Supporting the client's right to effective treatment: touching a raw nerve?

Thyer, Bruce A. ; Myers, Laura L.

Saul Raw has prepared a thoughtful response to our earlier article (Myers & Thyer, 1997), in which we argued that social workers should have an ethical obligation to provide clients with empirically supported treatments in situations where these have been established. Raw has succinctly expressed many of the doubts we have heard from some of our colleagues about this proposition, doubts which may have been shared by one or two readers as well.

It seems that one of Raw's major objections is that research findings obtained through studies of an intervention's efficacy (usually demonstrated in well-controlled clinical trials, using expert therapists, possibly recruited client-subjects meeting select inclusive criteria and so forth) may not translate into effective practice in real world settings. These efforts have also been labeled "research therapy" (efficacy) and "clinic therapy" (effectiveness). These are legitimate distinctions to make and a concern to raise.

Science does provide a solution. It consists of building on previous efficacy studies of research therapy to subsequently conduct effectiveness studies in real world agencies with real clients and social work practitioners (that is, clinic therapy). This process is the next logical step in the progressive nature of validating psychosocial treatments. It has been undertaken in many instances.

Similarly, the generalizability and applicability of treatment manuals to agency or clinic settings is an empirical question. Some translate well, and some do not. Empirical research will answer such questions, not an uncritical acceptance or a broad-brushed dismissal. For example, the treatment approach labeled exposure therapy and response prevention (ETRP) for clients meeting the criteria for obsessive-compulsive disorder has been shown in dozens of well-controlled trials of research therapy to be a moderately effective psychosocial intervention (see Cohen & Steketee, 1998, for a recent review of this literature). One of the foremost practitioner-researchers involved in the development of ETRP is Gail Steketee, a clinical social worker now turned professor. Steketee coauthored the self-help book When Once Is Not Enough (Steketee & White, 1990), solidly grounded in several decades of efficacy trials, designed for clients to learn and apply ETRP to themselves, with or without professional social work assistance. When this self-help book (the maligned manual-based therapy) was applied in the context of a mental health clinic, it was found that clients significantly and clinically improved (Fritzler, Hecker, & Losee, 1997). What a marvelous legacy for a social worker such as Steketee to give us - a psychosocial treatment that works for clients with a seriously handicapping disorder, not only under tightly controlled conditions (efficacy) but in routine clinical practice as well (effectiveness).

Fritzler et al. (1997) is not an isolated example. ETRP has been subjected to numerous efficacy trials in routine clinical practice, some involving small groups of clients (see, for example, Kirk, 1983; Krone, Himle, & Nesse, 1991), and others using individual clients whose outcomes were evaluated using single-case research designs (Himle & Thyer, 1989; Thyer, 1985). The same situation pertains to a wide variety of psychosocial interventions applied to other so-called mental disorders (see Hickling & Blanchard, 1997, for a discussion of posttraumatic stress disorder) and to many nonmental disorders and psychosocial problem-solving interventions, such as case management services for homeless people (Toro et al., 1997), job-finding clubs for chronically unemployed people (Rife & Belcher, 1994; Vinokur, Price, & Caplan, 1991), controlling anger among adolescents (Nugent, Champlin, & Wiinimaki, 1997), and various medical problems.

In reading Raw's article, the reader could come away with the impression that conventional research has completely ignored the problem of translating research therapy findings into real world contexts - that is, applied in regular human services agencies by the usual social workers with actual clients. The reality is that there is a thriving industry devoted to applying and testing such clinic-based therapies. Shadish et al. (1997) provide a comprehensive review of the evidence pertaining to the effectiveness of theoretically diverse research therapies in clinic-agency settings (for example, community mental health clinics, schools, private practice, general hospitals, and prisons). Problems involved issues such as depression, school difficulties, headache, caregiver distress, and agoraphobia; treatments involved brief psychodynamic psychotherapy, family therapy, rational - emotive therapy, behavior therapy, marital therapy. Clients were from the United States, Spain, Germany, and several countries in Latin America. Generally speaking, clinic-based therapies yielded positive effects similar to those obtained from research-based therapies. What, we wonder, is Raw's reaction to such well-designed effectiveness studies conducted with real clients and standard practitioners that yielded positive results. Are such findings also dismissed as useless for guiding practice?

Who Said That Symptom Removal Is the Only Acceptable Goal?

We are not sure where Raw got the impression that we believe that symptom removal is the only acceptable goal. It was certainly not from our article. We believe that symptom removal is often very important in situations involving domestic violence, child abuse and neglect, unemployment, and crisis services. Hundreds of thousands of social workers devote much of their professional lives toward alleviating such symptoms. We also believe that discovering and remedying underlying causes is often very important. Advocating the client's right to receive effective treatments advances the likelihood of a careful social work assessment revealing underlying causes.

What Medical Model?

Because we advocate careful assessment and using such assessments (which may or may not involve a diagnosis of a so-called mental disorder) to provide guidance in selecting interventions, and then empirically evaluating the outcomes of social work practice, Raw accuses us of supporting a "medical model" (an odd criticism from someone employed by a medical college). We believe that the practices advocated in our original article are much more consistent with a "traditional" social work model, dating back to Mary Richmond or even earlier. Our argument does not rely on using the Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition (American Psychiatric Association, 1994). Our advocacy of the client's right to effective treatment does not apply only to the so-called psychiatric disorders, but also to all examples of harmful dysfunction or psychosocial problems that are the focus of social work services. We now know about some reasonably effective methods of deterring domestic violence, reducing school truancy, helping unemployed people find work or training, or adjusting to the loss of a loved one. Advocating that social workers learn about these methods and attempt to use them in their practices hardly constitutes advocating a medical model. It does constitute supporting a "scientific" model, and as such it shares some features with evidence-based medicine and similar movements within psychology, and related fields. Our view is certainly consistent with that of a recent (nonmedical) social work assessment text: "Assumption one is that clinical assessment must be empirically based. . . . Empirical assessment also means that practitioners are knowledgeable about the empirical research literature in their particular field. . . . Practitioners know which treatments have been demonstrated to work with which clients in which conditions, and they conduct their practice accordingly" (Jordan & Franklin, 1995, p. 4).

In the absence of defining psychosocial problems as biologically based conditions, requiring biologically based interventions (that is, medications or surgery), provided primarily by physicians, we dispute the straw-man argument that we are advocating a medical model.

Major Controversies Are Ignored?

Raw is correct in that we did not extensively present the controversial aspects of the empirical practice movement. Somehow we suspected that keen-eyed readers would undertake this task for us. We are not persuaded that the position is controversial at all. We believe it makes a great deal of sense. Actually, most lay people express surprise when we tell them that clients in social work, psychology, psychiatry, and education currently do not have the right to effective treatments. Perhaps it is time to clothe the emperor before the innocent child (or taxpayer, lawyers, or managed care firm) speaks?

Hegemony of Research over Practice?

Raw speaks of the hegemony of research over practice. All sound efficacy and effectiveness research in the human services is informed by practice. Indeed it is from the insightful observations of practitioners that researchers know what to look for, figure out what hypotheses to frame, and what therapies to evaluate. Moreover, most researchers on practice are themselves practitioners. They have taken the extra professional and educational steps necessary to learn to design, conduct, and interpret research studies on that most complex of all fields, human behavior.

Although hegemony is a harsh word, the reality is that social work has some hard choices to make. Who will decide what are appropriate social work interventions for particular problems? Raw's intuition? Practice wisdom? Managed care corporations? Practice guidelines developed by psychiatrists? The government? The best protection against inappropriate choices is provided by the process known as scientific research. No other approach to knowledge building possesses its inherent safeguards, evidentiary standards, self-correcting nature, public accountability, and progress-by-consensus approach. Mistakes can and will be made in scientific inquiry, but these are more likely to be discovered and corrected than erroneous knowledge developed through "other ways of knowing."

What Raw Does Not Do

Raw fails to inform us of how interventions should be selected, yet this is a fundamental question facing practitioners. We are left with the impression that he believes the sole arbitrator of decision making in practice should be the individual social worker. This position is inconsistent with contemporary standards established by NASW and the Council on Social Work Education; these standards emphasize the importance of grounding practice on empirical research, not solely practice wisdom.

Empirical research is one very useful method for developing generalizable knowledge about effective psychosocial interventions. Through the replication of positive outcomes in increasingly more complex practice environments with diverse clients, the profession's confidence grows that particular interventions exert reliable effects, although not with every client or all the time. But well-crafted, agency-based outcome studies again provide the best medium for discovering the strengths and limitations of particular treatments. As positive outcomes about particular interventions applied to varying clients with specific problems become reasonably well-established, at least compared with alternative, unsupported treatments, this knowledge should be incorporated into the practice repertoire of everyday social work. This process is given the highly technical name of progress. Lacking it, how will the profession advance? What are the alternative methodologies that Raw would advocate for the profession to gain in knowledge, knowledge that is reliable, generalizable, and capable of being taught to others? The failure of Raw and similar critics to proactively answer this fundamental question exposes the hollowness of their argument.

How much of the controversy regarding the purported limitations of empirical research stems from the fact that studies have shown many traditional social work interventions are not effective (Fischer, 1976)? Is all this criticism merely "turf protection" on the part of elements in the profession desperately trying to justify holding on to discredited practice theories? If research provides "bad news," then kill the messenger? Would we read so many dismissive criticisms of conventional research if these traditional models were strongly supported with positive research outcomes? We think not.

To the extent that critics contend that scientific research is a flawed mechanism, the findings of which should be seen as tentative and subject to revision as additional credible data accrue, we agree with such criticisms. The contentions that empirical research is fatally flawed, should not be relied on at all by practitioners, or simply represents one way of discovering knowledge amidst a plethora of alternative, equally valid approaches represent a destructive perspective within social work that will ultimately result in the demise of our profession. As noted by Ell (1996),

Failure to dramatically increase empirical research on interventions by social workers presents numerous risks for patients and the profession. . . . At issue is no longer whether controlled psychosocial intervention studies will be conducted, nor whether the results of that research will be used to influence health care policies and practices. The question is, Will social work significantly increase its contributions to this area of research? (p. 586)

References

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Cohen, I., & Steketee, G. S. (1998). Obsessive-compulsive disorder. In B. A. Thyer & J. S. Wodarski (Eds.), Handbook of empirically based social work practice: Mental disorders (Vol. 1, pp. 343-363). New York: John Wiley & Sons.

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Fischer, J. (1976). The effectiveness of social casework. Springfield, IL: Charles C Thomas.

Fritzler, B. K., Hecker, J. E., & Losee, M. C. (1997). Self-directed treatment with minimal therapist contact: Preliminary findings for obsessive-compulsive disorder. Behaviour Research and Therapy, 35, 627-631.

Hickling, E. J., & Blanchard, E. B. (1997). The private practice psychologist and manual-based treatments: Post-traumatic stress disorder secondary to motor vehicle accidents. Behaviour Research and Therapy, 35, 191-203.

Himle, J., & Thyer, B. A. (1989). Clinical social work and obsessive-compulsive disorder: A single-subject investigation. Behavior Modification, 3, 459-470.

Jordan, C., & Franklin, C. (1995). Clinical assessment for social workers. Chicago: Lyceum.

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Nugent, W. R., Champlin, D., & Wiinimaki, L. (1997). The effects of anger control training on adolescent antisocial behavior. Research on Social Work Practice, 7, 446-462.

Rife, J. C., & Belcher, J. R. (1994). Assisting unemployed older workers to become re-employed: An experimental evaluation. Research on Social Work Practice, 4, 3-13.

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Steketee, G. S., & White, K. (1990). When once is not enough. Oakland, CA: New Harbinger.

Thyer, B. A. (1985). Audio-taped exposure therapy in a case of obsessional neurosis. Journal of Behavior Therapy and Experimental Psychiatry, 16, 271-273.

Toro, P. A., Rabideau, J. M., Bellavia, C. W., Daeschler, C. V., Wall, D. D., Thomas, D. M., & Smith, S. J. (1997). Evaluating an intervention for homeless persons: Results of a field experiment. Journal of Consulting and Clinical Psychology, 65, 476-484.

Vinokur, A. D., Price, R. D., & Caplan, R. D. (1991). From field experiments to program implementation: Assessing the potential outcomes of an experimental intervention program for unemployed persons. American Journal of Community Psychology, 19, 543-562.

Bruce A. Thyer, PhD, ACSW, LCSW, is research professor, School of Social Work, University of Georgia, Athens, GA 30602; e-mail: bthyer@uga. cc.uga.edu. Laura L. Myers, MSW, is doctoral candidate, School of Social Work, University of Georgia.