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Evidence-based practice behind the scenes: How evidence in social work is used and produced
Stockholm University, Faculty of Social Sciences, Department of Social Work. (Addiction Research Group)
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The aim of this dissertation is to examine empirically what Evidence-based practice (EBP) and its standardized procedures become when put into practice in social work. EBP builds on the idea that professional practice should be based on systematic and reliable knowledge of the interventions and instruments used in this work. This implies a standardization of both research and practice that has been highly contested. Inspired by works within science and technology studies (STS), this dissertation analyses the actual content of the standardized procedures and their uses in social work practice.

The dissertation examines a ‘critical case’, a substance abuse social services agency that has worked extensively for several years at implementing EBP, and consists of four papers focusing on three standardized procedures used by the agency in order to enact EBP: 1) the Addiction severity index (ASI) assessment instrument; 2) the psychosocial intervention Motivational interviewing, and 3) the decision-making model Critical appraisal (CA). Ethnographic methods were employed to study the agency’s concrete uses of the standardized procedures in daily practice. MI was also followed in the research literature as it became established as an ‘evidence-based’ intervention.

Fundamentally, the development of the standards of EBP can be a messy and paradoxical process. In the stabilization of MI, its differences and ‘fluidity’ have eventually been made to disappear and left a stable ‘evidence-based’ object.

Findings from the ethnographic studies show that EBP, as enacted in the agency’s daily practice, is a bureaucratic project where the agency’s managers have decided on and control the use of a set of standards. Thus, what constitutes relevant evidence is based not on professional discussion within the agency but is ultimately determined by the managers.

In practice, the standards introduce new logics that cause tensions within the agency, tensions which the social workers are left to handle. Main conflicts concern how the client work is ordered and contradictory organizational rationales. The three standards are used to varying extent, which can be understood by examining what they seek to standardize and how they are put to work. CA was not used at all, mainly due to its design. Disregarding organizational rationales that are unavoidable within the social services, it could not be adapted to the agency’s work. With ASI and MI the situation was different, mostly because of their organizational adaptability. ASI could be implemented in several phases of the agency’s work flow resulting in adjustments of both the instrument and the work flow. As a ‘fluid intervention’, MI was constrained by, but also adjustable to the organization. It was thus possible for both ASI and MI to transform and be transformed by pre-existing practices, in effect creating new practices.

A major conclusion is that EBP and its standardized procedures is a more dynamic and multifaceted process than previously acknowledged in social work. Rather than a deterministic one-way path, there are different kinds, degrees, and mutual transformations of standardization processes, which must be appreciated in research and in practical efforts to implement EBP. Given the importance of the organization in professional social work, there is a need to move away from individualistic conceptions of EBP and to consider what evidence use might mean from an organizational perspective.

Place, publisher, year, edition, pages
Stockholm: Stockholm University, 2016. , 81 p.
Series
Stockholm studies in social work, ISSN 0281-2851 ; 32
Keyword [en]
Evidence-based practice, Evidence-based medicine, Addiction severity index, Motivational interviewing, critical appraisal, ethnography, social work, substance abuse, science and technology studies, standardization
National Category
Social Work
Research subject
Social Work
Identifiers
URN: urn:nbn:se:su:diva-126503ISBN: 978-91-7649-345-8 (print)OAI: oai:DiVA.org:su-126503DiVA: diva2:900625
Public defence
2016-03-18, Aula Svea, Sveavägen 160, Stockholm, 10:00
Opponent
Supervisors
Funder
Forte, Swedish Research Council for Health, Working Life and Welfare
Note

At the time of the doctoral defense, the following paper was unpublished and had a status as follows: Paper 4: Manuscript.

Available from: 2016-02-24 Created: 2016-02-04 Last updated: 2017-02-17Bibliographically approved
List of papers
1. Working with different logics: A case study on the use of the Addiction Severity Index in addiction treatment practice
Open this publication in new window or tab >>Working with different logics: A case study on the use of the Addiction Severity Index in addiction treatment practice
2013 (English)In: Nordic Studies on Alcohol and Drugs, ISSN 1455-0725, Vol. 30, no 3, 179-199 p.Article in journal (Refereed) Published
Abstract [en]

AIM - This article explores the implementation and use of the Addiction Severity Index in addiction treatment practice, both as a clinical instrument and as a way of facilitating outcome measurement. This is regarded as incorporating laboratory logic into clinical practice characterised by the logic of care. DATA - The data is based on ethnographic fieldwork in a Swedish metropolitan social service agency known for its systematic ASI work. RESULTS - The findings suggest that much effort must be dedicated to co-ordinate activities in the agency in line with the laboratory logic, making sure that the interviews are administered systematically. In use, the ASI and the variables in clinical practice are adjusted to each other, making it possible to follow both logics at the same time. In some cases, however, there is a conflict: the ASI becomes an extra task that does not further the clinical work. Once collected, the ASI data must be co-ordinated in line with other information. This has not yet been realised in the agency, which makes the value of the ASI data unknown. CONCLUSIONS - It requires hard work to handle the two logics simultaneously in addiction treatment practice: activities must be co-ordinated, and instruments and variables in clinical practice must be continuously tinkered with. Further, outcome measurement is not only about systematic use of standardised instruments, but much work must be done after the ASI data has been collected.

Keyword
Addiction severity index (ASI), standardised assessment instruments, outcome measurement, clinical practice, ethnography, Sweden
National Category
Social Work
Research subject
Social Work
Identifiers
urn:nbn:se:su:diva-90384 (URN)10.2478/nsad-2013-0015 (DOI)000318420500006 ()
Note

AuthorCount:1;

Available from: 2013-06-05 Created: 2013-06-03 Last updated: 2016-02-08Bibliographically approved
2. Stabilizing a fluid intervention: The development of Motivational Interviewing, 1983-2013
Open this publication in new window or tab >>Stabilizing a fluid intervention: The development of Motivational Interviewing, 1983-2013
2014 (English)In: Addiction Research and Theory, ISSN 1058-6989, Vol. 22, no 4, 313-324 p.Article in journal (Refereed) Published
Abstract [en]

Introduced in 1983, Motivational Interviewing (MI) is now widely regarded as an efficacious psychosocial intervention in the addiction treatment field. Drawing on research literature, this article asks how this was achieved. Contrary to common conceptions of the dissemination of psychosocial interventions within the addiction treatment field, this analysis takes neither MI's identity nor its efficacy to be inherent qualities, but sees them as being constructed by various actors. This construction work is described as stabilizing processes. Being loosely structured and flexible, it is suggested that MI can be regarded as a fluid intervention. This has presented difficulties for its subsequent stabilization. As MI has been differently operationalized in clinical trials, it was not obvious at first to talk about the efficacy of MI as a single object of concern in systematical reviews and meta-analyses. The article discusses some of the complexities involved in the production and dissemination of efficacious psychosocial interventions. Compared with other cases, MI displays a somewhat different mode of stabilization. It is argued that MI has been stabilized enough to be considered an efficacious intervention while simultaneously incorporating fluidity, which makes it useful in a wide range of clinical settings.

Keyword
Motivational interviewing, stabilization, treatment fidelity, historical account, evidence-based practice
National Category
Social Work
Research subject
Social Work
Identifiers
urn:nbn:se:su:diva-98735 (URN)10.3109/16066359.2013.845174 (DOI)000339139000005 ()
Available from: 2014-01-09 Created: 2014-01-09 Last updated: 2017-12-06Bibliographically approved
3. Evidence, fidelity, and organisational rationales: Multiple uses of Motivational Interviewing in a social services agency
Open this publication in new window or tab >>Evidence, fidelity, and organisational rationales: Multiple uses of Motivational Interviewing in a social services agency
2016 (English)In: Evidence & Policy: A Journal of Research, Debate and Practice, ISSN 1744-2648, E-ISSN 1744-2656, Vol. 12, no 1, 53-71 p.Article in journal (Refereed) Published
Abstract [en]

In discussions and empirical investigations of the implementation of evidence-based interventions there is often a narrow focus on treatment fidelity. Studying a social services agency trying to incorporate Motivational Interviewing (MI), commonly regarded as evidence-based, this paper problematises a one-sided attention to treatment fidelity by showing how non-fidelity can be constructive from an organisational perspective. While treatment fidelity is one important aspect, it is argued that there might be other rationales to take into account when implementing evidence-based interventions in professional practices.

Keyword
Implementation, treatment fidelity, evidence-based practice, motivational interviewing
National Category
Social Work
Research subject
Social Work
Identifiers
urn:nbn:se:su:diva-126508 (URN)10.1332/174426415X14358305421172 (DOI)000369338200004 ()
Funder
Forte, Swedish Research Council for Health, Working Life and Welfare
Available from: 2016-02-04 Created: 2016-02-04 Last updated: 2017-11-30Bibliographically approved
4. Reconsidering critical appraisal in social work: Choice, care and organization in real-time treatment decisions
Open this publication in new window or tab >>Reconsidering critical appraisal in social work: Choice, care and organization in real-time treatment decisions
(English)Manuscript (preprint) (Other academic)
Abstract [en]

This paper seeks to provide an empirically grounded discussion of the critical appraisal model of EBP in social work practice. Studying decisions in practice, the paper looks ethnographically at an attempt to implement critical appraisal in social work practice, and problematizes some of the assumptions underlying this idea. Whereas critical appraisal tends to view treatment decisions as clear-cut events that are made by autonomous social workers, participant observation shows that decisions emerge over time and that they are ‘organizational’ rather than emanating from individual social workers. Drawing on Mol’s (2008) notion of the ‘logic of care’ and findings from studies of organizational decision making, a more practice oriented understanding of treatment decision-making is outlined.

Keyword
Evidence-based practice, decision making, critical appraisal, ethnography, logic of care, organizational decision-making
National Category
Social Work
Research subject
Social Work
Identifiers
urn:nbn:se:su:diva-126505 (URN)
Funder
Forte, Swedish Research Council for Health, Working Life and Welfare
Available from: 2016-02-04 Created: 2016-02-04 Last updated: 2016-02-08Bibliographically approved

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