• By Dartington SRU
  • Posted on Monday 07th February, 2011

Getting into practice

The basic tenets of evidence-based practice are not new in social work in the USA, but calls to make the profession more scientific have had less impact than proponents desired. And while social work teachers have spent decades trying to address this, some of the resistance comes from within.One argument is that many social workers whose education has not gone beyond a master’s level will agree that they lack the level of training in research design or statistics which is needed to appraise research studies critically and confidently. But, says Allen Rubin from the University of Texas at Austin, this is not a reason to give up. Instead, he believes, it is a call to improve curricula. Teaching statistics, for example, might focus less on the intricacies of various tests and more on what they mean. Research methods courses could get students appraising research as opposed to producing it.A common argument against teaching evidence-based practice in social work is that the evidence is often lacking or so contradictory as to be overwhelming. As Rubin notes, this is only partially true. There are interventions with adequate and consistent empirical support, just as some are known to be harmful.Furthermore, practitioners who search for the best approach will have acted professionally, even if that search yields nothing. Not to do that would be to operate in the dark. And not to find consistent evidence does not mean that a practitioner is not being evidence-based in their practice: “The EBP process allows for practitioners to utilize theory or practice judgment when deciding how to intervene when the evidence is not compelling.”Some sceptics also claim that many evaluations supporting the efficacy of programs focus on participants who are unrepresentative of many of those with whom social workers actually work. Ethnic minority groups tend to be under-represented, while clients with morbidity diagnoses are often excluded. One response to this, Rubin suggests, is to stress that in the EBP process practitioners can use their discretion to either select a proven program, even though it was evaluated with clients unlike the ones they are serving, or to intervene in a fashion based on less rigorous studies that had matching clients.A related criticism of evidence-based practice is that social workers who deal with many different problems cannot reasonably be expected to be skilled in using the various evidence-based programs each requires: motivational interviewing with people who abuse substances or psycho-educational family therapy with relatives of people with psychotic illnesses, for instance. But Rubin’s response is that this is less a problem with evidence-based practice per se than with practitioners being overloaded and having caseloads that are too diverse.What of the claim that “as long as there is a good therapeutic relationship, the choice of intervention does not matter”? This is based on meta-analyses showing that, when it comes to outcomes, the quality of the relationship between practitioner and client has a greater impact than the choice of intervention.But, claims Rubin, other meta-analyses reach the opposite conclusion, while the studies cited in favour of the argument have important methodological flaws: crucially, they include ineffective and even harmful interventions, cancelling out the impact of the effective interventions.Moreover, even those who argue for the greater importance of relationship factors implicitly acknowledge that the choice of intervention matters – just not as much. And Rubin shows that even that ‘not as much’ can be significant. In one example, he shows that a contribution depicted as ‘small’ could be explained by success rates of 69% in the treatment condition and 31% in the control respectively: “What practitioner who cares about their client’s well-being would not want to buttress the impact of their relationship skills by selecting an intervention that could bolster their impact to that degree?”A fear frequently expressed by social work academics is that teaching evidence-based practice will lead to an over-emphasis on a hierarchy of evidence that values experimental and quasi-experimental designs and relegates alternatives. This should only hold when the research question concerns impact, Rubin maintains. Studies looking at, say, what it feels like to receive a certain service or why people drop out of treatment prematurely need surveys or qualitative methods, not experiments.A further anxiety is that an emphasis on evidence-based practice in the curriculum runs the risk of “producing technicians who can find and appraise research studies and follow directions in implementing (perhaps manualized) practice guidelines but who are less adept at integrating and applying theoretical knowledge to complex practice situations”. However, suggests Rubin, the process of evidence-based practice recognizes that “conclusive evidence may not exist and that, in that eventuality, the choice of an intervention might have to be based on theory. The step in the EBP process that requires the integration of research evidence with practitioner expertise implies that theoretical knowledge is important in that such knowledge is a key component of practitioner expertise.”Another criticism of teaching about such practice is that it will divert attention away from social justice issues. But, as Rubin argues, disregarding the most effective interventions might be an even greater social injustice. More practically, evidence-supported treatments should not be mechanistically applied to those who are poor if it is judged to be inappropriate, just as the fact that poor or minority ethnic clients are under-represented in a randomized control trial does not automatically mean that the intervention in question should be disqualified for consideration.Rubin’s conclusion is balanced but clear: “The real danger is not in increasing the emphasis on EBP in the curriculum, but in doing so in an inappropriate and overly narrow manner that puts too much emphasis on certain kinds of EBP questions and certain kinds of research while ignoring others and that gives short shrift to the significant degree of practitioner flexibility encouraged by the EBP process as well as the important role of theory and relationship factors in that process.”ReferencesRubin, A. (2011) ‘Teaching EBP in social work: retrospective and prospective’, Journal of Social Work 11 (1), 64-79.

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