Supporting the Client's Right to Effective Treatment: Touching a Raw Nerve?

Saul Raw has prepared a thoughtful response to our earlier article (Myers & Thyer, 1997), in which we argued that social workers should have an ethical obligation to provide clients with empirically supported treatments in situations where these have been established. Raw has succinctly expressed many of the doubts we have heard from some of our colleagues about this proposition, doubts which may have been shared by one or two readers as well. It seems that one of Raw's major objections is that research findings obtained through studies of an intervention's efficacy (usually demonstrated in well-controlled clinical trials, using expert therapists, possibly recruited client-subjects meeting select inclusive criteria and so forth) may not translate into effective practice in real world settings. These efforts have also been labeled "research therapy" (efficacy) and "clinic therapy" (effectiveness). These are legitimate distinctions to make and a concern to raise. Science does provide a solution. It consists of building on previous efficacy studies of research therapy to subsequently conduct effectiveness studies in real world agencies with real clients and social work practitioners (that is, clinic therapy). This process is the next logical step in the progressive nature of validating psychosocial treatments. It has been undertaken in many instances. Similarly, the generalizability and applicability of treatment manuals to agency or clinic settings is an empirical question. Some translate well, and some do not. Empirical research will answer such questions, not an uncritical acceptance or a broad-brushed dismissal. For example, the treatment approach labeled exposure therapy and response prevention (ETRP) for clients meeting the criteria for obsessive-compulsive disorder has been shown in dozens of well-controlled trials of research therapy to be a moderately effective psychosocial intervention (see Cohen & Steketee, 1998, for a recent review of this literature). One of the foremost practitioner-researchers involved in the development of ETRP is Gail Steketee, a clinical social worker now turned professor. Steketee coauthored the self-help book When Once Is Not Enough (Steketee & White, 1990), solidly grounded in several decades of efficacy trials, designed for clients to learn and apply ETRP to themselves, with or without professional social work assistance. When this self-help book (the maligned manual-based therapy) was applied in the context of a mental health clinic, it was found that clients significantly and clinically improved (Fritzler, Hecker, & Losee, 1997). What a marvelous legacy for a social worker such as Steketee to give us - a psychosocial treatment that works for clients with a seriously handicapping disorder, not only under tightly controlled conditions (efficacy) but in routine clinical practice as well (effectiveness). Fritzler et al. (1997) is not an isolated example. ETRP has been subjected to numerous efficacy trials in routine clinical practice, some involving small groups of clients (see, for example, Kirk, 1983; Krone, Himle, & Nesse, 1991), and others using individual clients whose outcomes were evaluated using single-case research designs (Himle & Thyer, 1989; Thyer, 1985). The same situation pertains to a wide variety of psychosocial interventions applied to other so-called mental disorders (see Hickling & Blanchard, 1997, for a discussion of posttraumatic stress disorder) and to many nonmental disorders and psychosocial problem-solving interventions, such as case management services for homeless people (Toro et al., 1997), job-finding clubs for chronically unemployed people (Rife & Belcher, 1994; Vinokur, Price, & Caplan, 1991), controlling anger among adolescents (Nugent, Champlin, & Wiinimaki, 1997), and various medical problems. In reading Raw's article, the reader could come away with the impression that conventional research has completely ignored the problem of translating research therapy findings into real world contexts - that is, applied in regular human services agencies by the usual social workers with actual clients. …