Examining evidence-based practice, I want to use professional experience to look at how putting-the-cart-first treatment translates into wasted public dollars and second class services.
I take myself out of the State Hospital, and insert myself 13 years later in the ranks of the mental health workers. Not only are we perhaps wrongly trained in the universality of counseling theories (as part 1 of this article suggests) but we are also the rank and file that gets hired into local systems that use fidelity measures to promote proven recovery practices.
Much like with economics, it appears to be widely presumed among administrators that recovery services can only transform via academic trickle down guided by research.
I contend that this reductionist view is self-serving to the power structure not taking into consideration the nuances of local culture and recovery itself.
I have seen evidence-based practices in community mental health perpetuate myths, stigma, unstable relationships and limit healing.
They may be used to fuel programs that are chasing money and more concerned about silos and statistics than the community.
From the Rank and File
I, like others in the rank and file, have a difficult time when a person with a highly reputable background comes in from out of town and says, “this is the best way to do it.”
I look at their culture and wonder what they know about the systemic history of their subjects. I wonder how much money they are going to take and waste. I could do this and that alone could easily prevent a researched recovery principle from materializing.
Evidence-based practices, as I’ve seen them play out, presume that there is no such thing as class, race and gender biases or local distinctions that are going to get in the way of implementation.
They need to.
A Social Experiment: Three Competing EBPs
Four years ago, I left my job in a community I love and to which I’ve since returned to join an effort to jumpstart recovery via importing three evidence-based practices.
In 2008, Cook County imported the Housing First best practice; the IPS employment model; and the best practice of Peer Support by a leading out-of-state company.
Clients were given all three practices at the same time and expected to transform into work and end their dependence on Social Security.
Teams were set up with representatives of all three of these best practices. They were led by case managers from seven local case management teams.
I came on board during the second year of operation as the back-up administrator of peer support. I completed a comprehensive and experiential peer-employment training with a new team of workers and my first task was to attend all the team meetings and represent the peer workers.
Sure enough, I would find many of our peer workers, just out of the system and battling external and internal stigma, being bullied into silence at meetings.
After I made the rounds, on a day when the top administrator and our boss were present, a worker who appeared most effectiv, and on-the-ground respected, came into my office before meetings commenced. He shook my hand and told me I was walking into a bee hive. As soon as he was gone, I discovered that the top administrator had a file on this worker. He was a racial minority and he was on track to be fired alongside another minority worker, who was axed that day.
This man was trying to provide for his family on wages that barely cut it according to the local standard of living. The things he had done, in my mind, demonstrated his economic need.
Memories were triggered of my own sense of financial hopelessness. Indeed, the more I took inventory, I became alarmed about what I considered to be racial and class in-sensitivities: workers who had harder inner-city backgrounds seemed to be more heavily scrutinized.
I felt that the best thing to do was to send an email expressing my concerns to the boss.
Bullying at the Table
Meanwhile, as I was feeling bullied and insulted at the tables, I got feedback from my own company that I didn’t know how to present as a professional. However, the feedback from the program evaluation came back that I was well received in the eyes of the local workers.
Time passed and the worker who warned me about the bee hive was fired. Likewise, a minority director who I had forged a relationship with was replaced. I continued to observe the other male minorities to be not treated well from my perspective. The new director formed a close relationship with my domain boss, who, though rarely around, seemed to be offended by my email.
The bullying at the table overseen by the county’s new director escalated.
At the center of a table attack, I was told my actions weren’t intelligent. I was likened to Stuart Smalley. On another occasion, I was ambushed with several domain leaders present and accused of influencing and enabling “psychotic” clients to be against medication.
When I explained that I myself believe in and take medication, a worker from another domain who supported me was written up for not being a team player. I experienced no sense of an apology. I was accused of being paranoid by leadership when I complained. Shortly thereafter, I was vanquished from the meetings.
Meanwhile, back on the company’s ranch, the top administrator was out on disability. I hoped that the fact that our domain’s productivity numbers were steadily growing with me as the temporary leader, and that our specific company boss was replaced with someone who seemed to respect me might mean job security.
I was not looking for control of the program. I was fine with being number two. I was interested in being in a position to advocate for better wages for the workers. From my perspective, this was key to promoting quality services making a permanent stay in the county.
After two years, I got word that at the call of the county’s program director, I be demoted and put in charge of the charts.
My powers were totally stripped. When a worker was sick, I was not allowed to release them. The person had to work until my rarely responded to emails gave me the approval.
Unanswered emails resulted in much suffering. Productivity sank. Simultaneously, I was micromanaged. Company people publicly sabotaged my credibility in front of the team.
It occurred to me letting productivity tank could justify my demotion. I was told that I was disorganized which is true, but never had been brought to me as a concern. All details of the job that I was responsible for were done on time. I worked 60-hour weeks.
I never realized that disorganized people who have a history of success conducting therapy were only gifted when it comes to taking care of charts.
I made a rapid exit to a part-time gig at my old place and opened up a private practice for Medi-Cal clients. My application to be a Medi-Cal provider mysteriously stalled at the county’s highest level for reason that did not make sense. I pinched pennies, worried about mortgage payments, and eventually got back to full time back in the community I love.
Looking Beyond My Own Scars
I learned a lot about community dysfunction caused by EBPs from this experience. I believe it’s possible that this kind of experience has happened before in history as streams of funding and innovation have come in.
Ultimately, the county closed this expensive collaborative program and the out-of-state company I worked for lost its contract.
It was true that the company I worked for had some pretty awesome training and that they have successfully expanded.
I continue to agree with much of what they have to convey about mental health. I wouldn’t even be so brazen as to conclude that they unilaterally discriminate against racial minorities.
But I contend that they did not know the ethos of the community in which they were operating. Though it’s not their fault that local people were insulted because they got the contract and attacked, the unhealthy attack back mode made a few heads roll, including mine. In the process, the strong local consumer base was denied the opportunity to run the peer support.
I believe what happened in Cook County is likely when a practice uses research to proclaim that fidelity measures are going to work anywhere. It’s a false sales pitch. It presumes there is no such thing as politics. It presumes that an academic elite is needed to train the masses of people who may well have walked a different path.
It releases all or nothing funding streams without taking into account that there are cultural factors at play, personalities, egos, cliques and competing financial incentives.
In the bee hive where I was hired, competing fidelity measures didn’t match. Local case managers and the employment IPS domain were highly critical of the peer domain in part for survival purposes. If peers could do what they could, jobs might be lost or pay cut.
Recovery didn’t seem to be promoted because of a lack of collaboration and enormous amount of political infighting. Some disenfranchised workers blamed it on clients.
Recovery cannot be replicated in a uniform manner. I’d argue that what is more important is a healthy family mental health system that is in a cultural state of learning in order to meet people where they are.
In spite of the difficulties, the pilot program did transform some lives on the ground in ways that aren’t measurable. Although the dysfunction is memorable, I also learned a lot about different EBPs.
But my intial questions stand: Did all the money for all the promises of the evidence-based practices trickle down into the lives of the people served? Would the county not have been better off going to its strong consumer base, taking the ideas from these evidence-based practices and co-constructing locally sensitive recovery? Was imposing change in top-down ways based on the notion of a superior intelligentsia cost effective?
Theorists need to first define themselves culturally and then assert themselves locally. They need to interact with their local consumer base and not gear themselves up to sell their experience on a global market.
When it comes to practice of mental health, a theorist and a therapist need to constantly define the limits of themselves. They should not focus on growth and impose their values and experience in universal terms on others. Administrators must ease up on the evidence-based demands.
Bees photo available from Shutterstock