1 Forward via the Past? Evidence-Based Practice as Strategy in Social Work Catherine McDonald, University of Queensland ABSTRACT The concept of evidence-based practice is enjoying resurgence across the applied social sciences. This paper examines the concept s deployment in social work, an activity that exemplifies the optimistic institutionalisation of the applied social sciences within post war welfare states. Employing the notion of the professional project, I chart the development of Australian social work in the 20th century, noting the ambiguities and tensions of working in a humanist profession acting on behalf of the state. Evidence-based practice is one way some social workers have attempted to manage these tensions, a means congruent with the professional project. As the welfare state is destabilised, and in response to managerialist-inspired modes of reform, evidence-based practice has been revitalised. I assess the capacity and merit of evidence-based practice as a political strategy articulated by sections of a destabilised occupational group to promote the goals of social work in a context of institutional upheaval. Catherine McDonald teaches in the undergraduate and postgraduate programs of the School of Social Work and Social Policy at the University of Queensland. She is also the Director of the Bachelor of Social Work. One of her research interests is the future of social work ISSN Volume 3, Number 3: March 2003, The Drawing Board: An Australian Review of Public Affairs 2003 School of Economics and Political Science, University of Sydney
2 124 THE DRAWING BOARD Introduction The renaissance of evidence, or of a particular form of evidence, in the contemporary politics of welfare is entirely congruent with the times. Social policy discussion increasingly refers to the proactive use of evidence. I explore here the current deployment of the idea of evidence in one domain of service delivery; that is, the promotion of evidence-based practice by some members of the social work profession. Social work has always been a difficult entity to pin down precisely. It encompasses an extremely diverse set of activities (for example casework, case management, counselling, group work, community development, policy development, advocacy, and activism) undertaken in diverse contexts (including hospitals, community correction offices, youth shelters, aged care settings, child welfare departments, juvenile correction facilities, local communities, local government authorities, schools, and so forth). Whatever the activity undertaken and in whichever context, social workers mediate between institutions and individuals, in particular between the state and the people it governs. The range of activities social workers undertake, the multiplicity of locations in which they practise, and the variety of techniques they deploy are held together by a collectively articulated commitment to individual and social well being and justice. The diversity of practices organised under the rubric of social work can accommodate the differences, ambiguities, and contradictions that inevitably arise in the pursuit of these commitments. The establishment of social work as a collective activity in societies such as Australia is an archetypical example of the optimism of the twentieth century evidence of the belief that society could improve the conditions in which people live their lives, and in which we could maximise people s capacities to live their lives to their fullest potential. Ultimately, this optimism is what social work offers the societies in which it is practised and why the history and future of social work is of interest beyond the confines of the profession itself. What social arrangements should we make and foster as a society, if we wish to continue to propel that twentieth century optimism into the 21st century? Is social work the most appropriate vehicle for social progress? Is it capable of fulfilling such a role, and if so, in what form? If not, what should replace it? These questions motivate and justify this paper. I discuss one currently very popular approach to social work, and contrast it with three alternatives proposed in the social work literature. In this way, I provide a modest contribution to a broader debate about how to further the commitments and normative orientations embedded in and articulated by social work. With these comments in mind, I turn to an analysis of evidence-based practice in social work at the present time. In its current form, proponents of evidence-based practice argue that social work intervention knowledge should be developed through the application of positivist research methods, and that social work practice,
3 MCDONALD: EVIDENCE-BASED PRACTICE 125 particularly the decisions that social workers make in the conduct of case intervention, should be based on the best available evidence. The general orientation of evidence-based practice has been clearly articulated and debated within the formal social work literature virtually since the profession s inception (see, for example, Richmond 1917). Over the last decade, however, it has experienced a renaissance in popularity, mooted by some social work scholars and practitioners in the United Kingdom, the United States, and Australia as one of the most productive developments seen in some time. This renaissance has been spurred by range of objectives. Proponents of evidence-based practice usually advance as reason for its embrace the (desirable) promotion of practitioner accountability to people who use social work services and to other relevant bodies (Gambrill 1999, 2001; Rosen 1999). Another important although not as clearly acknowledged impetus also arises from the desire to counter the increasingly precarious image of social work in the managerialist state (Foster & Wilding 2000). One way of critically engaging with evidence-based practice is to reiterate the technical and epistemological debates that can be found in the social work literature (for example, Goldstein 1992; Trinder 2000; Witkin & Harrison 2001; Webb 2001; Sheldon 2001). Irrespective of the validity and intellectual integrity of the claims and counter-claims, such accounts employ epistemologically distinct positions such that their advocates are unable to engage in dialogue over the best way forward. Here, I propose another approach to engagement with evidence-based practice; one that decentres epistemology as the primary axis of debate. My purpose is to shift the debate out of the good/bad binary divide in which it is often located, particularly in the social work literature. I do so to focus attention not so much on the intellectual and practice merits or otherwise of evidence-based practice, but to locate it within a broader understanding of developments in social work, all of which are attempting to respond to contemporary conditions. I advance the very simple proposition that developments such as evidence-based practice can also be understood as a political strategy articulated by sections of a destabilised occupational group in a context of institutional upheaval. The argument that I develop here is that at this level (that is, at the strategic level), evidence-based practice may not be the best way forward. Earlier, I argued that social work as a collective activity represents the optimism of the twentieth century welfare state. The ideas and aspirations fuelling that optimism are not misplaced in the 21st century. The way social work responds to the new forms of governance and new modes of enhancing welfare promoted by neo-liberalism, and its success or failure in the face of these developments will have significant implications. At one end are prosaic concerns: what will all those social workers do? At the other are profound implications for how we, as a society, organise and operationalise our response to social disadvantage and personal pain. If social workers and all the attendant social work look-alikes disappear, who will constitute the human
4 126 THE DRAWING BOARD component of the new welfare state and its attendant service delivery system? More importantly, what will those people, if indeed there are people, be doing? The professional project To advance my evaluation of the strategic dimensions and merits of evidence-based practice, I employ a construct from the sociology of professions: the professional project. The idea of the professional project builds on the Weberian conception of society as an arena in which social entities compete for economic, social, and political rewards. In particular, it develops Weber s nomination of the occupational group, in some cases holding specific educational qualifications from which a living is derived, as one category of competitor. Such entities, in this case the professions, work to bring themselves into existence and to maintain or improve the groups relative standing. In this way, the group pursues a project. Taken up and extended by Friedson (1970) and Larson (1977), the idea of the professional project as strategy developed. 1 Applied to social work, the professional project refers to the activities undertaken and characteristics projected by those wishing to propel the idea that an activity called social work existed (and still exists), and has the characteristics of a modern profession. While the claims asserted throughout the exercise of the professional project rarely explicitly acknowledge it, the professional project is political in the sense that it is fundamentally concerned with erecting boundaries that exert a distinction and create a border between insiders and outsiders. Insiders are accorded, among other things, a degree of regard, some status, and some reward by the state in particular and society more broadly. Theoretically, outsiders are not accorded such privileges (or are in receipt of lesser or different levels of regard, status, and reward). In Australia, the Australian Association of Social Workers (AASW), in conjunction with the state, propels the professional project. The state creates designated positions for social workers accredited by the professional association in its human service agencies; in hospitals and other health programs for example, and in child welfare and child protection agencies. The political nature of the professional project is also reflected in attempts (irrespective of success or failure, or right or wrong) to exert authority over other people: that is, those who use social work services, either voluntarily or involuntarily, due to some sort of (usually serious) problem. This very real authority is legitimised by reference to a body of professional knowledge held by social workers (practice theory and skills). As well as guiding social work intervention, professional knowledge also gives the profession s accounts of the nature of the client 1 See Macdonald (1995) for a more thorough discussion of the Weberian origins and development of the concept of a professional project.
5 MCDONALD: EVIDENCE-BASED PRACTICE 127 experience greater legitimacy than a layperson s account. It is also reflected in attempts with varying degrees of success to hitch social work to the power of the state and other professions through various institutions and institutional arrangements. The professional project in social work is, therefore, the strategic effort of a group of people (social workers) to be known and accepted as a distinct occupational group entitled to sole (or at least privileged) occupation of a niche in the steadily expanding post World War II human services labour market. The professional project also entails efforts by the occupants of this niche to be accorded regard, status, and reward by significant others other professions, the state, people who use social work services, and the general community at large. Professionalisers in social work have pursued their project by adopting the strategies of the established professions like law and medicine, and claiming possession of various traits or attributes said to characterise such professions (Greenwood 1957, 1981). (Jones (2000) has called it the aspirant model of professionalism, in that it is aspiring to the status of the more established professions.) The professional project in social work has been quite successful in gaining the formal and conventional accoutrements of a profession. In the 1960s, its place as a legitimate area of tertiary education and scholarly endeavour in universities was consolidated. The professional association developed and maintained its membership and its control over entry, through control over university curricula. The AASW has also successfully developed many of the other characteristics of a professional body: a national structure, a code of ethics, an academic journal, professional indemnity insurance, a system of continuing professional education, and regular national conferences (McDonald & Jones 2000). Notwithstanding this apparent success, and while social work as an occupational group certainly grew over the decades, it had and continues to have a marginal role in the Australian welfare state. Professionalising activists in Australia failed to position social work centrally in the post war arrangements for social welfare and health service delivery. Prior to World War II, the very few social workers in Australia were mostly employed in charitable organisations, with an increasing number establishing social work in acute care hospitals (Lawrence 1965, 1976). At the end of the war and in an effort to promote post war reconstruction, Commonwealth Government policy opened up significant employment for social workers in what was to develop into the Department of Social Security. Here lay the potential for social work to establish itself as central to income security, and therefore central to the promotion of social citizenship rights. However, despite the opportunities, for a variety of reasons such as problems of supply, social work was unable to consolidate its position. Some gains were made in the states in the 1950s, particularly in statutory child welfare, corrections, and health. Significant differences in the institutional arrangements of service delivery between the states mean that these gains were piecemeal and very
6 128 THE DRAWING BOARD uneven. Nevertheless, by the 1960s, social workers believed that the field had achieved public recognition as a distinct professional occupation (Lawrence 1965). 2 This belief persisted despite the small size of this occupational group within a similarly small social welfare labour market. In fact, significant expansionary opportunities did not occur until the 1970s, when the progressive but short-lived social policy orientation of the Whitlam Government again created a climate for substantial growth in social welfare services (Lawrence 1976). Consequently, social welfare became more visible within the overall welfare regime. Unfortunately, as one commentator noted at the time, social work was again unprepared, and was not able to establish itself as the primary occupation putting the expanding regime into practice. Instead, it remained one player in an expanding and diversifying human services labour market (Chamberlain 1976). Overall, the evidence suggests that social work failed to fully capitalise on the rapid growth of social welfare services, growth that continued through the 1980s (Martin 1996). Being only one of a number of occupational groups implementing health and social welfare policies in the Australian welfare state, social work did not and has not achieved a pivotal, influential, or even particularly large role. Depending on the subsector, social workers have worked beside nurses, psychologists, and occupational therapists, with a significant proportion of the labour force consisting of people with no pre-service vocational education or training in human service delivery (McDonald 1999). This marginal status is further reflected by social work s lack of success in gaining state recognition through formal registration, despite repeated attempts (McDonald & Jones 2000). In summary, social work has not been able to assert itself as a key profession in the Australian welfare state. Social work is one of many players in what remains a fragmented system of social welfare and health services situated on the margins of Australia s institutional arrangements for redistribution and social protection. This double marginality suggests that the professional project of Australian social work has had very modest strategic success. Nevertheless, social work as an occupation has managed to promote the appearance of success in that social workers, along with other occupational groups, continue to be employed by human service agencies. 2 In Britain, by contrast, professional social work successfully gained a key role under new arrangements for social welfare and social care delivery, via what is known as the Seebohm Report (Department of Health and Social Security 1968). Professional social workers became the core labour force in British social service departments, which were established with universalistic orientations to broad ranging services delivered within a framework of social democracy and social rights. In Australia, social work never managed to achieve such centrality, and the Australian welfare service delivery system was not integral to the establishment of the local form of citizenship rights (Wearing 1994).
7 MCDONALD: EVIDENCE-BASED PRACTICE 129 Evidence-based practice in social work As I noted earlier, modern social work developed and acted upon ideas about the relationship between the individual and the state (Lawrence 1965; Kennedy 1982). Contemporary social work practice continues to work this way, in response to poverty, disadvantage, and exclusion. Over the second half of the 20th century social workers became one of a few groups of people sanctioned to both judge the actions of others and seek to treat those actions on behalf of the state. 3 To a certain degree and in limited contexts, social work practice developed as a positive solution to a major problem for the liberal state social work mediates between those actually or potentially excluded from mainstream society, those who pose a threat to society, and those who are integrated into that society. To do so, professional social workers systematically employ disciplinary knowledge expressed in the language of the social and psychological sciences, applying their insights and explanations to social problems and to problematic people. In this way, social work was thoroughly immersed in one of modernity s key projects: bringing discipline, order, and improvement to the human condition. Professional social work practice was seen as a positive development, drawing on twentieth century optimism about the human condition. Whether or not this optimism was warranted is irrelevant. The important point to acknowledge here is that any conception of social work must account for its contextual relations with the state, and its mediating role between the state and the state s subjects. To put this role into practice, social workers mainly worked within various welfare state bureaucracies or in other non-state social welfare agencies primarily funded by the government. While doing so, Australian social work continuously articulated its objective to stand on the side of those who were the objects of their interventions, committed to working with and enabling people to achieve the best possible levels of personal and social well-being (AASW 1999, p. 1). This humanist orientation often stood at odds with the intrusive and controlling aspects of social work, illustrating the moral ambiguity and contradictory nature of certain social work roles (for example, in child protection and community corrections). The professional literature is replete with discussions and suggestions about ways of managing this ambiguity, discussions which in one form or other constitute the core schism and paradigmatic struggle within the profession. For some, resolution of the ambiguity involved developing alternative, radical forms of practice (Throssell 1975; Bailey & Brake 1975) that recommended shifting social work out of the contexts that induce ambiguity in the first place most notably, out 3 Here, we should note that, unlike psychiatrists, for example, this sanction always remained partial.
8 130 THE DRAWING BOARD of work for government agencies. Others sought resolution in ways that involved active engagement in ambiguous contexts of practice, to understand better how effective social work intervention may be developed. These modes of responding rested on the assumption that social workers can retain their commitments to client well being through, for example, the judicious use of valid knowledge rigorously developed, applied, and evaluated within the framework of professional values and commitments. This kind of response long promoted the role of empirical research in clinical social work practice (see, for example, Thyer & Myers 1999). The adoption of evidence-based practice can be understood as the latest manifestation of this response; that is, a continuation of attempts to deal with ambiguity and uncertainty. Evidence-based practice in social work clearly draws on developments in the health field generally and medicine in particular (Trinder 2000). In health, Cochrane s seminal work (1972) evolved into a highly influential international research program called The Cochrane Collaboration (Reynolds 2000). Drawing upon this program, the widespread adoption of evidence-based approaches can be seen in clinical practice in medicine (Sackett et al. 1997), in virtually all aspects of allied health (Bloomfield & Hardy 2000; Dawes et al. 1999; Tickle-Degnen 1998) and in health policy and management (Gray 1997). Though not without its critics in health (Polychronis et al. 1996), and with increasing cognisance of its limitations (Sheldon et al. 1998), evidence-based practice is now a dominant paradigm in health care. From health, the idea of evidence-based practice has spread to social work. Sheldon and MacDonald (1999) clearly locate evidence-based practice as part of an identifiable tradition of scientific research and evaluation evident in social work since the profession s founding days. They also acknowledge, albeit minimally, the strategic objectives of scientific approaches to social work, remarking that social work, particularly social work in the United States, tried to put the matter of its distinctive contribution and its effectiveness beyond the reach of political ideology as early as did any of the other professions (Sheldon & MacDonald 1999, p. 1). Within the broad domain of social work, evidence-based practice has been most enthusiastically adopted in certain fields, for example among social workers working in health and mental heath (Sheldon 1994), corrections (Macdonald 1995), juvenile justice and child protection (Macdonald 1995). I propose (in company with Witkin and Harrison 2001) that the current engagement with scientific research in the form of evidence-based practice represents, in part, enactment of the professional social work project. That is, advocacy and adoption of an evidence-based practice approach to social work practice emulates the approach promoted by the professional project. A recent publication by the Centre for Evidence-Based Social Care in the United Kingdom, for example, states that it is important that professionally qualified social workers base their practice on the best evidence of what works (Newman 2002), and that a social worker s claim to authority resides in her claim to expert knowledge
9 MCDONALD: EVIDENCE-BASED PRACTICE 131 (Newman 2002, p. 3). Thus, the deployment of evidence-based practice can be considered as an enactment of cultural beliefs about what a profession should do and be (Witkin & Harris 2001, p. 294). Contextual developments Undoubtedly, a range of motivations encouraged the promotion of evidence-based practice in social work, the most often expressed of which are to foster client well being and professional accountability. I have no desire to trivialise the aspirations of the supporters of evidence-based practice, but it is also important to acknowledge that evidence-based practice is being promoted within a specific institutional, economic, and organisational context. Modern professions are linked to particular forms of the social organisation of work, themselves creations of the dominant mode of industrial capitalism. The emergence of post-industrial or post-fordist modes of capitalism has involved restructuring of the social organisation of work (Allen 1992). Sociologists have argued that changes to the organisation of professional work have amounted to de-professionalisation, proletarianisation, or de-skilling (Fournier 2000; Hugman 1998, p. 117). In professions such as social work, these processes are experienced as the whittling away of professional privilege and autonomy, the tightening of professional accountability to managers, and the relaxation of professional boundaries. Linking this explicitly with the prevailing ideology of neo-liberalism and associated practices of managerial public sector reform, Lymberly (2000) and others suggest that the benign conditions of the high point of the professional project are gone. Instead, the policy and institutional contexts of service delivery and professional practice have changed significantly (Leonard 1997; Parton 1996; Clarke 1996). Some observers adopt an apocalyptic tone, suggesting that the forces of change are so great that the demise of social work is inevitable (see, for example, Kreuger 1997; Stoesz 1997; Meinhert et al. 2000). Others are more sanguine, arguing instead that social work practice is changing because of pressures imposed by the new public sector managers operating in transformed human service organisations (May & Buck 2000; Harris 2003). These organisations increasingly focus on outcomes, that is, on ensuring that organisational inputs such as social work interventions lead to demonstrable, desirable effects. In this context, proponents of evidence-based practice position it the ideal strategy to reinvigorate the professional project at a time when managers view professions generally and social work in particular sceptically. In child protection, juvenile corrections, and mental health, for example, evidence-based practice has been promoted as the best response to manage risks to the populations in question and to the general community (Powell 2001).
10 132 THE DRAWING BOARD Responding to change: Four strategic options Among social work researchers and occupational activists, evidence-based practice is, however, only one of four identifiable responses to current challenges. Each proposal is positioned somewhat differently in relation to the professional project. Some share its strategic and epistemological assumptions, while others are quite distinct from it. Like evidence-based practice itself, not all of these strategies are new, but represent contemporary re-workings of pre-existing themes in social work. The four responses are: 1. enterprising professionalism 2. global/international social work (including human rights based practice) 3. critical/post-modern/post-structural social work 4. evidence-based practice. Mooted by Jones (2000) enterprising professionalism is compatible with the professional project, and so sits comfortably with evidence-based practice. Enterprising professionalism is a frank call for strategic opportunism by social workers in general, and the AASW in particular. Proponents argue, for example, that given the expansion of the human services labour market and the proliferation of non-social work vocational courses in the human services, the AASW should relax its membership boundaries and create different categories of membership. In this way, enterprising professionalism hopes to reposition social work as the lead profession in an expanding and diverse human services labour market. While proponents of this approach position themselves as offering an alternative to the aspirant professional project, they do so only to criticise those parts of the aspirant project deemed unable to accommodate or respond to contemporary pressures. In contrast with the aspirant approaches to professionalism, the enterprising profession should nurture new attributes that allow social work to rearticulate its linkages and position within emerging institutional arrangements. Specifically, enterprising professionalism re-works the professional boundaries from closed to permeable, and in doing so both recognises and responds to labour force growth and diversity. It responds, for example, to the new reality that employment opportunities in human services are no longer primarily defined in terms of particular occupations and professions (Hawkins 2000). Further, enterprising professionalism links into the developments in pre-service vocational education and training, mirroring the sorts of articulations currently in place between TAFE colleges, three-year human services degrees, and undergraduate social work education.
11 MCDONALD: EVIDENCE-BASED PRACTICE 133 The enterprising professional does not, however, reject or challenge the professional project or its attendant epistemological and ontological assumptions as such. Rather, it promotes an almost natural evolution of the professional project into a newer, better, adapted form. Within this overall strategy, the profession s current attraction to such ideas as social inclusion can be understood. Adoption of these constructs represents one attempt by social work to demonstrate its fitness to the new regime, or new institutional order. Global or international social work (which can incorporate conceptually what is known as human-rights based practice) has also been around as a mode of practice for some time (Midgely 1990; Nagy & Falk 2000; Harris 1990; Healy 2001; Ife 2001). Indeed, it represents an application of the mode of practice associated with professional project, but in different contexts. Recently, interest in international social work as a distinct area of field of practice has escalated, emerging in part as a result of economic, social, and cultural globalisation. It is an omnibus term for diverse practices incorporating cross-cultural social work within advanced welfare states, international adoptions, work with legal and illegal refugees, other forms of migration-related work such as settlement services, health promotion in areas such as AIDS work, and policy development and advocacy in international arenas. International social work also reflects the long-standing professional interest in social development worldwide. The establishment of the United Nations after World War II, for example, influenced social work to engage in international activities, and was largely responsible for the spread of social work education programs throughout the developing world. The profile of international social work as a key activity within the profession diminished somewhat during the high water days of advanced industrialised welfare states, that is, during the late 1960s to the 1980s. For the most part, this transnational or global professional project was and is a modernist enterprise (Leonard 1997; Hugman 1996; Sacco 1996). However, some more recent versions particularly those drawing on post-colonial and postmodern thinking, and on critical geography (Haylett 2001; Harvey 2001) represent a distinct break with the professional project. These developments reconceptualise social work within frameworks of social development, working in what is known as the global-local nexus ; that is, working developmentally via non-government aid organisations with local communities in third world countries struggling with the impact of economic globalisation (Burkett 2001). Critical post-modern social work theory is the most recent development that, as yet, has limited expression in social work practice (Healy 2000; Pease & Fook 1999; Parton & O Byrne 2000; Leonard 1997). Nevertheless, it represents the clearest conceptual break with the professional project. This body of work attempts to engage with social work intervention as discursive practice and social work
12 134 THE DRAWING BOARD knowledge as discourse. Proponents argue that social workers can engage with people in significantly different ways from those promoted by professional social work interventions. Specifically, these developments suggest that social workers should develop a more sophisticated analysis of power operating in worker-client interactions. Critical social work theorists encourage social workers to understand the implications of their privileged position in the relationship, and develop ways of working that are more democratic and participatory. This body of practice theory harbours an implicit (and often explicit) critique of the professional project, arguing that traditional professionalism constructs clients as passive beings, to be acted upon by social workers as technologists drawing upon rational bodies of scientific knowledge. In this way, we can see that critical post-modern approaches to social work are also the conceptual antithesis of evidence-based practice approaches. Finally, we return to evidence-based practice. As a strategy, evidence-based practice clearly sits as the natural heir to the professional project. It draws on a variety of sources: behavioural social work, medical and health care research, positivist and empirical research, and evaluative research of practice effectiveness. Some claim that its popularity resides in its apparent capacity to respond to the managerialist agendas of recent and contemporary governments concerned with effectiveness and accountability (Webb 2001; Harris 1998). The strategic dominance of evidence-based practice in the United Kingdom is demonstrated by the recent investment of over 1.5 million and the promise of another 3 million by the British Economic and Social Research Council to establish the Centre for Evidence-Based Policy and Practice. In Britain, the primary pressure prompting its adoption has been one of rescuing social work s reputation and role in the personal social services, particularly child protection, in a context highly critical of its past failures and seeming ineptitude. Evidence-based practice also dominates in the United States, reflecting the desire by the profession there to continue to exhibit clinical effectiveness. A recent policy document produced by the National Association of Social Work, for example, called for 25 per cent of all physical health, mental health, and substance abuse dollars to be spent on research-based prevention and intervention services (Proctor 2002). The ubiquity of the case management model in that country, promoted by the health insurance companies, has prompted the profession to urgently and seriously engage with evidence-based practice in an attempt to retain its significant role and labour market share, particularly in mental health. In Australia, the pressures are not as clear-cut, because of differences in institutional arrangements for the delivery of health and welfare services, and in how social work fits in those systems. Nevertheless, escalating competition in the human services labour market (McDonald 1999; Martin 1996; Franklin & Eu 1996), expansion of
13 MCDONALD: EVIDENCE-BASED PRACTICE 135 evidence-based practice in medicine and the allied health field, and increased political pressure for effective intervention in child protection all provide the impetus for active engagement. In the short term then, evidence-based practice is alive and well. The strategic viability of evidence-based practice In the long term, some questions remain. Will evidence-based practice result in the sorts of outcomes claimed for it? Will evidence-based practice create a more responsive, effective, and accountable profession? Ultimately, will evidence-based practice provide a solid foundation for the future of social work? In some highly specific contexts of practice it probably will be moderately effective in assisting social workers to make research-informed decisions. It might, for example, be usefully deployed in some forms of clinical intervention, such as anger management programs with juvenile offenders. However, it will not achieve what it claims across the broad domain and in the multiple contexts where social workers currently work, and where they are likely to work in the future. For evidence-based practice to succeed as the primary strategy for the profession s future, it has to work everywhere. If it does not, then social work will not be able to legitimise its presence or stake a credible claim within that framework. Here, we return to epistemology, but not to argue the wrongness of the epistemological foundations of evidence-based practice, a response I contend is not helpful to the debate about the future. Rather, the position I take is that all social science knowledge is partial, in terms of both what and how it is able to know. I argued earlier that social work is a range of activities mediating an ever shifting and often-contested relationship between the state and its subjects. It is also a set of activities attempting to promote individual and social well being which, given the state of social science knowledge, is inevitably limited and partial. In such conditions, placing boundaries around what can be known and how knowledge should be produced is counter-productive. Rather, if social workers in all of their many guises are to succeed in promoting the undeniably optimistic goals of the profession, then all forms of knowledge and ways of knowing need to be available and, as far as is humanly possible, taken up. An evidence-based practice framework does not reflect the sometimes contested and divergent knowledge brought into play in the many places and ways social work is practised. For example, contemporary ways of understanding young women with eating disorders swing between the polar opposites of a psycho-medical approach to one informed by various bodies of feminist theory. Similarly, social workers working with people with disabilities need to know about impairment and its effects from the evidence available, but they also need to know about the social and political experience of living in a disabling world. In the first example, evidence-based practice frameworks limit the capacity of practitioners to draw on contested and oppositional knowledge;
14 136 THE DRAWING BOARD in this case feminist approaches to eating disorders. In the second example, it limits their capacity to draw on knowledge developed by and with people with disabilities. In this case, it is not so much that this knowledge is rejected, but rather that it fails to meet the epistemological standards of evidence-based practice. Evidence-based practice attempts to overlay a template on ways of knowing and acting that may be qualitatively different from its own ways of knowing, and accordingly, cannot see what is going on. In contexts such as work with indigenous people or engaging in community development, evidence-based practice asks the wrong questions. In working with indigenous people in an acute health-care setting, for example, a social worker employing an evidence-based practice framework would not, in all likelihood, consider the impact of dispossession or alienation, or if she did, it might be within an epidemiological framework which itself cannot fully engage with the reality of the experience. Similarly, an evidence-based practice framework would not assist a practitioner to attend to the importance and impact of culture in groups of people such as the profoundly deaf. In these forms of social work practice, evidence-based practice would fail, and more importantly, would fail in terms of its own indicators of success. What I mean by this is that, by not encouraging attention to such defining factors as culture or power, interventions designed within an evidence-based practice framework would not achieve the sorts of measurable outcomes desired, and in fact may exacerbate the presenting problem. For these reasons, the capacity for evidence-based practice to successfully propel the professional project into the future alone is doubtful. If social work is to continue doing what it does in all its diversity, and if it is to engage in new arenas and new ways of delivering welfare, it needs to look beyond evidence-based practice for direction. Instead, social workers should proactively engage with the totality and breadth of existing and emergent ways of acting and thinking to produce ways forward, rather than retreating to the past. Each of the strategic directions discussed above has something to offer. The enterprising profession, for example, provides one way for the profession to embrace the complexities and diversity of the human service labour market. There is much Australian social workers can learn from international social development practitioners in emerging areas of local practice such as community capacity building and other forms of local and regional development. Human rights practice, for example, reasserts indeed privileges the adoption of a strong moral stance. Such a stance provides social work with the opportunity to reinvigorate common value commitments as a defining feature of the profession in destabilising times. Finally, ideas about managing and working with power developed in critical and post-modern approaches to social work could usefully be brought to bear in case management with, for example, unemployed people and other dependent populations in the context of welfare reform.
15 MCDONALD: EVIDENCE-BASED PRACTICE 137 One of the great strengths of social work has been its capacity to acknowledge and respond to diversity among people, in ways of knowing, and in ways of practising. The need for diversity in social work practice has not gone away. If anything, it has intensified, particularly in a social service delivery system increasingly operating in a variety of contexts outside the state: outside state bureaucracies, and even outside nation states. Evidence-based practice has something to offer in some of these contexts, but certainly not all. If the proponents of evidence-based practice propose a one size fits all model, they do the profession and the community no favours. Rather, the future lies in an active embrace of diversity in forms of knowledge and ways of practising. REFERENCES AASW 1999, Code of Ethics, Australian Association of Social Workers, Canberra. Allen, F. 1992, Post-industrialism and post-fordism, in Modernity and its Futures, eds S. Hall, D. Held & T. McGrew, Polity Press, Cambridge, pp Bailey, R. & Brake, M. 1975, Radical Social Work, Pantheon Books, New York. Bloomfield, R. & Hardy, S. 2000, Evidence-based nursing practice, in Evidence-Based Practice: A Critical Appraisal, eds L. Trinder & S. Reynolds, Blackwell Science, Oxford, pp Burkett, I. 2001, Traversing the swampy terrain of postmodern communities: Towards theoretical revisionings of community development, European Journal of Social Work, vol. 4, no. 3, pp Chamberlain, E. 1976, Future shock for social workers: Insulation or adaption?, in Social Work in Australia: Responses to a Changing Context, eds J. Boas & J. Crawley, Australia International Press, Melbourne, pp Clarke, J. 1996, After social work, in Social Theory, Social Change and Social Work, ed. N. Parton, Routledge, London, pp Cochrane, A. 1972, Effectiveness and Efficiency: Random Reflections on Health Services, Nuffield Provincial Hospitals Trust, London. Dawes, M., Davies, P., Gray, A., Mant, J., Seers, K., & Snowball, R. 1999, Evidence- Based Practice: A Primer for Health Care Professionals, Churchill Livingstone, London. Department of Health and Social Security 1968, Report of the Committee on Local Authority and Allied Personal Social Services (The Seebohm Report), Cmnd 3073, HMSO, London.
16 138 THE DRAWING BOARD Foster, P. & Wilding, P. 2000, Whither welfare professionalism?, Social Policy and Administration, vol. 34, no. 2, pp Fournier, V. 2000, Boundary work and the (un)making of the professions, in Professionalism, Boundaries and the Workplace, ed. N. Malin, Routledge, London, pp Franklin, J. A. & Eu, K. 1996, Comparative employment opportunities for social workers, Australian Social Work, vol. 49, no. 1, pp Friedson, E. 1970, The Profession of Medicine: A Study of the Sociology of Applied Knowledge, Dodd, Mead & Company, New York. Gambrill, E. 1999, Evidence-based practice: An alternative to authority-based practice, Families in Society: The Journal of Contemporary Human Services, vol. 80, no. 4, pp Gambrill, E. 2001, Social Work: An authority-based profession, Research on Social Work Practice, vol. 11, no. 2, pp Goldstein, H. 1992, Should social workers base practice decisions on empirical research? No!, in Controversial Issues in Social Work, eds E. Gambrill & R. Pruger, Allyn & Bacon, Boston, pp Gray, J. A. M. 1997, Evidence-Based Health Care: How to make health policy and management decisions, Churchill Livingstone, London. Greenwood, E. 1957, Attributes of a profession, Social Work, vol. 2, no. 3, pp Greenwood, E. 1981, Attributes of a profession revisited, in The Emergence of Social Welfare and Social Work, eds N. Gilbert & H. Specht, 2nd edn., Peacock Publishers, Itasca. Harris, J. 1998, Scientific management, bureau-professionalism, new managerialism: The labour process of state social work, British Journal of Social Work, vol. 28, no. 6, pp Harris, J. 2003, The Social Work Business, Routledge, London. Harris, R. 1990, Beyond rhetoric: A challenge for international social work, International Social Work, vol. 33, no. 3, pp Harvey, D. 2001, Spaces of Capital Towards a Critical Geography, Edinburgh University Press, Edinburgh.
17 MCDONALD: EVIDENCE-BASED PRACTICE 139 Hawkins, L. 2000, Supply and demand: A study of labour market trends and the employment of new social work graduates in Victoria, Australian Social Work, vol. 53, no. 1, pp Haylett, C. 2001, Modernization, welfare and the third way politics: Limits to theorizing in thirds, Transactions of the Institute of British Geographers, vol. 36, no. 1, pp Healy, K. 2000, Social Work Practices, Sage, London. Healy, L. M. 2001, International Social Work: Professional Action in an Interdependent World, Oxford University Press, New York. Hugman, R. 1996, Professionalization in social work: The challenge of diversity, International Social Work, vol. 39, no. 2, pp Hugman, R. 1998, Social Welfare and Social Value: The Role of Caring Professions, Macmillan, London. Ife, J. 2001, Human Rights and Social Work: Towards Rights Based Practice, Cambridge University Press, Cambridge. Jones, A. 2000, Social work: An enterprising profession in a competitive environment, in Contemporary Perspectives on Social Work and the Human Services: Challenges and Changes, eds I. O Connor, P. Smyth & J. Warburton, Longman, Melbourne, pp Kennedy, R. 1982, Australian Welfare History: Critical Essays, Macmillan, Melbourne. Kreuger, L. W. 1997, The end of social work, Journal of Social Work Education, vol. 33, no. 1, pp Larson, M. S. 1977, The Rise of Professionalism: A Sociological Analysis, University of California Press, London. Lawrence, R. J. 1965, Professional Social Work in Australia, Australian National University Press, Canberra. Lawrence, R. J. 1976, Australian social work in historical, international and social welfare context, in Social Work in Australia: Responses to a Changing Context, eds P. J. Boas & J. Crawley, Australian International Press, Melbourne, pp Leonard, P. 1997, Post-modern Welfare: An Emancipatory Project, Sage, London.
18 140 THE DRAWING BOARD Lymberly, M. 2000, The retreat from professionalism: From social worker to care manager, in Professionalism, Boundaries and the Workplace, ed. N. Malin, Routledge, London, pp Macdonald, K. 1995, The Sociology of the Professions, Sage, London. Martin, E. 1996, An update on census data: Good news for social work, Australian Social Work, vol. 49, no. 2, pp May, T. & Buck, M. 2000, Social work, professionalism and the rationality of organisational change, in Professionalism, Boundaries and the Workplace, ed. N. Malin, Routledge, London, pp McDonald, C. 1999, Human service professionals in the community services industry, Australian Social Work, vol. 52, no. 1, pp McDonald, C. & Jones, A. 2000, Reconstructing and reconceptualizing social work in the emerging milieu, Australian Social Work, vol. 53, no. 3, pp Meinert, R., Pardeck, J. & Kreuger, L. 2000, Social Work: Seeking relevancy in the 21st Century, The Haworth Press, New York. Midgley, J. 1990, International social work: Learning from the Third World, Social Work, vol. 35, no. 4, pp Nagy, G. & Falk, D. 2000, Dilemmas in international and cross-cultural social work education, International Social Work, vol. 43, no. 1, pp Newman, T. 2002, Developing Evidence-Based Practice in Social Care: Guidelines for Practitioners, Centre for Evidence-Based Social Services, Exeter University [Online], Available: [17 March 2003]. Parton, N. 1996, Social Theory, Social Change and Social Work, Routledge, London. Parton, N. & O Byrne, P. 2000, Constructive Social Work: Towards a New Practice, Macmillan, London. Pease, B. & Fook, J. 1999, Transforming Social Work Practice: Postmodern Critical Perspectives, Allen & Unwin, Sydney. Polychronis, A., Miles, A. & Bentley, D. P. 1996, Evidence-based medicine: Reference? Dogma? Neologism? New orthodoxy?, Journal of Evaluation in Clinical Practice, vol. 2, pp Powell, F. 2001, The Politics of Social Work, Sage, London.
19 MCDONALD: EVIDENCE-BASED PRACTICE 141 Proctor, E. K. 2002, Social work, school violence, mental health and drug abuse: A call for evidence-based practices, Social Work Research, vol. 26, no. 2, pp Reynolds, S. 2000, The anatomy of evidence-based practice: Principles and methods, in Evidence-Based Practice: A Critical Appraisal, eds L. Trinder & S. Reynolds, Blackwell Science, Oxford, pp Richmond, M. 1917, Social Diagnosis, Russell Sage Foundation, New York. Rosen, A. 1999, Social work research and the search for effective practice, Social Work Research, vol. 23, no. 1, pp Sacco, T. 1996, Towards an inclusive paradigm for social work, in Social Work in a Changing World: An International Perspective on Practice Learning, eds M. Doel & S. Shardlow, Arena, Aldershot, pp Sackett, D. L., Richardson, W. S., Rosenberg, W. & Haynes, R. B. 1997, Evidence Based Medicine: How to Practice and Teach EPM, Churchill Livingstone, New York. Sheldon, B. 1994, The social and biological components of mental health disorder: Implications for services, International Journal of Social Psychiatry, vol. 40, no. 2, pp Sheldon, B. 2001, The validity of evidence-based practice in social work: A reply to Stephen Webb, British Journal of Social Work, vol. 31, no. 5, pp Sheldon, B. & Macdonald, G. M. 1999, Research and Practice in Social Care: Mind the Gap, Centre for Evidence-Based Social Services, University of Exeter. Sheldon, T., Guyatt, G. & Haines, A. 1998, When to act on evidence, British Medical Journal, vol. 317, pp Stoesz, D. 1997, The end of social work, in Social Work in the 21st Century, eds M. Reisch & E. Gambrill, Pine Forge Press, Thousand Oaks, CA. Throsell, H. 1975, Social Work: Radical Essays, University of Queensland Press, St Lucia. Thyer, B. A. & Myers, L. L. 1999, On science, anti-science and the client s right to effective treatment, Social Work, vol. 44, no. 5, pp Tickle-Degnen, L. 1998, Using research evidence in planning treatment for the individual client, Canadian Journal of Occupational Therapy, vol. 65, no. 3, pp
20 142 THE DRAWING BOARD Trinder, L. 2000, Evidence-based practice in social work and probation, in Evidence- Based Practice: A Critical Appraisal, eds L. Trinder & S. Reynolds, Blackwell Science, Oxford, pp Wearing, M. 1994, Dis/claiming citizenship? Social justice, social rights and welfare in the 1990s, in Welfare and Social Policy in Australia, eds M. Wearing & R. Bereen, Harcourt Brace, Sydney, pp Webb, S. A. 2001, Some considerations on the validity of evidence-based practice in social work, British Journal of Social Work, vol. 31, no. 1, pp Witkin, S. L. & Harrison, W. D. 2001, Whose evidence and for what purpose?, Social Work, vol. 46, no. 4, pp
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