Intermediate outcomes pursued by practitioners: A qualitative analysis

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. 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 the 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. …