Ethical considerations of evidenced based practice

Ethical Considerations of Evidence-based Practice By Rich Furman, MSW, PhD Furman, R. (2009). Ethical considerations of evidence-based practice. Social Work, 54(1), 82-84. Abstract: Evidence-based practice has become an important approach to social work practice. This paper highlights some of the ethical dilemmas which may be implicated by this approach, and encourages social workers and social work researchers to carefully consider these potential quandaries. Key Words: Ethics, evidence-based practice Introduction During the last decade evidenced-based practice has become increasingly influential in social work practice and education (Gilgun, 2005). The increasing influence is evidenced by the proliferation of articles and books about the subject (Chwalisz, 2003). Evidence-based practice has largely been accepted as a positive advancement in the profession (Fook, 2004; Gilgun, 2005). Its proponents contend that basing social work practice on research evidence is an important ethical mandate (Gibbs & Grambrill, 2002). Indeed, incorporating state-of-the-art knowledge and research has long been considered essential to good social work practice (Goldstein, 1990; NASW, 1999). It is perhaps because of this recognition that the potential ethical consequences of the evidencebased practice movement have too infrequently been explored. Science, and by extension evidencebased practice, hold elevated and privileged positions within modern societies, and are commonly viewed a value free, and accepted on face value. Yet, within any epistemology lies implicit values which silently guide those who adopt its approaches and methods. This is also true for social work movements, theories and perspectives; values are imbedded deeply within each and have implications for what problems the profession pays attention to, and how it responds to them. Embedded within the structure and core elements of evidence-based are implied organizing principles which can lead to the privileging of certain sets of values, knowledge and actions over others. Webb (2001) has asserted that “the emerging panacea of evidence-based practice in social work has thus far developed without critical commentary (p.15).” The purpose of this commentary is to briefly illuminate these tendencies as a means of stimulating dialogue and debate within the profession. The aim of this article is not to disparage the evidence-based practice movement, but to highlight some of the dilemmas which call for more careful exploration. Privileging Knowledge over Values 1 While the evidence-based practice movement does not ignore professional values, the importance of validated scientific evidence is the central aspect of the approach, and may overshadow social work values. While science has provided many valuable insights for social work, there is a risk of overreliance on knowledge. Gordon articulated this concern over forty years ago (1965) when she asserted: If knowledge is called on when a value is needed as a guide to action, the resulting action may be unpurposeful (p. 365). That is, social workers may achieve their stated aims, but their stated aims may not be the most important and necessary to achieve. Social work practice may indeed lose its “depth” or conscious. At its core, social work is a profession predicated on ideology and values (Perlman, 1986). For instance, one of the ways in which the elevation of knowledge over values can affect social work is through the privileging of efficiency over autonomy. If outcome research becomes the most important factor guiding social work service provision, a focus on client empowerment and autonomy may become at risk. For instance, research may show a specific medication or treatment approach to be most effective, yet a client may wish to handle these problems in a manner which is more consonant with their personal values or strengths. For example, a Puerto Rican client living in Philadelphia may wish to seek the services of a healer before they consider an evidenced-based cognitive behavioral or pharmacological intervention for their depression. While evidence-based practice does not call for practitioners to ignore the wishes of clients, it is feared that the focus on outcomes research will lead practitioners to overzealously “pushing” certain approaches. How this may affect work with vulnerable and oppressed populations over time is still unknown. Evidencedbased studies have not ascertained the degree to which the use of its practices impacts client empowerment, freedom, or "emancipation", longitudinally (Fook, Ryan & Hawkins, 1997). In the quest for effectiveness, vulnerable populations may become less empowered by the profession which has historically worked towards helping clients achieve psychosocial aims related to social 2 and institutional inequities. Evidence-based approaches have yet to demonstrate a focus on these core social work values. Privileging Some Types of Knowledge over Others One of the central notions of evidence-based practice is that certain types of knowledge are viewed as more valuable than others (Hardiman, Theriot & Hodges, 2005). Knowledge is ranked and classified in a hierarchical model in which knowledge gained through longitudinal, large sample studies are viewed as more valuable than other types of knowledge (Hoagwood, 2001). The language of evidence-based practice mirrors the language of logical positivism, the paradigm on which it is predicated; knowledge is evaluated as being more or less “reliable” or “valid”. However, many authors have argued that for social work practice, more heuristic, qualitative models may be more applicable to the actual nature of social work practice (Butler & Ford & Tregaskis, 2007; Heineman, 1981). Most research of this type is not based-upon large, generalizable samples, but instead in-depth explorations with smaller, more purposefully selected samples. Qualitative studies often seek to understand the meaning that clients place on how their problems and services are experienced, lending valuable insights for those who provide clients with direct services. In-depth qualitative studies serve the function of calling attention to the process variables of social work practice, which often are extremely useful in helping practitioners design services in real-world situations. Social work practice is complex, and calls for the creation of individually tailored services that often do not follow cookie cutter models and approaches. Qualitative data may be of particular important to social work practitioners who need to become sensitized to important client issues for which quantitative data may not lend sufficient insights (Furman, 2006). While not generalizable in the traditional sense, in-depth, qualitative data can resonate within the worker and help them develop empathic responses to their clients. This notion has been referred to in the 3 qualitative literature as “metaphoric generalizable,” (Stein, 2004) and is an essential means of learning about the lived experiences of diverse client populations (Langer & Furman, 2004) Privileging That Which is Measurable By its valuation of science as the dominant metaphor for the profession, evidence-based practice has naturally focused on issues and concerns that are relatively easy, or quick, to measure. Many topics are difficult to assess in controlled, randomized studies or experimental designs. For instance, large-scale social change efforts to ameliorate racism and discrimination often take years to accomplish. Change is often only made in incrementally, in ways that are difficult to assess. Often, less traditional forms of research or more theoretical scholarship are needed to help understand the social change process. The type of process variables that one would need to measure to help understand the processes of social change are considered to be a lower level of evidence to proponents of evidence-based practice (Thyer, 2002). Therefore, studies related to macro level, social change are less likely to be encouraged by those advocating for more scientific approaches to practice. Evidenced-based practice thus privileges micro level approaches that focus on problems that fit more neatly into a biological or mechanistic model. Imbedded within the mission of the profession are core values related to social change aims (Gibelman & Furman, 2008). This core mission includes the centrality of social justice, social change, and the empowerment of communities, groups, families and individuals. However, over that last quarter century, social work has become far more focused on the individual as a focus of intervention (Furman, 2003Furman & Bender, 2003). While numerous factors, such as managed mental health care, advances in biomedical treatments, and the movement towards a more conservative society have each contributed to this transformation, evidence-based practice, as it is currently constructed, contributes mightily to this shift in the profession. Privileging Developing Methods over Social Workers 4 Evidence-based practice has heretofore focused on social work methods and techniques. However, many evidence-based authors and developers have largely ignored some of the most compelling research on the nature of helping. Numerous studies and metaanylysis have shown the helping relationship to be the most significant factor in predicting outcomes in clinical practice (Lambert & Barley, 2001). Increasingly, schools of social work and social work training centers that focus on methods or technique may be paying less attention to developing social work students and practitioners themselves. It is through the vehicle of the self that social workers understand their own emotional blocks, biases, strengths and limitations that either facilitate or hinter their capacity to establish quality helping relationships. A program or educational experience (i.e. a practice course in a BSW or MSW program) that focuses predominantly on programmatic issues (i.e. effective programs and interventions) may not sufficiently help future social workers develop the capacity for self reflection, which is a key to developing functional or “good enough” helping relationships (Butler, Ford & Tregakis, 2007). Butler, Ford & Tregakis (2007) noted that postmodern scholars and practitioners in the United Kingdom, where the evidence-based practice movement is more developed and institutionalized than in the United States, are becoming increasingly concerned that social workers may be losing the capacity for professional use of self. In their view, social work approaches that focus on outcomes over process leads to an overly bureaucratic, rigid and unhelpful system of social care. Conclusion As noted, the purpose of this commentary is not to challenge the legitimacy or utility of evidence base practice, but to highlight some of the potential concerns with the approach. Researchers, proponents and practitioners of any approach must clearly understand its counterindications. By not critically examining potential value conflicts and considerations, the profession runs the risk of blindly adopting an approach that may, over time, need to be modified, adapted and changed. 5 References Chwalisz, K. 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