Assignment: Relationship Between Qualitative Analysis and Evidence-Based Practice
Evidence-based practice is integral to social work, as it often informs best practices. Competent social workers understand this connection in general and the ways it benefits clients in particular. For this Assignment, consider your informed opinion on the relationship between qualitative analysis and evidence-based practice.
By Day 7
Submit a 2-page paper that addresses the following:
- Choose two qualitative research studies from this week’s resources and analyze the relationship between qualitative analysis and evidence-based practice.
- Consider how the qualitative study contributes to social work practice and how this type of knowledge would fit into building evidence-based practice.
Client Advocacy in Marriage and Family Therapy:
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A Qualitative Case Study
Diane R. Gehart Brandy M. Lucas
ABSTRACT. Client advocacy and social justice are topics of increasing importance in clinical practice. This study addresses the pragmatics of client advocacy in daily MFT (Marriage and Family Therapy) prac- tice using qualitative case analysis. Researchers used Kvale’s (1996) interview and analysis procedures to access detailed descriptions of the lived experience of advocacy from the client’s perspective. The client’s descriptions identify subtle aspects of advocacy that expand its current definition and challenge the suitability of certain clinical techniques, es- pecially with diverse clients. Implications for practice include (1) con- ceptualizing advocacy as an attitude; (2) providing flexibility in service delivery; (3) collaborating with social services as a clinical intervention; and (4) promoting self-advocacy. doi:10.1300/J085v18n01_04 [Article cop- ies available for a fee from The Haworth Document Delivery Service: 1-800- HAWORTH. E-mail address: <email@example.com> Website: <http://www.HaworthPress.com> © 2007 by The Haworth Press, Inc. All rights reserved.]
KEYWORDS. Advocacy, marriage and family therapy, case study, qualitative research
Diane R. Gehart is Associate Professor, California State University, Northridge, CA. Brandy M. Lucas is a doctoral student at Texas Tech University, Lubbock, TX. Address correspondence to: Diane R. Gehart, Department of Educational Psychol-
ogy and Counseling, California State University, 18111 Nordhoff, Northridge, CA 91330 (E-mail: firstname.lastname@example.org).
Journal of Family Psychotherapy, Vol. 18(1) 2007 Available online at http://jfp.haworthpress.com
© 2007 by The Haworth Press, Inc. All rights reserved. doi:10.1300/J085v18n01_04 39http://www.HaworthPress.comhttp://jfp.haworthpress.com
Client advocacy and the related issue of social justice are issues of increasing importance in clinical practice. With few exceptions, mar- riage and family therapists have not been on the forefront of these movements (Laszloffy & Hardy, 2000; McGoldrick, 1998). Nonethe- less, marriage and family therapists have begun to meaningfully wrestle with questions related to social justice. Johnson (2001) challenges the idea that marriage and family therapy (MFT) as a profession can affect changes at the societal level because MFTs are not trained to intervene at broader systemic levels. If family therapists are not positioned to di- rectly intervene in matters of social injustice, then how is an individual clinician to respond when these issues are brought into the therapy room by clients experiencing injustice and challenges due to their ethnicity, race, gender, sexual orientation, social economic class, country of ori- gin, religion, language, or similar factors? Does an individual clinician have an ethical responsibility to address issues of subtle and gross social injustice in the lives of their clients? Is it possible to not address these issues? After all, is no response in effect a response?
We propose that the pragmatic answers to these questions are best conceptualized by clinicians not in terms of social justice but client advocacy. For those who work closely with marginalized populations, it is readily evident that family therapists can and do “heal the world in 50-min intervals” (Hardy, 2001, p. 22). Rather than ask can or should family therapists affect societal change, this article addresses practical ways in which a clinician can make a difference in everyday practice. This article provides a real-world glimpse of client advocacy by describ- ing the process in an MFT private practice setting based on case analysis.
CLIENT ADVOCACY IN CLINICAL PRACTICE
Client advocacy is most generally defined as helping clients to ad- dress institutional and social barriers that impede their ability to achieve goals or access needed services. Advocacy most often, but not always, involves addressing issues of social justice, and therefore the two tend to be discussed simultaneously. For the purposes of this article, client advocacy is referred to in the broadest terms, helping all clients address institutional and social barriers.
It must be conceded that as a discipline social work has long been at the forefront of issues related to client advocacy and social justice (Swenson, 1998). Social justice is easily recognizable as an organizing value within social work, and advocacy is addressed at both the micro
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and macro levels. However, Jordan (1987) argues that advocacy is “un- characteristic of everyday social work practice” (p. 135), particularly clinical social work. The apparent discrepancy may lie in the disci- pline’s emphasis on developing sensitivity and awareness of social jus- tice issues with fewer models for operationalizing these values in clinical practice. A similar pattern replicates in counseling and family therapy as well.
Professional counselors and counseling psychologists have begun pro- moting client advocacy as a core value within their professions (Ivey & Collins, 2003; Myers, Sweeney, & White, 2002). Similar to social workers, their emphasis has been to develop sensitivity to social justice issues: “Raising awareness about the needs of neglected populations and fighting for the civil rights of exploited people are profound human experiences that require counselors to be committed humanitarians” (Kiselica & Robinson, 2001, p. 391). This goal is codified in multicul- tural guidelines for the profession (Ivey & Collins, 2003). However, there is less agreement on how to operationalize these values. Some call for traditional political action at the broader social level (Kiselica & Robinson, 2001; Lee, 1998; Lee & Waltz, 1998; Toporek, 2000), while others call for more interdisciplinary collaboration (Bemak, 1998; Myers, Sweeney, & White, 2002). Both alternatives emphasize broad sys- tem-level interventions and do not address opportunities to intervene in clinical settings.
Similar to social workers and counselors, family therapists have fo- cused on increasing awareness of social justice issues with few models for operationalizing client advocacy. Grounding their work in social constructionist, critical, and feminist theories, McDowell and Shelton (2002) outline strategies for raising student awareness of social justice issues at various points in marriage and family therapy curricula. Simi- larly, Laszloffy and Hardy (2000) outline steps for addressing racism in family therapy, emphasizing the need to increase therapists’ racial sensitivities and abilities to actively respond to incidents of racism. Although they focus primarily on addressing forms of racism in the therapeutic relationship and dialogue, they specifically identify advo- cacy as a means to address racism when it is part of the presenting problem: “Therapists can serve as advocates on behalf of clients to address unjust situations, wherever these may occur (schools, the work- place, etc.)” (p. 42).
Aponte (1994) includes advocacy in his work with the poor. He warns that “in today’s politically correct atmosphere, many therapists and professional associations have determined that they should be the
Diane R. Gehart and Brandy M. Lucas 41
source of solutions for today’s social problems” (p. 11) and thereby impose their values on clients. Instead, he proposes that marginalized populations such as the poor are more in need of reconnecting with tra- ditional community resources and strengthening of spirit than they are of social services. In working with the poor, he identifies two ap- proaches to advocacy: direct and analogue interventions. In direct in- terventions, the therapist actively participates in conversations with outside systems related to the problem, such as schools, medical profes- sionals, and social services. Analogue approaches involve intervening on dysfunctional structural patterns at more accessible levels of the sys- tem and allowing the changes at one level to transfer to others. For ex- ample, by creating opportunities for a client to assertively interact with a therapist in session, the client can transfer this style of relating to other professionals.
Ecosystemic approaches have offered the most detailed models for advocacy in MFT. Imber-Black (1988) details an ecosystemic model, for working with families and larger systems, that provides a frame- work for client advocacy. Her model includes systemic assessment of broad system boundaries, triads, problem definitions, and binds and prescribes interventions using isomorphism and various forms of rit- uals. This ecosystemic model provides therapists with a model for ad- vocating in cases involving labeling, stigmatism, and secrets. More recent evolutions of ecosystemic theory incorporate postmodern con- cepts, such as a strength-based perspective and collaborative relation- ships with clients, to work with families and social service systems (Pulleyblank Coffey, 2004).
Postmodern therapists offer a unique approach to social justice and client advocacy. Narrative therapists have been active spokespersons regarding issues of social justice (Zimmerman & Dickerson, 1994), and the relational stance of narrative therapists often embodies a social justice ethic (Author, 2003). Narrative therapy provides a theoretical rationale and clinical approach for working with the effects of domi- nant social discourses, a concept frequently neglected in many thera- peutic models. Narrative therapists position themselves as advocates at the individual level by changing how a person relates to oppressive dominant discourses and increasing the person’s sense of community (Freedman & Combs, 1996). However, descriptions of narrative ther- apy generally focus on advocacy that occurs within session and with friendly “audiences” rather than engaging broader social service sys- tems (Freedman & Combs, 1996; White & Epston, 1990).
42 JOURNAL OF FAMILY PSYCHOTHERAPY
Grounding their work in social constructionism, collaborative thera- pists have developed a postmodern approach to advocacy. Problems are conceptualized as emerging through dialogue, and therefore, the thera- peutic process requires that the therapist involve not only the client and family but involved professionals, extended family, and others in dia- logue about the problem (Anderson, 1997). Engaging multiple voices allows for clients, therapists, social workers, and other professionals to better understand each other. In this process, the client’s perspective is considered equally alongside professional views of the situation, a pro- cess that is referred to as acknowledging client expertise (Anderson & Goolishian, 1992). Additionally, collaborative therapists are “public” with their clients about the business of therapy including conversations with other professionals, social services, and legal institutions. By mak- ing these conversations public, therapists open many avenues for advo- cacy. For example, St. George and Wulff (1998) work collaboratively with clients in drafting letters to courts and other interested parties, in- creasing clients’ sense of autonomy, initiative, and responsibility.
FROM AWARENESS TO ACTION
Mental health practitioners have made strides in raising awareness of social injustice issues, and now the task is translating this increased awareness into action. The majority of advocacy approaches are based on existing theories, which are adapted and/or applied to advocacy work, such as the work of Imber-Black (1988) and Aponte (1994). This study represents an attempt to develop guidelines for advocacy based on one client’s lived experience of what advocacy is and how it was enacted over several years of treatment in private practice and social service set- tings. The purpose of this study is not to produce generalizable results but to systematically capture the richness and detail of one client’s lived experience in order to generate client-informed guidelines for advocacy practices. Such an approach is consistent with the ethic of advocacy, which demands that the client’s voice be included in this work.
QUALITATIVE CASE STUDY IN ADVOCACY
The following case study involves an in-depth interview with a client about her experiences of client advocacy. In an unusual departure from most research interviews, this interview was initiated by the client whose hopes were that therapists could learn from her experiences. One year
Diane R. Gehart and Brandy M. Lucas 43
after the termination of treatment, the client approached her former ther- apist (DG) and asked if there was some way to share her knowledge in a useful way with students in the therapist’s training courses. The client said she did not feel able to prepare a formal lecture and asked if the therapist could interview her. The client set the agenda for the interview, which was the advocacy agenda.
The client had been in therapy for six-and-a-half years; during the last four years of treatment, she was in individual therapy with a family thera- pist in private practice (DG). She was a 17-year-old Caucasian living in a homeless shelter with her mother at the start of treatment with this thera- pist. She had been in and out of a county mental health system and non- profit counseling since age 15 when a close relative was arrested for sexually abusing her. Over the course of therapy, she was admitted four times to a 24-hour crisis center for suicidal ideation and attempts; was in a county day-treatment program for two months; received case manage- ment from county mental health and Victims of Crime; was seen by a county psychiatrist; was briefly involved in two sexual abuse groups and day-treatment groups; and was in a welfare-to-work program.