Hi

At the Educational Retreat, Phil Cushman showed me a copy of his article Will managed care change our way of being?, that he wrote together with Peter Gilford (American Psychologist, 9/00). He is talking about being and he says that when the managers take over the psychological space from the therapists, there becomes a “necessity of moral deliberation” being raised by the therapists if they are to cope. I hope if Philip reads this (he’s on the S-ACC list), he will handle the ‘clientisms’ of my discourse w/o too much pain.

In Santa Clara County, one kind of follow-up we need to do is with the line staff. See the brief comment on our followup document. We need to produce a kind of reorganization that will get them more involved in the Visions & creativity & integrity of the clients. If we apply Philip’s prescription, we need to develop a kind of ‘hermeneutic conspiracy’ [FYI ‘hermeneutics’ is the method of interpretation], where the line providers who have heart get together to PUSH the moral upgrade of the ‘treatment’, ‘case management’, etc. Specifically Philip writes:

What practical structure could be used that would be fitting for a hermeneutic understanding of psychotherapy? There is much in this that is still unclear to us. However, we can say that disengaged diagnostic practices, although not dismissed, would not be accorded the unquestioned value they now enjoy. The activity of peer [i.e. therapeutic peer] consultation, perhaps supplemented with periodic supervision, could substitute for bureaucratic decision making regarding dispersal of benefits. In other words, oversight that protects patients and reinforces the ethics of the profession would require not a product but a process: not a disengaged Diagnostic and statistical manual of mental disorders number but an ongoing, cooperative, challenging intellectual and affective engagement with one’s colleagues. If peer consultation groups composed of practicing theraptists could furnish the opportunity for meaningful and responsible dialogue about cases, therapists would be engaged in ongoing, challenging feedback from their peers regarding diagnosis, treatment, and case management. Of course, there is no ultimate guarantee against the entanglements of self-interest, guild affiliation, and theoretical allegiance in these peer consultation processes, but there never is. There are only the hard-won understandings that the well-meaning but flawed human beings develop together, in dialogue.

So I’m trying to envision the way this upgrade of line staff could go. My own sense is that Philip has spoken to the provider side of this. But there is also the social construction problem, namely, how to bring in the ‘client-driven’ side of this and mesh it with this. We are talking about ‘client providers’ who use their own ‘client hermeneutics’ .. we have such in the Accountability Caucus even if they might not describe themselves just so. And we would also need to look at client oversight, within the ethos of sensitivity and confidentiality appropriate. So I’m thinking about a structure that includes (say for an individual provider site):

1.   ‘hermeneutic conspiracies’ of providers who drive the interpretation as above
2.   involvement of ‘client providers’ with an eye to bringing the therapeutic discourse into client culture sensitive interpretions

Hermeneutics is not just the matter of interpreting text, it’s the matter of interpreting it within a certain frame. The classical example is Phillip Melanchthon, Martin Luther’s #2 guy, who was not just interpreting, but interpreting (biblical) text from within the framework of the faith. Here the therapists, I think, should be looking at what our client providers do, which is interpret the ‘cases’ from within the framework of the client involvement of the process.

We also have to speak to the actual issues of organization:

3.   some kind of attention to the behavior control system that regulates the line staff (caseloads, abusive working conditions, etc.)
4.   some kind of liaison with the independently organized clients, which is accountable both to the clients (a point of access) and to the integrity and confidentiality of the hermeneutic process given in [1] & [2].

Hmmmm. No answers, but anyway, maybe this is enough text so that others can add to it.

Best

Andrew