Developing Practice Guidelines for Social Work Intervention

Issues, Methods, and Research Agenda

Aaron Rosen, Enola K. Proctor, Aaron Rosen, Enola Proctor

• Publisher: Columbia University Press
• Year: 2003
• eBook ISBN: 9780231508988
• Topic: Social Sciences
• Subtopic: Social Work
• Index: Social Sciences

This book bridges the gap between social work knowledge and empirically based practice. Although there is a significant need for the use of empirically tested and verified knowledge in social work practice, the empirical basis of support is nearly absent from practitioners'considerations as they make clinical decisions in routine practice. The authors advocate the development of readily available, accessible, and professionally sanctioned practice guidelines for use by practitioners, a necessity in the age of managed care and demands for greater accountability, effectiveness, and efficiency in practice. This book features a much-needed discussion of racial and ethnic differentials in relation to practice guidelines and on the relationship between practice guidelines and different aspects of service delivery.

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PRACTICE GUIDELINES AND THE CHALLENGE OF EFFECTIVE PRACTICE

AARON ROSEN AND ENOLA K. PROCTOR

This book addresses what we believe is the most basic challenge facing the profession of social work—ensuring the effectiveness of social work practice. This complex and multifaceted task has two primary dimensions: (1) ensuring the availability of tested knowledge that is relevant to and can inform effective practice and (2) ensuring that social work practitioners have access to, understand, and properly use that knowledge in their work. This book examines these two dimensions through the concept of practice guidelines.

Practice guidelines, which have been the subject of considerable developmental work in allied professions, are also being discussed with increasing frequency within social work (cf. Howard and Jenson 1999, chapter 5, this volume). In general, across all professions espousing them, practice guidelines are viewed as a means to ensure that practitioner behaviors conform to desirable standards. Explicit adherence to guidelines of desirable practice is intended to promote the effectiveness of practice, reduce variability in implementing best practice, increase the predictability of practice behaviors, and enhance client confidence in treatment as meeting professional standards.

Practice guidelines are meant to assist practitioners in decision making; potentially, they can address any aspect of practice in which decisions and resultant behaviors are likely to vary among practitioners—determining eligibility for service, performing assessment and diagnosis, selecting and implementing interventions, and evaluating treatment results, for example. In this volume we focus on practice guidelines for selecting and implementing interventions. Our working definition of practice guidelines is that they are a set of systematically compiled and organized statements of empirically tested knowledge and procedures to help practitioners select and implement interventions that are most effective and appropriate for attaining the desired outcomes. We believe that this definition is applicable to all the contributions in this volume.

Practice guidelines that meet this definition serve as an indispensable tool for confronting the two basic challenges of social work practice—enhancing practitioner use of tested and appropriate knowledge and encouraging further knowledge development that is attuned to and addresses the needs of practice. These two themes are further developed in the following chapters. The volume concludes with a singular focus on the knowledge needed for effective practice and an attempt to evolve and suggest the format and substance of a research agenda to guide further development and use of practice guidelines.

PREMISES UNDERLYING OUR APPROACH TO SOCIAL WORK PRACTICE

This volume, its content, and its organization are rooted in a number of premises that we see as basic and necessary for responsible social work practice. Although some are widely espoused among social workers, we realize that they may not be universally endorsed—in substance or in emphasis. These premises are so basic to practice that they merit full discussion. But because their analysis and the advocacy of their pros and cons appear throughout the social work literature, we will mention here only those principles that are most germane to explicating the assumptive framework of our approach (Rosen 1993).

First, like most professional endeavors, social work practice is utilitarian and goal directed, with improvement in the clients’ welfare being its ultimate purpose. That is, social work practice must be justified by the pursuit of worthwhile goals for its clientele. Accordingly, the primary criterion for undertaking service and for selecting practice methods should be evidence of their potential to achieve the desired goals for clients. Second, since social work is a profession with a public mandate, its sanction to practice is conditioned on a number of expectations (which are also shared by other professions). The expectations most pertinent to this discussion are the following:

1. Social work practice is not random but is guided by a body of knowledge and skills that are discernible and transmittable and that facilitate attainment of its socially worthwhile and publicly sanctioned goals.

2. Social work is responsible for maintaining the institutions necessary to update its knowledge base, to train its practitioners, and to oversee the proper and ethical discharge of its services.

3. Practicing as part of a publicly sanctioned profession, social workers must be accountable—to clients, to peers, and to a variety of sanctioning bodies. Accountability is most rudimentarily expressed by a commitment to and a responsibility for demonstrating that practice is effective and efficient. Demonstrating the effectiveness of practice requires evidence that service goals have been achieved and that goal attainment was causally linked to the activities (programs, methods) undertaken to reach the goals. Demonstrating efficient practice also requires evidence that service goals are attained with the least possible cost—in time, money, effort, and client suffering. Thus, in order for social work practice to be accountable it must be subject to scrutiny according to acceptable evidentiary standards.

4. A fourth basic premise is that professional knowledge in general, and knowledge that guides intervention in particular, must be tested and supported by empirical evidence obtained and evaluated according to prevailing scientific standards. Such standards must include, at the minimum, an explicit and systematic procedure for defining, gathering, and analyzing relevant evidence.

5. Finally, human behavior, individually and in the aggregate, as well as the process of behavior change, is complex and multi-determined. Hence, interventions cannot be viewed as or expected to be uniformly applicable or universally effective. Their effectiveness is likely to vary in relation to the out-comes that are pursued, to the problem and other client characteristics, and to factors of the helping and in vivo situation.

LACUNAE IN PRACTICE AND RESEARCH

Unfortunately, the correspondence between these basic premises and day-to-day, real-world practice cannot be assumed. Indeed, the gap between some of the premises and the realities of practice is considerable. We believe, however, that through the development and use of practice guidelines the gap can be appreciably narrowed. In this section we note instances in which practice, as well as efforts to develop practice knowledge, diverges from some of these premises.

Social work has long vacillated between approaches to practice that are intuitive, relying on implicit considerations, and those that advocate greater explicitness of and transparency for the rationales that guide practice decisions (cf. Rosen, Proctor, and Livne 1985; Rosen 1993; Zeira and Rosen 2000). Particularly as they pertain to the process of clinical treatment, the implicit and ad hoc nature of practice decisions has been defended and even extolled (Kondrat 1992). Such an orientation to practice necessarily compromises the standards of accountability and evidence, as well as rendering practice non-amenable to systematic evaluation and study (Rosen 1994).

Another departure from the basic premises of practice, which is likely reinforced by a nonsystematic and implicit approach to decision making, is the extremely low utilization in practice of the products of research—and hence of interventions whose effectiveness has been empirically tested (Rosen 1994; Rosen et al. 1995). Not only is there little actual utilization of research products in practice, but studies have also found little practitioner exposure to practice-relevant research, as well as reluctance to use systematic approaches to practice, such as single-system designs (Cheatham 1987; Fischer 1993; Kirk and Penka 1992; Richey, Blythe, and Berlin 1987).

Compounding these trends has been social work’s relative neglect of undertaking the kind of research that aims to develop and test the effectiveness of interventions. As we found in a recent survey of research studies published in social work journals, research focusing on development and testing of interventions to influence and change human conditions has been meager compared with research devoted to description and explanation of existing conditions (Rosen, Proctor, and Staudt 1999). These findings reinforce the by-now-prevalent calls for social work to intensify its efforts and investment in intervention research (Austin 1999; Fortune 1999; Fortune and Proctor 2001; Schilling 1997; Task Force on Social Work Research 1991).

Research devoted to development and testing of effective interventions has also been justly criticized for insufficiently taking into consideration and investigating possible moderators of effectiveness, such as different conditions and settings of practice and diverse characteristics of client populations. Interventions tested under selective or optimal conditions (efficacy studies) are not similarly or necessarily effective when applied to different populations under a variety of service conditions (Chambless and Hollon 1998; Newman and Tejeda 1996; Seligman 1996). There is undoubtedly a need to intensify and improve basic intervention research and efficacy studies using randomized clinical trials (RCT), but further research is also needed to test the effectiveness of interventions across different clienteles and settings, and with more appropriate designs (see Fraser, chapter 2, this volume).

The extent to which practice uses research is undoubtedly related to the availability of research that is relevant to and capable of guiding interventions. Nonutilization, however, cannot be attributed simply to the relatively low volume of relevant research. Results of intervention research relevant to guiding practice are available both from within and from outside social work (Nathan and Gorman 1998; Reid and Fortune, chapter 4, this volume; Reid and Hanrahan 1982; Thyer and Wodarski 1998). Additionally, an interdisciplinary effort spearheaded by the Campbell Collaboration (Campbell Collaboration Steering Committee 2001) is conducting and compiling systematic reviews of research on intervention with the potential of informing practitioner decision making.

Assuming the availability of at least a modicum of relevant research on intervention, proponents of evidence-based practice (EBP) advocate its use in practice decisions, supplemented as necessary by nonresearch evidence. Practicing according to EBP tenets requires, in addition to adherence to the premises of responsible professional practice as described above, espousal of a critical attitude regarding practice decisions, involvement of and commitment to clients, and other practice attributes (Gambrill 1999, chapter 3, this volume). We concur with the objectives and premises underlying EBP, but we believe that it places too heavy a burden on practitioners, exceeding their capacity to systematically process and judiciously integrate research results from disparate studies (or critical reviews) and to then apply those results to treatment decisions for individual clients (Gigerenzer and Goldstein 1996; Janis and Mann 1977; Tversky and Kahneman 1974; Wilson and Brekke 1994). We think that in order to base decisions for individual clients on the best available evidence, practitioners must also be equipped with a means of organizing, synthesizing, and judiciously using empirically based probabilistic evidence to guide practice decisions. We view practice guidelines, as we conceive their function and structure (see Proctor and Rosen, chapter 6, this volume), as a requisite tool for implementing evidence-based practice.

PRACTICE GUIDELINES AND THE PRACTITIONER

Our position is that practice guidelines for social work intervention, particularly those having the features that we advocate and consider to be essential (see Proctor and Rosen, chapter 6, this volume), can enhance the correspondence between practice and the basic premises that underlie it. In particular, we believe that practice guidelines for intervention will aid practitioners in overcoming some of the hurdles that are inherent in everyday practice and will contribute to more responsible and empirically supported practice decisions. But a number of dilemmas need to be considered.

By their very nature, practice guidelines aim to increase the predictability of practice around a set of standardized “best practices” and reduce the variability between practitioners in departing from such practices. That intent brings to the fore a fundamental assumption that underlies the use of guidelines—and perhaps the use of all professional knowledge: In spite of its diversity and complexity, human behavior has significant commonalities, and interventions can have applicability across clients and situations. Thus, empirically supported principles warrant cautious generalization to clients and situations other than those that were directly studied. This assumption notwithstanding, we recognize that practice situations also have idiosyncratic elements and that in order to be maximally effective with different individuals and conditions, interventions need to be developed and tested for relevant groupings of clients and situations and carefully applied accordingly.

We acknowledge the uniqueness of individuals and of practice situations, but we disagree with extant particularistic notions of practice that view treatment as not amenable to appropriate use of preformulated interventive principles (Kondrat 1992). In that, we differ from such views as those of Witkin and Harrison, who, in a purportedly dispassionate discussion of EBP and the concept of evidence, argue the fallibility of all evidence for capturing the true existential meaning of practice, particularly the experiences of clients from diverse groups (Witkin and Harrison 2001). Although they state that preformulated interventions may be appropriate for problems that “are believed to exist stably across time and context,” they proceed to reject such a possibility “for a world characterized by shifting, multiple identities and relational constructions, in which an ‘outcome’ is at most the beginning of something else” (Witkin and Harrison 2001:294). Such characterizations of the realities of social work practice—highlighting the transitory, unique, and ephemeral in human behavior—serve only to place it outside the realm of responsible professional practice as we outlined it above.

Our position is that beyond their unique characteristics, individuals, problems, situations, and their associated behaviors can be distinguished along certain treatment-relevant dimensions or variables (e.g., age, ethnic origin, personality type, health status, service auspices). Individuals and situations with similar placement on a given dimension have some common characteristics and may be grouped by such. Development of practice guidelines must capitalize on such group-specific commonalities, for they permit formulation of better-targeted interventions than those based only on the more universal commonalities of human behavior. Description and understanding of commonalities and variability of behavior, within and across groupings, are important elem...

Table of contents

• Cover 
• Half title
• Title
• Copyright
• Contents 
• Preface
• List of Contributors
• 1. Practice Guidelines and the Challenge of Effective Practice
• Part I. Precursors of Guidelines: Intervention Research and Evidence-Based Practice
• Part II. Practice Guidelines for Social Work: Need, Nature, and Challenges
• Part III. Responsiveness of Practice Guidelines to Diversity in Client Populations and Practice Settings: The Idiographic Application of Normative Generalizations
• Part IV. Practitioner, Organizational, and Institutional Factors in the Utilization of Practice Guidelines
• Part V. Conclusion
• Index