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Families in society: the Journal of contemporary social services ©2013 alliance for children and Families issn: Print 1044-3894; electronic 1945-1350

2013, 94(2), 79–84 Doi: 10.1606/1044-3894.4283

Evidence-based practice or Evidence-guided practice: A Rose by Any Other Name would Smell as Sweet [Invited Response to gitterman & knight’s “Evidence- guided practice”] Bruce a. thyer

Gitterman and Knight (2013) expand upon the original model of evidence-based practice (eBp) by proposing an

approach they label evidence-guided practice (eGp). they justify this by highlighting some supposed limitations of

the original eBp model and by presenting some additional features to amend eBp into eGp. i attempt to show that

the limitations they say characterize eBp are not actually a part of the real eBp model and are based upon either a

misreading of the eBp literature, or by overlooking some of the features of eBp. i also try to demonstrate that most

of the add-on elements to eBp they propose to label eGB are actually already present in the original model of eBp.

one of their add-ons, an increased reliance upon formal theory as evidence, in addition to empirical research, seems

to me a retrograde step and will perpetuate the harmful influence of some aspects of theory in social work practice.

However, i judge their eGp model to be an improvement upon current social work practice, which largely tends to

ignore empirical research findings to assist in decision making.

it is encouraging to see such distinguished social workers as Alex Gitterman and Carolyn Knight (2013) address the issue of evidence-based practice (EBP), try and identify some of the shortcomings of EBP, and propose some con- structive improvements for the model of EBP, resulting in a related perspective they label “evidence-guided practice” (EGP). In their article I find a number of points about EBP and its supposed limitations that have appeared in the social work literature, as well as a number of new ideas. Their goal is admirable—to improve upon the practice models which can promote social workers’ efforts to improve practice outcomes. I share this goal and it is in this spirit that I will try and address what I believe to be some misconceptions in their presentation of EBP—misconceptions which, once cor- rected, demonstrate that EBP already possesses most of the features of their proposed alternative, evidence-guided prac- tice. It goes without saying that I appreciate their willingness to engage in this dialog, as well as the invitation from the co-editors of Families in Society to author this response. It is worth noting that the first article introducing the topic of evidence-based practice to a social work audience appeared in this journal (Gambrill, 1999).

to begin my response in a simplified manner, it seems to me that gitterman and Knight (2013) make some claims about the model of ebP and say it is associated with certain limitations or undesirable features, which i will generically call features abC. They propose their alternative model, egP, which is said to possess the more desirable attributes of features XYZ. What i will try and do in this response is to demonstrate that the undesired features abC said to characterize ebP, are actually not a part of the ebP model. Moreover, i will try and demonstrate that the desired features XYZ are ac-

tually already present in ebP. Thus, there is no need for any modification or amplification of ebP as it is pres- ently construed in the primary sources of information about this practice model.

Undesired Features Said to be Associated with Evidence-based practice

evidence-based proponents argue that social workers should base their practice decisions on a critical review of available intervention strategies for particular client’s challenges and difficulties. the intent is to identify and employ those techniques that have been found to help an individual, family, or group with a specified problem. the social worker selects the most relevant, empirically verified approach. (gitterman & Knight, 2013, p. 70)

This misrepresentation asserts that the social worker selects the intervention based on the research evi- dence. There is no apparent role for client input or consideration of other factors, such as environmental considerations. in reality, ebP is much more holistic than that. so that the reader has a clear understand- ing of what ebP really is, i provide the definition pub- lished originally in Evidence-Based Medicine (now in its fourth edition):

evidence-based medicine (ebM) requires the integration of the best research evidence with our clinical expertise and our patient’s unique values and circumstances....by patient values we mean the unique preferences, concerns and expectations each

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patient brings to a clinical encounter and which must be integrated into clinical decisions if they are to serve the patient....by patient circumstances we mean their individual clinical state and the clinical setting. (straus, glasziou, richardson, & haynes, 2011, p. 1, emphasis in original)

understanding this definition of real ebP is cru- cial to avoid any implication that ebP is only about research evidence. it is equally about client values, expectations, and circumstances. research does not trump these other considerations—they are all equally and compellingly important. This is largely ignored in presentations on ebP which appear in the social work literature and convey the impression that in ebP one merely selects the best supported treatments. This is a massive distortion and its repetition is likely respon- sible for some of the resistance to this approach.

since the professions of social work and medicine have different functions, social work’s renewed reliance on medical tenets is puzzling. (gitterman & Knight, 2013, p. 71)

This is the hoary canard that ebP is a medical model. it is not. it originated in medicine, but is itself atheo- retical with respect to etiology (biological or psychoso- cial), neutral with respect to who provides the services (physicians versus social workers), and neutral with respect to what those services should be (e.g., biologi- cal or psychosocial). in contrast, the medical model asserts that a given condition has a biological etiology, interventions are focused on biological interventions such as drugs or surgery, and the service providers should be physicians. ebP possesses none of these fea- tures of the medical model. ebP is a broadly scientific model but its origins in medicine need no more imply adherence to a medical model than the use of split-plot factorial studies in social work research means that one is following an agricultural model (from whence r. a. fisher derived this type of experimental design in statistical science). The disciplinary backgrounds of the founders of a model need have no direct bearing on that model’s applicability to social work. ebP is being widely adopted across all the health care and human service professions because of its utility in operation- alizing a more scientific approach to practice, not be- cause it is somehow intrinsically medical.

evidence-based practice proposes that specific interventions exist to solve most types of problems, and social workers can find them and then use the most effective—the “best”—intervention. (gitterman & Knight, 2013, p. 71)

no, ebP requires one to search the current best litera- ture to find out what methods of assessment and inter- vention possess the greatest amount of scientific sup- port. There is no a priori assumption that the answer already exists, only the mandate that one seek out the available evidence. and there is no assertion that one must use the “best” evidence, if the most promising in- terventions are somehow unsuitable. amputation of the hands of convicted thieves might effectively deter na- scent criminals from stealing, but the ethics and laws of our country prohibit cruel and unusual punishment. if a client is clinically depressed, the research might well indicate that cognitive behavior therapy (Cbt) is a well-supported treatment. if, however, the client was intellectually disabled and unable to comply with the self-monitoring and homework exercises required of Cbt, the evidence-based social worker may suggest an intervention less well-supported. a practitioner can still adhere to the original ebP model while not offering the best research-supported interventions if there are con- flicting or counterproductive ethics, client preferences and values, or environmental considerations present. This flexibility is inherent in the approach.

Complex social problems do not lend themselves to narrow and discrete interventions that are the foundation of evidence-based practice. (gitterman & Knight, 2013, p. 71)

it depends. sometimes complex social problems require complex interventions, and sometimes they respond well to simple interventions. ebP lends itself equally well to simple as well as complex interventions. Witness the large amount of work being undertaken in the field of social policy using the traditional ebP model (boruch, 2012; bogenschneider & Corbett, 2010; Vanlandingham & drake, 2012) and the fine work of the Coalition for ev- idence-based Policy (see http://coalition4evidence.org). a review of the completed systematic reviews available on the websites of The Campbell Collaboration (http:// www.campbellcollaboration.org) and The Cochrane Collaboration (http://www.cochrane.org) reveals many examples of complex health and social problems (e.g., the effectiveness of welfare-to-work programs) which have been extensively investigated using high-quality research studies. What alternative to evidence-based practice do we have to tackle complex social problems? The status quo?

evidence-based social work practice emphasizes studies that typically involve brief, cognitive, and skill-focused interventions...less straightforward, harder-to-measure problems and interventions are excluded. (gitterman & Knight, 2013, p. 71)

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similar complaints have been registered with respect to the application of randomized controlled trials (rCts) in general. if the advocates of longer term and more complex interventions fail to undertake cred- ible evaluations of their own methods, whose fault is that? are we surprised that a new model such as ebP is initially explored with simpler practice issues rath- er than more complex ones? There is a natural pro- gression to the types of intervention research studies needed to investigate the effectiveness of treatments, usually from simpler to more complex problems, in- terventions, and environments. This can take many years. but it is being done.

There is nothing with the original model of ebP to preclude more complex studies. in any event, this sup- posed limitation is being overtaken by events since rCts, meta-analyses, and systematic reviews are being conducted on complex problems and interventions. to illustrate, the december 2011 issue of the Clinical Social Work Journal contains a number of articles discussing a widely cited meta-analysis of the effectiveness of long- term psychodynamic psychotherapy. see also rosebor- ough, Mcleod, and bradshaw (2012) for an innovative social work outcome study on psychodynamic psycho- therapy, and drisko & simmons (2012) for a compre- hensive survey of the evidence base for psychodynamic psychotherapy. ebP places no limitations on the types of problems investigated or interventions tested. if an intervention can be applied, its outcomes can be evalu- ated. if client functioning can be validly measured, the potential impacts of intervention can be assessed. More complex interventions and problems increase the diffi- culty of the task but they do not preclude it.

the realities of contemporary social work practice work against a purely evidence-based orientation. Most social workers simply do not have access to bibliographic databases and the peer-reviewed literature, both of which are required to practice from an evidence-based foundation...practicing social workers lack the skills and expertise necessary to operate from an evidence-based foundation. (gitterman & Knight, 2013, p. 72)

The increasing ease of access to these databases and literature is rendering this point moot. Much useful information is available via open-access electronic sources (see, for example, gary holden’s wonderful resource information for Practice, available at http:// ifp.nyu.edu/); government-maintained websites, such as the national registry for evidence-based Programs and Practices, supported by the substance abuse and Mental health services administration (see http:// www.nrepp.samhsa.gov); and the national Coalition for evidence-based Policy, cited above. greater num-

bers of colleges grant library access privileges to their alumni. at one point, office computers were said to be too expensive to be made widely available for use by social workers. time took care of that problem. The problem of limited access to the research literature is similarly being taken care of. regardless, this limita- tion is one that is shared with gitterman and Knight’s alternative, egP, which also requires access to such da- tabases and literature.

it is embarrassing and limiting for us to assert that our graduates lack the skills and expertise necessary to operate from an ebP perspective. again, if true, whose fault is this? are social workers any less intelligent or re- search-trained than, say, nurses, public health workers, or other largely bachelor’s- and master’s-level profes- sions which have widely adopted ebP? We have barely begun focusing our professional training in the research skills needed to effectively engage in ebP (shlonsky, 2009)—namely how to formulate answerable questions (gambrill & gibbs, 2009), track down the best available literature (rubin & Parrish, 2009), critically analyze it (bronson, 2009), apply any lessons learned to our work with our own clients, and evaluate our effectiveness in carrying out ebP. instead, we teach a wide array of re- search methods with little connection to those needed to carry out ebP (e.g., how to conduct a survey study), in lieu of how to conduct outcome research on our own practice—a crucial skill needed for ebP.

Desired Features Said to be Associated with Evidence-guided practice

We intentionally use the term evidence-guided to refer to an approach to practice in which interventions are suggested, rather than prescribed, by research findings...it also recognizes the uniqueness of the individual and the inherent dignity and worth of the person. evidence-guided practice reinforces client empowerment and clients’ right to self- determination...it adopts an ecological view of client problems and worker interventions. (gitterman & Knight, 2013, p. 72–73, emphasis in original)

Yet, these features are also true of ebP. The evidence in ebP is only used as a guide, and taken into account when considering clients’ preferences and values, professional ethics, and clinical and environmental circumstances. it only takes a reading of the primary sources describ- ing ebP to realize this. for example, here is what the founder of the term evidence-based medicine, gordon guyatt, asserted as central to this model:

as a distinctive approach to patient care, ebM involves two fundamental principles. first, evidence alone is never sufficient to make a clinical decision.

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decision makers must always trade the benefits and risk, inconvenience and costs associated with alternative management strategies, and in doing so consider the patients values. (guyatt & rennie, 2002, p. 8, emphasis added).

Knowing the tools of evidence-based practice is necessary but not sufficient for delivering the highest quality of patient care. In addition to clinical expertise, the clinician requires compassion, sensitive listening skills, and broad perspectives from the humanities and social sciences. these attributes allow understanding of patient’s illnesses in the context of their experience, personalities and cultures...for some of these patients and problems, this discussion should involve the patient’s family. for other problems-attempts to involve other family members might violate strong cultural norms. (guyatt & rennie, 2002, p. 15, emphasis added)

understanding and implementing the sort of decision-making process patients desire and effectively communicating the information they need requires skills in understanding the patient’s narrative and the person behind that narrative... Most physicians see their role as focusing on health care interventions for their patients....they focus on individual patient behavior. However, we consider this focus too narrow....Physicians concerned about the health of their patients as a group, or about the health of the community, should consider how they might contribute to reducing poverty (guyatt & rennie, 2002, p. 16, emphasis added)

any presentation of ebP that solely focuses on ap- plying research evidence to make important practice decisions and ignores the unique features of indi- vidual clients or larger societal or contextual issues is either a mischaracterization, a misunderstanding, or uninformed.

unlike evidence-based practice, egP explicitly recognizes relevant theory. theories, as well as research, provide significant guidelines for practice.... evidence-guided practice reflects...a solid grounding in theory. (gitterman & Knight, 2013, p. 74)

This is a legitimate observation, but i consider the atheoretical nature of ebP to be a strength, not a limi- tation to this approach. although nothing in the ebP model precludes a judicious consideration of relevant theory as possibly pertinent to one’s searching for evi- dence, in terms of helping to make practice decisions it posits a decided preference for relying on sound data-based studies in lieu of theoretical conceptualiza-

tions. Though there is nothing as practical as a good theory, there is also nothing as harmful as a bad one (Thyer, 2012). Many theories in social work have been and are actively injurious to practitioners and clients. They waste our time, most are not well-supported empirically, and many have led to the development of interventions which do not work and in some cas- es are harmful. give me a good empirical study over theoretical speculation any time. given how academic social work has traditionally prized theory develop- ment and extension (Thyer, 2002), i suspect that the relative lack of focused attention on theory in ebP is a source of much resistance to this model, as it flies in the face of some our most cherished views. Yet egP provides no guidance on how to select theory—surely all theories are not equally valid? ignoring this issue leaves the field wide open to every wildly speculative conceptualization proposed by someone. We now have social workers being taught reiki (using one’s hands to realign a client’s supposed invisible body energies) by our academic programs (i am not making it up), as if it were a legitimate model of practice for our field. Why? because it is an appealing theory to some.

When social workers rigidly adhere to prescribed interventions, they are unable to be authentically present or actively listen to clients’ verbal and nonverbal responses. [gitterman and Knight go on to critique the use of practice manuals.] (gitterman & Knight, 2013, p. 75)

first off, practice manuals and guidelines are an en- tirely different model of practice than ebP, having pre- ceded it by many years. There is nothing in the ebP literature that elevates practice manuals above any other form of evidence; rather, manuals would still need to be located, critically reviewed, and used only if the evidence is sufficiently supportive. ebP is actually rather suspicious of practice guidelines, since so many of them are of poor quality. for example, straus et al. (2011) note:

While substantial advances have been made in the science of guideline development, less work has been done to enhance the implementability of guidelines. often, recommendations lack sufficient information or clarity to allow clinicians, patients, or other decision-makers to implement them. and guidelines are often complex and contain large numbers of recommendations with varying evidential support, health impact and feasibility of use in practice and decision making...ideally, guidelines should include some mentions of values, who assigned these values (patient derived or author derived) and whether they came from one source or many sources. the

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values assumed in a guideline, either explicitly or implicitly, may not match those of our patient or our community. (pp. 128–129)

are gitterman and Knight correct in their cautions about the role of practice guidelines and treatment protocols? indeed, and in doing so they share views identical with those of ebP and reservations which i have expressed elsewhere (Thyer, 2003).

Summary

it is very important that social workers who wish to learn more about evidence-based practice take the time to read the original sources on this innovative and influential model. Much of the social work litera- ture on ebP relies on second- and third-hand inter- pretations. sackett, straus, richardson, rosenberg, and haynes (2000); straus, glasziou, richardson, and haynes (2011); and guyatt and rennie (2002) are good places to begin.

it is particularly important to recognize that ebP is independent from, and has nothing to do with, other similar-sounding initiatives (Thyer & Myers, 2011), such as the empirically supported treatment (est) initiative of division 12 (society of Clinical Psychol- ogy) of the american Psychological association, or the empirical clinical practice model developed within social work (Jayaratne & levy, 1979). Yet ebP is often confused with the est model which does rely solely on lists of “approved” treatments for various disorders, or upon the earlier and continuing practice guideline movement which describes intervention protocols for clients with various conditions. ebP does not designate any treatment as “evidence-based.” doing so would elevate the research elements of the model above the other equally important ones, such as clinical exper- tise, client’s personal values, expectations, and situa- tion. as i have written earlier, there are no such things as evidence-based practices (Thyer & Pignotti, 2011). nowhere in the primary ebP literature will you find lists of approved treatments or practice guidelines, yet this is the common conception of the model and one seemingly shared by gitterman and Knight. abandon this misconception, carefully read the real ebP liter- ature, and you will find that it shares almost all the features proposed by gitterman and Knight in their evidence-guided practice model.

eileen gambrill, who introduced to the concept of ebP into the social work literature (1999), has recently used the phrase evidence-informed practice in lieu of ebP, in part due to her concern that the phrase evi- dence-based inadvertently perpetuates the misconcep- tion that ebP ignores other nonresearch factors in ar- riving at decisions (gambrill, 2010; gambrill & gibbs,

2009). now gitterman and Knight suggest the term evidence-guided practice, in part for the same reason. good luck with that. The ebP train has left the station and it will prove very difficult to amend this crucial phrase. however, it makes little difference to me, ebP or egP, so long as the five steps of the original ebP model (straus et al., 2011) are adhered to, perhaps with some additions. i believe that this is the case with git- terman and Knight’s practice model. With apologies to William shakespeare, let me close by paraphrasing Juliet from Romeo and Juliet:

o ebP, ebP! wherefore art thou ebP? deny thy father and refuse thy name; ’tis but thy name that is my enemy; thou art thyself, o, be some other name! What’s in a name? that which we call a rose by any other name would smell as sweet; so ebP would, were he not ebP call’d, retain that dear perfection which he owes Without that title. ebP, doff thy name; and for that name, which is no part of thee, take all myself.

References bogenschneider, K., & Corbett, t. J. (2010). Evidence-based

policymaking. new York, nY: routledge. boruch, r. (2012). deploying randomized field experiments in the

service of evidence-based crime policy. Journal of Experimental Criminology, 8, 331–341.

bronson, d. e. (2009). Critically appraising studies for evidence- based practice. in a. r. roberts (ed.), Social workers’ desk reference (2nd ed.; pp. 1137–1141). new York, nY: oxford university Press.

drisko, J. W., & simmons, b. M. (2012). the evidence-based for psychodynamic psychotherapy. Smith College Studies in Social Work, 82, 374–400.

gambrill, e. (1999). evidence-based practice: an alternative to authority-based practice. Families in Society: The Journal of Contemporary Human Services, 80, 341–350. doi:10.1606/1044- 3894.1214

gambrill, e. (2010). evidence-informed practice: antidote to propaganda in the helping profession. Research on Social Work Practice, 20, 302–320.

gambrill, e., & gibbs, l. (2009). developing well-structured questions for evidence-informed practice. in a. r. roberts (ed.), Social workers’ desk reference (2nd ed.; pp. 1120–1126). new York, nY: oxford university Press.

gitterman, a., & Knight, C. (2013). evidence-guided practice: integrating the science and art of social work. Families in Society: The Journal of Contemporary Social Services, 94(2), 70–78. doi:10.1606/1044-3894.4282

guyatt, g., & rennie, d. (eds.). (2002). Users’ guides to the medical literature: Essentials of evidence-based clinical practice. Chicago, il: american Medical association.

Jayaratne, s., & levy, r. l. (1979). Empirical clinical practice. new York, nY: Columbia university Press.

roseborough, d. J., Mcleod, J. t., & bradshaw, W. h. (2012). Psychodynamic psychotherapy: a quantitative, longitudinal perspective. Research on Social Work Practice, 22, 54–67.

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rubin, a., & Parrish, d. (2009). locating credible studies for evidence-based practice. in a. r. roberts (ed.), Social workers’ desk reference (2nd ed.; pp. 1127–1136). new York, nY: oxford university Press.

sackett, d. l., straus, s. e., richardson, W. s., rosenberg, W., & haynes, r. b. (2000). Evidence-based medicine: How to practice and teach it (2nd ed.). new York, nY: Churchill livingstone.

shlonsky, a. (2009). evidence-based practice in social work education. in a. r. roberts (ed.), Social workers’ desk reference (2nd ed.; pp. 1169–1176). new York, nY: oxford university Press.

straus, s. e., glasziou, P., richardson, W. s., & haynes, r. b. (2011). Evidence-based medicine: How to practice and teach it (4th ed.). new York, nY: Churchill livingstone.

thyer, b. a. (2002). the role of theory in research on social work practice. Journal of Social Work Education, 37, 9–25.

thyer, b. a. (2003). social work should help develop interdisciplinary evidence-based practice guidelines, not discipline-specific ones. in a. rosen & e. K. Proctor (eds.), Developing practice guidelines for social work intervention: Issues, methods, and research agenda (pp. 128–139). new York, nY: Columbia university Press.

thyer, b. a. (2012). the potentially harmful effects of theory in social work. in b. a. thyer, C. n. dulmus, & K. M. sowers (eds.), Human behavior in the social environment: Theories for social work practice (pp. 459–487). new York, nY: Wiley.

thyer, b. a., & Myers, l. l. (2011). the quest for evidence-based practice: a view from the united states. Journal of Social Work, 11, 8–25.

thyer, b. a., & Pignotti, M. (2011). evidence-based practices do not exist. Clinical Social Work Journal, 39, 328–333.

Vanlandingham, g. r., & drake, e. K. (2012). results first: using evidence-based policy models in state policymaking. Public Performance and Management Review, 35, 550–563.

bruce A. Thyer, phD, lCsW, professor, Florida state University. Cor- respondence: Bthyer@fsu.edu; College of social Work, Florida state University, 296 Champions Way, tallahassee, Fl 32306.

invited response submitted: December 21, 2012 accepted: January 9, 2013 invited response editors: Jessica strolin-Goltzman and susan e. mason

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