On Science, Antiscience, and the Client's Right to Effective Treatment.

Thyer, Bruce A. ; Myers, Laura L.

In the May 1997 issue of Social Work, we published an article entitled "Should Social Work Clients Have the Right to Effective Treatment?" (Myers & Thyer, 1997). In it, we argued that as certain specific psychosocial interventions become well established as effective treatments for particular forms of psychosocial problems, clients consulting social workers should have the right to be provided with such interventions as a first-choice treatment. We reviewed some of the evidentiary standards that have led to certain interventions being labeled "empirically supported" and proposed some ethical standards to promote social workers' training in and applying of these treatments, where appropriate.

In the January 1998 issue of this journal, Professor Stanley Witkin (1998a) responded to our earlier article, arguing that our position was untenable for a number of reasons. Among them was our purported use of such tactics as "misuse of analogy, oversimplification, false consensus, appeals to authority, and the use of testimonials and misrepresentation" (p. 75). We would like to respond to these charges.

To some extent Witkin's issues are legitimate. We did not present a balanced argument, listing the pros and cons of our position, the differing philosophies of science, the real and imagined flaws of empirically oriented science, a review of postmodernism's influence on social work practice, and so forth. We have no doubt that the reader will recognize the acute journal space constraints, which preclude addressing all possible issues dealing with a topic as controversial as ours (some philosophical issues are dealt with in chapter-length form by Thyer & Wodarski, 1998). Witkin's review of some of these issues is a useful service. However, his call for us to provide data to back up an argument based on values and ethical principles strikes us as mixing apples and oranges. Data are called for in evaluating claims to effectiveness of particular interventions, not in advancing positions based on rationality, values, and professional standards. It is perfectly appropriate for empirically oriented social workers to make use of the language of "rights," "ethics," and "obligations," because we are as concerned (if not more so) with such issues as are our nonempiricist colleagues. The use of such language would be a problem if empiricists maintained that scientific considerations should be the only relevant criteria in making practice decisions, but of course, as Witkin well knows, to advocate that empirical considerations be given a greater voice in practice is not to assert that they should be the only voice heard.

What Appeals to Authority?

Of course we made careful and extensive references to earlier work supportive of our position, drawing on the literatures of social work, psychology, psychiatry, and behavior analysis. What Witkin calls "appeals to authority" we prefer to reframe as being consistent with the conventional standards called "scholarship." We would be remiss in not citing such earlier work. We cannot help but note that Witkin engaged in precisely the same practice in crafting his response, bolstering his views by citing the work of Gergen, Heinemann, Gewirth, Witkin himself, Denzin, and other postmodernist authorities. At no point did we contend that because someone else says something, it must be true, and we should therefore follow their recommendations. That argument truly would be a straightforward appeal to authority, and as such would carry little weight in terms of scientific evidence. There are compelling differences between appeals to authority and placing one's current work in scholarly context, and we are confident that the reader can discriminate between the two practices.

What Misrepresentation of Social Work?

Our article did focus primarily on clinical problems and interventions related to mental health practice, because these are the two areas in which the greatest numbers of evidence-based treatments have been developed and psychosocial problems addressed. We believe that a similar right to effective treatment should apply in other areas of practice, community work, policy practice, administration, and so forth, as analogous progress is made in these more macro areas. NASW is collaborating with other mental health fields in the development of practice guidelines for various so-called mental disorders ("Work on Clinical Guides Begun," 1998), not because of any agenda to make the discipline more like psychiatry or psychology, but because practice guidelines are presently feasible only in the mental and behavioral health arenas. In the senior author's recent books, one can find chapters authored by social workers, which review the empirically based methods of intervention for psychosocial problems not defined primarily as mental disorders - problems such as unemployment, racism, child maltreatment, homelessness, crime, school violence, and teenage pregnancy (Mattaini & Thyer, 1996; Wodarski & Thyer, 1998), and what is known about effectively helping people of color and other historically oppressed groups (Harrison, Thyer, & Wodarski, 1996). However, the evidence-based research foundations for these areas are comparatively weak compared with analogous studies in the clinical areas we cited. All long journeys must begin with single steps, and our 1997 article can be seen as one such step, necessarily concentrating on those areas of social work practice in which the most progress has been made: clinical social work in the field of mental health. That this is the largest area of practice in the social work profession is fact, not misrepresentation.

Additional Standards? Good Ideal

Witkin proposed some additional standards, which need to be considered in deciding what treatments should be offered to clients, apart from the issue of empirical support. Not surprisingly, we completely agree with Witkin. We view his additional considerations as supplementary, however, to be applied first to those empirically supported treatments that already possess scientifically credible evidence of efficacy. Nothing in our argument dismisses the social worker's obligation to follow the accepted ethical standards of the profession with respect to working with clients. At present, the empirical foundations of social work interventions are a weak consideration in the selection of treatments to be offered to clients. We think that this should be the prime consideration, but by no means the only one. No doubt the mandatory castration of rapists would lower their reoffense rates and requiring mothers on welfare to use implantable contraceptives would decrease the numbers of children in poverty. But of course other considerations pertaining to ethics and human rights need to be considered, not simply empirical evidence of effectiveness. Has anyone ever argued otherwise?

Is Nothing Known?

Where we widely diverge from Witkin is his contention that no advances have been made in empirically supporting certain psychosocial interventions over others. He has previously stated that "virtually any intervention can be justified on the grounds that it has as much support as alternative methods" (Witkin, 1991, p. 158) and maintains a similar stance in his 1998 critique. This form of intellectual nihilism may have been appropriate 30 years ago, but to disregard completely the magnificent progress made by the profession in testing and validating its services during the past few decades strikes us as surreal! (See Gorey, Thyer, & Pawluck, 1998; Reid, 1997.) More scholarly language would label Witkin's position as "antiscience," defined by Gambrill (1997) as the

rejection of scientific methods as valid. For example, some people believe that there is no such thing as privileged knowledge, that is, that some is more sound than others. Typically, such views are not related to a particular real life problem and to a candid appraisal of the results of different ways of solving a problem. Antiscience is common in academic settings. (p. 86)

Witkin contends that "clients should be able to choose from among those practices that they believe are best for them" (Witkin, 1998a, p. 78). Does this include parents opting for genital infibulation of their daughters (Berg, 1997)? Or permitting intellectually impaired clients with Prader-Willi syndrome to gorge themselves to death (Dykens et al., 1997)? Clearly there are limits on such "client choices." But Witkin's point in this regard is mere obfuscation, because we in no way addressed clients' rights to choose their treatment. Our article dealt with the professional obligation of social workers to provide empirically supported interventions for particular client problems, where such knowledge has been developed. This is a distinctly different issue.

But Just Suppose . . .

We will concede, for the sake of argument, that if there is not a single example of a psychosocial intervention that can be currently considered empirically supported on the basis of present research findings, our earlier article's title was a mere exercise in rhetoric (a question for which an answer is not expected). But suppose, just suppose, that there does exist a number of evidence-based therapies for use by social workers. For example, Witkin himself has claimed that "the efficacy of a group approach to couple therapy has some empirical support" (Witkin & Cayner, 1980, p. 256). Wouldn't you be comforted knowing that the social worker you were consulting had a professional and ethical obligation to provide such services? Wouldn't you be upset if your social worker were woefully ignorant of the latest science-based developments in helping people with problems like yours? Wouldn't you be calling your lawyer if your social worker did know about effective methods of helping but instead opted to provide you with untested therapies or interventions previously shown through empirical research to be ineffective? Suppose that our assertion is correct, and that science is slowly demonstrating that some psychosocial treatments really do work well and that others do not. One ethical implication is that social work clients should have the right to receive these effective treatments. Far from being a rhetorical question, a clear and compelling response to our title "Should social work clients have the right to effective treatment?" does exist. The answer is yes!

Whither the Profession?

Witkin expresses concern about "tightening the grip of empiricism on social work practice research and education" (Witkin, 1998a, p. 79). We believe that the greater problem is the converse, that the present state of evidence-based practice in social work is more akin to a flaccid handshake. We are confident that the field will eventually adopt, in some form, the standards we have proposed. We applaud the establishment of the new journal, Evidence-based Mental Health (published by the BMJ Publishing Group) in 1998; the new Centre for Evidence-based Social Services at the University of Exeter in the United Kingdom; NASW's collaboration with psychology, nursing, and psychiatry in the development of practice guidelines in mental health and substance abuse ("Work on Clinical Guides Begun," 1998); the growing numbers (500+) of social workers who have joined the Society for Social Work and Research, founded in 1994; the proliferation of well-crafted scientific studies demonstrating that research-based therapies can be applied with equal effectiveness in agency-based settings by everyday practitioners (for example, Wade, Treat, & Stuart, 1998; Westbrook & Hill, 1998); and increased litigation by consumers who were provided with ineffective psychotherapies and harmed thereby. In our view, these are undeniable milestones marking the profession's progress.

In his new role as editor, Witkin (1998b) has raised the possibility of locating the journal Social Work "outside of the mainstream, defying the literary conventions that signify and reproduce scientific legitimacy. For some, this will be seen as a dangerous shift that risks undermining efforts to improve social work's acceptance and respectability" (p. 102). We could not have said it better ourselves! In the long run we shall see which position proves to be the most useful for the profession and its clients, science or antiscience.

References

Berg, K. (1997). Female genital mutilation: Implications for social work. Social Worker, 65(3), 16-26.

Dykens, E. M., Goff, B. J., Hodapp, R. M., Davis, L., Devanzo, P., Moss, F., Halliday, J., Shah, B., State, M., & King, B. (1997). Eating themselves to death: Have "personal rights" gone too far in treating persons with Prader-Willi syndrome? Mental Retardation, 35, 312-314.

Gambrill, E. (1997). Social work practice: A critical thinker's guide. New York: Oxford University Press.

Gorey, K. M., Thyer, B. A., & Pawluck, D. E. (1998). Differential effectiveness of prevalent social work practice models: A meta-analysis. Social Work, 43, 269-278.

Harrison, D. F., Thyer, B. A., & Wodarski, J. S. (Eds.). (1996). Cultural diversity and social work practice (2nd ed.). Springfield, IL: Charles C Thomas.

Mattaini, M. A., & Thyer, B. A. (Eds.). (1996). Finding solutions to social problems: Behavioral strategies for change. Washington, DC: American Psychological Association Press.

Myers, L. L., & Thyer, B. A. (1997). Should social work clients have the right to effective treatment? Social Work, 42, 288-298.

Reid, W. R. (1997). Research on task centered practice. Social Work Research, 21,132-137.

Thyer, B. A., & Wodarski, J. S. (1998). First principles of empirical social work practice. In B. A. Thyer & J. S. Wodarski (Eds.), Handbook of empirical social work practice: Volume 1 - Mental disorders (pp. 1-21). New York: John Wiley & Sons.

Wade, W. A., Treat, T. A., & Stuart, G. L. (1998). Transporting an empirically-supported treatment for panic disorder to a service clinical setting: A benchmarking strategy. Journal of Consulting and Clinical Psychology, 66, 231-239.

Westbrook, D., & Hill, L. (1998). The long-term outcome of cognitive behaviour therapy for adults in routine clinical practice. Behaviour Research and Therapy, 36, 635-643.

Witkin, S. L. (1991). Empirical clinical practice: A critical analysis. Social Work, 36, 158-163. Witkin, S. L. (1998a). The right to effective treatment and the effective treatment of rights: Rhetorical empiricism and the politics of research. Social Work, 43, 75-80.

Witkin, S. L. (1998b). "Greetings" [Editorial]. Social Work, 43, 101-103.

Witkin, S. L., & Cayner, J. J. (1980). Communication and problem solving skills training for couples: A case study. In S. D. Rose (Ed.), A casebook in group therapy (pp. 219-248). Englewood Cliffs, NJ: Prentice Hall.

Wodarski, J. S., & Thyer, B. A. (Eds.). (1998). Handbook of empirical social work practice: Volume 2 - Social problems and practice issues. New York: John Wiley & Sons.

Work on clinical guides begun. (1998, February). NASW News, p. 13.

Bruce A. Thyer, PhD, ACSW, LCSW, is research professor, School of Social Work, University of Georgia, Athens, GA 30602, and visiting professor, School of Human and Health Sciences, University of Huddersfield, UK; e-mail: bthyer@arches.uga.edu. Laura L. Myers, PhD, is project coordinator, School of Social Work, University of Georgia, Athens. Correspondence may be addressed to B. A. Thyer, School of Social Work, University of Georgia, Athens, GA 30602 or via the Internet to bthyer@arches.uga.edu.