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Randomised Trials in UK Social Work: A Discussion of Possible Approaches

Randomised Trials in UK Social Work: A Discussion of Possible Approaches. Donald Forrester Professor of Social Work Research Director of the Tilda Goldberg Centre. Proposed RCT . Early stages of development (2012-14) Want to openly discuss issues and challenges

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Randomised Trials in UK Social Work: A Discussion of Possible Approaches

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  1. Randomised Trials in UK Social Work: A Discussion of Possible Approaches Donald Forrester Professor of Social Work Research Director of the Tilda Goldberg Centre

  2. Proposed RCT • Early stages of development (2012-14) • Want to openly discuss issues and challenges • Not got all answers and would rather have errors pointed out now... • Focus: whether Motivational Interviewing improves engagement of parents who misuse drugs or alcohol • But first a bit of history, theory and background

  3. Social Work’s Evidence Base: Emperor’s New Clothes?

  4. RCTs are one of the greatest intellectual achievements of the 20th century

  5. What is an “RCT”?

  6. What are advantages? • The best way of ruling out bias • Bias defined as explanations other than the intervention that might explain results • Key types of bias: • Self selection bias • People are active and resolve problems • Social work is about maintenance not cure... • Self-report not good indicator of impact – people usually appreciate services

  7. History of RCTs • First comparative trial – in the Bible. Daniel compares vegetarian diet with meat and drink. • RCTs in education and social work 1930s • Medicine from the late 1940s • Now dominant approach in medicine

  8. Selective history of RCTs Cambridge and Sommerville Study • USA 1930s • Intensive, long-term befriending from social worker for boys considered at risk of offending • Much appreciated by young men • Increased offending From Oakley, 2002

  9. Social work and RCTs • Dominant social work approach in 1960s, psycho-dynamic casework • Reid and Shyne tested and found: • Long-term work LESS effective than short term • Developed task-centred approaches based on approach

  10. Social work and RCTs • Homebuilders Intensive Family Preservation Service • Aimed at preventing children entering care • Success rates from 70 – 100% • Large-scale RCT – no impact

  11. Field social work RCTs in the UK 1970-2010

  12. Problems with RCTs

  13. Context Pawson and Tilley – Realist critique – context crucial for understanding nature of intervention and its impact Orford (2008) from within the RCT field – reflecting on the “Dodo Bird” effect • Whatever is happening across interventions more important than differences between interventions • Context of service, client or research • Requires emphasis on understanding context, process as well as outcomes

  14. Generalisability • RCTs on drugs establish general knowledge • This isn’t true for psychosocial interventions: • Implementation fidelity and innovation effects • What the control group receives eg “nothing works in Sweden…” • Or Dodo effects – everything works equally… • This is a fair criticism of naïve positivism • But ALL research makes claims to generalisability – and all should be considered critically

  15. Outcomes and social work: the politics of research

  16. Reimagining RCTs • Starting point to develop a critical form of RCTs that addresses these concerns – a characteristically and perhaps distinctively social work approach to RCTs • Many of problems with RCTs are of RCTs as done not as should or could be • So how should we do RCTs...

  17. Early social work RCTs • Reid and Shyne (1969) – brief vs open-ended social work with middle class couples with relationship problems • Randomization purely on length of intervention • Taped interviews and found this led to more focussed approach • Extensive outline of context of intervention • Both women and (particularly) men preferred this • Social work, service user and standardised measures of outcome all agreed ST work produced better outcomes at 12 months

  18. Goldberg (1970): Helping the Aged • Randomised older people to “normal service” (with unqualified workers) or service from qualified social workers • Detailed description of needs, services and outcomes and combination of qualitative and quantitative methods • High levels of need, improvements in both groups • Major problem: the “intervention” differed in multiple ways

  19. Evaluating Helping the Aged • The descriptive work was fantastic • The research is transparent and self-critical • Contributed to the programme of work that culminated in “Community Care” • Should have been the start for RCTs in social work...

  20. Field social work RCTs in the UK 1970-2010

  21. Not the research questions • Can we show that any of the approaches taught to social workers makes a positive difference – compared to “normal practice”? • Can we do this in a “normal” local authority setting? (chosen child and family work) • Can we make an RCT “work” in social work?

  22. Key Considerations: Outcomes • What outcome/s to measure? • Legal basis (Children Act 1989) • Protection from harm • Meeting needs • Every Child Matters outcomes (2004) • Health • Safety (eg from abuse) • Education • Making positive contribution • Achieving economic wellbeing

  23. Key Considerations: Outcomes • Complex factors influencing outcome/s • Social situation (eg poverty, racism etc) • Personal problems of parents (eg addiction) • Difficulties in child (eg challenging behaviour) • Patterns of family functioning and parenting • Complexity of social work “intervention” • Direct work • Interagency linkage • Risk assessment and decisions • Not voluntary clients seeking help

  24. Key Considerations: Outcomes Single biggest problem likely to be family participation rate in research Commonly as low as 5% - we need 60-70% Or a good proxy...

  25. Key Considerations: Intervention • Chose Motivational Interviewing as: • Strong evidence base in substance misuse field • Very flexible style of working • General style of communication aimed at engaging resistant clients • Consistent with social work values • Initial piloting study undertaken – which highlighted challenges

  26. Simple Overview of Intervention Process

  27. Piloting approach to outcomes

  28. Current Pilot • Combining small-scale RCT of MI with quasi-experimental study of “Hackney Model” • 40 workers in 10 teams/units in 2 contrasting LAs receive intensive MI input • 40 workers do not • Piloting MI input, types of data collection and success of different approaches to families

  29. Elements of Data Collection Piloted • Direct tapes of practice • Measured for MI-ness • Social work skill ratings being developed with group of experts by experience through iterative process • Brief questionnaires to all families allocated • With follow-up from administrators • Research interviews with families using various standardised instruments • Key problem likely to be low response rate • Social worker questionnaires on families • Key problem validity • To be tested by comparing with research intvws • Exploring using LA data measures

  30. Concluding Thoughts An RCT is the most robust test of effectiveness, because it minimises bias Social work needs to engage with the complexity of RCTs in order to evaluate whether what we do works A critical social work perspective is also likely to create better RCTs

  31. Concluding Thoughts Developing RCTs fit for use in social work settings is not straightforward or easy Doing so will not provide all of the answers However, hopefully it will provide some evidence about what skilful social work is and the difference it can make...

  32. “If we knew what it was we were doing, it would not be called research, would it?” Einstein

  33. References Forrester, D. (2010) Playing with fire or rediscovering fire? The perils and Potential for Evidence Based Practice in Child and Family Social Work”, in Ayre, P. and Preston-Shoot, M. (Eds) Children’s Services at the Crossroads. A Critical Evaluation of Contemporary Policy for Practice, Russell House Publishing; Dorset Goldberg, E.M., with Mortimer, A. and Williams, B.T. (1970) Helping The Aged—A Field Experiment In Social Work National Institute for Social Work Training, No. 19, George Allen & Unwin: London. 1970. Holosko, M. J. (2010) “What Types of Designs are We Using in Social Work Research and Evaluation?”Research on Social Work Practice; Nov2010, Vol. 20 Issue 6, p665-673 Oakley, A. (2000) Experiments in Knowing: Gender and Method in the Social Sciences, Polity Press Orford, J. (2008) “Asking the right questions in the right way: the need for a shift in research on psychological treatments for addiction”, Addiction, Volume 103, Issue 6, pages 875–885, June 2008 Reid, W.J. and Shyne, A.W. (1969) Brief and Extended Casework, Columbia University Press Torgerson, D.J. and Torgerson, C.J. (2008) Designing Randomised Trials in Health, Education and the Social Sciences, An Introduction, Palgrave Macmillan; Basingstoke

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