Re: Construing Psychotherapy Outcomes and the Role of Persuasion
Fri, 12 Apr 1996 01:22:51 -0400

Tim and Others-

It would seem the PCP therapist (or case manager) can remain in good standing
with the managed care company whose goals may be only to lower hospital bed
days and to keep a person at their highest functioning level in the
community. I have always believed that the heart of PCP was to determine
practical solutions and alternate constructions to help the client live in
the real world while respecting their system of beliefs. While I think I can
answer and defend PCP to managed care somewhat adequately (and need to
daily), I find another question very troubling within a PCP framework.
Without this answer, I can not answer for myself how to evaluate the
outcomes from a PCP framework.

I have always worked in the field of Community Mental Health or Child Care in
Residential Treatment Facilities (Generally from extremely disturbed families
where the child was unlikey to return). Society has removed these people
from the original environments because they or their original environments
were deemed unacceptable by authorities (Generally a government institution
such as police, child welfare, state mental institutions). I am paid by
society (Government institutions) to parent and shepard these people back
into society. I attempt to do so while respecting their belief systems. The
goverment authorities who pay for this service (often against the client's
wishes although they agree that my settings are preferable to other setting
they may end up in), want me to work on certain core beliefs and make some
changes to reintegrate my clients back into society as quickly and as closely
integrated as is possible. I am fairly efffective at this as compared with
others in the field by comparing statistics such as hospital recidivism,
medication compliance, length of community stays.....

I am given a set of precoceived notions for which I am to impart as a
quasi-parent. Whereas, someone may come to me happily remaining in the
hospital, I impart to them that it is preferable to:

1. Continue to live even though suicide may be preferred
2. Stay in the communiy and to integrate to the highest degree possible
despite evidence that tells the client this is dangerous. Strive towards
independance even though you do not think it is wise and it is preferred not
3. Be honest and trustworthy
4. Take medication and fit in even if there are awful side effects
5. Move to the highest level of functioning including working, addional
education and "better use of your leisure time."
6. ...............

While doing this I adopt a constructivist standpoint in understanding my
client. I also learn how they are likely to proceed and where and how fast
they will experiment. This does not deviate from my conceptions of a PCP
approach...Throughout my work, I also attempt to work within the frame of
reference of my client and to preserve as much of the core beliefs and
learnings as is possible from their past. I build upon strengths rather than
weaknesses. I try to be extremely sensitive to a client's idiosyncracies
while meeting societies goals. I respect and subsume their present
construction while exposing them to new experiences and evidence in a
controlled way.

What happens next is a conceptual leap. As I have a time limit to my
interactions and a finite set of goals, I modify the environment in ways to
speed experimentation and to develop a line of testing consistent with where
I need to direct the client. I take it upon myself to already know some
things that may work for them if I can get that client to trust me and to try
some thing new. I am careful at this stage of risk as the member will take a
long time to trust anyone if I am incorrect so I am careful in this stage
before moving to it. I often even inform the client of how I have modified
the environment and why. I may use RET or cognitive behavioral tecniques
consistent with problems they are experiencing. I work to get them to try a
community setting and to integrate as this is the function of my work. I
have a pre-defined set of values for which I must impart based on community
needs and expectations. I believe they can be integrated generally with most
of the client's existing belief systems. Sometime this is just not

As I make these decisions as to what is right and I in my role as case
manager and guardian impart these values, have I abandoned what are core
principles of PCP?
Am I good in the eyes of a PCP therapist, if I work to move towards a
preconceived set of ideas or beliefs as the right behaviors. Theswe seem
dangerously close to "truths" discussed earlier. These "truths" are
culturally based and are always subject to discussion across time and

As I am particularly good using the client's frame of reference (using PCP
techniques of ongoing assessment and intervention) in getting a person to
integrate into the community ( as compared with other casemanagers with other
techniques) am I a good person at using PCP or am I merely exceptionally
manipulative? If I am good at PCP, and exceptionally manipulative at
persuading the client to follow or incorporate society's ideas, have I
abandoned the basic PCP principle to wait and allow the client to discover
these ideas for themselves?

Managed care may still dictate me to continue to be manipulative if I am so
defined by the group but I would like to know what others think. I may also
feel justified in being very directive in the experimentation based on how I
see my clients feel later.. but I want to know what others think of this
ethical dilema? Who made me right or gave society the right to decide this
other than "it's their money?" Does the end justify the means?

I also want to know how others resolve the problem of directedness or not to
be directive. When you are working for someone else and the client is there
against their will and not interested in experimenting with the constructs
society needs changed, how do you speed up the questioning under time