Evidence Based Practice
Content
EBP
This page offers a starting point for finding information on Evidence Based Practice [EBP].
There are many definitions of EBP with differing emphases. A survey of social work faculty even
showed they have different ideas about just what makes up EBP (This can be a source of confusion
for students and newcomers to this topic of study. Perhaps the best known is Sackett et al's (1996,
71-72) now dated definition from evidence based medicine: "Evidence based medicine is the
conscientious, explicit, and judicious use of current best evidence in making decisions about the care
of individual patients. The practice of evidence based medicine means integrating individual clinical
expertise with the best available external clinical evidence from systematic research. By individual
clinical expertise we mean the proficiency and judgment that individual clinicians acquire through
clinical experience and clinical practice. Increased expertise is reflected in many ways, but especially
in more effective and efficient diagnosis and in the more thoughtful identification and compassionate
use of individual patients' predicaments, rights, and preferences in making clinical decisions about
their care. By best available external clinical evidence we mean clinically relevant research, often
from the basic sciences of medicine, but especially from patient centered clinical research into the
accuracy and precision of diagnostic tests (including the clinical examination), the power of
prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive
regimens."
This early definition, however, proved to have some important limitations in practice. Haynes et al
(2002) - Sackett's colleagues in the McMaster Group of physicians in Canada - pointed out the
definition did not pay enough attention to the traditional determinants of clinical decisions. That is, it
purposefully emphasized research knowledge but did not equally emphasize the client's needs and
situation, nor the client's stated wishes and goals, nor the clinicians' expertise in assessing and
integrating all these elements into a plan of intervention.
The contemporary definition of EBP is simply "the integration of the best research evidence with
clinical expertise and patient values" (Sackett, et al. 2000, p. x). This simpler, current, definition
gives equal emphasis to 1) the patient's situation, 2) the patient's goals, values and wishes, 3) the best
available research evidence, and 4) the clinical expertise of the practitioner. The difference is that a
patient may refuse interventions with strong research support due to differences in beliefs and values.
Similarly, the clinician may be aware of factors in the situation (co-occurring disorders, lack of
resources, lack of funding, etc.) that indicate interventions with the best research support may not be
practical to offer. The clinician may also notice that the best research was done on a population
different from the current client, making its relevance questionable, even though its rigor is strong.
Such differences may include age, medical conditions, gender, race or culture and many others.
This contemporary definition of EBP has been endorsed by many social workers. Gibbs and Gambrill
(2002), Mullen and Shlonsky (2004, Rubin (2008), and Drisko and Grady (2012) all apply it in their
publications. Social workers often add emphasis to client values and views as a key part of
intervention planning. Many social workers also argue that clients should be active participants in
intervention planning, not merely recipient's of a summary of "what works" from an "expert" (Drisko
& Grady, 2012) Actively involving clients in intervention planning may also be a useful way to
enhancing client motivation and to empower clients.
Some in social work view EBP as a mix of a) learning what treatments "work" based on the best
available research (whether experiential or not), b) discussing client views about the treatment to
consider cultural and other differences, and to honor client self determination and autonomy, c)
considering the professionals "clinical wisdom" based on work with similar and dissimilar cases that
may provide a context for understanding the research evidence, and d) considering what the
professional can, and can not, provide fully and ethically (Gambrill, 2003; Gilgun, 2005). With much
similarity but some differences, the American Psychological Association (2006, p. 273) defines EBP
as "the integration of the best available research with clinical expertise in the context of patient
characteristics, culture and preferences." Gilgun (2005) notes that while research is widely discussed,
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the meanings of "clinical expertise" and "client values and preferences" have not been widely
discussed and have no common definition.
Drisko & Grady (2012) argue that the EBP practice decision making process defined by Sackett and
colleagues seems to fit poorly with the way health care payers enact EBP at a macro, policy, level.
Clinical social workers point to list of approved treatments that will be funded for specific disorders and note this application of EBP does not include specific client values and preferences and ignores
situational clinical expertise. Drisko & Grady point out that there is a conflict between the EBP model
and how it is implemented administratively to save costs in health care. While cost savings are very
important, this use of "EBP" is not consistent with the Sackett model. Further, the criteria used to
develop lists of approved treatments is generally not clear or transparent - or even stated. Payers very
often appear to apply standards that are different from multidisciplinary sources of systematic reviews
of research like the Cochrane Collaboration. Clinical expertise and client values too often drop out of
the administrative applications of EBP.
Evidence based practice is one useful approach to improving the impact of practice in medicine,
psychology, social work, nursing and allied fields. Of course, professions have directed considerable
attention to "evidence" for many years (if not for as long as they have existed!). They have also
honored many different kinds of evidence. EBP advocates put particular emphasis on the results of
large-scale experimental comparisons to document the efficacy of treatments against untreated control
groups, against other treatments, or both. (See, for example, the University of Oxford's Hierarchy of
Evidence for EBM). They do this because well conceptualized and completed experiments (also
called RCTs) are a great way to show a treatment caused a specific change. The ability to make cause
and effect determinations is the great strength of experiments. Note that this frames "evidence" in a
very specific and delimited manner. Scholars in social work and other professions have argued for
"Many Ways of Knowing" (Hartman, 1990). They seek to honor the knowledge developed by many
different kinds of research - and to remind clinicians, researchers and the public that the
conceptualization underlying research may be too narrow and limited. Thus Drisko & Grady (2012)
argue that EBP, as summarized by researchers, may devalue non-experimental research. Experiments
are only as good as the exploratory research that discovers new concepts, and the descriptive research
that helps in the development of tests and measures. Only emphasizing experiments ignores the very
premises on which they rest. Finally, note that EBM/EBP hierarchies of research evidence include
many non-experimental forms of research since experiments for some populations may be unethical
or impractical - or simply don't address the kinds of knowledge needed in practice.
All the "underpinnings" of experimental research: the quality of conceptualizations, the quality of
measures, the clarity and specificity of treatments used, the quality of samples studied and of the
quality and completeness of collected data are assumed to be sound and fully adequate when used to
determine "what works." There is also an assumption that the questions framing the research allow
for critical perspectives and are fully ethical. Social workers would argue they should also include
social diversity samples well - since diverse kinds of people show up at real world clinics.
International standards affirm basic ethical principles supporting respect for persons, beneficence and
social justice (see The Belmont Report.)
Is EBP only about Intervention or Treatment Planning?
No. This may be the most common application of EBP for clinical social workers, but the EBP
process can also be applied to a) making choices about diagnostic tests and protocols to insure
thorough and accurate diagnosis), b) selecting preventive or harm-reduction interventions or
programs, c) determining the etiology of a disorder or illness, d) determining the course or
progression of a disorder or illness, e) determining the prevalence of symptoms as part of establishing
or refining diagnostic criteria, f) completing economic decision-making about medical and social
service programs (University of Oxford Centre for Evidence-based Medicine, 2011), and even g)
understanding how a client experiences a problem or disorder (Rubin, 2008).
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EBP is also not the same as defining empirically supported treatments (ESTs), empirically supported
interventions (ESIs), or 'best practices.' These are different ideas and are based on different models.
These models don't include client values and preferences nor clinical expertise as EBP does.
EBP as a Social Movement
While EBP is most often described in terms of a practice decision-making process, it is also useful to
think of it as a much larger social movement. Drisko and Grady (2012) argue that at a macro-level,
EBP is actively used by policy makers to shape service delivery and funding. At a messo- level, EBP
is impacting the kinds of interventions that agencies offer, and even shaping how supervision is done.
Drisko and Grady (2012) also argue that EBP is establishing a hierarchy of research evidence that is
privileging experimental research over other ways of knowing. Experimental evidence has many
merits, but is not the only way of knowing of use and importance in social work practice. Finally, the
impact of EBP may alter how both practice and research courses are taught in social work. There are
other aspects of EBP beyond the core practice decision-making process that are re-shaping social
work practice, social work education, and our clients' lives. As such, it may be viewed as a public idea
or a social movement at a macro level.
Why Evidence Based Practice or EBP?
It is one step toward making sure each client gets the best service possible.
Some argue it helps keep your knowledge up to date, supplements clinical judgment, can save time
and most important can improve care and even save lives. Its a way to balance your own views with
large scale research evidence.
Some say it's unethical to use treatments that aren't known to work. (Of course, services may need to
be so individualized in unique circumstances that so that knowing "what works" in general may not be
the most salient factor in helping any particular client. Still, using the best available research
knowledge is always beneficial.)
Several web sites serve as portals to bodies of research useful to EBP. The focus on these
organizations varies, but the emphasis remains on (mainly) experimental demonstration of the
efficacy of treatments.
How is EBP Implemented in Practice?
Profiling research that informs professionals and clients about what works is where evidence based
practice starts. These summaries tells us what we know about treatment and program efficacy based
on experimental work - as well as what we don't know or aren't really sure about.
Having access to information on what works allows professionals, in conjunction with clients, to
select treatments that are most likely to be helpful (and least likely to be harmful) before intervention
is begun. Practice evaluation is quite different in that takes place at the start of treatment, during
treatment and after treatment. Practice evaluation also uses single case methods rather than large
sample, experimental research designs. EBP and practice evaluation work together very well, but
they have different purposes and use very different methods.
The creation of "User's Guides" is one way to make the results of research more available to
practitioners. In medicine, the idea is to get research results to the practitioner in an easy to
assimilate fashion, though this often has a price.
Funding is being offered to support EBP from governments and private/insurance sources.
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However, to understand and critically appraise this material, a lot of methodological knowledge is
needed. Sites offering introductions to the technology of EBP are growing.
How is EBP Taught?
There are some useful resources for Teaching and Learning about EBP. One fine example is offered
by Middlesex University in the United Kingdom which includes good information on critical
appraisal of information in EBP.
The State University of New York's Downstate Medical center offers a (medically oriented) online
course in EBP, including a brief but useful glossary.
The Major Sources of Research for use in EBP:
The Cochrane Collaboration [ www.cochrane.org ] sets standards for reviews of medical, health and
mental health treatments and offers "systematic reviews" of related research by disorder. The
Cochrane Reviews offer a summary of international published and sometimes pre-publication
research. Cochrane also offers Methodological Abstracts to orient researchers and research
consumers alike.
The Campbell Collaboration [ www.campbellcollaboration.org ] offers review of the impact of social
service programs. "The Campbell Collaboration (C2) is an organization that aims to help people
make well-informed decisions about the effects of interventions in the social, behavioral and
educational arenas. C2's objectives are to prepare, maintain and disseminate systematic reviews of
studies of interventions. C2 acquires and promotes access to information about trials of interventions.
C2 builds summaries and electronic brochures of reviews and reports of trials for policy makers,
practitioners, researchers and the public."
C2 SPECTR is a registry of over 10,000 randomized and possibly randomized trials in education,
social work and welfare, and criminal justice.
C2 RIPE [Register of Interventions and Policy Evaluation] offers researchers, policymakers,
practitioners, and the public free access to reviews and review-related documents. These materials
cover 4 content areas: Education, Crime and Justice, Social Welfare and Methods.
The United States government also offers treatment guidelines based on EBP principles at the
National Guideline Clearinghouse. [ http://www.guideline.gov/ ] This site includes very good
information on medication as wll as very clear statements of concern about medications indicated in
guidelines which later prove to have limitations.
The U.S. government provides information on ongoing, government sponsored, clinical trials.
Other Online Resources for EBP and Treatment Guidelines Derived from EBP Criteria and
Procedures:
The American Psychiatric Association offers Practices Guidelines. Please be aware that the numbers
of practice guidelines are few. Existing guidelines may be up to 50 pages in length. If you are not
allowed to enter via this hyperlink, paste the following URL into your browser:
http://www.psych.org/psych_pract/treatg/pg/prac_guide.cfm
The Agency for Healthcare Research and Quality also offers outcome research information. AHRQ
offers an alphabetical listing out outcome studies.
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Note that there are a growing number of commercial [.com] sites that offer their consultation
regarding EBP. It is not always easy to determine their organization structure and purposes, the basis
of their recommendations and any potential conflicts of interest. In this regard, the sites of the
government and of professional organizations are "better" resources as their purposes, missions and
funding sources are generally more clear and publicly stated.
References:
American Psychological Association. (2006). APA presidential task force on evidence based practice. Washington, DC: Author
Dobson, K., & Craig, K. (1998). Empirically supported therapies: Best practice in professional psychology. Thousand Oaks, CA: Sage.
Drisko, J. & Grady, M. (2012). Evidence-based practice in clinical social work. New York: Springer-Verlag.
Elwood, J.M. (2007). Critical appraisal of epidemiological studies and clinical trials (3rd ed.) New York: Oxford University Press.
Gambrill, E. (2003). Evidence-based practice: Implications for knowledge development and use in social work. In A. Rosen & E. Proctor
(Eds.), Developing practice guidelines for social work intervention (pp. 37-58). New York: Columbia University Press.
Gibbs, L. (2003). Evidence-based practice for the helping professions. New York: Wadsworth.
Gilgun, J. (2005). The four cornerstones of qualitative research. Qualitative Health Research, 16(3), 436-443.
Howard, M., McMillen, C., & Pollio, D. (2003). Teaching evidence-based practice: Toward a new paradigm for social work education.
Research on Social Work Practice, 13, 234-259.
Mace, C., Moorey, S., & Roberts, B. (Eds.). (2001). Evidence in the psychological therapies: A critical guide for practitioners.
Philadelphia, PA: Taylor & Francis.
Mantzoukas, S. (2008). A review of evidence-based practice, nursing research and reflection: Levelling the hierarchy. Journal of Clinical
Nursing, 17(2), 214-223.
Roberts, A., & Yeager, K. (Eds.). (2004). Evidence-based practice manual: Research and outcome measures in health and human services.
New York: Oxford University Press.
Sackett, D., Rosenberg, W., Muir Gray, J., Haynes, R. Richardson, W. (1996). Evidencebased medicine: what it is and what it isn't. British
Medical Journal, 312, 71-72. http://cebm.jr2.ox.ac.uk/ebmisisnt.html
Sackett, D., Richardson, W., Rosenberg, W., & Haynes, R. (1997). Evidence-based medicine: How to practice and teach EBM. New
York: Churchill Livingstone.
Simpson, G., Segall, A., & Williams, J. (2007). Social work education and clinical learning: Reply to Goldstein and Thyer. Clinical Social
Work Journal, (35), 33-36.
Smith, S., Daunic, A., & taylor, G. (2007). Treatment fidelity in applied educational research: Expanding the adoption and application of
measures to ensure evidence-based practice. Education & Treatment of Children, 30(4), pp. 121-134.
Stout, C., & Hayes, R. (Eds.). (2005). The evidence-based practice: Methods, models, and tools for mental health professionals. Hoboken,
NJ: Wiley.
Stuart, R., & Lilienfeld, S. (2007). The evidence missing from evidence-based practice. American Psychologist, 62(6), pp. 615-616.
Trinder, L., & Reynolds, S. (2000). Evidence-based practice: A critical appraisal. New York: Blackwell.
Wampold, B. (2007). Psychotherapy: The humanistic (and effective) treatment. American Psychologist, 62(8), pp. 857-873.
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WHAT IS EBP
Evidence based practice (EBP) might best be viewed as an ideology or a "public idea" in Robert
Reich's (1990) terminology. The movement began with the work of Scottish physician Archie
Cochrane who sought to identify "treatments that work" using the results of experimental research.
Another important aspect of Cochrane's interest was to identify and end treatments that do harm or are
not effective. In practice, the idea was to supplement professional decision making with the latest
research knowledge. [It is worth noting that some critics might argue "replace" professional decision
making might even be applicable.] The goal was to enhance the scientific base of professional
practice in several disciplines - medicine, nursing, psychology, social work, etc. In turn, educational
efforts in these disciplines could be oriented to provide beginning professionals with effective tools
and a model for the continuing improvement and renewal of their professional practices.
EBP as described here is not the same as an empirically supported treatment [EST]. ESTs are
variously defined, but are basically treatments or services that have been empirically studied and
found to be helpful or effective - in one or more settings. The difference is that ESTs may be
treatments or services that are not fully replicable in other settings and most have not been studied in
multiple contexts. ESTs may not have been replicated - tested more than once - to insure the result
will be the same or similar in another setting. The efforts of the Cochrane Collaboration include
setting rigorous standards for examining the methods by which outcome research is done as well as
reporting research results. This is to insure transparency in their findings [that others can know
exactly how the conclusions were drawn] and not to exaggerate the results of a single test of any
treatment.
Why EBP? Some Say Any Other Approach Is Unethical
Some advocates argue that to treat anyone using treatments without known efficacy is unethical. That
is, if we know a given medicine or substance abuse program or treatment for attachment problems
works better than another treatment, it is an ethical obligation to use it in order to best serve clients or
patients. This is an argument that is hard to challenge - at least in an ideal world. Given strong and
unambiguous research evidence that is clearly useful to a given practice situation, and consistent with
the client's world view and values, using EBP "best treatment" is the best way to go.
Policy and Funding Issues
In social work and psychology, advocates have also argued that only interventions with demonstrated
efficacy should be supported financially. Such an argument links demonstrations of efficacy with the
funding structure of the current managed care environment. It may be seen as either a way to best use
limited dollars or yet another method to curtail funding for costly services. Without provision of
adequate funds to do thorough research on the great variety of treatments in use, the requirement of
proven efficacy may be used as a tool to limit treatment services.
Assessing EBP -- Some Key Issues
In psychology, the initial unveiling of "empirically validated treatments" by an American
Psychological Association Task Force brought forth both interest and criticism. It also brought out
differences regarding interpretations of the existing research literature and regarding the merits of
certain research methods. One key concern was the over-reliance on randomized control trials
[RCTs]. An RCT is an experiment in which participants are randomly assigned to either a treatment
or a control group. Ideally, neither participant or treating clinician knows which group is which. After
a course of treatment (or control), improvement is determined by comparing pre-treatment status with
post-treatment status. If the treated group improves significantly more that the controls, we can say
the treatment caused the change and that the treatment works (better than no treatment). In another
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form of RCT, the best known treatment is compared to a new treatment using random assignment. If
the new treatment produces better results than does the standard treatment, it is viewed as empirically
supported and "more efficacious."
Efficacy versus Effectiveness
Some practitioners argued that the RCTs don't always reflect "real world" conditions well, so the
results of such studies may not be the same as what is found in real clinics. The core of the concern is
that RCTs often use carefully assessed participants that have only a single disorder and often have
relatively strong social supports. Real world clinics are rarely able to undertake similarly detailed
assessments and, even if they could, would often have to treat people with co-existing (co-morbid)
conditions, less persistence, perhaps fewer social supports and perhaps lower motivation to be in
treatment. Thus carefully run RCTs reflect laboratory conditions rather than real world conditions.
The distinction is know as "effectiveness" versus "efficacy. Laboratory RCTs produce knowledge
about the "efficacy" of a treatment - that it works under ideal conditions. Experimental studies done
under less carefully defined conditions reflecting the variation in real world clinics are known as
"effectiveness" studies.
Conceptualizations of Disorders
It should be noted that most researchers undertaking RCTs assume that the problems or disorders they
are studying are completely and adequately defined. In mental health, the definition of problems most
often follows the American Psychiatric Association Diagnostic and Statistical Manual of Mental
Disorders (DSM) or the World Health Organization's ICD Manual. These definitions vary in clarity
and in their own empirical validation.
Social workers adopt a world view that suggests problems are best understood by viewing "persons in
situations." That is, both external environmental and social factors as well as internal health and
psychological factors will be important in understanding the whole person. This perspective is
partially incorporated in the DSM's Axes IV and V, but in a summary form.
Operational Definitions of Problems
Simply put, EBP generally applies operational definitions of problems in RCT reviews of treatment
effects. This is consistent with the medical model of research and general use in psychology and
social work research. The potential limitation is that such definitions of target problems locate the
problem within the individual and (mostly) ignore social circumstances, supportive and/or
oppressive. This may represent a limited definition of the target problem or a flaw in
conceptualization.
In much organic medical treatment, causes or etiologies may be more clearer identified than is
possible (or at least currently possible) in the world of mental health and social problems. Thus
applying an outcome model that assumes a single, clearly identified "cause" and problems that reflect
symptoms may, or may not, be optimal. Further, different "doses" of treatment may be identifiable
for organic medical conditions but may be less clear cut in the functional, mental health and social
world. Both conceptual and operational diagnoses in mental health pose some challenges and
multiple, comorbid disorders are commonplace -- making real world practice quite different from
tightly controlled and extensively tested experimental studies. (Which ties back into the Efficacy vs.
Effectiveness issue described above.)
Common Factors versus Specific Techniques
Some argue that treatment effects are due more to "common factors" shared by therapies than they are
due to specific treatment techniques. The level of client motivation, the strength and quality of the
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therapeutic relationship, a shared vision of what treatment will include, a shared sense of hope or
expectancy of improvement and even placebo effects are elements of treatment common across
differences in theory and technique -- especially in psychotherapy and social services. RCTs are often
designed to test differences of technique, but ignore or limit the role common factors.
Several meta-analytic studies of psychotherapy for adults demonstrate empirically that several types
of therapy for depression and anxiety are effective. This indicates that common factors, rather than
different treatment techniques, generate roughly equivalent change (at least for these disorders).
On the other hand, Reid (1997) did a meta-analysis of social work interventions for several quite
different problems (mental retardation, smoking cessation, substance abuse. etc.). He found many
types of treatments were helpful but behavioral and cognitive approaches appeared to work better than
did the other techniques. Note, however, that the study compares "apples and oranges", aggregating
dissimilar problems.
The common factors versus specific techniques question is as yet unresolved. Some honor it, others
believe it is not particularly important.
Variation Among Clients, Clinicians and the Treatments they Deliver
Since most quantitative experimental studies are based on group means, we know that "on average"
treatments generate a certain effect. This is valuable information. Yet it does not help the clinician
distinguish which specific client is like the mean responder and who may differ. With medication
some people respond to a smaller than average does, others need more than the average to be helped.
We might assume the same is true in mental health - some people respond with less effort (or are able
to better use opportunities and resources) while others will need much more help (or are less able to
use their resources and opportunities) to improve. Thus the clinician is left to think critically and fit
aggregate treatment results to the specific, unique reality of a given client.
We must also assume that clinicians vary in ability to deliver any given treatment. Referral may be
indicated where a treatment in which one is not fully trained is indicated as the best practice.
We can also assume that their is variation in effectiveness even among well trained clinicians. Unlike
pills, mental health issues appear heavily influenced by relationship factors and expectancy factors.
The Client's Views About the Treatment
In a profession that supports autonomous decision making by the client or client system, clinical
social workers must ask the client about their views of what EBP suggest is the most likely effective
treatment. If the client has concerns about the treatment, these views must be honored. Eileen
Gambrill has developed this idea in several published articles.
Critical thinking and efforts to find knowledge are needed, along with efforts to individualize
treatment to the person and environment (including culture) of the client.
Practice Wisdom and What Professionals Can Do
It would seem wise to allow professionals to use their knowledge, skills, training and experience to
determine if the best available research knowledge fits well with the circumstances at hand. This may
take some wisdom and judgment; may not be automatic. Of course, some supporters of EBP believe
the purpose of EBP is in large part to limit such application of practice wisdom.
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It may also be the case that what research shows is most likely to help based on other's experiences
may not be something the professional is trained to provide or is not comfortable providing. Referrals
may be made in such instances.
Racial, Ethnic and Social Diversity
Many scholars note that there is very little research on services and treatments to populations of color,
immigrant populations (who may have culturally different ideas about mental health and its
treatment), class differences in treatment effectiveness, differences in sexual orientation, and
sometimes gender differences. Research on children, teens and the elder is also often minimal. EBP,
as much of medicine, assumes people are people and that treatments are universally effective. This
may often be so for organic disorders, but is less certain for socially complex concerns such as mental
disorders. Research on the effectiveness of many treatments on diverse populations is lacking. This
is a major shortcoming of EBP at this time.
Reference:
Reich, R. (1988). The power of public ideas. Cambridge, MA: Ballinger Publishing.
THE STEPS OF EBP
The Steps of the EBP Practice Decision-Making Process
There are several steps in doing EBP, but the number varies a bit by author. Still, the key content is
essentially the same in them all.
Drisko & Grady (2012) have worked carefully to honor client values and preferences along with
research evidence and clinical expertise in formulating these six steps of EBP:
1) Drawing on client needs and circumstances learned in a thorough assessment, identify
answerable practice questions and related research information needs;
2) Efficiently locate relevant research knowledge;
3) Critically appraise the quality and applicability of this knowledge to the client's needs and
situation;
4) Discuss the research results with the client to determine how likely effective options fit with
the client's values and goals;
5) Synthesizing the client�s clinical needs and circumstances with the relevant research,
develop a shared plan of intervention collaboratively with the client;
6) Implement the intervention.
Our care in wording the steps of EBP starts with the fact that doing EBP rests first on a well done and
thorough clinical assessment. This is not directly stated in the EBP practice decision-making model,
but is the foundation on which all good intervention planning rests (Drisko & Grady, 2011). We also
view intervention or treatment planning as participatory and collaborative between client and clinician
- not a top-down process (as it appears in many EBM/EBP textbooks). Client values and preferences
are key parts of EBP. Finally, clinical expertise is needed to insure the best research evidence really
fits this the views and needs of client in this situation.
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Additional Steps?
Step 7. A few authors (Gibbs, for one) appear to make practice evaluation an aspect of EBP. That is,
the professional should audit the intervention (to verify it was done appropriately) and evaluate its
yield. This makes some sense, but note that the practice evaluation of the single case would be done
using methods quite different from those used in EBP. Single case or single system designs can help
identify progress, but are based on replication logic rather than the sampling logic underlying
experimental research. That is, the case studies one would use in practice evaluation are not highly
valued in EBP research summaries. Still, practice evaluation is a key part of all good practice.
Step 8. A few authors (Gibbs, for one) also add sharing your results with others and work toward
improving the quality of available evidence. This would be useful but again does not necessarily draw
on the same core logic of experimental research EBP emphasizes. In fact, case studies are often
viewed as the least useful source of evidence in many EBP "evidence hierarchies". Note, however,
that such work may be very helpful in identifying to whom and in what circumstances the best
research evidence does not work or is not appropriate. Ironically, very small scale research may be
very useful in shaping how and when and where to use large scale experimental evidence to best
advantage. Clinicians should publish about their work, but individual case outcomes have ethical
challenges and may not be much valued within EBP hierarchies of evidence.
The University of Oxford offers a fine page on the Steps of EBM.
Note that all steps are meant to be transparent and replicable by others. That is, the steps should be so
clear you could re-do them yourself with enough time and access. It also means many things are
accepted at face value (or as face valid) such as definitions of mental and social disorders (usually
defined via DSM or ICD) though these categories do change over time. Measures of treatments are
assumed to be adequate, valid, reliable and complete. Treatments though often only broadly
described, as assumed to be replicable by others in different settings, with different training and with
different backgrounds.
Note, too, that EBP focuses on the outcome of treatment, not the processes by which change
occurs. Understanding both outcome and change process is the cornerstone of science.
References
Drisko, J. & Grady, M. (2012). Evidence-based practice in clinical social work. New York: Springer-Verlag.
Gibbs, L. (2003). Evidence-based practice for the helping professions. New York: Wadsworth.
ESTs and EBP
The Steps of the EBP Practice Decision-Making Process
There are several steps in doing EBP, but the number varies a bit by author. Still, the key content is
essentially the same in them all.
Drisko & Grady (2012) have worked carefully to honor client values and preferences along with
research evidence and clinical expertise in formulating these six steps of EBP:
1) Drawing on client needs and circumstances learned in a thorough assessment, identify
answerable practice questions and related research information needs;
2) Efficiently locate relevant research knowledge;
3) Critically appraise the quality and applicability of this knowledge to the client's needs and
situation;
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4) Discuss the research results with the client to determine how likely effective options fit with
the client's values and goals;
5) Synthesizing the client�s clinical needs and circumstances with the relevant research,
develop a shared plan of intervention collaboratively with the client;
6) Implement the intervention.
Our care in wording the steps of EBP starts with the fact that doing EBP rests first on a well done and
thorough clinical assessment. This is not directly stated in the EBP practice decision-making model,
but is the foundation on which all good intervention planning rests (Drisko & Grady, 2011). We also
view intervention or treatment planning as participatory and collaborative between client and clinician
- not a top-down process (as it appears in many EBM/EBP textbooks). Client values and preferences
are key parts of EBP. Finally, clinical expertise is needed to insure the best research evidence really
fits this the views and needs of client in this situation.
Additional Steps?
Step 7. A few authors (Gibbs, for one) appear to make practice evaluation an aspect of EBP. That is,
the professional should audit the intervention (to verify it was done appropriately) and evaluate its
yield. This makes some sense, but note that the practice evaluation of the single case would be done
using methods quite different from those used in EBP. Single case or single system designs can help
identify progress, but are based on replication logic rather than the sampling logic underlying
experimental research. That is, the case studies one would use in practice evaluation are not highly
valued in EBP research summaries. Still, practice evaluation is a key part of all good practice.
Step 8. A few authors (Gibbs, for one) also add sharing your results with others and work toward
improving the quality of available evidence. This would be useful but again does not necessarily draw
on the same core logic of experimental research EBP emphasizes. In fact, case studies are often
viewed as the least useful source of evidence in many EBP "evidence hierarchies". Note, however,
that such work may be very helpful in identifying to whom and in what circumstances the best
research evidence does not work or is not appropriate. Ironically, very small scale research may be
very useful in shaping how and when and where to use large scale experimental evidence to best
advantage. Clinicians should publish about their work, but individual case outcomes have ethical
challenges and may not be much valued within EBP hierarchies of evidence.
The University of Oxford offers a fine page on the Steps of EBM.
Note that all steps are meant to be transparent and replicable by others. That is, the steps should be so
clear you could re-do them yourself with enough time and access. It also means many things are
accepted at face value (or as face valid) such as definitions of mental and social disorders (usually
defined via DSM or ICD) though these categories do change over time. Measures of treatments are
assumed to be adequate, valid, reliable and complete. Treatments though often only broadly
described, as assumed to be replicable by others in different settings, with different training and with
different backgrounds.
Note, too, that EBP focuses on the outcome of treatment, not the processes by which change
occurs. Understanding both outcome and change process is the cornerstone of science.
References
Drisko, J. & Grady, M. (2012). Evidence-based practice in clinical social work. New York: Springer-Verlag.
Gibbs, L. (2003). Evidence-based practice for the helping professions. New York: Wadsworth.
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EBP
RATING THE EVIDENCE
While assessing research evidence on any given topic can be very complex, EBP reviews are
categorized in a manner designed to convey quality in a simple format. (Note, however, there are a
lot of assumptions built into -- and omitted from -- such ratings!)
Here is an example of the use of evidence hierarchies in EBP. This is taken from the U.S. Department
of Health and Human Services' National Guidelines Clearinghouse which (as the name implies) sets
guidelines for treatment guidelines. The categories themselves are clearly imported from an uncited
source used in the United Kingdom.
Evidence Categories
I: Evidence obtained from a single randomised [sic - British spelling from the original] controlled trial
or a meta-analysis of randomised controlled trials
IIa: Evidence obtained from at least one well-designed controlled study without randomisation
IIb: Evidence obtained from at least one well-designed quasi-experimental study [i.e., no
randomization and use of existing groups]
III: Evidence obtained from well-designed non-experimental descriptive studies, such as comparative
studies, correlation studies, and case-control studies
IV: Evidence obtained from expert committee reports or opinions and/or clinical experience of
respected authorities
Recommendation Grades
Grade A - At least one randomised controlled trial as part of a body of literature of overall good
quality and consistency addressing the specific recommendation (evidence level I) without
extrapolation
Grade B - Well-conducted clinical studies but no randomised clinical trials on the topic of
recommendation (evidence levels II or III); or extrapolated from level I evidence
Grade C - Expert committee reports or opinions and/or clinical experiences of respected authorities
(evidence level IV) or extrapolated from level I or II evidence. This grading indicates that directly
applicable clinical studies of good quality are absent or not readily available.�
[Retrieved Feb 20, 2007 from
http://www.guideline.gov/summary/summary.aspx?doc_id=5066&nbr=003550&string=eating+AND
+disorders ]
One can plainly see that the Evidence Categories or hierarchies are used to 'grade' the
Recommendations that constitute practice guidelines. Note too that research evidence based on
multiple RCTs is privileged, while an work based on quasi-experiments, correlational studies, case
studies or qualitative research is viewed as not particularly useful. Quality of conceptualization (of
disorder and of treatment) is assumed; samples sizes and composition are not mentioned beyond
randomization; generalization from prior work is assumed to be non-problematic; analyses are
presumed to be done appropriately and issues of diversity and context are not considered.
_______________________
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EBP
Another, quite similar, rating system is used by the United States Preventive Services Task Force.
They use the following system:
Strength of Recommendations
The U.S. Preventive Services Task Force (USPSTF) grades its recommendations according to one of
five classifications (A, B, C, D, I) reflecting the strength of evidence and magnitude of net benefit
(benefits minus harms).
A.- The USPSTF strongly recommends that clinicians provide [the service] to eligible patients. The
USPSTF found good evidence that [the service] improves important health outcomes and concludes
that benefits substantially outweigh harms.
B.- The USPSTF recommends that clinicians provide [this service] to eligible patients. The USPSTF
found at least fair evidence that [the service] improves important health outcomes and concludes that
benefits outweigh harms.
C.- The USPSTF makes no recommendation for or against routine provision of [the service]. The
USPSTF found at least fair evidence that [the service] can improve health outcomes but concludes
that the balance of benefits and harms is too close to justify a general recommendation.
D.- The USPSTF recommends against routinely providing [the service] to asymptomatic patients. The
USPSTF found at least fair evidence that [the service] is ineffective or that harms outweigh benefits.
I.- The USPSTF concludes that the evidence is insufficient to recommend for or against routinely
providing [the service]. Evidence that the [service] is effective is lacking, of poor quality, or
conflicting and the balance of benefits and harms cannot be determined.
Quality of Evidence
The USPSTF grades the quality of the overall evidence for a service on a 3-point scale (good, fair,
poor):
Good: Evidence includes consistent results from well-designed, well-conducted studies in
representative populations that directly assess effects on health outcomes.
Fair: Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is
limited by the number, quality, or consistency of the individual studies, generalizability to routine
practice, or indirect nature of the evidence on health outcomes.
Poor: Evidence is insufficient to assess the effects on health outcomes because of limited number or
power of studies, important flaws in their design or conduct, gaps in the chain of evidence, or lack of
information on important health outcomes.
Once again, research evidence based on multiple RCTs is privileged, while an work based on quasiexperiments, correlational studies, case studies or qualitative research is viewed as not particularly
useful. Quality of conceptualization (of disorder and of treatment) is assumed; samples sizes and
composition are not mentioned beyond randomization; generalization from prior work is assumed to
be non-problematic; analyses are presumed to be done appropriately and issues of diversity and
context are not considered. Still, the clarity is valuable - and useful if you understand the rating
system and its underlying logic.
This said, note that guidelines which lack any clear and explicit linkage to a research-based evidence
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EBP
are labeled in the Guideline's Clearinghouse materials. An example is a search for Asperger's
Syndrome" which yields Assessment and Screening Guidelines from the California Department of
Developmental Services. of the State of California [as of Feb 2007]. These guidelines lack any clear
linkage to a specific research evidence base. Specifically they state:
"TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS
The type of evidence supporting the recommendations is not specifically stated."
[Retrieved February 20, 2007 from
http://www.guideline.gov/summary/summary.aspx?doc_id=8269&nbr=004601&string=asperger''s+A
ND+syndrome ]
Such information does make plain to practitioners that there is no obvious research base for the
guidelines presented. This is very unhelpful and makes the criteria by which judgments were made
wholly unclear.
14 / 14
This page offers a starting point for finding information on Evidence Based Practice [EBP].
There are many definitions of EBP with differing emphases. A survey of social work faculty even
showed they have different ideas about just what makes up EBP (This can be a source of confusion
for students and newcomers to this topic of study. Perhaps the best known is Sackett et al's (1996,
71-72) now dated definition from evidence based medicine: "Evidence based medicine is the
conscientious, explicit, and judicious use of current best evidence in making decisions about the care
of individual patients. The practice of evidence based medicine means integrating individual clinical
expertise with the best available external clinical evidence from systematic research. By individual
clinical expertise we mean the proficiency and judgment that individual clinicians acquire through
clinical experience and clinical practice. Increased expertise is reflected in many ways, but especially
in more effective and efficient diagnosis and in the more thoughtful identification and compassionate
use of individual patients' predicaments, rights, and preferences in making clinical decisions about
their care. By best available external clinical evidence we mean clinically relevant research, often
from the basic sciences of medicine, but especially from patient centered clinical research into the
accuracy and precision of diagnostic tests (including the clinical examination), the power of
prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive
regimens."
This early definition, however, proved to have some important limitations in practice. Haynes et al
(2002) - Sackett's colleagues in the McMaster Group of physicians in Canada - pointed out the
definition did not pay enough attention to the traditional determinants of clinical decisions. That is, it
purposefully emphasized research knowledge but did not equally emphasize the client's needs and
situation, nor the client's stated wishes and goals, nor the clinicians' expertise in assessing and
integrating all these elements into a plan of intervention.
The contemporary definition of EBP is simply "the integration of the best research evidence with
clinical expertise and patient values" (Sackett, et al. 2000, p. x). This simpler, current, definition
gives equal emphasis to 1) the patient's situation, 2) the patient's goals, values and wishes, 3) the best
available research evidence, and 4) the clinical expertise of the practitioner. The difference is that a
patient may refuse interventions with strong research support due to differences in beliefs and values.
Similarly, the clinician may be aware of factors in the situation (co-occurring disorders, lack of
resources, lack of funding, etc.) that indicate interventions with the best research support may not be
practical to offer. The clinician may also notice that the best research was done on a population
different from the current client, making its relevance questionable, even though its rigor is strong.
Such differences may include age, medical conditions, gender, race or culture and many others.
This contemporary definition of EBP has been endorsed by many social workers. Gibbs and Gambrill
(2002), Mullen and Shlonsky (2004, Rubin (2008), and Drisko and Grady (2012) all apply it in their
publications. Social workers often add emphasis to client values and views as a key part of
intervention planning. Many social workers also argue that clients should be active participants in
intervention planning, not merely recipient's of a summary of "what works" from an "expert" (Drisko
& Grady, 2012) Actively involving clients in intervention planning may also be a useful way to
enhancing client motivation and to empower clients.
Some in social work view EBP as a mix of a) learning what treatments "work" based on the best
available research (whether experiential or not), b) discussing client views about the treatment to
consider cultural and other differences, and to honor client self determination and autonomy, c)
considering the professionals "clinical wisdom" based on work with similar and dissimilar cases that
may provide a context for understanding the research evidence, and d) considering what the
professional can, and can not, provide fully and ethically (Gambrill, 2003; Gilgun, 2005). With much
similarity but some differences, the American Psychological Association (2006, p. 273) defines EBP
as "the integration of the best available research with clinical expertise in the context of patient
characteristics, culture and preferences." Gilgun (2005) notes that while research is widely discussed,
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EBP
the meanings of "clinical expertise" and "client values and preferences" have not been widely
discussed and have no common definition.
Drisko & Grady (2012) argue that the EBP practice decision making process defined by Sackett and
colleagues seems to fit poorly with the way health care payers enact EBP at a macro, policy, level.
Clinical social workers point to list of approved treatments that will be funded for specific disorders and note this application of EBP does not include specific client values and preferences and ignores
situational clinical expertise. Drisko & Grady point out that there is a conflict between the EBP model
and how it is implemented administratively to save costs in health care. While cost savings are very
important, this use of "EBP" is not consistent with the Sackett model. Further, the criteria used to
develop lists of approved treatments is generally not clear or transparent - or even stated. Payers very
often appear to apply standards that are different from multidisciplinary sources of systematic reviews
of research like the Cochrane Collaboration. Clinical expertise and client values too often drop out of
the administrative applications of EBP.
Evidence based practice is one useful approach to improving the impact of practice in medicine,
psychology, social work, nursing and allied fields. Of course, professions have directed considerable
attention to "evidence" for many years (if not for as long as they have existed!). They have also
honored many different kinds of evidence. EBP advocates put particular emphasis on the results of
large-scale experimental comparisons to document the efficacy of treatments against untreated control
groups, against other treatments, or both. (See, for example, the University of Oxford's Hierarchy of
Evidence for EBM). They do this because well conceptualized and completed experiments (also
called RCTs) are a great way to show a treatment caused a specific change. The ability to make cause
and effect determinations is the great strength of experiments. Note that this frames "evidence" in a
very specific and delimited manner. Scholars in social work and other professions have argued for
"Many Ways of Knowing" (Hartman, 1990). They seek to honor the knowledge developed by many
different kinds of research - and to remind clinicians, researchers and the public that the
conceptualization underlying research may be too narrow and limited. Thus Drisko & Grady (2012)
argue that EBP, as summarized by researchers, may devalue non-experimental research. Experiments
are only as good as the exploratory research that discovers new concepts, and the descriptive research
that helps in the development of tests and measures. Only emphasizing experiments ignores the very
premises on which they rest. Finally, note that EBM/EBP hierarchies of research evidence include
many non-experimental forms of research since experiments for some populations may be unethical
or impractical - or simply don't address the kinds of knowledge needed in practice.
All the "underpinnings" of experimental research: the quality of conceptualizations, the quality of
measures, the clarity and specificity of treatments used, the quality of samples studied and of the
quality and completeness of collected data are assumed to be sound and fully adequate when used to
determine "what works." There is also an assumption that the questions framing the research allow
for critical perspectives and are fully ethical. Social workers would argue they should also include
social diversity samples well - since diverse kinds of people show up at real world clinics.
International standards affirm basic ethical principles supporting respect for persons, beneficence and
social justice (see The Belmont Report.)
Is EBP only about Intervention or Treatment Planning?
No. This may be the most common application of EBP for clinical social workers, but the EBP
process can also be applied to a) making choices about diagnostic tests and protocols to insure
thorough and accurate diagnosis), b) selecting preventive or harm-reduction interventions or
programs, c) determining the etiology of a disorder or illness, d) determining the course or
progression of a disorder or illness, e) determining the prevalence of symptoms as part of establishing
or refining diagnostic criteria, f) completing economic decision-making about medical and social
service programs (University of Oxford Centre for Evidence-based Medicine, 2011), and even g)
understanding how a client experiences a problem or disorder (Rubin, 2008).
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EBP
EBP is also not the same as defining empirically supported treatments (ESTs), empirically supported
interventions (ESIs), or 'best practices.' These are different ideas and are based on different models.
These models don't include client values and preferences nor clinical expertise as EBP does.
EBP as a Social Movement
While EBP is most often described in terms of a practice decision-making process, it is also useful to
think of it as a much larger social movement. Drisko and Grady (2012) argue that at a macro-level,
EBP is actively used by policy makers to shape service delivery and funding. At a messo- level, EBP
is impacting the kinds of interventions that agencies offer, and even shaping how supervision is done.
Drisko and Grady (2012) also argue that EBP is establishing a hierarchy of research evidence that is
privileging experimental research over other ways of knowing. Experimental evidence has many
merits, but is not the only way of knowing of use and importance in social work practice. Finally, the
impact of EBP may alter how both practice and research courses are taught in social work. There are
other aspects of EBP beyond the core practice decision-making process that are re-shaping social
work practice, social work education, and our clients' lives. As such, it may be viewed as a public idea
or a social movement at a macro level.
Why Evidence Based Practice or EBP?
It is one step toward making sure each client gets the best service possible.
Some argue it helps keep your knowledge up to date, supplements clinical judgment, can save time
and most important can improve care and even save lives. Its a way to balance your own views with
large scale research evidence.
Some say it's unethical to use treatments that aren't known to work. (Of course, services may need to
be so individualized in unique circumstances that so that knowing "what works" in general may not be
the most salient factor in helping any particular client. Still, using the best available research
knowledge is always beneficial.)
Several web sites serve as portals to bodies of research useful to EBP. The focus on these
organizations varies, but the emphasis remains on (mainly) experimental demonstration of the
efficacy of treatments.
How is EBP Implemented in Practice?
Profiling research that informs professionals and clients about what works is where evidence based
practice starts. These summaries tells us what we know about treatment and program efficacy based
on experimental work - as well as what we don't know or aren't really sure about.
Having access to information on what works allows professionals, in conjunction with clients, to
select treatments that are most likely to be helpful (and least likely to be harmful) before intervention
is begun. Practice evaluation is quite different in that takes place at the start of treatment, during
treatment and after treatment. Practice evaluation also uses single case methods rather than large
sample, experimental research designs. EBP and practice evaluation work together very well, but
they have different purposes and use very different methods.
The creation of "User's Guides" is one way to make the results of research more available to
practitioners. In medicine, the idea is to get research results to the practitioner in an easy to
assimilate fashion, though this often has a price.
Funding is being offered to support EBP from governments and private/insurance sources.
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EBP
However, to understand and critically appraise this material, a lot of methodological knowledge is
needed. Sites offering introductions to the technology of EBP are growing.
How is EBP Taught?
There are some useful resources for Teaching and Learning about EBP. One fine example is offered
by Middlesex University in the United Kingdom which includes good information on critical
appraisal of information in EBP.
The State University of New York's Downstate Medical center offers a (medically oriented) online
course in EBP, including a brief but useful glossary.
The Major Sources of Research for use in EBP:
The Cochrane Collaboration [ www.cochrane.org ] sets standards for reviews of medical, health and
mental health treatments and offers "systematic reviews" of related research by disorder. The
Cochrane Reviews offer a summary of international published and sometimes pre-publication
research. Cochrane also offers Methodological Abstracts to orient researchers and research
consumers alike.
The Campbell Collaboration [ www.campbellcollaboration.org ] offers review of the impact of social
service programs. "The Campbell Collaboration (C2) is an organization that aims to help people
make well-informed decisions about the effects of interventions in the social, behavioral and
educational arenas. C2's objectives are to prepare, maintain and disseminate systematic reviews of
studies of interventions. C2 acquires and promotes access to information about trials of interventions.
C2 builds summaries and electronic brochures of reviews and reports of trials for policy makers,
practitioners, researchers and the public."
C2 SPECTR is a registry of over 10,000 randomized and possibly randomized trials in education,
social work and welfare, and criminal justice.
C2 RIPE [Register of Interventions and Policy Evaluation] offers researchers, policymakers,
practitioners, and the public free access to reviews and review-related documents. These materials
cover 4 content areas: Education, Crime and Justice, Social Welfare and Methods.
The United States government also offers treatment guidelines based on EBP principles at the
National Guideline Clearinghouse. [ http://www.guideline.gov/ ] This site includes very good
information on medication as wll as very clear statements of concern about medications indicated in
guidelines which later prove to have limitations.
The U.S. government provides information on ongoing, government sponsored, clinical trials.
Other Online Resources for EBP and Treatment Guidelines Derived from EBP Criteria and
Procedures:
The American Psychiatric Association offers Practices Guidelines. Please be aware that the numbers
of practice guidelines are few. Existing guidelines may be up to 50 pages in length. If you are not
allowed to enter via this hyperlink, paste the following URL into your browser:
http://www.psych.org/psych_pract/treatg/pg/prac_guide.cfm
The Agency for Healthcare Research and Quality also offers outcome research information. AHRQ
offers an alphabetical listing out outcome studies.
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EBP
Note that there are a growing number of commercial [.com] sites that offer their consultation
regarding EBP. It is not always easy to determine their organization structure and purposes, the basis
of their recommendations and any potential conflicts of interest. In this regard, the sites of the
government and of professional organizations are "better" resources as their purposes, missions and
funding sources are generally more clear and publicly stated.
References:
American Psychological Association. (2006). APA presidential task force on evidence based practice. Washington, DC: Author
Dobson, K., & Craig, K. (1998). Empirically supported therapies: Best practice in professional psychology. Thousand Oaks, CA: Sage.
Drisko, J. & Grady, M. (2012). Evidence-based practice in clinical social work. New York: Springer-Verlag.
Elwood, J.M. (2007). Critical appraisal of epidemiological studies and clinical trials (3rd ed.) New York: Oxford University Press.
Gambrill, E. (2003). Evidence-based practice: Implications for knowledge development and use in social work. In A. Rosen & E. Proctor
(Eds.), Developing practice guidelines for social work intervention (pp. 37-58). New York: Columbia University Press.
Gibbs, L. (2003). Evidence-based practice for the helping professions. New York: Wadsworth.
Gilgun, J. (2005). The four cornerstones of qualitative research. Qualitative Health Research, 16(3), 436-443.
Howard, M., McMillen, C., & Pollio, D. (2003). Teaching evidence-based practice: Toward a new paradigm for social work education.
Research on Social Work Practice, 13, 234-259.
Mace, C., Moorey, S., & Roberts, B. (Eds.). (2001). Evidence in the psychological therapies: A critical guide for practitioners.
Philadelphia, PA: Taylor & Francis.
Mantzoukas, S. (2008). A review of evidence-based practice, nursing research and reflection: Levelling the hierarchy. Journal of Clinical
Nursing, 17(2), 214-223.
Roberts, A., & Yeager, K. (Eds.). (2004). Evidence-based practice manual: Research and outcome measures in health and human services.
New York: Oxford University Press.
Sackett, D., Rosenberg, W., Muir Gray, J., Haynes, R. Richardson, W. (1996). Evidencebased medicine: what it is and what it isn't. British
Medical Journal, 312, 71-72. http://cebm.jr2.ox.ac.uk/ebmisisnt.html
Sackett, D., Richardson, W., Rosenberg, W., & Haynes, R. (1997). Evidence-based medicine: How to practice and teach EBM. New
York: Churchill Livingstone.
Simpson, G., Segall, A., & Williams, J. (2007). Social work education and clinical learning: Reply to Goldstein and Thyer. Clinical Social
Work Journal, (35), 33-36.
Smith, S., Daunic, A., & taylor, G. (2007). Treatment fidelity in applied educational research: Expanding the adoption and application of
measures to ensure evidence-based practice. Education & Treatment of Children, 30(4), pp. 121-134.
Stout, C., & Hayes, R. (Eds.). (2005). The evidence-based practice: Methods, models, and tools for mental health professionals. Hoboken,
NJ: Wiley.
Stuart, R., & Lilienfeld, S. (2007). The evidence missing from evidence-based practice. American Psychologist, 62(6), pp. 615-616.
Trinder, L., & Reynolds, S. (2000). Evidence-based practice: A critical appraisal. New York: Blackwell.
Wampold, B. (2007). Psychotherapy: The humanistic (and effective) treatment. American Psychologist, 62(8), pp. 857-873.
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EBP
WHAT IS EBP
Evidence based practice (EBP) might best be viewed as an ideology or a "public idea" in Robert
Reich's (1990) terminology. The movement began with the work of Scottish physician Archie
Cochrane who sought to identify "treatments that work" using the results of experimental research.
Another important aspect of Cochrane's interest was to identify and end treatments that do harm or are
not effective. In practice, the idea was to supplement professional decision making with the latest
research knowledge. [It is worth noting that some critics might argue "replace" professional decision
making might even be applicable.] The goal was to enhance the scientific base of professional
practice in several disciplines - medicine, nursing, psychology, social work, etc. In turn, educational
efforts in these disciplines could be oriented to provide beginning professionals with effective tools
and a model for the continuing improvement and renewal of their professional practices.
EBP as described here is not the same as an empirically supported treatment [EST]. ESTs are
variously defined, but are basically treatments or services that have been empirically studied and
found to be helpful or effective - in one or more settings. The difference is that ESTs may be
treatments or services that are not fully replicable in other settings and most have not been studied in
multiple contexts. ESTs may not have been replicated - tested more than once - to insure the result
will be the same or similar in another setting. The efforts of the Cochrane Collaboration include
setting rigorous standards for examining the methods by which outcome research is done as well as
reporting research results. This is to insure transparency in their findings [that others can know
exactly how the conclusions were drawn] and not to exaggerate the results of a single test of any
treatment.
Why EBP? Some Say Any Other Approach Is Unethical
Some advocates argue that to treat anyone using treatments without known efficacy is unethical. That
is, if we know a given medicine or substance abuse program or treatment for attachment problems
works better than another treatment, it is an ethical obligation to use it in order to best serve clients or
patients. This is an argument that is hard to challenge - at least in an ideal world. Given strong and
unambiguous research evidence that is clearly useful to a given practice situation, and consistent with
the client's world view and values, using EBP "best treatment" is the best way to go.
Policy and Funding Issues
In social work and psychology, advocates have also argued that only interventions with demonstrated
efficacy should be supported financially. Such an argument links demonstrations of efficacy with the
funding structure of the current managed care environment. It may be seen as either a way to best use
limited dollars or yet another method to curtail funding for costly services. Without provision of
adequate funds to do thorough research on the great variety of treatments in use, the requirement of
proven efficacy may be used as a tool to limit treatment services.
Assessing EBP -- Some Key Issues
In psychology, the initial unveiling of "empirically validated treatments" by an American
Psychological Association Task Force brought forth both interest and criticism. It also brought out
differences regarding interpretations of the existing research literature and regarding the merits of
certain research methods. One key concern was the over-reliance on randomized control trials
[RCTs]. An RCT is an experiment in which participants are randomly assigned to either a treatment
or a control group. Ideally, neither participant or treating clinician knows which group is which. After
a course of treatment (or control), improvement is determined by comparing pre-treatment status with
post-treatment status. If the treated group improves significantly more that the controls, we can say
the treatment caused the change and that the treatment works (better than no treatment). In another
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EBP
form of RCT, the best known treatment is compared to a new treatment using random assignment. If
the new treatment produces better results than does the standard treatment, it is viewed as empirically
supported and "more efficacious."
Efficacy versus Effectiveness
Some practitioners argued that the RCTs don't always reflect "real world" conditions well, so the
results of such studies may not be the same as what is found in real clinics. The core of the concern is
that RCTs often use carefully assessed participants that have only a single disorder and often have
relatively strong social supports. Real world clinics are rarely able to undertake similarly detailed
assessments and, even if they could, would often have to treat people with co-existing (co-morbid)
conditions, less persistence, perhaps fewer social supports and perhaps lower motivation to be in
treatment. Thus carefully run RCTs reflect laboratory conditions rather than real world conditions.
The distinction is know as "effectiveness" versus "efficacy. Laboratory RCTs produce knowledge
about the "efficacy" of a treatment - that it works under ideal conditions. Experimental studies done
under less carefully defined conditions reflecting the variation in real world clinics are known as
"effectiveness" studies.
Conceptualizations of Disorders
It should be noted that most researchers undertaking RCTs assume that the problems or disorders they
are studying are completely and adequately defined. In mental health, the definition of problems most
often follows the American Psychiatric Association Diagnostic and Statistical Manual of Mental
Disorders (DSM) or the World Health Organization's ICD Manual. These definitions vary in clarity
and in their own empirical validation.
Social workers adopt a world view that suggests problems are best understood by viewing "persons in
situations." That is, both external environmental and social factors as well as internal health and
psychological factors will be important in understanding the whole person. This perspective is
partially incorporated in the DSM's Axes IV and V, but in a summary form.
Operational Definitions of Problems
Simply put, EBP generally applies operational definitions of problems in RCT reviews of treatment
effects. This is consistent with the medical model of research and general use in psychology and
social work research. The potential limitation is that such definitions of target problems locate the
problem within the individual and (mostly) ignore social circumstances, supportive and/or
oppressive. This may represent a limited definition of the target problem or a flaw in
conceptualization.
In much organic medical treatment, causes or etiologies may be more clearer identified than is
possible (or at least currently possible) in the world of mental health and social problems. Thus
applying an outcome model that assumes a single, clearly identified "cause" and problems that reflect
symptoms may, or may not, be optimal. Further, different "doses" of treatment may be identifiable
for organic medical conditions but may be less clear cut in the functional, mental health and social
world. Both conceptual and operational diagnoses in mental health pose some challenges and
multiple, comorbid disorders are commonplace -- making real world practice quite different from
tightly controlled and extensively tested experimental studies. (Which ties back into the Efficacy vs.
Effectiveness issue described above.)
Common Factors versus Specific Techniques
Some argue that treatment effects are due more to "common factors" shared by therapies than they are
due to specific treatment techniques. The level of client motivation, the strength and quality of the
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EBP
therapeutic relationship, a shared vision of what treatment will include, a shared sense of hope or
expectancy of improvement and even placebo effects are elements of treatment common across
differences in theory and technique -- especially in psychotherapy and social services. RCTs are often
designed to test differences of technique, but ignore or limit the role common factors.
Several meta-analytic studies of psychotherapy for adults demonstrate empirically that several types
of therapy for depression and anxiety are effective. This indicates that common factors, rather than
different treatment techniques, generate roughly equivalent change (at least for these disorders).
On the other hand, Reid (1997) did a meta-analysis of social work interventions for several quite
different problems (mental retardation, smoking cessation, substance abuse. etc.). He found many
types of treatments were helpful but behavioral and cognitive approaches appeared to work better than
did the other techniques. Note, however, that the study compares "apples and oranges", aggregating
dissimilar problems.
The common factors versus specific techniques question is as yet unresolved. Some honor it, others
believe it is not particularly important.
Variation Among Clients, Clinicians and the Treatments they Deliver
Since most quantitative experimental studies are based on group means, we know that "on average"
treatments generate a certain effect. This is valuable information. Yet it does not help the clinician
distinguish which specific client is like the mean responder and who may differ. With medication
some people respond to a smaller than average does, others need more than the average to be helped.
We might assume the same is true in mental health - some people respond with less effort (or are able
to better use opportunities and resources) while others will need much more help (or are less able to
use their resources and opportunities) to improve. Thus the clinician is left to think critically and fit
aggregate treatment results to the specific, unique reality of a given client.
We must also assume that clinicians vary in ability to deliver any given treatment. Referral may be
indicated where a treatment in which one is not fully trained is indicated as the best practice.
We can also assume that their is variation in effectiveness even among well trained clinicians. Unlike
pills, mental health issues appear heavily influenced by relationship factors and expectancy factors.
The Client's Views About the Treatment
In a profession that supports autonomous decision making by the client or client system, clinical
social workers must ask the client about their views of what EBP suggest is the most likely effective
treatment. If the client has concerns about the treatment, these views must be honored. Eileen
Gambrill has developed this idea in several published articles.
Critical thinking and efforts to find knowledge are needed, along with efforts to individualize
treatment to the person and environment (including culture) of the client.
Practice Wisdom and What Professionals Can Do
It would seem wise to allow professionals to use their knowledge, skills, training and experience to
determine if the best available research knowledge fits well with the circumstances at hand. This may
take some wisdom and judgment; may not be automatic. Of course, some supporters of EBP believe
the purpose of EBP is in large part to limit such application of practice wisdom.
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EBP
It may also be the case that what research shows is most likely to help based on other's experiences
may not be something the professional is trained to provide or is not comfortable providing. Referrals
may be made in such instances.
Racial, Ethnic and Social Diversity
Many scholars note that there is very little research on services and treatments to populations of color,
immigrant populations (who may have culturally different ideas about mental health and its
treatment), class differences in treatment effectiveness, differences in sexual orientation, and
sometimes gender differences. Research on children, teens and the elder is also often minimal. EBP,
as much of medicine, assumes people are people and that treatments are universally effective. This
may often be so for organic disorders, but is less certain for socially complex concerns such as mental
disorders. Research on the effectiveness of many treatments on diverse populations is lacking. This
is a major shortcoming of EBP at this time.
Reference:
Reich, R. (1988). The power of public ideas. Cambridge, MA: Ballinger Publishing.
THE STEPS OF EBP
The Steps of the EBP Practice Decision-Making Process
There are several steps in doing EBP, but the number varies a bit by author. Still, the key content is
essentially the same in them all.
Drisko & Grady (2012) have worked carefully to honor client values and preferences along with
research evidence and clinical expertise in formulating these six steps of EBP:
1) Drawing on client needs and circumstances learned in a thorough assessment, identify
answerable practice questions and related research information needs;
2) Efficiently locate relevant research knowledge;
3) Critically appraise the quality and applicability of this knowledge to the client's needs and
situation;
4) Discuss the research results with the client to determine how likely effective options fit with
the client's values and goals;
5) Synthesizing the client�s clinical needs and circumstances with the relevant research,
develop a shared plan of intervention collaboratively with the client;
6) Implement the intervention.
Our care in wording the steps of EBP starts with the fact that doing EBP rests first on a well done and
thorough clinical assessment. This is not directly stated in the EBP practice decision-making model,
but is the foundation on which all good intervention planning rests (Drisko & Grady, 2011). We also
view intervention or treatment planning as participatory and collaborative between client and clinician
- not a top-down process (as it appears in many EBM/EBP textbooks). Client values and preferences
are key parts of EBP. Finally, clinical expertise is needed to insure the best research evidence really
fits this the views and needs of client in this situation.
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EBP
Additional Steps?
Step 7. A few authors (Gibbs, for one) appear to make practice evaluation an aspect of EBP. That is,
the professional should audit the intervention (to verify it was done appropriately) and evaluate its
yield. This makes some sense, but note that the practice evaluation of the single case would be done
using methods quite different from those used in EBP. Single case or single system designs can help
identify progress, but are based on replication logic rather than the sampling logic underlying
experimental research. That is, the case studies one would use in practice evaluation are not highly
valued in EBP research summaries. Still, practice evaluation is a key part of all good practice.
Step 8. A few authors (Gibbs, for one) also add sharing your results with others and work toward
improving the quality of available evidence. This would be useful but again does not necessarily draw
on the same core logic of experimental research EBP emphasizes. In fact, case studies are often
viewed as the least useful source of evidence in many EBP "evidence hierarchies". Note, however,
that such work may be very helpful in identifying to whom and in what circumstances the best
research evidence does not work or is not appropriate. Ironically, very small scale research may be
very useful in shaping how and when and where to use large scale experimental evidence to best
advantage. Clinicians should publish about their work, but individual case outcomes have ethical
challenges and may not be much valued within EBP hierarchies of evidence.
The University of Oxford offers a fine page on the Steps of EBM.
Note that all steps are meant to be transparent and replicable by others. That is, the steps should be so
clear you could re-do them yourself with enough time and access. It also means many things are
accepted at face value (or as face valid) such as definitions of mental and social disorders (usually
defined via DSM or ICD) though these categories do change over time. Measures of treatments are
assumed to be adequate, valid, reliable and complete. Treatments though often only broadly
described, as assumed to be replicable by others in different settings, with different training and with
different backgrounds.
Note, too, that EBP focuses on the outcome of treatment, not the processes by which change
occurs. Understanding both outcome and change process is the cornerstone of science.
References
Drisko, J. & Grady, M. (2012). Evidence-based practice in clinical social work. New York: Springer-Verlag.
Gibbs, L. (2003). Evidence-based practice for the helping professions. New York: Wadsworth.
ESTs and EBP
The Steps of the EBP Practice Decision-Making Process
There are several steps in doing EBP, but the number varies a bit by author. Still, the key content is
essentially the same in them all.
Drisko & Grady (2012) have worked carefully to honor client values and preferences along with
research evidence and clinical expertise in formulating these six steps of EBP:
1) Drawing on client needs and circumstances learned in a thorough assessment, identify
answerable practice questions and related research information needs;
2) Efficiently locate relevant research knowledge;
3) Critically appraise the quality and applicability of this knowledge to the client's needs and
situation;
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EBP
4) Discuss the research results with the client to determine how likely effective options fit with
the client's values and goals;
5) Synthesizing the client�s clinical needs and circumstances with the relevant research,
develop a shared plan of intervention collaboratively with the client;
6) Implement the intervention.
Our care in wording the steps of EBP starts with the fact that doing EBP rests first on a well done and
thorough clinical assessment. This is not directly stated in the EBP practice decision-making model,
but is the foundation on which all good intervention planning rests (Drisko & Grady, 2011). We also
view intervention or treatment planning as participatory and collaborative between client and clinician
- not a top-down process (as it appears in many EBM/EBP textbooks). Client values and preferences
are key parts of EBP. Finally, clinical expertise is needed to insure the best research evidence really
fits this the views and needs of client in this situation.
Additional Steps?
Step 7. A few authors (Gibbs, for one) appear to make practice evaluation an aspect of EBP. That is,
the professional should audit the intervention (to verify it was done appropriately) and evaluate its
yield. This makes some sense, but note that the practice evaluation of the single case would be done
using methods quite different from those used in EBP. Single case or single system designs can help
identify progress, but are based on replication logic rather than the sampling logic underlying
experimental research. That is, the case studies one would use in practice evaluation are not highly
valued in EBP research summaries. Still, practice evaluation is a key part of all good practice.
Step 8. A few authors (Gibbs, for one) also add sharing your results with others and work toward
improving the quality of available evidence. This would be useful but again does not necessarily draw
on the same core logic of experimental research EBP emphasizes. In fact, case studies are often
viewed as the least useful source of evidence in many EBP "evidence hierarchies". Note, however,
that such work may be very helpful in identifying to whom and in what circumstances the best
research evidence does not work or is not appropriate. Ironically, very small scale research may be
very useful in shaping how and when and where to use large scale experimental evidence to best
advantage. Clinicians should publish about their work, but individual case outcomes have ethical
challenges and may not be much valued within EBP hierarchies of evidence.
The University of Oxford offers a fine page on the Steps of EBM.
Note that all steps are meant to be transparent and replicable by others. That is, the steps should be so
clear you could re-do them yourself with enough time and access. It also means many things are
accepted at face value (or as face valid) such as definitions of mental and social disorders (usually
defined via DSM or ICD) though these categories do change over time. Measures of treatments are
assumed to be adequate, valid, reliable and complete. Treatments though often only broadly
described, as assumed to be replicable by others in different settings, with different training and with
different backgrounds.
Note, too, that EBP focuses on the outcome of treatment, not the processes by which change
occurs. Understanding both outcome and change process is the cornerstone of science.
References
Drisko, J. & Grady, M. (2012). Evidence-based practice in clinical social work. New York: Springer-Verlag.
Gibbs, L. (2003). Evidence-based practice for the helping professions. New York: Wadsworth.
11 / 14
EBP
RATING THE EVIDENCE
While assessing research evidence on any given topic can be very complex, EBP reviews are
categorized in a manner designed to convey quality in a simple format. (Note, however, there are a
lot of assumptions built into -- and omitted from -- such ratings!)
Here is an example of the use of evidence hierarchies in EBP. This is taken from the U.S. Department
of Health and Human Services' National Guidelines Clearinghouse which (as the name implies) sets
guidelines for treatment guidelines. The categories themselves are clearly imported from an uncited
source used in the United Kingdom.
Evidence Categories
I: Evidence obtained from a single randomised [sic - British spelling from the original] controlled trial
or a meta-analysis of randomised controlled trials
IIa: Evidence obtained from at least one well-designed controlled study without randomisation
IIb: Evidence obtained from at least one well-designed quasi-experimental study [i.e., no
randomization and use of existing groups]
III: Evidence obtained from well-designed non-experimental descriptive studies, such as comparative
studies, correlation studies, and case-control studies
IV: Evidence obtained from expert committee reports or opinions and/or clinical experience of
respected authorities
Recommendation Grades
Grade A - At least one randomised controlled trial as part of a body of literature of overall good
quality and consistency addressing the specific recommendation (evidence level I) without
extrapolation
Grade B - Well-conducted clinical studies but no randomised clinical trials on the topic of
recommendation (evidence levels II or III); or extrapolated from level I evidence
Grade C - Expert committee reports or opinions and/or clinical experiences of respected authorities
(evidence level IV) or extrapolated from level I or II evidence. This grading indicates that directly
applicable clinical studies of good quality are absent or not readily available.�
[Retrieved Feb 20, 2007 from
http://www.guideline.gov/summary/summary.aspx?doc_id=5066&nbr=003550&string=eating+AND
+disorders ]
One can plainly see that the Evidence Categories or hierarchies are used to 'grade' the
Recommendations that constitute practice guidelines. Note too that research evidence based on
multiple RCTs is privileged, while an work based on quasi-experiments, correlational studies, case
studies or qualitative research is viewed as not particularly useful. Quality of conceptualization (of
disorder and of treatment) is assumed; samples sizes and composition are not mentioned beyond
randomization; generalization from prior work is assumed to be non-problematic; analyses are
presumed to be done appropriately and issues of diversity and context are not considered.
_______________________
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EBP
Another, quite similar, rating system is used by the United States Preventive Services Task Force.
They use the following system:
Strength of Recommendations
The U.S. Preventive Services Task Force (USPSTF) grades its recommendations according to one of
five classifications (A, B, C, D, I) reflecting the strength of evidence and magnitude of net benefit
(benefits minus harms).
A.- The USPSTF strongly recommends that clinicians provide [the service] to eligible patients. The
USPSTF found good evidence that [the service] improves important health outcomes and concludes
that benefits substantially outweigh harms.
B.- The USPSTF recommends that clinicians provide [this service] to eligible patients. The USPSTF
found at least fair evidence that [the service] improves important health outcomes and concludes that
benefits outweigh harms.
C.- The USPSTF makes no recommendation for or against routine provision of [the service]. The
USPSTF found at least fair evidence that [the service] can improve health outcomes but concludes
that the balance of benefits and harms is too close to justify a general recommendation.
D.- The USPSTF recommends against routinely providing [the service] to asymptomatic patients. The
USPSTF found at least fair evidence that [the service] is ineffective or that harms outweigh benefits.
I.- The USPSTF concludes that the evidence is insufficient to recommend for or against routinely
providing [the service]. Evidence that the [service] is effective is lacking, of poor quality, or
conflicting and the balance of benefits and harms cannot be determined.
Quality of Evidence
The USPSTF grades the quality of the overall evidence for a service on a 3-point scale (good, fair,
poor):
Good: Evidence includes consistent results from well-designed, well-conducted studies in
representative populations that directly assess effects on health outcomes.
Fair: Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is
limited by the number, quality, or consistency of the individual studies, generalizability to routine
practice, or indirect nature of the evidence on health outcomes.
Poor: Evidence is insufficient to assess the effects on health outcomes because of limited number or
power of studies, important flaws in their design or conduct, gaps in the chain of evidence, or lack of
information on important health outcomes.
Once again, research evidence based on multiple RCTs is privileged, while an work based on quasiexperiments, correlational studies, case studies or qualitative research is viewed as not particularly
useful. Quality of conceptualization (of disorder and of treatment) is assumed; samples sizes and
composition are not mentioned beyond randomization; generalization from prior work is assumed to
be non-problematic; analyses are presumed to be done appropriately and issues of diversity and
context are not considered. Still, the clarity is valuable - and useful if you understand the rating
system and its underlying logic.
This said, note that guidelines which lack any clear and explicit linkage to a research-based evidence
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EBP
are labeled in the Guideline's Clearinghouse materials. An example is a search for Asperger's
Syndrome" which yields Assessment and Screening Guidelines from the California Department of
Developmental Services. of the State of California [as of Feb 2007]. These guidelines lack any clear
linkage to a specific research evidence base. Specifically they state:
"TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS
The type of evidence supporting the recommendations is not specifically stated."
[Retrieved February 20, 2007 from
http://www.guideline.gov/summary/summary.aspx?doc_id=8269&nbr=004601&string=asperger''s+A
ND+syndrome ]
Such information does make plain to practitioners that there is no obvious research base for the
guidelines presented. This is very unhelpful and makes the criteria by which judgments were made
wholly unclear.
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