Evidence-based Policy and Practice in Mental Health Social Work

Martin Webber

• Publisher: Learning Matters
• Year: 2011
• Print ISBN: 9780857254252
• eBook ISBN: 9780857254269
• Edition: 2
• Topic: Social Sciences
• Subtopic: Social Work
• Index: Social Sciences

Mental health social workers work within multidisciplinary teams, often based in health settings. The variety of services they work within are shaped by mental health policy that is increasingly being influenced by research evidence of ?what works?. This fully-revised second edition has a new chapter on systematic reviews and greater coverage of the impact of the 2007 amendment to Mental Health Act 1983 on mental health practitioners and services.

Chapter 1
Epistemology and evidence-based practice in mental health social work

Introduction

Mental health social workers typically work within multidisciplinary settings alongside colleagues from a variety of health disciplines. In statutory settings, mental health social workers work in community mental health teams, early intervention teams, assertive outreach teams, crisis resolution and home treatment teams and a range of specialist services. Many of these services are the products of evidence-based mental health policy or guidelines from the National Institute for Health and Clinical Excellence (NICE). As these services increasingly impinge on social work practice, it is important for social workers to have the skills and confidence to engage with the research evidence on which they are based.

In these teams social workers typically work alongside psychiatrists, psychologists, community psychiatric nurses, occupational therapists, education and employment workers and other social care workers. Increasingly social workers are called upon to justify their practice to their health colleagues whose training is founded on empirical research evidence from within a scientific paradigm. As social work practice is traditionally derived from theoretical schema rather than empirical research, this can lead to a number of misunderstandings. In the worst case, the profession is perceived as lacking in credibility as it struggles to articulate its evidence base.

This presents a serious challenge for mental health social work, which already faces the battle of convincing sceptical health managers of the strengths of the profession. Social workers undoubtedly make a unique contribution to these teams and they are particularly respected for their specialist knowledge and application of mental health law (Gould, 2010). However, their contribution to the mental health evidence base is meagre in contrast to the prolific research activity of psychiatrists and allied health professionals (Huxley, 2001; McCrae et al., 2003).

To equip social work practitioners with the skills to understand and evaluate the evidence on which their practice is based, the notion of evidence-based practice may be a useful concept to consider. Although it has its origins in medicine, the concept can help practitioners to consider the best available empirical research evidence when they are making important decisions in their day-to-day work. To gain influence on mental health policy and its own professional future, social work needs to develop its evidence base and the confidence to assert its contribution to mental health services (McCrae et al., 2004; Webber, 2010).

This chapter will review contemporary evidence-based practice in social work and the nature of ‘evidence’. We will outline different methods used in mental health research that will be explored in more depth later in this book. We will then critically evaluate some of the criticisms of the evidence-based practice paradigm with reference to the epistemology of social work research.

A brief history of evidence-based practice in social work

Contemporary interest in evidence based practice in social work can be traced to an article written by Geraldine MacDonald and colleagues in the early 1990s (Macdonald et al., 1992). In contrast to earlier reviews that focused solely on experimental studies (e.g. Reid and Hanrahan, 1980), MacDonald and her colleagues looked at the results from experimental studies, quasi-experimental studies, pre-experimental and client-opinion studies of the effectiveness of social work. They found that three-quarters of reviewed papers produced positive results, evidence to bolster the profession which they felt at that time was rather ‘beleaguered’ (p.640).

However, this review acknowledged that the evidence on the effectiveness of social work practice was limited to research on therapeutic work which did not reflect the full complexity of social work roles. Discrete interventions such as behavioural therapy or family therapy can be more easily subjected to methodologically rigorous studies such as randomised controlled trials than complex social work interventions that involve a range of tasks including advocacy, liaison, co-ordination, making referrals and management of resources, for example. This early indication that effectiveness research can be biased towards the easily-researchable, which hasn’t changed much in the last 20 years (Mullen and Shuluk, 2011), is a theme we will return to later.

In 1996 the Department of Health invested in the establishment of the Centre for Evidence-Based Social Services at the University of Exeter. Headed by Professor Brian Sheldon, a leading exponent of evidence-based practice, this development saw a renewed focus on the research evidence that underpins social work practice. The Centre worked in partnership with 15 local social services departments to develop evidence-based practice. Similar academic centres for evidence-based practice in health and social care were established at universities in Salford, Oxford, Nottingham and York.

At the same time Department of Health policy was placing a stronger emphasis upon evidence. For example, the Framework for the Assessment of Children in Need and their Families (Department of Health, 2000a) and the National Service Framework for Mental Health (Department of Health, 1999c), both placed a strong emphasis on research evidence to inform practice and service models. Contemporary policy remains strongly influenced by research. The Social Care Institute for Excellence (SCIE) and NICE both publish influential guidance based on research evidence that influences mental health social work practice.

Definition of evidence-based practice

What exactly do we mean by the phrase ‘evidence-based practice’? Sheldon and colleagues adapted a definition of evidence-based medicine (Sackett et al., 1996) and derived the following, which has remained as the core definition of evidence-based practice in social work ever since:

Evidence-based social care is the conscientious, explicit and judicious use of current best evidence in making decisions regarding the welfare of those in need of social services.

(Sheldon and Chilvers, 2000: 5, adapted from Sackett et al., 1996)

This adaptation embodies a conceptual transfer from medicine to social care. Some see this as the colonising of social care practice by medicine, whose traditions, values and origins are different and, possibly, at odds with each other. However, others argue that the concept validates social care interventions through the production of good evidence of effectiveness. These perspectives will be discussed below. Meanwhile, let’s consider the three key elements of the definition that its authors highlight.

Key elements of evidence-based practice

Firstly, a conscientious practitioner is one who uses interventions with good evidence of their effectiveness. This may sound obvious, but social workers are not immune from making mistakes. Professional competence is crucial to the future of social work and is scrutinised through the process of registration. By using the most effective interventions and having an up-to-date understanding of personal and social problems, social workers are more likely to be able to provide an effective service to the people they work with.

It is good practice for social workers to be as explicit as possible with the people they work with about what they are doing and why they are doing it. It is important to review available options with service users, informed by a thorough assessment of their needs and an understanding of research on relevant effective interventions.

Finally, judicious practice is based on the exercise of sound, prudent and sensitive judgement. It requires practitioners not to be influenced by outside pressures. Social workers operate under the potential spotlight of media infamy and professional disgrace if a tragedy were to unfold as a result of a decision they made. For example, if a social worker working as an Approved Mental Health Professional decided on the best-available evidence not to compulsorily admit someone to hospital, although they had the necessary medical recommendations to do so, and this person went on to commit a homicide, their professional career would be all but over. It has even been suggested that the risk-averse society in which we live could have been responsible for the increasing numbers of people admitted to hospital under the Mental Health Act 1983 during the 1990s (Rogers and Pilgrim, 2003), a pattern that has been exacerbated in the 2000s due to cuts in bed numbers (Keown et al., 2008). An imperative of evidence-based practice is to remain judicious in the face of these external pressures.

Evidence-based practice is about considered rather than reflexive action. Or, in other words, it requires practitioners to consider evidence before making decisions, rather than acting first and reflecting after the event. This involves a critical appraisal of research findings to inform judgements about possible courses of action. However, it also requires supervisors to assist practitioners and discuss case-specific pieces of evidence in supervision with them.

Definition of evidence

What exactly do we mean by ‘evidence’? According to the Cambridge Advanced Learner’s Dictionary, ‘evidence’ is ‘one or more reasons for believing that something is or is not true’ (Cambridge Dictionaries, 2007). This definition is rather vague so let’s explore it a little further.

Imagine that you are sitting on a jury of a murder trial. A number of witnesses will take the stand to give evidence. They might include the defendant, witnesses of the incident, character witnesses, police, paramedics, forensic scientists, pathologists or expert witnesses, for example.

Jury members are asked to assess the reliability of the evidence given by each witness to assist them in deciding on the defendant’s guilt or innocence. It is likely that they will consider evidence given by witnesses of the incident or character witnesses to be of varying quality and reliability. People who witnessed the incident may have had a limited view of it or may have forgotten some details about it by the time of the trial. Also character witnesses often present biased evidence in favour of the person’s character that they are defending. Their evidence often encounters fierce cross-examination from opposing barristers.

On the other hand, the evidence provided by forensic scientists or pathologists is often considered to be consistently valid and reliable. It often holds up under cross-examination and can hold the key to the jury making a decisive verdict. Their evidence is often held in high regard as it is seen to be objective, scientific and independent (although there have been, of course, cases where it has been found to be flawed).

Scientific paradigm

In the same way, evidence in health and social care that is largely considered to be consistently valid and reliable is based on scientific principles. The scientific paradigm has been conveniently summarised by Bolton (2002) and comprises the following elements:

• Objectivity of observation, based in sense-experience – this is the opposite of subjective, esoteric, un-replicable knowledge based in intuition.
• Experiment – knowledge is not only based on observation of reality, but in the process of intervention and observation. The idea of an experiment is a question that we test out.
• Causality – the aim of the experiment is to determine a causal process, to find explanations of events and to make predictions.
• Generality – causality is vital to the establishment of general laws of nature.

Randomised controlled trials

The application of scientific principles to evaluations of health and social care interventions is most clearly exemplified in the methodology of the randomised controlled trial (RCT). This is widely used in medicine in the evaluation of drug treatments and in psychology in the evaluation of talking or behavioural therapies, for example. It is now increasingly being applied to social care interventions, but not without its attendant problems.

The RCT is widely viewed as the ‘gold standard’ method of intervention evaluation. It involves the random allocation of a study population to a new intervention, known as the ‘case group’, or to a benign or placebo intervention, known as the ‘control group’. The random allocation controls the influence of any other associated factors and is perhaps the most important element of this methodology. Accurate measurements of the outcomes of interest are taken using standardised measures before and after the intervention. The effect of the intervention is calculated using a statistical comparison between the two groups, which need to be sufficiently large to detect this accurately.

The UK 700 study is an example of an RCT (Burns et al., 1999...

Table of contents

• Cover
• Title
• Copyright
• Contents
• List of figures
• List of tables
• Foreword by Professor Peter Huxley
• Foreword by the Series Editor
• About the author
• Acknowledgements
• List of abbreviations
• Introduction
• 1 Epistemology and evidence-based practice in mental health social work
• 2 Contemporary mental health social work: a synergy of professional practice and legal process
• 3 Mental health policy: shaping social work practice
• 4 Mental health policy: exploring its evidence base
• 5 Becoming an evidence-based practitioner: steps towards evidence-based practice in mental health social work
• 6 How to critically appraise cross-sectional surveys
• 7 How to critically appraise randomised controlled trials
• 8 How to critically appraise cohort studies
• 9 How to critically appraise case-control studies
• 10 How to critically appraise systematic reviews
• 11 Demystifying p-values: a user-friendly introduction to statistics used in mental health research
• 12 How to critically appraise qualitative studies
• Conclusion – Advanced practitioners: bringing research into practice
• Appendix 1
• Appendix 2
• Bibliography
• Index