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LIMITATIONS OF EVIDENCE-BASED PRACTICE FOR SOCIAL WORK EDUCATION: UNPACKING THE COMPLEXITY

Kathryn Betts Adams

Craig Winston LeCroy

Case Western Reserve University

Arizona State University

Holly C. Matto Virginia Commonwealth University

Although some academic scholars have called for adoption of evidence-based practice (EBP) as a unifying model for social work education and practice, controversies with the EBP approach for the social work profession still need to be examined. Some of the limitations of EBP to be recognized and addressed before recommending broad changes within social work education are described. Conceptual and definitional limitations include following a medical model, privileging certain types of evidence, and downplaying the importance of theory. Implementation and feasibility limitations include sorting the complexity of research information and providing necessary practice grounding and supervision to facilitate knowledge application. Dialogue on the role of EBP in social work education must continue.

EVIDENCE-BASED PRACTICE (EBP)

is a term that is

for a client’s particular presenting problem or

now widely used in social work and psycho-

condition in collaboration with the client

social disciplines. Modeled after evidence-based

(Gambrill, 1999; 2001). In social work, propo-

medicine, a state-of-the-art approach where

nents of EBP link this approach to social work

the focus is on finding appropriate treatments

values, noting the ethical imperative to offer

(pharmaceutical, medical, and surgical) for a

clients treatments that are known to work and

patient’s medical conditions (Eddy, 2005;

to use the best evidence available (McNeece &

Sackett, Rosenberg, Gray, Haynes, & Richard-

Thyer, 2004). Reviews of EBPs have been pub-

son, 1996; Sackett, Straus, Richardson, Rosen-

lished in such diverse social work areas as the

berg, & Haynes, 2000), EBP within psychoso-

substance abuse field (O’Hare, 2002); direct

cial disciplines focuses on using intervention

practice in aging (Cummings, Kropf, Cassie, &

approaches with demonstrated effectiveness

Bride, 2004); and school-based interventions

Journal of Social Work Education, Vol. 45, No. 2 (Spring/Summer). Copyright © 2009, Council on Social Work Education, Inc. All rights reserved.

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JOURNAL OF SOCIAL WORK EDUCATION

(Franklin & Hopson, 2004), and EBP in these

ical social work practice. Behaviorally orient-

areas appears to be increasing rapidly. Prac-

ed and cognitive-behavioral treatments (e.g.,

tice guidelines are being developed (Duncan,

Thomas, 1967) and time-limited, structured

Solovey, & Rusk, 1992; Howard, Edmond, &

intervention approaches (e.g., Reid & Epstein,

Vaughn, 2005; Rosen & Proctor, 2003), and

1972) have become commonplace in social

manualized treatments are being published

work service delivery (Mullen & Streiner,

(Fraser, 2004; LeCroy, 2008) in many areas of

2004). In the early 21st century, the generalist

practice. Social work textbooks with the

practice models we teach our students

“evidence-based” label in their titles are be-

emphasize behavioral specificity in goal set-

coming commonplace (e.g., Corcoran, 2000;

ting, skills training, or psychoeducation and

Roberts & Yeager, 2006; Thyer & Wodarski,

regular evaluation of measurable practice out-

2007), and other textbooks also reference an

comes (Hepworth, Rooney, Dewberry-Rooney,

increasing amount of intervention research on

Strom-Gottfried, & Larson, 2006). In its latest

practice approaches. Scholars, educators, and

incarnation, however, EBP focuses more ex-

students are affected by these trends, as

clusively on using the best available research

Educational Policies and Accreditation Stand-

to make practice decisions.

ards (EPAS) standards for social work educa-

Two broadly defined conceptualizations

tion require schools to incorporate teaching

of EBP, or the sometimes preferred term,

evidence-based practices (Council on Social

evidence-informed practice, are used. First is a

Work Education, 2004). Across the country,

focus on the use of evidence-based practices

schools of social work are deciding where and

(e.g., Norcross, Beutler, & Levant, 2006; Roth

how EBP will fit in their curricula.

& Fonagy, 2006), also known as empirically

Whereas the idea of giving preference to

supported treatments (ESTs). In this conceptu-

practices with empirical support is not new, it

alization, certain practices or intervention pro-

is being redefined in today’s social work EBP

grams become established as being effective

with renewed fervor. As Kirk and Reid (2002)

through intervention outcome literature,

describe in Science and Social Work, beginning

either individual studies or systematic

in the 1970s with “the effectiveness crisis” in

reviews and meta-analyses that synthesize

social work, efforts to make the profession

and quantify the results of a number of stud-

more scientific have received strong academic

ies. Evidence-based practices may be formally

support, most notably with the scientific-

designated by certain government bodies or

practitioner and the empirical-clinical practice

agencies. For example, the American Psycho-

models (e.g., Jayaratne & Levy, 1979 and oth-

logical Association has a clear set of criteria

ers). Those models, emphasizing systematic

for categorizing practice approaches as effica-

evaluation of one’s own practice and use of

cious, possibly efficacious, and so on (Cham-

research evidence to inform practice, although

bless & Hollon, 1998), and lists and databases

not adopted wholesale by the practice commu-

produced by these bodies are becoming wide-

nity, nevertheless have been responsible for

ly available (e.g., National Registry of Evidence-

introducing a number of innovations into typ-

Based Practices and Programs [NREPP], 2007;

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LIMITATIONS OF EVIDENCE-BASED PRACTICE

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Substance Abuse and Mental Health Services

although other authors have presented alter-

Administration [SAMHSA], 2007). A hierar-

native steps (e.g., Pollio, 2006). The EBP

chy of research evidence according to the level

process has been enabled by broad access to

of causal inference attributable to the research

the Internet and the increasing availability

design of the study, with the randomized-

online of full-text research articles, systematic

controlled trial, or true experiment, at the top,

reviews of studies, and practice guidelines.

has been outlined in social work literature

Many schools of social work have begun

(McNeece & Thyer, 2004; Rosenthal, 2006).

to incorporate the EBP paradigm into one or

Some scholars have distinguished evidence-

more courses (Howard, McMillen, & Pollio,

based practices and best practice protocols

2003). Some authors now recommend using

(Corcoran & Vandiver, 2006). Evidence-based

the EBP process as the conceptual basis of

practices are generally based on formal quan-

social work education in practice and research

titative research support and may be less flex-

(McNeece & Thyer, 2004; Regehr, Stern, &

ible to individual client or agency-specific

Shlonsky, 2007). A special issue of Research on

modifications, as the goal is to replicate exist-

Social Work Practice on “Improving the Teach-

ing treatment protocols found within the

ing of Evidence-Based Practice” featured

research literature or to follow treatment man-

papers presented at a symposium in Austin,

uals. In contrast, best practice protocols allow

TX, in October 2006. These scholars generally

for modification in the agency context, even

favored using the EBP process within both the

though there may not be evidence to support

research and practice sequences in schools of

the effectiveness of such modifications

social work (Rubin, 2007b). A recommenda-

(Hayes, 2005).

tion made was that schools of social work

A second conceptualization defines EBP

should abandon the generalist social work

as a process whereby practitioners actively

practice model and teach only specialized,

engage in seeking, digesting, and critically

evidence-based practices, beginning at the

appraising the latest and best evidence to

foundation level (Howard, Allen-Meares, &

inform practice with particular client systems

Ruffalo, 2007). Also proposed was retooling

and target problems (Gambrill, 2001, 2003;

the research sequence to focus on content nec-

Gibbs, 2003; Rubin, 2007b; Sackett et al., 2000).

essary to become an EBP practitioner; placing

This is a multistep process consisting of (a)

emphasis on skills in searching for evidence to

converting information needs into answerable

become an informed consumer of interven-

questions; (b) finding the best evidence with

tion outcome research; and reducing coverage

which to answer these questions; (c) critically

of descriptive, survey, or qualitative research

appraising that evidence for its validity and

or content on single-subject design for evalu-

usefulness; (d) deciding how the evidence

ating one’s own practice (Howard et al., 2007;

applies to a particular client and involving

Jenson, 2007; Schlonsky & Stern, 2007). Others

clients in the decision making; (e) taking

recommended checking all syllabi to be sure

action based on the best evidence; and (f) eval-

non-EBPs were not being taught and limiting

uating the outcome (Gambrill, 2001, p. 167),

field sites to those that use EBPs (Rubin,

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JOURNAL OF SOCIAL WORK EDUCATION

2007b). In response to the 2006 Austin sympo-

gauge the gaps in performance, and (d) inad-

sium, social work faculty leaders in EBP

equate integration of findings into daily oper-

formed the Austin Initiative, with plans to

ations (pp. 244–245). In the social work profes-

continue meeting and presenting symposia

sion also, we must address the potential limi-

“to improve the teaching of EBP and advance

tations to this approach both for educating

EBP in general,” (Rubin, 2007a, p. 630).

students and for current social work practice.

According to Soyden (2007), the Inititative’s

Although some have stated that concerns

purpose is “to transform schools of social

about EBP are “well established and fully dis-

work from predominantly opinion-based to

cussed in the literature,” (Mullen & Streiner,

predominantly evidence-based institutions of

2004, p. 113), we believe that now is a good

education” (p. 616).

time to revisit and expand on these concerns.

Professional social workers are committed

A critical examination and discussion of the

to reflective practice and the use of critical

limitations of EBP as a unifying approach for

thinking skills in practice-based decision mak-

social work practice and education are neces-

ing, using multiple knowledge sources. The

sary before moving forward with sweeping

EBP literature provides support to these central

curriculum changes. This article reviews some

tenets of good social work practice by suggest-

of the key limitations of EBP and considers the

ing a systematic approach to investigating a

difficult questions that confront social work

problem area and using existing empirical liter-

education in light of the EBP movement.

ature to support work with clients and communities. It would no doubt be difficult to find a

Conceptual and Definitional

social work practitioner today, much less a

Limitations of EBP

social work educator, who would admit to renouncing the importance of examining exist-

Medicine as the Model for Social Work

ing best practices to inform programming or

The EBP process model is patterned after

the benefit of employing critical thinking skills

evidence-based medicine (EBM), yet the disci-

in practice-based decision making with clients.

plines of social work and medicine are quite

However, there are controversies regard-

different. Given these differences, we need to

ing both an increased emphasis on using and

ask whether EBM is an optimal model after

teaching EBPs and adoption of the EBP

which to pattern social work practice and

process for the social work profession that still

education. As Staller (2006) asserts, “insuffi-

need to be examined. Other disciplines have

cient attention has been paid to adapting EBP

attended to some of these controversies. For

to the specific needs and natures of the new

example, for health care disciplines, Stout

professions to which it is being applied” (p.

(2005) suggests four specific challenges to

507). To expect that a practice or process that

implementing EBPs: (a) lack of clinician sup-

is adopted for medicine will be equally appro-

port, (b) difficulties in converting clinical

priate or helpful for other professional disci-

guidelines into actionable performance meas-

plines is perhaps misguided. This issue was

ures, (c) poor use of available technologies to

raised by Webb (2001) and by Mullen and

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LIMITATIONS OF EVIDENCE-BASED PRACTICE

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Streiner (2004), who noted that some have

they build a therapeutic relationship, identify

criticized EBP “on philosophical grounds,

needs, goals, and resources, emphasizing

arguing that an evidence-based, rational

mutuality in the relational context.

model of decision making does not fit the real-

Social work practice is embedded within

ities of individualized, contextualized prac-

social problems or problems of living such as

tice, especially nonmedical practice, wherein

homelessness, domestic violence, and child

problems are less well defined” (p. 114). Our

abuse. These are complex social difficulties

concerns with the use of a medical model may

that require a person-in-environment perspec-

be less philosophical and more conceptual,

tive and are quite different from the difficul-

definitional, and practical.

ties dealt with in medicine. Clients seeking

Medicine tends to have a strictly individ-

social work services do so because of a unique

ual focus whereas, among health and mental

combination of situations and symptoms;

health disciplines, social work espouses a

they are dealing with problems of living for

unique approach, taking as its focus individu-

which they need assistance and support.

als within their social environment: families,

Initially, they may not be able to express or

communities, and larger social systems. In

understand everything that is wrong. Dif-

medicine, EBM has achieved a relatively high

ferent areas that need to be addressed may

degree of acceptance in part because of the

unfold over time; many approaches may lead

“critical and sometimes life-saving nature

to appropriate outcomes. “Goals are modified

of decision-making processes . . . the quantita-

or adapted, new goals are chosen, each

tive nature of medical science,” (Roberts,

responsive to the individual client’s need as it

Yeager, & Regehr, 2006, p. 9). A primary focus

changes over the span of the intervention,”

of EBM is the diagnosis of symptoms and

(Pollio, 2006, p. 225).

determining which procedures and pharma-

Finding information to apply to practice

cological agents to prescribe. Most medical

may be more difficult for social work than for

procedures are discrete and can be precisely

medicine. Stone and Gambrill (2007) suggest

followed. Within this narrow model of prac-

the use of a resource manager within the

tice, the physician using EBM reviews studies

agency setting, a process used successfully in

and applies evidence or follows evidence-

the United Kingdom by physicians, noting

based guidelines drawn by consensus panels,

that ”line staff can e-mail questions that arise

based on existing research findings (Eddy,

to this person and receive answers and feed-

2005). In social work practice, an exclusive

back in a timely manner” (p. 115).” Here

focus on discrete symptoms and problems is

again, the medical analogy may not work as

less appropriate. The social worker’s frame of

well for social work. If a practitioner e-mails a

reference is the person in developmental, cul-

question such as “How can I get a low-income

tural, family, community, and occupational

mother to be motivated to come to a parent

contexts. One of the hallmarks of good social

group for her children?” the answer might not

work practice is individualizing clients. Social

be as easily obtained as the answer to “What

workers do not simply treat the problem—

is the best treatment for appendicitis?” The

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JOURNAL OF SOCIAL WORK EDUCATION

questions investigated in EBM tend to be

psychology and psychiatry has broadened.

organized around symptoms and diseases,

Reviews such as Reid and Fortune (2003) and

and many of them address a narrower focus

Reid, Kenaly, and Colvin (2004) have shown

of practice with clear right or wrong answers.

the effectiveness of various types of social work

Thus, because it is based on a medical model

practice. These reviews have documented that

and EBM, it is possible that EBP might steer

the treatments with demonstrated effectiveness

students or practitioners to focus on the

tend to be brief, group, skills-focused, interven-

wrong targets. For example, a family presents

tion approaches. However, there are still signif-

with a child who has attention deficity hyper-

icant limitations to the evidence base in social

activity disorder. What is the appropriate

work in many practice areas.

social work role? What services would social

Methodological biases. It is an accepted fact

work offer families with children who suffer

that those approaches with the most evidence

from this disorder? The social worker’s role

of effectiveness also happen to be those that

extends beyond cure or “treating” the ADHD

have lent themselves most readily to replica-

itself. The social worker needs to assess the

tion and testing (Fonagy, Roth, & Higgitt,

particular situation of that family, their pre-

2005; Kirk & Reid, 2002). A decontextualized

senting concerns, what they have already

review of the literature may lead to mislead-

tried, what strengths and resources they have,

ing assumptions and misinformed practice.

and their need for services and guidance. She

For example, practitioners may conclude that

may offer the child and the parents a combina-

what is not represented in the EBP literature is

tion of support, information, parenting skills,

considered “bad practice,” rather than non-

behavioral management, family therapy,

published practice. Given that not all human

advocacy in the school, physician and pro-

and social problems (or populations) are

gram referrals, and case management to mon-

equally valued, biases may exist in the empir-

itor and support the family. Key social work

ical literature toward those practices that

skills such as support, understanding, and

reflect the social values and priorities of fun-

resource referral do not fit neatly within the

ders and others. And given that the social sci-

EBP process model. Exclusive focus on the

ence base will always be empirically incom-

EBP aspect of social work service and inter-

plete and often methodologically inconsistent

vention delivery may inadvertently de-

across studies and findings, an exact prescrip-

emphasize other important aspects of a holis-

tion for intervention can never be relied on.

tic social work approach.

The prevalent methodological biases toward treatments that are easier to measure or more

Assumption of the Outcome Literature Base as the Gold Standard

likely to garner funding priority, mean that many types of practice are simply not well-

Over the past 30 years more sophisticated in-

represented in the research literature. Al-

tervention outcome research has become in-

though the number of intervention studies

creasingly available, and the evidence base in

may be increasing, there is still not enough

social work and related practice areas such as

research evidence to inform practice in some

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LIMITATIONS OF EVIDENCE-BASED PRACTICE

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of these areas, for instance, interpersonal ther-

controlled treatment studies excluded poten-

apeutic approaches, naturalistic studies of

tial clients exhibiting comorbid disorders.

social work practice, or effectiveness research

Because estimates of comorbid disorders are

in the field under real life conditions. Practices

quite high, many of these studies are limited

that are considered to be evidence-based with

in their generalizability to typical clinical

racially and culturally diverse client groups

practice. And the corollary is that the necessi-

are particularly underdeveloped and not

ty of maintaining strict treatment fidelity,

widely available (Sue & Zane, 2006).

keeping the treatment brief, and so forth, pro-

Types of evidence that are privileged in the

duces interventions in experimental studies

EBP model. According to the “evidence pyra-

that do not resemble actual clinical practice

mid” of the validity and importance of evi-

(Goldfried & Wolfe, 1998; Westen, Novotnoy,

dence sources, true experimental designs,

& Thompson-Brenner, 2005). Although efforts

such as randomized controlled trials (RCTs),

are underway to increase research funding

are considered to be of the highest value with-

and studies that include clients with more

in EBP (McNeece & Thyer, 2004; Sackett et al.,

comorbid conditions and take place in real

2000). Yet these types of studies do not always

field settings (Rubin & Parrish, 2007a), propo-

meet the needs of everyday practice. Concerns

nents of EBP too often fail to acknowledge

with the typical RCTs that inform EBP have

such clear limitations to how evidence from

been raised surrounding the application of

these so-called gold standard studies can be

global evidence—average effects—to individ-

applied to practice.

uals, who generally differ from the average,

Other concerns have been raised sur-

which may mask differential treatment effects

rounding the choice of control or comparison

or yield a poor match between client and

conditions used in RCTs, particularly no-

treatment (Goldfried & Wolfe, 1998; Kravitz,

treatment or attention-placebo control condi-

Duan, & Braslow, 2004).

tions (Kendall, Holmbeck, & Verdun, 2004).

Moreover, RCTs are so highly controlled

For instance, a convincing argument can be

that they could be said to lack “external or

made that evidence of a legitimate treatment’s

ecological validity” (Persons & Silberschatz,

superiority compared with a bogus treatment,

1998, p. 128). These studies are often charac-

which is intrinsically designed to fail (e.g.,

terized by exclusion criteria, which omit

attention-placebo condition), does not tell us

clients with multiple problems; reliance on a

much about the treatment’s effectiveness

strict duration of treatment or number of ses-

(Westen et al., 2005). And finally, a number of

sions; and either a manualized treatment

authors in social work and psychology have

approach, which fails to address all of the

noted that experimental outcome studies tend

issues of real-life clients, or a less-detailed de-

to be designed by proponents of the ap-

scription of a treatment approach, which

proaches, introducing an element of bias in the

makes replication by regular practitioners im-

design, conduct, and interpretation of these

practical. For instance, Westen, Novotny, and

studies as a result of the effects of “investigator

Thompson-Brenner (2004) found that most

allegiance” (Gellis & Reid, 2004; Kirk & Reid,

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JOURNAL OF SOCIAL WORK EDUCATION

2002). Thus, results of experimental evalua-

those social work skills that work from prob-

tions may be less informative and objective

lem to problem and client to client, the non-

than we realize (see, e.g., Gorman, 2002).

specific factors, have impact on the outcome of treatment (Drisko, 2004). The relationship

Difficulties in Defining

Evidence-Based

between worker and client, the therapeutic alliance, has been demonstrated to have sig-

Practitioners, educators, or administrators do

nificant influence across numerous studies

not agree on definitions of EBP (Rubin &

(Norcross & Lambert, 2006; Wampold, 2001).

Parrish, 2007b). Although some authors have

In fact, research on treatment outcomes sug-

decried the loosening of evidentiary stan-

gest that four factors can account for much of

dards as EBP becomes a buzzword in social

the improvement in clients: client or extra-

work and related disciplines (Rubin & Par-

therapeutic factors (40%); relationship factors

rish, 2007b; Shlonsky & Gibbs, 2004), others

(30%); placebo, hope, and expectancy factors

are concerned that strict criteria to define

(15%); and model/technique factors (only

evidence-based may end up excluding impor-

15%) (Duncan & Miller, 2000; Hubble, Dun-

tant and effective social work practices. As an

can, & Miller, 1999). Thus, nearly half of the

example, Franklin (2007) describes her work

outcome relies on fundamental skills and abil-

with solution-focused therapy, which she

ities that must be fostered in social workers,

notes is not yet considered an evidence-based

apart from the type of treatment offered.

treatment, but argues that developing a prom-

It is not clear that the EBP perspective

ising treatment model has a rightful place in

fully takes into account the importance of

social work research and scholarship.

these nonspecific factor skills and abilities.

Common factors. A related definitional lim-

There are two important points here. First, we

itation of the EBP model is that intervention

are concerned with the matter of emphasis

studies usually test one practice model or pro-

and presentation to our students. The EBP

cedure as a package, but variations on that

process emphasizes use of evidence rather

model, perhaps including some but not all of

than use of good social work interviewing,

the treatment elements, may not have been

giving the impression to students who do not

formally evaluated in the literature and, thus,

know about practice that evidence is the key

will not be acknowledged as EBP. For exam-

to good practice. Second, we notice a failure of

ple, interviewing and relationship skills such

scholars to acknowledge in writings on EPB

as active listening, reciprocal empathy, dis-

that generalist practice skills, the nonspecific

cerning and confronting discrepancies, and

factors, are evidence-based. Although social

reframing form the basis for the social work

work practice textbooks present generalist

generalist practice model (e.g., Hepworth et

practice skills, some social work scholars con-

al., 2006). These generalist practice skills

tinue to state that the social work profession is

derive from a number of traditions in social

conducting work that is of unknown effective-

work and have been shown to be important

ness and not evidence-based (Gambrill, 1999,

elements of psychosocial practice. Precisely

2001; McNeece & Thyer, 2004). This discrep-

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LIMITATIONS OF EVIDENCE-BASED PRACTICE

9

ancy points to the difficulty in unpacking the

or contradict each other. For example, social

evidence used in practice. Stone and Gambrill

work has embraced multisystemic therapy

(2007) review school social work texts to

(MST; Henggeler, Melton, & Smith, 1992) as an

assess the extent to which they provide evi-

evidence-based intervention (Kazdin & Weisz,

dence in discussing school social work prac-

2003). More recently, a systematic review

tice. They conclude that there is limited evi-

(Littell, 2005) of MST has raised significant

dence presented in social work textbooks and

questions about the evidence of effectiveness

suggest such books may be overshadowed by

for this widely accepted intervention. Asser-

electronic information, one rationale being

tive community treatment (ACT; Drake et al.,

that text reviews of research are outdated too

1998), another well-studied and established

quickly (Stone & Gambrill, 2007; Thyer, 2004).

practice model, has also been criticized for

However, textbooks are usually updated

methodological shortcomings and possibly

every few years, and more important, the cru-

coercive practices (Gomory, 2005). However,

cial common practice skills have already

the “information cascade” has already placed

established evidence. When social work schol-

both MST and ACT into the EBP category, and

ars fail to recognize that common factors

they are widely cited as exemplary models of

make up many EBPs as well as the basis of

EBP (NREPP, 2007). Even though one review-

social work generalist practice skills, and that

er found evidence lacking, many other re-

these factors may be, in fact, evidence-based

viewers have reached different conclusions.

in their own right, they do not give credence

We must acknowledge the complication of

to transferable skills or components of inter-

applying systematic reviews to advance

ventions that can be used or applied in a flex-

evidence-based knowledge.

ible way. Helping social work students devel-

In addition to MST and ACT, a number of

op their fundamental knowledge and skill

other multicomponent programs such as inte-

base is just as important to good practice as

grated dual disorder treatment (Drake, et al.

being updated on recent knowledge derived

2001) and dialectical behavioral therapy

from the evidence base. We should acknowl-

(Linehan, 1993) are considered to be evidence-

edge that good practice is derived from fun-

based (NREPP, 2007; SAMHSA, 2007). These

damental knowledge and skill as well as

programs tackle some of the most challenging

newly discovered knowledge and skill.

social work problems that exist and consist of

Complex and contradictory evidence. A fur-

several parts that are often delivered by more

ther difficulty with the EBP process is how to

than one practitioner. However, multicompo-

evaluate complex studies and sort through

nent programs require sophisticated method-

contradictory reviews. Randomized control-

ological designs to tease out component-

led trials of the same approach frequently

specific effects and, therefore, it is not surpris-

offer discrepant findings, particularly given

ing that quality evidentiary support with the

the use of multiple outcome measures (De Los

appropriate detail necessary to comprehen-

Reyes & Kazdin, 2008); reviews of research

sively answer effectiveness questions about

studies in a given area may also be equivocal

multicomponent programs is scant.

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With this degree of complexity in the liter-

As we see it, although theory undergirds

ature, how do we teach our students and train

specific EBPs such as cognitive behavior thera-

our practitioners to be able to discern between

py, the importance of theory is not clearly artic-

harmful practices that exist, best practices that

ulated in the EBP process model. EBP appears

have empirical support but that have not been

to offer social work students and practitioners

comprehensively tested with all practice pa-

resources to access research and practice guide-

rameters, and those practices that hold infor-

lines but it offers no theoretical underpinnings

mal or anecdotal promise but have not yet

on which to base activities in practice such as

seen empirical support? What is the value-

conceptualizing a problem or assessing client

base that undergirds a particular area of

needs. The theory piece appears to be largely

knowledge development? How do we manage

omitted because of the privileged status of

biases that contribute to knowledge gaps in

“what has worked” in research studies with

the formal literature base of our profession and

similar target problems or types of clients. This

in other disciplines from which we borrow

may lead to unfortunate oversights in practice.

knowledge? These questions need answers as

For example, a social worker attempting to

we advance EBP into the day-to-day practice of

provide a preventive intervention for teenage

social work.

HIV and STDs might search the literature and find “programs” with some evidence of effec-

Deemphasis on Human Behavior Theory and Theories of Change

tiveness. However, knowledge of relevant human behavior theory might suggest the use

Theory is an integral part of the knowledge,

of cognitive dissonance, which addresses how

skills, and abilities needed for professional

to increase behaviors in participants who are

social work practice. Polansky’s classic article

not motivated to change their behavior. A cog-

(1986) about the value of a good theory noted

nitive dissonance strategy to teenage preven-

that theory offers tentative explanation about

tion of HIV and STDs is to develop a peer-

what occurs, why it occurs, and predictions

based program whereby the teens teach princi-

about what may occur in the future. Just as

ples of prevention and safe condom use to oth-

theory guides research, it can guide practice.

ers, creating conditions of dissonance for their

Social workers with a framework for under-

own behavior. Substantial empirical evidence

standing human behaviors, human problems,

exists for the use of cognitive dissonance theo-

and methods to help and change are able to

ry and behavior change (Aronson, Fried, &

enter into the social work relationship with

Stone, 1991; Kelly et al., 1997), yet this type of

clients prepared to begin the work. They can

evidence would not likely be found in a sys-

be confident that they have a working hypoth-

tematic search for evidence on prevention of

esis about what may be going on with the

HIV or STDs.

client and an idea of how they might proceed,

We see this as an area for significant at-

albeit a tentative one. What role will theory

tention because it may facilitate the applica-

play in education for evidence-based social

tion of EBPs to the practice context. Exam-

work practice?

ining the underlying theoretical framework in

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LIMITATIONS OF EVIDENCE-BASED PRACTICE

11

evidence-based searches opens up the oppor-

been empirically derived by social scientists

tunity for modifying and adapting the evi-

and clinicians through research), experiential

dence to better accommodate existing practice

knowledge, and knowledge about the current

challenges. For example, a social worker work-

client situation. Research knowledge and

ing in a substance abuse outpatient facility

“evidence” that supersedes these other impor-

might be intrigued by the strong evidence to

tant sources of knowledge may not provide

support motivational interviewing (MI) tech-

sufficient guidance for professional practice.

niques in obtaining early client commitment and treatment engagement, but may view such techniques as limiting in their emphasis

Barriers and Concerns with Implementation of EBP

on personal change over person–environment

Although EBPs are found in social work text-

transactional change. However, incorporating

books and described on practice Web sites, con-

an expanded theoretical approach from public

verting all of social work education and prac-

health to explain human motivation, such as

tice to the EBP model would be an enormously

the theory of reasoned action (Ajzen &

complex undertaking. Being attentive students

Fishbein, 1980), allows the practitioner to more

of history, we can examine lessons learned

effectively understand the influence of social

from the scientific practitioner (SP) movement

norms and relational configurations that con-

in the 1980s and 1990s, which failed to capture

tribute to behavior change and allows the

the interest and the hearts of everyday social

practitioner to adapt or expand the MI tech-

workers. Its most ardent proponents did not

niques accordingly.

address the implementation problems nor gain

Without understanding the reciprocal

the buy-in of many practicing social workers in

interactions between theory and the evidence

the field, who did not see the need for or the

base, there is a danger that we will be training

appeal of the SP model in everyday practice,

technicians who know how to find research

even though a subset of academic social work

studies and follow directions in practice

scholars displayed a zealous certainty about

guidelines rather than developing independ-

adopting the model and incorporating it into

ent professionals who can appropriately

social work education (Kirk & Reid, 2002;

apply and adapt such knowledge to their

Wakefield & Kirk, 1996).

practice context (Goldstein, 2007). Critical

We see a similarity to the EBP process

thinking skills of social work students and

movement. Are we overestimating the potential

practitioners may decrease, rather than

contribution of EBPs and the EBP process for

increase, if the result of the EBP movement is

social work? Some have cautioned that the cur-

reliance on rote prescriptive literature search-

rent situation regarding EBP in social work

es with less attention to the harder work of

veers toward “methodological fundamental-

how to critically evaluate, appropriately

ism” (Staller, 2006, p. 509). Is there adequate evi-

apply, and effectively employ such best prac-

dence that EBP as a process can be successfully

tices. This requires the work of integrating

applied to social work practice? Without this

theoretical knowledge (much of which has

evidence should we proceed with a wholesale

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JOURNAL OF SOCIAL WORK EDUCATION

acceptance of the movement? Will the EBP

to interpret and are not necessarily geared

movement uphold some of the very authority-

toward practitioners’ needs.

based propositions it claims to critique? Several feasibility and implementation issues present serious impediments to wide-scale

Application of Knowledge From Research to Practice

adoption of EBP as a unifying conceptual

A second related issue is that of transfer of

model in social work practice.

knowledge. The whole notion of “transportability” of EBP has emerged (Reid & Colvin,

Interpretation of Research Evidence

2005; Schoenwald & Hoagwood, 2001).

First, interpreting evidence from research stud-

Application of knowledge often does not lead

ies or reviews is complex, time-consuming, and

to appropriate actions. Knowing about and

difficult, and we believe the literature on EBP

knowing how are different, and it is unclear

in social work has underestimated this. Social

how the EBP approach helps to bridge gener-

workers with bachelor’s or master’s degrees

al knowledge acquisition with specific skill

do not have the training in research design

application. Indeed, the perplexing gap in

and statistics that scholars with doctorates

knowledge transfer has been of concern for

have, and even these scholars have difficulty

some time (see U.S. Department of Health and

interpreting the intervention outcome litera-

Human Services [USDHHS], 1999). Questions

ture. The skilled and thoughtful critical

emerge about individual intervention studies

review required is beyond the capabilities and

and their clarity as guides for practice. Do

interests of most practitioners, who are busy

they give adequate guidance on worker activ-

with the actual day-to-day work of seeing

ities? Is there enough detail to allow replica-

clients and being change agents. Although

tion in the field with real clients? Related con-

master’s level students can learn much about

cerns have been raised about manualized psy-

intervention research that will help them in

chosocial treatments. Practice guidelines are

interpreting research evidence, expecting that

proposed as an antidote to the difficulty of

the master of social work curriculum can add

interpreting research literature (Howard et al.,

enough content on research design and statis-

2005; Rosen & Proctor, 2003) and are available

tics for students to seriously evaluate studies

for certain disorders (e.g., American Psycho-

is perhaps not realistic. This added material

logical Association, 2005). Yet experts agree

would inevitably lessen the weight given to

that finding the evidence and implementing it

other important aspects of social work educa-

according to directions from practice guide-

tion, even other research methodologies such

lines and treatment manuals is unlikely to be

as survey or qualitative research. Systematic

successful without the undergirding of impor-

reviews and meta-analyses of the literature by

tant knowledge and skills, precisely because

the Campbell and Cochrane collaborations

social work practice is interactive in nature

and many others are helpful in obtaining

and process oriented (Witkin & Harrison,

summaries of the intervention studies in a

2001). Kendall and Chu (2006) acknowledge

given area, but they also can be very difficult

the limitations found in treatment manuals for

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LIMITATIONS OF EVIDENCE-BASED PRACTICE

13

guiding practice and have noted that EBP

viewing with others, behavioral rehearsal and

needs to incorporate “flexible” practice. They

skills training with others, family psychoedu-

define flexible practice as “a construct that

cation with others, and interpersonal psy-

assesses the therapist’s adaptiveness to the sit-

chotherapy with still others. But constantly

uation at hand while he or she is adhering to

trying to do new things may not lend itself to

the instructions and suggestions in the manu-

competent practice and may work to under-

al” (p. 211).

mine the confidence of the worker, which

In addition to concerns about application

could directly affect client outcomes.

and transfer of information (i.e., availability of

Practice models and methods require

research studies, guidelines, and practice

solid understanding and supervised training.

descriptions), we also do not have a clear idea

Social workers, like any professionals, are

of standards to be used in assessing prac-

likely to function better when they are

titioner training and competencies for apply-

engaged in approaches with which they are

ing specific EBP practices. Although some

comfortable and well-trained. But where does

EBPs articulate practitioner competencies

EBP as a process draw the line? Is it acceptable

needed for implementation, others do not,

for a practitioner to have a favored method of

and for those that do, it is not clear how

working? Is there a set of skills that can be

adherence to skill level requirements could be

transferred from case to case, the nonspecific,

monitored in the day-to-day operations of an

generalist practice skills? Zayas, Gonzales,

agency culture.

and Hansen (2003) have thoughtfully addressed this question, suggesting that social work

Competent and Confident Practice

has the process of engagement and termina-

In the EBP model, social workers are encour-

tion down pat, but we need to use EBPs for

aged to take a nonauthoritative stance and to

the middle portion of treatment. To our

admit uncertainty (Gambrill, 1999, 2001,

knowledge, they are among the few scholars

2003). The client is seen as a full partner, and

writing about EBP recently to credit social

the social worker determines how to work

work’s unique and positive attributes that are

with each client based in part on client values

already in place and that we can build on.

as well as the research evidence available. The

Most writers about EBP have largely ignored

social worker is essentially starting anew with

the issue of continuity of skills and methods

each type of client or target problem. On the

that may contribute to a sense of competence

one hand, every type of human services inter-

and comfort among practitioners.

action is better if it is individualized to the

How in the 2 years of MSW programs are

needs of the particular client and situation.

students learning to conduct all these different

However, at the extreme, the EBP process

treatments? And once in practice, who is going

model suggests that a social worker attempt-

to supervise them as they struggle to adapt to

ing to use the best available evidence could

a number of different practice approaches?

end up trying to conduct cognitive behavioral

Might it not be more practical, and more real-

therapy with some clients, motivational inter-

istic, to give students an in-depth practice

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JOURNAL OF SOCIAL WORK EDUCATION

14

experience that they can carry with them and

endeavor and is also the one we know

apply to much of the work they do? As previ-

the least about. We must be honest

ously

variables,

about our current limitations. EBP is an

including competence, relationship skills, and

emerging approach, and it will take

alliance with the client, are among the nonspe-

considerable time and effort to make it

cific factors related to obtaining positive client

work. (p. 608)

discussed,

practitioner

outcomes. In this sense, it is the social worker’s influence that provides the condition for

We agree with this statement. But future

client change to take place (Duncan et al.,

generations of social workers will not auto-

1992). Social workers attempting to imple-

matically gain “practice wisdom” without

ment practice approaches without having the

good teaching in practice, above, beyond, and

time, supervision, and solid understanding of

aside from anything to do with seeking out

the approaches will be less apt to be authentic

research evidence. As Goldstein argues, EBPs

with clients, satisfied with their work, or con-

taught in isolation, “separated from the core

fident in their abilities, that is, less apt to be

principles that define clinical social work

effective practitioners.

broadly defined do not provide students with a holistic approach to practice that helps them

The Role of Clinical Decision Making (Practice Wisdom)

make professional judgments,” (2007, p. 20). Failure to adequately offer those crucial clini-

Although writings on the EBP model in social

cal skills (e.g., skills in assessment, engage-

work assert that clinical wisdom and expertise

ment, goal setting, monitoring) and failure to

remain important (e.g., Mullen & Streiner,

take into account real-life messiness and the

2004), we do not have a clear template for how

highly interactive nature of practice, means

practitioners will balance clinical wisdom with

we are at risk of sending into the world social

available research evidence. How does this

work graduates who are poorly prepared for

look in practice? A number of authors have

the realities of practice.

made valiant efforts to address this issue (McNeill, 2006; Pollio, 2006), but as their

Agency and Practice Constraints

reported experiences suggest, it has not been

Agency needs, missions and mandates, input

easy. To our knowledge, there is little hard

from supervisors and administrators, and

data on the way EBP works in practice. Schlon-

resource limitations all factor into how social

sky and Stern (2007) state the following:

workers practice. Practitioner and client acceptance and other aspects of clinical utility,

It takes a great deal of clinical skill to

such as organizational processes that may

successfully integrate current best evi-

facilitate or impede implementation, are

dence with client preferences/actions,

important in contextually analyzing the feasi-

clinical state/circumstances, and the

bility of EBP. Writing about child welfare,

practice context. Indeed, this coming

Whiting-Blome and Streib (2004) argue “Un-

together is the hardest part of the

fortunately, no one evidence-based program

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LIMITATIONS OF EVIDENCE-BASED PRACTICE

leads to faster reunification, more stable place-

existing knowledge. In the fast-paced

ments, or higher rates of recovery from addic-

world of many clinical settings, social

tion. Many programs and practices may affect

workers need feasible strategies that

these outcomes depending on a myriad of

allow them to balance the many com-

organizational and staffing issues” (p. 611).

peting demands on their time and

They further focus on ways agency context

resources. (p. 148)

15

affects efforts to adopt EBP: There is a great deal of human need that Engagement has solid evidence as a

professional social workers heroically try to

practice that may enhance reunifica-

meet every day. Requiring the use of the EBP

tion. Individualized planning is not

process or sanctioned EBPs will not change

only a federal mandate, but also repre-

this and may be counter-productive in some

sents good practice and should be

instances.

done with engaged families. But if the worker has large caseloads and short

Inequities in Implementing EBP

time frames and the agency favors

The social and economic justice implications

computer-generated plans, organiza-

related to implementation of an EBP approach

tional expectations may thwart imple-

across populations, settings, and organiza-

mentation of engagement strategies

tions have not been adequately addressed.

deemed successful through studies. (p.

Reliance on EBP may set up barriers to service

613)

that discriminates against those clients and agencies with less economic means, decreased

Singer (2006) provided another relevant

human and social capital, and minimal per-

example when he attempted to implement an

sonal or organizational influence. What type

EBP protocol but discovered some of the EBP

of agencies will have the appropriate re-

procedures were against agency policy.

sources to keep up with researching the latest

Human services agencies and practition-

literature and implementing practice updates?

ers are faced with many issues. A survey of

What other aspects of organizational capacity

agency-based field instructors found lack of

will be diminished in EBP implementation

time was the top barrier to implementation of

efforts and at what human cost to which pop-

EBP (Edmond, Rochman, Megivern, Howard,

ulations in which organizational settings? As

& Williams, 2006). McNeill (2006), writing

a practice matter, how much time should

about implementation of EBP, states,

agencies devote to active searches for evidence? In an era of cost containment, who will

I suspect many clinicians would find it

pay for such efforts?

a daunting task, particularly if they do

How will incorporation of EBP processes

not have all of the requisite skills such

be implemented in fair and equitable ways

as those needed to gain access to the

across agencies, populations served, and com-

literature and analyze the quality of

munities (e.g., urban vs. rural; private- versus

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16

JOURNAL OF SOCIAL WORK EDUCATION

public-funded; well-connected vs. isolated or-

prietary nature of our society may inhibit its

ganizations)? Will insurance companies begin

full-scale implementation. How can social

uncritically supporting a short list of certain

work as a profession respond to this challenge?

EBP protocols without attention to differential application according to gender, age, race,

Conclusions

ethnicity, or culture, particularly if such differ-

As social work researchers and teachers of

ential specification is missing from the empir-

social work practice, we are very much in

ical literature? Will there be disproportionate

favor of establishing the evidence base in

referring out of ethnic and minority groups on

social work practice through a variety of

whom such EBPs have not been conducted, if

research approaches and clinical and case

practitioners cannot ensure competency with

reporting as well as teaching students about

such groups? Will such treatments be denied

research evidence, how to access and interpret

to groups who might benefit from the treat-

it, and how to apply it within a solid concep-

ment because the research has not extended to

tual framework for practice. We favor the def-

these groups? Or will such treatments be

inition of the social work practitioner as life-

blindly applied to diverse groups despite the

long learner, open to new knowledge and evi-

lack of empirical support?

dence to inform practice. However, as out-

The practical complications of becoming

lined in this article, we believe there are signif-

an EBP agency or practitioner have not been

icant limitations to EBP, and that EBP should

fully addressed and raise difficult questions

not replace much of what is already in place in

about implementation. Technological resources

social work education and practice. This is a

for the EBP model are not consistently avail-

question of emphasis. Skills in finding and

able in practice settings (Rubin & Parrish,

interpreting research evidence are among

2007a). Many agencies do not have the up-to-

many other very important skills for students

date Internet connection that is needed to do

of social work. We caution against making

extensive online searching and downloading.

broad changes to the curricula at schools of

Most do not subscribe to the research databas-

social work to incorporate the process of EBP,

es that universities and social work faculty

as these changes risk diminishing theory,

members are fortunate to access. Manualized

knowledge of human development, practice

treatments are frequently available only to

skills, and clinical teaching.

those who can pay the cost of the manuals as

Good social work practice, and by exten-

well as the cost of training and licensure. Both

sion, good social work education for future

interpersonal psychotherapy and multisys-

practitioners, needs to be grounded in theory

temic therapy are managed by organizations

and practice skills overlaid with in-depth

that sell manuals, training, and licensure

training in selected intervention approaches.

through the organization. The proprietary na-

It is an ethical responsibility to our students

ture of many of these endeavors means that

and the profession to offer the skills they will

they can be costly for agencies and individual

need to begin practice competently and confi-

practitioners. As EBP becomes valued, the pro-

dently. It is important to recall the mistakes

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LIMITATIONS OF EVIDENCE-BASED PRACTICE

17

and missteps of the past as we move forward

Cummings, S. M., Kropf, N. P., Cassie, K. M.,

with EBP. We wish to see the dialogue about

& Bride, B. (2004). Evidence-based treat-

EBP in social work education avoid ideologi-

ments with older adults. Journal of

cal rhetoric. A focus on both the advantages

Evidence-Based Social Work, 1(4), 53–81.

and limitations of EBP is needed as the social

De Los Reyes, A., & Kazdin, A. E. (2008).

work profession begins to incorporate EBP

When the evidence says, “Yes, no, and

content into its curriculum.

maybe so.” Current Directions in Psychological Science, 17, 47–51.

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Accepted: 04/08 Kathryn Betts Adams is assistant professor, Case Western Reserve University. Holly C. Matto is associate professor, Virginia Commonwealth University. Craig Winston LeCroy is professor, Arizona State University. Address correspondence to Kathryn Adams, Mandel School of Applied Social Sciences, Case Western Reserve University, 10900 Euclid Ave., Cleveland, OH 44106; e-mail: [email protected].