Please note: This long blog has been divided into two parts and will be republished
I feel that the mental health field’s current preoccupation with evidence based practice is one of the greatest impediments to putting dollars to good use on the ground. It comes out of the psychotherapeutic tradition of teaching theory that has been tried and tested to cross cultural boundaries. I am here to exclaim that this claim alone is corrupt and a piss poor way to promote mental health! And I am here to reflect an opinion from the rank and file: that when administrators expand these concepts and suggest that fidelity measures supersede local culture, the potential for doing damage and being wasteful rises exponentially.
You can give me any amount of research that a best practice is universal and I will go back to my experience in life and gawk. I don’t think I am the only one who’d argue that authentic contact with the culture of the local situation one sees in the therapy context is more important than a measured technique. It is time administrators and therapists’ alike wake up and study themselves before they waste money on importing academic concepts.
My beef with therapy that follows strict theoretical fidelity measures started twenty-seven years ago when I was first hospitalized at age seventeen for anorexia in Salvador Minuchin’s clinic. My family was to receive a best practice Structural Family Therapy performed with the highest of fidelity measures with one-way mirrors and expert consultation. I was expected to gain a half pound a day or my family would be viewed as a failure. I would later learn that 6000 calories a day would not anatomically gain me a half pound a day. In therapy I kept making this point but the team was instructed to ignore me when I was oppositional. In other words, I was to lose my voice in the family system if I behaved that way. We went through intense and traumatic experiences as a family including my father being encouraged to bully me into eating. While he later did many things that worked, I was not able to conceptualize my rage and started to throw up indiscriminately. I had no idea what we were supposed to do, only that we were failing at an impractical expectation.
In working my way through my Master’s level education I did some extra reading on Salvador Minuchin. I learned that he was an Argentinian, Israeli Army guy who developed his theory for people of the “slums.” Going after psychosomatic problems like eating disorders and juvenile diabetes was a way for him to penetrate middle class markets and prove that his work was manifest destiny universal. This way students could learn that they could use his theory with anyone.
When I reflect on this, it tickles me. All those years ago Minchin was dealing with two aristocratic Quaker families who were in many ways the highest of authorities on being anti-authoritarian. My father, a Quaker school principal; my grandfather, an Ivy League administrator; being trained to insert military structure so Minuchin could prove that his ideas were universal. But the results of this simple mismatch were lasting. My family on all sides weren’t used to being told they were failures. None of us took kindly to that news and what essentially ensued was a thirteen year emotional cut-off.
When, thirteen years later, in a political thriller against the powerful housing authority of a major US city, I finally descended into a two year schizophrenia. Reunification as a prodigal son didn’t go very well. Suddenly I, considering myself a whistle-blower, found society hell-bent on incarcerating and making me accountable for being a eugenic failure. And my only remaining supporters, my long-lost family agreed. My father did what he could to get me to stay an extra nine months on the most chronic of back-wards; and later to prevent me from having a car.
This was a hard way to be treated, when, six months after the three month hospitalization, I was only able to find a minimum wage job with a two hour bike/BART routine while in “psychosis.” A car was key to enable me to grow out of this situation. After ten months, I was finally able to manipulate my mother into helping me. And with a car I did improve my job performance, start back on medications and eventually escape the grasp of a company that I was later able to confirm really did cooperate with a local mob boss, just as I thought.
Though most Master’s-level clinicians of my era learned that multiculturalism was important, we also learned that if you chose a best practice orientation like Minuchin’s Structural Family Therapy, or CBT and apply the concept across cultural divides and you were okay. In those days we were not taught to study the cultural ethos within which the best practice was created and translate it through ourselves while considering the cultural experiences of the subject. I often wonder if this is still the case. I certainly was not blessed with such thoughtfulness from any of the mental health providers I came into contact with. I am now left to wonder what would have happened if I received the treatment of Minuchin’s primary competitor Bowen who worked with Midwestern, white-bread schizophrenic families. Maybe then some of the pain and suffering would have been averted.
Now fifteen years later from my stint in a state hospital, I am finding that those of us workers, trained in counseling theories, are additionally hired into systems that use fidelity measures to promote proven recovery practices. Four years ago I left my job in a community I love and have since returned to, to join a county collaborative effort to jumpstart recovery via importing three evidence based practices. And so we get to my initial contention that evidence based practice, like theory, cannot override culture.
The county I work in 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 out-of-context best practices were and 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 the meetings. Though this was not what the company wanted, those who spoke up affectively also would somehow end up targeted by company.
After I made the rounds, on a day when the top administrator and our boss were present, a worker who seemed most effective, 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 and the door closed, I found out that the top administrator had a file on this worker, who was a racial minority; he was on track for being fired along with another minority worker, who was axed that day.
Sure enough, the man of a minority race 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 of my own sense of financial hopelessness were triggered. Indeed, the more I took inventory, I quickly became alarmed of what I considered to be racial and class in-sensitivities: workers who had harder inner-city backgrounds seemed to me to be more heavily scrutinized. With this vague sense, I forged a relationship with the county’s program director who was a racial minority and was under attack by our company’s bosses. Peer support and the training I had gone through is something I have come to believe very strongly in so I felt that the best thing to do was to send an email expressing my concerns to the boss.
Meanwhile, as I was feeling quite bullied and insulted at the tables, I quickly 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 and the minority director was replaced. I continued to observe the other male minorities to be not treated well from my perspective: one, I had trained with seemed to be getting targeted in part for having non-Christian spiritual beliefs. The top Administrator was out sick much of the time and calling shots from her bedside and the county’s new director formed a strong relationship with our boss who seemed offended after my email.
The bullying at the table overseen by the county’s new director was now escalated. I often felt insulted and attacked. One day 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 who supported me was written up for not being a team player. I experienced no sense of an apology. 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 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 be job security. I was not looking for control of the program I was fine with being number two. I was more interested in being in a position to advocate for better wages for the workers. From my perspective, this way key to promoting quality services making a permanent stay in the county. When the person who was hired over top of me turned out to have a temper and walk out on the job after a month; I got the 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. They had to work until my rarely responded to emails gave me the approval. There were many examples suffering that occurred from unanswered emails. Meanwhile the productivity sank. At the same time I was micromanaged. Company people were brought in who publicly sabotaged my credibility in from of the team. Being attacked in this manner can do a number to old self-esteem scars.
It occurred to me as they hired the wife of the leader of the collaborative program that 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 factitiously done on time because, I worked sixty hour weeks. I never realized that disorganized people who have a history of success in therapy (and who’ve written their own therapeutic theory,) were gifted when it comes to taking care of charts. I went back to my old job part-time 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.
Ultimately, the county closed this expensive collaborative program and the out-of-state company I worked for lost its contract. I learned that the county had decided against using local peer leaders to run the peer support aspect of their program. It was true that the company I worked for had some pretty awesome training and that they have successfully expanded. I think ours was the first of their programs to close. Much of what they have to convey about mental health, I continue to agree with. I don’t even think it’s fair to conclude from what I experienced that they discriminate against racial minorities. But they did not know the ground of the community they were operating in. Though not their fault that local people were insulted that they got the contract and attacked, the unhealthy attack back mode made a few heads roll.
I believe what happened in the county is likely when a practice uses research to proclaim that their fidelity measures are going to work anywhere. It’s a false sales pitch. There are so many cultural factors at play, personalities, egos, and competing financial incentives in community mental health. There were times when competing fidelity measures didn’t match up. Perhaps the employment IPS domain was 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. Likewise the more educated case managers may not have only felt threatened for those financial reasons, but there I was with more experience challenging their clinical culture and notions of superiority; that couldn’t have been very easy. I don’t like clinical culture. I was after all exhibiting some degree of ego.
In sum, with a high need for collaboration and an enormous amount of political infighting recovery was not promoted. Perhaps some will say it’s the clients’ faults. In spite of all this, though, the pilot program did transform lives on the ground. Yet, my question stands: 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?
I go back to my original paragraph and point out that things would work better if money was not spent proving that because a set of ideas worked in one place, that fidelity measures can assure it can be reproduced in another. This entails that Theorists need to first define themselves culturally and then assert themselves locally. They need to interact with their local consumer base and not sell their experience on a global market. When it comes to practice of mental health a theorist and a therapist needs to constantly define the limits of themselves and not grow so large in the head as to impose their values and experience in universal terms on others.
I think it is time for administrators to wake up and limit the relevance of evidence based strategies. Step inside a state hospital backward, or prison and you get a pretty good sense of where all the good intentions of counseling theorists and therapists and administrators may well lead you. I think that most other survivors of these environments will tell you that they did not get much support from a theory in that squalor. Speaking for myself, I was only helped by people who threw the theory away and treated me like a human being. And believe me we clients can tell when people are treating us like a statistic, like we are one of their “folks.” That is not helpful.
Please note: This long blog has been divided into two parts and will be republished