Note: this article was originally published in the August 2006 newsletter of the National Association of Social Workers, Oklahoma chapter (NASW-OK).

Evidence-Based Practice: a Holy Grail or the Emperor with No Clothes?

By Kevin Acers, MSW

        Evidence-Based Practice (EBP) is being promoted with greater and greater urgency in the mental health field of which social work is a part. Study after study appear in journals documenting the pursuit of this empirical Holy Grail: a sacred chalice brimming with EBP models matched to specific diagnoses and populations. Meanwhile, heavenly visions of EBP-linked dollars appear in the clouds, courtesy of the funding deities, further inspiring would-be Percevals on their mythical quest.

        In less Arthurian terms, once the state and federal holders of the purse strings give a model the EBP nod, savvy agencies can enhance their perceived legitimacy by implementing it, better positioning themselves for competitive funding.

        At first glance the push for EBP appears to serve the interests of both clients and of the profession. It is a safeguard against quackery (or less sleazy, unintended forms of ineffectiveness) and demonstrates the science in social science.

        That said, constructive dissent is important to any profession. While the EBP movement is fast taking hold, it has its detractors. In the spirit of critical reflection, I invite readers to question the premise that Evidence-Based Practice means superior, predictably effective practice.

        It is a premise that is a powerful driving force in the economics of our profession. It is based on the assertion that social workers “should use knowledge that has been gathered and tested empirically in the most rigorous ways possible” in order to best meet our ethical obligations to clients (Payne, 2005).

        Alternative views exist, however. For example, social constructionism and other interpretivist perspectives see EBP as “naïve” in its attempts to measure the “rich, complex reality” of human situations and social work practice (Payne, 2005). How people make sense of their lives is at the heart of social work and cannot be accurately captured, it is suggested, by randomized clinical trials and their statistical analyses of outcomes. Interpretivists question the empirical view of knowledge, and by extension the validity of EBP’s purported “evidence.”

        Other critics use a broader view of empirical evidence to challenge the EBP trend. In a book chapter entitled “The Myth of the Medical Model,” Duncan, Miller, and Sparks (2004) sneer at EBP as “the ultimate silver bullet.” They decry EBP as an “empirically bankrupt notion” based on the “crazy idea” that treatment procedures and techniques are “isolated from the most powerful factors that contribute to change -- the client’s resources, perceptions, and participation” (pp. 38-39). They point to meta-analyses of decades’ worth of therapy (Hubble et al, 1999). This research suggests that client-related factors account on average for 85% of the benefits clients experience, whatever the professional’s theoretical stance or the model/techniques employed.

        The implication here is that instead of focusing on the idiosyncrasies of different models, whose procedures must be artificially standardized in order to fit into a conventional research design, practitioners -- and funding sources -- would be wiser to focus on the factors the different models have in common: client resources and strengths; the placebo effect of client hopes and expectations; and most importantly, the quality of the therapeutic relationship between professional and client. The authors insist that these are far more critical than the factors that EBP takes into account. And the research backs them up.

        The meta-studies they reference (Hubble et al, 1999) bolster their argument that transtheoretical factors -- the common factors different models share -- are what make therapy effective, not the competing models themselves. The rise to EBP superstardom of CBT, then, may be more attributable to its lending itself to the standardization required of randomized clinical trials than to any actual superiority over more individualized procedures that emerge from the therapeutic relationship and follow the client’s own theory of change.

        The effective tailoring of therapy to accommodate individual clients is likely a more widespread practice than clinically preserving the “purity” of CBT or any other EBP model. Absurdly, such practice cannot be validated as being evidence-based and effective because individualized interventions defy the controlled experiment designs that are the basis of EBP!

        What, then, are social workers and other helping professionals to conclude? Shall we uncritically pursue the EBP Holy Grail? Do we play the tired game of “going along to get along?” Or do we consider adding our voices to the shouts from the back of the crowd that the EBP emperor has no clothes?

__________________________________________________

Duncan, B.L., Miller, S.D., & Sparks, J.A. (2004). The heroic client: A revolutionary way to improve effectiveness through client-directed, outcome-informed therapy. San Francisco: Jossey-Bass.

Hubble, M.A., Duncan, B.L., & Miller, S.D. (1999). The heart and soul of change: What works in therapy. Washington, DC: American Psychological Association.

Payne, M. (2005). Modern social work theory (3^{rd ed.). Chicago: Lyceum Books.}