Clin Soc Work J (2011) 39:400405

DOI 10.1007/s10615-010-0306-1

ORIGINAL PAPER

Overrating or Dismissing the Value of Evidence-Based Practice:

Consequences for Clinical Practice
Luis H. Zayas Brett Drake Melissa Jonson-Reid

Published online: 12 October 2010

Springer Science+Business Media, LLC 2010

Abstract Current implementation of the evidence based

practice (EBP) model in social work has focused on
empirical evidence from efficacy studies, with far less
attention to practitioner judgment and client values.
Among many clinical social workers the opposite is often
true: clinical judgment supersedes the use of scientifically
tested techniques. Clinicians may reject EBP as coming out
of narrowly focused, possibly irrelevant research, and
adherents of EBP run the risk of discounting psychotherapy
techniques derived from practice experience or the vast
diversity of client situationsboth positions threaten our
effectiveness. Reasserting clinical judgment and the centrality of clients experience into EBP, while enhancing
traditional psychotherapy with strong treatment-effectiveness evidence, will improve clinical social work practice,
especially in addressing the wide array of human problems
and suffering that clients present, especially in the context
of globalization and cultural diversity.
L. H. Zayas (&)
Center for Latino Family Research, George Warren Brown
School of Social Work, Washington University
in St. Louis, Campus Box 1196, One Brookings Drive,
St. Louis, MO 63130, USA
e-mail: lzayas@wustl.edu
B. Drake
George Warren Brown School of Social Work, Washington
University in St. Louis, Campus Box 1196, One Brookings
Drive, St. Louis, MO 63130, USA
e-mail: brettd@wustl.edu
M. Jonson-Reid
Center for Violence and Injury Prevention, George Warren
Brown School of Social Work, Washington University
in St. Louis, Campus Box 1196, One Brookings Drive,
St. Louis, MO 63130, USA
e-mail: jonsonrd@wustl.edu

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Keywords Evidence-based practice
Social work

education
Culture
Globalization
Clinical judgment

Introduction
A burgeoning literature on the importance of evidencebased practice (EBP) in research and education has captured social works imagination (Howard and Jensen
2003), much as psychoanalytic theory did decades ago.
Social work writers have elucidated EBPs role in the
practice and research realm (Fraser 2003; Gambrill 1999;
Thyer 2001), and others have focused on graduate curricula
(Crisp 2004; Drake et al. 2007; Howard et al. 2003; Zayas
et al. 2003). In this literature, there are many strong, eloquent
arguments for evidence-based practice in social work,
making it clear that EBP will increase social works
effectiveness and credibility. Arguments about the importance of incorporating evidence into our practice and ways
of identifying and integrating the best available evidence
are virtually unassailable (Rubin 2000).
The roots of EBP (Evidence-Based Medicine Working
Group [EBMWG] 1992; Sackett et al. 1997) show that the
reliance on evidence is only one of the three main components of EBP. The other two are clinical judgment and client
values. The evidentiary component, originally called the
critical appraisal exercise (EBMWG 1992, p. 2421) has
garnered virtually all the attention, but even this part of EBP
has been dramatically reduced in the current discourse. Too
many authors appear to limit their conceptualization of
evidence to treatment efficacy and effectiveness studies of
specific disorders (Messer 2004; Swinkels et al. 2002).
Indeed, the original vignette exemplifying EBP contains
evidence which is purely descriptive and prognostic in
nature, the kind of evidence for which clinical trials are

Clin Soc Work J (2011) 39:400405

inappropriate designs. Other evidence such as information

about a clients culture or the nature of other co-occurring
issues may be equally important in determining the course of
treatment. The ardent application of the critical appraisal
process in isolation from practitioner judgment and client
values can eclipse other ways of thinking about practice
(Aveline 2005; Messer 2004; Strand 2004; Thompson et al.
2005).
In this essay, we challenge both uncritical acceptance of
narrowly focused EBP as well as the perfunctory rejection
of the utility of EBP by some clinical practitioners. (For
clarification, the term EBP in this essay includes both the
process of integrating research evidence and empirically
supported treatments. For simplicity, the terms EBP
or EBPs are used to refer to both EBP and empirically
supported treatments.) We argue that scientific evidence
cannot be defined solely as efficacy research (the highly
controlled intervention study that is often associated with
randomized clinical trials) or effectiveness research
(wherein efficacious interventions are taken into the community context for testing, taking into account that few
controls can be applied). Rather we include other forms of
data such as those derived from descriptive and correlational studies, epidemiological surveys, correlational and
cohort studies, and other quasi-experiments, qualitative
research, etiological studies, diagnostic information, costbenefit studies, single-case designs, clinical opinion, theory
and from personal ethnographies, whether from published
accounts or the clinicians own experience. There is truth to
the concern that many EBPs were developed and tested with
research subjects from mainstream populations (i.e., nonminority) and often with a targeted problem or diagnosis.
EBP may be too specifically targeted at a single psychosocial problem when, in fact, most client come into therapy
with messes, lives with many problems not all of which
are psychological, and for which there are likely few if any
EBP developed. In the hands of clinicians with rich practice
experience and practical wisdom, the data from empirically
designed studies combined with the careful inspection and
consideration of clients cultural characteristics can make
for potent psychotherapeutic interventions. The problem in
the practice of social work psychotherapy is that our tendency has been to emphasize or oscillate from one or two of
the three practice elementsclinical judgment or client
values or empirical evidencerather than to apply the three
elements coequally (Liberati 2004). We wish to point out
that this essay, published in a journal widely read by clinical
social workers (defined as those who conduct individual and
group psychotherapy and family therapy), does not deal
with the macro-practitioner who is dealing with community-level quality-of-life issues, or policy analysis and
advocacy, or administrative social workers running programs and large service systems. The reader should be

401

alerted to this fact. Rather, we are discussing social work

psychotherapists whose work commonly focuses on changes in individual cognitions, behaviors and emotions. This
practice usually comes with the need to arrive at psychiatric
diagnoses, whether they merit the diagnosis clinically or for
purposes of meeting billing and reimbursement needs or
reasons.
In much of traditional psychotherapy, our attention has
been to the therapist-client relationship, unconditional
positive regard, intrapsychic conflict and its interpretation,
the emphasis on insight about psychological functioning
from a Western cultural paradigm, and therapeutic changes
in behavior, cognitions or emotions based on subjective
evaluations by clients and therapists. For too long, social
work psychotherapy has sought the means to client change
through insight, self-awareness, and introspection. Clients
are often seen in weekly therapy, sessions in which free
association or something approximating it is fundamental;
clients are to introduce material uncontaminated by the
therapist in the belief that it is the clients utterances that
hold the mysteries of and the answers to their psychic
suffering. By introducing the topic of the session or urging
behavioral change the therapist is violating the clients free
will or self-determination or smudges the clients spontaneous telling of the story of their psychic conflicts. Often,
change comes slowly, if at all.
The error in this process is the belief that client insight
precedes client behavioral change. This positions therapists
to reject or look warily at EBPs that specified therapists
roles, interventions, timing and sequence of techniques
manualized treatmentsas a misguided corruption of
the therapeutic process. But when clients, or the important
persons around them, do not see change, they may experience a sense of failure in themselves or disillusionment in
the therapy.
We argue that one of the benefits of EBPs is that they
emphasize the ignition of behavior change in clients as
soon as possible. EBPs tend not to use protracted, insightbuilding sessions but rather focus on initiating change
through therapist engagement and leadership. Having
clients experience behavioral changes early in the therapy
helps jump start the process of the growth they seek.
Change propels the understanding of emotional life which
further solidifies the change. In other words, change comes
before insight, not after. Wachtel (1993) states it best when
he notes that if one attempts to live differently, not only is
change effected by that very fact, but one also gains a new
vantage point for which to examine ones life. As a consequence [of behavior change], new insights are promoted,
insights that are a product of change rather than its cause
(p. 51, original italics).
This is the value of EBP for the social work psychotherapist: its capacity to initiate the change that gives clients an

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indication that they can change and the hope that with their
therapist more change and insight can ensue. This effectiveness comes about when we realize that just as it is a
mistake to adhere to a narrow definition of EBP, it is also a
dire mistake for clinicians to reject valid evidence on treatment effectiveness perfunctorily because of its limitations.

Imperfect Scientific Foundations of Evidence

One problem, as we see it, is that by defining EBP on the
assumption that efficacy and effectiveness research are the
prime foundations, the result is a relatively narrow definition
of evidence. Cournoyer and Powers (2002), for example,
present a definition of EBP that enjoins the practitioner to
seek exclusively interventions that have been rigorously
tested, that stand the test of refutation, and are grounded in
prior findings that demonstrate empirically that certain
actions performed with a particular type of client or client
system are likely to produce predictable, beneficial, and
effective results (p. 799). There are not that many psychotherapeutic interventions that meet the high standard of
rigor or generalizability that some authors would require
(Cournoyer and Powers 2002; Howard et al. 2003). Most
intervention researchwhether efficacy or effectiveness
studiestypically suffers from serious methodological
shortcomings, especially regarding the populations that are
sampled (Sue and Zane 2006). Invariably these studies have
limited generalizability because of the restricted range of the
sample studied and the similarly restricted range of interventions that are tested. Many of these studies lack testing in
the real world of community practice, that ever-shifting
environment in which most practitioners actually toil. One
result is the so-called bench to trench or efficacy-effectiveness problem, when treatments judged effective in
experimental conditions do not generalize to the real world.
Clinical social workers can claim some solace from
writers who apply broader definitions to EBP, such as when
they suggest that all good evidence, not just intervention
evidence, is to be considered (e.g., Fraser 2003; Strand
2004; Thompson et al. 2005). Howard et al. (2003) capture
much of the sentiment of those who would broaden definitions of evidence when they write that evidence-based
practitioners will integrate relevant scientific information
with informed professional judgment and the personal
preferences of service consumers if they hope to practice
effectively and ethically (p. 239). They even point out that
a new approach acknowledging the importance of practice wisdom and scientific findingsevidence-based practicemay well promote more effective social work
practice and enhance the credibility of the profession
(p. 236; emphasis added). Fraser and Galinsky (1997)
encourage the integration of local knowledge, influences

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from the person, family, and community that affect the

problem. Witkin and Harrison (2001) propose that evidence needs to fit the social and psychological context of
our clients, and that this needs to be negotiated between
clients and the holders of power who legitimate the definitions of a problem.
But even when a glancing nod is given to practice wisdom,
tacit knowledge, client values, local knowledge, or other
non-research findings as evidence to be used, writers seldom
stress these sources of knowledge, preferring instead to focus
on results of efficacy and effectiveness research outcomes.
The overwhelming weight of the argument for EBP returns to
an emphasis on empirically tested mental health intervention
evidence. It is this lapsing into a narrow definition of EBP
over all other ways of thinking and practicing that fogs the
discussion about EBP and causes clinicians to run in the
opposite direction. But what do clinicians run toward? We
believe that in turning away from EBP clinicians run,
instead, to placing undue value on sometimes arcane theories
to decide on the course of psychotherapy and the measurement of its progress. Much of psychotherapeutic literature
and teaching relies on case materials and learning that is
based on an oral tradition, knowledge and wisdom learned at
the feet of the mighty supervisor. Seldom do we know how
effective the therapy truly is; we are given the supervisors or
therapists word that it was successful and they give us
selective evidence of it.

Errors Flowing from a Restricted View of Evidence

Originally, EBP coequally valued a positivistic approach to
evidence (the clinical appraisal exercise), clinical judgment
and client values (EBMWG 1992). In another time and
literature, clinical social work relied on theories and
approaches to therapeutic practice that took evidence from
case studies, published or spoken, from which the clinician
would generalize, sometimes taking into consideration
client values, sometimes not. For example, over 30 years
ago, social work practice education was served up an
ecological model for social work practice that provided a
diluted epistemology for practice, carving human problems
into three types: developmental, transitional, and interpersonal (Germain and Gitterman 1980). It was yet another
effort by social workers to make sense of a chaotic, complex world of human misery, replacing previous unworkable models with yet another limited one.
Those past models of clinical social work practice were
based on authority rather than scientific evidence (Gambrill
1999); if your supervisor or favorite theorist said it, then it
was sufficient evidence. Most EBP authors have somehow
forgotten that the original intent of EBP was to put a
much lower value on authority (EBPWG 1992, p. 2421).

Clin Soc Work J (2011) 39:400405

This was to be achieved by training the psychotherapy

practitioner as an independent decision maker, basing
decisions on the triad of clinical judgment, evidence and
client values. Unfortunately, the vast majority of literature
on EBP in social work does not stress practitioner autonomy at all. Quite the opposite may be occurring in that
dedication to applying treatments without consideration of
other factors may actually reduce practitioner autonomy.
And our over-emphasis in other social work therapies is to
place clinical wisdom above evidence and often the unique
characteristics, values, and cultures of our clients. The
faults for practitioner are located at the extremes of the
continuum.
Moreover, critics and proponents on both sides of the
EBP and traditional therapy debate forget that the emphasis
in traditional psychotherapy as well as in evidence-based
practice is, as Kirmayer and Minas (2000) so aptly point
out, part of an economically driven, politically underwritten, and contextually constrained movement. Some social
work writers and educators seem beguiled by a movement
that glorifies positivistic evidence-based practice. There are
others who hold tightly to be the allegorically rich language
of psychodynamic experience: of unconscious conflicts
derived from internal despair, objects that are transmuted
and internalized, and sharing intersubjective spaces with
clients to get at the change they seek.
Some concepts have been issued that explain the results
of movements such as those that favor EBPs or traditional
psychotherapeutic practice. Kleinman (1977) calls it the
category fallacy, in which we study and treat problems
with tools and interventions developed by those who
defined the problem and the treatment in the first place,
usually those in power. The powerfulin the past psychoanalysis, in the present neurosciencemay perceive the
problem through their lenses; develop a hypothesis; measure the problems with their tools; confirm the problems
existence; pose, test, and prove their hypotheses; determine
the problems treatability; select preferred outcomes;
fashion treatments; measure treatment efficacy; and decide
when the problem has been cured. Treatments, based on
such a process, confirm the very categories or symptoms
the perceivers created. Hacking (2000) calls it a looping
effect, a situation in which human actions and institutions
take certain conceptual categories and transform them into
social realities. The effect follows a pattern: We identify a
problem, name it and promote it. The problem and its
empirically supported interventions are then made suitable
for professional practice. The problem and treatment are
disseminated widely and the populace begins to adopt the
problem as conceptualized by those who defined it. The
public sees the problem all around them, and initiate consumer movements to make treatments available to all those
afflicted.

403

Unfortunately, in more typical bifurcation of our

responses we fall into the category fallacy or get ensnared
in a looping effect by construing mental distress through
Western notions of illness and applying our therapies
without appreciation of the variety of cultural life-ways
(Sue and Zane 2006). Cultures may have approaches to
treatment that are common in their culture and make our
EBP-based or traditional psychotherapy simply useless.
The problem is that the therapist may fail to think or look
outside the box or, as may be the case in some contemporary psychotherapy theories, outside the frame.
Returning to the original three-part conceptualization of
EBP as valuing evidence only in the context of clinical
judgment and client values allows for a means of using best
available evidence which does not dehumanize and may
well be far more effective. It will save us from category
fallacies and looping effects.

Culture and Globalization

When we treat people as diagnostic problems or categories
that must be treated with scripted therapies we leave out the
human capacity to create and respond to symbolsthose
evocative codes imbued with powerful meanings to our
psyches, emotions, and spirits, to which we respond with
sadness, joy, revulsion, tears, nostalgia, longing, nausea,
confusion, liberation, or fear. If mainly diagnostically driven
to treat problems that are identified through empirical studies, EBP will not deal with other existential problems of the
human condition: things like loneliness, alienation, acculturation stress, or the interpersonal suspicion and distrust of
persons who have lived under totalitarian governments, lives
ruled by political oppression and constant threat of statesponsored violence and torture. On the other side, when we
treat persons of different backgrounds with therapies based
on definitions of psychic functioning emanating in Western
culture, and that view human capacities or dilemmas of the
human condition through this perspective, we are repeating
the problems that we complain about in EBPs. If we are to
seek evidence, we must ask What evidence? and Who
defines the evidence? These questions points to the limitations of both EBP and psychodynamic psychotherapy as
currently implemented. After all, most evidence and its
definitions come from Western models based on positivistic
approaches that are often worlds apart from the cultural lives
of our clients.
In modern life in a post-industrial nation such as the
United States, the concepts of immigration, ethnicity, race,
religion and culture complicate the questions about evidence
and its definition. Only by taking these issues into consideration can we fully appreciate the impact of migration and
globalization and how cultures very different from ours

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determine what interventions for emotional distress, psychological disequilibrium, and behavioral problems that
people will accept. With the massive movements of peoples
from one place on the globe to another carrying many different cultures in their rucksacks come unique contextual
issues. Culture-bound syndromes, idioms of distress, and
similar phenomena require a more subtle application of the
EBP or the psychodynamic psychotherapy approaches.
Presented with a Pakistani immigrant complaining of heat
in the head, what EBP can the typical social worker draw
on? If social workers in the US encounter a Central American
woman suffering from susto (a cultural syndrome akin to
fright that emerges after experiencing or witnessing a
frightening event), should the practitioner promote the
treatment commonly prescribed in her culture (i.e., calming
teas and rituals that restore the souls balance)? Or should the
therapist go with what she has been trained in such as a
psychodynamic model that focuses on transferential phenomenon and unexpressed libidinal desires or with a cognitive based intervention that reconditions her thinking? If a
person from the African continent complains of a peppery
feeling or worms in the head, we may risk misdiagnosing
the disorder on the basis of a subclinical idiom of distress,
instituting a treatment that may produce iatrogenic effects,
and losing the client along with our credibility. Even for
better known cultural syndromes, what evidence-based
practice would we draw on? Take, for example, a relatively
well-documented culture bound syndrome, ataques de
nervios, which lacks evidence-based treatments. We know
that the ataque is frequently a response by some in the Hispanic population to a sudden event threatening family stability. What treatment, if any, would we institute in the
absence of EBP for such a syndrome? One shortcut is to use
best available information, redefine the ataque into a
pre-existing diagnostic category, and apply an empirically
supported family intervention probably developed in a
non-Hispanic population. Or when we redefine the ataque as
a psychic conflict that can be eliminated through an exploration of the unconscious mind rather than a culturally based
idiom of distress, we are applying an intervention not based
on an understanding of the cultural conditions in which it
emerged.
In short, a restriction of EBP to treatments for specific
diagnostic entities or a traditional psychotherapy that views
the mind in Western terms, approaches developed by the
powerful holders of the evidence, devalues the cultures of
so many of our clients. But to be sure, we are not saying
that EBP discards the importance of the clients culture or
reduces the value of traditional healing or ways of interpreting suffering. What we are saying is that both the EBP
and traditional psychotherapy must understand the cultural
belief systems and explanatory models of illness and
wellness that clients present. Some of these beliefs can be

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incorporated into the approach used to engage the client (if

not to modify the evidence-based treatment). The result of
minimizing clients cultural beliefs and the remedies they
bring can be to lose our clients.

Conclusion
Many authors have voiced concern that current applications of EBP are based on misinterpretations of the original
model that overemphasize an authoritarian, mechanistic
implementation of best practices, becoming a tool for
defending the status quo to the exclusion of common sense
(Gambrill 2005; Michelson 2004; Rosenfeld 2005; Thyer
2004). Some authors are even concerned that an overly
strict adherence to practice guidelines may be used to
impose rationing of services (Saarni and Gylling 2004). In
contrast, we argue, clutching to notions and theories of
psychic functioning exclusively and a clinical stance that
prescribes a taut behavioral repertory for the therapist
produces the same problems.
Like other therapeutic misadventures when fads and
fashions captured social works imagination only to
be discarded (Howard et al. 2003), the mirage of EBP as
panacea for contemporary practice can vanish just as
quickly (Reid and Colvin 2005). Remaining on a path
where EBP is simply an exhortation to use treatments
absent of consideration of client characteristics or clinicians best judgment will certainly result in such demise.
Crossing over to a therapy that deals in orally transmitted
knowledge and lore does not remedy the problems of
EBP. Returning to an integrative EBP that incorporates
more of the human experience and to a dynamic psychotherapy practice that does not shun the value of scientifically derived approaches can allow clinicians to
continue to rely also on clinical judgment and client
uniqueness.

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Author Biographies
Luis H. Zayas, PhD, is the Shanti K. Khinduka Distinguished
Professor and Director, Center for Latino Family Research at the
George Warren Brown School of Social Work of Washington
University in St Louis. He is also Professor of Psychiatry in the
Washington University School of Medicine.
Brett Drake, PhD, is Professor of Social Work at the George Warren
Brown School of Social Work of Washington University in St Louis.
Melissa Jonson-Reid, PhD, is Professor of Social Work and Director
of the Center for Violence and Injury Prevention at the George Warren
Brown School of Social Work of Washington University in St Louis.

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