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 pa

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intermediate outcomes are an important class of outcomes that usually are pursued in the process of treatment. They consist of the necessary preconditions, or the facilitators, for successful attainment of the desired treatment goals–the ultimate outcomes. But empirical research on interventions and treatment effectiveness has paid little attention to the role of intermediate outcomes in the success of treatment, and the intermediate outcomes nested within or characterizing social work interventions have not been explicated sufficiently. This article is based on a study of the treatment records of 141 clients treated by 69 social workers in community family agencies. Qualitative data analysis was used to explicate and categorize the intermediate outcomes that were pursued in these treatments. The findings yielded a rich variety of intermediate outcomes, which were classified into a number of conceptual categories characterizing social services. The article discusses the findings within the context of the method used and addresses implications for further research. [ABSTRACT FROM AUTHOR]

1. METHOD

2. Overview

3. Sample and Procedure

4. Unit of Analysis

5. FINDINGS

6. DISCUSSION

7. TABLE 1–Example of Four Components of the Treatment Plan

8. TABLE 2–Categories of Intermediate Outcomes, by Frequency and Percentage

9. REFERENCES

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Intermediate outcomes are an important class of outcomes that usually ore pursued in the process of treatment. They consist of the necessary preconditions, or the facilitators, for successful attainment of the desired treatment goals–the ultimate outcomes. But empirical research on interventions and treatment effectiveness has paid little attention to the role of intermediate outcomes in the success of treatment, and the intermediate outcomes nested within or characterizing social work interventions have not been explicated sufficiently. This article is based on a study of the treatment records of 141 clients treated by 69 social workers in community family agencies. Qualitative data analysis was used to explicate and categorize the intermediate outcomes that were pursued in these treatments. The findings yielded a rich variety of intermediate outcomes, which were classified into a number of conceptual categories characterizing social services. The article discusses the findings within the context of the method used and addresses implications for further research.

Key words: intermediate outcomes; practice research; practice wisdom; systematic planned practice

The clinical research literature, particularly that concerned with studying the effectiveness of clinical treatment, long has been wedded to e process-outcome distinction. Studies either dealt with assessing treatment outcomes or focused on understanding the treatment process as a process of dyadic interaction (compare reviews by Orlinsky & Howard, 1978, 1986). In the tradition of this distinction, treatment outcomes were studied in relation to practitioner and client variables, and the process element in evaluative studies usually was treated as a "black box" (Gurman & Razin, 1977; Kazdin, 1986). Although the process was not explicated, things were assumed to transpire there and inexplicably contribute to the attainment of treatment outcomes (Bergin & Lambert, 1978). Studies showing moderate gains in treatment but failing to find that differences in outcome were associated with different treatment approaches led to the suggestion that the treatment process contains seemingly effective "common ingredients" that need to be specified (Lambert & Bergin, 1994; Lambert, Shapiro, & Bergin, 1986). That realization directed attention to conceptualizing and studying the treatment process in terms that would make it amenable to deliberate manipulation by practitioners to attain desired outcomes.

The black box status of the process of treatment in evaluative studies is now progressively being abandoned. In addition to the continued search for the common ingredients in all change efforts (Omer & Dar, 1992), a potent research agenda has been testing the effectiveness of different approaches to treatment through use of specific treatment manuals (for example, Elkin et al., 1989; Hill, O'Grady, & Elkin, 1992; Jacobson et al., 1996; Wills, Faitler, & Snyder, 1987). The potential applicability of such research is enhanced further by use of the "aptitude X treatment" interaction paradigm, which considers the moderating effects of client variables on the effectiveness of interventions (Shoham-Solomon & Hannah, 1991; Smith & Sechrest, 1991).

But studying interventions as elements of the treatment process fills the proverbial black box only partially. Still unattended to are the many and varied outcomes that are an integral part of and are embedded in the treatment process. The term "outcome" is used here to designate any state or condition (of a client, or client-related) that a social worker attempts to reach through his or her intervention efforts. To better guide research on the effectiveness of practice, treatment outcomes were differentiated according to the role they have in a particular treatment effort (Rosen, 1993; Rosen & Proctor, 1978, 1981). The primary distinction made was between the roles in treatment of ultimate and intermediate outcomes. Ultimate outcomes are those desired conditions or states the pursuit of which justifies engaging in treatment in the first place. Ultimate outcomes derive from, and should be formulated in relation to, the client's problems, characteristics, and situation. Thus, ultimate outcomes constitute and express the purposes and goals of treatment in terms of specific client-related conditions, the attainment of which, in turn, signifies the extent of treatment's success.

Intermediate outcomes are client-related states or conditions that in a given treatment a social worker views as facilitative of or as necessary preconditions for successful attainment of the desired ultimate outcomes. Thus, intermediate outcomes are pursued because the social worker views them in a particular treatment as way stations (Hollis, 1972)–the conditions that are necessary to go through and attain when pursuing the ultimate outcomes. Ultimate and intermediate outcomes are distinguished only in terms of the clinical role that the worker assigns them in any given treatment situation. Substantively, the same client-related states or conditions can assume either role (compare Rosen 1992, 1993; Rosen, Proctor, & Livne, 1985).

In most if not all treatment situations, successful pursuit of ultimate outcomes requires that workers first pursue and attain the relevant intermediate outcomes. Decisions on which intermediate outcomes need to be pursued, and by what interventions, take into account client's resources and liabilities, service constraints, and environmental factors and are influenced by workers' experience and clinical orientation. These factors express the uniqueness of each treatment effort. Whereas in most responsible treatment efforts workers commonly formulate and state explicitly the desired ultimate outcomes, the intermediate outcomes for pursuit are likely to be enveloped within the black box of the treatment process. But, in actuality, practitioners do pursue a variety of intermediate outcomes as they work toward reaching ultimate outcomes, although much of what social workers actually do and try to attain as part of the process of treatment still remains implicit (Mattaini & Kirk, 1991; Reid, 1994).

A number of intermediate outcomes generally thought to be involved in psychotherapy have been more clearly conceptualized and studied of late. Among these were attempts to define components of a good therapeutic relationship, such as the therapeutic alliance (for example, Greenberg, 1986a; Greenberg, 1986b; Krupnick, Sotsky, Simmens, Moyer, Elkin, Watkins, & Pikonis, 1996) and other variables (Muran et al., 1995). Social services are of broader scope and often have goals that differ from those of psychotherapy. Despite such attempts to formulate psychotherapeutically relevant intermediate outcomes, it is incumbent on social work to focus on the intermediate outcomes that are relevant in practice. Although social services stand to benefit from more knowledge of the psychotherapeutic process, they probably also have a unique set of intermediate outcomes that may be essential to their success. These outcomes need to be formulated and studied.

Social workers did relatively little research to study intermediate outcomes in the context of actual treatment (Cheetham, 1997; Reid, 1997). An important task of such research is to formulate intermediate outcomes from the apparent wealth of experiences, expert knowledge, and "practice wisdom" that underlie and guide practice (Klein & Bloom, 1995; Scott, 1990), and that often remain covert and private (Rosen, 1996). In advocating that social work research pursue the explication of implicit practice knowledge, Scott (1990) concluded, "Practice wisdom or tacit knowledge that can be transformed into testable propositions presents an exciting challenge. That challenge must be met with creative approaches to developing practice research methods that start where the practitioner is and end with findings of direct relevance to practice" (p. 567).

We agree with Scott's (1990) conclusion and view the investigation we report on here as one step in meeting this challenge. We report on an effort to explicate and describe the intermediate outcomes that social workers pursue in the process of treatment. Such explication is required to give substance to and to depict social workers' conceptions of the process of treatment in terms of the way stations used to reach the treatment goals. It is also a necessary step for efforts to explore further and uncover testable clinical hypotheses (Nelsen, 1993; Scott, 1990) regarding workers' conception of potent interventions to attain the intermediate outcomes.

METHOD

Overview

The method selected for explicating the knowledge on which workers base practice decisions plays a critical and determining role in the nature of the findings. A number of different methods have been suggested for such tasks (compare Nelsen, 1993; Scott, 1990), and some have been used by researchers (compare Bitonti, 1993; Gilgun, 1992; Harrison, 1987). In general, these methods rely on use of qualitative analytic components. For example, Gilgun (1994) suggested that to learn "what works," a better understanding of the practice situation is needed, and this understanding can be attained through case studies. According to Gilgun, qualitative case studies give practitioners the opportunity to describe the process specifically for each case. Another qualitative approach to uncover practice, based on cognitive mapping, was used by Bitonti (1993) to learn about the self-esteem and coping of women during major life transitions.

Klein and Bloom (1995), Reid and Fortune (1992), and Mullen (1978, 1983) all have suggested that practitioners may arrive at, and be guided by, personal models of practice. These personal models involve making practice decisions through a complex process, at least partially covert, and of using knowledge derived from personal experiences, theory, research findings, and other sources (compare findings by Rosen, 1994 and by Rosen, Proctor, Morrow-Howell, & Staudt, 1995). Whatever the source and however composed, the knowledge and considerations contained in such personal models of practice are what actually guide in-practice decisions and worker actions. Therefore, in studying practice wisdom, the procedures devised to help workers become aware of, think through, evaluate (judge the worth of), and explicate their practice decisions are most important and determine the results.

The method for explicating that knowledge in the present study is based on and was developed as part of a continuing program of research and development of practitioner-friendly procedures for systematic planned practice (SPP). SPP was designed to aid practitioners in treatment planning, implementation, and evaluation through standardized guidelines for workers to explicate and give the rationale for their primary practice decisions (compare Rosen, 1992, 1993; Rosen et al., 1985). SPP and its procedures are based on a view that social work practice and its process involve a set of considerations and goal-directed actions deliberately formulated and enacted by practitioners in relation to their clients and their situation. For any given case, these considerations, goals, and contemplated actions are represented in the treatment plan. A treatment plan reflects the intentions of the worker. Although it is not yet tempered by the unavoidable compromises involved in actual implementation, the treatment plan can be viewed as the worker's statement of a behavioral intention (Ajzen & Fishbein, 1977). Despite compromises in implementation, behavioral intentions were considered theoretically, and treatment plans were found to be empirically, highly correlated with their actual enactment (Ajzen, 1991; Rosen & Mutschler, 1982). Consequently, behavioral intentions, as represented in carefully considered, justified, and explicitly stated treatment plans, can be appropriately used as a source of information on practitioners' treatment decisions. Thus, in addition to being guided in making judicious and defensible practice decisions, when workers implement SPP and thereby record their decisions and rationales, they enhance self- and peer review of practice, as well as the accumulation of data for research.

In this study we used qualitative methodology to identify the intermediate outcomes practitioners pursued, but we systematized the conditions for eliciting the information by instructing social workers to practice and make decisions within the SPP framework (see Rosen, 1992, for detailed description). Practice within this framework ensures that all social workers are asked the same thing but are encouraged to respond in their own unique way. These procedures capture differences in judgment and decisions that result from client and situational characteristics and worker factors such as experience, knowledge, and professional orientation. Such unrestrained responding yields rich and varied information and suggests qualitative analysis as the method of choice to exploit that richness (compare Rosen, 1994).

Treatment planning decisions guided by the SPP conception revolve around four components: (1) client's problems to be addressed, (2) desired ultimate outcomes, (3) the necessary intermediate outcomes, and (4) the interventions needed to attain the outcomes (Rosen, 1993; Rosen et al., 1985). Consistent with social work's presumed commitment to a rational problem-solving model (Rosen, 1996), these decisions are posited to be sequential and logically interrelated as the example in Table 1 demonstrates. The treatment episode portrayed is anchored in one client problem and the ultimate outcome that the social worker decided to pursue to address that problem. The social worker had decided to reach the ultimate outcome through a process requiring the attainment of three different intermediate outcomes, which were sequentially ordered in relation to the ultimate outcome. Each of the intermediate outcomes is shown in relation to the interventions selected by the social worker to attain it.

Sample and Procedure

The study was conducted as part of a demonstration project sponsored by the Ministry of Social Welfare of Israel to train social workers to practice systematically. Six public family service agencies from different municipalities across Israel were selected and agreed to participate in the project. All agencies were subject to the same Ministry of Social Welfare guidelines regarding staffing, clientele, and services. Selection of participating agencies was based on location (to include different regions and demographic characteristics of the population) and size of agency's social work staff (a minimum of 10 social workers). Agency directors and supervisors fully supported all activities related to the project. Project staff taught the social workers (didactically and through case presentations) the concepts and procedures of SPP over four consecutive, weekly, four-hour training sessions. Following the training, social workers implemented (with consultation by project staff) that model of practice with two of their new clients concurrently (randomly assigned and with replacement for closed cases), for a period of six months. The data for the study were obtained from the records of implementation.

Seventy-three social workers were trained in and implemented SPP with 15 ! of their clients. Full sets of data (filled-out SPP forms on all phases of treatment) were available from 69 social workers regarding 141 clients, who made up the sample for the present study (6.5 percent data loss). The number of clients per agency ranged from 16 to 33, with a mean of 2.04 clients per social worker. Social workers' mean age was 34 (SD = 7.6, range 24 to 53 years); most were experienced practitioners (mean practice experience = 6.5 years, SD = 5); and most (93 percent) had full academic-professional training equivalent in content and skills to the MSW degree in the United States; 7 percent had professional certification only, which is roughly equivalent to the BSW degree in the United States; most of the social workers (93 percent) were women. Most of the social workers (72 percent) defined themselves as generalist social workers (that is, social workers who work with different client populations), and others said they specialized in working with families (9 percent), elderly people (8 percent), youths (7 percent), or as child welfare officers (4 percent). Fifteen (22 percent) of the social workers also served as field instructors for a school of social work.

Unit of Analysis

The intermediate outcomes posited for pursuit with a client and recorded by the social worker in the SPP forms were the data for the study. To qualify for consideration as an intermediate outcome according to the SPP conception and to constitute a unit of analysis, the intermediate outcome recorded had to be part of a treatment episode that included, in a logical sequence, a client's problem, an ultimate outcome, an intermediate outcome, and an intervention. (Examples of three intermediate outcomes, each constituting a unit of analysis–that is, having a related problem, an ultimate outcome, and an intervention-are provided in Table 1). The SPP records of all 141 cases yielded a total of 1,001 units of analysis (M = 7.1, SD = 4.2, range = 6 to 20 intermediate outcomes per case). Interrater agreement in designating units of analysis was 96 percent. All nonagreements were due to unclear handwriting.

FINDINGS

The 1,001 intermediate outcomes were classified into categories by qualitative content analysis following the "open coding" technique (Strauss & Corbin, 1990). This procedure was conducted jointly by two judges working together. The judges were professional social workers (MSWs) with advanced training and rich practice experience. They formulated the categories and classified the outcomes by an iterative process. The judges first studied all the intermediate outcomes in the context of their respective units of analysis, reflecting on and searching for more general and professionally meaningful concepts that related to the discrete outcomes and that could be used to summarize them. A few general categories emerged. The judges canvassed the original outcomes within their meaning units again, attempting to classify each outcome into one of the then existing categories, while being vigilant for additional emerging general categories. Whenever a new category emerged, all intermediate outcomes previously classified were reviewed to see if they would better fit into the new category. This process was repeated, with consultation between the judges, until no new categories could be formulated or the definitions of existing categories refined, and each of the intermediate outcomes seemed to be appropriately classified (best fit) into one of the general categories. In that manner the 1,001 intermediate outcomes were classified into 13 discrete categories (Table 2).

The 13 general categories summarize the array and variability of the specific intermediate outcomes. They reflect the extent of differentiation of the treatment process by the social workers, as well as the range of practice issues and client problems in the community-based family services studied. The first three categories are the most frequently occurring intermediate outcomes, encompassing more than 50 percent of the total. These categories all refer to some form of interpersonal or personal change as necessary preconditions for accomplishing the treatment goals. The first category, change in an interpersonal relationship, includes such specific outcomes as "husband and wife will express their emotions to each other," and "parents will see how their relationship affect their children." The category of personal change includes such outcomes as "client will become aware of own behavior," and "husband will take responsibility for use of contraceptives." Realization of affective or cognitive potential consists of such specific outcomes as "removing fear of failure as barrier to achievement in school," or "increase wife's emotional expressiveness to better perform in role of mother." These three general categories and their specific outcomes all involve some personal change and likely reflect a counseling orientation to treatment.

Categories 8 and 11 also pertain to cognitive or affective personal change, and together include about 10 percent of the specific outcomes. But unlike the first three categories, these concern specific types of change. Category 8 deals with accepting the reality of loss or crisis, such as "wife accepting her husband's desertion," or "accepting the need for a mastectomy." Category 11 includes such outcomes as "reach a divorce decision," or "decision to move to a nursing home." Together with these two categories, about 62 percent of the specific intermediate outcomes, concerned some form of personal or interpersonal change.

Meeting of clients' basic needs (category 4) such as housing, meals-on-wheels, and homemaker services constituted more than 12 percent of the total outcomes. In community-based social services, such outcomes usually are pursued as ultimate outcomes. That such basic-need outcomes had the role of intermediate outcomes is perhaps a reflection of the apparent counseling orientation of the social workers in the study. Category 5, client's implementation of decisions made in treatment, was a relatively frequently pursued outcome (11.4 percent). This category includes such specific outcomes as "client will get HIV test," or "client will apply for an abortion." This outcome category may reflect a hands-on approach by workers, viewing client's implementation of treatment decisions as their responsibility and part of the treatment process. This ca

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