“Decision-Making” In Crisis Intervention: Results of An Ethnographic Study of Mental Health Workers In a Residential Treatment Center for Children

Background and Purpose: Social work scholars have proposed and promoted particular processes for making clinical decisions. From personal practice models (Mullen, 1983) to more recent formulations of the evidence-based practice (EBP) process (e.g., Gibbs, 2003), these prescriptive models for clinical decision-making specify sources of knowledge upon which to base effective clinical decisions, but they rely on the assumption that the actions of mental health workers do, in fact, derive from decisions. This ethnographic study of mental health workers in a residential treatment center for emotionally disturbed children looks more broadly at the processes through which social workers' actions arise, asking 1) To what extent do workers report making intervention decisions during or immediately prior to behavioral crises? 2) How is formal training in Therapeutic Crisis Intervention (TCI) and other knowledge mobilized during crisis intervention? 3) How is the agency of mental health workers during crisis best characterized?

Methods: This paper is part of a larger ethnographic study conducted by the author, which is based on 13-months of participant observation and interviews in a residential treatment center for children in the Midwestern U.S. 1500 hours of participant observation of 78 consenting mental health workers—including MSW and BA level dormitory counselors, LCSW and PhD level psychotherapists, program managers, and executive staff—were conducted during work shifts, which included interactions with clients in the residential milieu , group psychotherapy, staff meetings, and trainings. Tentative theories in regard to the research questions were developed through participant observation, and checked and refined through 35 semi-structured interviews with key informants. In the iterative process of theory building characteristic of ethnography, these theories were refined again through additional informal conversations with key informants.

Results: While the researcher observed that workers almost uniformly used the specific de-escalation and intervention skills they learned during mandatory training in TCI, few reported using the formal decision-making process taught in the TCI curriculum. Workers reported that they most often acted “instinctively” during crisis. They described this form of agency as highly embodied rather than mediated by cognition, and as well-suited to the compressed, high-stakes temporality of behavioral crisis. This study suggests that the actions of skilled mental health workers during crisis may not arise from decision-making, but rather through a process like habitus (Bourdieu, 1977), by which knowledge from a variety of sources—including formal crisis intervention training—is mobilized without the conscious awareness of the worker.

Implications: These findings suggest that prescriptive clinical decision-making models, including the EBP process, may be of limited use in crisis intervention because the temporality of crisis is not conducive to rational, reflective consideration of intervention alternatives, but demands a more automatic response by the worker. This study demonstrates how, under some circumstances, knowledge of particular interventions may guide practice without an explicit decision to use a particular intervention. It suggests the need for further empirical research to understand the agency of mental health workers in a variety of practice contexts before relying on the assumption that workers' interventions are the product of clinical decisions.