Fluent Essays

Over the past several years, there has been an increasing focus on evidence-based practice and measurable outcomes for clinical interventions. Discuss why these concepts are important to clinical practice. What are some of the ethical challenges that exist when there are no clearly defined outcomes? How have managed care practices impacted requirements for measurable outcomes? How have managed care practices limited clinical interventions? Cite from at least one professional code of ethics and from the course text to support post 297 C H A P T E R 12 Evaluation and Accountability Dr. Flournoy: Hello, Ms. Wicks? Ms. Wicks: Yes. Dr. Flournoy: I am Dr. Flournoy from Children and Youth Services. Ms. Wicks: Hello. Dr. Flournoy: The Ramerez family has been referred to our service, and I understand that you have been working with Maria, here at school. I have requested that your counseling records be subpoenaed, and I simply wanted to let you know ahead of time, so that you could begin to get them in order. C ounseling records? Subpoenas? For some mental health practitioners the idea of maintaining records may be an anathema to the nature of the helping process. Further, the invitation to disclose these records as a result of a simple request, subpoena, or court order can arouse debilitat- ing anxiety. The need and ethical responsibility of keeping and maintaining records along with the inherent conflict that may exist when disclosure of these records is requested serves as the focus for the current chapter. Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. ProQuest Ebook Central <a onclick=window.open(http://ebookcentral.proquest.com,_blank) href=http://ebookcentral.proquest.com target=_blank style=cursor: pointer;>http://ebookcentral.proquest.com</a> Created from capella on 2021-08-08 12:52:37. C o p yr ig h t © 2 0 1 6 . S A G E P u b lic a tio n s. A ll ri g h ts r e se rv e d . 298–●–ETHICAL PRACTICE IN THE HUMAN SERVICES ● OBJECTIVES The chapter will introduce you to the importance of maintaining records as both a measure of professional accountability and an essential step toward demonstrating ethical practice. After reading this chapter you should be able to do the following: • Describe the benefits of utilizing a system of evaluation within one’s practice • Define the terms formative and summative evaluation • Describe one approach to measuring outcome and goal achievement • Identify the minimal records necessary for demonstrating competent, ethical practice While it is true that no one professional can guarantee success in each and every encounter, the ethical practitioner will monitor services and adjust as required. Such a monitoring—or evaluation—be it through the informal collection of data or more formal forms, can offer direction and serve to demonstrate accountability. However, for some helpers, the concept of evaluation may be viewed as superfluous or tangential to the primary function of helping. While there is abundant evidence of the need for all mental health professionals to be able to demonstrate client progress and treatment effectiveness to the stakeholders they serve (Astra- movich & Coker, 2007), the use of a well-developed system of practice assessment simply makes good practical sense. Such a system of assess- ment and accountability not only highlights the reality of the terminal nature of the professional relationship and provides a reference point for knowing when the process has achieved its desired end (i.e., summative evaluation), but it also provides markers to guide the process (i.e., forma- tive evaluation) and thus ensure it remains on target for goal achievement. When viewed through the lens of accountability, to the client and the profession, an eval uation system becomes an essential ethical practice (see Table 12.1). ● MONITORING AND EVALUATING INTERVENTION EFFECTS Evaluation is often thought of as something that is done at the end of a process. As suggested above, for evaluation to be prescriptive it needs to be ongoing and formative as well as summative in form. Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. ProQuest Ebook Central <a onclick=window.open(http://ebookcentral.proquest.com,_blank) href=http://ebookcentral.proquest.com target=_blank style=cursor: pointer;>http://ebookcentral.proquest.com</a> Created from capella on 2021-08-08 12:52:37. C o p yr ig h t © 2 0 1 6 . S A G E P u b lic a tio n s. A ll ri g h ts r e se rv e d . Chapter 12. Evaluation and Accountability–●–299 Table 12.1 Ethical Positions on Record Keeping Professional Organization Position on Record Keeping American Counseling Association (2014) B.6. Records and documentation a. Creating and maintaining records and documentation Counselors create and maintain records and documentation necessary for rendering professional services. b. Respect for confidentiality Counselors protect the confidential information of prospective and current clients. Counselors disclose information only with appropriate consent or with sound legal or ethical justification. American Psychological Association (2010) 6.01. Documentation of professional and scientific work and maintenance of records Psychologists create, and to the extent the records are under control, maintain, disseminate, store, retain, and dispose of records and data relating to their professional and scientific work in order to (1) facilitate provision of services later by them or by other professionals, (2) allow for replication of research design and analysis, (3) meet institutional requirements, (4) ensure accuracy of billing and payments, and (5) ensure compliance with law. 6.04. Maintenance, dissemination, and disposal of confidential records of professional and scientific work a. Psychologists maintain confidentiality in creating, storing, accessing, transferring, and disposing of records under their control, whether these are written, automated, or in any other medium. b. If confidential information concerning recipients of psychological services is entered into databases or systems of records available to persons whose access has not be consented to by the recipient, psychologists use coding or other techniques to avoid the inclusion of personal identifiers. c. Psychologists make plans in advance to facilitate the appropriate transfer and to protect the confidentiality of records and data in the event of psychologists’ withdrawal from positions or practice. American Association for Marriage and Family Therapy (2015) 2.5. Marriage and family therapists store, safeguard, and dispose of client records in ways that maintain confidentiality and in accord with applicable laws and professional standards. (Continued) Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. ProQuest Ebook Central <a onclick=window.open(http://ebookcentral.proquest.com,_blank) href=http://ebookcentral.proquest.com target=_blank style=cursor: pointer;>http://ebookcentral.proquest.com</a> Created from capella on 2021-08-08 12:52:37. C o p yr ig h t © 2 0 1 6 . S A G E P u b lic a tio n s. A ll ri g h ts r e se rv e d . 300–●–ETHICAL PRACTICE IN THE HUMAN SERVICES Professional Organization Position on Record Keeping National Association of Social Workers (2008) 3.04. a. Social workers should take reasonable steps to ensure that documentation in records are accurate and reflective of services provided. b. Social workers should include sufficient and timely documentation in records to facilitate the delivery of services and to ensure continuity of service provided to clients in the future. c. Social workers’ documentation should protect clients’ privacy to the extent that is possible and appropriate and should include only information that is directly relevant to the delivery of services. d. Social workers should store records following the termination of services to ensure reasonable future access. Records should be maintained for the number of years required by state statues or relevant contracts. Table 12.1 (Continued) Formative Evaluation Formative evaluation is evaluation that occurs as an ongoing process throughout the helping encounter. It is the gathering of feedback and data used to expedite decision-making about the current process and the upcom- ing steps and procedures to be employed. It pro vides data that give form to the ongoing process. The means of collecting formative data can range in degree of formality. For example, a practitioner may choose to use a structured survey or questionnaire at various points in the helping encounter. Or more infor- mally, the practitioner may simply set time aside to solicit feedback from the client about his or her experience in the relationship with the helper and the pro cedures employed up to this par ticular point (see Case Illustration 12.1). Case Illustration 12.1 Formative Evaluation Dr. Brown: First let me tell you how much I appreciate your open- ness and willingness to share with me some of your concerns about your social relationships and your desire Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. ProQuest Ebook Central <a onclick=window.open(http://ebookcentral.proquest.com,_blank) href=http://ebookcentral.proquest.com target=_blank style=cursor: pointer;>http://ebookcentral.proquest.com</a> Created from capella on 2021-08-08 12:52:37. C o p yr ig h t © 2 0 1 6 . S A G E P u b lic a tio n s. A ll ri g h ts r e se rv e d . Chapter 12. Evaluation and Accountability–●–301 to become more assertive in these. I feel very comfort- able working with you and feel that the things we have talked about in this first session have really helped us to clarify your goal and even begin developing a strategy for getting there. I think it may be helpful if we took a moment to share our perceptions on this session as a way of making future sessions more productive. I would be very inter ested in receiving your feedback about our session today. Jim: To be honest, I was very nervous when I made the appointment. However, I am really surprised how much I shared. I really feel like I can trust you. I feel very comfortable speaking with you, and that is not my style, usually. Dr. Brown: Well, that is very nice to hear, and I know from what you told me that you tend to be a private person. Jim, as you are aware, we will probably want to talk more about your fam- ily background and previous relationships as our sessions go on. How do you feel about that? (Dr. Brown checks Jim’s understanding of the help ing process.) Jim: I know that probably needs to be done. It makes me a little anxious, but as I said, I do feel comfortable with you and trust you, especially how you explained the idea of confidentiality, I just may need to go slow. Dr. Brown: That’s good feedback for me. The pace of the sessions really will be the one that feels right for you. So if we need to go slow, we will. If you want to dive into something and it seems right to me, we will. I think as long as we continue to “process” how we are doing, we can make sure we stay on track at a pace which is both productive and comfortable. (Dr. Brown checks Jim’s comfort level and takes direction.) Jim: Yeah, me too. Dr. Brown: So, while overall you are hoping to get some help with developing assertiveness skills, our immediate goal is for you to take notes on two incidents: one in which you felt you were assertive and one in which you felt (Continued) Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. ProQuest Ebook Central <a onclick=window.open(http://ebookcentral.proquest.com,_blank) href=http://ebookcentral.proquest.com target=_blank style=cursor: pointer;>http://ebookcentral.proquest.com</a> Created from capella on 2021-08-08 12:52:37. C o p yr ig h t © 2 0 1 6 . S A G E P u b lic a tio n s. A ll ri g h ts r e se rv e d . 302–●–ETHICAL PRACTICE IN THE HUMAN SERVICES For this evaluation to truly form and give shape to the decision-making pro- cesses, it should begin with the first session. As evident in Case Illustration 12.1, the helper engaged in for mative evaluation within the first session. The approach taken by this helper provided insight into the client’s level of comfort with the interaction and his ability to engage col laboratively in the helping process. This evaluation also served as a check on the accuracy of the helper’s understanding regarding the desired goals and outcome for the helping process. The use of such a formative evaluation not only provides for helper accountabil ity but also provides the data for monitoring and increasing efficacy of treatment. Summative Evaluation Summative evaluation is the type of evaluation most typically thought of when considering goal or outcome assessment. The specific purpose of summative evaluation is to demonstrate that the action plan has reached its original objective. Summative evaluation provides the helper and the client data to determine (a) if the original goals were achieved, (b) the factors that contributed to this goal attainment, and (c) maybe even the value of this strategy versus some alternative. The articulation of clear treatment goals and the employment of summative evaluation strategies serve as invaluable sources for demonstrating treatment efficacy and helper accountability. The presence of clearly articulated goals or outcomes is essential for both formative and summative forms of evaluation. Without a clear, shared vision of where the helping process is going, it will be hard to know if it is on track or even if it has arrived. Thus, the establishment of treatment goals and objec- tives, the identification of outcome measures, and the maintenance of appro- priate responsible records serve as keystones to ethical and efficient practice. Setting Treatment Goals and Objectives While it may seem obvious that the counseling relationship and process is neither totally open ended nor aimless, as a professional encounter, our helping very unassertive. Are these the goals we agreed on? (Dr. Brown checks agreement on goals.) Jim: Yes, that’s exactly what I want to do . . . get more assertive! And I like the idea of doing some “research work” for our next session. (Continued) Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. ProQuest Ebook Central <a onclick=window.open(http://ebookcentral.proquest.com,_blank) href=http://ebookcentral.proquest.com target=_blank style=cursor: pointer;>http://ebookcentral.proquest.com</a> Created from capella on 2021-08-08 12:52:37. C o p yr ig h t © 2 0 1 6 . S A G E P u b lic a tio n s. A ll ri g h ts r e se rv e d . Chapter 12. Evaluation and Accountability–●–303 is both intentional and directional. To be effective, it is essential that the helper, along with the client, identifies and clarifies client needs and desired goals. Research (e.g., Seijts, Latham, Tasa, & Latham, 2004) has demonstrated that the articulation of goals is essential to the problem-solving process. However, to be effective, these goals cannot be vague, overly generalized, or unrealistic. As such, it is suggested that the effective, ethical practitioner will help the client to set goals that are specific, measureable, attainable, relevant, and time bound (Parsons & Zhang, 2014). Such goals may be identified with the acronym SMART goals. Taking these into consideration for one’s own practice, the ques- tions posed in Table 12.2 will be helpful in the development of these goals. Table 12.2 Developing SMART Goals Goal Characteristics Questions to Guide Goal Setting Specific Does the goal outline exactly what you are trying to achieve? Measurable How will you know if progress is being made? How will others know if progress is being made? Is the progress quantifiable? Attainable What resources do you need to achieve this goal? Can the goal be achieved independently? Is the goal too big? If so, can the goal be broken down into smaller SMART goals? What factors or forces exist that could interfere with the achievement of the goal? What is the plan to remove or navigate these forces? Relevant How important to you is this goal? What are the positive consequences of achieving this goal? How will achieving this goal affect your personal and professional life? Time Bound Have you set a target date? Can you establish benchmarks along the way to use as evidence of progress? Is the timeline reasonable? Flexible? Source: Adapted from Zhang & Parsons (2016). Field experience: Transitioning from student to professional. SAGE Publications, Thousand Oaks: CA. Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. ProQuest Ebook Central <a onclick=window.open(http://ebookcentral.proquest.com,_blank) href=http://ebookcentral.proquest.com target=_blank style=cursor: pointer;>http://ebookcentral.proquest.com</a> Created from capella on 2021-08-08 12:52:37. C o p yr ig h t © 2 0 1 6 . S A G E P u b lic a tio n s. A ll ri g h ts r e se rv e d . 304–●–ETHICAL PRACTICE IN THE HUMAN SERVICES Measuring Outcome and Goal Achievement The selection of appropriate outcome measures is far from easy. Clinicians recognize that the helping process, when effective, can reveal itself in many ways—even beyond the achievement of the terminal goal. For example, while attempting to help a client cope with his social anxiety it may not be unusual to find that the client exits the relationship with a better sense of his own vocational calling or insight into his current relationships or even a desire to pursue additional growth-oriented counseling. Using more than one outcome and outcome measure increases the probability of accurately depicting the entirety of the experience. At the most fundamental level, the prac titioner can assume that one outcome reflects the nature of the presenting concern. For example, if a clinician is interested in ameliorating a presenting complaint, the nature of that complaint (e.g., test anxiety, marital dissatisfaction, depression, etc.) provides direction to the outcomes desired. After targeting the general area in which the helper expects to demonstrate impact (i.e., reduce test anxiety, increase achievement level, etc.), that partic- ular area needs to be clearly and concretely defined. It is important to realize that while there will be a primary focus for the assessing outcome (e.g., reduce the amount of client depression or increase student attention, etc.), these tar- gets may be manifested in a number of different ways and occur within a unique context. The more perspectives we take on the outcome and the more mea- sures we employ, the greater the chance we have of under standing the nature and depth of impact our practice may have produced. Consider the approach taken by the helper illustrated in the following case (Case Illustration 12.2). Case Illustration 12.2 Assessing Outcomes of Treatment With Depressed Client Alicia came to therapy because of a “constant” feeling of sadness and an inability to get moti vated about anything in her life. At the initial meeting with Alicia, Dr. Warrick attempted to identify the various ways in which her feelings of sadness were experienced and were impact ing her life. Dr. Warrick: Alicia, you have mentioned that you are not “doing anything” and you can’t get motivated. Could you tell me more about that? Alicia: Well, I have a lot of school work that should be done, and each time I sit down to do it I think, why bother, Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. ProQuest Ebook Central <a onclick=window.open(http://ebookcentral.proquest.com,_blank) href=http://ebookcentral.proquest.com target=_blank style=cursor: pointer;>http://ebookcentral.proquest.com</a> Created from capella on 2021-08-08 12:52:37. C o p yr ig h t © 2 0 1 6 . S A G E P u b lic a tio n s. A ll ri g h ts r e se rv e d . Chapter 12. Evaluation and Accountability–●–305 nothing is going to come out, and then I walk away from the computer and get something to eat or go to bed. Dr. Warrick: So it seems that you not only feel sad, at times, but you also have this belief that “nothing is going to work”? Alicia: That’s right! And it is not just with school stuff. If I get a call from a friend I typically go out with, I think, why bother going out, it is not going to help. And I stay home. Dr. Warrick: So one of the things that we may watch as we work together isn’t just your feelings of sadness but also the frequency of this, why bother, it’s hopeless thinking? Alicia: I don’t want to feel sad anymore, but I also understand what you mean about the thinking. Dr. Warrick: You also seem to suggest that when you are feeling this way, you avoid your friends and avoid engaging in activities (like school work)? Alicia: Yeah, I have not seen my friends in weeks. I’m sure they are annoyed. And I don’t even do housework anymore. My place is a mess. Dr. Warrick: Well, Alicia, I appreciate how open you have been with me today, and I truly feel we have taken a good step toward helping you to feel and behave the way you want to. As we continue working together, we will not only keep our eyes on your feelings of sadness with the intent of gaining some relief, but we will see if there is an increase in the frequency with which you go out with your friends or do house chores and school work. Further, we will hopefully also see a change in your thinking. Rather than thinking why bother thoughts, we will see more productive thoughts. How does that sound? Alicia: It sounds like a lot and I’m not sure that we can do this. Wow, there is that why bother thought again! (Continued) Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. ProQuest Ebook Central <a onclick=window.open(http://ebookcentral.proquest.com,_blank) href=http://ebookcentral.proquest.com target=_blank style=cursor: pointer;>http://ebookcentral.proquest.com</a> Created from capella on 2021-08-08 12:52:37. C o p yr ig h t © 2 0 1 6 . S A G E P u b lic a tio n s. A ll ri g h ts r e se rv e d . 306–●–ETHICAL PRACTICE IN THE HUMAN SERVICES But, if I would start feeling and thinking and acting dif ferently, then I would not need to be here. Dr. Warrick: That’s good! I like the way you already attacked that thought of yours! (Continued) While most individuals recognize depression to be a mood, an affect, or a feeling, depression also manifests itself in a person’s behavior, thought processes, and interpersonal interactions. A helper, like Dr. Warrick (see Case Illustration 12.2), who may be attempting to assess the effec- tiveness of a particular medication or treatment approach on depres- sion, should assess changes not only in the client’s mood but also in the client’s behavior (e.g., doing school work), thought processes (e.g., hav- ing less frequent thoughts of suicide or thoughts of why bother), and interpersonal interactions (e.g., beginning to reengage with fam ily and friends), along with gathering information about how the client feels about these changes. Table 12.3 provides one useful way for conceptualizing the various domains in which interventions may impact the client. It is useful to con- sider gathering data in many, if not all, of these domains in an attempt to accurately evaluate the impact of practice decisions. The listing presented is an adaptation of the work of Arnold Lazarus (1989). The essence of this model is the belief that a person’s functioning or dysfunctioning is mani- fested along seven modalities: behavior, affect, sensation, images, cognition, interpersonal relationships, and biology/physiology. Lazarus represented these seven domains with the acronym BASIC ID. Using each of these com- ponents as a reference point, the helper can conceptu alize the impacts of his or her practice more broadly. Table 12.3 presents three dimensions for consideration when identifying outcomes to action research. First, modality refers to the specific arena in which this construct may be manifested (i.e., BASIC ID). The second dimen- sion, manifestation, is the place where the practitioner identifies the manner or form in which this particular target of the investigation appears. The final column, data collection techniques, identifies the types of techniques that can be useful when assessing that domain. It should be noted that while a specific method of data collection has been identified in Table 12.3, other methods may work as well. Exercise 12.1 provides an opportunity to employ to this approach with a problem of your choosing. Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. ProQuest Ebook Central <a onclick=window.open(http://ebookcentral.proquest.com,_blank) href=http://ebookcentral.proquest.com target=_blank style=cursor: pointer;>http://ebookcentral.proquest.com</a> Created from capella on 2021-08-08 12:52:37. C o p yr ig h t © 2 0 1 6 . S A G E P u b lic a tio n s. A ll ri g h ts r e se rv e d . Chapter 12. Evaluation and Accountability–●–307 Table 12.3 Classification Scheme for Outcome Measures: Using an Example of a Client Experiencing Anxiety in Social Settings Modality Manifestation Sample Methods of Data Collection Behavior Withdraws from social contact Observation Affect Anxious Survey (anxiety checklist) Sensation Muscle tension Self-report (journal) Imagery Dreams about being abandoned Self-report (journal) Cognition Believes he has no right to say no Assertiveness questionnaire Interpersonal Withdraws and fails to maintain eye contact Observation, interview peers Drugs/Biology Stomach upset/blood pressure high Self-report and blood pressure recordings Exercise 12.1 Identifying Personal Outcomes Directions: Below are a number of general statements about personal improvement and growth. Select one that may be of interest to you and using the table below, identify the various manifestations of this goal achievement along with techniques for assessment. ● Become a better student ● Become more social ● Become more spiritual ● Improve general health Modality Definition Sample Methods of Data Collection Behavior Affect (Continued) Parsons, R. D., & Dickinson, K. L. (2016). Ethical practice in the human services : From knowing to being. ProQuest Ebook Central <a onclick=window.open(http://ebookcentral.proquest.com,_blank) href=http://ebookcentral.proquest.com target=_blank style=cursor: pointer;>http://ebookcentral.proquest.com</a> Created from capella on 2021-08-08 12:52:37. C o p yr ig h t © 2 0 1 6 . S A G E P u b lic a tio n s. A ll ri g h ts r e se rv e d . 308–●–ETHICAL PRACTICE IN THE HUMAN SERVICES Modality Definition Sample Methods of Data Collection Sensations Imagery Cognition Interpersonal Drugs (Continued) Record Keeping Record keeping is important not just to document service but also to guide and direct the practitioner in his or her practice decisions. Accurate, complete records can, for example, allow a practitioner to review the thera- peutic process and thus foster self-monitoring on the part of the practitioner. Thus, implicit within the discussion of evaluation and outcome measure- ment is the understanding that data will be collected and recorded for later analy sis. These data can be of various forms, including test scores, clinician observations, and notations. In whatever form they are, these data constitute a client’s record and must be handled with sensitivity. Maintaining thorough records and clinical notes is essential to the plan- ning and mon itoring of services as well as to providing data, should the interaction ever be questioned as in the case of a lawsuit. Keeping good and accurate records provides a strong foundation for counselors in the event of claims regarding legal issues and ethics violations (Mitchell, 2007). Thus, even with concern about possible requirements to disclose, experiences of inconvenience, or a practitioner’s belief in the power of his or her memory, …