Learning how to act: An ethnographic study of worker agency and expertise in a residential treatment center for children

Social work scholars have long been concerned with shaping and transmitting the knowledge base of the profession. In recent years, greater attention has also been paid to transforming not only what social workers know, but how they use that knowledge in practice. In particular, social work scholars have developed and promoted a range of normative frameworks for how workers should make clinical decisions and at have times defined professional expertise itself as the adherence to these frameworks. However, relatively little empirical research documents how social workers and other mental health workers actually use knowledge in particular "real world" sites of clinical practice. This study of mental health workers' attempts to fill that gap in understanding, asking the question: How do people who work with children in a residential treatment program know how to do their jobs? Within this frame, this study investigates (1) Forms of knowledge valued by workers in this site of practice and the processes through which that knowledge is acquired; (2) How workers make decisions when a key decision point has been identified; (3) How workers customize a normative decision-making process prescribed by a manualized intervention to meet the demands of their work; and (4) How workers in this location understand and enact professional expertise.;This study uses ethnographic methods to naturalistically and inductively study these questions in the context of "The University Home and School" (or UHS), a residential treatment program for "emotionally disturbed" children and adolescents in the Midwestern United States. Through approximately 1560 hours of participant observation, 36 ethnographic interviews, and the review of locally-circulating documents and related literatures, I iteratively developed, checked, and revised understandings of relevant phenomena. Putting participant perspectives in dialogue with etic perspectives, I describe and analyze key processes of agency, knowledge use, and expertise among mental health workers at UHS. This study finds that mental health workers at UHS valued a form of knowledge that they called "common sense," which they believed was an innate, untutored quality of certain individuals. I suggest here that what they revered as "common sense" was in fact comprised largely of local knowledge learned on the job and was indeed learned through an informal process of apprenticeship facilitated by the transparent work environment of this milieu-based program. These findings provide an explanation of how workers gain locally salient expertise in an organization with few explicit rules and relatively little didactic instruction. I also identify a process through which UHS workers made decisions collaboratively when a decision point had been identified. This process relies on the locally valued ideas that "all behavior has meaning" and that proper worker responses must be matched to interpretations of those meanings. These collective practices of interpretation allowed workers to audition potential intervention strategies and integrate them into the overarching theoretical orientation of the program while simultaneously serving as an important venue in which developing clinical expertise was modeled, practiced, and evaluated.;Finally, this study examines the ways that UHS workers modified aspects of the Therapeutic Crisis Intervention (TCI) curriculum in which they were trained in order to better suit the conditions of practice. Specifically, this chapter addresses the ways that workers understood their own processes of initiating action during the compressed temporality of crisis intervention. I argue that the step-by-step process of decision-making taught in the TCI curriculum was inadequate to the needs of workers who needed to initiate responses to emerging behavioral crises quickly, and I describe an alternate mode of agency that workers reported using to mobilize knowledge and initiate specific intervention techniques under these conditions.;I consider the implications of these findings for mental health practice, professional education, and intervention and implementation research, with particular attention to how these findings contribute to and sometimes challenge aspects of the evidence-based practice process and the relationship between research and practice in the field of social work. These findings point to the value of viewing mental health practitioners as knowledgeable local experts who do not simply apply knowledge produced by researchers but modify and blend it with valued knowledge from other sources to meet the unique demands of their site of practice.