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Evidence-Based Practice and the Purpose of Clinical Social WorkMargaret Arnd-Caddigana; Richard Pozzutoaa School of Social Work, College of Human Ecology, East Carolina University, Greenville, North

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Online publication date: 08 February 2010

To cite this Article Arnd-Caddigan, Margaret and Pozzuto, Richard(2010) 'Evidence-Based Practice and the Purpose ofClinical Social Work', Smith College Studies in Social Work, 80: 1, 35 52

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Evidence-Based Practice and the Purpose ofClinical Social Work

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 clinicalsocial workers to the state mandate to use evidence-based practice(EBP) for Medicaid-supported clients. The portion of the study thatis explored in this article answers the research question, how doesthe mandate affect the provision of services? Data was collected

from three clinical social workers who were identified assuccessful by their peers. The data was analyzed by means of thematic analysis, and evaluations of research methods wereconducted. The data demonstrate the way in which the mandateto 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 narrowlydefined version of evidence-based practice (EBP) in the treatment ofindividuals receiving Medicaid (see, for example, Perloff, 1996; Ozawa,1995). EPB has fervent supporters and opponents. As an approach topsychotherapy EBP has been questioned on philosophical, theoretical, andmethodological grounds (see, e.g., Houston, 2005; Westin, Novotny, &

35

Received 27 July 2009; accepted 27 August 2009.

Address correspondence to Margaret Arnd-Caddigan, School of Social Work, EastCarolina University, Rivers West, 326, Greenville, NC 27858, USA. E-mail: arndcaddiganm@

ecu.edu

Smith College Studies In Social Work, 80:3552, 2010Copyright # Taylor & Francis Group, LLCISSN: 0037-7317 print / 1553-0426 onlineDOI: 10.1080/00377310903504965


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Thompson-Brenner, 2006). A more specific critique of this orientation topractice is the degree to which treatment outcomes are limited to symptomrelief rather than the well-being of the client. As the data will show, someclinicians believe that the goals identified by the company (pseudonym

HelpServ) that manages Medicaid for a particular state under studyeffectively prohibits comprehensive treatment. This leaves the therapists inthe position to choose between doing that for which Helpserv will pay forthose clients who cannot afford self-pay, or finding a way to providethorough treatment. This portion of the larger study explores how mentalhealth professionals handle this dilemma.

The concerns of the larger project inclusive of this article were exploredby means of a constructivist qualitative study. The researchers bias is animportant factor in the study. Both researchers are clinicians, and, based onanecdotal evidence from colleagues as well as personal experience believe

that policies which mandate the use of a narrowly defined version of EBPunnecessarily 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 (Arnd-Caddigan, 2005; Moxley & Manela, 2001; Scheyett & McCarthy, 2006). Thesampling plan in the study was purposive, centered on the experiences ofexperienced successful clinical social workers. The data collected includedan interview between each participant and a simulated client, the assessmentand 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 checksfor 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; goalsof treatment; case conceptualization; and other factors that influence thecourse of treatment. This article focuses on goals of treatment compared tothe ways that the participants conceptualize the case presented by thesimulated client. Based on the data, the participants view is that the mandateto use the form of EBP required by the state limits the goals of therapy and

excludes many clients from receiving potentially helpful services. Theseservices would not only be helpful to the individual but may also stem socialcosts. 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 wasconducted uses a definition that is in keeping with the spirit of dominant

usage (e.g., Gray, Elhai, & Schmidt, 2007): mental health treatment that

36 M. Arnd-Caddigan and R. Pozzuto


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employs methods that have demonstrated effectiveness in reducing thefrequency, intensity and duration of symptoms of a diagnosis that is listed inthe 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 frommany of the theoretical formulations about EBP, and is also consistent withmany usages of the term. A full exploration of the multiple definitions ofevidence-based practice and empirically validated treatments, and theattendant controversies, is beyond the scope of this article. The focus ofthe study is not on an abstract notion of EBP, but rather the actual practice ofclinicians 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 clinicalsocial work (Arnd-Caddigan, 2005; Witkin, 1991). As many and varied asthe definitions of EBP may be, there are a number of writers who identifya host of problems with the philosophy and methods associated with it.Perhaps the most severe critiques of EBP have been leveled at the valuesand assumptions of positivism, upon which EBP is based (e.g., Houston,2005; Witkin & Harrison, 2001). However, there are criticisms with a morenarrow scope as well. One specific difficulty with the use of EBP

associated with the state policy of interest here is the manner in whichtreatment goals are limited. For example, Scheyett and McCarthy (2006)explored the degree to which EBPs in adult mental health were or werenot able to provide for basic needs, including appropriate mental healthservices, for clientele. Participants in the research, who were clients ofpublic sector mental health agencies, indicated that EBPs limited thechoice and voice of clients due to the prescriptive and proscriptivenature 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 relationshipbased on mutuality between themselves and their mental health provideris important to them, but EBPs were limited in this respect.

Moxley and Manela (2001) and Arnd-Caddigan (2005) havechallenged the narrow scope of outcomes for EBP in more theoretical

works. Moxley and Manela discussed the issue of power differentialsbetween those who chose the desired outcomes of human servicesthepolicymakersand those who receive the service. Moxley and Manela(2001) argued that ultimately the push to produce outcome measures inhuman services is a covert method of imposing the values of the powerful

on service providers and recipients.

Evidence-Based Practice 37


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Arnd-Caddigan (2005) demonstrated how adult survivors of childhoodabuse are prevented from receiving comprehensive treatment as a result oftherapy being aimed exclusively at the symptoms of a DSM (AmericanPsychiatric Association, 2000) diagnosis. Adult survivors of childhood abuse

often have symptom constellations that are not consistent with a specificdiagnosis, as well as symptoms that are not part of any diagnostic category(Arnd-Caddigan, 2005). Therefore, treatment aimed solely at symptoms ofdiagnoses may be incomplete. Given that EBPs in psychotherapy aretargeted at the frequency, intensity and duration of symptoms of a DSMdiagnosis (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 feelthat the values of EBP are at odds with the values of clinical social work. TheCode of Ethics of the Clinical Social Work Association (formerly the Clinical

Social Work Federation, 1997) stands in clear distinction to the type ofpractice dictated by EBPs. The authors of the Code of Ethics made apparentthat the social work clinicians primary responsibility is for the welfare of theclient, in spite of any limitations managed care may impose. Wineberg(1998) clarified that this means that it is unethical to offer treatment that isinadequate for the presenting problem, and it is unethical to abandon aclient before the presenting problem has remitted. The difference inlanguage 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 theyprovide comprehensive treatment regardless of what the people whomanage Medicaid are willing to pay, and managing agencies such asHelpserv will only pay for symptoms of diagnoses, the social worker is left todecide how to best help clients.

Thus practitioners have two contradictory imperatives. On the one handthey are constrained to engage in evidence based practice as a condition forreimbursement for services, while concurrently they must provide compre-hensive treatment. How do they resolve this conundrum? One possiblesolution was discovered by Floresch (2004). His research demonstrated that

in many cases social workers wrote reports that reflected evidence basedpractice, however they actually formulated cases and provided interventionsbased on reflective practice. The research reported here, in exploring howclinical 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 problemexplored in the larger research from which this data was gathered is the

ways that experienced successful clinical social workers who provide mentalhealth 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 theface 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 fromEBP?

Researcher Reflexivity

The current constructivist study is based on a relational ontology andepistemology (Slife & Richardson, 2008). The researchers are acutely aware oftheir role in the dialogic process of knowledge creation: they do not assumethe role of the disinterested observer. Thus, the way that the researchers cameto 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, theresearchers gained a great deal of anecdotal evidence from colleaguesconcerning how they continue to provide what they consider to becomprehensive treatment under the restrictions attendant to EBP. Thestrategies of these clinicians may be passed on as clinical wisdom, but tothe authors knowledge is not represented in the literature. The researcherstherefore wanted to explore clinicians response to the EBP policy throughmore formal procedures, and include the clinical wisdom of experiencedclinicians in the literature. As stated above, it is the researchers bias that EBPunnecessarily 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 (Arnd-Caddigan, 2005; Moxley & Manela, 2001; Scheyette & McCarthy, 2006).

Sampling Plan

The sampling plan is purposive. In keeping with Glesnes (1999) observationsabout the unit of analysis in qualitative work, the researchers were sampling forthe experiences of clinical social workers in relation to the state policy to useEBP for Medicaid clients. The researchers enlisted three clinical social workers

who treat clients under the state Medicaid provisions and are thus familiar withthe policy for in-depth interviews. The three clinical social workers werechosen 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 toMedicaid recipients. The current study focuses on the approaches of highlyskilled 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 apractitioners perspective and an emic view of success, rather than anacademicians or researchers understanding of what constitutes goodclinical 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 ofthe interview. He worked in a private psychiatric practice and saw clientsfrom a variety of socioeconomic strata, including those whose services aresubsidized by Medicaid. Prior to becoming an LCSW he worked closely withadolescents 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 continuingeducation courses for LCSWs. During his Master of Social Work (MSW) fieldplacement he worked in a hospital and was able to take classes at themedical school with psychiatry students.

Terry had 23 years experience in mental health at the time of theinterview, 18 of those as an LCSW. He also worked at a private psychiatric

practice and saw clients from a variety of backgrounds, including those whoreceived Medicaid benefits. After receiving his degree he completed anexternship at a family therapy center and completed certificate programs atboth the Beck and Albert Ellis institutes. Early in his career he worked in acommunity mental health center where he saw exclusively clients who didnot have private insurance.

Jesse had been an LCSW for 18 years at the time of the interview; for15 of those years she had been in private practice. Prior to becoming anLCSW she was in education, and is currently teaching anthropology. Prior toopening 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 appropriateconsents, the participants each interviewed a simulated client in an intake-type interview, which was audiorecorded and transcribed. They wereinstructed to treat this client as a typical intake. The LCSWs also completedthe 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 andtranscribed. The interview was unstructured, based on a constructivist use ofthe grounded theory method of data collection (Charmaz, 2000).

Data Analysis and Evaluation Criteria

Data was analyzed by means of thematic analysis. The researchersspecifically followed Boyatziss (1998) method of rendering narrative datainto meaningful categories. Boyatzis has observed that a qualitative corollaryto reliability is consistency of judgment; one form is consistency of judgmentacross viewers. The two researchers independently coded approximately10% of the data. Agreement in coding between the researchers actingindependently 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 participantsthe analyzed data in the context of the research report is not appropriate. Inkeeping with this observation, the researchers instead gave the participantsthe formers summary of their interpretation of the data, divided into the finalcategories. The interpretations did not include any evaluative context. Theparticipants were asked if the summary divided into categories was a fairrepresentation of their views. All three participants responded and statedthat the researchers interpretive summary was reflective of their views.

RESULTS

The following categories emerged during the data analysis: participantprofile (professional experience and training); participants behaviors andattitudes relative to EBP; case conceptualization; purpose and goals oftherapy; and other factors that influence therapy. This article will exploretwo 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). Oneparticipant endorsed the notion that the goal of psychotherapy is only toreduce symptoms of the diagnosis of a mental illness. The other twoparticipants perceived other legitimate goals of therapy.

Terrys position on this was implicit in his interview and the Medicaidforms 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 likeshe 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 disorderunspecified. Apparently there is something that is bothering her, butshe 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 invasiveemotion, 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 DSMdiagnosis, Raygan may benefit from an advisor or a school counselor orsomeone on a level that wouldnt be clinically oriented, but notpsychotherapy.

Lee and Jesse had a different understanding of the ultimate goal ofpsychotherapy. 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 ofassessing for clients. The clients may have a different pain going on thanthe state feels that they have going on. So I think my clientsperspectivetheir subjective perception on the worldis more impor-tant than the form that I have to fill out.

When pressed about the role of symptoms and diagnosis in treatment herelated this:

L: Youre familiar obviously with how they come up with a DSM IVdiagnosis. They get all these wonderful, bright individuals in a room andthey all raise their hand to signify a diagnosis. So they all actuallydemocratically vote that this, um, this symptom belongs to this diagnosis I dont always think that thats the best process in the way ofunderstanding 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 moreimportant to their treatment because its their way of viewing the world. If

you go with their goals, thats more important and will be moreadvantageous than, say, whats mandated by risk management or by whatinsurance companies need rather than whats medically right what willhelp the client help themselves is more important than what is mandated bythe state government The client my focus is on the clients well-being.

Jesse, like Lee, saw a much larger goal for psychotherapy than theamelioration 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. Jesseperceived that precisely what needs to change in ones life is not alwaysimmediately apparent at the beginning of therapy. Instead, the ultimate goalsemerge 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 ofchanging their life, and so I tend to have clients who Ive seen for yearsand years But I like seeing people when theyre well, and I try toencourage people to continue, you know, when theyre well because Ithink when youre ill, Im not sure thats the best time that people reallymake 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 toidentify specific changes she wants to make in her life. Thus, rather than beingthe 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 makesme chuckle. And Ive said Thats like the first baby step. Butmaybe it depends on how you see therapy, I guess. If you see therapy ashelping people get over symptoms, like the general practitioner whosjust 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 reallyhelping people live a fuller life, you know, and that the goal is to be thebest we can be, then thats a different.

The participants thus presented with three very different views of thepurpose of therapy: the amelioration of symptoms, well-being as defined bythe client, and life changes that emerge over the course of treatment ratherthan being established or even identifiable at the beginning of treatment.These differences in the goal of treatment are particularly cogent in light ofthe 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. Itmust be clear then that this was not an exercise in testing the therapists tosee if they got the case right. Rather, the purpose of the research was tolook at actual practice in light of the state governments mandate to use aform of EBP. In light of this the perceptions of the therapists about thesimulated clients functioning are impressively consistent with the simulatedclients instructions regarding her role play for the participants. The strongestinstruction for the simulated client (Raygan) was to portray a person with aself-concept and relational patterns that are consistent with a masochisticpersonality pattern (McWilliams, 1994; Million & Davis, 1996; PDM TaskForce, 2006). That is, her own well-being was to be virtually unimportant toher, 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 presentwith 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 toconstant work. She overinvolved herself in care-taking behaviors vis-a-visher father (e.g., doing his ironing), and was given positive attention by herfather when she engaged in these behaviors.

One important point Terry made in reference to his conceptualization ofthis 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 heratified as representative of his case conceptualization. He noted that theclient overidentified with her father, prioritized his needs over hers, andengaged in excessive caregiving. Terry used the term parentified andreferred to Raygan as her fathers pseudo-wife. Terry suggested thatRaygan is repeating this pattern with her boyfriend. He suggested thatRaygan is externalizingacting out her problems with otherswhichcreates difficulty in resolving those problems. He also indicated the

following issues: Raygan is not able to handle stress; she allows people touse her; she has poor frustration tolerance; and she tolerates behavior on thepart 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 symptomprofile that would warrant a diagnosis.

According to Terry, addressing Raygans issues would have socialbenefit: 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 ofpsychotherapy. The issues would best be addressed through case manage-ment, vocational rehabilitation, and possibly a school counselor if clientreturned to school.

There is one other aspect of Raygans functioning that Terry noted. Thisis that Raygan is

T: the type of person that I was accustomed to working with at theMental 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 aprivate setting, people usually come in because they really know fromthe jump what it is they want to work on. Theres a lot of financialinvestment and time investment. So shes a little bit different than the

normal patient that would come through a private practice, but verysimilar 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 Idiagnosis, or was not able to identify or demonstrate symptoms consistent

with a diagnosis, is similar in her presentation to the kinds of clientsMedicaid is designed to serve. And yet, because of her presentation, she

would not receive psychotherapy. One may infer from this that for somepractitioners, the effect of the mandate to use EBP for Medicaid clients is tolimit the access these clients have to psychotherapy, in spite of clearlydisturbed functioning and the belief that not helping these clients wouldhave social costs.

Lee also indicated that one session is not sufficient to complete acomprehensive assessment. Having said that, Lee characterized Raygan asgiving herself up to important relationships to a fault. Additionally, hesees Raygans relationship with her mother as a mitigating influence. Thetreatment goals for Raygan as stated in the interview are: to help Raygan deal

with how frustrating her boyfriend is; increase coping mechanisms (bulimicsymptoms were framed as a negative coping mechanism); and increaseRaygans level of independence, in terms of future goals like returning toschool, and in terms of her current relationship with her boyfriend. Lee listedthe following treatment goals on the paperwork required by Helpserv: howto deal with how frustrating boyfriend is; coping mechanisms; going back toschool; 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 inschool 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 suchan assessment is premature. Alternatively, she may be suffering from typicaladolescent issues. Where Raygan may fall in this considerable range isunclear partly due to the fact that she was not forthcoming or trusting duringthe interview. Jesse suggested that this may be due to her lacking sufficientinsight to identify her concerns, or perhaps it may be indicative ofinsufficient communication skills to articulate her concerns. Jesse alsosuggested that family treatment may be pursued to help Raygan reestablish abond 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 therapeuticrelationship; facilitate the resolution of nagging problem in the processtrying to get more insight into the nature of interactions and the way therelationship is working for Raygan; pursue establishment of her personalgoals and attempt to facilitate a plan for initiating the implementation forthose goals; assist client in re-evaluating her relationships with her familymembers 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 andRaygans specific treatment needs, we see that for Terry there is no conflict.The managed care company requires that the treatment be targeted at thesymptoms of a DSM diagnosis, and unless a diagnosis becomes apparentduring the assessment phase, Terry does not believe that Raygan requirespsychotherapeutic treatment. Jesse and Lee, on the other hand, believe thatRaygan requires treatment aimed at goals that are more far reaching than themandates of the managed care company that administers Medicaid. How dothey handle this apparent conflict?

Lee observed that Helpservs policy to reimburse for V-codes gives himgreater latitude in pursuing appropriate treatment goals than many privateinsurance companies provide: Medicaid gives you the latitude, the

wonderful latitude to do [DSM] V-codes. I have much less translating todo with public mental health than I do private mental health. As this quotesuggests, Lee feels that sometimes he must translate what he is actuallypursuing with a client into language that is acceptable by Helpserv. Indiscussing his disagreement with the validity of certain diagnoses, he statedthat sometimes we have to translate to satisfy certain entities. The use ofthis 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 andtreatment: Unfortunately, in this world therapy and money are associated,but really as my philosophy as a therapist is, my therapy money is notassociated [with treatment].

Jesse sees the information required by the managed care company asjust 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 Iwould be reporting back toif you mean just filling out that form, youknow, 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 GAFscore, I guess, would be important. And Im sure that for anybody intherapy there are some depressive symptoms, theres anxiety. Who lives

without anxiety? So you feed that information in, but thats not the heartof whats going on.

At another point the interviewer asked, Do you ever feel that youtranslate what you actually do into language that the managed-carecompanies find acceptable? To which Jesse responded:

J: I would say I always feel like Im having to and thats where I mayuse a standardized manual, looking at the wording that I might put insomething. Thats helpful to me in that way, because I dont feel like Ithink in that wording.

Thus, for both Lee and Jesse the reports submitted to the managementcompany reflect merely a part of the process of therapy. They tell Helpservthose minimal aspects of treatment in which the company is interested, butthis part of treatment does not fully depict the work that is actually takingplace; 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 totranslate, or find wording that the managed care company will notquestion. They do not feel they are being misleading or misrepresentingtheir work, but simply finding ways to communicate their work in a way thatis acceptable to the managed care company.

Jesse has another strategy for resolving her departure from symptom-focused treatment. This is to provide treatment in stages. She engages in thesymptom-focused treatment first, which she termed the first baby step oftherapy, and bills Medicaid for this treatment. When the symptoms are undercontrol, 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 thatMedicaid-supported clients are not able to pay very much. Thus she worksoutside of the restrictions of managed care in order to provide what sheconsiders 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 significantbifurcation in the purpose of psychotherapy. One the one hand, there is themedical model, which is supported by the proponents of EBP. The goals forthis form of treatment are the frequency, intensity, and duration of thesymptoms of a DSM diagnosis. On the other hand, there is therapy aimed

more broadly on the quality of the clients life. Whether termed well-beingorlife changes, there are a host of issues that therapists help clients resolveoutside of the aegis of mental illnesses and managed care. For Jesse, thesegoals emerge over time. This has a profound implication for EBP. Thepreferred method for obtaining evidence of effectiveness in this systemrequires that the goals of treatment be stated prior to beginning theintervention. If, however, important goals cannot be known until treatmenthas progressed, the evidence for the achievement of the first goals may beirrelevant. For Lee the goals of treatment are centered on the clientssubjective experience of what needs to change, which again, makes the

evidence of the effectiveness of treatments aimed at predetermined goalsirrelevant. All three of the participants in this studyincluding the clinician

who would not treat a client for goals other than a diagnosisreadilyidentified social benefits to helping clients resolve issues other thansymptoms of a mental illness. This begs the question, why is there aninsistence on using a form of practice that cannot address the issues that arerelated to those social benefits?

For Lee and Jesse, the major change the mandate to use EBP centers onhow they do their paperwork. As Floresch (2004) suggested, they appear to

write one way and practice another. Lee and Jesse found ways to translatetheir workin Jesses case by referring to treatment manualsto presenttheir work in a manner that is acceptable to Helpserv. The major strategythey employed was simply to leave much of the work they do out of theassessment and treatment plans they submit to the managed care company.

Another effect the mandate to use EBP had on Jesse was to push her toproviding sliding-scale and/or pro bono therapy to clients who wished topursue treatment goals beyond symptom reduction. These practices high-light an emerging issue: what about those practitioners who do not go theextra 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 managedcare company but does not reflect the entirety of the treatment may be veryhelpful for the client. There is, however, a possible unfortunate side-effect tothis 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 subsequentpractitioner were to collect these documents and assume that they wererepresentative of the course of treatment? What does it mean toadministrators and policymakers who assume that experienced andsuccessful clinicians do that which the forms reflect? What kind of realityis being created by these documents?

Jesse and Lee spoke at length in the interview with the researcher aboutthe values on which they draw to justify their actions. That discussion isbeyond 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 forthose who cannot afford private insurance is grounded in values that areconsistent with social work and focused on the clients best interest.

Terry, Lee and Jesse were identified by their colleagues as experiencedsuccessful therapists. Terry does not provide therapy for clients who do notmeet the treatment criteria targeted by EBP. Lee and Jesse provide treatmentthat goes beyond what they report to the managed care company. One

wonders if there are clinicians who provide treatment for clients like Rayganbut do not take the measures Lee and Jesse take to ensure that their clientsreceive comprehensive treatment. Anecdotal evidence suggests that there

are. If so, though such therapists may take solace in the notion that they areproviding treatment that is proven to be effective, they may in fact beproviding treatment that is incomplete. And if, as all three participantssuggested, there are social costs to not providing comprehensive treatment,

what is the ultimate cost of treating Medicaid-supported clients solely forsymptoms of a DSM-identified (APA, 2000) mental illness?

Limitations

Like all research this study has limitations that one must keep in mind whileconsidering the results. As a qualitative study, it cannot be statisticallygeneralized to the population of practitioners who do or do not follow theprecepts of EBP. Rather, it is an explanation that describes how three specificclinical social workers have adapted to the policy. The exposition may havetheoretical and educational implications. The study is also based on thenarrow interpretation of EBP used by a particular state. Undoubtedly thereare other policies associated with the use of EBP defined in other terms that

will not produce the kinds of adaptations employed by the participants inthis study. A final consideration is that the participants were working with a

simulated client. Undoubtedly her presentation would have been more



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authentic if she were describing real issues. Differences in the feel and/orcounter-transference may have had a profound effect on the way theparticipants conceptualized this case.

CONCLUSION

This article was based on a larger constructivist qualitative study designed toexplore how practitioners respond to the mandate to use EBP in providingpsychotherapy to Medicaid-supported clients. The research questionsaddressed in this portion of the study are (1) how do practitionersconceptualize the treatment of a simulated client in the face of the statemandate to use EBP for clients receiving Medicaid benefits? (2) Does themandate 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 thatmanages Medicaid in their state about their practice?

The study was based on a purposive sampling plan that includedparticipants who were identified as experienced successful therapists byclinical social workers in the community. The three participants intervieweda simulated client, completed the Medicaid-required paperwork, and thenengaged in an unstructured interview with the researcher. The data wasanalyzed by means of thematic analysis, and consistency of judgment andcredibility/legitimacy of findings were determined through multiple codersand participant validation, respectively.

The findings of the current study suggest that there appear to be two verydifferent views of the appropriate goals for therapy. One participant, inagreement with EBP, sees psychotherapy as the amelioration of the symptomsof a DSM(APA, 2000) diagnosis. The other two participants see therapy aimedmore broadly at quality-of-life issues. Irrespective of what the appropriate goalof therapy may be, all three clinicians perceived serious issues attendant to thesimulated client and agreed that resolving those issues would not only helpher 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 tosecure reimbursement for treatment. As Floersch (2004) suggested, theypresent their case in the assessment and treatment plan forms a bit differentlythan how they actually conceptualize the case and practice. The presentationfor the managed care company is an abridgment of the actual understandingof the case and goals they pursue. In Jesses case, the completion ofcomprehensive treatment must come at her own personal expense: She feelsdriven by her values to help those supported by Medicaid to make lifechanges, and accepts whatever small payment they can make. One questionthis 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 atEast 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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