The Hermeneutics of “Behavior Has Meaning”: An Ethnographic Study of Clinical Decision-Making In a Residential Treatment Center for Children

BACKGROUND AND PURPOSE: Contemporary social work scholars have promoted various models as appropriate for making effective and ethical clinical decisions (Shlonsky & Gibbs, 2004). Whether promoting the evidence-based practice process (e.g., Gibbs, 2003) or implementation of particular evidence-based practices, research has rarely empirically addressed clinical decision-making as it naturally occurs in “real-world” mental health practice. This naturalistic ethnographic study of mental health workers in a residential treatment center for emotionally disturbed children documents the decision-making practices of counselors, psychotherapists, program managers, and executives in an organization that does not actively promote or practice evidence-based practice. The study asks: In an organization that does not support the evidence-based practice process or stipulate the use of a particular evidence-based practice, through what processes do clinicians and administrators know what to do at critical decision points?

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. More than 1500 hours of participant observation of 78 consenting mental health workers were conducted during work shifts, which included direct interactions with clients in the residential milieu, group psychotherapy, staff meetings, and trainings. Tentative understandings in regard to the above research question were developed primarily through participant observation of 152 staff meetings, 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 checked and refined again through informal conversations with key informants.

RESULTS: Mental health workers in all positions within the agency routinely participated in a recognizable pattern of interaction during staff meetings and informal conversations characterized by an exchange of interpretations of the “meaning” of clients' behaviors, followed by the suggestion of competing strategies for intervention based on these interpretations. These interactions, which workers found at times helpful and at other times frustratingly time-consuming, were the primary way that clients and their problems were discussed and formal decisions were made about how to best intervene at key decision points. Workers' willingness and ability to participate in this hermeneutic process constituted one form of expertise recognized in this setting. This interactional process also constituted a form of clinical eclecticism, characterized by deliberations about which interventions to employ given the meanings attributed to the behaviors identified as problematic.

IMPLICATIONS: The interactive process of decision-making described here suggests: 1) Models of evidence-based practice that view clinical decision-making primarily as a process undertaken by a worker and client may be at odds with existing organizational-level practices of collective decision-making. 2) This may be particularly true if those practices of collective decision-making privilege the matching of intervention strategies to the “meanings” of clients' behaviors, and when these hermeneutic interactions are a key site where workers' expertise is both enacted and evaluated. 3) The successful implementation of prescriptive models for clinical decision-making requires a thorough understanding of existing organizational practices of decision-making and their role in organizational culture.