The Multi-factorial Complexity of Social Work Practice and Implications for Interventions

Significant research efforts continue to evolve in regard to social work interventions. Few of these, however, address the factorial complexity of the phenomena addressed in social work practice. Just as medical research has often failed to adequately address population diversity in studies aimed at defining interventions, social work practice has not sufficiently addressed the multi-factorial aspects of treatment. Proposed here are challenges to the profession to define aspects of treatment and mechanisms for practice interventions for complex disease syndromes and diverse populations. Two examples are used to illustrate the complexity of practice - serious mental illness and homelessness- and possible solutions are proposed to address this conundrum.

Serious

Serious mental illness (SMI) among adults is defined in Public Law 102–321 as persons aged 18 or older who currently, or at any time in the past year, have had a diagnosable mental, behavioral, or emotional disorder (excluding developmental and substance use disorders) of sufficient duration to meet diagnostic criteria specified within DSM-IV that has resulted in functional impairment, which substantially interferes with or limits one or more major life activities. SMI is compounded by substance use disorders (SUD). Mental health and substance use disorders are of grave concern to our nation which is experiencing an epidemic of substance use in general. Using my current home state as an example, it has been estimated that one out of every ten Tennesseans is at risk for, or has, a substance abuse disorder SAMHSA, 2018), and studies suggest the magnitude of the problem of substance abuse will continue to strengthen.

In 2004 it was estimated that about 90% of those with substance use disorders had co-occurring mental health disorders (Turner et al., 2004). By today’s estimates about 1.5 million adult Americans (ages 18 and older) who had experienced an SMI in the past year had also misused an opioid during this period (Substance Abuse and Mental Health Services Administration [SAMHSA], 2017). The misuse of opioids includes any use of heroin and/or the misuse of opioid-based prescription pain relievers. These figures imply that about one in eight (13%) of adults who misused opioids also experienced an SMI. Adding to the problem of SMI, currently, is the number of military veterans returning from deployments in combat zones, many of whom face SUD and PTSD among other problems of SMI.

Treatment need vs. actual service delivery

Treatment need is defined as having substance dependence or abuse or receiving treatment at a specialty facility within the past 12 months. In 2011, 21.6 million persons ages 12 or older needed treatment for an illicit drug or alcohol use problem (8.4% of persons ages 12 or older). Of these, 2.3 million (0.9% of persons ages 12 or older and 10.8% of those who needed treatment) received treatment at a specialty facility. Of the 19.3 million persons ages 12 or older in 2011 who were classified as needing substance use treatment but did not receive treatment at a specialty facility in the past year, 912,000 persons (4.7%) reported that they felt they needed treatment for their illicit drug or alcohol use problem. Of these 912,000 persons who felt they needed treatment, 281,000 (30.8%) reported that they made an effort to get treatment, and 631,000 (69.2%) reported making no effort to get treatment (Substance Abuse and Mental Health Services Administration [SAMHSA], 2012a).

Homelessness

The majority of individuals with SMI are homeless. Homelessness can best be framed as an issue at the intersection of poverty, race, class, trauma, and gender, as the majority of families who experience homelessness are headed by a single mother of color typically with two young children (Gubits et al., 2015; Hayes et al., 2013; National Alliance to End Homelessness, 2012). Cultural gaps and barriers to service seriously impact the mental and physical health of a large portion of our nation’s population (Substance Abuse and Mental Health Services Administration [SAMHSA], 2017). For households headed by single mothers, income stagnation, decreased relative annual earning power, and persistent rates of poverty create considerable obstacles to household economic security that, for some, threaten the very possibility of attaining or maintaining safe and stable housing (Casey, 2011; DeNava-Walt et al., 2013; Fry, 2013; Goldberg, 2014). While homelessness alone may appear to be a substantial concern, it often puts children and families at further risk for countless other difficulties. Children within homeless families are three times more likely to have behavioral problems and educational deficits, and 80% of them will experience or witness a violent act by age 12 (Institute for Children, 2013).

Innovative advances in social work interventions and research to address

Multi-factorial components of practice

Digital therapeutics

When it comes to treating mental health and behavioral disorders, there traditionally have been two choices: medication and psychotherapy/behavioral interventions. There is, however, a third option: digital health devices, software and applications collectively known as “digital therapeutics”(Maples-Keller et al., 2017). These therapies aim to treat a variety of diseases and disorders, from asthma and diabetes to depression and attention-deficit hyperactivity disorder. Some digital therapeutics are designed to be used in conjunction with medication or behavioral interventions. Others aim to replace traditional treatments altogether. Examples include web-based cognitive-behavioral therapy (CBT) programs, digital dashboards that allow patients and providers to closely track indicators of health, and even game-based interventions. What the therapies have in common is a commitment to evidence-based practice. Unlike most wellness apps marketed directly to consumers, digital therapeutics follow an R&D path that looks more like drug development. The tools are evaluated in clinical studies and recommended by health care providers. And many of the companies producing digital therapies are seeking regulatory approval.

Mental and behavioral disorders lend themselves particularly well to digital interventions according to psychologist Colin Espie, Ph.D. a professor of sleep medicine at the University of Oxford and co-founder and chief medical officer of the digital therapeutics company Big Health. Espie states that “digital medicine is really personalized behavioral medicine”. Espie describes a web-based program called Sleepio that uses the research-supported treatment Cognitive Behavior Therapy (CBT) for insomnia, or CBT-I. Instead of being delivered in an office by a mental health clinician, Sleepio’s six-week intervention is led by an animated virtual sleep expert named The Prof and his narcoleptic dog Pavlov rather than by an office clinician. “It’s designed to feel entertaining, but it’s actually full-octane CBT,” Epsie says. Sleepio was tested in a randomized, placebo-controlled trial of people with chronic insomnia. According to Epsie, more than 70% of participants who completed the online CBT intervention had healthy sleep eight weeks after the program ended, compared with less than 30% of participants who received a placebo in the form of visualization exercises (Espie et al., 2012). Following the earlier trials further randomized controlled trials that included a study of more than 3,700 participants indicated that improving sleep also improves mental health (Freeman, Sheaves, et al., 2017). While emphasizing that CBT-I should be first-line treatment for people with chronic insomnia, there aren’t enough providers to meet the demand. Epsie and his Big Health team aim to close this treatment gap.

Pear Therapeutics provides another example of an innovative digital approach. Pear is developing prescription-based digital treatments for substance use disorder, post-traumatic stress disorder, generalized anxiety disorder and schizophrenia. Pear’s reSET therapy for the treatment of substance use disorders in 2017 became the first prescription digital therapeutic for disease treatment cleared by the Food and Drug Administration (FDA) (Freeman, Reeve, et al. 2017). Currently, reset-O is under review by the FDA for treatment of opioid use disorder. reSET-O is intended to be used in combination with the medication buprenorphine and utilizes a mobile app that leads patients with alcohol, cocaine, marijuana and stimulant use disorders through CBT-based tools and allows them to track substance use, cravings and triggers such as social pressure and loneliness (Rizzo & Shilling, 2017). The system is designed for patients who are undergoing outpatient therapy for treatment of SUD and requires a physician’s prescription (Maples-Keller et al., 2017). Pear’s chief medical officer Yuri Maricich, MD, states that reSET isn’t psychoeducation or self-help but rather an actual treatment intended to improve outcomes and enhance the therapeutic alliance between the patient and the clinician (Freeman, Reeve, et al., 2017).

Addressing the complexities of social work research through factorial design

Due to the complexities associated with social work research, the factorial design is an excellent research design that can advance social work knowledge. Factorial designs can more fully capture a variety of factors such as the type of client, the type of worker, the intervention, the duration, the context, and relapse-prevention procedures. Capturing accurate and informative social work research is crucial for guiding policies and for professional practice. However, the research design is not the only important issue in producing effective and comprehensive social work research. Social work research must also be a collaboration of experts in which knowledge and research centers can share knowledge and effectively disseminate that knowledge to the appropriate individuals and organizations. Social work research is integral to advancing the well-being of society. It informs policy and informs professional practice. Although social work research has advanced significantly, it still has many challenges to overcome. Funding certainly remains an obstacle for advancing social work research and should become a priority both within the circles of academia and in public policy research. Research centers should specialize in distinct research areas such that the body of knowledge for each area of social work can become centralized and be used to more effectively advance social work practice, research, and public policy.

The following questions should be answered throughout factorial designs:

1. Who should deliver the intervention to whom?

2. What intervention is the most effective with which clients?

3. When should the intervention occur?

4. Where and to what level should the intervention take place?

5. How long should the intervention continue?

6. How is behavior change maintained (relapse prevention, medication)?

7. What, if any, medication is appropriate? and

8. How, when and how often is the practice evaluated?

All research should endeavor to explain as much variance as possible in the phenomena of interest. Only when social workers employ factorial designs and multivariate statistics can we begin to explain the complexities of behavior change.

Implications for social work practice research

The overarching goal of social work research is to develop and maintain a collaborative network to support resource development and dissemination, training and technical assistance and workforce development to the field. The anticipated outcome is the assurance that high-quality and effective mental health treatment and recovery support services and research-supported treatments (RSTs) will be available for all individuals. Organizations and practitioners throughout the nation who are charged with delivering mental health services to expand and enhance their capacity to deliver RSTs to our population will benefit significantly from research efforts to define best RSTs. Thus, social work practice research should focus on:

1. Accelerating the adoption and implementation of mental health related evidence-based practices across the nation, and

1. Heightening the awareness, knowledge, and skills of the workforce that addresses the needs of individuals living with conditions that compromise their physical and mental health.

Social work practice research should aim to identify effective strategies and/or system approaches, develop resources, and provide training on best practices, in states and community settings across the nation, on areas of focus related to the provision of mental health promotion and mental disorder treatment. Specific goals include: mental health promotion, prevention, intervention, and recovery support services for our focus population; integrated school-based mental and behavioral health promotion, prevention, and intervention services; treatment for individuals living with serious mental illness (SMI), including the use of psychotropic medication; treatment for individuals with SMI who experience homelessness; outreach and intervention for youth and young adults at high risk for psychosis with particular focus on military veterans; coordinated care approaches for individuals with SMI; youth and transition-aged youth (ages 16–25) with serious emotional disturbance (SED) or SMI; infant and early childhood psychosocial and emotional development; recovery support services, including

peer-provided services; integration of primary and mental health care (i.e., integrated care approaches/models for primary care and mental health care); mental health awareness and literacy; and promotion of tobacco-free strategies and interventions.

Catering the intervention to the specific population and individual is crucial. Understanding what treatment model is appropriate in any given helping relationship is a huge benefit of the concentrated centers of research. Why are specific interventions used for specific populations, and what does new research conclude about treatment modalities for these populations? Critical thinking must be applied when choosing a treatment intervention for a client. With specific populations that may be transient, for example, the homeless, or for those who lack adequate transportation and barriers that make it difficult to receive mental health treatment, the most effective, evidence-based intervention must be employed. A well-suited treatment intervention could lead to better therapeutic outcomes and, for those who may attend only a few sessions of therapy, treatment could be more worthwhile and effective. The context in which treatment is offered must be examined, and the school of thought around the context in which services are provided must be concentrated. Numerous researchers have found that telemedicine, or therapy provided through the phone or interactively through video conferencing, can be an effective way to reach elderly rural clients, clients in the armed services, and children and adolescents (Kostiuk et al., 2009; Rabinowitz et al., 2010; Zanjani et al., 2010). Questioning the need for conducting therapy in an office setting as opposed to the home or through the telephone is continuing to be researched. With any intervention, the client and population must be considered. For example, data exist that adolescents respond well to telemedicine because of the information age in which they were raised and because the stigma is lessened by eliminating a face-to-face meeting with the practitioner (Naditz, 2010). Thinking outside the traditional location for providing services and opening up the realm of possibilities is important to an increased knowledge of how to effectively help clients. Information regarding context can be shared as centers for concentrated research exist and professionals can provide information to each other regarding what physical locations may work best for specific client populations. Just as the location of treatment must be studied, so must the duration of time that clients spend in the treatment process. As professionals convene to provide anecdotal, quantitative, and qualitative data through concentrated research centers, more effective treatment modalities can be created that include a critical examination of the number of therapeutic sessions needed to reach a specific outcome. With the high cost of insurance, stigma inherent in mental health treatment, and other barriers to mental health treatment, an effort must be made to improve treatment cost-effectiveness and efficiency. An examination of duration through professional social worker collaboration might yield answers that would allow for the most cost-effective treatments in which clients from all populations could participate. Challenging the traditional view of the duration of treatment, for example, 28 days for traditional alcohol or drug treatment or longer, could be a good practice for colleagues across the population and issue spectrum.

The roles of client and worker, the chosen treatment intervention, the location of the intervention, and the duration of the intervention all impact the quality of service that a client receives. Concentrated research centers could be a useful tool in examining all of these complexities and others through factorial designs that combine to create a treatment experience for clients. Arrangements to ensure that the services provided are effective and cost-effective will result in less waste of the client’s energy or money.

Conclusion

Over the decades, social sciences have adopted more and more evidentiary procedures and scientific principles in determining what can be defined as best practices. By following more rigid standards of data gathering, social work, like so many other related fields, hopes to increase the reliability and validity of treatments and thereby the confidence of clients. However, the black-and-white methodologies of natural sciences may not always be applicable or correctly used in the assessment of such gray areas as the human experience. The answer to this dilemma is not to simply discount the progress of data assessment in social sciences but rather to vigorously pursue further knowledge on how to measure and evaluate data to ensure that best practices used live up to that label. To rest on the existing measurement processes and data is to disserve clients and the integrity of practice. This editorial addressed salient issues in social work practice and salient issues in social work practice research and directions for areas in need of further research. To put social science research on a level equal to other sciences, a consolidated and cohesive dedication to continuing complex research (data and methodologies) must be maintained in the social work profession as a whole.