February 13, 2009

Evidence Based Practice vs. Practice Based Evidence

I recently had a discussion with a clinician to learn what they did and in this discussion, they brought up the idea of Practice Based Evidence (PBE). I pushed further, telling them that I thought it was called Evidence Based Practice(EBP), and that's when the discussion got interesting.

What the clinician said was that while EBP is always looked at and is more and more becoming a part of the mandate of many organizations, the evidence of its efficacy is really lacking in real world terms. The problem is that this evidence is coming out of controlled settings that are funded a lot better than most organizations, and don't take into consideration all of the other variables. So what we're trying to do is fit this ideal into a setting where it won't work. I immediately thought of Dialectical Behavior Therapy when he brought this up, as I'd never heard of pure DBT being used with clients, as it was too time consuming for clinicians, and union rules didn't allow some practices.

What the clinician I was talking with said was something at least they were working towards was PBE. What they mean by this is looking at what works in the actual workplace! Rather than having your practice dictated by academics, policy makers and supervisors, front line workers should be making a major contribution to the research that leads to policy. This would involve feedback and research with clinicians, supervisors and, most importantly, clients of the service!

While I am in favor of this approach, I am the first to admit that I see many barriers. Dynamics are different in all organizations. How do you factor that in? Clinicians are busy enough and now we want to add research onto their plates? It's also a matter of empowerment in getting power to go ahead with this from the ivory tower academics and policy makers. How does that work?

So yeah, there are more questions than answers in this post. I simply wanted to write about it to get it down somewhere so I can think through it further. If I've gotten anything wrong with either of these concepts, please let me know.



cb said...

Interesting stuff. I like the idea of greater use of practice-based evidence. Although I suspect that what really is the best way is a somewhat eclectic mix of an ideal and a practical way of implementation given obstacles as they arise. A pragmatic approach - as much as anything..

David G. Markham said...


You are asking great questions and are right on the money.

When Michael White, the Narrative Therapist from Australia, was asked the question of whether Narrative Therapy was "research based" he said it isn't a researcher and can't answer the question, but wondered if it was the "right" question to ask. He said he was more interested in whether the practice is "ethically based", is it an ethically based practice?

I thought it was an interesting perspective on the issue.

Like you, I have many thoughts on this issue and would love to read your further thoughts about it as you are ready.

all the best, and thanks for the great post,

David Markham

Jonathan B. Singer, LCSW said...

Your concerns echo those of hundreds of thousands of social workers - clinicians and researchers alike.

There are two concepts related to evidence that are sometimes confused. The first is "evidence-based practice" and the other is "evidence-based practices." The former is a process of developing a unique treatment based on three criteria: (1) wants / needs of the client; (2) experience / wisdom of the clinician; and (3) information from the research literature. The later is a list of treatments that have been subject to rigorous empirical testing. The later is sometimes referred to as "empirically validated treatments" or "EVTs." I prefer the term EVT to EBT because it is easier to distinguish the process from the list.

An example of the differences might be instructive. Let's say you are working with a woman diagnosed with BPD. If you used the process of developing an evidence-based treatment, you would identify your client's individual needs, combine that with your practice knowledge of BPD and this client, and what you know from the research. When you combine all of those, then you get and "Evidence-Based Treatment." In contrast, DBT has an impressive evidence base for helping women who self-harm and are diagnosed with BPD. However, if you selected DBT as the treatment for your BPD client without taking into consideration your client's needs / wants and your practice wisdom, then you're just pulling something off the shelf, not practicing evidence-based social work.

There are a couple of nice resources that talk about evidence based practice. Jim Drisko from Smith College has a page on EBP that is both readable and scholarly: http://sophia.smith.edu/~jdrisko/evidence_based_practice.htm.

I published an article that goes through the process of evidence-based practice for a presenting problem that has no EVT: youth with comorbid depression and ADHD who are suicidal.

Keep up the thoughtful comments.

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