I am a believer in the importance of social workers (and other health and social service professionals) using research evidence to inform their practice. That’s why I spend hours teaching reluctant social work students statistics and research methods and how to evaluate the quality of a research study. I am also straightforward about the challenges they will face in actually doing this. New research is published at a fast and furious pace and even a practitioner with the best of intentions can’t keep track of it all and keep up with already unwieldy caseloads and other demands of the job. Faced with the choice between helping a client in crisis and digesting the latest research on [insert your favorite problem here], of course we’ll pick the client.
Increasingly states mandate the use of particular evidence-based practices (EBPs), enacting laws that restrict state funding to programs shown to achieve particular outcomes. On the face of it this seems reasonable. After all, we want our tax dollars paying for services and programs that will work, right? (Do you see the ubiquitous but coming?)
But, mandating EBPs is fraught with a host of issues, particularly when providing services for people from underrepresented communities. An article just published in the journal Administration and Policy in Mental Health and Mental Health Services Research by Sarah Walker and colleagues from the University of Washington School of Medicine and School of Law highlights some of these issues in the context of behavioral interventions for American Indian and Alaskan Native youth. The article presents results from a gathering of tribal leaders and representatives from various state departments involved with the Washington State juvenile justice system. The focus of the gathering was to inform participants about evidence-based practices related to juvenile justice and behavioral health and get their feedback about the practices and their implementation methods. The evidence-based practices presented were those eligible for state funding.
The issues that emerged are applicable for work with other groups as well. At the most fundamental level, research supporting many mandated EBPs does not include people from underrepresented groups. How then can we say that these practices are truly evidence-based for them? In addition, the outcomes measured, and therefore validated as the “appropriate” outcomes are determined by the researchers, sometimes with input from community members, but often not. One of the themes that emerged in the study by Walker et al was respect for tradition including making sure that project outcomes align with those of the client or the community.
Many EBP outcomes may already be aligned with group values and needs. Other can be made to work with minimum adaptation. In reality, evidence-based practices are almost always adapted whether it is ad hoc or formal. From a researcher’s standpoint this is a headache, particularly in the initial stages of implementation. If practitioners adapt an program as they see fit, it compromises the research design and inhibits are ability to say that it was actually this intervention that caused (or failed to cause) change. But once some solid evidence supports a program and it begins to be used more widely, expecting no adaptation to occur is simply unrealistic and ignores the complexity of the various contexts in which EBPs are used. So why not encourage adaptation and provide tools for it to be done in a thoughtful way?
Walker et al note that when done thoughtfully, adaptation should not be a onetime adjustment, but a process that happens from the initial planning to implementation to efforts to sustain the project. Changes may need to be made in when, where, and how information is shared – for example, integrating information sharing into already existing community gatherings. It may take longer to engage some communities and explore the options. It may be important to integrate existing traditional programs into the EBP rather than replacing them. Methods of implementing the program may need to be adapted as well. For example, Walker et al found that a common theme discussed was the importance of providing services at home for logistical reasons, but also because of tribal values around family. They also discussed the pros and cons of non-native therapists and the need for them to have credibility within the community. It may also be necessary to broaden enrollment criteria to ensure sufficient numbers. Results from the gathering suggest that developing tribal consortiums and learning communities is one way to address these adaptations and provide a mechanism to help sustain programs. Such consortiums are already part of collaboration among tribes in this context. Other methods may be more appropriate in other contexts.
Really, this is all just good social work practice and is in line with how I and others teach evidence-based practice – integrating the best available research evidence with the needs and wishes of the client, community, or organization and with our clinical judgement as a professional; working with the client or community to decide how best to move forward; and checking in regularly to see how its working and what adjustments need to be made. Of course, that’s all easy for me to say sitting here snug behind my desk with a snoring cat on my lap. Putting it into action on the ground with funders, agencies, clients and other stakeholders having a say is a different matter altogether.