care. For Jesse, these goals emerge over time. This has a profound implication for EBP. The preferred method for obtaining evidence of effectiveness in this system requires that the goals of treatment be stated prior to beginning the intervention. If, however, important goals cannot be known until treatment has progressed, the evidence for the achievement of the first goals may be irrelevant. For Lee the goals of treatment are centered on the clients subjective experience of what needs to change, which again, makes the evidence of the effectiveness of treatments aimed at predetermined goals irrelevant. All three of the participants in this studyincluding the clinician who would not treat a client for goals other than a diagnosisreadily identified social benefits to helping clients resolve issues other than symptoms of a mental illness. This begs the question, why is there an insistence on using a form of practice that cannot address the issues that are related to those social benefits? For Lee and Jesse, the major change the mandate to use EBP centers on how they do their paperwork. As Floresch (2004) suggested, they appear to write one way and practice another. Lee and Jesse found ways to translate their workin Jesses case by referring to treatment manualsto present their work in a manner that is acceptable to Helpserv. The major strategy they employed was simply to leave much of the work they do out of the assessment and treatment plans they submit to the managed care company. Another effect the mandate to use EBP had on Jesse was to push her to providing sliding-scale and/or pro bono therapy to clients who wished to pursue treatment goals beyond symptom reduction. These practices highlight an emerging issue: what about those practitioners who do not go the extra mile? What of those clients who receive what may in fact be an abridged form of the therapy these experienced clinicians provide?
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The action of writing paperwork in a way that satisfies the managed care company but does not reflect the entirety of the treatment may be very helpful for the client. There is, however, a possible unfortunate side-effect to this practice. The written documents exist long after the therapy has terminated and have a broader audience than the therapist and client. How would this treatment be understood if a researcher or subsequent practitioner were to collect these documents and assume that they were representative of the course of treatment? What does it mean to administrators and policymakers who assume that experienced and successful clinicians do that which the forms reflect? What kind of reality is being created by these documents? Jesse and Lee spoke at length in the interview with the researcher about the values on which they draw to justify their actions. That discussion is beyond the scope of this article. However, let it suffice to say that the drive to provide what Lee and Jesse perceive to be comprehensive treatment for those who cannot afford private insurance is grounded in values that are consistent with social work and focused on the clients best interest. Terry, Lee and Jesse were identified by their colleagues as experienced successful therapists. Terry does not provide therapy for clients who do not meet the treatment criteria targeted by EBP. Lee and Jesse provide treatment that goes beyond what they report to the managed care company. One wonders if there are clinicians who provide treatment for clients like Raygan but do not take the measures Lee and Jesse take to ensure that their clients receive comprehensive treatment. Anecdotal evidence suggests that there are. If so, though such therapists may take solace in the notion that they are providing treatment that is proven to be effective, they may in fact be providing treatment that is incomplete. And if, as all three participants suggested, there are social costs to not providing comprehensive treatment, what is the ultimate cost of treating Medicaid-supported clients solely for symptoms of a DSM-identified (APA, 2000) mental illness?
Limitations
Like all research this study has limitations that one must keep in mind while considering the results. As a qualitative study, it cannot be statistically generalized to the population of practitioners who do or do not follow the precepts of EBP. Rather, it is an explanation that describes how three specific clinical social workers have adapted to the policy. The exposition may have theoretical and educational implications. The study is also based on the narrow interpretation of EBP used by a particular state. Undoubtedly there are other policies associated with the use of EBP defined in other terms that will not produce the kinds of adaptations employed by the participants in this study. A final consideration is that the participants were working with a simulated client. Undoubtedly her presentation would have been more
50
authentic if she were describing real issues. Differences in the feel and/or counter-transference may have had a profound effect on the way the participants conceptualized this case.
CONCLUSION
This article was based on a larger constructivist qualitative study designed to explore how practitioners respond to the mandate to use EBP in providing psychotherapy to Medicaid-supported clients. The research questions addressed in this portion of the study are (1) how do practitioners conceptualize the treatment of a simulated client in the face of the state mandate to use EBP for clients receiving Medicaid benefits? (2) Does the mandate affect their work, and if so, in what way(s)? and (3) How do the clinical social workers in the study communicate with the company that manages Medicaid in their state about their practice? The study was based on a purposive sampling plan that included participants who were identified as experienced successful therapists by clinical social workers in the community. The three participants interviewed a simulated client, completed the Medicaid-required paperwork, and then engaged in an unstructured interview with the researcher. The data was analyzed by means of thematic analysis, and consistency of judgment and credibility/legitimacy of findings were determined through multiple coders and participant validation, respectively. The findings of the current study suggest that there appear to be two very different views of the appropriate goals for therapy. One participant, in agreement with EBP, sees psychotherapy as the amelioration of the symptoms of a DSM (APA, 2000) diagnosis. The other two participants see therapy aimed more broadly at quality-of-life issues. Irrespective of what the appropriate goal of therapy may be, all three clinicians perceived serious issues attendant to the simulated client and agreed that resolving those issues would not only help her as an individual, but also would have social benefits as well. For those participants who did not adhere to the treatment goals of EBP, there was the additional issue of how they communicate with Helpserv to secure reimbursement for treatment. As Floersch (2004) suggested, they present their case in the assessment and treatment plan forms a bit differently than how they actually conceptualize the case and practice. The presentation for the managed care company is an abridgment of the actual understanding of the case and goals they pursue. In Jesses case, the completion of comprehensive treatment must come at her own personal expense: She feels driven by her values to help those supported by Medicaid to make life changes, and accepts whatever small payment they can make. One question this study raises is what is the ultimate cost of partial treatment for clients who are supported by Medicaid?
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ACKNOWLEDGEMENT
This research was funded by a grant from the College of Human Ecology at East Carolina University.
NOTE
1. The individual who imparted this information was acting in the capacity of an official representative of the states mental health division. His/her name is withheld for the confidentiality of the participants.
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Smith College Studies in Social Work

Evidence-Based Practice and the Purpose of Clinical Social Work

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Evidence-Based Practice and the Purpose of Clinical Social Work

MARGARET ARND-CADDIGAN AND RICHARD POZZUTO

M. Arnd-Caddigan and R. Pozzuto

THE STATE POLICY UNDER EXAMINATION

REVIEW OF THE LITERATURE

M. Arnd-Caddigan and R. Pozzuto

M. Arnd-Caddigan and R. Pozzuto

Data Analysis and Evaluation Criteria

The Purpose and Goals of Therapy

M. Arnd-Caddigan and R. Pozzuto

He went on the say:

M. Arnd-Caddigan and R. Pozzuto

M. Arnd-Caddigan and R. Pozzuto

M. Arnd-Caddigan and R. Pozzuto

M. Arnd-Caddigan and R. Pozzuto

M. Arnd-Caddigan and R. Pozzuto

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