Featured Articles

Wednesday, March 1

Mental health forum: Evidence-Based Social Work Practice

What is Evidence-Based Practice?

 Evidence Based Practice (EBP) has slowly made its appearance in many aspects of social work practice. In most settings, it is a controversial though insistent participant in how we do our work. There is a logical fit between EBP and academia, as evidence is generated by research most often in universities through faculty members. For agency-based practices seeking accreditation from various bodies, EBP is also omnipresent. Private practitioners have less to do with this although through Managed Care Organizations and pre-approval policies, it is affecting them as well. And if one were to look at the profession overall, realistically EBP is affecting the funding of our work for many reasons, which will be discussed in this brief article.

 EBP as a theory has been widely embraced. Certainly, most of us would not argue against evidence that supports our work with clients. It is really in the application of the theory in general and the particular practices that have been singled out as evidence based, that practitioners take issue.

 There are many definitions of EBP. Generally it applies to the application of research findings to social work interventions with our clients. It has been widely stated that the evidence in mental health care that is least controversial is that which exemplifies the “gold standard” of research, a concept borrowed from medicine whereby the study must be a randomized controlled trial. This research inevitably takes place in a controlled setting and as such doesn’t accurately represent work done in a real life setting. NASW Practice Snapshot” Evidence-Based Practices-For Social Workers defines EBP as “interventions for which scientific evidence consistently shows that they improve client outcomes.” Other definitions use other wording, “best practice models,” “Evidence supported Models” and so on.

Controversy

This concept has generated a great deal of controversy in social work practice. Beginning with the question of what standards of research make for “evidence-based” to how are the core values of the profession factored into to this, we are now questioning whether or not this concept is at all applicable to the profession. Briefly, the core values which I believe are most germane to this discussion are the dignity and worth of the person (including client self determination), competence, and the importance of human relationships.

It is important to ascertain whether or not the only standard by which to measure whether a practice method is evidence-based is the “gold” standard or one which includes randomized control groups. If we are practicing competently, the question of withholding treatment as one most likely would (in this type of study) be necessary to explore. If we adhere to this standard only, we are looking, in general, at treatments that are more easily identified and measured, mostly the cognitive and behavioral ones. The more psycho-dynamically oriented treatments get left out of the treatment pool in this way. Because they aren’t listed with treatments that have been determined to be evidence-based, they are not seen as effective. Glen Gabbard cites research by Bateman and Fonagy that provides “evidence” for psychoanalytically oriented therapy.

Controversy also exists about what actually has been designated as “evidence-based” in mental health. On its website, the Substance Abuse and Mental Health Services Administration (SAMHSA) provides tool kits for 5 Evidence-Based Practices in Mental Health Services which include: Illness Management and Recovery, Assertive Community Treatment, Family Psychoeducation, Supported Employment and Co-occurring Disorders- Integrated Dual Diagnosis Treatment. All of these treatments are manualized and none really take into consideration the choices of the clients in terms of cooperation and participation. In utilizing these treatments then, the social worker risks violating the core value of the dignity and worth of the individual, particularly in the area of client self-determination. In fact, when working with clients diagnosed with severe and persistent mental illness, one evidence-based practice would be pharmacological treatment. There are clients who believe that these medications and their side effects are problematic and refuse to comply with this treatment. If we abide by their choices are we abandoning evidence-based practice?

One striking omission from the exploration of the methods utilized in evidence-based practices is the importance of the client-worker relationship. Choosing Assertive Community Treatment (ACT) as one approved method of treatment, a clinician might question whether it is the services provided, the relationship with the workers or a combination of the two that is responsible for improvement in the client’s mental health. We can measure a manualized treatment approach, but we haven’t yet found a good way to measure the effects of the relationship. Yet, in our Code of Ethics, the importance of relationships is one of the core values. How research is carried out, “in the real world” (also referred to as: “naturalistic settings” ) or in research settings is an issue in studying social work interventions. When looking at natural settings, we also take into consideration the process taking place. It is very difficult to separate out how the social worker applies what has been learned from articles, books, and so on and what the social worker knows from sitting in her/his chair and over time learning what works- practice wisdom. In utilizing this type of knowledge, the social worker also sees each client as a unique individual and uses practices accordingly. Contrary to manualized approaches to treatment, individualized treatment is most often practiced in “real life settings.” How does one judge whether the treatment method that the practitioner, utilizing practice wisdom, uses is evidence-based? Sandra Tanenbaum asks, “Can EBP in mental health commit itself to an inclusive enough evidence hierarchy not to privilege technique unfairly over relationship?”

Before ending this discussion of evidence-based practice, I would like to explore the connections between Managed Behavioral Health Care and evidence-based practice. Most of the evidence-based practice models are short term. Most of them are designed to alleviate symptoms, as is the case in medical treatment. This is easier to accomplish than looking at recovery or even an improvement in the quality of life; goals which may be part of treatment plans for our clients. Either of those, however, would not be cost effective in the eyes of Managed Care. The coupling of EBP and “cost effectiveness” can be seen in Oregon where the state legislature passed a bill tied to funding whereby in 7/1/05 25% of addiction and mental health treatment must be provided by EBP’s. This rises by 25% every two years, until 2009 when continued funding will be based on whether the agency is providing 75% of its treatment through EBP’s. Tanenbaum also writes about Washington DC where the EBP psychotherapy policy specifies acceptable treatment. The only acceptable treatment for Borderline personality disorder is dialectical behavioral therapy. If practitioners are reimbursed for manualized short-term treatments, it will be the HMO’s which stand to gain the most.

 Clearly this author is not an unquestioning fan of evidence-based practice. It is still unclear to me who it is who makes a decision regarding what is and what is not EBP. I don’t agree with the researchers who set standards for evidence that are not applicable to social work practice settings. It is important to base our work on knowledge and not on hunches, but knowledge comes from experience as well as from researchers and academicians (of which I am one). NASW’s “Practice snapshot” in looking at the future utility of EBP as an overall concept says,

•EBP’s include clinical experience by definition. This means that their creation has taken into consideration the reality of providing services in the field; but it also means that clinical experience about specific clients and situations is needed for implementation…What is important to qualify an intervention as an

 EBP is that it must involve research evidence, clinical experience and family/client values. EBP is certainly a timely and controversial idea in social work practice. Embracing the general theory and questioning the implementation will allow social workers to utilize research-based approaches appropriately.

Resources

1 See http:www.socialworke r s . o r g / p r a c t i c e / c l i n i c a l / csw081605Snapshot.asp

 2 NASW (1999) NASW Code of Ethics: Preamble. p.1.

 3 Gabbard, G.(2001) Empirical evidence and psychotherapy: A growing scientific base. American Journal of Psychiatry 158 (1) 1.

 4 http://www.samhsa.gov go to the “Evidence –Based Practices Implementation Resources Tool Kits Link

 5 Gabbard, p.2.

 6 Tanenbaum, S. (2005) Evidencebased practice as mental health policy: Three controversies and a caveat. Health Affairs (24) 1, 163- 173. Retrieved from http://content. healthaffairs.org/egi/content/ full/24/1/163.

 7 Ibid.