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Evidence-based practice and clinical social work
  1. Bruce A Thyer, PhD, LCSW
  1. Distinguished Research Professor School of Social Work, University of Georgia Visiting Professor of Social Work The University of Huddersfield and the Queen's University of Belfast, UK

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    The evidence-based practice (EBP) movement in mental health is beginning to influence the discipline of clinical social work (CSW). Given that clinical social workers are now the largest discipline (in terms of numbers of practitioners) providing mental health services in North America, to the extent that EBP can affect the daily services of these clinicians, the care of patients and their outcomes can potentially be markedly improved.

    Background

    By way of some background, a clinical social worker in the US is an individual who has earned a Masters of Social Work (MSW) degree from a programme accredited by the Council on Social Work Education (see www.cswe.org), has obtained several years of appropriately supervised clinical experience post-MSW, has passed a standardised licensure examination administered by the state one practices in, and has received a license to practise. The practice of CSW is now legally regulated in all 50 states and several Canadian provinces, and the multiple choice examinations developed by the autonomous Association of Social Work Boards (see www.aswb.org) are the standard method (with just a couple of exceptions) adopted by the states and provinces for determining that a candidate for licensure has the minimal necessary competencies to practice safely. Other criteria required for licensure include satisfactory letters of recommendation, passing a criminal background check, and earning a certain number of approved continuing education units biannually (usually around 30).

    The scope of practice of CSW is quite broad, and overlaps considerably with the fields of psychiatry, professional psychology, psychiatric nursing, and marriage and family therapy. Within North America, most licensure laws include language permitting the private practice of CSW and note that social work intervention includes psychotherapy, behaviour therapy, supportive counselling, marital and family treatment, and substance abuse counselling. Many states' scope of practice laws explicitly permit CSWs to diagnose mental disorders (training in the DSM is now routine in MSW programmes), testify in court as expert witnesses, and involuntarily admit patients in crisis to mental hospitals. At present, there are >150 accredited MSW and some 65 doctoral programmes in social work in North America, and many more in other countries. Most social work doctorates award the PhD degree, but a dwindling few still offer the DSW (Doctor of Social Work) degree. Both the PhD and the DSW are usually research oriented academic degrees, not clinically oriented ones.

    The main themes of contemporary EBP were central to the development of social work as a discipline1–2 and to clinical social work in particular. Over 20 years ago, Jayaratne and Levy's landmark text Empirical clinical practice explicitly claimed that “Empirical practice is conducted by clinicians who strive to measure and demonstrate the effect of their clinical practice by adapting traditional experimental research techniques to clinical practice (p xiv)...The clinician would first be interested in using an intervention strategy that has been successful in the past...When established techniques are available, they should be used, but they should be based on objective evaluation rather than subjective feeling (p 7)”.3 Explicit in Jayaratne and Levy's text was the premise that empirical outcomes research related to potential interventions, client informed consent and participation, and one's professional values and ethics were important considerations in the selection of treatments. In 1982 the US Curriculum Policy Statement of the Council on Social Work Education mandated that all MSW programmes must teach research “...designs for the systematic evaluation of the student's own practice...(and should) prepare them systematically to evaluate their own practice,”4 an educational standard which remains to this day, but oddly, is not a training requirement for psychologists or psychiatrists in the US, even though such evaluations are an intrinsic component of EBP.

    Contributions of social workers to the study of mental health

    Many individual social workers have been at the forefront of clinical research in various areas of mental health. Professors Gerald Hogarty, MSW, and Carole Anderson, MSW, PhD, are known worldwide for their published randomised controlled trials (RCTs) evaluating family psychoeducational interventions for persons with chronic mental illness, interventions they were instrumental in developing. Social worker Myrna Weissman, MSW, PhD, well known for her psychiatric epidemiological work, was a co-developer of interpersonal psychotherapy, an emerging evidence-based treatment for major depression. Janet Williams, DSW, was an editor of the DSM-III and DSM-III-R. Gail Steketee, MSW, PhD, is widely recognised for her RCTs evaluating cognitive behavioural treatment for persons with obsessive compulsive disorder. Social work professor Geraldine Macdonald (University of Bristol, UK) is an active member of the Cochrane Collaboration, and social workers are now joining the developing Campbell Collaboration, which focuses on preparing evidence-based reviews of interventions in the fields of education, criminal justice, and social welfare, and is co-directed by a Swedish social worker, Soydan Haluk.

    Sometimes the disciplinary backgrounds of clinical social workers can be difficult to ascertain from journal articles that identify authors only by the generic PhD; at other times, the contributions of clinical social workers take the form of delivering the psychosocial interventions being tested in RCTs that are run and published by members of other disciplines. Such disciplinary obscurity may result in the work of clinical social workers being under-recognised by the members of other professions.

    Organisations promoting EBP in social work

    In 1995 the Centre for Evidence-based Social Services (www.ex.ac.uk/cebss) was founded and housed at the University of Exeter (UK), with social work professor Brian Sheldon serving as Director, and a similar Centre has recently been established at Flinders University in Australia, headed by social work professor James Barber. There are dozens of social work research centres located in the US, most often affiliated with a university-based school of social work, such as the author's Center for Social Service Research at the University of Georgia. These organisations do research across the scope of social work practice, but their main efforts are devoted to seeking federal and state funding to scientifically evaluate the outcomes of social work and social welfare services, using credible research methodologies such as randomised controlled clinical trials and quasi-experiments. The nature of social work services, and the fact that we as a discipline are (perhaps) more involved in particularly vulnerable populations such as the poor, minorities of colour, and other historically oppressed groups, renders the design and conduct of RCTs a particularly challenging endeavour, and often quasi-experimental or even single subject research designs are the most sophisticated methodologies that may be practical in given circumstances. A strength of clinical social work research is that we are particularly well positioned to design and do efficacy studies and translational research, evaluations of psychosocial and pharmacological interventions undertaken with actual treatment seeking patients possessing multiple problems, with services delivered by everyday practitioners who provide the “real” care in the mental health system.

    Many social work organisations, spearheaded by the Institute for the Advancement of Social Work Research (see www.cosw.sc.edu/iaswr/) established in 1994, are collaborating in advocacy and lobbying efforts aimed at passage of a federally funded National Center for Social Work Research, modelled after the National Institutes of Health's existing National Center for Nursing Research. The largest American social work organisation (with over 150 000 members), the National Association of Social Workers (NASW), is now developing a Practice Research Network (PRN) modelled after a similar entity within American psychiatry, and is aimed at gathering systematic information about everyday social work practice, and on evaluating the outcomes of social services. Overall however, the NASW's research initiatives have been disappointing to many in the profession, which led a small group of social work researchers to establish in 1994 the new membership group the Society for Social Work and Research (SSWR), among whose aims are the promotion of EBP in social work. SSWR has formally affiliated with the Campbell Collaboration and is contemplating participating in one or more systematic reviews of the empirical literature regarding various psychosocial interventions for particular problems. The SSWR now has >800 members, and sponsors an annual scientific conference which most recently attracted >700 registrants (Atlanta, 2001). The SSWR sponsors the bimonthly journal Research on Social Work Practice (RSWP), produced by Sage Publications, by providing a subscription to all SSWR members. RSWP was explicitly established in 1991 by the author to serve as an outlet for reports of high quality, empirical, evaluation research on the outcomes of social work practice, and is modelled after the best journals in related disciplines such as the Archives of General Psychiatry and the Journal of Consulting and Clinical Psychology. The May 1999 issue of Research on Social Work Practice was devoted to the topic of evidence-based practice guideline development, as is a forthcoming social work text.5

    It is important not only that social work disciplinary organisations be proactive in promoting evidence-based services within their field, but also that related groups in other disciplines be proactive in inviting social worker participation in preparing practice guidelines, in developing practice research networks, in serving on study teams affiliated with the Cochrane and Campbell Collaborations, and related activities. In my opinion, something to be avoided by social work is the attempted development of disciplinary specific PGs (ie, practice guidelines prepared exclusively by social workers, for use by clinical social workers), as opposed to the more laudable and scientifically credible effort of having social workers collaborate with other mental health disciplines in the development of genuinely interdisciplinary PGs which are problem or disorder focused, and can be used by members of all mental health fields which apply the EBP model to their efforts. Other social workers take the opposite stance. Of additional importance is the extension by social workers of the concept of EBP to larger scale mental health and other practice venues, such as school-based interventions,6 work with probationers,7 care provided in the fields of child abuse and neglect,8 family therapy,9 and community interventions.10 Quite apart from the US, Canada, and the UK, evidence-based practice is emerging (admittedly unevenly) as a viable practice perspective in a number of other countries.11 There is some resistance to the idea of EBP, of course,12 with common objections relating to a perceived restriction in professional judgement and autonomy, the elevation of certain research methodologies (eg, randomised controlled trials) over other approaches, and a concern over the supposedly unacknowledged (and under criticised) philosophical assumptions under girding conventional science.

    Conclusion

    Clinical social workers, and the broader field of social work as a whole (which encompasses much more than mental health), represent an immense reservoir of scientific and practitioner talent which is eager to lend service in promoting evidence-based mental health services. Although we are active in promoting EBP within our own profession, we welcome invitations to participate in interdisciplinary endeavours along these lines.

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