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While there is recent movement toward Evidence-Based Practice (EBP) in social work, criticisms subsist regarding the profession’s translation of research into viable practices. Evidence describing effective interventions exists, but research that addresses dissemination and implementation is generally lacking. This paper highlights existing literature on dissemination and explores the barriers, themes, and trends in EBP through eight expert interviews. The interviews reflect the issues described in the literature and provide additional insight to the process of implementation and dissemination of EBP. Findings from the literature and interviews are synthesized into research and practice recommendations.
While there is a call for Evidence-Based Practice (EBP) in social work and mental health services, there have also been a number of criticisms about the implementation of research findings into viable methods of practice. These barriers range from the egregious lag-time between research development to dissemination of evidence to practice settings to a veritable lack of support and training for community practitioners. There is a growing body of evidence describing effective interventions, but there is not a substantial body of work addressing the dissemination of these programs and other research findings for use in the field. This paper highlights some of the work around dissemination of EBPs in the field of social work with an emphasis on mental health services including an overview of the barriers to the use of evidence in practice and proposed models of conceptualization and implementation of EBP. To further highlight the current barriers, themes, and trends in EBP eight experts in the field of EBP were interviewed. The goal of the interviews was to survey the opinions of expert researchers in the area of EBP to supplement knowledge described in the literature. The experts’ responses reflected many of the same issues described in the literature as well as additional information regarding their efforts toward determining the most viable options to address the barriers to implementing and disseminating EBP. Findings from the literature review and interviews are synthesized into recommendations for future research and practice efforts.
Practice decisions based on research evidence have increasingly become an identified need in the treatment of mental illnesses. Three of the most influential reports on mental health services policy in recent years, The President’s New Freedom Commission on Mental Health Report (2003), The World Health Organization Report on Mental Health (2001), and Mental Health: A report of the Surgeon General (1999), emphasize the need for research and evidence-based practices (EBPs) in mental health services. Even more broad health policy reports, such as Healthy People 2010 (2000) from the U.S. Department of Health and Human Services (DHHS), point to “an emphasis on translating new knowledge into clinical applications” in the mental health arena. The President’s New Freedom Commission on Mental Health (2003) recently released a final report calling for evidence based and recovery focused interventions in the treatment of mental illness; and the National Institute of Mental Health echoes this approach (Insel, 2003). Goal five of the President’s New Freedom Commission on Mental Health Report (2003) stresses the need to deliver excellent mental health care by accelerating research to promote recovery, resilience, prevention, and a cure for mental illness, advancing evidence-based practice dissemination and demonstration, expanding the workforce providing evidence-based practices, and developing a knowledge base in mental health disparities, long term medication effects, trauma, and acute care.
These national and international health and mental health reports are important to social work, not only as signposts of current trends in policy thought, but also as frameworks for future policy and funding activity. Federal agencies like the Substance Abuse and Mental Health Services Administration (SAMHSA), Agency for Healthcare Research and Quality (AHRQ), and National Institute on Drug Abuse (NIDA) are beginning to link grants and contracts to EBP themes such as research-based interventions and the translation of research into practice as well as hosting conferences dedicated to EBP. These and other agencies are also outlining science-based program standards and rating systems. For example, the Center for Substance Abuse Prevention (CSAP) and SAMHSA recently constructed a comparison matrix of science based prevention programs examining the standards and effectiveness ratings of 150 different programs sponsored by five different federal agencies (2002).
According to Thomas Insel (2004), director of the National Institute of Mental Health, social workers are doing the majority of front line work treating individuals with mental illnesses. Citing a 1998 SAMHSA report, the current psychotherapy workforce is dominated by social work consisting of 192,814 social workers, 73,014 psychologists, 33,486 psychiatrists, and 17,318 psychiatric nurses (Insel, 2004). Despite social worker dominance in the field of mental health and the National Association of Social Workers (NASW) code of ethics emphasis on research based service, the majority of social workers do not appear to draw on research findings to inform their practice (Gibbs & Gambrill, 2002; Kirk & Rosenblatt, 1981; Mullen & Bacon, 2004; NASW, 1996; Rosen, 1994). Social workers, including researchers, educators, agency administrators, and practitioners, are therefore challenged with an important question: “How can the profession better disseminate the rich and growing body of research and evidence based interventions in social work and mental health services to practitioners providing direct services to individuals with mental illnesses?” This paper contains a review of the current literature around the dissemination of EBP, current social work models for dissemination of EBP, interviews with experts in the field, and a synthesis of this combined knowledge into recommendations for future dissemination of research and EBP efforts.
For this project, research was conducted through a review of the literature, including both books and scholarly articles, on EBP in mental health services in social work as well as other relevant professions and by interviewing a convenience sample of experts currently conducting research related to the development and dissemination of evidence based interventions for mental illnesses. Relevant literature was identified through a search of local social work and public health library holdings and by searching electronically using the following databases: Social Work Abstracts, PsychLit, and Medline. Additional citations were collected via the reference lists of identified sources and through the draft reference list of EBP dissemination literature collected by the Research Unit for Research Utilization (RURU), a part of the Evidence Network of Great Britain (RURU, 2003). This review was limited to published literature that directly describes the use of research in social work practice specifically.
The first widespread push for EBP in social work came out of a series of studies that began to appear in the 1970s and called into question the effectiveness of existing social work interventions (Fisher, 1973; Reid, 1994). The 1970s and 1980s witnessed a movement to develop evidence based models of practice in mental health and further the development of well researched psychosocial intervention models such as the behavioral, cognitive, interpersonal, and social approaches, as well as the biological and biopsychosocial theories of mental illness (Turnbull, 1991). Evidence-based researchers in many disciplines pioneered models used in social work practice including: psychology, psychiatry, and social work. In the late 1980s and early 1990s substantial evidence regarding the treatment of common mental health disorders were high-lighted by the publication of the results of studies such as the National Institute of Mental Health Treatment of Depression Collaborative Research Program (Elkin, Shea, Watkins et al., 1989). Over the past decade, the proportion and number of articles referring to EBP published in professional journals has risen in the disciplines focused on mental health services, health, and social welfare (Shlonsky & Gibbs, 2004). For a more detailed description of the history of the development and use of EBP in social work see Kirk and Reid (2002).
Today, New York State’s Office of Mental Health, identified as a progressive program by NIMH (Insel, 2003), is promoting the use of the following EBP for adults with serious mental illnesses. These EBP interventions include: Assertive Community Treatment (ACT), supported employment, intensive case management, wellness self-management, family psychoeducation, integrated treatment for co-occurring substance abuse and mental health disorders, medication (and guidelines for practitioners to promote optimal prescribing practices), self-help and peer support services, and post-traumatic stress disorder (PTSD) treatment (New York State Office of Mental Health, 2001). The President’s New Freedom Commission (2003) report identified the following additional EBPs for the treatment of mental health disorders: cognitive and interpersonal therapies for depression, preventive interventions for children at risk for serious emotional disturbances, treatment foster care, multi-systemic therapy (MST), parent-child interaction therapy, and collaborative treatment in primary care. The commission also recommended emerging best practices including: consumer operated services, jail diversion, and community re-entry programs, school mental health services, trauma-specific intervention, wraparound services, multi-family group therapies, and systems of care for children with serious emotional disturbances and their families (New Freedom Commission, 2003).
The wider field of social science knowledge utilization is just beginning to build a theoretical framework that explains why research evidence, such as the EBPs listed above, is or is not utilized in social work practice (Landry, Amara, & Lamari, 2001). While researchers have identified evidence-based mental health services, the translation and implementation of these services into practice has been problematic. One of the greatest complaints has been the lag of nearly 15 to 20 years between the identification and incorporation of EBP interventions into routine care (Balas & Boren, 2000). Moreover, social work is a profession that claims expertise and specialized knowledge, values, skills, and professional ethics aimed at addressing difficult human problems, including mental illness (Gambrill, 1999); however, licenses, experiences, and training are not supported by evidence as necessarily related to helping clients through the use of evidence (Dawes, 1994).
Gambrill (1999) describes two different strategies for addressing the problem that social work is a profession based on “claimed rather than demonstrated effectiveness” in assisting clients in obtaining targeted outcomes. The first strategy, and arguably the most common historically, has been to ignore the contradiction between claims and reality and to censure this information from the academic and practice community (Gambrill, 1999). The second strategy is to investigate the values, skills, and knowledge needed to achieve certain outcomes and then to identify who has these resources and the capability to provide them (Gambrill, 1999). Social workers can, in this way, become integral participants in the process of shaping and delivering supported and needed interventions for clients and communities.
Perhaps the most common subject described in the EBP literature has been the concrete and psychological barriers that impede dissemination and implementation of EBPs. These barriers, outlined by practitioners, researchers, and administrators alike, have generally revolved around four major themes: knowledge, lack of fit, suspicion, and resources.
Knowledge barriers are those that speak to the general lack of awareness of available EBPs and the difficulty in processing or understanding research findings when they are identified (Anderson, Cosby, Swan, Moore, & Broekhoven, 1999; Mullen & Bacon, 2004). This Includes practitioners’ lack of knowledge about how to best access, critically evaluate, and translate evidence for appropriate use with their clients. Gray, one of the foremost thinkers in evidence based healthcare and policy, likens research-based facts to uncut diamonds, which are valuable but of little use in their raw form (1997). Few practitioners access traditional outlets for research findings, such as scholarly journals (Kirk & Reid, 2002) and the information found in these journals is not easily digested or translated into practice (Anderson, Cosby, Swan, Moore, & Broekhoven, 1999; Bartels, Haley, & Dums, 1998). Even when evidence is identified in journals, much journal evidence is three-to four-years-old by the time it is published (Thyer, 2004). The lack of knowledge also includes arguments that are based on a misunderstanding of what constitutes an EBP. For example, some have argued that social work is already using and teaching EBP, that effectiveness is a matter of personal opinion, or that no clear evidence is available for the questions social workers pose (Gibbs & Gambrill, 2002).
Even if practitioners are able to identify and understand research they may still discredit its value. The lack of fit theme includes the reasons why practitioners feel that available evidence or research is not often helpful. Some feel that the EBPs are cookbook approaches that are too broad and do not speak to the unique contextual or cultural needs of clients (Bartels, Haley, & Dums, 1998; Gibbs & Gambrill, 2002; Mullen & Bacon, 2004). Others have noted that the methodology of treatment may not be applicable within the confines of their practice. For example, many EBPs emphasize short-term treatment, but this format is not appropriate to all clients across diverse settings (Mullen & Bacon, 2004). Moreover, practitioners have noted that research and current policy are often at odds. Research findings are slow to develop, and once findings are presented, it may take considerable time before policies are aligned with new knowledge. As a result, policy and agency requirements and technology frequently do not support current evidence (Anderson, Cosby, Swan, Moore, & Broekhoven, 1999; Gibbs & Gambrill, 2002). Finally, the culture of knowledge transmission within social work has been historically unsupportive of the use of research evidence in practice (Barratt, 2003).
Related to the idea of the lack of fit between research findings and practice is the theme of suspicion. This includes a basic distrust for evidence, based on objections related to political, ethical, or control issues. Gibbs sites a natural resistance to innovation (including EBPs) as one of the main barriers of teaching EBP to practitioners (Gibbs, 2003). Some practitioners feel that research evidence is simply a cost-cutting tool, politically motivated, guided by efficiency, or otherwise influenced by something other than the client’s best interest (Anderson, Cosby, Swan, Moore, & Broekhoven, 1999; Gibbs & Gambrill, 2002). Other practitioners feel the experts are more often guided by their own view or model rather than an objective examination of the evidence (Barratt, 2003). Landry, Amara, and Lamari (2001) point oat that there is an inherent disconnect between the goals and needs of researchers and practitioners. Practitioners need and want guidance that is tailored to clients and practice. However, the degree to which research results are customized to only one or two users increase costs to the scholars. Their work becomes less generalizable to the wider world and they must reformat or repackage it if they want others to utilize their work. It becomes a catch-22 where researchers are pushed toward developing broad applications and their work becomes likewise less useful for the individual practitioner. Moreover, as Barnes and Clouder (2000) point out, the determination of what is disseminated is largely dependent upon the researcher’s judgment of what is significant or worth sharing. Others believe that EBPs exclude the practitioner’s professional judgment, clinical expertise, or the judgment, values and preferences of the client (Gibbs & Gambrill, 2002; Mullen & Bacon, 2004). An argument has also been made that those who advocate EBP want only to set trends, be first, be controversial, or further their reputations and that evidence can be found to support any favored point of view or that all methods are equally valuable in arriving at the truth (Gibbs & Gambrill, 2002). The idea that research is suspect seems also, in part, due to the generally poor relationship that researchers and scholars have had with community agencies and practitioners in the past. Administrators have described a lack of communication and a disjoint between the goals of the agency and that of researchers (Anderson, Cosby, Swan, Moore, & Broekhoven, 1999; Barratt, 2003). Furthermore, practitioners’ may collaborate in creating or testing interventions with researchers, but their participation in building and sharing knowledge with the wider profession has generally been limited (Kirk & Reid, 2002). The chasm between research and practice is further widened by practitioners’ inability to contribute to the formal body of social work knowledge that they are expected to employ. “Thus, knowledge production and dissemination is largely in the hands of a small number of academics, while expectations for use have often been placed on the vast number of practitioners” (p. 205, Kirk & Reid, 2002).
Even practitioners and agencies that understand, appreciate, and want to use research evidence in their work may find themselves incapable due to a lack of resources (Anderson, Cosby, Swan, Moore, & Broekhoven, 1999; Barrett, 2003; Mullen & Bacon, 2004) and reluctance to ask more of an overextended staff (Barratt, 2003). Without the necessary training, materials, time and staff dedication to researching the evidence, EBPs cannot often be employed. Interventions may be shaped instead by limitations rather than knowledge. A lack of technology is particularly troublesome in a day and age where most cutting-edge information is accessed through computers and the Internet. Many agencies do not have access to these resources. The issue is not only what resources are realistically available, but also beliefs or policies about who can have access to these resources. Some administrators feel that not all social workers should have access to computers and the Internet (Barratt, 2003). The issue of a lack of resources is partly a result of generally poor or inconsistent funding for many social work agencies. However, funds that are available are rarely routed toward identifying, instituting and maintaining research, technology, or EBPs.
Despite the numerous barriers to dissemination outlined above, social workers in the mental health services arena do have a number of compelling reasons to implement evidence into their practice with mentally ill individuals. Practitioners have cited advantages of using EBPs such as: (1) conceptualizing, planning, and guiding treatment, (2) increasing knowledge and skills, (3) improving treatment outcomes for clients, (4) integrating and supplementing, not supplanting, clinical judgment and knowledge, (5) complying with current practice, values, and professional consensus, and (6) satisfying grant or managed care reimbursement requirements (Mullen & Bacon, 2004). Overall, the basic tenet of EBPs is that clients should receive the benefit of the best technology that social work has to offer.
It is, however, difficult to imagine the basis on which structured, fact-based and well-informed decision making and planning referenced to the best available published research can be viewed as counter either to the provision of effective outcomes for service users, or to the ethos of the social work professional, (p. 144, Barratt, 2003)
There are many questions as to what exactly should be used as evidence to identify the best technology possible. Undoubtedly this argument will, and should, continue within the field. However, if some agreement upon what is a validated intervention can be secured, the question becomes one of dissemination and implementation.
Until recently the prevailing approach to dissemination has been to report evidence in journal articles and published or unpublished practice manuals or to provide limited didactic trainings (Gibbs & Gambrill, 2003). Additionally, in recent years some masters programs have offered limited numbers of courses on some EBPs, such as cognitive behavioral therapy (Gibbs & Gambrill, 2002). However, evidence suggests that these strategies have been largely unsuccessful in social work, as well as in the other professions treating individuals with mental health needs, as few mental health professionals are basing practice decisions on research evidence (Gibbs & Gambrill, 2002; Kirk & Reid, 2002; Kirk & Rosenblatt, 1981; Mullen & Bacon, 2004; NASW, 1996; Rosen, 1994). To facilitate implementation of EBPs in the community, “… it is increasingly recognized that simply improving the content and availability of the evidence base is not sufficient to secure such changes. Explicit and active strategies are required to ensure that research really does have an impact on policy and practice” (p. 2, Walter, Nutley, & Davies, 2003). In order to flourish, efforts to implement evidence-based practices must be “multifaceted, broad-based and carefully targeted” (p. 144, Barratt, 2003).
Many researchers, program developers, and others have employed a cornucopia of what Walter, Nutley, and Davies (2003) term “mechanisms” to disseminate research findings. These authors reviewed over one hundred papers that evaluated or described efforts to facilitate the use of research. Nearly two hundred individual practices or packages were identified through this review. Based on these, the authors developed a taxonomy of approaches by both intervention type (format through which the information flows) and mechanisms employed, as well as a brief description of the research or theory that lends support to the specific approach. For example, one category of mechanisms described by the authors is incentives. The adoption of desired behaviors or information is encouraged through reward, or perhaps linking funding to specific practices. This mechanism is supported by learning theories, economic models of rational behavior, and power theory. Using such taxonomy to organize and understand dissemination research could potentially prove useful.
A number of researchers have taken the process a step further than individual mechanisms or approaches and proposed more developed frameworks for the delivery of research evidence into practice. While no single best method has been identified, there are a number of emerging social work implementation strategies described in the literature. The following is a brief overview of this work.
Based on interviews with community organization leaders, Anderson and colleagues suggest a model based on a relationship between researchers and community organizations that moves through three different stages. In the first stage, awareness, both researchers and community organizations are educated about the needs of one another (Anderson, Cosby, Swan, Moore, & Broekhoven, 1999). In many cases both researchers and community-based organizations have little contact and are generally ignorant of the other’s work. In the second stage, communication, mechanisms are built to facilitate the transfer of information. Both community organizations and research stakeholders come together to formulate a plan for sharing skills and knowledge. A variety of methods may be employed such as: workshops, databases, and open houses. Finally, in the last stage, interaction, mutual activities toward common goals are shared and negotiated. In this model, a relationship is built to facilitate communication and knowledge transfer between community organizations and researchers allowing each to inform the other’s work. This model is general, offers some specific recommendations, but seems to focus largely on encouraging local groups to work together in order to find the methods that match their shared needs, abilities, and resources.
Leonard Gibbs and Eileen Gambrill propose a model defining EBP as the ‘conscientious, explicit, and judicious use of current best evidence to make decisions about the care of clients’ (Gibbs & Gambrill, 2002). The aim of their model is to create lifelong learners who, in collaboration with clients, draw on practice related research findings to make practice related decisions (Gibbs & Gambrill, 2002). In this model, EBP is a process that results from the careful consideration of practitioner’s individual experience, best available evidence, and client values and expectations (Shlonsky & Gibbs, 2004). EBP is characterized by: (1) becoming motivated to apply evidence to practice decision making, (2) an individual assessment and well formulated question, (3) an external electronic search for practice findings related to practice questions, (4) decision-making regarding the evidence’s fit with the individual client, (5) using individual expertise to integrate the best external practice evidence, (6) evaluating the outcome (7) and sharing what is learned with others (Gibbs, 2003; Gibbs & Gambrill, 2002). These authors propose a method of dissemination heavily focused on the education of practitioners in this model of EBP at the master’s level (Gibbs, 2003; Gibbs & Gambrill, 2002).
Outside of the implementation of EBP as core curricula in master’s level social work programs and continuing education, Gibbs and Gambrill offer little advice on implementation suggesting that practitioner’s ‘obey your own conscience and implement EBP into your own practice however you feel it most appropriate to do so’ (Gibbs, 2003). The following suggestions are offered, (1) consider the quality and applicability of evidence, (2) consider the context or organizational environment, and (3) consider the process of implementing change (Gibbs, 2003). However, a clear design for implementation, outside of teaching, master’s level education, and continuing education, is not offered.
Aaron Rosen and Enola Proctor have devised an implementation strategy that relieves the practitioner of the burden of formulating and identifying the relevant research, locating, and assembling the information, critically evaluating the relevancy and validity of the evidence with regard to their practice decisions with an individual client, and adapting that knowledge to the client’s particular needs and situation (Rosen, Proctor, Morrow-Howell, Auslander, & Staudt, 1993). The strategy proposed involves the use of Systematic Planned Practice (SPP), a tool for treatment planning and evaluation that includes the planning and recording of critical elements of practice such as the presenting problem(s), desired outcomes, interventions, and observed results (Rosen et al., 1993). Application is guided by forms that serve two functions: to prompt and guide the worker in laying out the treatment plan and as a rationale for decisions made and to provide documentation for treatment planning decisions, what is actually implemented, and the outcomes obtained (Rosen et al., 1993). A dissemination plan is proposed that combines SPP with components of practice guidelines to facilitate practitioner use and knowledge of evidence in practice (Rosen, 2002). According to Proctor, the adoption of EBP consists of multiple distinct outcomes whose attainment requires “systematic, targeted efforts by many players, at multiple levels of influence” (Proctor, in press). These include the following provider outcomes necessary for evidence based practice; identifying and accessing EBPs, accepting and adopting EBPs, implementing EBPs and evaluating EBPs (Proctor, 2004). As in the Gambrill and Gibbs model, Rosen and Proctor place much of the burden of utilization on the practitioner to locate and implement research knowledge. While Anderson and colleagues frame the process as more of a partnership between researchers and practitioners, it lacks specificity in terms of implementation.
Another approach to the dissemination of EBPs is the tool kit method. Tool kits are materials constructed from original research and translated for use by practitioners, agencies, or institutions. In this model, specific tools rather than a framework or mandate are provided to support social workers’ efforts toward using EBPs. Resources, such as the Sociometrics Program Archives, have taken up the business of culling through research with the help of expert panels to develop a collection of tools such as: user’s guides, teacher or facilitator manuals, student or participant workbooks, videos or other supplemental media, and homework or exercises (Card, 2001). Practitioners can order such tool kits from for profit and nonprofit enterprises at a cost. The idea is that the necessary research evidence is distilled into an attractive user-friendly format that is ready for implementation in the community. Evaluation processes are also sometimes included to provide a conduit for user feedback and further refinement of the toolkit package (Card, 2001).
Instituting practice guidelines, which have often been employed in using practice theory and wisdom since the beginning of the profession, has been another method recommended for the dissemination of EBPs (Kirk & Reid, 2002). Using this format, treatment is directed by an outline of acceptable practices in specific areas of treatment. These practices would be determined by a professional body-charged with surveying, evaluating, and choosing both prescribed and proscribed interventions. Researchers have made arguments against such guidelines including: (1) the paucity of research needed to support good guidelines, (2) the lack of agreement on what constitutes evidence, (3) too little flexibility for practitioners, (4) little agency support, (5) and the fear of the use of guidelines as de facto standards in litigation against practitioners (Howard & Jensen, 1999). Despite these objections, Howard and Jensen (1999) argue that practice guidelines can go a long way toward improving social work interventions (for an excellent discussion of the potential problems and benefits of practice guidelines in social work please see the May 1999 issue of the journal Research on Social Work Practice).
Historically other models have been explored to marry research and practice. Kirk and Reid (2002) describe efforts that grew out of industry and technology beginning in the 1960s and 70s such as the Research Development and Diffusion (RD&R) and Design and Development (D&D) models. These models describe a paradigm by which research and practice can be mutually informative in a constant feedback loop. However, as Kirk and Reid point out, these efforts would be enhanced if they were to be exposed to the same processes that they propose in order to become more flexible and useful across diverse social work contexts.
Beyond the more developed models described above, several researchers have made general recommendations for dissemination of evidence into practice. First, it is essential to secure organizational and practitioner buy-in (Anderson, Cosby, Swan, Moore, & Broekhoven, 1999; Lewis, 1998; Mullen, 2004). Before any real progress is made toward dissemination stakeholders must both agree that EBP is valuable and important enough to merit a commitment of time, training, and other resources. Leadership is a crucial ingredient for change in this area (Barratt, 2003). Although the dissemination of EBPs must occur at all levels, important issues such as protecting practitioner time for research and training as well monitoring and following up on implementation activities must be guided by administrators and other persons or agencies with authority. Also, some authors have described the importance of establishing a network of local organizations and practitioners so that they can pool resources such as training and research, become actively involved, and develop broad community goals (Anderson, Cosby, Swan, Moore, & Broekhoven, 1999; Howard & Jensen, 1999). McKay and colleagues stress the importance of training and the establishment of an “engagement team” consisting of intake workers, clinical and administrative staff, and supervisors who oversee the implementation of interventions at each site (McKay, Hibbert, Hoagwood, Rodriguez, Murray, Legerski, & Fernandez, 2004). Agencies and practitioners cannot be realistically expected to “go it alone” on tight budgets, timelines, and a research base that is a moving target. A much more efficient approach seems to be one of networking and sharing with other social workers, community organizations, educational institutions, and other stakeholders.
Unfortunately, the authors found few studies testing the efficacy of these approaches to the dissemination and utilization of research in practice. In essence, the research evidence on the use of EBPs has not been well developed. “Researchers have been relatively oblivious to the processes by which knowledge, once developed, might be effectively disseminated and used” (Kirk & Reid, 2002).
Based on themes identified in the literature review, the authors conducted qualitative interviews with experts in the field of EBP. The goal of the interviews was to survey expert researchers in order to explore current strategies, struggles, and observations about EBP to supplement and speak to the themes described in the literature.
Interviews with expert researchers experienced in mental health services research and evidence-based clinical interventions were conducted using open ended questions related to the topic of the dissemination and implementation of evidence based practices. Because this research is exploratory in nature, a convenience sample of interview candidates was selected on the basis of reputation and body of work in the field of EBP. In addition, a snowball method of interviewee selection was employed where respondents referred the authors to other experts for further data collection. All participants were researchers trained at the doctoral level. In total eight experts were interviewed including: five social worker professors, one professor of psychiatric epidemiology, one psychiatrist who directs a children’s mental health research program, and one national policy organization researcher.
Each potential respondent was invited to share thoughts and opinions regarding the use of EBP in mental health services and was provided a copy of the questions before the interview. Interviews were voluntary and the experts were not compensated for participating. Any identifying information regarding the individual interviewees was not included in the analysis and confidential interviews were maintained on password-protected computers in a locked office. Participants were given copies of the data collected in order to edit or make any additions to their responses.
The three authors interviewed all of the participants in the participants’ offices. For six of the eight interviews all three authors were present. For two of the interviews, only two authors were present. Each author took detailed notes during the interview highlighting major themes. Participants were provided with the following list of questions prior to the interview:
Authors took notes to highlight major themes in the interviews from each respondent. Following the interviews, the authors compiled notes for content analysis. To ensure inter-rater reliability the three interviewers transcribed all interviews separately. Transcription reports were compiled into one report for each participant to generate the most accurate representation of their comments.
Content analysis was conducted for each interview. Krippendorf (1980) defines content analysis as “a research technique for making replicable and valid inferences from data to their context” (p. 21). Janis (1965) defines it as:
Any technique (a) for the classification of the sign-vehicles (words that carry meaning), (b) which relies solely upon the judgment (which theoretically may range from perceptual discrimination to sheer guesses) of an analyst or group of analysts as to which sign-vehicles fall into which categories, (c) provided that the analyst’s judgments are regarded as the report of a scientific observer, (p. 55)
For the purpose of this analysis, semantical content analysis was conducted to classify sign-vehicles according to their meanings. The interviewers reviewed protocols for three types of semantical content analysis; designations analysis, which determines the frequency with which certain objects are mentioned, attribution analysis, which examines the frequency with which certain characterizations or descriptors are used, assertions analysis, which provides the frequency with which certain objects are characterized in particular ways. Assertions analysis involves combining designation analysis and attribution analysis. Such an analysis often takes the form of a matrix, with objects as columns and descriptors as rows.
Because assertions analysis is the most comprehensive form of semantical analysis, the authors employed this method of examination. Past experience with EBP, levels of dissemination, barriers to dissemination, gaps in dissemination, methods of addressing barriers, results of not using EBP, and the future of EBP were designated as objects and 70 items were designated as descriptors.
The majority of participants had experience with EBP program design including; running an intervention, evaluating the effectiveness of interventions, the process of forensic evaluation of children referred for sexual abuse, adapting interventions, and coordinating advocacy, policy, technical assistance, and research synthesis efforts at the state level. Beyond program design, participants had developed evidence based interventions, taught EBP in the classroom, and developed tool kit models of EBP.
The experts had experience with tool kits, literature, and training as methods of disseminating evidence based practice. Inclusion of practitioners in design, developing programs in the communities where they will be implemented, state and agency dissemination, norm changing, appropriate targeting of stakeholders, Requests for Proposals (RFPs) for models, supervision, national networks, quality assurance, and masters education programs were mentioned as means of dissemination they have seen employed. One interviewee said that when evidence based practices are disseminated and implemented they look like “rocket science” in comparison to standard care because standard care is so poor. However, as one expert stated, “there is a lot more ‘talk’ about EBP than actual implementation.”
Interviewees mentioned training time and funding policies as the biggest barriers to implementing EBP. They cited lack of consumer input, lack of practitioner input, lack of translation research, and lack of EBP training in master’s level education as barriers. For example, one expert described how clients may not like interventions based on EBP because practitioners who employ EBPs tend to approach treatment as if they are the experts. However, practitioners need to use EBP and remain open to the idea that the consumer has something to teach.
A lack of practitioner involvement, testing EBP in research labs, limited provider skills, training time, and belief that EBP is too restrictive were each described by the experts as problems. “Most agencies are reactive and just trying to get by. EBP isn’t part of the culture.” Also mentioned were dissent among stakeholders, a lack of education across systems, lack of agency staff, misunderstanding of what EBP is, and professors who do not apply their EBP research to their teaching as ultimate barriers to implementing EBP.
There was less variation in responses to gaps in implementing EBP than in respondents’ description of barriers to implementation. Experts mentioned both the limited research of EBPs and unclear methods of training in EBP as gaps in the system of dissemination. Also cited was a lack of consumer input and the limited number of EBPs, a reluctance to over generalize interventions, and the difficulty of transferring programs from research into practice as limitations. Respondents claimed that lack of education and training in EBP were major problems that keep EBP from being disseminated and implemented in the practice community. One respondent suggested:
The language is off when we talk about dissemination. There is an assumption that development happens in one place and then it is rolled out elsewhere. You can get into trouble with this. You need to include practitioners and support staff. How do they integrate services? Roll-out is rejected by providers because there is no ownership. You need key constituents to sit around the table and create something that will fit–knowledge about practice outside of practice. You have to get practitioners invested in the process of adaptation. Without early involvement of administrators and practitioners, the treatment will not be sustained after the researcher leaves the setting.
To address barriers the respondents recommended ongoing training, EBP in master’s level curriculum, stakeholder buy-in and consumer buy-in. For example, the Gibbs model that incorporates EBP, client preference, and practitioner expertise allows enough flexibility for all parties to feel invested in the intervention. Manualized treatments and beginning research in agencies, as well as tool kits, technical assistance on site, and systemization were identified as effective strategies to overcome the hurdles of disseminating and implementing EBP. According to some of the experts interviewed, state involvement in EBP curriculum for universities has proven to be a good method to address the barriers for disseminating EBPs.
Research experts agreed that interventions may not be helpful, and may even be harmful, if they are not backed by research evidence. Some felt that in the future agencies will not be reimbursed if they fail to practice from an evidence base and the field of social work will fail to progress in the absence of EBPs. Social work will continue to be viewed as a second-class citizen in comparison to other professions that are more willing to embrace research evidence.
Respondents offered diverse views of the future of EBP. Some respondents stated that there will be more funding for EBP in the future. On the other hand, other respondents felt that EBP is a buzz term that will probably die out with time. The experts interviewed described the future of EBP moving toward more qualitative methods, training in EBP at the master’s level, incorporation of the art of clinical practice, diverse EBP models, well-developed research on EBP, studies in actual practice settings, and more sophisticated and informed implementation and dissemination efforts.
This analysis is limited due to its sample size as well as by the lack of variation of professional affiliation. However, it does provide a starting point for future analysis. It is clear that experts in the field are indeed aware of the gaps and barriers to EBP dissemination. Future efforts would benefit from the incorporation of larger and more varied interview samples that include researchers and educators as well as agency administrators, direct service providers, and consumers of mental health and social work services. Additionally, future researchers should focus their attention on addressing barriers to dissemination and on the opinions and recommendations of other mental health services stake-holders such as clients, community members, and policy makers. Future EBP research needs to focus greater attention on strategies of effectively disseminating the programs that constitute the best practice standards.
The original aim of this study was to build a framework for the dissemination of evidence based mental health practices for social workers in community agencies through a review of the literature and interviews with experts in the field. Both the literature reviewed and the respondents offer similar observations and themes regarding EBP. The greatest agreement between the different researchers was found in the description of gaps and barriers to implementing and disseminating EBP. Problems include poor funding, a lack of training and support for agency staff and practitioners, a lack of consumer involvement, a failure to translate research into practice, and a lack of EBP education, particularly at the master’s level. Interviewees also described efforts to identify the most viable options to address barriers to implementing and disseminating. They, along with other researchers, have identified needs that must be addressed to move EBP forward. If social work does not meet these challenges, practitioners, and community organizations will not be best serving clients and will be in danger of losing competitive funding for services.
Some of the misconceptions about EBPs must be addressed in order to facilitate dissemination and implementation of evidence based interventions. EBPs are not promoted by the experts interviewed in this study as the final draft of best practices for mental health services. Rather, they are being promoted as efficacious treatments for specific disorders in certain populations of individuals suffering from mental illnesses. While further testing is needed to validate findings regarding EBPs for additional mental health disorders and different cultural groups, the information currently available regarding EBPs may be a best beginning practices guide in treatment planning for individuals with mental illnesses. Empirically validated EBPs are not recommended as a ‘magic bullet’ for the treatment of all mental illnesses. Research has, and continues to, explore the populations and disorders that are responding to specific EBPs, develop approaches to the flexible and practical employment of EBPs, and acknowledge that it is equally important to understand when the utilization of EBPs in treatment planning is or is not indicated.
Perhaps the most important finding of this study with regard to future research is the paucity of studies testing and validating implementation and dissemination strategies. No such studies have been conducted in social work (Gibbs, 2002). This research is needed to meet the growing demand for practitioners to base decisions on evidence. Researchers must also face the challenge of developing collaborative relationships with agencies, practitioners, communities, and clients. If research is not tailored to the questions posed by these stakeholders as well as researchers, the likelihood of its implementation into everyday practice is greatly decreased. The challenge to researchers in academic settings has the added component of focusing on incorporating research on EBPs into teaching curriculum.
Any successful effort toward the dissemination of EBP will have to address the four areas of barriers described in the literature and by respondents: knowledge, lack of fit, suspicion, and resources. Efforts that are not active and multifaceted seem unlikely to succeed. Organizational, practitioner, community, and client buy-in are also essential to a well-formed dissemination approach. Leadership backed by the power to effect change will be crucial. It takes more than an individual practitioner, agency, or educational institution to effect a cultural change within social work mental health services.
Existing frameworks offer a step in the right direction. However, they do not appear to provide a comprehensive and united approach to improving the dissemination of EBPs. Anderson and colleagues’ framework highlights the importance of developing shared goals between community organizations and researchers to combat problems inherent in poor relationships and communication and thus has the potential for impacting all four barriers by increasing coordination, understanding, and efficiency. However, this framework seems overly general. More detailed solutions would assist researchers and community organizations in efforts toward translating research into practice and constructing common goals. Additionally, the question of leadership is not addressed. Forging networks and consensus building can take a heroic effort and consume a considerable amount of time and energy. Strong leadership is needed to catalyze this process of change. Gibbs and Gambrill similarly offer useful approaches, such as involving social work education in the process of change and helping individual workers to be flexible and skilled in processing and applying new research. However, a large burden is placed on the practitioner and the problem of resources in particular is not addressed. Many social workers do not have the time or access to needed resources such as the internet. Rosen and Proctor’s model is more specific than either Anderson and colleagues or Gibbs and Gambrill, however they do not offer solutions to the problems of resources, translation of research into practice, or needed professional and cultural buy-in. While the industry-inspired D&D models offers important insights into how researchers might form a feedback loop with practitioners in the field to form more user-friendly tools, these approach seems limited in its application, particularly in the absence of a sophisticated infrastructure to support activities. General methods such as toolkits and practice guidelines are potentially useful strategies, and may supplement any of the other models. While each framework offers important insights into the best approaches toward the dissemination of EBP, none stands alone or above the rest.
To encourage practitioners to implement EBPs a unified approach that incorporates the best of all of the strategies outlined above and addresses the major barriers identified in this paper:
The most important factor in facilitating change toward the use of research in professional practice is whether or not the profession wants to change (Naylor, 1995). As the call for EBP in mental health services grows, social workers will benefit by being more research-minded and thereby improve services for their clients. The call for the use of research evidence in practice is not limited to a trend of policy, but is also aligned with the professional code of ethics (NASW, 1996) and meeting the expectations of an increasingly savvy consumer movement in mental health (Mowbray & Holter, 2002). Major national reports, which often shape federal and private funding streams, continually call for the use of research-supported interventions. However, policies that encourage, if not require, the use of EBPs cannot succeed without adequate training, resources, technical assistance and other infrastructure support necessary to deliver evidence based mental health interventions, Even if social workers endorse the value of EBP, practitioners and administrators may not have the knowledge or the resources to implement research based practices. The search for research evidence alone is difficult, and the more complicated the decision the less available the evidence (Gray, 1997). Additional demonstration projects, and research and policy efforts aimed at moving EBPs into community-based organizations there-by building professional and organizational capacity are needed to address these and other barriers. Social workers are poised to move this work forward by transferring the increasingly broad and sophisticated body of research mindfully into the hands of the community agencies and practitioners.
The authors would like to thank Edward J. Mullen and Sandra Nutley for their assistance with this project. In addition, the contributions of all experts interviewed for this project are gratefully acknowledged.
This work was supported by the National Institute of Mental Health Grant 5T32-MH014623-24.
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This work was presented at the AcademyHealth 2004 Annual Research Meeting, San Diego, CA; the National Service Research Award (NSRA) Trainee Conference, San Diego, CA; and the Fourth International Conference on Social Work in Health and Mental Health, Quebec City, Quebec, Canada.
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