Social work needs more research so it’s not left out in the cold

Published today on Community Care Big Picture blog:

Social workers consider evidence-based practice to be a ‘good thing’, but can rarely identify research evidence which underpins their practice. This is the finding of many surveys on evidence-based practice in social work and of our work with experienced social workers undertaking advanced post-qualifying training at the Institute of Psychiatry.

The lack of a robust evidence base is a particularly acute problem for mental health social workers. Working alongside psychiatrists and psychologists whose medical and psychological interventions are supported by a well-developed evidence base, social workers often struggle to find evidence for the effectiveness of their practice.

This undermines their position within multi-disciplinary teams and makes them a soft target for cuts.

Mental health services are increasingly shaped by National Institute for Health and Clinical Excellence (NICE) clinical guidelines. NICE guidelines recommend interventions with randomised controlled trial evidence of their effectiveness.

This rational way to make policy makes sense, but has led to evidence-biased practice with more easily-measurable medical and psychological interventions taking provenance over ‘messy’ and complex social interventions.

NICE guidelines mean that community mental health team managers now appoint new staff on their ability to deliver cognitive behavioural therapy rather than their professional background.

Further, the bureau-medicalisation of mental health care, a concept which prioritises care co-ordination and risk management within a medicalised framework over social interventions or relationship-based practice, leaves social workers out in the cold (unless they are performing their statutory functions, that is).

If social work is serious about developing an evidence base to support its practice, it needs to produce it in a form which will be recognised by health colleagues and policy makers.

Unfortunately, this means using randomised controlled trials.

Although expensive, unpopular and complex, they can be done and they should be led by social work researchers. If not, psychiatrists and psychologists will do it for us and claim it as theirs, as is happening with the recovery agenda.

At the Institute of Psychiatry we are developing practice guidelines for practitioners to support people recovering from psychosis to connect or reconnect with other people. Funded by the National Institute for Health Research School for Social Care Research, the Connecting People Study is using ethnographic methods to develop this social intervention which mental health social workers will lead.

Grounded in existing good practice, we are aiming to incorporate as much practice wisdom as possible to make the guidelines both relevant and accessible. Next year we aim to pilot these guidelines and pave the way for a randomised controlled trial.

Systematising practice in this way may be an uncomfortable culture shift for social work, but it may be necessary in order to demonstrate the effectiveness of our practice.

On being a pracademic

I have finally resolved my identity crisis! I have discovered that I am a pracademic.

What am I on about? Well, the term almagamates the identity of a ‘practitioner’ with that of an ‘academic’ in the tradition of the twittonary. Although it doesn’t feature in there yet, it is a pragmatic term to describe someone working at the interface of research and practice.

I came across the term yesterday at the Social Capital World Forum (SCWF). The SCWF aims to connect practitioners who are intentionally using social capital to enhance community wellbeing; share knowledge and experiences of ‘social capital in practice’; build a collaborative network for effective future communication between SCWF participants; and expand opportunities to promote the value of social capital regionally, nationally and internationally.

When Colin from Assist Social Capital first used the term ‘pracademic’ to describe my role at the SCWF, I wasn’t sure what to think. Am I not considered robust enough in my work to be considered an ‘academic’? Am I not considered sufficiently grounded in practice to be called a ‘practitioner’? On reflection I consider it quite an accurate descriptor, as ‘academic’ often brings to mind ivory towers apart from the real world; ‘practitioner’ is inaccurate as I am not currently practicing social work; and ‘clinical academic’ (the health equivalent) is, well, too clinical. So, I will settle with ‘pracademic’.

The term was coined in a discussion at the SCWF about developing an evidence base for social practice and social interventions. Social capital activists, social entrepreneurs, civil servants concerned with public social spaces and others interested in the fabric of society were discussing the need to research the return on investment in social capital, for individuals, groups and communities within civil society. Bedevilled by measurement and concept operationalisation issues, this is not an easy task. The real-world expertise of practitioners needs research expertise to explore process or outcomes, and to produce valid and reliable findings.

The Connecting People Study is a good example of pracademic research. It is grounded in real-world practice and the intervention it is developing (to enhance access to social capital) arises from an ethnographic study of social care practice. Its grounded approach is combined with a social capital theoretical framework to inform the intervention model. The purpose of the intervention model is to articulate practice in such a way that it can be replicated in experimental studies. My engagement with the SCWF allowed me to meet others working in this field; explore shared agendas and pursue opportunities for collaboration.

I think the term ‘pracademic’  would have been recognised by Martin van der Gaag and Miriam Notten who I met in Delft on Thursday. Both are interested in practical applications of social network theory and analysis. Martin is a social networks and social capital analyst, who created the Resource Generator methodology which I adapted for use in the UK. Miriam is an entrepreneur providing social network consultancy to corporations. Our discussion bridged the gap between research, theory and their applications in the real world. I came away with many ideas for the Connecting People Study, intervention development and potential future collaborators, including a list of Dutch experts to draw upon.

Social work academics are prime examples of this new breed of ‘pracademic’. Their research and teaching is grounded in the social reality which they seek to address or, at least, it should be. They hold a tension between conducting ‘pure’ research, favoured by their employers, and the applied research favoured by practitioners. However, they need to ensure that their research has an impact on society so it needs to be both robust and relevant. Identifying and engaging with both the academy and the real world can be challenging, but when it is achieved I believe that the results could potentially be quite exciting.

Show respect to our advanced practitioners

Today was dissertation submission day for the experienced social workers completing the MSc Mental Health Social Work with Children & Adults programme at the Institute of Psychiatry.

Uniquely amongst advanced level post-qualifying social work programmes in the UK, we require all our practitioners to undertake original quantitative research for their dissertation. While not devaluing high quality qualitative research, we have chosen this strategy to expose social workers to methods used by colleagues working in health whose work is often viewed as more ‘scientific’.

The journey began for these practitioners in September 2009 when they enrolled on the programme and started to learn about a diversity of epidemiological and evaluation methodologies, and the statistics which are used within them to explore differences, associations and outcomes. Some practitioners question the relevance of this for their practice. But when you consider that most are working in multi-disciplinary teams often alongside health colleagues, it is important for them to be able to engage in discussion about underpinning research evidence across disciplinary boundaries. In multi-disciplinary mental health teams, in particular, where psychiatrists and psychologists assume an elevated status because of the more ‘scientific’ nature of their interventions, it is important for social workers to be able to engage in discussions about the research that underpins their work.

Many of our graduates have told us that our programme has equipped them with the skills and confidence to read and appraise papers from a range of disciplines. This has helped them to question the strength of health colleagues’ evidence-base (which is particularly useful when social work is accused – often rightly, sometimes wrongly – of not being evidence-based!).

Practitioners completing the programme today told me that they still recall me talking about confidence intervals (on the online lectures which serve as revision aides), or understanding positive and negative numbers (using a simple number line analogy) during the first term of the programme almost two years ago. These may be technical details and appear to be a world away from the messy reality of social work practice, but they form some of the building blocks of understanding statistical significance, or what makes a real difference, which is at the heart of evidence-based practice.

On completion of the first research module, they moved on to design their own research projects to answer practice-based questions which have arisen in their agencies. Then, over the last year, they obtained ethical approval for their research project, collected and analysed their data, and wrote up their dissertations. After today they will begin the process of dissemination. First to their agencies, and then beyond.

Over the last few years I have supported a number of students to publish their research in respected social work peer-reviewed journals and contribute to the international evidence base for practice. Here are a few examples:

Bookle, M. & Webber, M. (2011) Ethnicity and access to an inner city home treatment service: a case-control study, Health and Social Care in the Community, 19 (3), 280-288

Dutt, K. & Webber, M. (2010) Access to social capital and social support amongst South East Asian women with severe mental health problems: a cross-sectional survey, International Journal of Social Psychiatry, 56 (6), 593-605

Kingsford, R. & Webber, M. (2010) Social deprivation and the outcomes of crisis resolution and home treatment for people with mental health problems: an historical cohort study, Health and Social Care in the Community, 18 (5), 456-464

Furminger, E. & Webber, M. (2009) The effect of crisis resolution and home treatment on assessments under the Mental Health Act 1983. An increased workload for Approved Social Workers?, British Journal of Social Work, 39 (5), 901-917

Slack, K. & Webber, M. (2008) Do we care? Adult mental health professionals’ attitudes towards supporting service users’ children, Child & Family Social Work, 13 (1), 72-79

(I haven’t mentioned the advanced case consultation group and practice viva which the practitioners also undertook as part of the MSc to demonstrate their advanced practice. That’s for another post…)

But what struck me today was the continuing lack of respect for advanced social work practitioners in the UK. I heard about intolerable case loads, an almost total absence of clinical supervision, being moved from team to team irrespective of preference, or, more worryingly, authoritarian and abusive management styles which have caused practitioners to take time off sick because of stress and depression. There is a lack of respect for the expertise and knowledge of our most experienced and highly skilled practitioners; limited opportunities for them to demonstrate their innovative practice; and a lack of vision about the role of advanced practitioners. Of course, there are exceptions. The London Borough of Hackney’s Children’s Services’ use of Consultant Social Workers has been positively evaluated and slowly being replicated in other places. But most social work employers fail to see the bigger picture.

The practitioners completing their advanced level post-qualifying awards today have mostly got there because of their own motivation and dedication. They have either paid the tuition fees themselves, used up their annual leave or have foregone their holidays to attend college, study hard and complete the coursework. It is completely unacceptable that the profession does not support their professional development or have a vision for the potential professional leadership they could provide if given the opportunity.

In numerous discussions I have had with employers and training managers about this issue, I have been repeatedly told that the advanced level awards are the ‘icing on the cake’ and in a time of fiscal crisis they are struggling to even bake the cake. I would argue that advanced social work practitioners are the ingredients of the cake.

Unless you use high quality ingredients, the cake will taste sour.