Читать книгу Practitioner's Guide to Using Research for Evidence-Informed Practice - Allen Rubin - Страница 44
BOX 2.1 The Importance of Practice Context: A Policy Example
ОглавлениеDuring the 1970s and 1980s, assertive case management came to be seen as a panacea for helping severely mentally ill patients dumped from state hospitals into communities in the midst of the deinstitutionalization movement. Studies supporting the effectiveness of assertive case management typically were carried out in states and communities that provided an adequate community-based service system for these patients. Likewise, ample funding enabled the case managers to have relatively low caseloads, sometimes less than 10 (Rubin, 1992). One study assigned only two cases at a time to their case managers and provided them with discretionary funds that they could use to purchase resources for their two clients (Bush et al., 1990). These were high-quality studies, and their results certainly supported the effectiveness of assertive case management when provided under the relatively ideal study conditions.
Rubin had recently moved from New York to Texas at the time that those studies were emerging. His teaching and research in those days focused on the plight of the deinstitutionalized mentally ill. Included in his focus was the promise of, as well as issues in, case management. His work brought him into contact with various case managers and mental health administrators in Texas. They pointed out some huge discrepancies between the conditions in Texas compared to the conditions under which case management was found to be effective in other (northern) states. Compared to other states, and especially to those states where the studies were conducted, public funding in Texas for mental health services was quite meager. Case managers in Texas were less able to link their clients to needed community services due to the shortage of such services. Moreover, the Texas case managers lamented their caseloads, which they reported to be well in excess of 100 at that time. One case manager claimed to have a caseload of about 250! To these case managers, the studies supporting the effectiveness of assertive case management elsewhere were actually causing harm in Texas. That is, those studies were being exploited by state politicians and bureaucrats as a way to justify cutting costlier direct services with the rationale that they are not needed because of the effectiveness of (supposedly cheaper) case management services.
In light of the influence of practice context, deciding which intervention to implement involves a judgment call based in part on the best evidence – in part on your practice expertise; in part on your practice context; and in part on the idiosyncratic characteristics, values, and preferences of your clients. While you should not underestimate the importance of your judgment and expertise in making the decision, neither should you interpret this flexibility as carte blanche to allow your practice predilections to overrule the evidence. The fact that you are well trained in and enjoy providing an intervention that solid research has shown to be ineffective or much less effective than some alternative is not a sufficient rationale to automatically eschew alternative interventions on the basis of your expertise. Likewise, you should not let your practice preferences influence your appraisal regarding which studies offer the best evidence.
You should base that appraisal on what you learn from reading subsequent chapters in this book. Just as you would not want to be treated by a physician who mechanically prescribes treatments for you without first learning about your idiosyncratic health factors (an allergy to the most effective medication, for example), neither would you want to be treated by a physician who does a thorough diagnosis and takes a thorough health history, and then provides a treatment solely based on her comfort level and experience in providing that treatment, ignorant of or dismissing research on its effectiveness solely on the basis of her own predilections.