Transcript Evidence-Based Practice and Social Work

Evidence-Based Practice
and Interprofessional Education
Bruce A. Thyer, Ph.D., LCSW, BCBA-D
College of Social Work, Florida State University
Visiting Fulbright Specialist, King’s College, UWO, 4–16 March 2013
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What is Evidence Based Practice?
• “Evidence-based practice requires the
integration of the best research evidence
with our clinical expertise and our patient’s
unique values and circumstances”
From Strauss et al. (2005). Evidence-based medicine: How to practice
and teach EBM (third edition). New York: Elsevier.
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Note the equivalent importance of ALL these
factors in the EBP process
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What is ‘Best Research Evidence’?
• Clinically relevant research from basic and
applied scientific investigations, especially
drawing from intervention research
evaluating the outcomes of health and
human services, and from studies on the
reliability and validity of assessment
measures.
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Higher End of Internal Validity
(in terms of causal inference)
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Systematic Reviews (highest form of evidence)
Meta-analyses
Multi-site Randomized Clinical Trials
Individual RCTs
Quasi-experiments
Pre-experiments
Single Subject Studies
Correlational Studies/Epidemiological Studies
Qualitative Research
Narrative Case Studies
Basic Science Studies
Expert or consensus opinion, Theory (lowest
form of evidence)
Lower End of Internal Validity
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‘Best Evidence’ Means Best Available
• Look for relevant systematic reviews, then metaanalyses, then RCTs, then quasi-experiments,
etc. Integrate this best available evidence into
your decision-making practice. EBP does NOT
depend on having a large body of RCT’s
available to consult. It does depend on one
examining the best available evidence.
• There is ALWAYS evidence, even if it is of low
quality.
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What are Client Values?
• The unique preferences, concerns and
expectations each client brings to a clinical
encounter with a practitioner, and which
must be integrated into practice decisions
if they are to serve the client.
• A thorough consideration of ethical
considerations and client considerations is
integral to the EBP model.
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What is Clinical Expertise?
• Our ability to use our education, interpersonal
skills and past experience to assess client
functioning, diagnose mental disorders and/or
other relevant conditions, including
environmental factors, and to understand client
values and preferences.
• Clinical expertise factors, costs, available
resources, etc. are integral to the EBP model.
• Research findings are NOT accorded greater
weight. All are compellingly important.
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What are the Major Steps of
Evidence-based Practice?
1. Convert the need for information into an answerable
questions(s).
2. Track down the best available evidence to answer each
question.
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Critically evaluate this evidence in terms of its validity,
impact, and potential relevance to our client.
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Integrate relevant evidence with our own clinical
expertise and client values and circumstances.
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Evaluate our expertise in conducting Steps 1-4 above,
and evaluate the outcomes of our services to the client,
especially focusing on an assessment of enhanced client
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functioning and/or problem resolution.
What are ‘Answerable
Questions’?
1. A question with a verb, as in
• What has been shown to help….? Or
• What psychosocial treatments work….?
• What community-based interventions reduce….?
• What group therapies improve….?
2. A question including some aspect of the client’s or
condition. As in
• What psychosocial interventions reduce the risk of teenage
pregnancy?
• What individual therapies are the most successful in getting
clients to stop abusing crack cocaine?
• How can schools reduce student absenteeism?
• What treatments are effective in improving prenatal care
adherence?
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How Can You Track Down the
Best Available Evidence?
There are LOTS of resources!
• Evidence-based Practice-research
journals, as in
– Research on Social Work Practice
– Journal of Consulting and Clinical
Psychology
– Evidence-based Mental Health
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• Evidence-based Textbooks, as in
– Social Work in Mental Health: An Evidence-based
Approach
– Effective Interventions for Child Abuse and Neglect:
An Evidence-based Approach to Planning and
Evaluating Interventions
– Evidence-based Social Work Practice with Families
– Clinical Applications of Evidence-based Family
Interventions
– Substance Abuse Treatment for Criminal Offenders:
An Evidence-based Guide for Professionals
– A Guide to Treatments that Work,
and some invaluable websites (next slides)
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3. How Can You Critically Evaluate the
Available Evidence?
• Develop
critical appraisal skills in evaluating
research yourself. (a bottom-up search)
• Seek out and rely on credible groups which
have already done this (e.g. Cochrane and
Campbell Collaboration, APA’s Division 12’s
lists of ESTs, SAMSHA, California Clearing
House…etc.) (a top-down search)
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In the last 30 years, social work has
seen three major initiatives intended
to better integrate scientific findings
within the human services.
Empirical Clinical Practice (1979)
by Siri Jayaratne and Rona Levy
Empirically Supported Treatments
by APA’s Division 12, Section III, early
90s
Evidence-based Practice (early ‘90s)
by Evidence-based Medicine Work
Group
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Empirical Clinical Practice involved
Encouraging practitioners to
make use of psychosocial
interventions supported
by credible outcome
studies, &
Encouraging practitioners to
evaluate clinical
outcomes using singlesystem designs
See The empirical practice movement, by William J.
Reid (1994).
Social Service Review, June, 165 – 184.
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What are Empirically-Supported Treatments
and Where Do They Come From?
Division 12 (Clinical Psychology of the APA)
organized a “Task for on Promotion and
Dissemination of Psychological Procedures” in
the early 1990s. Its purpose was to “publish
information for both the practitioner and the
general public on the random assignment,
controlled outcome study literature of
psychotherapy and of psychoactive
medications.”
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The Task Force had Two Sequential Tasks:
1. To develop evidentiary standards to be
used to designate a given
treatment/assessment methods as
“empirically validated” (later changed to
“empirically supported”.
2. To review the literature and publish lists
of treatments that met or did not meet
these evidentiary standards.
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What Evidentiary Standards Did They Develop?
They (APA, Division 12)came up with two sets of
standards or evidence benchmarks, one to
designate an treatment as ‘empirically
supported”(hence ESTs) or well supported,
and another, less stringent one, used to
designate an intervention as promising or
probably efficacious.
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OK – Where are these lists of ‘approved’
treatments?
Two major publication pathways emerged
from the Task Force’s efforts:
Initially, one book -
Nathan, P. E. & Gorman, J. M. (Eds.)
(2007). A Guide to Treatments That Work
(third edition). New York: Oxford
University Press
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And a series of articles
These are available for free at:
http://www.apa.org/divisions/div12/journals.h
tml#ESTs
You can also find their current lists of ESTs
on this website, broken down by
“Treatments” and by “Disorders” (this list is
focused on so-called mental disorders
only). See…
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See also:
A new Division 12 developed, edited and
supported book series titled
“Keeping up with the Advances in
Psychotherapy: Evidence-based
Practice”, published by Hogrefe & Huber.
Note the crucial terminology change from
‘empirically supported to “evidence-based”
This is a problem. These are different things.
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The EST movement remains
alive and well through the efforts
of the Committee on Science
and Practice, Society of Clinical
Psychology (e.g., Section III of
Division 12 of the APA), Chaired
by David Klonsky, Ph.D.
[email protected]
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Individuals who wish to
participate in this initiative to
update lists of ESTs are
welcome to contact Dr.
Klonsky. He is especially
interested in competent
people who will review draft
documents.
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While the EST movement
remains alive and well, it has
largely been overtaken by the
Evidence-based Practice
Movement
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WARNING!
Folks who wish to intelligently discuss evidencebased practice should be very familiar with the
primary source readings on EBP. It is NOT the
SAME as Empirically Supported Treatments!
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EBP is a PROCESS of learning,
it is NOT A LISTING OF
EFFECTIVE TREATMENTS!
Crucial Definitional Terms such as
• “Best Research Evidence”,
• “Clinical Expertise”
• “Patient Values” and
• “Patient Circumstances”
are all operationalized reasonably well.
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What Should Social Work Do and
NOT Do?
When we talk about interventions that are
supported by credible research, please
use the language of empiricallysupported treatments, and call these
ESTs.
When we are talking about evidencebased practice, lets keep in mind that
this is a process, not a listing of
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interventions.
There is no such thing as
EVIDENCE-BASED PRACTICES
It is mixing apples and oranges to refer to
evidence-based practices, when we
really mean empirically supported
treatments! See Thyer & Pignotti (2011).
Evidence-based practices do not exist. Clinical
Social Work Journal,
38, 328-333.
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In fact, nowhere in the Campbell or
Cochrane Collaborations do you see
lists of endorsed treatments. Such lists
would actually be antithetical to EBP,
since these ignore clinical variables,
ethics, and clinical expertise, other
elements valued equally with scientific
support.
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The EST program is less
scientifically and professionally
credible than EBP. When we talk
about EBP in terms only of lists of
approved therapies, we tar EBP with
the deficiencies of the EST model,
distorting EBP.
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Some Problems with lists of ESTs
• “One legitimate criticism is that the EST list is based on
an overly simple “all or none” model of effectiveness: A
treatment is either empirically supported or it is not. Yet
the true state of affairs is likely far more more complex”
(ABCT website, on ESTs)
• Such lists of ESTs ignore ethical considerations, client
preferences, resource consideration and the adequacy
or clinical expertise.
• They also focus on positive studies and ignore negative
outcome studies. (a treatment with two positive studies
and 8 negative ones could be considered empirically
supported!)
• They are based on p-values in determining effectiveness
and ignore effect sizes of treatments.
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Also, the EBP Process does NOT involve recourse
to Practice Guidelines. Some Problems with
Practice Guidelines include
• They are usually created by members of one
discipline, and fail to adequately take into
account interdisciplinary literature.
• Disciplinary prejudices are rife (PGs prepared by
psychiatrists tend to ignore effective
psychosocial treatments)
• ‘Expert consensus’ sometimes overrules
scientific considerations.
• They are usually not too comprehensive, and
ignore the ‘gray’ literature.
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Other Misconceptions
• EBP is only applicable to clinical practice. For example,
“…studies relating to macro level, social change are less
likely to be encouraged by those advocating for more
scientific approaches to practice. (EBP) thus privileges
micro-level approaches that focus on problems…”
(Furman, 2009, Social Work, 54, p. 83)
• Rebuttal?
See the Coalition for Evidence-based Policy, which
evaluates social programs in terms of their effectiveness.
http://www.evidencebasedprograms.org/
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And the special issue of the
Journal of Evidence-based Social Work
• Devoted to EBP and macro-level practice.
2008, 5(3/4).
• The journal Evidence and Policy
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Other Misconceptions
• “If outcome research becomes the most
important factor guiding social work services
provision, a focus on client empowerment and
autonomy may become at risk” (Furman, 2009,
p. 82)
In reality, in EBP outcome research is one required
consideration but it is not elevated in importance
relative to ethics, client preferences, etc.
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Other Misconceptions
• “(EBP) has naturally focused on issues and concerns that are
relatively easy, or quick, to measure” (Furman, 2009, p. 82)
EBP as a process is applicable to all problems of concern to social
workers, simple or complex. Look over the complex problems that
have been the focus of systematic reviews, found within the
Campbell and Cochrane websites, to find examples (e.g., the effects
of welfare-to-work programs; or improving the conditions of slum
neighborhoods)
List of ESTs do tend to focus on discrete DSM-defined disorders, but
this limitation of the EST movement is inapplicable to the EBP
process model.
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Other Misconceptions
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“EBP will increase social workers’ stress, workload, and monetary output. This will
likely force many social workers to leave the social work profession and look for other
jobs. As a result, the status of social work in the hierarchy of the professions will
become much lower.”
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“…the present adoption of EBP in social work makes people who might not be
professional in practice the judges of practice.”
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“…adopting EBP may merely serve to provide a source of legitimacy that contributes
to the authority of social work managers. This is likely to put frontline social workers
under increased managerial control and thus damage their incentives to remain social
workers”
(c.f. Yunong & Fengzhi, 2009, Social Work, 54, p. 177-181)!
EBP actually is PRACTITIONER-driver, not managerial in nature. Again, the authors
seem to be confusing EBP with empirically supported treatments.
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Other Misconceptions
“According to this view, social work decisions
should rest solely on evidence leading to
effective outcomes.” (emphasis added)…
“undermines professional judgment and discretion
in social work…”
By underplaying the values and anticipations of
social workers…”
“Evidence-based practice assumes that social
work is decontextualized.”
(c.f. Webb, S. Some considerations on the validity of evidence-based practice
in social work. British Journal of Social Work, 31, 57-59).
See prior commentary on what the EBP process is
really like.
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Other Misconceptions
“There is an inadequate foundation of high quality
evidence regarding the problem of XXX.
Therefore, we cannot be expected to make use
of the EBP model.”
EBP does not require the existence of lots of high
quality evidence. It does require the practitioner
to seek out, appraise, and judge the applicability
of the highest quality available evidence.
There is always evidence, even it is consists of
informed clinical opinion, or theoretical systems.
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Summary
It is possible that the EBP process model
represents a significant positive step in the
professional maturation of social work and in our
ability to genuinely help clients, and to
implement effective social policies and
programs.
It is also possible that it represents simply another
conceptual fad which will enjoy a brief flurry of
interest, and then fade from view. We have had
many examples of this latter scenario. Time will
tell.
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Summary
When the primary sources describing EBP are
consulted, it is troubling to see the numerous
misconceptions that are being promulgated
about this potentially useful model.
Social workers are urged to acquaint themselves
with this approach, make their own informed
decisions as to its usefulness, and take steps to
adopt it, if moved to do so.
EBP represents the most sophisticated model to
date that has been developed to guide our
practice and improve the services we provide.
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Copies of this powerpoint
presentation are available from the
author, via
• [email protected]
Bruce Thyer, Ph.D., LCSW
College of Social Work
Florida State University
Tallahassee, FL 32306 USA
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