Making clinical decisions when 'behavior has meaning': An ethnographic study of expertise in a residential treatment center for children and adolescents

Although social work scholars have proposed and promoted various models for making effective and ethical clinical decisions, little empirical research has addressed processes of clinical decision-making as they occur naturally in 'real world' mental health practice. This article briefly reviews approaches to the study of decision-making, and presents findings from an ethnographic study of the collaborative decision-making activities of mental health workers in a residential treatment center for children and adolescents. This article describes and analyzes a local theory and practice of interactional clinical decision-making in which workers provide competing interpretations of the 'meaning' of clients' behaviors before committing to a particular course of clinical action. This process, which I term the 'behavior-has-meaning' hermeneutic, serves not only to guide clinical interventions, but as a forum for modeling, developing, and evaluating locally valued forms of clinical expertise. Implications of these findings for the implementation of prescriptive models of clinical decision-making - such as the evidence-based practice process - are discussed.